Steady State - Finding a Sustainable Balance Point:
International Review of Health Workforce Planning
Prepared by Ann L. Mable and John Marriott For
the Health Human Resources Strategies Division, Health Canada
2002
Cat. No.: H39-622/2002
ISBN 0-662-66561-9
Help on accessing alternative formats, such as PDF, MP3 and WAV files, can be obtained in the alternate format help section.
(786KB)
Table of Contents
Executive Summary
Introduction
Background
Understanding the Health Workforce and Workforce
Planning
Review of Current Workforce Planning Approaches
Implications and Possible Approaches for Canada
References
Executive Summary
Health workforce planning is the latest plank in health system
reform being pursued by countries around the world. A main
objective of health workforce planning is to have the right number
and mix of health practitioners with appropriate skills in the
right places at the right time, to provide quality services to
those who need them. Historically, however, workforce planning has
more often referred to less-than-perfect approaches to planning for
physician 'manpower,' based on maintaining existing
physician-population ratios. Less focus was placed on planning for
nurses and other health providers.
In spite of recent health reform initiatives that emphasize
"team," the planning that has taken place has tended to continue a
pattern of working 'in the silos' of profession-specific
approaches. Less work has been done in the area of determining
future requirements for physicians, nurses and other health
providers overall. And as a result, past efforts have not proven to
be as accurate, effective or as comprehensive as needed, or enough
to inform decision makers and planners sufficiently to adjust to
changing demographics and other patterns in both the population at
large, as well as provider groups and changing models of health
care delivery.
A lack of a more sophisticated, or systematic or modern approach
has exacerbated the current context of "shortages" in many health
professions in Canada and other countries. A number of other
countries are pursuing the development of more modern approaches to
health workforce planning. Information from these countries can
inform the development of a national, systematic approach to
identifying and planning for future health workforce to meet the
needs of Canadians. As health systems become more complex and
involve a widening array of kinds of health providers and
practitioners, the need for improvement of approaches to planning
becomes more compelling.
It appears that most countries are only now beginning the process of
re-examining their approach to workforce planning. Many appear not
to have made fundamental changes yet. A small number are moving to
introduce or encourage the introduction of organizational
structures to add some permanency to the workforce planning process
and to avoid the reactive or self-serving products of the past.
Some are also moving to embrace multiple modalities of workforce
planning methodology and process. A smaller number are moving to
incorporate planning for all of the workforce, including integrated
planning, as well as review of the individual health providers and
workers.
Workforce planning processes and methodologies are still
dominated by an extensive focus on and experience with physician
workforce planning. There is still a paucity of specific approaches
or experience with nurse workforce planning and even less that is
focussed on other health professionals or staff who work in the
health system. At the same time, many of the processes and
methodological approaches for physicians can be and have been
applied to some extent to nurses and others. This is all the more
important, given the focus upon primary health care reform and the
evolution of vertically integrated health organizations, with their
associated requirement to think more in terms of multi- or
inter-disciplinary teams, as in many of the other countries
reviewed.
Six country overviews provide illustrations of approaches to
workforce planning organizational structures, methodologies and
processes. The countries presented include Germany, the Netherlands
and Australia where the national organizational structures are
still focussed on physician workforce planning. And New Zealand,
the United States and the United Kingdom represent countries making
a commitment to looking at the total workforce and integrated
workforce planning. Australia presents one of the more advanced
examples of 'multi-modalities' of workforce planning methodology
and process - although focussed exclusively on physicians at this
point.
In Germany, the Federal Committee of Physicians and Health
Insurance Funds has responsibility for making recommendations to
the government. Based on agreement, guidelines are provided to the
Regional/Local Associations of Panel Physicians and Regional Social
Insurance Funds to determine the supply and need for physicians by
general practice and by specialty per planning area. The initial
level of review will determine if there is an oversupply (i.e. 10%
more physicians by category than needed) or an under-supply (i.e.
where there are 75% or less of the number of GPs required, and for
specialists 50% or less than the required number). In both cases,
additional assessments are carried out to confirm the initial
finding. If an oversupply is confirmed in a given area, no new physicians will be allowed to join the Panel of Physicians for a
given specialty. If an under-supply, a number of new physicians by
category will be allowed to join the panel.
In the Netherlands, the government established a national
organization in 1999 for physicians workforce planning called the
'Capacity Organization' to provide advice to the Minister of
Health. The organization, funded by government, has a tri-partite
composition with representation from the professional groups, the
health insurance companies (Sickness Funds), and the training
institutions such as universities. Bringing the three parties
together to form the organization was considered to be a worthwhile
exercise on its own. Using experienced research institutes such as
NIVEL, the organization examines both supply and demand. It
provided its first report to the Minister of Health in March
2001.
Australia established the Australian Medical Workforce Advisory
Committee (AMWAC) in 1995 to provide reports to the Australian
Health Ministers Advisory Council, and through that body, to the
Health Minister's Conference. The committee works with a number of
government agencies and department, national and state institutes,
medical schools, medical colleges, various workforce agencies and
physician organizations, including the Divisions of General
Practice. Based on a strategic framework, AMWAC carried out a
number of studies of all physicians and then by discipline. Various
issues associated with workforce planning were examined, including
immigrant physicians, trends in medical education, impacts of
change on medical students, female participation, and various
guidelines. Multi-modal methodologies have been applied to assess
both supply and requirements as a foundation for establishing and
implementing a plan of action to deal with surpluses or shortages
by discipline or group of disciplines. Once in place, the
Australian plan calls for a process for monitoring to ensure that
recommendations are being put in place and for revisiting each
group workforce plan at least every five years to account for
unforeseen changes or problems with previous plans. Australia has
also acknowledged that changes in organizational structure or
policy changes that incorporate multi-disciplinary teams of
providers, will also fundamentally change projections of supply and
need. Also emphasized was the need to connect workforce planning to
service planning, particularly given the direct connection between
supporting infrastructure to some degree or other, for all
specialist physicians.
New Zealand is emerging from a long period of rejecting central
workforce planning. The government established the Health Workforce
Advisory Committee (HWAC) in 2000 to coordinate workforce planning
and is in the process of introducing new legislation to regulate
health professionals. At this stage, the Committee will be taking a
strategic view of the workforce required to deliver health services
in the future rather than working out how many of each will be
required in the future and trying to plan accordingly.
In the United States, the state governments are the major players
in workforce planning. States hold responsibility for education,
licensing, and regulation of practice for all health professionals,
and regulation of private health insurance as well as
administration of Medicaid. The federal government involvement has
been in supply policies associated with Medicare, student
assistance, construction grants and other institutional supports.
The National Center for Health Workforce Information and Analysis
provides support for various studies and guidelines as well as
funding university based workforce centres. Three examples are
presented of workforce studies for three areas: primary care
physicians, nurses, and integrated workforce planning in
Wisconsin.
The United Kingdom is in the process of moving to integrated
planning for the whole workforce. Within this approach, there is a
commitment to multi-disciplinary team work and supporting ways to
maximize the contributions of all staff. Rather than a single
workforce advisory body, the emerging structure includes a
commitment at the local level for Primary Care Trusts and others to
produce workforce plans for five year time frames. At the regional
level, New Workforce Development Confederations will support and
work with Health Authorities and National Health Service regional
offices. Ultimately a National Workforce Development Board,
supported by Care Group Workforce Development Boards will have
responsibility for the proper integration of workforce issues with
service development. The UK is also looking closely at information
requirements to support workforce planning at the local, regional
and national levels. The UK has already established a number of
targets to increase physicians, nurses and allied health
professionals. In addition, the National Service Frameworks have
been in the process of developing a ten year vision of where
particular services should go (e.g. for coronary heart disease,
cancer etc.).
Canada has not yet achieved a comprehensive approach to health
human resources, but is situated on the cusp of more focussed and
concerted action. High level commitment has been shown in a variety
of ways to improve health workforce planning capacity, including
the F/P/T Ministers of Health in 1998 and the First Ministers in
the September 2000 Action Plan for Health System Renewal, including an explicit agreement to
collaborate on specific priorities, including the supply of
doctors, nurses and other health personnel.
A first step to focus the action and future direction for Canada
could include establishing a task force to examine development of a
permanent National Workforce Planning Organization. It would have
an appropriate budget and staff to operate on an on-going basis and
appropriate representation, input and linkages. The new
organization would be a focal point dedicated to building and
refining a 'national' capacity for workforce planning in Canada.
The potential this brings is for fewer dramatic shifts and improved
quality, stability and sustainability for the health system - in
short, a 'steady state' future for the Canadian health
workforce.
" Make up your
mind how many doctors the community needs to keep it well. Do not
register more or less than this number; and let registration
constitute the doctor a civil servant with a dignified living
wage paid out of public funds."(George Bernard Shaw, The Doctor's
Dilemma (1911), preface)
Introduction
Health workforce planning is the latest plank in health system
reform being pursued by countries around the world. Because health
care is labour intensive, and health human resources represent over
70% of health care cost (Pong et al, 1996), there is increasing
need to address planning for the health workforce in a more
comprehensive way. The health system encompasses an increasingly
complex human resource milieu as compared to other sectors of the
economy, and is significant in terms of the sheer number and
variety of professions, trades and functions that comprise and
interact with this environment.
Anything that influences or changes the system at any level has
direct and sometimes profound implications for those who work
within it. Impacts on health human resources can directly influence
the capacity of the health system to respond to needs and to
deliver services. This becomes all the more important in view of
the present context of reform and global efforts to refine and
improve the performance of health systems. New or renewed areas of
focus, such as the development of vertically integrated health
organizations - such as Health Maintenance Organizations in the US,
Primary Care Groups or Primary Care Trusts in the UK, Sickness
Funds in the Netherlands/Europe, or integrated trials in Australia,
etc. - and growing emphasis upon primary health care, require
multi- or inter-disciplinary teams and approaches to service
delivery. The way health workers are prepared, organized, deployed
and remunerated affects their ability to provide quality care
within the context of changing service delivery models and roles.
In short, no plan of reform is achievable without taking human
resources into account (Marriott Mable 1996).
To ensure the best use of precious system resources, it is
important to any country to ensure that the health workforce is
present in the 'right' number and mix, with the 'right' skills.
They must be organized in the 'right' way to provide appropriate,
timely quality services that meet the defined needs of the
populations they serve. The problem in general has been to sort out
just what is 'right' amidst a diverse set of possibilities, and
then to determine how to achieve this. Any notion of what is right or appropriate is
multi-dimensional because it bears a relationship to many different
things, including what is needed or desired, or what is typical, or available - and these relate to other aspects such as timing, cost, expedience, quality or other
kinds and levels of targets as set locally, provincially or
nationally.
To get it 'right,' governments, health organizations and more
recently, planners have tried over time to anticipate or project
health system needs with respect to health human resources, too
often unsuccessfully. As a result, in general, planning has historically been reactive at best, very ad hoc and unscientific, responding to needs
or issues in the system, rather than being able to effectively
anticipate or project them. As health systems become more complex
and involve a widening array of types of health providers and
practitioners, the need for improvement of approaches to planning
becomes more compelling.
Purpose and Methodology
The purpose of this paper is to present the results of a review
of international literature on health workforce planning and to
identify implications and lessons for Canada. It is hoped that this
information will support a more fundamental goal-to develop an
objective and reliable system for determining the required number
and distribution of physicians, nurses and other health providers
to meet the evolving health needs of Canadians over time.
The project entailed a three-phased approach. Phase 1 included a
broad overview of international literature, government, and other
web sites and contacts to determine where the most promising
workforce planning policies and approaches might be. Phase 2 was
directly based on the results of Phase 1, to conduct a more
detailed and in-depth exploration of the literature, web sites and
contacts of a smaller selection of 'most promising' countries and
approaches. Phase 3 entailed the synthesis and analysis of
information gathered, to identify and summarize most promising
approaches and implications for Canada.
Key words were utilized to satisfy the information collection
needs of the project such as "workforce planning," "manpower
planning," "health human resources planning," and others. The
process included keyword searches on computerized databases such as
MEDLINE, Publine and other databases; identification of titles
cited in the reference sections of studies; and examination of
published bibliographies on these subject areas. Also accessed were
'grey literature' and other unpublished material through a variety
of government, academic, and professional association contacts for
the various jurisdictions under study. Selected key informants were
identified with input from Health Canada, and some were contacted
for subject areas and the countries selected for review.
Despite growing interest in the subject at present, there is still
a relative scarcity of useful articles on workforce planning or
well-detailed information on approaches by different countries. It
appears that most countries are still predominantly focussed on
planning for the physician workforce and are still engaged in
periodic examinations conducted by governments, professional
associations, universities and other training institutes and
others. Also, much of the even more limited workforce literature on
providers other than physicians tends to focus on one discipline or
another at a time, rather than broader approaches which include
most or all of the health workforce in an integrated approach. A
'comprehensive' picture must be pieced together somewhat like a
puzzle, to form a more complete view of options that might be
involved in an integrated approach to health workforce
planning.
