Health Workforce Policies in OECD Countries Right Jobs, Right Skills, Right Places Gaetan Lafortune, OECD Health Division EU Joint Action Health Workforce Planning and Forecasting Closure Event, Belgium, Mons, 3-4 May 2016
Three-point plan to improve health workforce strategies Right jobs: Train a sufficient number and proper mix of health workers to meet future needs, without unduly relying on the training efforts of other countries, particularly those suffering from acute shortages Right skills: Ensure that health workers acquire the right skills and competences and given opportunities to adapt their skills during their working life to deliver high-quality health services in more team-based and patient-centred approaches Right places: Provide all the population with adequate access to health care regardless of where they live, by promoting a more even geographic distribution of health workers, and making greater use of innovative health service delivery models, notably telemedicine
Variations in stock of health workers depend on inflows and outflows
1.8 1.9 2.2 2.2 2.2 2.3 2.6 2.6 2.6 2.7 2.8 2.8 2.8 3.0 3.0 3.2 3.3 3.3 3.3 3.3 3.4 3.4 3.4 3.6 3.6 3.7 3.8 3.9 4.0 4.0 4.1 4.3 4.3 5.0 6.3 The number of doctors has increased in nearly all EU and OECD countries since 2000 Practising Per 1 doctors 000 population per 1 000 population 7 6 5 2013 (or nearest year) 2000 4 3 2 1 0 1. Data include not only doctors providing direct care to patients, but also those working in the health sector as managers, educators, researchers, etc. (adding another 5-10% of doctors). 2. Data refer to all doctors licensed to practice (resulting in a large over-estimation of the number of practising doctors in Portugal, of around 30%). Source: Health Workforce Policies in OECD Countries: Right Jobs, Right Skills, Right Places; OECD (2016)
But the share of generalists has decreased Only one in three doctors now in OECD countries are generalists % 60 Australia Belgium France Germany Netherlands United Kingdom OECD 55 50 45 40 35 30 25 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Note: Generalists include general practitioners ( family doctors ) and other generalists (non-specialists). Source: Health Workforce Policies in OECD Countries: Right Jobs, Right Skills, Right Places; OECD (2016)
The number of doctors also varies widely across regions in each country Australia Austria Belgium Canada Chile Czech Rep. Denmark Estonia Finland France Germany Greece Hungary Israel Italy Japan Korea Luxembourg Mexico Netherlands New Zealand Norway Poland Portugal Slovak Rep. Slovenia Spain Sweden Switzerland Turkey United Kingdom United States Physician density, by Territorial Level 2 regions, 2013 0 1 2 3 4 5 6 7 8 9 10 Density per 1 000 population Note: Each observation (point) represents a territorial level 2 region (for example, region in France, Länder in Germany or State in the United States) in each country. The data for Chile relate to 2009 and do not reflect the increase in the number of physicians since then. Helsinki Mexico city Copenhagen Region Vienna Brussels Source: Health Workforce Policies in OECD Countries: Right Jobs, Right Skills, Right Places; OECD (2016) Lisbon Prague Bratislava Athens Region Washington, D.C.
Key policy priorities in most OECD countries is to achieving better geographic distribution and mix of doctors 30 Number of countries (Based on 31 OECD country responses in 2012) 25 20 15 10 5 0 No issue identified* Maintaining the current level of physician supply Meeting increased demand for services Maintaining share of GPs Shortages of certain specialty areas Mal-distribution of physician supply * The Netherlands is the only country that did not indicate any particular issue about physician supply. Source: Health Workforce Policies in OECD Countries: Right Jobs, Right Skills, Right Places; OECD (2016)
1.8 2.6 3.6 4.9 5.1 5.2 5.3 5.6 5.8 6.1 6.1 6.2 6.4 7.9 8.0 8.2 8.3 9.1 9.4 9.5 9.5 10.0 10.5 11.1 11.2 11.5 11.9 12.1 12.4 13.0 14.1 15.5 16.3 16.7 17.4 The number of nurses has also increased in nearly all OECD countries since 2000 Practising Per 1 000 nurses population per 1 000 population 18 15 2013 (or nearest year) 2000 12 9 6 3 0 1. Data include not only nurses providing direct care to patients, but also those working as managers, educators, researchers, etc. 2. Chile reports all nurses who are licensed to practice (less than one-third are professional nurses with a university degree). 3. Austria reports only nurses employed in hospital. Source: Health Workforce Policies in OECD Countries: Right Jobs, Right Skills, Right Places; OECD (2016)
Changes in domestic education and training capacity ( numerus clausus ) is the main policy lever to increase supply
Most OECD countries have increased intakes in medical education since 2000 Example of evolution of numerus clausus for medical education in France, 1972-2014 10000 9000 8000 7000 6000 5000 4000 3000 2000 1000 0 Source: ONDPS 2015
Increase in medical student intakes has led to growing numbers of graduates Number of medical graduates has doubled in the UK since 2000 and increased by 75% in Netherlands 250 Australia Japan Index (2000=100) Non-European countries Canada United States 250 France Netherlands Index (2000=100) European countries Germany United Kingdom 200 200 150 150 100 100 50 50 Nordic countries Finland Norway Sweden Central and Eastern European Countries Czech Republic Hungary Poland Slovak Republic 250 Index (2000=100) 250 Index (2000=100) 200 200 150 150 100 100 50 Source: OECD Health Statistics 2015, DOI 50 Source: OECD Health at a Glance 2015 (based on data from the OECD/Eurostat/WHO-Europe Joint Questionnaire)
