Tessa Richards: Now is the winter of our discontent

Tessa RichardsStorm clouds hovered above Brussels. Europe’s heads of state battled away, yet again, to try and save the eurozone from collapse. Down the road an international group of clinicians, researchers, and policy makers questioned how Europe’s beleaguered health systems can cope as demand for care soars and workforces shrink.

The European Commission warned member states they would be short of a million skilled healthcare workers by 2020 over a year ago. Over the past three years it’s stumped up several millions of euro’s to support three vast quantitative and qualitative data mapping projects on Europe’s workforce. Information from these provided the backbone for a recent meeting on workforce planning and mobility.

Europe is not facing Armageddon. The average number of doctors per 100,000 of the population in the EU is around 120. It’s closer to 5 in sub-Saharan Africa. And the OECD average of nurses per 1000 of the population is 8.4, compared with 0.9 in India.

But as in Africa and India, the problem in Europe is one of a massively uneven distribution of nurses and doctors between and within countries. This makes workforce planning difficult. Planning is also undermined by the fact that few countries collect good data on the numbers and skill mix of health staff employed, where they come from, how long they stay, why they leave the profession or opt to work in another country, and how many return.

One of the three European studies,  RN4CAST, has looked at nurse staffing ratio’s,  skills mix, educational attainment, impact on health outcomes and patient satisfaction in 12 EU member states. One of the main messages from this project is that although numbers vary (Denmark has four times the number of nurses than Greece, which boasts the highest doctor nurse ratio) burn out and job dissatisfaction are worryingly high in many countries, including the UK.

Discontent is less about numbers or poor wages, the study suggests, than difficult and discouraging work environments. Older, sicker, heavier patients who are being propelled ever more rapidly through secondary care have made the job of being a nurse more stressful, and management takes too little notice of nurses concerns. Fewer would leave and more might be attracted to the profession if their concerns were addressed, the meeting agreed.

Money is, however, a key driver for doctors to cross national borders. Todorka Kostadinova, a Bulgarian epidemiologist, cited regional data from the MoHprof study showing an exodus of skilled staff from Romania, Bulgaria, Russia and the Ukraine (they get diploma’s in Bulgaria and move on) to countries in Western Europe.

Salaries are low and in Bulgaria and Romania they have been cut by 25% in the past year. Additional factors that fuel migration include poor terms and conditions of service, rundown facilities, few opportunities for postgraduate education and training, and a lack of status.

Throughout Europe, and well beyond, recruitment agencies have capitalised on the discontent of health professionals and (for a price) facilitated their movement abroad to countries which offer, or appear to offer, better opportunities.

Patients, not least in the UK, which is a poacher of health professionals second to none, have become inured to the fact that many of the medical staff they encounter are “foreign.” The day to day problems this throws up for patients and staff, and its impact on the cost and quality of medical care are not well quantified. Anecdotes are common but only high profile cases such as the Ubani case, spur wide debate and change.

Public awareness of the mobile global health workforce is, however, rising.  On the day the Brussels meeting ended, Le Soir 8 December, published a two page article “Hopitaux; 1 medecin sur 5 est etranger” critical of Belgium’s dependence on migrant workers from Tunisia, Libya, Portugal, and Romania. Its messages are generic.

Not all countries are aiming to train for “self sufficiency” and  regulated “circular migration,” which is strongly supported by some countries, particularly low and middle income ones, has merit, but countries need to get a better handle on their health workforces. They also need to take preventive action to stop (more) discontented staff voting with their feet.

Tessa Richards is analysis editor, BMJ.