1.1 Introduction: why skill-mix?
Access to and the quality of health services are closely linked to the density and skill-mix of a country’s health workforce (OECD, 2016; World Health Organization, 2006, 2016). High rates of chronic conditions and multimorbidity, new treatment options, and technological advances and economic pressure have led to fundamental changes to health systems and have impacted on the daily work of health professionals. Many countries worldwide are experiencing a shortage of primary care providers, particularly in rural or socially deprived urban areas (OECD, 2016; World Health Organization, 2013). Primary care systems face the challenge of ensuring a sustainable workforce to allow timely access to services, high-quality care and person-centred services (Reference Kringos, Boerma and HutchinsonKringos et al., 2015a, Reference Kringos, Boerma and Hutchinson2015b). Against this backdrop, the skills and composition of the workforce have changed in many countries and settings to meet the increasing and diversifying demands of patients (Reference Dubois and SinghDubois & Singh, 2009; Reference Freund, Everett and GriffithsFreund et al., 2015). At the same time, health promotion and prevention are gaining increasing attention among primary care providers to ensure that all people can live in good health. Moreover, the global coronavirus disease 2019 (COVID-19) pandemic has brought to the forefront the necessity of having a well-qualified health workforce that has surge capacity, competencies and flexibility to react to short-term crises (WHO Regional Office for Europe, 2020). The pandemic has not only attracted more policy interest in strengthening the health workforce, it has also triggered a change in the public’s view of the value and importance of health professionals and their contribution to the health of individuals and patients.
In a context where health care needs, demands and resources are rapidly changing, policy-makers aim to better understand which skill-mix reforms and strategies are effective. Global debates have in the past frequently focused on the required density and distribution of specific health professions to ensure universal access to and coverage of health services (for example, the number of physicians, nurses or other professions per population) (Reference Campbell, Dussault and BuchanCampbell et al., 2013). There has been limited attention on identifying the right composition and skill-mix of the health workforce. This has changed over the past decade, with the World Health Organization (WHO), Organization for Economic Co-operation and Development (OECD) and European Commission moving skill-mix higher up the political agenda. The notion that the education, skills and competencies of health professions are essential for high-quality care and efficiency has been increasingly recognized. For instance, the OECD report “right skills, right jobs, right places” took an integrated approach covering the density, distribution and skill-mix of health professions (OECD, 2016). The WHO has published several reports on the health workforce including skill-mix or task shifting specifically (World Health Organization, 2007, 2008, 2016).
Yet, there has been a lack of common understanding of what skill-mix is, what professions are involved and what models exist in different care contexts. This knowledge is critical for identifying the effects of skill-mix on outcomes for patients, population groups and health systems. It is likewise important to identify lessons for implementation. Previous research has primarily focused on skill-mix among individual professions or between two professions, with less evidence available covering multiple professions. One skill-mix example that has been the subject of a considerable amount of research is the changing roles of nurses at the interface to the medical profession (Reference MaierMaier, 2015; Reference Maier and AikenMaier & Aiken, 2016; Reference Maier, Aiken and BusseMaier, Aiken & Busse, 2017; Reference Maier, Barnes and AikenMaier et al., 2016; Reference Martínez-González, Djalali and TandjungMartínez-González et al., 2014a, Reference Martínez-González, Tandjung and Djalali2014b, Reference Martínez-González, Rosemann and Djalali2015a, Reference Martínez-González, Tandjung and Djalali2015b; Reference Morilla-Herrera, Garcia-Mayor and Martin-SantosMorilla-Herrera et al., 2016; Reference Swan, Ferguson and ChangSwan et al., 2015). Fewer studies have analysed skill-mix changes covering multiple professions (Reference Dubois and SinghDubois & Singh, 2009; Reference Freund, Everett and GriffithsFreund et al., 2015; Reference Sibbald, Shen and McBrideSibbald, Shen & McBride, 2004; Reference Tsiachristas, Wallenburg and BondTsiachristas et al., 2015). One cross-country analysis focused on a description of “typical” primary care teams in six countries (the United States of America, Canada, Australia, England, Germany and the Netherlands) (Reference Freund, Everett and GriffithsFreund et al., 2015). It found that general practitioners (GPs) and nurses were the main professions providing primary care in all countries, but they performed considerably different tasks and roles. Moreover, the number and contributions of medical assistants and other support workers varied considerably within practices. According to an international study on primary care systems in Europe, the organizational structures of primary care providers also vary, ranging from primarily solo practices to health centres (Reference Kringos, Boerma and HutchinsonKringos et al., 2015a, Reference Kringos, Boerma and Hutchinson2015b). These cross-country variations in the composition and roles of the health workforce and health systems are critical to identify as important contextual factors, which will be described in Section 1.5. A systematic review (Reference Tsiachristas, Wallenburg and BondTsiachristas et al., 2015) analysed the effects of new professional roles on a variety of outcome parameters, including all professions. It identified primarily studies on nurses and a few studies on new professional roles among other professions. The review included all care sectors, including hospital settings. It did not differentiate by care sectors, conditions or care contexts and concluded that more research on the optimal skill-mix is required (Reference Tsiachristas, Wallenburg and BondTsiachristas et al., 2015).
