Competencies as a Tool for Employers: Necessary but Not Sufficient

“Man, if you gotta ask, you'll never know.”—Louis Armstrong

Louis Armstrong is said to have responded with this quote when someone asked him what jazz was. Brilliant artists can perhaps be permitted such lack of definition and leave their fans to make up their own minds, but what about the rest of us? I remember a similarly illuminating answer when, as a recent arrival from clinical medicine in the early 1990s, I asked my public health trainer how I would know what was expected of me and whether I was doing a good job. The response, “Don't worry; if you don't make the grade, we'll tell you,” left me feeling decidedly vulnerable during the first part of my training.

Perhaps unsurprisingly, I was an early convert to the competency movement; here at last was a way of objectively establishing what was required for professional practice and then measuring whether this was achieved. With experience over the years of developing competency-based approaches to public health specialist training programs, I have grown somewhat skeptical. A recent invitation to talk to an expert group developing competencies for epidemiologists gave me the chance to explore the subject from a novel angle, as I was asked to consider competencies as a tool for employers.

Having worked for several years as a member of the senior management of a national public health agency, my starting point was to consider what constitutes success for a public health organization. Any publicly funded body nowadays must expect to be held accountable by its sponsors for delivery of agreed-upon goals within its allocated budget, and possibly even to generate cost savings to enable it to expand into new areas of work. At the same time, the organization will need to maintain public confidence, and to demonstrate that it operates to accepted professional standards. A skilled and motivated workforce is essential for delivering organizational success. So, can competencies help?

A competency-based approach could begin by defining the functional roles necessary to achieve organizational goals, and then turning these roles into job descriptions. Competencies help describe the detail of what is expected of each role. Take, for example, the job description for someone to lead the design, development, and introduction of new surveillance programs. This description can be broken down into elements such as those related to the technicalities of surveillance programs, and those related to team leadership, the ability to influence stakeholders, and so on. These elements can then be translated into competencies, which the candidates for the post will be expected to achieve.

Public bodies are increasingly required to demonstrate that they are fit for purpose. Having an accredited workforce helps provide assurance that the staff has been trained to an explicit level of achievement. In addition, by working with professional regulatory bodies to define individual competencies independent of the traditional ties between professional qualifications needed and performance of certain tasks, competencies can help public health organizations keep costs down. Thus, tasks that used to require a medical qualification—for example, prescribing certain medicines—can be undertaken by other professionals, such as physicians' assistants, provided that they have been certified for that task. Consequently, the organization can review its staff mix and potentially reduce its workforce costs.

A staff is the most important—and costly—resource a public health body has, so successful organizations will want to build up career structures that will support staff development and retention. Here again, competencies could provide a framework to assist employers in assessing current skill levels as well as a basis for developing training programs to equip staff to take on more complex or more senior roles.

All of the aforementioned goals are very logical, reassuringly objective, and straightforward for employers to achieve. Well, perhaps in theory, but in practice? Anyone who has been involved in describing and defining competencies for complex, professional roles knows how difficult and time-consuming this work can be. Developing valid and reproducible ways to measure competencies is even more challenging, and whether this work is undertaken by the professionals' own accreditation bodies or by the employing public health organizations themselves, the latter will most probably end up paying for the expensive staff time required. The constant battle to find resources on a recurrent basis—in which organizations use competencies in the annual appraisal process or for periodic review—can induce despair even in the most ardent adherents to the competency-based approach.

Ultimately, public health organizations will be judged by what they achieve, by outcomes such as the impact of public health programs. While providing a framework to help describe expectations of the workforce and assess current skill levels, competencies are at best a measure of the potential for future achievement,¹ and many of the important personal attributes that underpin high-level professional achievement do not lend themselves to easy measurement through a competency framework. Creativity, integrity, flair, drive, and motivation, for example, are not easily measured, and perhaps risk being devalued in organizations that recruit and reward staff primarily based on how well they match a set of measurable competencies. In addition, competency-based approaches to professional development are criticized for concentrating on the delivery of target knowledge and skills at the expense of the learning process, and failing to foster and develop the tools for lifelong learning that are so crucial to continued development of professional expertise.

Another criticism is that programs tend to focus on achievement of competency in individual tasks but ignore their interconnectedness, thus losing sight of the whole. Professional practice requires the ability to synthesize, to make situation-specific judgments in a complex and dynamic environment. Along with other skeptics, I now increasingly question whether deconstructing professional roles into discrete tasks can adequately encompass the breadth and depth of expertise required for the practice of public health—defined so eloquently as “the science and art of preventing disease, prolonging life, and promoting health through organized efforts of society.”² Are we in danger of losing sight of the art?