Human resources in health systems

Introduction

The opportunity to study medicine is subject to restrictions in all EU Member States, with the exception of Austria. In France, although there are no restrictions on access to medical studies, students must pass a "concours" before they are allowed to continue in the second year. Council Directive 93/16/EECpdf states that basic medical training in the EU must be at least 6 years, or 5 500 hours, in or under the supervision of a university. The majority of Member States meet this requirement. However, there are two countries where the minimum duration is shorter - Great Britain (4 or 5 years) and Sweden (5.5 years), and two where this minimum duration is longer - Finland (6.5 years) and Belgium (7 years). In some EU Member States, doctors are awarded their license to engage in independent medical practice immediately after completing their medical studies. This is the case in Greece, Italy, Spain, Netherlands and Belgium. In other Member States, doctors, upon graduation from the medical university, take up a probationary period of practical postgraduate training which, if successfully completed, allows them to carry out independent medical practice as a doctor. The duration of this training period varies: it is 12 months in Great Britain and Ireland (which allows these countries to meet the basic requirement of the Directive) but 18 months in Germany, Portugal and Sweden. In Luxembourg, the Ministry of Health grants an authorisation to practice medicine on the grounds of a diploma issued in another EU Member State (postgraduate training is not possible in Luxembourg). The conferral of the license alone does not mean that the doctor is admitted into the system of social security. The prerequisite for the public health care systems as well as for the social insurance systems is additional specific training in general medical practice or in a speciality. In France, Finland and Austria, the licence to independently practise medicine is conferred only after the completion of specific training in general medical practice or specialist training. Therefore, there are no doctors in those countries who have only an "Approbation", i.e. doctors are only entitled to exercise the medical profession independently after completion of their training as general medical practitioners or as specialists.

Council Directive 93/16/EEC states that general practitioners intending to exercise their profession within the social security system must furnish proof of postgraduate practical training. At the moment, a minimum duration of 2 years training is required in Finland, Italy and Belgium, while 2.5 years is required in France for training in general medical practice. General practitioners in Sweden generally undergo free specialist training for a minimum period of 5 years in Family Medicine/GP. A training period of 3 years in general medical practice is required in Greece, Spain, Portugal, the Netherlands, Ireland and Austria. In Denmark, the duration of training in general medical practice is 3.5 years. In Germany, the requirement is 4 years of 'specialist' training in general medical practice that includes the 18-month period of "Approbation".

See Österreichische Ärztekammer - Short overview of the health care systems in the EU Member States: Medical educationde .

The EU has also agreed a set of acceptable minimum standards for the training of nursing professionals in order to allow free movement for nurses in the Member States. This is for NRGCs [nurses responsible for general care, or general nurses (EC)] who have completed a basic general training of at least three years (Directives 77/452/EEC, 77/453/EEC and amendments of 10.10.1989 and 30.10.1989). Midwives are professionals with training in accordance with the EC Midwives Directives (80/154/EEC, 80/155/EEC).

Responding to the need for comparable data on EU human health resources

The EU project Human resources of European health systems, coordinated by the BASYS Institute under the Health Monitoring Programme, has produced a positive outcome in terms of the broad availability of data in many of the countries that delivered information on metadata. At the same time, however, the main problem is the limited availability of data in some areas (actors according to the ICHA-HP classification) and the various levels (age, gender, head counts etc.) at which data are broken down. This, along with differences in the quality of reporting, causes difficulties for the production of comparable statistics on human resources at European level. The assessment of metadata on the human resources of the health sector in the Member States shows that some countries have started to establish labour accounting systems for the health sector (HLA). The project calls for a new methodology to be used to develop and implement an integrative statistical tool, termed Health Labour Accounts (HLA), at least at the 1-digit level, which will be compatible with the SHA. The system will be based on existing statistics. By using and combining a broad variety of existing data on HLA, this approach will provide added value for health policy information in all European countries.

The concept of Labour Accounting Systems has been defined in depth in the Eurostat project Implementing the Concept of Health Care - Manpower in Member States on a Prototype Basispdf(790 KB) , coordinated by the BASYS Institute. Member States use various data sources to compile coherent aggregates. Some statistics focus on the total, others on parts of the total. Their reliability often varies. Experiences with Health Labour Accounts (HLA) show that the HLA has to be built bottom-up and can be derived neither from the EU Labour Force Survey nor from the SNA exclusively. The problem is similar to the SHA, where all available statistics have to be linked in a consistent way, with SHA providing the main framework. As manpower is the most important production factor, consistency can also be ensured by linking production values to manpower, usually described as labour productivity. The comparison of productivity ratios among different actors as well as among countries can provide considerable support for the review of the outcome of the labour accounts.

Responding to the need for comparable data on medical professions

Member States use different concepts when reporting the number of health care professionals - both for national purposes and for international comparison. The most commonly used definitions are the following:

  • Health Care professionals "immediately serving patients" have direct contact with patients as consumers of health care services (final consumption in the health care economic sector). Terms like "practising" for doctors or dentists or "dispensing" pharmacists refer to this category. This definition is the best one for describing the availability of health care human resources, because all persons included here produce directly for final demand.
  • Economically active" health care professionals include in addition those health care professionals who work in their profession, but outside the health care system. Pharmacists working for the pharmaceutical industry, physicians working in government administration or nurses working in occupational health for enterprises serve as examples here.
  • Health care professionals "entitled to provide services" are defined in terms of their 'ability or qualification to render medical services' rather than in terms of their actual economic activity. Terms like "entitled to practice" for doctors or dentists or "graduated" for nurses refer to this category. The definition includes all health care professionals who successfully graduated from their respective training institutions, irrespective of whether they are economically active or not (e.g. retired, unemployed or abroad) or whether they are active in their profession or not (e.g. a doctor working as a taxi driver).