Overview of the Paper
Section two Background presents some foundations for understanding workforce planning from
an historical perspective, to provide lessons from the past. This
is followed by an overview of Definitions and Meanings with respect to the
health workforce and workforce planning. This includes a depiction
of historical imbalances resulting in surpluses and shortages, and
an introduction to mechanisms or policies used to address these
imbalances. This is followed by a presentation of various Issues and Implications that are still
present, which are the subject of recent and continuing efforts to
restructure and reform both organizations and methodologies.
The paper then moves to an overview of current workforce planning
approaches in selected countries. The discussion within each
country is organized in two parts. It begins by identifying some of
the recently emerging workforce planning Organizations in Germany, The Netherlands and Australia, where the focus is predominantly on physicians. These are followed by New Zealand, The United States,
and the United Kingdom (primarily England), where the focus is
increasingly on all of the workforce with an emerging commitment to integrated planning. These
illustrations serve to present the distinctions in national context
and variations on organizational approaches.
The second part presents an overview of evolving and emerging
variations in methodology and process approaches in the selected
countries. This excludes The Netherlands, where other than
reporting that they are planning based on various supply and demand
approaches, detailed information on methodology is not available at
this time. In the presentation of what is happening in Germany,
Australia, and The United Kingdom, the overview is of their
'national' approaches. By comparison, the approaches of The United
States and one additional example from Scotland provide examples of
specific workforce planning studies or exercises.
Implications and recommendations for a possible strategy for Canada are then
presented to conclude the paper.
Background
Post World War II to the Present
As of the mid-1900's, any 'workforce' planning activity that
occurred was sporadic, with a predominant focus on physicians
rather than other health providers. A
shortage-to-surplus-to-shortage cycle that had evolved post-World
War II was the norm. This was to some extent a multi-national
phenomenon including western European countries, the US, Canada and
others, regardless of whether the country had a publicly
funded/social health system or a privately funded market system.
The initial identification of a shortage of physicians was more
often the result of a 'sense' or perception of a problem rather
than exhaustive study. Coordination was lacking and studies
throughout this period and even up to today, have been primarily
'one at a time' and 'one of a kind' reports, usually led and/or
funded by one of the major stakeholders - government or corporate
medicine (the professional physician associations) - or less often,
by the Universities or Medical Schools. The focus during this
period was on augmenting supply by increasing numbers of training
positions and even the number of medical schools (Rosenthal, Butter
and Feld 1990, Doan 1990, Maynard 1990 & 1995, Ginzburg
1990).
This ultimately lead, through studies and experience within
systems over time, to a realization that all western countries
appeared to be moving to a surplus of physicians. Again, while
studies were more frequent, they were still uncoordinated, ad hoc,
infrequent and championed by one or more of the major stakeholders
- all, including government, with 'vested' interests. Various
assessments were carried out, depending to a great extent on
physician/population ratios and some international comparisons.
Political momentum and the interests of physician organizations,
university medical schools and some politicians still favoured
producing more physicians. In general, the time frame from first
identification of a problem to taking some action was often a
decade or more. In some countries, such as Italy and Mexico, the
issue of 'surplus' physicians continues. For most other Western
European countries, US and Canada, the major strategy to correct
the 'surplus' issue was to reduce student intake and even to close
some medical schools. Canada, for example, reduced medical school
enrollment by 4% in 1984 and by a further 10% by 1993. Once again,
but not surprisingly, in keeping with cyclic patterns, many
countries are now facing a 'shortage' again.
A Legacy of Issues
A consistent experience of this period has been that various
approaches to assessing and predicting the required 'number' and
types of physicians for the future too often proved to be wrong as
compared to what actually transpired. In general, processes of
workforce planning or management were absent or were not effective.
This was due to a number of factors. Organized and coordinated
planning was insufficient or non-existent. Planning, when it did
occur, was often ad hoc, and was influenced and/or funded by one or
the other of the major stakeholders. Governments, medical or other
health professional schools tended to think about their own
perspective, or one profession at a time, and as expressed by
Davies (2000) when referring to the UK, "doctors planned for
doctors, nurses for nurses and so on." This was true of all
countries examined. There appeared to be little or no cooperation
or collaboration among the major stakeholders in the process and in
many cases they were adversaries with competing interests. Over
all, studies or assessments were infrequent and inconsistent in
approach - so that no fine tuning or adjustments for changes in the
total environment were accounted for over time.
In addition to this, politics played a large role in perceptions
and created delays in action. Governments and politicians didn't
want to lose the image-promoting perks associated with building up
medical schools and producing more physicians. This was reinforced
by public pressure and some resistance to reductions in access to
training positions, considered highly desirable and preferential
career options. Corporate medicine moved to protect its own
self-interest. Interestingly, the positions, strategies and tactics
taken varied depending on the nature or context of the country in
terms of how physicians were employed (government post, contracted,
employees or self-employed).
Corporate medicine in countries with system controlled posts
moved to either increase the number of 'posts' and reacted to the
numbers of physicians in the system based on whether there were too
many for available posts (therefore cut back), or if too few, to
advocate increases. Where a fee-for-service environment existed,
the tendency was to resist large increases in numbers as it was
felt that it would create too much competition, and reduce income
for those in practice - with the caveat that if populations and/or
economies were growing it would work out. At the same time,
Universities'/Medical Schools' survival instincts reinforced
resistance to dramatic reduction of training positions, and
stronger resistance to closure (Doan1990).
The expansion of graduates post WW II for several decades was due
in part to rosy expectations about growth in the future economy and
populations. Therefore the outlook anticipated a continuing
'demand' for services from a growing population, coupled with a
continuing capacity to pay for the expansion. The policy, or
practice, of focus on 'input' (e.g. training positions)
demonstrated an inadequate appreciation of the lag time of six to
ten years to produce new physicians, during which many things could
and did change within society and the profession. In areas of
mal-distribution (e.g. excess in urban versus shortages in inner
city, rural, isolated, etc.), a policy of relying on creating
surpluses of physicians to create a 'spill over' effect didn't
work.
Mexico still demonstrates the weakness of that approach, with a
continuing 'surplus' resulting in under-employed and unemployed
physicians in urban areas, and yet rural and isolated areas are
still in great need of physicians. Mal-distribution remains a major
problem in most environments today (Rosenthal, Butter and Feld
1990, Frenk 1990). A similar approach to over-production of supply
to 'fill-in' shortages in certain disciplines also failed (AMWAC
2000, Klein 1990). Population to physician ratios were often more
the result of lobbying by professional organizations and therefore
of dubious validity. Maynard (1995) presents the example of the
British Medical Association ratio of 1 physician per 1,700
patients, and the implications of higher GP to population ratios. A
ratio of 1/3,000 would have resulted in a need for 13,000 fewer GPs
and the potential to purchase 27,823 nurses. A ratio 1/4,000 would
have resulted in a need for 17,000 fewer GPs and the potential to
purchase 39,338 nurses. Maynard goes on to recommend sensitivity
analysis to examine various ratios (not just one) and further
advocated the need to move beyond just looking at doctors.
There was a lack of sophistication in the process. For example,
various aspects of change were not adequately taken into account,
such as: in populations (or the emergence of population-based
thinking, or correlation with supply of providers), professional
dynamics, professional productivity, health system reform and
organizational alternatives, potential changes in working patterns
or multi-disciplinary teams in an integrated approach. In
international comparisons, there was a lack of appreciation or
recognition of the distinctions in 'context' of different
jurisdictions. As such, while gross or macro assessments of numbers
can be instructive in broad terms regarding supply of physicians
for given populations, applying such information precisely without
appreciation of local realities can lead to gross errors.
For example, the working hours for physicians may vary in
different settings, leading to different conclusions across
jurisdictions. The legal context in Germany provides another kind
of example. Germany faces a major challenge to implementing
controls over provider numbers. This is due in large part to a
post-Nazi democratic constitution which enshrined rights of
individuals to make choices, including that of choice of access to
education, and choice of career, without interference from the
government. Because of this, attempts to control the number of students in medical school poses a particular challenge.
Even the more limited methodologies that were used, such as ratios
of physicians per unit of population (per 1,000, or 10,000 or
100,000) didn't account for variable, changing or emerging factors
such as mix of full and part-time; numbers of men and women (or
emerging today, men and women physicians who want a more balanced
work and personal life), variances in working weeks, etc. (Klein
1990). And finally, there was a persistent absence of consistent
and reliable data-always acknowledged but until recently-little
done about it. And there was little to no focus on nurses, other
health practitioners or health workers.
Understanding the Health Workforce and Workforce Planning
This section of the paper moves beyond the historical context and
lessons to an overview of basic foundational information. This
includes an overview of what constitutes 'the workforce,' a
discussion and definition of workforce planning and associated
concepts, and finishes with a discussion of some of the system and
policy issues that countries still strive to overcome.
The Changing Health Workforce
The health workforce represent an increasingly diverse
aggregation of individuals and groups who work in a wide variety of
settings. It is particularly important to understand this, given
the implications of the movement toward planning for the 'total'
workforce- both in terms of each profession or trade and in terms
of integrated or blended workforce planning.
Many influences have shaped the health workforce, including
recent trends. Fiscal constraints represents one major example. The
shift away from institutional care toward community-based service
delivery models is another. Increased emphasis on individual and
community responsibility as well as prevention and health
promotion, hold implications which transform health care
organizational behaviour, and require new channels of communication
and information. The resurgence of a primary care focus and the
emergence of new technology raise questions regarding what is
"medically necessary" and expose the present limits of health care
professionals' training and experience. Gaps and barriers are being
uncovered in present methods of funding, administration, training
and service delivery. At the same time, with changes come
opportunities and new roles for health human resources, opening the
door to a future where the services
provided may become more important than which practitioners may provide
them. Functions previously exclusive to one group might, through
system reform, be performed by others, and there might be a wider
group of 'first points of contact' for access by consumers to the
system. All of this has implications for workforce planning.
For a group which represents a significant portion of the health
care expenditure, the health workforce is not necessarily well
known or understood in the aggregate. It is important to begin with
a fundamental (if not exact) appreciation of its magnitude. This is
not easy, because 'health human resources' or 'health workforce'
does not denote one fixed group. The meaning differs according to
the diverse perspectives of stakeholders, and definitions vary as
to which classifications and levels of health care professionals
are included. The terms by which health human resources are
addressed can influence an understanding or appreciation of their
roles, and often set the conditions under which they must operate.
Inconsistency and uncertainty of definition and professional
typology across the health system, perpetuate a lack of clarity
which impedes any examination of health human resources in the
aggregate, to properly assess them from a national perspective.
The World Health Organization has used the term 'human resources
for health' to refer to "all who contribute to the health system's
objectives, whether or not they have formal health-related training
or work in the organizational health sector" (WHO 2000). At this
stage, there is no expanded typology presented in the literature to
encompass this very broad and inclusive approach. Most approaches
tend to focus on direct care givers, with a particular emphasis on
those most readily recognized in the system (e.g. physicians,
nurses, etc.). Others categorize providers with a high degree of
self-direction and direct care (e.g. physicians, dentists, etc.)
separate than those who are considered to be supportive or
'complementary' (e.g. nurses, dental assistants), or those who can
'substitute' for a primary care provider (e.g. nurse practitioner,
midwife, dental therapist, etc.). However presented, the meaning of
such classifications blurs for example, in isolated areas, where
nurses operating in expanded roles provide many 'medical'
services.
Health human resources have also been classified according to
whether or not they are regulated or recognized. In Canada, for
example, 37 regulated professions are recognized for the purpose of
the Agreement on Internal Trade, but only 12 are recognized in all
provinces (Health Canada 2000); and when the Territories are
included, only nine professions are recognized. Modes of funding
create inconsistency across the country in terms of which
professions are funded predominantly through the public
single-payer system, versus private multiple-source funding. The
majority of the widely recognized professions, including physicians
and nurses, are predominantly funded through the public
single-payer system, either directly or indirectly through a
recognized employer (e.g. hospital).
Dentists are another example of a widely recognized and
consistently regulated profession, but they are funded
predominantly from the private sector (with the exception in most
provinces, of some in-hospital care). Many regulated professions
practice totally outside the publicly funded environment, such as
Naturopathic Physicians. Some providers unique to the First Nations
environment are not yet afforded formal recognition by provincial
jurisdictions, and thus can't practice in the rest of the system.
Under such varying conditions, as the labour force has evolved over
time, different approaches have developed in training, licensing,
notions of competency, and regulation of practice. These variations
in patterns of regulation, recognition and remuneration, present
particular challenges to reform of the health system and to proper
management of health human resources.