1.2 Aims of this skill-mix volume
Given the general paucity of systematic reviews on skill-mix covering multiple professions and a break-down by patient groups, this volume seeks to provide a synthesis of skill-mix in primary care and ambulatory care and outcomes in individuals and health systems. The volume therefore addresses skill-mix changes aimed at different population or patient groups, ranging from prevention to long-term and palliative care. Moreover, this volume aims to identify country reforms, common developments and lessons for implementation.
This volume has two overarching aims:
First, to identify skill-mix changes, and in particular skill-mix innovations and the evidence on outcomes in patients and health systems. Within health systems, the role of health care professionals is critical, so a particular emphasis was given on outcomes for health professionals.
Second, to identify lessons for implementation in different contexts and countries. The volume will analyse what the common barriers and enablers are that have been shown to influence the uptake of new skill-mix reforms in practice. It will address if and how education, regulation, financing and payment policies impact on the timely implementation of skill-mix reforms. Based on the evidence from country experiences, it will suggest lessons to overcome barriers in practice. Moreover, it will analyse what factors and strategies exist to implement skill-mix changes in health care organizations.
How are skill-mix innovations defined for the purpose of this study? Skill-mix innovations are examples of changes to the skills, roles or clinical activities involving at least two professions, and characterized by three parameters: first, (perceived as) new in a country-specific context (novelty); second, discontinuous with previous practice (disruptive); and third, aimed at improving at least one health outcome (aimed at value), for example, with positive effects on access, quality, patient experience, coordination of care and/or costs (Reference Greenhalgh, Robert and MacfarlaneGreenhalgh et al., 2004).
This volume was written before the COVID-19 pandemic; therefore the book does not cover the literature on skill-mix changes that originated during the pandemic. Moreover, as the pandemic is still ongoing, it is premature to analyse what effects changes to the roles, tasks and competencies of specific health professionals have had on patient or health system outcomes.
1.3 Policy relevance: why now?
The notion that the health workforce is instrumental for improving access to health services as well as the quality of care has been recognized for decades, most notably with the publication of the The World Health Report 2006: working together for health (World Health Organization, 2006). Investing in the health workforce has received renewed policy attention recently during the COVID-19 pandemic (WHO Regional Office for Europe, 2020), in addition to previously ongoing WHO action on strengthening the health workforce (Reference Campbell, Dussault and BuchanCampbell et al., 2013; Reference Cometto, Boerma and CampbellCometto et al., 2013). Achieving universal health coverage and other health-related sustainable development goals (SDGs) is dependent on a multitude of investments and reforms, including a sufficiently educated health workforce with the right skills and competencies (Reference Cometto, Boerma and CampbellCometto et al., 2013; World Health Organization, 2016). There is increasing evidence that strengthening the health workforce can not only have positive effects on health (for example, maternal and child health, among many others) (World Health Organization, 2006), but can also positively impact on other sectors beyond health. Effects beyond health include multiple potential spill-over effects on the economy, women’s participation and societal well-being (World Health Organization, 2018). Yet, globally, health worker shortages, skill-mix imbalances, maldistribution and barriers to interprofessional collaboration prevail and are among the main obstacles preventing countries from reaching universal health coverage (Reference Cometto, Boerma and CampbellCometto et al., 2013).
The Global Burden of Disease study suggested that the health worker density would need to increase from a global average of 5.9 physicians, nurses and midwives per 1000 population in 2015 to 10.9 in 2030 (Global Burden of Disease 2017 SDG Collaborators, 2018). The study recognized the limitation of not covering other health professions, nor taking account of team composition and skill-mix requirements in reaching the SDGs. From an international perspective, there is little research evidence available that goes beyond density levels per profession and covers teams, the composition and the specific division of roles and tasks in practice. This is of relevance for all health systems and all care sectors, including primary care. Primary care is the care sector that has been estimated to determine to a large extent whether the goals of achieving universal health coverage and the SDGs can be met (Reference Campbell, Dussault and BuchanCampbell et al., 2013; Reference Cometto, Boerma and CampbellCometto et al., 2013), yet, it is often less financed and not as attractive to health professionals compared with the secondary and tertiary care sectors.