A large increase also of student intakes in nursing in many countries, notably the USA Evolution in the number of nursing graduates Denmark Finland France Germany Norway Switzerland Japan United States Index (2003=100) Index (2003=100) 200 200 150 150 100 100 50 50 Source: OECD Health at a Glance 2015
Impact of large rise in nurse training in USA: From projected shortages to projected surpluses In 2004: US Department of Health and Human Services projected a shortage of almost one million registered nurses by 2020 (if student admission had remained at their 2001 level) In 2014: US Department of Health and Human Services projected a surplus of 340 000 registered nurses by 2025 (if student admission remains at their 2013 level)
Immigration of health workers also contributed to the increase in number of doctors and nurses in several countries
Number of domestic graduates exceeds inflows of foreign-trained doctors and nurses in US and UK Doctors Number Domestic graduates Foreign-trained 24 000 20 000 16 000 12 000 8 000 4 000 United States Nurses Number Domestic graduates Foreign-trained 160 000 140 000 120 000 100 000 80 000 60 000 40 000 20 000 0 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Doctors Number Domestic graduates Foreign-trained 16 000 United Kingdom 0 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Nurses Number Domestic graduates Foreign-trained 30 000 14 000 12 000 10 000 8 000 6 000 4 000 2 000 25 000 20 000 15 000 10 000 5 000 0 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Sources: UK Graduate Output 1991/92 to 2012/13, Health and Source: OECD/Eurostat/WHO-Europe Joint Questionnaire on non-monetary health care statistics (2015)
Changing countries of origin of foreigntrained doctors working in United Kingdom 2008 2009 2010 2011 2012 2013 2014 Total number of doctors 146 834 153 497 155 448 158 577 160 748 169 601 172 561 Domestically-trained doctors 99 817 104 913 104 657 108 152 110 341 116 359 119 171 Foreign-trained doctors 43 885 45 775 45 771 45 983 46 192 48 734 48 766 - of which native-born but foreign-trained 2 175 1 977 1 905 1 816 1 758 1 700 1 632 Unknown place of training 3 135 2 811 5 019 4 439 4 222 4 512 4 625 Share of foreign-trained doctors 29.9% 29.8% 29.4% 29.0% 28.7% 28.7% 28.3% Foreign-trained doctors by country of first qualification 2008 2009 2010 2011 2012 2013 2014 India 17 503 17 738 17 517 17 285 16 941 17 378 16 833 Pakistan 3 956 4 311 4 544 4 731 4 868 5 200 5 275 Nigeria 1 790 1 950 1 989 2 041 2 137 2 205 2 189 Ireland 2 046 2 007 1 926 1 883 1 860 1 916 1 859 Egypt 1 396 1 470 1 538 1 561 1 569 1 674 1 718 South Africa 1 595 1 620 1 551 1 500 1 455 1 470 1 424 Sri Lanka 1 356 1 222 1 481 1 421 1 333 1 353 1 354 Germany 1 381 1 421 1 400 1 360 1 335 1 374 1 347 Iraq 1 329 1 403 1 395 1 380 1 340 1 408 1 343 Greece 537 609 632 667 839 1 070 1 162 Italy 495 600 587 622 691 836 930 Romania 273 344 423 563 618 763 848 Poland 666 723 733 735 730 775 831 Spain 543 551 549 557 605 714 767 Sudan 429 470 517 536 572 679 729 Czech Republic 319 416 424 456 504 574 616 Bangladesh 396 430 454 474 498 530 536 Australia 593 601 590 546 527 501 497 Hungary 227 277 286 345 399 463 496 16 Source: OECD/Eurostat/WHO-Europe Joint Questionnaire on non-monetary health care statistics
There is considerable skills mismatch in the health sector
More than 75% of doctors and nurses report being over-skilled for some of the tasks they do 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% Reported over-skilling by physicians, nurses and other occupations, 0% Physicians Nurses Others Note: Others = workers in other technical and professional occupations. The figure shows 95% confidence interval. Source: PIAAC Survey, 2011-12
At same time, 50% of doctors and 40% of nurses report being under-skilled for some tasks Reported under-skilling by physicians, nurses and other occupations 60% 50% 40% 30% 20% 10% 0% Physicians Nurses Others Note: Others = workers in other technical and professional occupations. The figure shows 95% confidence interval. Source: PIAAC Survey, 2011-12
Highly-qualified nurses are much more likely to report being over-skilled, suggesting a waste in human capital Skills mismatch among nurses by level of education (odds ratios) 2 1.5 1.98 Lower than bachelor's degree Bachelor or equivalent Master or equivalent 1 1.08 1 1 0.5 0.58 0.48 Source: PIAAC Survey, 2011-12 0 Overskilled Underskilled
Policy levers to address different types of skills mismatch Source: Health Workforce Policies in OECD Countries: Right Jobs, Right Skills, Right Places; OECD (2016)
For more information http://www.oecd.org/health/health-workforce-policiesin-oecd-countries-9789264239517-en.htm @OECD_Social
Health workers includes more than doctors and nurses NHS Clinical Staff in England (2014) GP practice nurses, 15100, 2% Ambulance staff, 17700, 2% GPs, 32700, 4% Consultants, 40400, 5% Allied health professionnals, 66100, 8% Nursing, midwifery and health visiting staff, 313500, 38% Doctors in training and equivalent, 68200, 8% Support to clinical staff, 201200, 25% Healthcare scientists, 69300, 8% Source: Health and Social Care Information Centre, NHS Hospital and Community Services Workforce Census England: 30 September 2014