Because no one system adequately or consistently captures the
full array of human effort in health systems, the following points
simply summarize the types of groups associated with health human
resources in Canada. It is only intended to serve as a generic
foundation from which to appreciate the diversity of the workforce
landscape. It reflects the broader approach to typology suggested
by the World Health Organization, with representative examples of
human resource groups in each category.
- Consumers/Users:
Patients who exercise self-care and their families who
provide an enormous amount of voluntary care
- Non-professional health
resources: Volunteers and other community supporters
(religious leaders/clergy)
- Regulated direct health care
providers and other professionals: examples include
Physicians, Nurses, Physiotherapists, Dentists, Chiropractors,
Audiologists, Optometrists, Pharmacists, Nursing Assistants,
Dieticians, and Psychologists
- Providers unique to
environments such as First Nations: National Native
Alcohol and Drug Abuse Program (NNADP) Workers, Community
Health Representatives, Dental Therapists
- Supporting health care
providers/professionals: examples include
Pathologists, Radiologists, Laboratory Technologists, Dental
Hygienists
- Non-Regulated/Alternatives: examples include Health
Care Aides, Herbalists, Elders, Iridology, Homeop
athy, Shiatsu,
Reflexology
In addition, there are others in the health workforce who may not
participate directly in treatments, but are nonetheless part of the
infrastructure of support and influence decision-making in the
health care system, such as:
- Information Technology:
personnel to support the development, management,
training and on-going maintenance of information systems,
related hardware and software, etc.
-
Administrative/Management: health care executives,
health care financial officers and staff, health care human
resource officers, etc.
- Support or 'Hotel' Functions
of institutions and home care: maintenance, food service,
housekeeping/custodial, administrative, etc.
- Academic/Education:
teachers/administrative staff involved in health
education/ health promotion in universities, community
col
leges, other training institutions, etc.
- Academic/Evaluative:
representatives of the health provider community who do
research evaluation, in addition to, statisticians, economists,
health policy and systems/organizational design, health
geographers, etc.
- Government: the human
resources of federal, provincial health ministry and other
departmental bureaucracies, regional health boards, etc.
The above presents a more complete portrayal of the magnitude of
health-related human resources than is traditionally presented in
this area. A more precise system to identify and quantify the
sub-groups of health human resources, using common terms, measures
and values, would serve at all levels to build a stronger
foundation of data to support more effective and balanced planning
and management. According to the World Health Organization,
ensuring a supply of associated professionals adequately trained
for health issues, such as economists, statisticians,
administrators, managers and accountants - is a systemic problem
and has called for strategies to be developed to address this. In
any case, it is important to keep this larger menu of health human
resources in mind when considering questions associated with
policy, planning, management, and education of the health
workforce, as the implications affect a broader group than is
typically acknowledged (Marriott and Mable 1996).
Health Workforce Planning
Definitions and Various Meanings
The importance of workforce planning can be understood in terms
of its role in anticipating the total workforce required for
emerging integrated health organizations and planning, in keeping
with changes in health services, organizational and systems reform.
The associated implications and policy options for management
reinforce both the importance of managing imbalances and the
limitations to date on policy mechanisms to carry that out. To
understand the implications, it is useful to begin with various
interpretations of workforce planning.
Workforce planning has been defined as "the process of estimating
the number of persons and the kind of knowledge, skills and
attitudes they need to achieve predetermined health targets and
ultimately health status objectives" (Hall 1978). Another
definition presents a broader perspective reflective of the
direction of health care reform. It casts workforce planning as
"integrated health human resource planning that involves
determining the numbers, mix, and distribution of health providers
that will be required to meet population health needs at some
identified point in time" (O'Brien-Pallas et al 2000). From a
perspective highlighting multi-cultural priority, in the US, the
objective of workforce planning has been presented as "The ability
to provide essential health care services to all Americans [which]
depends upon the proper supply, racial/ethnic composition,
specialty mix and geographical distribution of physicians and other
health professionals" (COGME 2000).
The fundamental purpose of workforce planning, as simply
expressed in the UK is to "ensure that there are sufficient staff
available with the right skills to deliver high quality care to
patients" (Department of Health 2000). Further, it should answer
the basic question: "Is the supply of health care workers adequate
to meet the health care needs of the population to be served?"
(HRSA 2000). Australia adds the following delineation: At the macro
level it involves estimating the numbers of health human resources
required to meet (but not exceed) future population requirements in
order to achieve a balancing of supply and requirements. At the
micro level it includes determining the functions and task
assignments of the workforce (AMWAC 2000). A large part of this now
includes ensuring that the health workforce has the skill mix for
high quality care and also whether there is an adequate reflection
in the workforce of the cultural and racial makeup of the
population served (HRSA 2000). This reflects an appreciation that
planning should take into consideration workforce characteristics
in terms of the level and timeliness of their skills, and capacity
to reflect or to understand the characteristics of the population
they serve.
Workforce planning is increasingly expressed in broader terms
beyond just counting numbers or types or locations, to include
consideration of when and how they are or will be produced (i.e.
universities/colleges and training programs), as well as how they
are or will be managed (i.e. brought into place and maintained, or
recruitment/retention, their roles or functions within existing or
new organizational models, remuneration policy,
team/interdisciplinary, etc).
Planning can also be applied to more specific situations or
particular contexts such as:
- The present supply and needs or the future supply and needs;
- Different health care settings (e.g. hospitals or long-term
care facilities);
- Individual professions or occupations (e.g. nurses or
dentists);
- Different delivery systems (e.g. acute care or mental
health);
- Specific target populations (e.g. the elderly or children);
- Specific health problems (e.g. AIDS or heart disease);
- Specific policy initiatives (e.g. expanding access to
primary care) (HRSA 2000).
There are other major influences which add to the
multi-dimensional nature of planning. The first is that workforce
planning does not take place in a vacuum - the health systems and
populations served present a dynamic environment of continuously
evolving and overlapping issues, needs and goals which do not wait
for planners to address them. This contributes to the complexity
and the 'catch up' nature of planning to date, within evolving
circumstances, as stakeholders try to move themselves out ahead of
the issues and targets, to better anticipate them. In addition, the
kinds of information needs such as identified above appear to be
and in many ways may be concise terms (nurses, workforce, delivery
system, policy), but they don't just 'boil down' to simple
'numbers.' They are in fact embedded with or underpinned by many
sub-elements and variables which have eluded precise or timely
documentation or assessment, for a variety of reasons.
Another contributor to complexity is that there are many
different stakeholders who are, have been or may be involved in
influencing the workforce planning process in all jurisdictions,
including those within and outside of traditional health care
boundaries. Inter-sectoral stakeholders can include: professional
associations, medical schools and other health provider training
institutions and faculty, government agencies including ministries
of hea
lth, hospitals, other health employers and the publicly
funded health system. Intra-sectoral stakeholders can include:
national and provincial/state governments, universities/colleges,
parents, students, unions, political parties, the insurance
industry (for supplementary and non-insured areas in Canada)
(Rosenthal, Butter and Feld 1990, and Doan 1990), to which should
be added citizens.
The Process
Health workforce planning can be depicted simply as a search for
balance in the 'equation' between supply and demand for health
services. Both 'sides' of the equation reflect many sub-elements
which are perpetually evolving over time, in accordance with
changes in the character and availability of resources on one side,
and population health 'needs' or goals on the other. Both must
operate within larger systemic targets or parameters. Basic steps
of workforce planning in the simplest terms involve an
analytical phase, followed by the development and
implementation
of a pl
an of action,
followed by an evaluation and monitoring of the
workforce
environment, to provide input for refinement or changes over
time.
The analytical phase for supply examines and projects both
current and future workforce supply, of which there are two major
inflows - new graduates and immigrants from other countries and
three outflows - retirements, deaths and emigration to other
countries. The analysis determines current supply by discipline,
nationally, provincially, regionally or in specific geographic
areas designated by combinations of population and/or economic
status or other population identifiers. Estimates are based on the
current workforce and the expected number of graduates, adjusted
for average hours worked by different age and sex cohorts and
expected age of retirement. The projection of supply is based on
the current situation and is done by taking the current workforce
and adjusting it for likely exits (e.g. retirement) and expected
entries (e.g. of new graduates).
The analysis of current and future workforce requirements to meet
population 'need'/demand is more subjective involving a number of
measures. Projecting involves the adequacy of the current workforce
and likely trends in requirements. The future supply and
requirements are then examined to determine whether there is a
surplus or shortage and from there, determine what steps to take to
bring the workforce into balance with population need (AMWAC 2000;
Horvath, Gavel and Harding 1998).
Recent moves include an ability to look at each specialty within
physicians as well as growing recognition of both the implications
and need to include nurses and others health professionals in the
planning process. In keeping with health systems reform, there is
also a growing appreciation of the implications of introducing
multi/interdisciplinary teams associated with primary health care
organizations and vertically integrated health care organizations,
which are the organizations increasingly responsible for a range or
the 'full continuum' of services for the populations they serve.
The reference to integration of workforce planning refers
primarily to planning for all the
health workforce within the context of a multi/interdisciplinary
workforce policy. However, it can have many meanings with
implications for workforce planning. For example:
- between workforce and service/business planning at Trust
level;
- between different groups of health care workers;
- towards an integrated workforce of multi-disciplinary teams;
- also implies addressing the interface between primary and
secondary care in health;
- between health and social care;
- between professional education and vocational training
(Edmonson 1999).
Implications of Surpluses/Shortages
The goal of attempting to achieve a 'balance' is particularly
critical given the implications of surplus and shortages. While
most of the literature deals with this in terms of physician
surplus and/or shortage, many of the implications could also apply
to other health providers in the system. Surpluses encourage
'competition' for patients, which some believe may undermine the
prestige and authority of the profession and may lead to provision
of unneeded services and other practices which are ultimately
detrimental to the welfare of patients. The production of 'excess'
providers [e.g. beyond what is needed] using public funding leads
to 'unnecessary' education/training costs, with heavy public cost
in all countries including the US. This in turn, raises total
health system costs. It may also impede access. Physicians will be
either unemployed, under-employed, or working at tasks other than
those for which they received lengthy and expensive education and
training. The workforce may not maintain skills because of
insufficient consultation rates. The potential for over servicing
of patients increases when physicians and others on fee-for-service
may respond to surplus situations by simply generating more
activity (e.g. scheduling more patients for more frequent
visits)-the so called 'elasticity' effect. This all could lead to
potentially higher costs as well as poorer health outcomes for the
population.
Conversely, shortages mean that patients may not be able to
receive needed services, or will wait in long waiting lines for
services. Less or little time would be available for each person as
well as consideration of aggregate group issues. Health care
professionals and associated practitioners and staff would be
overworked. As shown by trends, physicians could be increasingly
unwilling to settle in areas of great medical needs (e.g.
rural/remote, inner city), which exacerbates the differences in
access to physicians (e.g. poor versus rich) for different
populations. Because of the inflationary aspect of increased
financial incentives or other measures offered by some localities
to entice physicians, this kind of situation could similarly lead
to the potential for higher costs as well as poorer health outcomes
for the population (The Centre for Health Professions 1997, Klein
1990, AMWAC 2000). In the end, both scenarios present similarly
negative potential implications for system costs and patient
care.
Mechanisms and policy options to address workforce
imbalances
There are a limited number of policy levers and mechanisms to
deal with workforce imbalances including surplus, shortages and
mal-distribution. What follows are a few examples for each.
Examples for dealing with surplus include:
- encouragement of use of substitute professionals [to reduce
demand on higher cost practitioners]
- encouragement of self-management of care needs through
information provision or other strategies
- reduction of demand through changing consumer
expectations
- reduction of enrollment in universities and residency
programs in general
- reduction of education intakes and flow of foreign providers
Examples for dealing with shortages include:
- increase remuneration for health care providers in areas of
shortage
- increase/introduce recruitment/retention bonuses
- introduce retraining incentives to re-skill professionals to
skill areas of short supply
- introduce mobility incentives to encourage relocation to
geographic areas of short supply
- increase education intakes
- increase flow of foreign providers into the workforce
- facilitate re-entry through retraining programs, job
redesign to make more attractive etc.
- increase use of technology to expand available provision
(e.g. telehealth).
Examples for dealing with mal-distribution:
- expand opportunities for education in under serviced areas;
- increase enrollment of under-represented minorities in
school and residency programs; (The Centre for Health
Professions 1997, Duckett 2000).
Continuing Issues and Implications for Workforce Planning
As more attention is increasingly being paid to other health
workforce participants beyond physicians, health workforce planners
in many countries continue to face a number of issues and
challenges in the developing field. They present obstacles to both
workforce planning and larger strategies of system reform.
Addressing these is, in part, what drives the current move to
reform workforce planning itself. The politics surrounding health
workforce issues have been rampant (Osterweiss et a
l 1996).