The year 2016 was a landmark year with the creation of the United Nation’s High Level Commission of Health Employment and Economic Growth (United Nations, 2016). The commission increased policy attention and commitment internationally on the necessity of strengthening the health workforce towards achieving the SDGs. The commission brought together heads of state and government, health and finance ministers and a wide research and practice community to demonstrate the evidence and create awareness of the link between strengthening the health workforce, economic growth and gender equality, which mutually reinforce each other on the quest towards the SDGs. There is increased recognition now that investment in a strong health workforce is required to reach the SDGs. The Commission developed a Five year action plan for health employment and inclusive economic growth led by the WHO, OECD and the International Labour Organization (ILO) in 2018 (World Health Organization, 2018). The action plan aims to strengthen the health and social care workforce globally as an important means to achieve the SDGs. The plan lists ten recommendations and five immediate actions, including actions to improve the education, skills and jobs of all health professionals, but with a particular focus on those countries with the largest shortage of health professionals in low- and middle-income countries. The action plan recommends the assessment of skill-mix shortages and suggests strategies to overcome these shortages. At the same time, the action plan is directed at all countries, including high-income countries. The reason is that many countries worldwide are facing challenges in ensuring a sustainable health workforce, particularly in primary care, long-term and palliative care and in underserved regions. The plan identifies interprofessional education and multiprofessional service provision, including the identification of skills and competencies as critical to achieve integrated people-centred care (World Health Organization, 2018, p. 15).
Moreover, in 2016, the WHO published the Global strategy on human resources for health: Workforce 2030 (World Health Organization, 2016). Its main aim is to reach universal health coverage via a new global strategy for human resources for health. The strategy paper recommends the implementation of “health-care delivery models with an appropriate and sustainable skills mix in order to meet population health needs equitably” (World Health Organization, 2016). According to the WHO, the skill-mix should be community-based and include a variety of different health professions from different educational levels and backgrounds, including mid-level health workers in interprofessional primary care teams. There is limited additional guidance and evidence for what an appropriate and sustainable skill-mix entails, particularly for high-income countries and different care sectors.
For strengthening primary health care, the 2018 Astana declaration was critical to reach a renewed commitment among policy-makers, 30 years after the 1978 Alma Ata declaration (World Health Organization/UNICEF, 2018). The declaration highlighted the importance of knowledge and capacity-building and strengthened capacity in human resources for health in primary health care, alongside the use of new technologies and financing. Through governmental, intersectoral action and a coordinated governance strategy, the aim is to build capacity for a high-quality, well-performing health workforce with an effective skill-set to provide high-quality, safe, comprehensive, integrated, accessible, available and affordable care (World Health Organization/UNICEF, 2018).
At the European Union (EU) level, several initiatives have been introduced, including the Support for the health workforce planning and forecasting expert network (SEPEN) (SEPEN, 2019). SEPEN was a follow-up network emanating from the Joint Action on Health Workforce Planning and Forecasting to foster exchange of knowledge, capacity and good practice in the field of European health workforce planning. The aims of the network are to encourage and sustain cross-country collaboration, to provide support to Member States and improve countries’ health workforce planning processes and policy (SEPEN, 2019). The network has suggested capacity building so that the workforce can effectively work in multiprofessional teams, has access to high-quality knowledge and evidence about policies, regulations and planning. One major focus is on the mobility and migration of health professionals in the EU’s single market and how countries can react and plan for inflows and outflows. Moreover, in 2019 the European Commission’s Expert Panel on effective ways of investing in Health published an expert opinion on task shifting and health system design (European Commission, 2019). The publication of an opinion on this topic demonstrated the timeliness of skill-mix and health workforce themes at EU level. The opinion focused on one element of skill-mix (see definitions below, Table 1.1), namely task shifting; from one health professional to another, to patients or caregivers or to machines, hence including digital transformation. It did not, however, analyse other skill-mix changes, for instance the add-on of new roles and tasks (supplementation) or changes to multiprofessional teamwork.
Table 1.1 Definitions: skill-mix and its typologies
| Term | Definitions and examples |
|---|---|
| Skill-mix | Changes to the skills, competencies, roles or tasks within and across health professionals and health workers (including community-based workers, peers, informal caregivers) and/or teams |
| Skill-mix typologies | |
| 1. Re-allocating tasks | Task-shifting (other terms: delegation, substitution) between physicians, nurses, pharmacists and other providers. Examples include: nonmedical prescribing of medicines, diagnosis performed by advanced practice providers, screening performed by nurses or pharmacists |
| 2. Adding new tasks/roles | Supplementation of tasks or add-on of new roles that did not previously exist or were not routinely provided. Examples include care coordination role, patient navigator, eHealth monitoring, health promotion role |
| 3. Introducing or changing teamwork | Changes to the (way) of collaboration between at least two professions or more. Examples include shared care provided jointly by physicians and nurses and multiprofessional collaboration |
The section below provides an overview of the definitions on skill-mix as an umbrella term and different typologies that fall within the definition.
