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Managing medical workforces: from relative stability to disequilibrium in the UK NHS.

The management of the medical workforce, in particular the market for physicians, is costly and complex. For decades this process has been dominated by largely mechanistic forecasting (e.g., fixed doctor-population ratios), which ignored economic determinants. Internationally, and specifically in the UK, such practices achieved some success in producing modest cyclical shortages and surpluses in the past. However with large increases in UK health care funding, together with the international recognition of significant practice, activity and outcome variations in health care, this approach is now inadequate. With physician shortages emerging internationally, the impact of incentives (both financial and non-financial) on skill-mix (are nurses cost effective substitutes or complements for physicians?), activity (can distribution means be shifted and variation reduced?) and outcomes (can survival duration and quality of life of survival be improved?) is now central to policy development. Such issues create nice challenges for researchers and policy makers.

Budgets↗

North Carolina Institute of Medicine Task Force on the North Carolina Nursing Workforce (2004).

North Carolina is indeed fortunate to have avoided many of the extreme shortages of nurses reported in other states. Yet, there are important developments on the horizon that have the potential to cause such shortages. Taking action today to expand the production of new nurses, enhance their education, augment school-to-work transitions, and improve the nursing workplace environment can help reduce the likelihood of a future nursing workforce crisis. Some steps will require new financial commitments either from public or private sources. Others will require a renewed commitment on the part of employers, educators, regulators and the nursing community. However, these steps are necessary if we are to recruit and retain well-prepared and motivated nurses who are needed to meet our healthcare needs now and in the future. Nursing, especially nursing at the bedside in hospitals and in long-term care, requires increasingly sophisticated technical skills and continues to demand intellectual, physical and emotional energy beyond what would be required in many other professions and occupations. It is hoped that the recommendations offered here will help focus the efforts of legislators, educators, employers, the nursing community, trade associations, foundations and the public at large to ensure an adequate supply of well-trained nursing personnel for the future.

Adult↗

The report of the Task Force on the North Carolina Nursing Workforce--May 2004.

North Carolina is indeed fortunate to have avoided many of the extreme shortages of nurses reported in other states. Yet, even as this was noted, there were important developments on the horizon which had the potential to cause such shortages even here. The fact that there are so many pathways into this field and throughout an individual nurse's career made it necessary to organize our deliberations in a way that enabled the Task Force to deal with the special (often unique) situations faced by one form of nursing education, or one avenue of nursing practice. The Task Force then had to synthesize these findings and recommendations in a format that offered a potential framework for future policy decisions affecting the profession of nursing as a whole. It is a tribute to both the process and the participants that the way these discussions unfolded may have identified ways in which seemingly disjointed elements of North Carolina nursing might begin to see opportunities for collaboration, coordination, and ultimately greater levels of accomplishment in relation to the broad goals of this effort as a whole. In this report, as one would expect, there are identifiable needs: for additional financial support for nursing education (through support to our public and private institutions and their faculties offering different types of nursing credentials, as well as for the scholarship support of those who choose to enter this field), for programs and initiatives to enable recent nursing school graduates to enter nursing better prepared to render the professional services for which they were employed, and for concrete improvements in the nursing work environments. The fact that nursing, especially nursing at the bedside in hospitals and in long-term care, requires increasingly sophisticated technical skills and continues to demand intellectual, physical and emotional energy beyond what would be required in many other professions and occupations, the recruitment and retention of well-prepared and motivated nurses remains a challenge now and in the future. But, as these discussions and the interactions with Task Force members have demonstrated over and over again, nursing is both a dynamic and exciting field of professional practice. And North Carolina is considered by most to be one of the very best states within which to be a nurse. It is hoped that all the 47 recommendations offered in this report, only 16 of which are specified here, will serve as a template for a deliberate policy agenda through which the nursing workforce for North Carolina can continue to be the vibrant example of the highest standards of practice for which its reputation has been well-earned.

Advisory Committees↗

Bringing magic to the nursing workforce of the future.

