Anita Charlesworth, Director of Research and Economics, The Health Foundation, and Honorary Professor, College of Social Sciences Health Services Management Centre (HSMC), University of Birmingham, acted as moderator during the EHFG 2019 Lunch Workshop “Health workforce disruption; effectiveness and implementation of skill-mix innovations”, organised by The Health Foundation and the European Observatory on Health Systems and Policies. After the session, Young Gasteiners, Olga Löblová and Elisa Boekhorst interviewed Anita on the topic of skill-mix in the health workforce, its success stories, challenges, and the potential for a sustainable future for our health systems.
Olga Löblová and Elisa Boekhorst (OL-EB): How did you become interested in the topic of workforce disruption?
Anita Charlesworth (AC): As an economist, I examine issues around the sustainability of the healthcare system. When I initially began working in this area I was very focused on the long-term demand pressures, for example ageing, and what that meant for fiscal sustainability and cost. However, as time went on, it became apparent that for the sustainability of a healthcare system, our ability to meet the demand through the workforce is equally, if not more important than the changing patterns of need themselves. It is key to focus on the cost and productivity of meeting that need.
Workforce issues are probably the most fundamental question for our sustainability over the medium to long-term. Patients understand that healthcare systems are only as good as the people who work in them, therefore one of the key tasks of any system is to ensure it is adequately resourced with workers who have the ability to use their skills and talents effectively – that is the make-or-break for healthcare systems.
How we achieve this will be profoundly impacted by new technologies, by altering the expectations of those who work in the healthcare system as younger generations come through, and by various types of needs. As people age, frailty, chronic disease, multi-morbidity, and mental health issues become as important as our physical health. All these aspects change the nature of the workforce response, but they do not alter the fact that a good healthcare system will stand or fall on its ability to mobilise, motivate, and engage the workforce.
OL-EB: How does skill-mix fit into all this from your perspective?
AC: Skill-mix is imperative given the various professions that exist within healthcare. We are a highly regulated sector, for good reason, with very strong professional tribes and loyalties. Yet, patients and those who avail of our services, need the care to be well-coordinated and they need the right mix of skills to be deployed. No one professional in modern healthcare has all the skills that one patient will need in order to be supported effectively. So, it is not enough for us to just train workers and to motivate them as individuals. We must really think about how we can make the sum greater than its parts, how we bring the varying skills of individuals together effectively. That is important for patient care, but also for funding. We must make effective use of the talents we have available to us and guarantee there is no waste or duplication by ensuring we do not have tasks sitting with certain professionals purely because of historic loyalties. We train people and when they begin working they often find it difficult to optimally use all the skills they have, because there are artificial barriers. These can be legislative artificial barriers, for example due to payment systems. But if we are honest, the barriers can also be hierarchies and tribalism from other professions.
OL-EB: Could you share any skill-mix success or disruption stories with us?
AC: We are going through a very interesting example right now in the United Kingdom (UK). The UK has a strong history of primary care, it is often seen as the jewel in the crown of the NHS system: you have family physicians pivotal in the system who play a strong gatekeeping role. Recently the challenge has been the fact that there is not enough family physicians – the number has been decreasing. We want to strengthen primary care in the UK, but everybody recognises now that we cannot do that with a purely GP-based model.
There is a new reform in the UK that came into effect in January 2019, called the “primary care network”. It will invest a substantial amount of money towards a major change in the composition of GP services so that there will be not only GPs and nurses in general practice, but we will see a major expansion in skill-mix with a major new role for pharmacists, physiotherapists, and paramedics. There is also a new role for a “social prescriber”, which involves considering how important social determinants are in both the need for healthcare and in the effective response to healthcare. We should bring in people whose role is connecting patients with civil society and with social prescribing options. The money is going to deliver an expansion of about 20,000 workers in general practice who are not GPs. That is against a background of about 30,000 GPs in England. So, it is a big, big change. If it is effectively implemented, it will transform the landscape of general practice in England.
OL-EB: Is there any resistance to this?
AC: Actually, no. I do not think there is resistance to the principle. The reform has been quite carefully crafted to ensure involvement of the professions. It is well rooted in evidence – the skill-mix changes, particularly around pharmacy and physiotherapy services, are very well evidenced. There is favourable research that these professions can make a significant contribution and deliver high-quality, cost-effective care. There is also ring-fenced funding to support people and where there is experimentation, as with the social prescriber, there is more funding, so that individual practices do not bear the risk. The social prescriber role will be 100% funded by the government in the early phase.
At the same time, there are concerns about the quality of the implementation. We see this a lot with skill-mix reforms: you need a lot of other changes at the same time. One of the main concerns is that, particularly in more deprived or disadvantaged areas, GPs are often working out of old premises, often a room in a house, in small practices. Where is the capital investment to provide the modern facilities, particularly in disadvantaged areas, that will be needed for this kind of multidisciplinary general practice? And another thing which is important: this profoundly changes the role of the general practitioners. They become responsible for a team, for coordination and accountability across the team, and they will have to deal with more complex patients. The big question is: where is the support for the GPs to really develop the skills and understanding of what this means for their evolving role?
OL-EB: “Skill-mix” is a term open to interpretation. Do you see any myths around the term?
AC: I understand skill-mix as thinking carefully about the competences and experiential expertise different members of the team have or could have if we created new roles and new training, and how we optimally combine those different competences and expertise for the needs of the patient. I think skill-mix is often understood as task-shifting or task-dumping to other people for cost-saving purposes. In the past that has happened in healthcare systems and people’s personal experience has therefore given this agenda a bad name. It is seen as either a way of undermining some professional groups to reduce their power or professional status, or as a way of just cost-shifting or cost-cutting.
OL-EB: Is that why you put the emphasis on the team in the skill-mix?
AC: Absolutely. The key is to start with the patient’s need. Too often we start with professional boundaries. The disruption, which is what we have been talking about this year in Gastein, is to start with the patient.
OL-EB: But that is a disruption we have been talking about for decades…
AC: Indeed. If I knew how to do that, I would be very successful!