1.4 Skill-mix and the health workforce: definitions
Before addressing what is meant by skill-mix, it is necessary to provide clarity on what is meant by the health workforce. The WHO defines the health workforce as “all people engaged in actions whose primary intent is to enhance health” (World Health Organization, 2006). This broad definition encompasses in its widest meaning also lay health workers, for example, community health workers, peers or family carers. To distinguish between the formally qualified and unqualified members of the health workforce, this volume will refer to health professionals as those with formal education (physicians, nurses, midwives, pharmacists, physiotherapists) and to health workers as those with no or very limited health-related education (lay, informal, community-based or peer workers). A similar approach is taken by the International Standard Classification of Occupations (ISCO) (International Labour Organization (ILO), 2010a), which has classified the health workforce into three major functions: health professionals, health associate professionals and (personal care) workers. For example, GPs, nurses and physiotherapists are covered under health professionals; whereas nurse assistants and medical technicians are summarized under health associate professionals. Home-based personal care workers subsume a large number of diverse, primarily lay workers with considerable contribution to individual health, particularly in long-term care. This volume covers all health professions working in primary and ambulatory care settings or at the interface to hospital care, and also includes lay workers, such as peers, community-based workers and family caregivers as long as they are covered by skill-mix changes and reforms.
What is skill-mix?
Several definitions of the term skill-mix exist in the literature with different focus, levels of breadth and depth (Reference Buchan and Dal PozBuchan & Dal Poz, 2002; Reference Dubois and SinghDubois & Singh, 2009). Terms used commonly are skill-mix as an overarching term, but also changing roles, task shifting, task sharing, task supplementation, delegation and substitution, among others. For the purpose of this study and informed by two definitions (Reference Buchan and Dal PozBuchan & Dal Poz, 2002; Reference Sibbald, Shen and McBrideSibbald, Shen & McBride, 2004), the following working definition was developed: skill-mix is defined as “directly changing the skills, competencies, attitudes, roles or tasks within and across individuals and teams”. This definition was chosen deliberately with a broad remit to cover all changes that directly and purposefully change the roles of individual health professionals or teams in primary and ambulatory care settings. Differentiating between skill-mix change and a skill-mix innovation, the following additional three criteria were applied to qualify as an innovation: novelty of skill-mix changes (in its widest sense), being of disruptive nature (changing the status quo) and aimed at improving at least one health or health system outcome (Reference Greenhalgh, Robert and MacfarlaneGreenhalgh et al., 2004).
Further, to grasp the range and type of changes in the health workforce a modified typology of skill-mix innovations has been used for the study (Reference Laurant, Reeves and HermensLaurant et al., 2005; Reference Friedman, Hahn and EtzFriedman et al., 2014) (Table 1.1).
The first typology addresses re-allocating tasks between two professions. Commonly the term task shifting, or sometimes task sharing, has been used, although the latter term often lacks clarity over which tasks are shifted and which ones are being shared and by whom. Task shifting has also been referred to as substitution or delegation. While substitution refers to tasks being entirely shifted to a new profession, delegation is frequently referred to as the transfer of tasks to nonmedical professions such as nurses, but with physicians maintaining ultimate responsibility (Reference Laurant, Reeves and HermensLaurant et al., 2005; Reference Sibbald, Shen and McBrideSibbald, Shen & McBride, 2004). The two terms are sometimes also used simultaneously when it comes to questions of oversight and jurisdictional responsibility. This typology refers to a new division of work between at least two professions and the team in which they work.
The second typology concerns the addition of new tasks or roles, also referred to as task supplementation, such as care coordination, use of new technologies or eHealth monitoring. Adapted from Reference Laurant, Reeves and HermensLaurant et al. (2005), this typology refers to health professionals expanding their roles and performing new functions that were previously not or not routinely performed. Hence, this typology refers to expansions of the skills set and roles of an individual and the team.
The third typology covers the introduction of teamwork and collaboration for at least two professions, for instance shared care of physicians and nurses. The use of the term teamwork across this volume is based on changes to at least two professions directly affecting their method of collaboration. This also touches upon interventions to improve cooperation and collaboration such as teamwork effectiveness or interprofessional education (Reference Friedman, Hahn and EtzFriedman et al., 2014; Reference Laurant, Reeves and HermensLaurant et al., 2005).
In some cases, skill-mix changes result directly or indirectly in response to changes in service delivery models, which change the interface of care provision. A transfer of care from hospital to ambulatory or community care (such as community-based treatment and testing, for example, for HIV/AIDS, which would previously have been provided in hospitals or clinics) has major implications for the composition of teams providing this service and is also influenced by new technologies, treatment options and laboratory testing devices. Liaison functions are skill-mix changes aimed at improving the care across care settings to provide a smooth, continuous provision of services. This also applies to the relocation of care, which comprises a shift of entire service delivery models (for example, hospital-at-home). These models are more complex and although they may result in skill-mix changes, they are larger service delivery reforms of which skill-mix is only one important element among others. Hence, the evaluation of these models is more complex and attribution of causality is limited compared with the typologies 1–3 listed in Table 1.1.