Schroeder (1994) outlined numerous potential obstacles to workforce
reform including:
- "Attitudes:
- Concern about precision of projections
- Desire to let market forces work © Distrust of
government
- Distaste for regulation
- Academic medicine's resistance to change
- Details and logistics:
- The transition phase
- As many losers as winners?
- Loss of residency positions
- Parents lobby."
In addition, hospitals fear the loss of medical resident
positions (as illustrated in New York State), which "represent a
source of captive, available, and inexpensive labour, which if
removed could cost the state $750 million a year to replace. A
reduction in specialty residency positions ultimately may chip away
at the specialty expertise that has served NY well in drawing top
notch doctors and leading the way in medical breakthroughs. The
loss of residency slots is further exacerbated by the recent trend
in limiting residents work week to 80 hours or less."
From a policy perspective, health human resources and workforce
planning have been only weakly linked to national health policies
and population health needs (O'Brien-Pallas et al 2000). The same
relates to linkages with larger planning for services. A focus on
services rather than just focussing on specific health providers
may lead to different conclusions in terms of who or which provider
or set of providers should be providing that service. As
illustrated by Mirvis (1999), "Perhaps we need a different view of
the problem-instead of generalists-look at 'generalist care', i.e.
coordinated care including preventive and wellness measures."
There are also issues associated particularly with providers.
Rosenthal, Butter and Feld (1990) point to the tendency to view
physicians in "splendid isolation" from all other types of health
human resources-particularly those with the skills and capacity to
be complementary and substitutable. They point to the need to move
beyond planning for each profession and specialty in isolation from
the others, to move toward a more holistic approach. At the same
time, accepting other professionals and their potential roles
presents other challenges. There are legal constraints and
questions regarding which group can handle certain activities. The
area of prescribing drugs has presented major issues, given its
traditional positioning within a physician's role. In the present
environment involving high tech requirements for many nursing
tasks, the 'traditional' physician's prescribing role may be
unnecessary, particularly as related to minor drugs.
In addition, professions have at times resisted acceptance of
other professions' roles. Using the nurses as an example again, one
can illustrate countless examples of an historical resistance by
medical staff to certain tasks being delegated to nurses. This
pattern, however, is not confined to just physician resistance. It
applies to some extent to all the health professional hierarchies
and 'pecking orders' within and among health professionals.
"Examples continue to exist primarily between doctors and nurses,
nurses and the professionals allied to medicine - physiotherapists,
occupational therapists, etc., and between the various allied
health professionals" (Gill 1996).
The time it takes to educate professionals also has to be
factored into workforce planning-particularly given the long lead
time for physicians and particularly specialist training. Sweden
has used a 13 year planning horizon while Australia looks at 10
years with adjustments per discipline/specialty (AIHW 1996). Given
this length of time, predictions of what providers are needed could
change due to unforseen circumstances. Many professionals would
like to 'change' their selection of speciality, but the absence of
flexibility in career pathways makes it difficult to switch
training paths without having to start their training afresh. In
addition, in rural areas, there is a need for generalists with
'additional' skills in select specialty areas (Edmonson 1999).
The attitudes of professions are also changing in terms of a
desire for a more balanced life, including time with family and for
other interests outside of work. As expressed by Saltman (1995),
"Despite our beliefs about ourselves and the expectations of our
patients, no GP is a human night-and-day doctoring bank. All of us
need our time off." This has implications for 'working hours' per
professional, and demand for more flexibility in terms of options
for new working arrangements such as job sharing, and permanent
part-time (AIHW 1996).
The average age of the workforce is advancing and there is a
trend toward earlier retirement (AIHW 1996, Buchan and Edwards
2000). This applies to physicians and nurses. In the case of
nurses, some of this may in part be the result of the lay off of
nurses with less seniority and therefore younger during the
restructuring and downsizing in the hospital and other sectors in
the mid-nineties around the world. In turn, this also means that,
except for those who left their respective countries, there are
nurses in the community who may be encouraged to return, with the
right incentives. And finally, there is still a chronic problem in
many jurisdictions with mal-distribution of providers. Inner city
as well as rural and remote populations are often unable to access
a physician, and nurses are filling the primary health care
provider role in many cases.
Access to timely, appropriate and good quality information is
still a problem in many jurisdictions. It is necessary to support
the analysis of supply, demand, requirements and other aspects
associated with workforce planning (de Roo 1990). Information
relates to more than data or numbers. It also relates to an
appreciation of the implications of other dynamics that can
influence health workforce planning such as the implications of new
institutional arrangements (Rosenthal, Butter and Feld 1990, Klein
1990). This would include understanding the workforce implications
of emerging primary health care and vertically integrated health
organizations (i.e. organizations responsible for all health
services for a defined population), which encompass imperative for
multi/inter-disciplinary teams and alternative forms of funding and
remuneration, such as capitation.
Also associated with evolution of new organizational arrangements
is the need to incorporate population enrollment/rostering linkages
into policy and methodology. For example, variations include
enrollment or rostering with an organization versus enrollment with
a given provider. In this context, the potential complication and
need for clarity relates to whether patients are enrolled and cared
for by systems or groups of providers, rather than by a single
physician. These systems may also include nurse practitioners,
clinical pharmacists
, patient educators, etc.. In such a system, it
would be difficult, if not impossible to assign the role of primary
provider to any one person or to any one specialty (Mirvis1999,
Marriott and Mable 2000 and 2001).
There are other implications regarding enrollment or rostering
policy. If the only option is enrollment to 'one' (usually
physician) provider, this may create or reinforce existing barriers
against nurses and others to practice independently according to
their training, scope or potential, forcing others to be
'supervised' (entailing perhaps unnecessary time or efforts in
supervision by physicians or others). It may also deny the rights
of citizens to seek care from other providers in the organization,
such as Nurse Practitioners, in addition to their choice of
physician.
In addition, there are issues associated with international
recruitment and health professional migration and the impact that
they have on workforce planning. These relate to policy associated
with both foreign trained physicians
as part of th
e new supply, and
the ethical issue of recruiting health professionals from other
countries. There are a number of ethical dilemmas concerning
recruitment from less developed countries and the rights of
individuals to migrate if desired (Bundred and Levitt 2000). These
expose other issues of recruitment and more importantly, retention,
illustrated by a recent UK study of graduates showing a lack of
commitment to practising medicine in the UK (Jinks, Ong and Paton
1998). As a result, the UK is actively recruiting elsewhere (as are
other countries), except that they are promising not to take up
physicians without the agreement of the other country. Canada has
also pursued and experienced active recruitment of both physicians
and nurses to and from Canada.
Finally, there are a number of persistent issues associated with
methodology and process. For example, the models for determining
workforce supply, need and demand are imperfect and characterized
by a number of problems. Some of these problems as presented by
Edmonson (1999) include, for example, a tendency to behave as if
planning was an isolated function separate from the rest of
management. Health workforce planning and planning for health
services has been "compartmentalised" or "isolated" with workforce
planning often done after service planning rather than as an
integral part of it. There has also been a narrow focus on
"numbers-based" quantitative analysis. And frequently, methodology
has been influenced by an implicit view that the future could be
simply predicted by a process of extrapolation from the present. As
a result, workforce planning presented highly variable quality with
regard to standards and processes (Edmonson 1999).
Needs-based planning relies on panels of experts to estimate the
per capita number of physicians needed to treat the diseases
managed by a given specialty. According to Goodman et al (1996)
experts are "required to have detailed knowledge of the efficacy of
individual medical services for specific conditions, such as
tonsillectomy for tonsillar hypertrophy or a physician visit for
hypertension. Yet, the efficacy of most medical services and the
productivity of physicians in delivering these services is
uncertain." Demand-based planning uses current utilization as a
proxy for patient demand and as an indicator of physician
requirements. The problem with it is that it perpetuates current
utilization patterns without regard to patient or population
outcomes and ignores the evidence that, at least in non-capitated
health care markets, an increased supply of medical resources leads
to increased utilization (Goodman et al 1996).
This occurs as a result of what has been referred to as
'physician practice elasticity,' which simply means that when there
are fewer patients, physicians on fee-for-service can schedule more
visits to ensure their income is protected. Both Needs-based and
Demand-based planning are sensitive to assumptions about physician
effort, utilization patterns, the effects of managed care or other
equivalent models that are vertically integrated that tend to have
groups, multi-disciplinary teams and use non-physician providers
such as nurse practitioners and physician assistants (Schroeder
1996).
Benchmarking offers an alternative to these planning methods.
Comparing physician resources with a benchmark health plan or
region provides a guidepost that does not depend on a hypothetical
optimal physician level but depends on a real-world and attainable
health care system. But benchmarking is not without its
limitations. For example, it is not intended to identify
populations with inadequate access to basic medical services. And
there is no agreement regarding the amount of work that constitutes
a full-time equivalent clinically active physician (Goodman et al,
1996). As well, a key challenge has been the lack of easily
accessed clinical, administrative and provider data bases to
conduct complex modelling activities, such as health need and
health system and caregiver outcome data, and management
information systems which reflect utilization and costs
(O'Brien-Pallas et al 2000).
A discussion such as this cannot be completed without calling
particular attention to nurses and other health providers, for at
least two reasons. So much more is known about the physicians, as
illustrated in this document. And now that nurses are finding more
areas to practice given the trend to more emphasis on community
services, more attention is being paid to this profession than ever
before. This is particularly true in terms of implications for
workforce planning and associated issues and challenges that will
need to be overcome. In Australia, for example, universities have
been making independent decisions about curriculum and appearing to
disregard the National Review of Nursing Education. In addition
State and territorial governments are making independent decisions
about the structure of nursing with relatively weak national
coordination policies.
The nursing workforce is increasingly segmented into
sub-specialties such as midwife, emergency nursing,
intensive/critical care nursing, nurse anaesthetists in the US,
etc. (Duckett 2000). This suggests that there is the potential to
identify work groups for planning, as is presently the case with
physicians, to be incorporated as a sub-set of workforce planning.
At the same time, a major issue for nursing in all jurisdictions is
clarification of the roles of nursing, such as to what extent will
they function as substitutes or work in complementary practice with
physicians. Opportunities in this area are greater where nurses
have, for example, independent prescribing rights, or capacity to
refer patients. Without clarity in this area, it is difficult to
determine how many nurses will be required from a workforce
planning perspective. And in turn, evolution in this area impacts
on workforce planning for physicians.
Another complication for nursing, particularly for those with
expanded roles, is how to pay them. While fee-for-service
represents a traditional mode of payment for independent providers,
in the present environment the trend is away from this, as it is
not a pre-requisite and increasingly appears not to be the favoured
option. In addition, legal recognition and protection for nurses
with expanded roles, such as nurse practitioners, must be
considered as part of the introduction or reinforcement of this
direction. And finally, as it is with many health professionals,
the nursing population is aging, which points to a potentially very
serious problem in many jurisdictions. Already in many countries,
there appears to be a shortage of nurses. As a result, more
countries are paying additional attention to nursing. For example,
ministers of health at the WHO European regional conference on
Nursing and Midwifery in Munich formally demonstrated this,
proclaiming a strong commitment to strengthen nursing and midwifery
(WHO 2000).
Among other supports, ministers dedicated commitment to the
development and dissemination of comprehensive workforce planning
strategies to ensure adequate numbers of well educated nurses and
midwives. In addition, WHO will be reviewing information on
national efforts for health workforce planning, and will identify
and disseminate information on models appropriate to different
health systems. Similarly, technical assistance will be provided to
ensure enhanced human resource relevance to the actual needs in the
health services and populations. This is a major step, given that a
number of European countries have not actively carried out nursing
workforce planning on a national scale, as has been the case with
physicians.
There is a similar inattention to and lack of good information on
other health professions, as it would relate to or support
planning. There are occasional or isolated profession-specific
papers on one or other aspect of workforce planning - often lacking
detail. For example, it is known from selected information that the
UK has a shortage of physiotherapists and will be recruiting
abroad, as the number of new graduates won't meet demand/need
(Buchan 2000). In addition, optometrists
in the US carrie
d out a
study to confirm that they, along with other eye care professionals
are in a surplus nationally. An interesting conclusion of this
particular study provided an explicit example of professional self
interest, documenting the professional call to stimulate
demand to correct their surplus
'problem' (White, Doksum and White 2000). A small number of studies
in the US examine dentists, pharmacists and other
professionals.
Part of the problem relative to other professionals has been the
extent to which they have been in a relatively weak or subordinated
position relative to physicians and nurses. Duckett (2000) has
suggested that this is due to the relative political and social
status of physicians and the numbers and increasing power of the
nursing profession. The main challenge for workforce planning in
the area of 'other' health professionals will be bringing them into
the forefront of processes, and establishing better information as
well as appropriate appreciation of their place within and
contribution to health care.
