11.3.1. Health workforce

The health sector is highly labour intensive. Typically, the health system is among the largest, if not the largest employer in the country. There is a substantial variation in the supply of physicians per capita across Europe. The highest density of physicians is seen in Greece, with almost 500 physicians per 100,000 population. High density also exists in Belgium, with the lowest density in Turkey, Romania and the UK. It is possible these data are slightly inaccurate due to the potential inclusion of unemployed physicians in the Greek calculations, and possibly of the exclusion of private physicians in the UK. When physicians are separated into general practitioners and specialists, a relatively high supply of GPs is seen in Austria, Belgium, Finland and France, with the lowest levels in Slovakia, Slovenia and the Netherlands. A greater range of specialist physicians, again with high density, is seen in Greece, Norway, Poland, Germany and Slovakia. There seems to be a trend in most countries of a declining proportion of general physicians, partly reflecting the increasing complexity of medical treatments (Simoens and Hurst, 2006) or cultural and financial reasons.

Table 11.6. Numbers of practising physicians, GPs, specialists, nurses, dentists, and pharmacists per 100,000 population, 2006 or latest available year

The ratio of practising doctors per 1,000 population grew between 1990 and 2005 in nearly all OECD countries, but at a slower rate than in the previous fifteen year period. The level of physicians relates both to characteristics of the population (demand) and also to how the system is organized (supply). With regards to the latter, a key factor influencing physician density is the presence of a restriction or limit to the number of physicians trained in the country - numerus clausus. Among OECD countries in Europe, Austria, Germany, Switzerland, and to some extent Belgium and Greece do not place a restriction on the number of admissions to medical schools (Simoens and Hurst 2006). It has been suggested that the level and growth rate of physician density over time has been higher in those countries that do not, or have only recently, controlled the intake to medical schools. But the lower numbers of physicians also reflect cost-containment measures introduced by many countries during the 1980s and 1990s, which reduced the number of new doctors, and included limiting medical school intake. From 1990 to 2005, the annual number of medical students graduating in France, Germany, Italy, Japan, Spain and Switzerland declined. If training efforts do not increase significantly in the near future, many countries will have to rely on foreign-trained doctors as the baby-boom generation of doctors retires from the profession.

The OECD’s June 2007 International Migration Outlook examined the “brain drain” of doctors from lower-income to higher-income countries. Between 2000 and 2005, the share of foreign-trained doctors rose in many OECD countries. In 2005, the UK, Ireland, the US, Australia, New Zealand and Canada had the highest shares of foreign-trained doctors, with some one-quarter to one-third of all practising doctors trained in another country. The share of foreign-trained doctors is also growing rapidly in Switzerland, France and some of the Nordic countries.

Not only the number and density of physicians, but also their geographical distribution within the country is an issue faced by most countries. Countries that experience inequity in the distribution of physicians, typically in favour of urban areas, have introduced measures to attract physicians to rural and deprived urban areas. Greece applies educational initiatives where the medical degree is conditional on undertaking two years of practice in rural areas. In the UK, the GP vocational training scheme involves training specific to rural practice. Norway and Sweden locate medical schools in rural areas to attract more diverse students and to train them in rural health issues. Financial incentives related to training, such as offering scholarships to medical students who commit to practice in underserved areas, as seen in Norway, are also used. Regulatory mechanisms to improve geographical equity in physician supply, such as setting a threshold for the number of physicians contracted by a regional insurance fund, are present in Austria and Germany. Financial incentives linked to the payment mechanism to attract physicians to underserved areas is seen mainly in the UK, and has proven to be effective, although possibly more costly (Simoens and Hurst, 2006).

The role of nurses in the health system varies across Europe. In some countries nurses are the first point of contact e.g. the Netherlands, while in others, patients can access specialists directly and the role of nurses is less prevalent. It is therefore not surprising that high numbers of nurses are seen in the Netherlands (1,454 nurses per 100,000 population), with high supply also in Belgium (1,341 per 100,000), and in particularly Ireland and Norway (over 1,500 nurses per 100,000).

Educational paths for medicine differ across Europe. These differences range from the type of training institution to the number of years and academic hurdles passed in order to advance to the next level. Differences in training are gradually being overcome, in particular due to the EU harmonization process. The typical training medical school in Europe is 5-6 years, with residency of 2-6 years and a life-long continuing medical education path.

Regardless of the profession or training level, in order to offer certificates or degrees that are acknowledged and usable elsewhere, institutions typically require accreditation by central and regional governments or professional bodies. This is part of their quality assurance profile and serves legal, contractual and professional purposes. Efforts are under way to develop accreditation programmes not just within particular states but also at EU level and even worldwide through agencies such as the WHO-sponsored World Federation for Medical Education. Regulating bodies may require a certain number of training hours, specific types of courses or rotations to be provided by an institution or completed by a candidate. Health professions’ education in Europe is tightly regulated by law rather than left under the purview of individual institutions as in other parts of the world. This has promoted more consistency within countries but has also hampered progress as laws are slow to change. EU membership requirements have added a new layer of standards and these in turn have brought new local laws and regulations. Details on the characteristics and challenges facing the healthcare workforce in nine countries - France, Germany, Lithuania, Malta, Norway, Poland, the Russian Federation, Spain and the United Kingdom - can be found in a recent publication reviewing the workforce supply, education and training, working conditions, performance management and regulation of health care personnel (Rechel et al 2006).