Preparing a 21st century workforce: is it time to consider clinically based, competency-based training of health practitioners?

Health workforce training in the 21st century is still based largely on 20th century healthcare paradigms that emphasise professionalisation at the expense of patient-focussed care. This is illustrated by the paradox of increased training times for health workers that have corresponded with workforce shortages, the limited career options and pathways for paraprofessional workers, and inefficient clinical training models that detract from, rather than add to, service capacity. We propose instead that a 21st century health workforce training model should be: situated in the clinical setting and supported by outsourced university training (not the other way around); based on the achievement of specific milestones rather than being time-defined; and incorporate para-professional career pathways that allow trainees to 'step-off' with a useable qualification following the achievement of specific competencies. Such a model could be facilitated by existing technology and clinical training infrastructure, with enormous potential for economies of scale in the provision of formal training. The benefits of a clinically based, competency-based model include an increase in clinical service capacity, and clinical training resources become a resource for the delivery of healthcare, not just education. Existing training models are unsustainable, and are not preparing a workforce with the flexibility the 21st century demands.