Various factors contribute to the global shortage, finds Helen Featherstone, Director and General Manager GMCSI
In order to hit the UN’s sustainable development goal of universal health coverage (UHC) it has been estimated by the World Health Organisation, that we will need another 10m healthcare workers globally by 2030. This shortfall comes against a backdrop of greater attrition rates, falling numbers of young people entering the health workforce and an extreme regional imbalance, in terms of workforce numbers.
While the primary purpose of regulators is to protect patient safety by ensuring healthcare practitioners’ competency, probity and fitness to practise, the panel examined if they could also play a role in solving the issues around the lack of healthcare workers and addressing shortage and distribution challenges.
This role could be enabling healthcare workers to move more easily between global health economies by reducing the time it takes to obtain registration in the new country. It could also provide equivalency between systems to allow professionals to operate at the top of their licences. In addition, it could ensure that any influx of trainees or re-entrants to the professions are suitably qualified to do so and are properly regulated. However, in the GMC’s view, it is an extremely complex situation as mutual recognition of medical qualifications is currently not an option due to the differing standards of medical education around the world. This is a significant hurdle to overcome.
This topic was debated in a Healthcare World Series webinar with a panel consisting of:
• Steve Gardner – Managing Director Healthcare World (Chair)
• Colin Melville – Medical Director and Director of Education and Standards – The General Medical Council (UK)
• James Campbell, Director for Workforce – World Health Organisation
• Professor Ged Byrne – International Director – NHS England
• Vivian Lin – University of Hong Kong, Elizabeth Oywer – Nursing Regulator, (Kenya)
• Joan Simeon – CEO Medical Council of New Zealand
• Jishnu Das -Center for Policy Research (India)
Multi-dimensional crisis
The panel found that the crisis is multifaceted. While there is high production of medical doctors around the world, there is poor absorption capacity into jobs, or poor management and retention of those jobs in certain countries, rather than simply a supply-side education shortage. In many African countries, there is now a plethora of medical schools but not all the graduates are being employed locally due to inefficient workforce planning. Many are leaving for other countries, creating a workforce shortage in their own country with resulting clinical burnout for those in post. Yet in countries such as the Philippines, reports show that the higher the demand for Filippino nurses overseas, the larger the supply response, creating more nursing staff who remain behind in the Philippines.
Thus, the shortage appears to be a supply and demand phenomenon. Health is now internationalised and democratised by providers and those workers who are willing to move can do so, if they want to. For this reason, areas such as sub-Saharan Africa are being denuded of their healthcare workforce, creating a workforce shortage in the respective countries. The NHS is focussing on loan return to help the international workforce by offering short term periods where they gain additional skills in the UK and then return to their country of origin (known as earn, learn and return). New Zealand has an excellent programme and registration pathway, that is temporary and time bound for doctors in the Pacific Islands to spend up to two years training in New Zealand, but afterwards they must go back to their home country. Similar sponsorship opportunities are also available in the UK.
Redistributing the workforce through regulation
The panel agreed that the idea that every healthcare worker globally is overworked is not backed up by the data. In countries such as Kenya, Vietnam and India, smaller primary care centres sometimes only see one patient a day. So there is a question regarding how many people are able to access healthcare, and for those who can’t, why not? Conversely, the growth in unmet needs across the world is increasing exponentially with the current economic circumstances, driven predominantly by conflict in Eastern Europe and the Middle East.
In New Zealand, the majority of people can access the healthcare they require, and those who don’t are often indigenous or disadvantaged people. Indigenous people may prefer to visit a more traditional healer rather than a medical doctor. Equally, there is a need to consider how to provide the right healthcare in the places where people live, such as geriatric provision in coastal retirement towns. As such, there are both supply and distribution issues and not just a supply issue. Furthermore, countries need to consider the balance between their need for specialists against their needs for more generalists. Many countries are experiencing shortages of general practitioners as medical students gravitate more to the specialty areas for the many prestige and financial rewards.
Educators could possibly influence workforce by requiring graduates to work in general practice, for example, to see how healthcare is delivered in local communities. Therefore, perhaps educators need to think about medical education differently. Blended learning programmes are one of the mechanisms to increase supply; yet there are large swathes of professionals in the world who carefully maintain their professional boundaries which potentially impacts on supply. So new ways of working for professional groups that analyse and utilise skill mix, based on population need, could be the way forward.
Finally, the panel agreed that there is a need to train more regulators while there is also a need to strengthen regulations in the interest of patient safety. In addition, there should be a professional qualification leading to regulation, so that regulators and professionals are clear about the regulations. One approach is to undertake more research and to publish more literature as the evidence base is currently lacking. In this way, with emphasis on regulation, the workforce challenges can begin to be addressed successfully.
Understanding the reasons behind workforce migration
The GMC has subsequently published a report Identifying Groups of Migrating Doctors that analyses the reasons behind such movement. In the UK, there are clear groups that are considering migration, each for their own specific reasons. These reasons are categorised into into Deep Discontent, System Sceptics, Burnt Out, Mobile Career Developers, Open to Opportunity and Happy in the UK.
The Deep Discontent group is dissatisfied on all fronts. The System Sceptics are concerned about the direction of the UK healthcare system and dissatisfied with their own working conditions. The Burnt Out group is defined by a focus on personal wellbeing and work-life balance, with UK practice being found wanting for both. The Mobile Career Developers are a segment with a high proportion of doctors who qualified overseas, who tend to be neutral about working in the UK, but could be tempted to leave if faced with obstacles to their career progression. On a more positive note, those Open to Opportunity are a relatively content group of doctors, some of whom would consider working abroad for a new challenge. Finally there are those who are Happy in the UK – a high proportion of doctors who qualified overseas, but many of whom will return to their home country at some point.
The report finds that some migration is inevitable and natural as doctors return to their origin country (33 per cent of leavers) and some are intent on experiencing new challenges abroad (20 per cent of leavers). Retention strategies that focus on working conditions and the UK’s competitive position, including pay, are likely to be most effective among doctors in the Deep Discontent, System Sceptic, and Burnt Out segments. These groups make up most of the doctors who say they are very likely to leave: 34 per cent, 33 per cent and 15 per cent respectively.
Identifying reasons for migration is hugely helpful for policy makers, so how well do countries understand such reasons and do the trends above in the UK sound familiar? Workforce migration is a complex puzzle to solve and there are many factors involved. Each aspect of the healthcare system has a role to play.
Here is a simplistic example using medical doctors. Medical schools can provide their numbers of students about to graduate (undergraduate) and the numbers of specialists due to complete their training (post-graduate) on an annual basis. This data collection feeds into a national dataset where an analysis can be performed of many undergraduate and post-graduate students entering the workforce on an annual basis. Regulators, Ministries of Education or Ministries of Health should ideally have access to this data as they are likely to be tracking student numbers as their role to assess the quality of the medical schools. This data then feeds into the data modelling of healthcare providers who can plan their workforces accordingly, ensuring there are adequate places available for these graduates to be absorbed into the workplace. This may discourage some migration as career opportunities exist and further training is provided within the workplace. Such a method enables an entire healthcare system to work in collaboration to meet the needs of the workforce whilst simultaneously protecting the patient.
Should your organisation require trusted business advice on the required data and data analytics processes, market research in identifying reasons behind workforce migration or surveys, to understand the current issues being experienced by the workforce, GMC Services International (GMCSI) can assist. As a wholly owned subsidiary of the General Medical Council (GMC), GMCSI utilises the subject matter expertise from within the GMC as trusted regulatory advisors, providing recommendations and practical advice based on its 160 year experience.
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