Review of Current Workforce Planning Approaches
Introduction
The purpose of this section is to present an overview and select
country examples of workforce planning organizations, planning
methodologies and processes. The literature reflects a growing
sophistication of appreciation and understanding of what is now
considered to be the relatively new field of health workforce
planning. Although some academics engaged in presenting more
sophisticated approaches in the 1970's, it appears that their work
was not taken into account or was mostly ignored by the
stakeholders in practice. By the mid to late 1980's, additional
sophistication was finding some expression in the literature and in
government studies. Efforts to actually reform and refine
approaches on a national scale in some countries didn't really
begin to start to take hold until the mid to late 1990's.
It is this latest phase that is still emerging and evolving at
different rates and forms of expression today that will provide a
richer environment for sharing and comparison over time. What is
emerging is an enhanced appreciation and expansion of workforce
planning reform and evolution on two fronts. The first, as
presented in this section, is that some countries are moving to put
in place permanent workforce planning organizations
supported by the participation and contribution of employers, health
professionals
and others. This is part of an expression of political will and a
commitment to an on-going, as opposed to intermittent, process. On
the other front, there is a movement to greater sophistication in
methodology and processes that incorporate multiple modalities of
analysis and planning. To further reinforce this direction,
governments are putting a priority on the development of
information systems to support the process.
Emerging Organizational Structures for Workforce Planning
In some countries, permanent workforce advisory organizations and
associated supports are emerging after a long period of leaving
workforce planning up to the various professional associations,
occasional government studies, or the market. These organizations
are charged with an on-going responsibility for workforce planning,
evaluation and monitoring and the provision of advice to
government, and the engagement of a broad partnership of
stakeholders and participants to provide input. This is a recent
movement that in some cases continues the emphasis and focus on
physicians, such as in the Netherlands, Australia and Germany.
Other countries are beginning to take a more expansive approach.
The UK has proposed new directions and consultations as of 1998. It
is now in the process of revamping its workforce planning to be
integrated and holistic with new organizational structures and
obligations to support planning for the total health workforce.
Similarly, New Zealand is moving to an integrated and holistic
approach with the establishment of its Health Workforce Advisory
Committee in 1999. And the Federal Bureau of Health Professionals
in the United States has established guidelines for State
governments to establish some form of central workforce advisory
body to look at the total health workforce.
Methodologies and Processes
Methodologies and processes are emerging for workforce planning
which are 'multi-modal,' and apply and refine a mixture of
approaches to measurement and analysis. They represent attempts to
respond to past failures, and to find the 'magic bullet' approach
to determining and projecting supply and requirements and future
needs (AMWAC 2000). Most of the experience depicted in the
literature is with physician workforce planning studies and
processes, although many principles and concepts appear to be
transferable to other health professionals.
The relative scarcity of 'national' examples of workforce
planning for nurses and other health providers may be due to the
fact the historically they have been employees of hospitals, long
term institutions, public health or within physician owned/managed
primary care or specialists practices. The responsibility for
planning and signalling shortages/surpluses was to a great extent
the responsibility of these organizations (particularly hospitals).
The movement toward primary health care reform and to vertically
integrated health organizations, with group practices and
multi/inter-disciplinary teams, including nurses and others, is
serving to highlight these professions more and to support the
notion of integrated holistic planning over time.
To supplement national initiatives, the World Health Organization
(WHO) is contributing to the refinement of methodologies and
processes through the commissioning of various studies and
discussion papers (Adams 2001). WHO has also made available a
'Toolkit' prepared by Thomas Hall, including information on
microcomputer spreadsheet models for developing 10 to 30 year
projection scenarios for workforce supply and requirements (Hall
2001).
Overview of Selected Countries
What follows is an overview of select countries including
Germany, The Netherlands, Australia, The United States and the
United Kingdom. Where applicable, each will begin with an overview
of their organizational arrangements followed by an overview of
their methodologies and process in workforce planning. Two
exceptions to a detailed discussion of methodology and process in
planning are the Netherlands where the details of approaches are
not available at this time, and New Zealand, where they have yet to
initiate looking at workforce numbers.
Germany, The Netherlands, and Australia have national
organizations in place only for physicians at this time. The intent
in New Zealand, and the direction in the United States and the
United Kingdom is to look at total workforce and integrated
planning. National planning overviews are presented for Germany,
Austra
lia and the United Kingdom. Some examples of a study or
workforce planning are presented for the United States including
one for physicians, one for nurses and one example of an integrated
planning exercise in Wisconsin. In addition, an integrated planning
exercise for Scotland is presented as part of the discussion of UK
methodology and process.
Germany
Organization:
Germany serves to illustrate a context with specific challenges
that are different from Canada. The German post-war constitution
stressed individual rights and limited rights of intervention and
regulation by the state. One right included the right to free
choice of an occupation and corresponding educational
opportunities. This meant that the government was not able to
approach workforce planning by controlling the number of students
in medical schools at university (Bussche 1990
). One result has
been a tendency to overproduce physicians. The government response
was the Health Reform Law of 1993 to restrict the budgets on
spending for physicians and limit the number of physicians based on
strict population to physician ratios (Weil and Brenner 1997,
Schneider and Spat 2001). In short, controlling the right to
employment in a panel of physicians.
The Government Ministry of Health receives advice, at the Federal
level, from the Federal Committee of Physicians and Health
Insurance Funds. At this point in history, there is no counterpart
for nursing or other health professionals in Germany. But given the
Munich accord, to support nurses more and develop workforce
planning for nurses, this may change in the future. The Committee
is responsible for establishing the guidelines for medical
workforce planning to be carried out at the regional/local level.
The policy mechanism is to limit the number of approved provider
reimbursement numbers available for physicians by municipality
(Weil and Brenner 1997). The Federal workforce plan at level 1 (to
be described under methodology and process) operates under the
following guidelines:
- regulations on workforce planning-with emphasis on how to
determine the content of workforce plans and the delimitation
of planning areas;
- standards, basis and procedures for the determination of the
general degree of supply of medical care and oversupply;
- standards of determination of special need related to
quality aspects as a precondition for granting exemptions from
admission restrictions (i.e. admission or acceptance of
application to work in a panel of physicians);
- standards, basis and procedures for the determination of
impending or existing under-supply; and,
- standards of a balanced provision structure for general and
specialist medical care.
Based on these guidelines, the Federal Committee establishes the
doctor/patient ratios per specialty, including General
Practitioners, and submits these to the Ministry of Health. The
German Federal Ministry of Health can and has demanded revisions to
these guidelines where they feel they do not meet the budgetary and
health need requirements of the system. Currently the government is
insisting on the use of 1990 numbers as the 'authoritative'
reference point. Based on agreement, the guidelines are then passed
to a 'local' or regional Associations of Panel Doctors and Regional
Federations of Social Insurance Funds. Plans are developed every
three years (Schneider and Spat 2001).
Methodology/Process
Regional/Local Associations of Panel Physicians and Regional
Social Insurance Funds participate in workforce planning based on
the guidelines concerning the number and ratios of doctors provided
by the Federal Committee and approved by the German Federal Health
Ministry.
For planning purposes, Germany is divided into four types of
regions which are in turn divided into 10 planning categories. They
include:
- Agglomerated areas: regions with large conurbation and towns
with populations of 300,000 inhabitants and/or with a density
of 300 inhabitants per square kilometre. Planning categories 1
to 4.
- Urban areas: regions with a smaller density and population
of from 100,000 to 300,000 inhabitants and partly characterized
by very rural surroundings and/or a density of 150 inhabitants
per square kilometre. Planning categories 5 to 7.
- Rural areas: characterized by rural surroundings. Planning
categories 8 and 9.
- Special areas: applies to towns that are administrative
districts as well as administrative districts for the Rehear
area only. Planning category 10.
There are two levels in the process. In the first level, the
general or current doctor / population ratio is determined using
the current populations and numbers of doctors by specialty
(including General Practitioners) per planning category. The
'established' ratios for given specialists and general
practitioners are then applied to the population in the planning
area to determine the number of physicians"needed" by specialty to
serve the population. The process then examines the actual number
of general practice and specialist physicians per planning category
by dividing the actual number of physicians by GP/specialty by the
need with 100 representing the correct amount. Initially under
supply is considered to be when there are 75% or less of the number
of GPs required and 50% or less for specialists. An oversupply is
when the percent of physicians of any category are 10% or more over
the required number.
In the second level of assessment, the regional committees examine
the results and carry out additional examinations. In the case of
under supply, the committees carry out additional assessments to
further guide their recommendations concerning admission of
additional physicians to the panels. For physicians, they look at
the areas of activity, productivity, age structure of the
physicians, the structure of the medical practice and whether there
are any specially authorized physicians. They then look further at
the population numbers, age structure, demand for services, and
other factors.
In the case of oversupply, they determine the number of physicians
working as psychotherapists, select admission patterns in two
areas, special needs, the level of group practice, and profiles of
ambulatory surgery. If the determination does not change the
earlier assessment, additional physicians will be blocked from
joining the physician panel in the given specialty or general
practice.
The Netherlands
Organization and Process
In the Netherlands there was no comprehensive government medical
or general workforce planning as of 1989 and the early 1990s.
Professional associations for the various medical specialists
formulated their own policy on the number of doctors to be trained
for their respective specialties. Training positions for general
practitioners and physicians in nursing homes were determined by
the government. The organizations responsible for hiring public
health physicians had responsibility for both determining the
number of training positions and the financing of those positions
(van der Velden 2001). This changed with the introduction in 1999
of what is known the Capacity Organization (or Capacity Body) for
physician workforce planning.
The organization, funded by government, has a tri-partite
composition with representatives from the professional groups, the
health insurance companies (Sickness Funds), and the training
institutions (i.e. academic institutes such as universities and the
affiliated hospitals). The three participating organizations are
responsible for establishing the model-a process of bringing
together partners is considered to be as important as the outcome
in the view of its Director (Leliefield 2001). The Capacity
Organization provides physicians workforce advice on an annual
basis regarding the number of doctors to be trained. The Capacity
Body uses experienced research institutes like the Netherlands
Institute for Health Services Research (NIVEL), to examine both
supply and demand within the health system with 10 to 20 year
planning horizons.
The first reporting commenced March 2001 with recommendations,
supported by government to increase the number of medical students
admitted to universities, increase the number of training positions
for general practitioners and additional funding has been set aside
for training medical specialists (van der Velden 2001). NIVEL also
conducts various studies for health professions and has a registers
of practising and recently qualified health practitioners including
GPs, midwives, physiotherapists, and medical specialists (NIVEL
2001).
Nursing and other health professional workforce planning is still
handled at the nation
al level by both the Departments of Health and
Education in terms of establishing numbers of training slots. In
addition, for nurses, there are several regional"planning
committees" that include the participation of the training schools
and hospitals along with other parties (van der Velden 2001).
Australia
Organization
In Australia, the primary focus of recent efforts is still on
physician workforce. The Australian Medical Workforce Advisory
Committee (AMWAC) was established in 1995. AMWAC reports to the
Australian Health Ministers Advisory Council (AHMAC) and through
that body to the Australian Health Minister's Conference. The
Committee works with a number of stakeholders including: the
Institute of Health and Welfare, especially on data issues, the
Health Insurance Commission, Departments of Immigration and
Multicultural Affairs, Department of Education Training and Youth
Affairs, the Commonwealth Department of Health and Aged Care, State
and Territory Health Authorities, University Medical Schools,
Medical Colleges, Divisions of General Practice and State and
Territory Rural Workforce Agencies.
AMWAC's first task was to produce an overall strategic framework
for its work. From that point, as will be discussed under
methodology and process, it focussed on all physicians and then on
each discipline as well as specific subject areas of importance
including immigrant physicians, trends in medical education,
impacts of changes on medical students, female participation,
development of guidelines for sustainable specialist services and
other special subject areas (AMWAC 2000). AMWAC's broad view of the
workforce for 2010 was as follows:
“The health workforce is mobile,
multi skilled and motivated. It has a primary care focus, supported
by other types of services. The workforce is well educated and
involved in continuing education, training and re-skilling. Much of
the workforce is part time, and some engage and disengage in
particular services as required. They are employable, rather than
employed for life" (Horvath, Gavel and Harding 1998).
Methodology/Process
In Australia, the focus has been on refining physician workforce
planning using a multi-modal approach to blend a number of
methodologies and create various options and scenarios for the
future.
AMWAC uses a computerized software model designed by van
Konkelenberg (1995) for its workforce planning. On the supply side,
the model takes into account any shortfall in the current
workforce, expected entrants to the workforce, those leaving and
then converts the numbers of doctors to a full time equivalent
figure using the average hours worked per week by age and gender.
On the requirements side the computer model looks at the likely
trend in demand for services based on growth estimates (e.g.
population growth, and other needs based indicators) selected for
use with the respective discipline. Both supply and requirements
are then projected over a 10 year period using a range of demand
side growth estimates and supply side scenarios (e.g. doctors
working fewer/more hours per week, increases/decreases in the
number of overseas doctors entering the workforce).
