Human resources for health in Europe

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Human resources for health in Europe

• Martin McKee
• European Observatory on Health Systems and
  Policies
• Vilnius
• September 2005

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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

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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,

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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

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• OK, well vote. How many say the heart has four
  chambers?
• Trained staff dont appear overnight

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Two approaches (among many)

• Changing skill-mix
• Enhancing performance

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Changing roles Changing roles
Enhancement Increasing the depth of a job by extending the role or skills of a particular group of workers
Substitution Expanding the breadth of a job, in particular by working across professional divides or exchanging one type of worker for another
Delegation Moving a task up or down a traditional uni-disciplinary ladder
Innovation Creating new jobs by introducing a new type of worker
Changing the interface between services Changing the interface between services
Transfer Moving the provision of a service from one health care setting to another (e.g. substituting community for hospital care)
Relocation Shifting the venue from which a service is provided from one health care sector to another without changing the people who provide it (e.g. running a hospital clinic in a primary care facility)
Liaison Using specialists in one health care sector to educate and support staff working in another (e.g. hospital outreach facilitators in primary care)
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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

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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

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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

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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)

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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

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Potential substitutes for nursing roles
Titles Roles
Traditional aides/ assistants/ auxiliaries Trained on the job, performing simple tasks in support of registered nurses
Non-clinical assistants/ extender clerks/ aides Undertaking non-clinical clerical and housekeeping work
Technical assistants/ operating department assistants Assisting nurses in areas where specific technical skills are required
Primary practice partner nursing assistants Paired with primary nurses to maintain delivery of care
Vocationally trained/ qualified carers Carers undergoing vocational training of several weeks or months, perhaps leading to a qualification, and taking on nursing responsibilities under the supervision of a qualified nurse or other health professional
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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

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Innovation

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

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New settings for care

• New skills needed for
• Stand alone emergency centres
• Telephone triage systems
• Enhancements in community pharmacy

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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?

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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 someones role and keep their
  status the same

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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

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Theoretical approaches to changing practice
Theory Assumptions Intervention
Adult learning Change occurs when people have personal experience of problem and help develop solution Develop guidelines based on local consensus, interactive learning
Cognitive Undesirable behaviour caused by lack of information Improve knowledge by disseminating information
Social marketing Behaviours changed by clear messages and products Assess local needs, disseminating messages via multiple channels
Behavioural Behaviours result from external stimuli Audit, feedback, reminders, incentives, sanctions
Social learning Change through interaction and influence of important people and new social norms Use of opinion leaders
Management Errors reduced by redesigning system Total Quality Management
Coercion Change occurs due to pressure and control Laws and regulations, punishment
Stages of change Those changing pass through stages (Pre-contemplation, contemplation, preparation, action, maintenance) with different interventions at different stages Predisposing strategies, enabling strategies, reinforcing strategies
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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
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Putting it into practice

• Health worker factors
• Patient factors
• Work factors
• Health facility environment
• Administrative environment
• Political and economic environment

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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