How can nursing education respond to the ominous signs of a serious shortage of nurses in the future? One answer to this question is a focus on reclaiming nurses' stories of the "real-world" of nursing practice. In the process of creating a childrens book, The Magic Stethoscope, a group of nurse authors found a new appreciation for the stories of their practice and the need to share these stories with children. The authors hope that these stories will inspire children to consider the exciting career opportunities for the nursing workforce of the future.

Attitude to Health↗

Integration of overseas-trained doctors into the Australian medical workforce.

Australian healthcare is greatly enriched by its overseas-trained doctors (OTDs). There is no national approach to support the integration of OTDs into the workforce. The problem areas are well defined--the need for better information access; better orientation to our healthcare systems and the workplace; improving communication with patients and healthcare workers; standardised assessment of knowledge and skills; and education and training support--so, let's get on with it.

Australia↗

Child neurology: workforce and practice characteristics.

For more than a decade, reports have indicated that the supply of child neurologists is inadequate to provide care for the growing number of children with acquired and genetic neurological conditions. It is critical to understand how the shortages affect the practice of child neurology, the attitudes of child neurologists, and ability of the field to attract new members. This Issue Brief examines these workforce issues, and profiles the attitudes and practice characteristics of child neurologists and trainees.

Appointments and Schedules↗

Family physicians and the primary care physicians workforce in 2004.

In 2004, there were 91,600 family physicians (FPs) and general practitioners (GPs) and 222,000 primary care physicians actively caring for patients, one for every 1321 persons. These primary care physicians represent the largest and best-trained primary care physician workforce that has ever existed in the United States.

Family Practice↗

Osteopathic physicians and the family medicine workforce.

Historically, osteopathic physicians have made an important contribution to the primary care workforce. More than one half of osteopathic physicians are primary care physicians, and most of these are family physicians. However, the proportion of osteopathic students choosing family medicine, like that of their allopathic peers, is declining, and currently is only one in five.

Family Practice↗

Texas' community health workforce: from state health promotion policy to community-level practice.

BACKGROUND: Imagine yourself in Texas as a newly arrived immigrant who does not speak English. What would you do if your child became ill? How would you find a doctor? When you find one, will the doctor speak your native language or understand your culture? In a state of approximately 22 million people, many Texas residents, marginalized by poverty and cultural traditions, find themselves in this situation. To help them, some communities across Texas offer the services of promotores, or community health workers, who provide health education and assist with navigating the health care system. CONTEXT: In 1999, Texas became the first state in the nation to recognize these workers and their contributions to keeping Texans healthy. This paper examines a state health promotion policy that culminated in a training and certification program for promotores and the impact of this program on the lay health education workforce in Texas. METHODS: In 1999, the Texas legislature established the 15-member Promotor(a) Program Development Committee to study issues involved in developing a statewide training and certification program. During its 2-year term, the committee met all six of its objectives toward establishing and maintaining a promotor(a) certification program. CONSEQUENCES: By the end of December 2005, it is estimated that there will be more than 700 certified promotores in Texas. State certification brings community health workers into the public health mainstream as never before. INTERPRETATION: Promotores, a community health safety net and a natural extension of the health and human services agencies, improve health at the neighborhood level. Certification brings renewed commitment to serving others and a distinction to those who have been the unsung heroes of public health for decades.

Community Health Services↗

Student debt amongst junior doctors in New Zealand; part 2: effects on intentions and workforce.

AIMS: To assess the effects of student debt on the intentions of first-year house officers in relation to location of practice and vocation, and to evaluate the relative importance of incentives to remain practising in New Zealand (NZ). METHODS: A questionnaire sent to all 296 New Zealand-graduate first-year house officers practicing in New Zealand. RESULTS: The response rate was 53%. Eighty percent of respondents intended to practice in New Zealand for the bulk of their careers; however, 65% of respondents intended to leave New Zealand within 3 years of graduating. The most important factors influencing the decision to leave NZ were overseas travel, financial opportunities, and job/training opportunities. Fifty-five percent of respondents had considered leaving the country, specifically because of the student loan debt. The most important factors influencing vocational intentions were interest, lifestyle, and intellectual challenge. Forty-three percent of respondents stated that their student debt had influenced their intended specialty, and only 9% of respondents indicated their intention to pursue a career in general practice. The highest rated incentives for staying in New Zealand were increased salaries, employer contributions towards student loans, and training opportunities within New Zealand. CONCLUSION: Student debt influences both emigration and specialty choice intentions of junior doctors in New Zealand. This effect is an unintended but important consequence of our current tertiary education system in New Zealand. These results paint a worrying picture for the junior doctor and general practitioner workforce in New Zealand's future.