1.5 The diversity and skill-mix of health professions in Europe: a snapshot
Strengthening primary care to meet the health and social care needs of an ageing population is prompting many countries in Europe to make far-reaching changes to the primary care workforce. The traditional primary care model of small, solo general practices is becoming increasingly unsustainable and unable to manage growing workloads, work intensity and work complexity, especially with many countries facing escalating GP shortages and economic constraints. As a result, these traditional ways of working are gradually being replaced by new models of primary care practice, centred on collaborative, multiprofessional teams (Reference Groenewegen, Heinemann and GreßGroenewegen et al., 2015; Reference Kuhlmann, Groenewegen and BondKuhlmann et al., 2018). To support these new ways of working and the delivery of more complex care and procedures, many countries have enhanced the scope of practice and skills of established health professionals such as nurses or pharmacists, reoriented professions such as paramedics or social workers that traditionally worked elsewhere in the health system into primary care settings or introduced new professions entirely such as physician assistants.
The scale and pace of these changes has, however, not been unified across Europe and considerable variation in the composition of the health workforce across the region exists (Reference Groenewegen, Heinemann and GreßGroenewegen et al., 2015; Reference Kringos, Boerma and HutchinsonKringos et al., 2015a). Although some countries (for example, the United Kingdom, Iceland, Lithuania, Spain, Sweden) have introduced health centres or larger practices with multiprofessional teams incorporating a range of health professionals such as physicians, nurses, medical assistants, health care assistants, psychologists, physiotherapists and social workers, other countries (for example, Austria, Belgium, Czech Republic, Germany and Romania) still rely primarily on smaller primary care practices where GPs work alone or with one or two other professionals, usually a nurse or medical assistant (Reference Groenewegen, Heinemann and GreßGroenewegen et al., 2015; Reference Kringos, Boerma and HutchinsonKringos et al., 2015a). In addition, the scope of practice and skill-profiles of an individual profession such as advanced practice nurses differs considerable from one country to the next (Reference Maier and AikenMaier & Aiken, 2016; Reference Maier, Aiken and BusseMaier, Aiken & Busse, 2017; Reference Maier, Koppen and BusseMaier, Koppen & Busse, 2018). Even within the same country, ways of working and responsibilities of different professions often vary between practices and settings, depending on patients’ needs, individual competencies, professional boundaries and the division of work.
International definitions of health professionals
In light of the variations of teams and skill-mix within and across countries, it is important to have an understanding of how a physician, a nurse or a pharmacist is defined in different country contexts and internationally. Although there are clear variations across countries, there are also attempts at the international level to define health professions, their core tasks and clinical roles. Core definitions are provided in the Appendix, for instance based on International Standard Classification of Occupations (ISCO)-08 codes that have been developed by the International Labour Organization (ILO) (International Labour Organization (ILO), 2010a, 2010b) or by standard definitions from other sources.
Hence, ISCO classifications provide a common understanding of the definition of different health professions and their scope of practice. For example, among other tasks, generalist medical practitioners or GPs are defined as carrying out clinical examinations of patients to assess, diagnose and monitor a patient’s condition and provide continuing medical care for patients including prescribing, administering, counselling on and monitoring of curative treatments and preventive measures (modified from: ILO: ISCO 2211). Nursing professionals, including specialist nurses, plan and provide personal care, treatments and therapies; develop and implement care plans for biological, social and psychological treatment and provide information about prevention of ill-health, treatment and care “for people who are in need of nursing care due to the effects of ageing, injury, illness or other physical or mental impairment, or potential risks to health” (ILO: ISCO 2221). Pharmacists meanwhile are professionals that “store, preserve, compound and dispense medicinal products and counsel on the proper use and adverse effects of drugs and medicines following prescriptions issued by medical doctors and other health professionals” (ILO: ISCO 2262). ISCO does not cover all health professions; new professions that have emerged more recently and have a comparatively younger tradition in many countries are often missing. Some examples are Nurse Practitioners/Advanced Practice Nurses and Physician Assistants, or dental hygienists. For these professions, standard definitions by other sources were used (see Appendix). Moreover, there are a multitude of other health professionals working in primary care, ambulatory care settings or at the interface between inpatient and outpatient care. Further details on these professions, their definitions and common tasks for other health professionals can be found in the Appendix.
Although international definitions are helpful to have a common, minimum understanding of the role and tasks of certain health professions, the definitions need to be seen in the country-specific contexts, which include the minimum level education of these professions, their scopes-of-practice, which comprises the clinical activities and tasks that these professions are officially authorized to perform, and the clinical practice settings.
