How 2008 financial crisis legacies impacted future health workforce resilience – a realist review

The 2008 financial crisis and subsequent recession led many Governments to adopt programmes of austerity. This had a lasting impact on health system functionality, resources, staff (numbers, motivation and morale) and patient outcomes. This study aimed to understand how health system resilience was impacted and how this affects readiness for subsequent shocks. A realist review identified legacies associated with austerity, with a particular focus on workforce resilience. EMBASE, CINAHL, MEDLINE, EconLit and Web of Science were searched (2007- May’21), followed by additional theory-driven searches. Descriptive, inductive, deductive and retroductive realist analysis (utilising excel and Nvivo) aided the development of Context, Mechanism, Outcomes Configurations (CMOCs), alongside stakeholder engagement to confirm, refine or refute emerging results. CMOCs revealed how: 1) priorities influenced by outside agents (e.g. Troika, governmental departments) led to a focus on external transparency and distrust in policy agenda, compounded by poor communication; 2) efficiency driven culture and performance monitoring meant professionals could not recognise their interests and values leading to sense of powerlessness, detachment and professional dissonance; 3) sustained restrictive economic policies that impacted patient care, eroded values, leading to a diminished view of profession; 4) health professionals maintained control by circumventing policy to deliver care - further isolating decision makers; and 5) street-level bureaucracy eventually leads to moral distress resulting in apathy and burn-out. Austerity challenged health system resilience but lessons can be leveraged by policy-makers and management to develop resilient strategies that protect and promote sustainable outcomes for the health workforce. This review reveals the importance of transparent, open communication, in addition to co-produced and value-driven policies.