International perspectives on health human resources

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International perspectives on health human
resources

• Karen Bloor
• University of York

Co-contributors Alan Maynard (York) Jane Hall
(Sydney) Philippe Ulmann (Paris) Oliver
Farhauer (Berlin) Björn Lindgren (Lund)
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Outline

• Background health human resources and planning
  of health human resources in five countries
• Australia, France, Germany, Sweden, UK
• Innovations in health human resources
• Barriers to change
• Lessons for Canada?

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Health human resources an international
comparison

• Countries chosen to represent diversity
• Australia, UK (liberal, health system dominated
  by national taxation)
• France, Germany (corporatist, health systems
  dominated by social insurance)
• Sweden (social democratic, health system
  dominated by local taxation)
• Parallels with Canada?
• Australia and France (ambulatory) pay doctors
  fee for service
• Sweden and Germany strong regional element to
  health care planning
• UK and Australia attempts to develop more
  strategic health care planning

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Total expenditure on health, per capita, USPPP
Source OECD health data
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Total expenditure on health percentage of GDP
Source OECD health data
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Public expenditure on health as a percentage of
total expenditure
Source OECD health data
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Physicians per 1000 population
Source OECD health data
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Nurses per 1000 population
Source OECD health data
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Health employment per 1000 population
Source OECD health data
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Health care labour markets

• As all markets, interaction between demand and
  supply
• Demand determinants include
• Size and structure of a population
• Patient expectations of health care
• Income of society
• Supply determinants include
• Income and perceived status of health
  professionals
• Skill mix of health professions
• Use of complements and substitutes
• External factors (e.g. EWTD)

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Weaknesses in workforce planning

• Typically narrow in focus
• Often examines medical practitioners in isolation
• Ignores interrelationships between health
  professionals and substitution possibilities
• Often mechanistic and supply side driven

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Assumptions about medical workforce supply
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Other questionable assumptions made by workforce
planners

• Existing health systems are efficient
• Current staffpatient ratios are appropriate
• Historical supply reflects demand
• Costing often incomplete
• Physical numbers of staff rather than accurate
  financial forecasts
• Variations in clinical practice ignored
• Labour and capital substitution ignored
• No consideration of potential to increase
  productivity of health professionals

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Planning health human resources in five countries

• Four of the five countries (Australia, France,
  Sweden, UK) control the medical workforce
  centrally
• Through intake of medical schools
• Appropriate numbers determined by a crude
  forecasting method
• Demand predictions tend to be based on
  demographic change
• Same four countries plan nursing and other
  professions, again by university intake
• Australia is developing an integrated approach

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Indicators of efficiency of health human
resources planning (I)

• existence of shortages and surpluses of
  health professionals at national level
• All five countries report a cycle of shortages
  and surpluses, particularly of doctors and
  nurses
• existence of shortages and surpluses in parts
  of the health care system
• Geographical and specialty distribution
• All five countries have some levels of inequity
  in staffing across geographic regions and between
  specialties

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Indicators of efficiency of health human
resources planning (II)

• Indicators of success of health services as
  employers
• Recruitment, retention, return and early
  retirement
• Performance of the health care workforce
• Activity, quality, outcomes
• General need for an improved information base

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Policy change in health human resource planning

• In all five countries, change has been modest,
  slow and lacking theoretical basis
• Ignores economic influences
• Some attempts to develop a more strategic
  approach
• Particularly Australia and UK
• But medical workforce still separated and still
  dominates workforce debate
• Is competition policy relevant?
• Attention to global marked for health labour
  force

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Common themes (I)

• Substantial workforce for health care
• All except Germany have central planning through
  student intake
• Despite this, all have experienced a cycle of
  shortages and surpluses
• Most acutely felt in nursing?
• shortage and surplus relative concepts, often
  unsubstantiated claims
• A number of countries rely on immigration

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Common themes (II)

• All countries have a partial approach to planning
• Ignoring interrelationships, substitution etc
• Little or no attention to geographical
  distribution
• Little or no performance management of
  professionals, particularly doctors
• General lack of attention to economics
• Increasing potential importance of competition
  and regulatory policy to control restrictive
  practices
• Emerging in US and UK

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A way forward?

• Improved data collection of stocks and flows of
  labour for forecasting
• Refocus from physician dominance of workforce
  planning
• Recognition that financial incentives affect
  supply and skill mix
• Fee for service limits substitution if it
  challenges physicians income
• Illustrated by comparing UK primary care
  substitution activity with Australian resistance

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A way forward? (II)

• Need for use of activity data at the level of
  individual physicians (beginning in UK)
• Need for development of better measures of
  quality and outcome (some UK progress)
• Need for costed policy options and better
  regulation of the labour market
• Need for a more empirical, comprehensive and
  economic approach, with more integrated and
  systematic workforce planning
• Complex and challenging but could have
  substantial influence on the health system