The EU’s free movement zone: minimum qualification of health professionals
In 2005 the Council of the EU adopted Directive 2005/36/EC on the recognition of professional qualifications in practice, with the Directive modernized in 2013 (European Union, 2013). The legally binding Directive aims to support the policy of freedom of movement by granting automatic and mutual recognition of professional qualifications between Member States and other countries belonging to the EU’s free movement zone (for example, Norway, Switzerland). The Directive covers five regulated health professions: physicians (including GPs and specialists), nurses, midwives, dental practitioners and pharmacists. The Directive provides a legal definition of minimum education qualifications and medical training that must be achieved in order to practice and has led to a process of minimum harmonization of education and training requirements across the EU, although variations remain across countries.
For physicians, basic medical education must consist of 5500 hours of practical and theoretical training over a minimum of 5 years. General practice is a distinct postgraduate qualification separate from other medical specialities, with mandatory postgraduate training defined as: (i) a full-time course of a minimum of 3 years; (ii) at least 6 months in an approved hospital or clinic and at least 6 months in an approved GP practice or centre where doctors provide primary care. Although specialist training is a mandatory prerequisite for becoming a GP in the EU/EEA, subjects studied and the duration of training vary markedly from 3 years (for example, Belgium, Bulgaria, Italy, Latvia, Malta, the Netherlands and the United Kingdom) to 6 years (Finland) (European Academy of Teachers in General Practice/Family Medicine (EURACT), 2020).
Following the Directive and reforms under the Bologna process, qualification as a registered nurse across the EU is now primarily achieved through obtaining a Bachelor-level degree (Reference Lahtinen, Leino-Kilpi and SalminenLahtinen, Leino-Kilpi & Salminen, 2014). Few countries (for example, Austria and Germany) still have a co-existence of educational pathways, consisting of Bachelor programmes and vocational trainings at nursing schools. Advanced practice nurses (including nurse practitioners) are generally educated to at least Master’s level (Reference Maier, Aiken and BusseMaier, Aiken & Busse, 2017). According to the Directive, pharmacists must complete “training of at least five years’ duration, including at least: (i) four years of full-time theoretical and practical training at a university or at a higher institute of a level recognised as equivalent, or under the supervision of a university; (ii) six-month traineeship in a pharmacy”. In France, completion of a 5- or 6-year Doctor of Pharmacy degree is necessary to become a licensed pharmacist. In a small number of countries (for example, England), specific education and training programmes are also available to support pharmacists working in primary care (Reference Middleton, Howard and WrightMiddleton, Howard & Wright, 2019).
Role developments and scope-of-practice variations across Europe
The roles and tasks undertaken by health professionals have expanded in scope and complexity in recent years in a number of countries (Reference Dubois and SinghDubois & Singh, 2009; Reference Freund, Everett and GriffithsFreund et al., 2015; Reference Kringos, Boerma and HutchinsonKringos et al., 2015a). In primary care, GPs are now increasingly expected to provide more complex, all-round care to patients, including those with multimorbidity or long-term chronic conditions and to work as part of multiprofessional teams. Reference Kringos, Boerma and HutchinsonKringos et al. (2015a, b) have grouped the range of services provided by GPs into five broad categories: first-contact care and triage; diagnostic services, treatment and follow-up care; medical technical procedures; prevention and health promotion; and mother, child and reproductive health care. However, an assessment of services provided by GPs in 13 case study countries found GP involvement in treatment and follow up was generally high but involvement in preventive care was limited. GP involvement in first-contact care was highest in countries with stronger and well-developed primary care services such as France, the Netherlands and the United Kingdom (Reference Kringos, Boerma and HutchinsonKringos et al., 2015b).
The move towards a broader skill-mix in primary care has allowed physicians to relinquish several clinical and non-clinical tasks to other professions such as to Advanced Practice Nurses/Nurse Practitioners with a Master’s degree or other postgraduate qualifications (for example, Finland, Ireland, the Netherlands, the United Kingdom) or nurses with additional education but not at the Master’s level (for example, Cyprus, Denmark, Estonia, Poland, Spain), to community pharmacists (for example, Switzerland, the United Kingdom), health care assistants (for example, in Spain and the United Kingdom), physician assistants (for example, in the Netherlands and the United Kingdom) or medical assistants (for example, in Austria, Germany and Switzerland) (Reference Freund, Everett and GriffithsFreund et al., 2015; Reference Maier, Aiken and BusseMaier, Aiken & Busse, 2017; Wismar, Glinos & Sagan, forthcoming). This task shifting, which has resulted in an expanded scopes-of-practice and a new division of work among teams, has been facilitated by reforms to the education and training of these professions in Europe.
Examples of the changing roles of health professionals are multifaceted and highly context-specific. An overview of in-depth country reforms and developments is provided in the European Observatory on Health Systems and Policies skill-mix case study companion volume (Wismar, Glinos & Sagan, forthcoming).
