Human resources for health in Europe

1. Human resources for health in Europe Martin McKee European Observatory on Health Systems and Policies Vilnius September 2005

2. The issue • Health care is a labour intensive sector • Demanding an appropriate mix of highly motivated people in the right place at the right time with the right set of competencies • Effective, efficient and high quality health services will be delivered • People and communities will enjoy a better health status • The health care workforce is key to improving the delivery of effective health care

3. Challenges facing health care • Changing patterns of disease • Socio-demographic transition • Emerging technologies • Emerging models of care • Changing expectations of consumers • Changes in the political and economic environment: globalisation, economic constraints, European integration and enlargement,…

4. Current imbalances in the health care workforce in Europe • Skills shortages • Inadequate deployment • Disconnection between the education system and health policy objectives • Poor working conditions • Perverse incentives • Shortcomings of regulatory arrangements

5. “OK, we’ll vote. How many say the heart has four chambers?” … Trained staff don’t appear overnight

6. Two approaches (among many) • Changing skill-mix • Enhancing performance

8. Enhancement • For medicine – a continuous process • Thoracic surgeons →cardiac surgeons → transplant surgeons • For nursing and other health professionals • often involves encroaching on role of physicians • Consistent evidence that nurses achieve better results than physicians in management of chronic diseases • However in some other areas (e.g. paramedics) results mixed

9. Substitution • When nurses replace doctors seeing patients with undifferentiated primary care problems, satisfaction is greater but consultations longer and more investigations ordered • In general, nurses have greater interpersonal skills than doctors but physicians better at solving technical problems • Results highly context specific

10. Nurse-led clinics • Growing uptake in primary and secondary care • Especially in countries where team working already established (which most often are tax-funded systems) • Widespread evidence that outcomes better than with traditional physician-led care

11. Examples of better outcomes with nurse-led care • Reduced mortality and admissions with heart failure (Sweden) • Better glycaemic control in diabetes (Netherlands) • Improved detection of diabetic nephropathy (UK) • Better management of anticoagulation (UK) • Better management of COPD (UK)

12. Transmural care in The Netherlands • As in other social insurance funded countries, hospital and home care delivered by separate organisations • Transmural nurse-led clinics established to bridge the gap • Evidence of benefit inconclusive

13. Potential substitutes for nursing roles

14. Delegation • Greater use of higher grade nurses associated with higher quality of care • General practitioners achieve better results than junior doctors in emergency departments • Conclusion: experience counts

15. Innovation • Emergence of new jobs – phlebotomists, specialist nurses, IT specialists • Impact of changing technology – near patient testing displacing laboratory staff

16. New settings for care • New skills needed for: • Stand alone emergency centres • Telephone triage systems • Enhancements in community pharmacy

17. The issues • Does what is being done work, whoever is doing it? • Is there sufficient training and support for new roles? • Are there legal or regulatory barriers to change? • Do the incentives support or obstruct change?

18. However • The status quo is not an option • Health systems are complex adaptive human systems • A change in one area often has unintended consequences in another • You cannot change someone’s role and keep their status the same

19. Enhancing performance • High quality health services require the right mix of resources: • Human resources • The right mix of people with the right skills • Physical resources • With the tools of the trade • Intellectual resources • In a knowledge-based system • Social resources • Built on trust and co-operation

20. Theoretical approaches to changing practice

21. What works? • Consistently effective • Managerial approaches (supervision, audit and feedback); group processes; • Mixed results • Combined managerial and educational; economic incentives; computer-based training; distance learning; telemedicine; community participation • May be useful with other interventions • Dissemination of guidelines; job aids; self-assessment; • Other • Training ineffective with large groups and didactic teaching, better with small groups and focused discussion Rowe et al., Lancet 2005

22. Putting it into practice • Health worker factors • Patient factors • Work factors • Health facility environment • Administrative environment • Political and economic environment

27. In conclusion … • There is no magic bullet • Improvements are more likely to come from doing a lot of things well • … responding to emerging problems and monitoring the effects of change • … and making sure that someone is in charge of seeing that things happen