With the support of this computer software system, the AMWAC
process is summarized as follows:
- Expert panels are used to advise on selection of measures
and the future impact of advances in technology, evidence based
decision making, as well as financial and health service
organization reform on utilization and productivity.
- Assessing supply begins with the selection of groups within
the physician community to be examined based on such known
problems of mal-distribution, shortage, oversupply, etc.-and
continues with further refinement of the definition of the
group (i.e. Oncologists, to include both medical Oncologists
and Haematologists).
- Once identified and defined, the characteristics of the
group are developed including the number of them, age/gender
profiles, geographic locations of practice, and number of
services by geographic area.
- Productivity is measured at this time by looking at average
hours of work per week and number of patients seen until better
productivity measures are available.
- Current and also future supply based on the current scenario
looks at both future increases due to new graduates and
immigration and losses due to retirement, death, or other
temporary or permanent withdrawal from the active service
providing workforce.
- Requirements (Population Demand/Need) are determined through
a number of approaches including:
- Doctor/population ratios-used mainly for describing
trends over time. In the future it is recommended that
'full-time equivalents' be used to provide for more
sensitivity in reflecting changes in practice styles,
average weekly hours worked, etc.
- Needs-based measures-to link workforce supply to
estimates of population health need, as evidenced by
population growth and patterns of morbidity using a range
of epidemiological and expressed need indicators. It is
recognized that there are still some refinements required
to accommodate assumptions about utilization and future
decisions on financing. To compensate for these issues,
surveys of physicians, consumer support organizations,
health authorities, and referring doctors are used to
produce complementary information by geographic location.
- Bench marking of international or between geographic
areas to assess workforce supply.
- Health services targets using health service facility
targets of workforce needs based on best practice
guidelines to determine the number of essential support
staff available now and in the future for a given medical
service.
- Economic demand-side measures-for estimates of the
future economic demand for medical services based on an
analysis of current level of utilization, population
demographics and socioeconomic attributes.
- Based on these studies of supply and
requirements-project
the levels of workforce by group (e.g. GPs, paediatricians,
dermatologists, oncologists etc.) to meet projected
requirements. (See further discussion of Australia's approach
to determining future need for specialists below.)
- Establish a plan to address any shortages or surplus to
achieve a 'balanced' workforce within 10 years. Policy options
include:
- project the adjustments required in training programs
- increase or decrease the number of overseas doctors
entering the workforce
- measures
to increase workforce productivity
- use of complementary staff or substitutes
- Once in place, the Australian plan calls for a
process for
monitoring to ensure that recommendations are being put in
place and for revisiting each group workforce plan at least
every five years to account for unforeseen changes or problems
with previous plans.
Australia also conducted discipline specific analysis for all the
physician specialties. The approach is essentially as already
described above. There were, however a number of additional points
raised. For example, when projecting needs for specialists, it is
important to keep in mind trends and additional indicators that
relate to particular specialties. For example, birth rate and
fertility rate for obstetrics, aged care assessments for geriatric
medicine, the prevalence of injury for rehabilitation medicine, and
incidence of cancer for radiation oncology. Horvath, Gave
l and
Hardi
ng (1998) also pointed out the need to consider available
supporting infrastructure. While this is a factor to some degree
for all the workforce, it has particular significance for some
specialists. For example, emergency medicine, intensive care and
radiation oncology were presented as examples where the trends and
future population needs are 'not likely as important as likely
future infrastructure; there being no point in having workforce
greater than available infrastructure."
What is not clear in the Australian approach, is how or whether
they take into account the service contribution of what they
call"Hospital Non-Specialists" including specialists in training or
what would be referred to in Canada as Residents.
In the 1998 report on"Sustainable Specialist Services: A
Compendium of Requirements" AMWAC presented a number of situational
factors influencing population catchment areas that should be
considered in supporting specialists' services:
Demand side
|
Supply Side
|
- population profile (age, gender, morbidity, and
socio-economic status)
- level of private insurance
- remoteness from an urban or regional referral centre
- the quality of existing transport systems
- established referral patterns
- attitudes and expectations of patients regarding a
particular specialist service
- attitudes and expectations of referring doctors
regarding a particular specialist service
|
- number of appropriately skilled primary care
practitioners
- the number of similar and associated medical and
surgical specialists resident in an area
- the availability of appropriate facilities and support
services, including the availability of hospital
facilities.
|
The report pointed out the importance of a supporting
infrastructure for all specialists. For many specialists, this
means access to an appropriate level of hospital beds, operating
theatres, delivery suites, day surgery units with appropriate
diagnostic and surgical equipment along with appropriately trained
nurses and other health professionals. With this as a foundation,
they examined populations required to support various specialists
within the more traditional health system structures:
- Rural areas with population catchment areas between 10,000
and 20,000 are large enough to support local specialist
services in general surgery and anaesthesia, provided there is
a district hospital, with required support and pharmacy and
pathology, diagnostic radiology, operating theatre, intensive
care unit, coronary care unit etc.
- 20,000 to 60,000-ob/gyn, paediatrics, psychiatry,
orthopaedic surgery, geriatric medicine and pathology
- 50,000 to 80,000-ENT surgery, dermatology, rehabilitation
medicine, neurology, and thoracic medicine
- specialist services may also be involved in provision of
outreach specialist services and consultancy services to GPs
and specialists in smaller rural communities
- 80,000 and above-urology, diagnostic radiology, cardiology,
intensive care medicine, nephrology, medical oncology, and
radiation oncology.
It was indicated that it may be possible to provide a number of
specialist services through a variety of specialist outreach
programs such as regional specialist clusters, urban based
teaching/research hospital teams visiting remote areas, or regional
hospital based centres as specialist service hubs.
In light of international trends and current organizational
trials, they also acknowledged the possible influence of new
organizational and funding arrangements including either regional
purchasers of services or vertically integrated health organization
growing out of groups of general practitioners as purchasers or
brokers of specialist services (AMWAC Sustainable Specialists
1998).
It is important to note that the underlying assumptions in the
Australian model are that there will be no radical changes in the
current national health structures over the 10 year projection
period and that estimates concerning population growth, training
programs, overseas doctor immigration and patterns of work and
organization remain static. They acknowledge that any change in the
use of other health care providers, a move to multidisciplinary
teams and or adoption of enhanced primary health care and
coordinated trials of vertically integrated health care
organizations for elderly and others currently being tested in
Australia would change the number and mix of physicians (AMWAC 1998
and 2000, Marriott and Mable 2000). In addition, workforce planning
would also have to move to one that examined all the health
workforce, and not just physicians. In the short term, however,
there is a recommendation to establish a workforce advisory
committee for nursing.
New Zealand
New Zealand had discontinued workforce planning in 1989 (AIHW
1996), and still rejected any central planning for a variety of
reasons including history or error in favour of leaving it to the
market and employers as recently as 1998 (de Raad). However, with a
new policy direction in favour of strengthening primary health care
and embracing interdisciplinary teams, the health minister
established a Health Workforce Advisory Committee (HWAC) to
coordinate the workforce and is in the process of introducing new
legislation to regulate health professionals (King 2000, Goddard
2001).
According to the New Zealand Ministry of Health (Goddard
2001),"it is proposed that the committee will take a strategic view
of the workforce required to deliver health services in the future
rather than working out how many of each will be required in the
future and trying to plan accordingly." HWAC is accountable to and
reports to the Minister of Health. Its key tasks are to provide an
independent assessment of the current workforce capacity and
foreseeable workforce needs to meet the objectives of the New
Zealand Health and Disabilities Strategies. Its advice will
consider what is currently known about the workforce (patterns of
excess/shortages or other imbalances) and what type of workforce is
required for the future (HWAC 2000).
The United States
Organization The US stands out from the other countries with its
mixture of publicly funded programs for the elderly and poor, and a
private market for others. Historically, both federal and state
governments have had a role in developing policy to shape the
health care workforce. As stated by Tim Henderson (2001),"The need
for government involvement in this area persists as the private
market typically fails to distribute the health workforce to
medically under served and uninsured areas, provide adequate
information and analysis on the nature of the workforce, improve
the racial and ethnic cultural diversity and cultural competence of
the workforce, promote adequate dental health of children, and
assess the quality of education and practice."
State governments are the major players in workforce issues and
planning given their responsibility for financing and governing
health professions education; licensing and regulating health
professions practice and private
health insurance; purchas
ing
services and paying providers under the Medicaid program; and
designing a variety of subsidy and regulatory programs providing
incentives for health professionals to choose certain specialities
and practice locations (Henderson 2001, Biviano 2001).
Federal government policies to improve or increase access to
health services tend to fall into three categories: supply policies
related to its medicare and other service reimbursements/payments;
direct supply policies such as student assistance, construction
grants and other institutional supports, and workforce geographic
distribution programs to deal with mal-distribution (Osterweiss et
al 1996). At the federal level, the Department of Health Resources
and Services Administration (HSRA) is responsible for the Bureau of
Health Professions and within that the National Center for Health
Workforce Information and Analysis. The Center funds a number of
studies and four regional based university workforce centers at the
University of California at San Francisco, University of Illinois
at Chicago, University of Washington and the State University of
New York at Albany. Other centres are planned. In addition the
Council on Graduate Medical Education (COGME) is also engaged in
workforce planning and providing advice to both the HSRA, the
Senate Committee on Health, Education, Labor and Pensions, as well
as the House of Representatives Committee on Commerce.
The federal government has produced a workforce data and resource
guide for State governments. The goal is:"to promote the
development of a health workforce that has the number and types of
health workers needed to take care of Americans" (HRSA 2000). The
guide presents a number of organizational options for State
governments to consider. They begin with a recommendation
concerning the maintenance of a basic set of health personnel data-
ideally with all states collecting their data using standard
definitions in order to allow multi-state comparisons and shared
analysis.
Several classes of data are recommended as needed in a minimum
data set with each collected or compiled for a number of recent
years so that trend data will be available on which to base
projections. The most important classes of data suggested are:
- Counts of licensed health professionals-several years, if
possible active practising as well as those simply licensed to
practice.
- Counts of other health workers-for several years-more
difficult as may not be licensed and their associations may not
have effective collecting of data system.
- Counts of new personnel-eg new licensees, provide important
insights about the attractiveness of the various health
professions and occupations and whether they are growing or
shrinking. If possible-disaggregated by source of personnel
(i.e. in-state, out-of-state, recent graduate etc.).
- Numbers of personnel employed by hospitals and other types
of health care facilities-at least year by year. Info from
hospitals should be easy but more difficult from other sources
such as doctor's offices. The best data will be for
nurses.
- Educational Pipeline Data: Numbers of students enrolled in
and graduated from health care education and training
programs-a critical component of pipeline for new personnel.
- Health Worker's Salaries: Average salary levels for
different health professions, occupations, and specialties in
different employment settings. Should be available for certain
types of personnel such as nurses, physician assistants,
physical therapists, occupational therapists, and radiation
technologists and, depending on local circumstances, could
compile separation tabulations for nurses such as emergency
room nurse, psychiatric nurses, and nurse specialists.
- Population Data: Population counts with 10-year age
breakouts for different political subdivision (e.g. cities,
counties)-a critical reference-to estimate the
demand/requirements for health care services. They can also
project future demand/requirements for health care.
- Health Facilities Data: Numbers of beds in hospitals,
nursing homes, and mental health facilities, and units of
service for home health agencies and ambulatory care
facilities. Can be used in a variety of ratios in models to
project future demand/requirements for health workers.
Information about openings and closings of facilities or
services can be particularly important for health workforce
planning and policy making.
- Health Care Expenditure: Expenditures on health care for
different kinds of service providers. Financial data should be
compiled from health care facilities, including acute care
hospitals, long-term care providers, and outpatient providers.
These data can be used in a variety of ratios and other models
to estimate workforce requirements.
In terms of what supporting organization that a State could put in
place, they recommend a number of options depending on budget and
other considerations.
- Establish a Health Workforce Advisory Council. A standing
advisory council could promote understanding of common issues,
facilitate the development of cooperative data collection
programs, and help coordinate data collection and
analysis.
- Establish a Small Health Workforce Data Unit. The assignment
of a small staff would provide a locus for workforce planning
and could help state agencies to define and address basic
policy questions.