In this section, we provide a snapshot of trends with regard to two professions: nurses and pharmacists, for which a large number of reforms and developments have occurred in Europe. One notable example is the introduction of Advanced Practice Nurses/Nurse Practitioners roles, facilitated by reforms in line with the Bologna process and the move of nursing education to Bachelor’s degree, followed by Master’s programmes (Reference Lahtinen, Leino-Kilpi and SalminenLahtinen, Leino-Kilpi & Salminen, 2014; Reference Praxmarer-Fernandes, Maier and OikarainenPraxmarer-Fernandes et al., 2017). An analysis in 39 countries found that within Europe, Finland, Ireland, the Netherlands and the United Kingdom have expanded the scopes-of-practice of Advanced Practice Nurses/Nurse Practitioners considerably, authorizing them to perform a complex set of clinical activities. These include being responsible for a panel of patients, performing diagnoses/clinical assessments, ordering medical tests, deciding on certain treatments, prescribing certain medications, acting as first-point-of-contact and referring patients to other providers or settings (Reference Maier and AikenMaier & Aiken, 2016; Reference Maier, Aiken and BusseMaier, Aiken & Busse, 2017). Another related trend across Europe is country reforms on nurse prescribing. As of 2019, 13 countries in Europe had adopted laws to grant nurses with additional qualifications certain prescribing rights, thereby expanding their official scopes-of-practice. These countries are Cyprus, Denmark, Estonia, Finland, France, Ireland, the Netherlands, Norway, Poland, Spain, Sweden, the United Kingdom and the canton of Vaud, in Switzerland. Of these, eight countries adopted new laws in the last decade, demonstrating the novelty of the skill-mix change (Reference MaierMaier, 2019).
In a similar way to changes in the role of nurses, several countries have expanded the role of pharmacists in primary care (for example, Belgium, Denmark, France, Italy, Portugal and the United Kingdom), leading to a substantial increase in the range of services provided by the profession (Pharmaceutical Group of the European Union, 2019).
Pharmacists now increasingly take on a more patient-focused role and work as part of a multidisciplinary team. Pharmacists are seen as key professionals to assess and treat patients and assist with medication management, in particular for older people and those with chronic conditions and complex polypharmacy. According to the European Pharmacists Forum, pharmacist services now include work in five key areas (European Pharmacists Forum, 2015): (i) medicine adherence, (ii) administering vaccines in pharmacies, (iii) pharmacist-provided screenings, (iv) supporting patients and the public in self-care, (v) disease prevention and support in individual behaviour change (European Pharmacists Forum, 2015).
In sum, the scope of practice, education and training of health professionals differs markedly across Europe. Many countries have implemented or started implementing reforms. This inevitably influences not only the roles and responsibilities that individual professions can undertake, but methods of working within the various ambulatory and primary care settings and the composition of multidisciplinary teams.
Yet, to date, there has been no systematic, cross-country synthesis of the evidence on the implications of skill-mix changes on individual and population health outcomes or health system outcomes, including on the professions themselves, which is the overarching aim of this study.
In the following section, the conceptual framework that guided the study is described.
1.6 Conceptual framework of the skill-mix study
This volume is based on a conceptual health workforce framework that illustrates the interrelated factors that can lead to skill-mix changes (Fig. 1.1). The major two objectives are to analyse the evidence of skill-mix changes on (i) outcomes and (ii) factors that influence the implementation process. The changes to skill-mix are influenced by the status quo of a workforce often triggered by health worker shortages (for example, in rural areas), skill gaps (for example, in providing health promotion or prevention or social care), and other health workforce challenges. Health workforce challenges are often influenced by changing patient needs as well as drivers at the macro level – mutually influencing each other, for example, new financing mechanisms or cost containment strategies.
Figure 1.1 Conceptual framework
Abbreviations: LTC: long-term care; PC: palliative care.
Specifically, this volume – which complements and builds upon its companion volume, consisting of in-depth country case studies (Wismar, Glinos & Sagan, forthcoming) – performs a systematic synthesis of the evidence on skill-mix changes with a focus on skill-mix innovations and outcomes. It focuses on five core care segments of relevance to any health system: health promotion and prevention, acute care, chronic care and multimorbidity, long-term and palliative care, and access to services in rural and socially deprived areas. Chapters 4 to 8 synthesize the current evidence on the effect of skill-mix innovations according to the five domains. Education, regulation, payment policies and organizational strategies present core elements of the implementation of skill-mix innovations and reforms. Hence, chapters 9 to 11 focus on lessons for implementation, including facilitators and barriers and possible outcomes.
1.7 Methods
The volume is based on a systematic review of the literature (“overview of reviews”), which analyses all relevant systematic reviews on skill-mix and outcomes in a systematic manner, and additional, complementary evidence on implementation and country-specific information on reforms and implementation.