Career Choice↗

The impact of tuberculosis on Zambia and the Zambian nursing workforce.

In Zambia, the incidence of tuberculosis (TB) has greatly increased in the last 10 years. This article describes Zambia and highlights the country's use of the United Nations Millennium Development Goals as a framework to guide TB treatment programmes. An overview of TB in Zambia is provided. Data related to TB cases at the county's main referral hospital, the University Teaching Hospital (UTH), is discussed. Treatment policies and barriers are described. Zambian nurses have been greatly affected by the rise in the morbidity and mortality of nurses with TB. This article explains the impact of TB on the Zambian nursing workforce. Review of Zambian government programmes designed to address this health crisis and targeted interventions to reduce TB among nurses are offered.

Antitubercular Agents↗

Perspectives on the physician workforce to the year 2020.

Physician supply and demand for the period extending to 2020 were assessed from three perspectives: physician utilization in group- and staff-model health maintenance organizations, physician distribution, and the future supply of nonphysician clinicians. The national norm for physician demand in 1993 was estimated to be 205 per 100,000 population. Demand is projected to increase 18% by 2020, because of both an expansion in beneficial services and a reduction in physician work effort. Supply initially will increase more rapidly, resulting in a surplus of 31,000 physicians (5% of patient care physicians) in the year 2000 and increasing to 62,000 physicians (8%) in 2010, after which the gap will narrow. Similar results were obtained when previous studies that had projected surpluses of 73,000 to 165,000 physicians (15% to 30%) in the year 2000 were reevaluated. However, physician distribution is not homogeneous, and the number of physicians per capita currently varies by more than twofold among states. Relative to the national norm, surpluses already exist in some states and shortages in others. In addition, the supply of nonphysician clinicians with independent practice authority is increasing. Their numbers are projected to double by 2010, equaling 60% of the number of patient care physicians. Measured as physician equivalents, their growth will equal the growth in physician supply. Thus, in terms of physicians alone, there is no evidence of a major impending national surplus. Local surpluses will be influenced principally by how physicians distribute themselves geographically. The major determinant of overall physician surpluses in the future will be the extent to which patients continue to seek physicians for services that also will be offered by an expanded workforce of nonphysician clinicians. Policy is needed that encompasses the universe of clinicians who will be providing care to patients in the next century.

Demography↗

The physician workforce in Louisiana, 1994: the quantity of doctors, residents, and fellows.

Health care system reform raises many issues for doctors, patients, and all components of the system: professional practice, health careers education, and medical research. This report was prepared to identify trends in the medical workforce and to quantify for 1994 the number of licensed physicians in Louisiana, the number of residents and fellows, their institutional locations and the types of educational programs. The yearly publication of the Louisiana State Board of Medical Examiners was utilized for physician numbers, and the 1994 house officer data was contributed by the several institutions with residency and fellowship educational programs. Of the 9031 licensed physicians located in Louisiana in 1994, 1769 were residents or fellows in educational programs. Over the four years from 1990 to 1994, total licensed physicians in Louisiana, including house officers in educational institutions, increased slowly from 8386 to 9031, a rate of 1.78% per year.

Family Practice↗

Medical workforce policy making in Canada: are we creating more problems for the future?

The current approach to the management of physician resources in Canada needs to be re-examined by all concerned. Canada is about to enter a phase of accelerating depletion of physicians as the result of two separate and evolving circumstances. Because of the unusually large number of physicians who graduated from Canadian medical schools in the late 1960s and early 1970s, a significantly larger than usual number of practising physicians will reach their normal retirement age in the decade ahead. In addition, if the recent surge in the emigration of Canadian physicians continues, the loss of so many physicians will exaggerate the impact of the expected increase in retirements. Therefore, the decision to cut medical school class sizes in the 1990s would have been more suitable in the early 1980s. Existing physician work force policies may be leading to unexpected or undeclared consequences for health care across Canada. On the basis of current trends, the author concludes that policy makers now should reconsider current physician workforce policies in anticipation of a possible shortfall of physicians beginning in the early decades of the next century.

