A large part of the employment growth in American society over the next two decades will be in the health care sector. While much of this increase will occur in areas we typically think of as highly visible health care professions - physicians, nurses, pharmacists - the majority of the employment growth will take place in the front line workforce - nursing assistants, home health aids, long-term care assistants and others - who will provide essential care and services to an aging population. Unlike many other health professionals, these individuals are often at risk by making lower wages, having less generous benefits, and fewer opportunities for education and advancement.

Last month I wrote about the looming movement to expand the capacity to produce more health professionals of every stripe. I called for us to consider what work these health professionals would move toward, how they would be organized for practice, and what new technologies might change the demand curve for their skills. Most of my comments were focused on the practice world and what might be done there to lessen or redirect the demand for health workforce. This month I want to return to the same question of whether or not we should build new capacity, but approach it from the perspective of education.

Across most of the health professions, from medicine and dentistry to nursing and allied health, there is a growing chorus calling for increased numbers of professionals. In its policy assessment and recommendations, the Center for the Health Professions has led a number of the calls in these professions. However, before we go headlong into building new campuses, enlarging programs, and attempting to alter the labor market, it is vital to look at how effectively we are using the resources we currently have. Which professions are in need of expansion? Do we want to create new visions for the roles that exist today?

The challenges confronting the nation's policy around health and health care are enormous. The litany of drivers for this reality are familiar - expenditures that are approaching two trillion dollars, rampant dissatisfaction from those that provide and receive service, the absence of fifteen percent of the population from the health care system, as well as avoidable deaths in the tens of thousands. These drivers, in addition to federal policy machinery that is incapable of action unless it involves a single women's request for a peaceful death in Florida, do not make the prospect for change look bright.

For the past twenty years the Center for the Health Professions here at UCSF, and the precursor programs at Duke University and the University of North Carolina at Chapel Hill, have divided emphasis more or less equally between research and policy work on where the health professional communities of the U.S. should be to create a better system of care and how they could get there. This second theme has generally been carried out under the theme of leadership development or, at times, organizational change. Today the Center for the Health Professions sponsors four high profile national or statewide leadership initiatives for the Robert Wood Johnson Foundation, the Pew Charitable Trusts, the California HealthCare Foundation, the California Endowment and the Gordon and Betty Moore Foundation. In addition, we sponsor half a dozen other initiatives to advance the practice of leadership among health care clinicians. Increasingly we are working directly with hospitals, professional practices, state associations, and care systems to bring what we have learned from two decades of practice in developing leaders.

Just when you thought it was safe to come out, "he's back" and we are running for cover. In case you haven't heard, California's Governor Schwarzenegger has proposed doing in over 88 regulatory agencies, including 18 that provide oversight for various health professional groups. The standard conventional wisdom is this will end life as we know it. But, for some that are offered protection by the regulations, nothing could be further from the truth. Before the health care establishment rejects this proposal out of hand it may be time to look at our current system of regulations to assess whether or not it serves the professions that created it; and, that in virtually every venue in America, dominate its workings. This is not to mention how this system serves the public interest.

The end of the year is often a time for rehashing the events of the past twelve months and looking into the future. I want to resurface five trends that health care futurists have been discussing for years, but which still sit about waiting to have an impact on the daily reality of health care. That these trends have not yet materialized the changes that were anticipated should not call their power into question. Rather, our timeframe for change in health care needs to incorporate the enormous power of maintaining accepted ways of financing and delivering care services. In the coming year, these forces, independently, but more powerfully in concert with one another, will begin to meet the promise they hold.