My View – Rethinking the workforce funding model for digital employees

VIEW - Charlene Tan-Smith, Fellow of HiNZ

I believe it is time to evolve the workforce model - from hands only to hybrid brains and bytes. This means rethinking the workforce funding model to accommodate Digital Full Time Equivalent (DFTE) employees.

In my clinical patient-facing role, I am a specialist dietitian treating refractory epilepsy children with Precision Medicalised Ketogenic Therapy (MKT), using a variety of medicalised ketogenic diets to reduce or eliminate seizures. 

This is a low-frequency, high-complexity, high-cost patient cohort. We are talking about 100s of seizures per day, a diet that can reach 90 perdcent fat content with very low carbohydrates and adequate protein to grow, and in most cases, measuring food ingredients to 0.1g. 

Ketogenics is complex for everyone involved and traditionally has an extremely high dietitian time burden.

Allocating tasks

I have been incredibly fortunate to have partnered with a fantastic colleague who is the Ketogenic Assistant. During the design of the ketogenic service, her Allied Health Assistant (AHA) role was also intentionally designed using Calderdale Framework principles.

The Calderdale Framework is an evidence-based workforce transformation tool. It uses a framework of defined Clinical Task Instructions (CTIs). Calderdale Framework uses a 3-stage training system of Taught, Modelled (simulated), and Competent (matching documented CTIs) before any tasks are allocated to another staff member. 

Governance including a fundamental ‘When to stop’ CTI excludes clinical tasks performed by untrained staff. So my keto assistant takes on a portfolio of tasks and allocated tasks. These include tracking when regular bloods are due, maintaining contact with patients to collect food and seizure records, managing admission tasks, and using tools to balance/exchange ingredients in meals and recipes. 

This frees up time for me, the practitioner, to work on top-of-scope tasks like fine-tuning individual patient keto prescriptions, and problem-solving acute medical events.

Available 24/7

I have another colleague who works with the AHA and me, who has similar ring-fenced tasks allocated, and there is governance to document and ensure the clinical safety of their tasks. 

Overseen by me as the registered practitioner, they help calculate patient-specific macronutrient food prescriptions for fat, protein, and carbohydrates, then split these into meals and snacks to create a daily meal plan. 

They also work for the AHA and sometimes directly with patients, balancing meals or recipes to patients' personal prescriptions, and give recipe options and guidance when a recipe does not balance. 

This work saves the whole team a lot of time and facilitates patients' participation in health care management. 

The amazing thing is this colleague is always available to everyone 24/7. They can work with everyone at once all over the country. They have one significant difference - let me introduce to you our digital team member.

Introducing DFTE

This experience has prompted me to write a white paper, ‘Introducing Digital-FTE into the NZ Health Environment - An alternative funding concept for a health system that requires more to be done with existing resources’. 

I am not exploring the ethical or philosophical questions around the considerable breadth of existing and future technology in the health sector, nor I am I specifically targeting any one technology such as AI. I am primarily questioning our funding model. 

Both my AHA and digital team member perform human tasks, just as I do. That is no disrespect to my AHA or myself; we have different skills. However, our digital team member is not any closer than we are to a laptop, monitor, or an electronic medical records platform. So why would it be funded like one? 

Here is the challenge to our thinking: why should we not fund digital solutions that perform human tasks from the workforce budget as a Digital Full Time Employee? Where there is unfilled human-FTE or business plans for new services, applying funding to DFTE, has great potential benefit for staff and patients.

A paradigm shift

In my Health New Zealand informatics consultant role, I have the privilege of working directly with staff on the ground across Canterbury and the West Coast to identify operational and clinical workflow challenges, codesign solutions and where needed implement digital solutions (hardware, software, data) to make life better and safer for both patients and staff. 

Difficulties exist, and it is fun and rewarding to contribute in such a real and impacting way. Colleagues probably see me as ‘techie’, but I’m primarily interested in what can be done with digital solutions. 

The computers, iPads, dashboards, EMR platforms, wearable tech, Software as a Medical Device (SaMDs), and AI tools do not exist for themselves; they exist to treat real live people and keep our staff safe. This same measure applies to DFTE. 

A paradigm shift to DFTE is possible now as this is not a futuristic concept; it is already happening. 

Recognising and reframing it as a workforce formally allows us to fund, manage, and scale qualifying health tech solutions as measurable, governable, and reliable team members. 

The potential is to contribute solutions to global health systems under strain while valuing our skilled clinicians and delivering better patient outcomes. 

Disclaimer: The views and opinions expressed in this paper are those of the author and do not necessarily reflect the official policy, position, opinions or views of Health NZ Te Whatu Ora or any affiliated organisation, health services or employers.

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