- Establish an Office of Health Workforce Planning. This is
seen as the ideal approach. Professional staff in the Office
would be available to respond to urgent or emerging health care
problems involving supply/demand. A full office would allow the
state to carry out a number of activities including:
- surveys of health facilities, health care practitioners,
and related educational programs to maintain current
information for planners and policy makers
- reports on the status of the health workforce in the
state produced on a regular biennial or triennial basis
- a quarterly newsletter summarizing current issues and
programs related to health workforce
- an annual action agenda which indicates the major health
workforce priorities for the coming year
- creation of standard definitions and protocols for basic
health workforce terminology to facilitate communication
and analysis
- special studies related to current executive and
legislative issues and initiatives
- models to project future health workforce supply and
demand
- obtaining consensus on responses to critical health
workforce issues
- other
And finally, the report recommends the development of an
electronic network through which a number of organizations could
share workforce data and files. While acknowledging that the
initial investment can be high, once in place it could greatly
facilitate the collection, sharing and analysis of health workforce
data (HRSA 2000).
Methodology/Process
What follows is a presentation of an approach to forecasting
primary care physicians followed by comment on projecting future
supply of nurses, and finally an example of interdisciplinary
workforce planning exercise in the state of Wisconsin.
Primary Care Physicians
What follows is an overview of the methodology used by Libby and
Kindig (2000) in a study funded by the HSRA to estimate primary
care physician needs for under-served Americans that incorporated
the following elements in its approach:
- Su
pply of physicians and infor
mation on population and
rural-urban continuum codes was determined using the Bureau of
Health Professions 1997 Area Resources File (ARF) with care
taken to define what 'specialists'/designations would be
recognized as 'primary care physicians (e.g. GP, FP, General
Internal Medicine, General Paediatrics and General
Ob/Gyn).
- 'Requirements' were estimated for each of five distinct
county types: Metro-Core, Metro-Fringe, Small City, Rural,
Sparse. Two sources for determining what is needed by
populations included:
- Expert panel survey of opinions on number of generalist
physicians per 100,000 required to provide (a) an adequate
level of physicians 'by county type,' and (b) a minimal
level of physicians by county type.
- Previous COGME recommendations of 60 to 80 generalist
physicians per 100,000.
- Future Need was determined by comparing the various
estimates of what is required (i.e. expert estimates, high and
low of COGME) with the existing per county to determine
surplus/shortage per county and ultimately for the nation. They
further refined the 'future' based on applying this methodology
to six future scenarios. The Status Quo meaning a continuance
of health insurance/system as is would require an increase of
10.4% , and when compared to this as a base of increase, the
following scenarios produced requirements for additional or
fewer physicians:
- A Baseline Insurance Projection to estimate expected
growth of managed care market would lead to an additional
1.1%.
- A high managed care penetration would lead to further
decrease in future needs of an additional 1.7%.
- Universal coverage (like Canada) would lead to an
additional increase of 9.9% due to assumption of higher
demand by those who did not have adequate access
previously.
- Equal Access and Universal Coverage - like the previous
scenario, but with improved access, and therefore increased
staffing would require an additional 12.3%.
- Doubling the use of non-physician providers such as
nurse practitioners, physician assistants, etc. resulted in
a 'decrease' in the baseline status quo of 12.6%.
- This served to demonstrate the impact of varying future
scenarios regarding the organization, funding, and coverage
provided in the health system as well as changes in
population size and composition.
Nurses
The National Advisory Council on Nursing Education and Practice
examined a number of approaches to determining the future supply
and requirements in its report to the Department of Health and
Human Services on the Basic Registered Nurse Workforce. A number of
assumptions were made about nursing in the future, as follows:
- The hospital will remain the major employer.
- RN practice roles are substantially changing.
- More technically advanced procedures are being provided in
nursing homes.
- Nurses will focus on primary care and health promotion.
- More nursing care is given within the community.
- The number of nurses in home health care will show rapid
expansion.
- Expansion of country's older population will require more
nurses to manage chronic conditions.
- Future role to manage care along a continuum.
- Work as peers in interdisciplinary teams.
- Integrate clinical knowledge with knowledge of community
resources.
- To better serve the population of the future, more cultural
sensitivity is required as the diversity of the population
increases.
Part of the picture of the future was that there would be a shift
from the emphasis on hospital-based care to community-based care,
coupled with increased complexity of acute care. As a result it was
determined that the educational mix of the registered nurse
workforce needs to be altered.
A number of modelling activities were carried out to examine and
project the future supply of and requirements for registered
nurses. To project future supply, a model was used that captured
the age-specific dynamics of the flow of nurses in and out of
licensure (including studies of first-time licensees and those
engaged in post-graduate studies). The effort also looked at flows
in and out of the workforce, and their state-to-state migration.
Data were developed for each state on:
- the population of nurses - all those with licenses to
practice on a given date;
- the supply - all those employed or available for employment
(if sufficient positions are not available at the time being
considered); and
- the full-time equivalent supply that expresses employment
independently of full- or part-time status. The derivation of
full-time equivalent used a national sample survey to identify
those nurses working full-time, those part-time and the number
of scheduled hours for each nurse. Ratios were then developed
for each age group cohort who were working full time and
a"full-time equivalent" for those who were working part time.
The US summary is an aggregate of state data.
To establish projections of the future requirements for Registered
Nurses, information was developed on a state- by-state basis. A
number of requirement projection models have been used in the past,
including the Historical Trend-Based Model, the Nurse Demand Model,
and the General Services Demand Model. At present, the Nursing
Demand Based Requirements Model (NDBR) is the latest modelling
effort to determine the future requirements for nursing personnel.
It was developed by the Division of Nursing (within the US Bureau
of Health Professions) to build upon the General Services Demand
Model, and incorporates nurse utilization per provided services. It
also allows users to access both geographic and nursing employment
(or health care services) sector detail, coupled with the ability
to make changes in the model's inputs to generate a variety of
scenarios. In its present iteration it forecasts solely the
requirements for full-time equivalent registered nurses. Future
work will extend the model to the total nursing personnel workforce
covered by the earlier nursing requirements models.
In the current approach, the health care system is partitioned
into a variety of health care sectors based on availability and
consistency of data to measure the level of services and personnel
resources required. Sectors include: hospitals, nursing homes,
ambulatory care, public/community care, nursing education, all
other. Socio-economic and health status measures were considered to
measure the growth behaviour of each of the health care sectors and
changes in nursing utilization rates. Health status variables
included numbers or levels of disabilities, death rates, and
changes in morbidity/mortality rates. Economic well-being of the
population or sub-groups within the population was measured through
such variables as per capita income, cost of living indices,
changes in rates or in total earnings. And as appropriate to the US
environment, insured or uninsured status was also considered.
Trends in demographic characteristics were measured including
gender, race, age groups, and residence in rural or urban areas.
Full-time equivalent RNs were then derived by relating the total
number of RN hours worked in the health care sector to the average
number of scheduled hours, without regard to leave, of an RN
employed full-time in that sector. Forecasts were developed on a
state-by-state basis and then aggregated to the US as a whole
(National Advisory Council on Nurse Education an
d Practice
2000).
Interdisciplinary
The Consortium for Primary Care in Wisconsin provides an example
of integrated planning for the total health workforce associated
with primary care. The Consortium established an interdisciplinary
team referred to as the Workforce Forum, made up of representatives
from the physician, nurse and physician assistant schools and
educational programs, employers, insurers, providers, managed care
organizations, state agencies, and underserved communities. Nurses
formed a significant leadership role in this exercise. Part of
their exercise was to establish an accurate demographic picture of
where primary care professionals were practising and an accurate
projection of future supply and demand.
The workforce took advantage of the Integrated Requirements Model
(IRM) Version 1.5 software developed by the Bureau of Health
Professions to integrate planning for different types and mix of
providers employed in the various health care settings. The IRM
links information of health insurance coverage, together with
information about the utilization of different providers under
different types of coverage, and estimates the number of providers
required to satisfy the population's primary care needs. The model
features a Windows-based graphical user interface that allows users
to generate multiple projections scenarios by adjusting the model's
assumptions about future trends in population and health care
organization. Six scenarios are distributed with IRG and the
Wisconsin forum developed a seventh. They are:
- Status Quo-insurance and staffing held constant
- Baseline Insurance Projection-best estimates of future HMO
penetration
- High Managed Care
- Universal Coverage-100% of population
- Equal Access with Universal Coverage-above with improved
access
- Double Non-physician Provider (NPP) use
- Double Non-physician use with equal access and universal
coverage
Based on this they were able to present the number of each type of
primary care provider required for each of the seven different
scenarios played out with Wisconsin data, projected forward from
1995 to 2005 (Riportella-Muller et al 2000).
The United Kingdom
Organization
The UK is in the process of moving to integrated planning of the
whole workforce-doctors, nurses, physiotherapists, ambulance staff,
pharmacists and others (Davies 2000) as part of their plan to
have"a quality workforce, in the right numbers, with the right
skills and diversity, organised in the right way, to deliver the
Government's service objectives for health and social care"
(Department of Health 1998). A commitment was made at this time to
put in place an annual workforce plan and the planning and
management capacity required to support this strategic
direction.
The House of Commons Health Select Committee re-affirmed this
direction in March 1999 within a set of principles including among
others that:"Planning should cover the whole health care workforce,
looking across sectors (primary, secondary and tertiary), employers
(public, private and voluntary) and staff groups (nurses, doctors,
dentists, other professions and other staff) and should take
account of evolving roles". Commitment was made to transform the
workforce as follows:
- "team work across
professional and organisational boundaries;
- flexible working to
make the best use of the range of skills and knowledge which
staff have;
- streamlined workforce
planning and development which stems from the needs of
patients not of professionals;
- maximising the contributions
of all staff to patient care, doing away with barriers
which say only doctors or nurses can provide particular types
of care;
- modernising education and
training to ensure that staff are equipped with the
skills they need to work in a complex, changing NHS;
- developing new, more
flexible, careers for staff of all professions and
more;
- expanding the workforce to meet future
demands"(Department of Health
2000).
Workforce plans are to be developed on a multi-disciplinary basis,
focussing on services to delivered and looking across primary,
secondary and tertiary care. Rather than a single workforce
advisory body, the emerging structure, initially proposed in A
Health Service of all the talents:
Developing the NHS workforce (2000) includes the
following:
Local Level
All NHS Trusts, including Primary Care Trusts are expected to
produce workforce plans for their own organizations that take into
account expected retirements, planned service changes, and skill
mix changes. Plans are to cover a 5 year time frame. Health
Authority executives are to assume responsibility for local
workforce planning and development in support of and aligned with
service planning through the Health Improvement Programmes
(HimP).
Regional Level
A total of 24 Workforce Development Confederations will be
established to take the lead on developing integrated workforce
planning for health care communities based on assessments of future
requirements for skills and competencies. To meet their mandate,
they will work closely with Health Authorities and the Health
Improvement Programs. They will also support both Health
Authorities and Trusts in the development of workforce planning
skills. It will also be their responsibility to ensure that
national, regional and local service plans are reflected in
workforce plans. The Confederations will also have overall
responsibility for commissioning and managing education and
training for all professional staff as well as working with key
professional groups to ensure the delivery of adequate numbers of
properly trained staff.
In addition, each NHS Regional Office will be strengthened with
the appointments of Directors of Workforce Development to whom
postgraduate deans of medicine and other would report. They will be
responsible for the management of a budget encompassing the
currently separate funding streams-service increment for teaching,
medical and dental education levy and non-medical education levy.
They will also work with confederations built on the foundations of
education consortia and local medical workforce advisory
groups.
National Level
A National Workforce Development Board, supported by Care Group
Workforce Development Boards will be responsible for ensuring the
proper integration of workforce issues with service development,
incorporating the work of existing uni-professional groups. The NHS
chief executiv
e officer will chair this Board. It will incorporate
existing groups including the Advisory Group on Medical Education,
Training and Staffing, the Specialist Workforce Advisory Group, the
Medical Workforce Standing Advisory Committee and the national
advisory groups for non-medical professions (Edmonson 1999, Queen
Margaret University College 2000, Department of Health 2001).
Related Initiatives
Reliable, and relevant and timely information is cited as a major
area of concern in the UK as elsewhere. A major strategic
initiative is a comprehensive review of information requirements to
support the new integrated approach to workforce planning.
Regarding nursing, and to some extent other health professionals,
there are a number of issues including the perceived shortage, the
aging of the profession and the reduction in the number of nurses
staying in the UK. One suggested contributor to today's shortage
was the employee downsizing reaction of employers to the market
forces, re
structuring and reform of the ea
rly 90s (both lay off and
influence on intake to training programs) (Buchan and Edwards
2000). This may be one of the contributors to the average age of
those employed in the system as their seniority would have left
them in place while younger nurses would face lay off and fewer
entered the workforce than were actually needed. In addition, there
is also a population of nurses in the community who may be
interested in returning.
A novel approach to encourage former nurses to return to work was
implemented by a consortium of Trusts and Health Authorities. The
initiative partnered with Directors of nursing, universities and
others to support a public information campaign that involved radio
and television, setting up information locations and a road show
bus. Those who expressed interest in returning were provided with
options for immediate return or tailored courses, including in-home
programs (Duguid 2000). In addition, specific targets have been set
for the nursing workforce in England by 2004. One goal is that by
2004, there will be 20,000 more nurses working in the system.
