January 27, 2015 katharina.janus

Kicking off the 4th Forum with a brainteaser on the right skill mix in healthcare

This post is part of a series of several posts related to the 4th European Forum on Health Policy and Management: Innovation & Implementation, to be held in Berlin, Germany on January 29 and 30, 2015. For more information or to request your personal invitation contact info@centerforhealthcaremanagement.org or follow @HCMatColumbia.

Finding and supporting a workforce with the right skill mix
By Federico Lega


Many health systems are experiencing shortages of health care workers. Policymakers and practitioners have tried for a long time to figure out how to assess workforce productivity, skills and roles, in order to achieve the best mix of professionals needed to deliver high quality care while preserving sustainability.
Unfortunately, many obstacles have slowed progress toward this goal. Open questions still concern not only how many doctors or nurses are needed in any given system or organization level, but also over what roles and responsibilities fall to different health professionals and specialists.

Shifting Disciplinary Boundaries

The health care professions have continuously rearranged their own disciplinary boundaries, and, in the process, their role or status in society. Doctors, nurses, and care assistants have seen major changes in their relationships to patients and to one another due to developments in societal expectations and beliefs.
Some nurses, for example, are increasingly allowed to prescribe drugs in many fields. And for minor injuries, many patients turn to a physiotherapist instead of an orthopedist. Health professionals’ changing relationships are also shaped by new technological possibilities, organizational constraints and opportunities, and recently, the formalization of many new professions through specific educational programs and certification processes.

An Aging Workforce

In many countries the development of health systems in the ‘70s and ‘80s led to the massive growth of their workforce in those years. Many of these workers are now turning fifty or sixty-years-old, with all the complications that this has, especially in an environment characterized by frequent shifts, long hours, and a workload that is heavy — both in the volume of work to be done and in the psychological burden of managing that volume.
It is not just an issue of supporting an aged workforce and developing human resource programs that address issues such as increased injuries, inabilities, and demotivation. It also requires a health system’s leaders to develop specific strategies aimed at changing and improving the skill mix of its workforce.

The Consequences of Austerity

Many health systems and organizations have responded to the pressure to reduce or contain the rise of costs by changing the skill mix of the health professionals they employ. Some are shifting tasks from doctors to nurses, and from nurses to health care assistants, for example, and are hiring fewer doctors as a result. Leaders must be careful, however, that the changes they make are not about simply cutting costs or responding to individual crises and problems. They should be driven instead by deliberate organizational development processes — with specific attention to unexpected and undesired consequences.
Further, the economic crisis, starting in 2009, has led many countries to reduce welfare policies and benefits to workers. This is especially true in nations with public health systems, where many workers have responded by using more of the remaining benefits granted by their status as civil servants, such as taking more leave. This trend has made it harder still to manage health professionals’ workloads. In response, systems and organizations see a need for greater flexibility in their workforce.
We still do not have enough evidence about the impact of changing a workforce’s skill mix. Some research has shown that using care assistants improves health systems’ organizational effectiveness. Other research has shown that many systems could take advantage of their nursing staff’s full skill set. However, most of the research has been undertaken in the US potentially limiting its relevance to other health systems. There is great need for much more international research, case studies, conceptualization, and comparisons across different countries. Progress toward a better skill mix also requires a constructive debate, free of prejudices, constraints, and choices determined by professional corporatism.
There are at least four directions in which existing skill mix can change: diversification, specialization, vertical, and horizontal substitution. As defined by Nancarrow and Borthwick, diversification and specialization involve the expansion of professional boundaries within a single discipline, or intra-disciplinary change. Vertical and horizontal substitution (often referred also as “encroachment”) involve the movement of a discipline outside its traditional boundaries to take on tasks that are normally performed by other health-service providers, or inter-disciplinary change. All four potential directions for change to the workforce’s skill mix deserve attention from policymakers, practitioners, and researchers.