For comparing health care services across Member States, Eurostat and DG SANCO give preference to the concept of "immediately serving patients", as it best describes the availability of health care resources.

The publication Health Care Eurostat Metadata in SDDS format: Summary Methodology provides all the necessary methodological descriptions for this data.

According to Eurostat, the total number of practising physicians has steadily increased in most Member States over the last 20 years. The number of licensed physicians exceeds the number of practising physicians in all countries, although the ratio observed in 2003 varies between countries. There are large variations in the number of medical specialists between countries, particularly in specialities such as oncology, infant surgery, occupational medicine and urology, where the range of density exceeds 10:1. This also holds for the 'large' groups such as internal medicine, with 12:0, and psychiatry and (to a lesser extent) general practitioners ,with a ratio of 6:1. In certain fields, there is a lack of specialists and an unbalanced distribution of specialists across countries. The number of practising dentists in the EU has increased over the last 20 years.

See Practising physicians per 100 000 inhabitantspdf(17 KB)
See Licensed physicians per 100 000 inhabitantspdf(17 KB)
See Medical Specialists per 100 000 inhabitants - per speciality - 2003pdf(22 KB)
See Practising dentists per 100 000 inhabitantspdf(23 KB)
See Eurostat Health statistics

Responding to the need for comparable data on nursing professions

According to Eurostat, the data on the numbers of qualified nurses and midwives vary in a similar way. The respective density rates fluctuate to a somewhat lesser degree. The range between the countries with the lowest and highest density rates is wider for qualified nurses than for practising nurses and midwives. Recent estimates of unfilled nursing positions reveal a large number of open nursing positions in hospitals. Medical practices report having greater difficulty hiring nurses to supervise clinical staff and to perform higher-level duties, waiting longer to hire nursing staff and not being able to offer higher salaries to attract qualified candidates. Enrolment in nursing studies has been steadily declining in recent years and the level of migration and mobility is high in this profession. For problems related to the nursing professions, see The Standing Committee of Nurses of the EU (PCN).

According to Eurostat, the variations are less pronounced for midwives. In the majority of Member States, midwives are considered as a completely separate group of health professionals, including those who trained before the adoption of the Midwives Directives and Decisions mentioned above.

See Total number of qualified nurses and midwives per 100 000 inhabitantspdf(75 KB).

ata on nursing professions, a Task Force European Data on Nursespdf(95 KB) cover all professionals was created by Eurostat to submit to Member States some recommendations for the collection of data. Raising the quality and comparability of data on nursing staff requires various criteria to be met: data must not mix different methodological concepts. Qualified nurses, irrespective of whether active, retired, working abroad, or active in a different profession, provides information of a different kind than Nurses economically active in their profession. This again differs from what is denoted by data on Nurses active in the health care sector or Nurses in direct patient treatment. The Task Force considers Nurses in direct patient treatment to be the best concept for the purpose here, where it includes nurses active in health programmes. The TF admits, however, that Nurses active in the health care sector may be the only available concept, and that data collections will have to settle for that. Data must cover all professionals providing nursing care in non-negligible amounts and quality.

Responding to the need for better knowledge of the planning and mobility of the health workforce

Economists have used standard location theory to explain and predict the practice location choices of health professionals. Assuming that health professionals are profit maximisers and price-takers, health professionals will be distributed in proportion to the demand for health care. Areas where health professionals encounter more demand for their services, and thus earn more, will attract more health professionals and vice versa. Ultimately, the number of local health professionals will adjust so as to equalise net advantages across areas. The overall effect of the increasing mobility of health care services on health quality outcomes is also far from clear. However, profit maximisation is probably not the most appropriate tool to describe the behaviour of health professionals. A number of additional factors inform the decision of health professionals to locate and hence play a role in the spatial distribution of health professionals by altering the relative attractiveness of areas.

The main factors to be considered at EU level are: the limited regulation of the health workforce in the EU, the absence of restrictions on independent practice for licensed physicians (free choice of region), the different models of access by patients to doctors (capitation, fee-for-service), the quantitative regulation of medical students, the numerus clausus in medical studies and the limitation on the number of specialists. Other factors include opportunities for continuing professional education, quality of schools and access to leisure activities in the EU regions.

The main objectives at EU level are to analyse and quantify the flows of medical and nursing professions between EU regions (and from the rest of the world), the main reasons behind these flows, the Member States and regions where a shortage in some professions and specialities exists, and the mechanisms and tools for health staff planning in the Member States.

See the DG SANCO presentation European mobility of medical and nursing workforcepdf(326 KB)

The OECD Human Resources for Health Care (HRHC) study analyses how decisionmakers can ensure an adequate supply of physicians and nurses. The project explores international variability in the employment of physicians and nurses; the extent of shortages and surpluses; and the effectiveness of certain management policies in influencing the supply of physicians and nurses across OECD countries.