Canada↗

Provider workforce model for regional TRICARE networks.

A model is presented that can estimate the total number and specialty mix of health care providers needed to serve a defined population. Military commanders in charge of TRICARE regions, known as "lead agents," can use this model to estimate the provider workforce composition needed to serve their area. Physician staffing patterns front managed-care organizations help define the provider-to-patient proportions on which this model is based. Data needed to perform the model's computations are derived from the regional enrolled beneficiary population and the number of active duty providers. As a result, the model provides an estimate of the number and type of civilian providers that need to be contracted to adequately serve the regional military network.

Forecasting↗

Can we predict the future evolution of anesthesiology workforce in Belgium?

Two models are proposed to predict the evolution of anesthesiology workforce over the next 20 years. Each model features various scenarios according to different assumptions related to future numbers of female anesthetists, working hours, or regulations for postgraduates' working for conditions. However the main uncertainties derive from the unknown evolution of demands. Despite their differences both models agree on several important conclusions: a 13 to 14% shortage of anesthesiologists currently exists to satisfy O.R. demands, this shortage will decrease over the next ten years, and after 2010 a new shortage could arise under the combined pressure of the numerus clausus, of the number of female anesthesiologists and of the aging of the still young population of anesthesiologists.

Age Factors↗

Generational differences in practice patterns of dermatologists in the United States: implications for workforce planning.

OBJECTIVE: To examine the effect of age and other demographic factors on dermatologists' practice characteristics. DESIGN: Anonymous practice profile survey. PARTICIPANTS: Dermatologist members of the American Academy of Dermatology Association. MAIN OUTCOME MEASURES: Analyzed survey questions included information about legal practice entity, geographic area served, weekly patient care hours, patients seen per hour, and scope of patient care activities. RESULTS: Of 4090 surveys sent, 1425 (35%) were returned. As the age of the cohorts increased, the percentage practicing in solo practices increased (range, 21%-39%), as did the percentage serving urban areas (range, 31%-46%). Measures of physician productivity increased in the older age cohorts; however, age was not a significant factor after controlling for other variables. More patient-hours per week were associated with male sex (P < .001), solo practices (P < .001), and non-urban-based practices (P = .04), whereas a greater number of patients per hour was associated with non-rural-based practices (P = .02) and male sex (P = .03). As the cohorts progressed in age, more time was spent practicing medical dermatology. The number of hours spent practicing cosmetic dermatology peaked in the 41- to 50-year-old cohort (P = .03). CONCLUSIONS: Practice patterns differ significantly among dermatologists of different ages. As the current cohorts age and new dermatologists emerge from training, changes in scope of practice and generational differences in productivity are likely to cause a contraction in the effective supply of dermatologists, which has important implications for dermatology workforce planning.

Adult↗

Work time estimates for ophthalmic diagnoses and procedures. Results from the Eye Care Workforce Study.

OBJECTIVE: To provide estimates of patient-level annual ophthalmologist work times for the care of common ophthalmic conditions and patient-level global surgical care time for common or important ophthalmic procedures. METHODS: A random sample of the domestic membership (excluding members-in-training) of the American Academy of Ophthalmology, stratified by self-designated practice concentration, was surveyed in 1994 to provide estimates of work times for common ophthalmic services. RESULTS: Comprehensive and subspecialty-specific results were obtained for ophthalmic diagnoses, services, and surgical procedures. For ophthalmic diagnoses and services, initial and follow-up visit work times are reported for comprehensive and subspecialty ophthalmologists separately. For common surgical procedures, aggregate results based on comprehensive and subspecialist survey responses are reported. CONCLUSIONS: These ophthalmology-specific survey results can be used for a variety of purposes, including practice management, "benchmarking," health plan administration and national workforce planning. Such surveys should be repeated as techniques and practice patterns change over time.

Diagnostic Techniques, Ophthalmological↗