Overview of reviews
An overview of reviews (“umbrella review”) was conducted, summarizing all systematic reviews either on skill-mix and outcomes or on implementation. A protocol was developed a priori, which includes further information about the methodology (Reference Maier, Kroezen and HartlMaier et al., 2018b). All patients and population groups in primary care and all ambulatory care were covered. Excluded were inpatient settings and emergency care (for example, hospitals, long-term care institutions, hospice if inpatient), except for skill-mix interventions across several sectors including inpatient and ambulatory care (for example, coordination across sectors, liaison roles). The intervention was defined as changes to skill-mix (see definition in Table 1.1) over status quo/compared with standard-of-care. The comparator consisted of status quo (no changes to skill-mix), and/or as standard-of-care (traditional service provision) at the time of the individual study. Systematic reviews covering only low- and middle-income countries were excluded.
Search strategy
The search for eligible reviews was carried out in the following databases: Embase, MEDLINE in Ovid, Cochrane CENTRAL, Web of Science Core Collection, CINAHL, PsycINFO Ovid; in addition, a search in Google Scholar was conducted in January 2018. Search terms were developed together with the core team of researchers and a medical librarian. The full list of search terms is available in the addendum of the protocol (Reference Maier, Koppen and BusseMaier et al., 2018a). For the search, no restrictions were applied regarding the year of publication, whereas in the screening process only articles with publication dates from January 2010 to January 2018 were taken into account. The reasons were twofold: first, for feasibility reasons as the screening showed a high number of relevant systematic reviews published in the time period, and second, the focus was on skill-mix innovations, hence the element of novelty also played a role in the decision to focus on more recent evidence instead of reviews published before 2010. Furthermore, snowballing was performed to identify additional relevant reviews.
Data collection and analysis
The data management was executed with Rayyan QCRI, which is online software specifically designed for screening of articles for systematic reviews. The search in the databases produced a total of 8300 hits. The snowballing produced an additional 323 possibly eligible reviews. After several pilot phases to ensure consistency of the screening phase, the titles and abstracts of the first 100 hits were reviewed by three reviewers according to the inclusion and exclusion criteria. From these search results, interrater agreement for the first 100 hits scored >0.8 using an extended version of Cohen’s k coefficient, suitable for three reviewers (Reference Zapf, Castell and MorawietzZapf et al., 2016). As a high interrater agreement was reached, the remaining hits were divided among the three reviewers for both the screening of titles and abstracts, and then the screening of full-text versions. Authors were contacted if the full-text version was not available or if additional information was needed. Data analysis was based on a narrative synthesis on the main outcome measures by each of the five care segments [see conceptual framework (OECD, 2017)]. The form used was informed by previous overviews of reviews (Reference Thomson, Russell and BeckerThomson et al., 2010) and covered the following elements: country, study design, methods, participants, intervention, health profession, comparator, outcomes, care settings and context. Meta-analysis was not a priori excluded, but because of the type of review (overview of reviews) and the coverage of a broad topic (skill-mix), the outcome measures were too heterogeneous to perform meta-analyses.
Additional evidence on implementation and country reforms
In addition to the overview of reviews, evidence from other sources was included in this volume, particularly with a focus on the implementation of skill-mix changes and the identification of country reforms. To this end, each author team from each of the chapters performed additional literature searches to identify relevant material: the material included additional studies, reports, policy documents as well as other grey literature (for example, from health-related international organizations such as WHO, OECD, European Commission). In addition, country experiences were summarized with a particular focus on the implementation of reforms and outcomes, as available. To this end, the author teams identified suitable countries to be covered as mini case studies in the chapters, based on the authors’ collective expertise in their field. Information on suitable country case studies was also supplemented from the companion volume on skill-mix, which includes in-depth country case studies in 17 countries in Europe and other regions (Wismar, Glinos & Sagan, forthcoming). The material together was synthesized for each chapter focused on country-specific policy reforms and barriers/facilitators to implementation.
1.8 Overview of this volume
The volume is divided into three parts (see Fig. 1.2). The volume begins with a general part arranged in three chapters (Part I) on the rationale, definitions and conceptual framework of the book and the skill-mix situation in Europe (Chapter 1), a synthesis of the evidence on skill-mix changes and relevant outcome measures on patients, health systems and professions (Chapter 2) and lessons for implementation (Chapter 3).
Figure 1.2 Structure of the skill-mix volume (Volume II)
The second part consists of five chapters that present the evidence on outcomes as well as major country developments and trends. These are categorized into five areas of relevance to health systems and primary care, identified by and modified from OECD classifications: Keeping people healthy, acute care, chronic conditions and multimorbidity, long-term and palliative care, and access to services (OECD, 2017). The last part (Part III) consists of three chapters covering the implementation and lessons for uptake in policy and practice, with a focus on education and workforce planning (Chapter 9), the policy level (Chapter 10) and organizational change (Chapter 11).
Open access