Another goal is to increase the number of nurses, midwives and
health visitors being trained each year by 5,500 (more than were
trained in 2000) (Queen Margaret University College 2000).
Methodology/Process
The UK has been undergoing change in its approach to workforce
planning as a result of both its relationship with the European
Union and its own health system reform. Approximately 7 years ago,
it brought specialist medical training in line with European
regulations on free movement of labour-with the Higher Specialist
Training (HST) to an average of 5 years varying by specialty.
Completion of this phase leads to a Certificate of Completion of
Specialist Training (CCST) and from that eligibility for a
consultant (specialist) position. All HST training positions were
assigned a National Training Number (NTN) to enable Post Graduate
Deans to keep track of trainees and to facilitate workforce
planning.
Workforce planning was, until April 1, 2001, done by the Specialty
Workforce Advisory Group (SWAG) consisting of workforce planners,
postgraduate deans of medicine, GP representatives, hospital
managers, the British Medical Association, junior doctors,
supported by a secretariat within the Department of Health
(Workforce Development). The process was as follows:
- In a series of detailed bilateral meetings, SWAG took
evidence each year from the Royal Colleges, Trusts, Regional
Offices (civil service) on the predicted need for consultants
in that particular specialty in 5 years time (training lead
time).
- Demand/Need was based on a combination of
specialist/population ratios for some specialties, medical
technology changes, impact of skill mix, service
reconfigurations and other measures.
- This demand scenario was then assessed in relationship to
the known and projected supply existing from the NTN profile,
with allowances for delays in training for flexible trainees,
uptake of additional study & research years, overseas
trainees returning abroad and other supply sources to determine
surplus or in this case, shortage.
- The resultant number is the number of trainees who will be
needed to take up training positions (NTNs) this year;
- if this number is more than the current number
available, then additional NTNs need to be created
- if less, then NTNs need to be removed.
- To avoid dramatic seesaws by creating and removing NTNs
each
year (with consequent service implications), targets were
smoothed over a few years, with gradual growth or
reductions.
- SWAG then aggregated all the individual specialty growth
predictions and these were submitted to Ministers for funding
consideration.
- Funding for HST places is through the central Medical and
Dental Education Levy (MADEL), which funds half the trainee's
salary which will probably be going up to 100% funding next
year according to Julia Moore of the Department of Health
(2001). Additional funding could not always be found for all
the growth recommended by SWAG, so training places would need
to be adjusted, or monies moved from training places being
removed.
While gaining in respect, the process was not without planning
problems. Those physicians who complete their training are expected
to 'vacate' those slots when their training is complete. If there
is no 'position' for them at this time, unemployment is a real
possibility. With the NHS perceived as a monopoly player, this also
poses a political as well as workforce problem. In addition,
several of the specialties have grown very fast and expect to fuel
a 10 % per annum expansion which is not sustainable in the long
term (Moore, 2001). To correct this would require pulling out
trainee numbers, which is very difficult as it impacts on current
service provision and is rarely supported by relevant Colleges or
understood in the face of perceived current shortages. One solution
would be flexibility in training to allow trainees to change
specialty by moving 'sideways' into a new stream-but this option is
not in place at this time. And finally there are currently
mismatches between the establishment of resident positions (SHOs)
based primarily on service needs in the hospitals rather than the
number of trainees required over time to satisfy the specialist
positions that are needed (Moore 2001).
The current situation is just emerging as a result of health
system reform and the new direction for health workforce planning.
As described under Organization above, the new
organizational structures are being put in
place to support an integrated, holistic process for the total
workforce within a policy of a multidisciplinary approach. At this
early stage, workforce numbers, for specialists, were predicated
mainly on what was achievable over the next three years (as an
optimistic estimate) based on the Health Specialist Training
positions that are currently in place plus a target for overseas
recruitment. The distribution between the various specialties will
be informed by the emerging Care Group plans.
In addition, National Service Frameworks (NSFs) have been in the
process of development of the past two years. The Frameworks set
out a ten year vision of where a particular service should go (e.g.
coronary heart disease, services for the elderly, cancer, etc.).
They are not intended to be prescriptive. Rather they are intended
to begin to give some shape to the overall direction of service
development, within which health workforce planners will plan. For
example, the emerging Care Group Workforce Groups will refer to
these Frameworks to assess workforce demand across the specialties
and other health professionals (medical, nursing and allied health
professionals).
Nursing target numbers are based, in part, on what was achievable
during
a three-year spending period. And in turn, this work will be
supported by the work of the local Workforce Confederations
assessing service developments in the field. There are a number of
concerns, mentioned previously, about the predicted retirement
rates and the capacity of nurse training to produce the required
numbers. As a result, more effort is being focussed on retention of
current staff, and on flexible working hours and pensions (Moore
2001).
Nursing plan in Scotland
In Scotland, there is one example of an approach to nurse
workforce planning that integrates service and workforce planning
using a"bottom-up approach involving all health service
employers-the Student Nurse Intake Project (SNIP). In this planning
process a simple computer spreadsheet is used, taking into account
future service plans and assessment of demand, each employer
determines an indicator of their probable future requirement for
nurses over the next 5 years. This information is then aggregated
to national level (Sc
otland) and used with other information
(retirement rates, turnover rates, etc.) to inform decisions on the
number of nursing students required to be educated in
preregistration nurse education. Estimates of future demand for
nurses from private sector employers are also factored into the
assessment (Buchan 1994).
Implications and Possible Approaches for Canada
Canada's experience with health workforce planning has tended to
parallel the major themes and implications that were presented
earlier as background of this paper. At present, reviews of
physicians and nurses as isolated studies still tend to be the
pattern. There is an opportunity now to learn from our own and
others' experiences. The workforce issues that have been associated
with policy, practice, societal elements and the professional
milieu, as well as with approaches and methodologies as summarized,
should serve to inform future directions and progress in terms of
what not to do, what needs to be corrected, and what might be
done.
It appears that Canada would benefit from a vision, framework and
definition as well as a more permanent and on-going organization
and process to plan for and monitor the health workforce. There is
great need at present for a good national picture and understanding
of workforce patterns across Canada as well as between it and
elsewhere. There are a number of reasons to do this. For one,
international agreements and trends as well as internal national
agreements are posing increasing impacts on the Canadian workforce.
Immigration in and out of the country is a reality, and mobility
within the country across provinces and territories is not just a
reality, but a right of Canadians to seek employment anywhere in
the country.
The mobility of health professionals is reinforced by the 1994
Agreement on Internal Trade
(Chapter 7) concerning labour mobility within Canada,
which asserts that"Governments are improving the ability of
Canadian residents to work anywhere in the country. The federal,
provincial and territorial governments have agreed to remove
barriers to interprovincial trade and ensure the free movement of
persons, goods, services and investments. The objective of the
Labour Mobility Chapter is to enable workers qualified for an
occupation in one part of Canada to have access to employment
opportunities in that occupation in any other province or
territory" (HRDC 2001). This would strongly imply that provincial
or territorial planning should not be done in isolation of these
realities. Planning efforts should be supported and refined with
input from a capacity to plan for and monitor workforce at all
levels - on a national, provincial/territorial and regional basis.
This in turn requires better information.
Canada does have some data available - mostly on physicians, some
on registered nurses and minimal to none on other nurses or allied
health professionals - in such resources as the Canadian Institute
for Health Information (CIHI 2001). At the same time, there is much
work yet to be done in the area of constructing and refining more
consistent and accessible data resources and linkages across the
country. With well integrated information, any special studies
carried out at the provincial or territorial level would be
enriched by access to a more comprehensive resource for input,
information and support. More research is required in the area of
health human resources to better understand their circumstances,
needs and possibilities. This was reinforced by a recent
cross-country consultation summarized in the paper Listening for
Direction (Gagnon and Menard 2001), which identified health
human resources as
the priority theme in need of research.
Present reform strategies plus some independent evolution of
scopes and patterns of practice are pressing the need for a more
comprehensive and organized approach to health workforce planning.
Primary health care reform is now a major international focus and
in Canada is a national as well as provincial/territorial priority.
This brings to the forefront the same kinds of realities that other
countries are addressing or are preparing to incorporate into their
thinking. More physicians have been moving to work in groups than
ever before, and there is increasing work in multi- and
inter-disciplinary teams of physicians, nurses, dieticians, social
workers, and other health professionals working within the same
organizations (Mable and Marriott 2001). A better understanding is
warranted of the implications and the opportunities that these
developments represent.
Canada has not yet achieved a comprehensive approach to health
human resources, but is situated on the cusp of more focussed and
concerted action. An increasing population health focus has been
reflected in program design as well as in the development of
clinical practice and other guidelines to improve responses to the
needs of particular populations (e.g. diabetics) - propelling the
system to greater functional integration and collaboration. Some
health organizations are taking greater steps by investigating the
potential of vertically integrated health organizations to assume
responsibility for the full continuum of health services, with
significant implications for health professionals. This all
strongly indicates, as concluded in other countries reviewed, that
it only makes sense to plan for the total workforce in an
integrated and systematic fashion on an on-going basis-not
just for one profession in isolation at a time.
Canada has indicated its commitment in a variety of ways to
improve capacity to determine the right number and mix of providers
with the right skills in the right place to meet the needs of the
population. In their September 1998 Ministers' meeting, the F/P/T
Ministers of Health agreed on future directions and key priorities,
including collaboration on health human resource planning. In a
1999 meeting in Charlottetown, they indicated concrete progress in
this area (Health Canada 1999). The First Ministers further
endorsed this direction in the September 2000 Action Plan for
Health System Renewal, with their agreement to collaborate on
specific
priorities, including the supply of doctors, nurses and other
health personnel. This is in addition to providing"more effective
information sharing within and across jurisdictions" (CICS
2000).
A good step toward focussing action would be to establish a task
force to develop a permanent National Workforce Planning
Organization (NWPO), with an appropriate budget and staff, to
operate on an on-going basis. The organization could have
representation or input into its governance by the federal,
provincial and territorial governments, as well as key professional
and educational institution stakeholders and citizens. It should
probably be a somewhat offset organization with a clear mandate for
objectivity, to avoid the past problems of 'self-interest' that
have been characteristic of stakeholders in general, including
governments. The mandate should be defined in explicit terms
relating to objective integrated wo
rkforce planning, with
responsibility for on-going monitoring and studies as fitting with
national, provincial, regional and local patterns.
The organization could have the support of a central advisory
committee and could develop special purpose committees as required.
It could build linkages and partnerships with any other permanent
organizations or staff within the federal, provincial and
territorial governments, that have responsibility for workforce
planning. It could also link to health services planning and
research bodies. The task force and ultimately, the NWPO could have
responsibility to carry out a number of tasks including, but not
limited to the steps which follow.
- Establish a vision for the organization and its
mandate.
- Establish a fitting 'definition' for workforce
planning-appropriately linked to and providing a contribution
to various aspects of provider 'supply' (education, training,
immigration, migration, etc.) a
nd workforce management (e.g.
effective organization; recruitment, and retention, etc.).
- Establish a framework for national, provincial, regional,
local and special focus workforce planning (e.g. related to
special populations, sectors, policy initiatives, etc.).
- Develop a number of future scenarios for Canada's health
system.
- Carry out a comprehensive review of 'data requirements' to
support workforce planning nationally with the capacity to
carry out cross-comparisons and analysis and to focus at
national, provincial, regional and local geographic areas
within Canada. A particular challenge in this area will be to
resolve the problem of 'linking' provincial and territorial
data.
- Work on creating guidelines and standards for information
collection.
- Identify policy requirements and options.
- Create appropriate linkages to ensure that workforce
planning is informed and guided by an explicit link to health
policy, organizational evolution and health services planning.
- Ensure that workforce planning is appropriately linked to
and supportive of broader health human resources planning and
management.
- Develop good information and understanding of individual
health professions in addition to the capacity to address them
within an integrated planning approach.
- Develop and implement multi-modality methodologies and
processes based on the emerging and evolving experiences in
other jurisdictions as well as Canadian leading edge
thinking.
- Consider a fund to support research and/or encourage
existing research funding agencies to focus on workforce to
provide additional assessments and evaluations of approaches
and performance of the Organization as well as contribute to
refinement of approaches.
- Establish a process for on-going monitoring of workforce
with capacity to flag and respond in a timely fashion to new or
changing circumstances that arise.
- Establish an internal information system as well as an
electronic network for partners and users to create a real time
'connectivity' for operations and communications.
If established, such an organization could become the focal point
for workforce planning in Canada, and would be an important
contributor to improving Canada's health system. The potential this
brings is for fewer dramatic shifts and improved quality, stability
and sustainability for the health system - in short, a 'steady
state' future for the Canadian health workforce.
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