Health Human Resources (HHR) in Canada Part 2: Where to next?

John G. Abbott, CEO, Health Council of Canada

In my previous blog post I outlined some of the pressing challenges our health care systems face when addressing the management of our health human resources and underlined the need for a strategic approach.

So, what steps should Canada take to get to the high-performing health care system all Canadians want? From the Health Council’s perspective, there are several basic elements we need to work on.

1. Set a vision and measurable goals 

 

We need to set specific targets nationally and provincially that are aligned for each of our professions. These have to be based on our population health needs, the interprofessional collaboration model of care and the capacity of our education and training system to meet them. For example, we should aim to be self-sufficient and set a timeframe to reduce our reliance on international recruitment across all professions. In addition, we could set explicit targets for training the workforce we know we’re going to need to care for the growing number of complex patients living in the community and at home.

2. Address our human resources challenges in workforce planning 

 

Canada has shown that, given time, it can implement innovative ways of delivering better quality care more efficiently at the “micro level”. But, when it comes to achieving a high-performing health care system, time is not on our side. We need governments and professional bodies to better collaborate to create supportive “macro level” policies that accelerate the implementation and spread of innovative practices. This includes regulatory frameworks that support professionals to work in teams and a post-secondary education system that is more responsive to training professionals that meet projected population health needs.

3. Central body of evidence 

 

Traditionally, knowledge translation on health human resources has been a one-way street where researchers produce evidence which they communicate to decision-makers. It is, therefore, not surprising that we don’t yet have a shared information base.

Seeing this, a number of Canadian health care stakeholders are calling for the establishment of a health human resources observatory. An observatory would be a forum where researchers, governments, employers, health professionals and unions can come together to share their views and gradually develop an evidence base that has “buy-in” from all sectors.

An observatory could also be a forum for coordinating research on health workforce issues, strengthening data collection and sharing approaches across provinces and territories. In this role it would build on the current trend towards increased interprovincial collaboration.

In 2010, the House of Commons Standing Committee on Health recommended the creation of a national observatory. The Health Council has endorsed this recommendation. Among peer nations, Australia has established an observatory whose work is highly regarded by experts in the field. Known as Health Workforce Australia, the observatory states as its goal: to build a sustainable health workforce for Australia.

In fact, the building blocks of an observatory are already up and running in the form of the Canadian HHR Network. The Pan-Canadian Health Human Resources Network (CHHRN) was established with federal funds and is made up of renowned researchers and policy makers. The Network has over 75 users from across Canada, and their Advisory Committee includes health ministry representatives.

The Network is already a valued source of best practice information on issues like health human resource retention and productivity.

To conclude, I believe that Canada is in a strong position to enact policy changes that would improve the productivity of our health workforce and improve the performance of our health care systems. Today’s governments and health care managers are well-versed in the language of quality improvement in health care. They also realize that there are cost-savings to be made by reorganizing our health systems to produce more effective care that is responsive to the needs and wishes of patients.

Just as Canada is proud of having one of the world’s strongest financial systems, shouldn’t we also want to have one of the best health care systems in the world? Canada has the knowledge and resources required to plan for our future health care needs, and this is more than true for our health workforce.

In the end, we want not only to be self-sufficient nationally, but to have the highly-skilled people to meet our health care demand needs in each region of the country. That will require a strategic approach built on continued collaboration amongst governments, professional bodies, their regulators and the education and training community.

Health Human Resources (HHR) in Canada Part 1: What is to be gained from HHR Planning?

John G. Abbott, CEO, Health Council of Canada

Health care always has been and always will be a labour-intensive industry. Canada, like most developed countries, spends a large proportion of health care spending on training and paying health care professionals.

The Canadian Institute for Health Information (CIHI) reported that between 1998 and 2008, total public sector spending grew at about 7% per year. In other words, over the course of a decade, public spending on health care doubled from about $60 billion to $121 billion. And from 2008 to 2012, public spending grew by another 20% (to $145 billion).

This analysis also showed that a significant portion of the increase went to higher wages for a larger workforce. Again, using CIHI’s figures, more than 360,000 regulated nurses were employed in Canada in 2011, an increase of more than 8% since 2007. This was nearly twice the rate of population growth in Canada.

There is a growing recognition that we could get a better return on our health human resource investments by organizing professionals to work more effectively. Primary health care teams are a good example of this.

We need to reframe our approach and our thinking to see the health workforce as the means; and, where the end is better health outcomes for Canadians, not just more care provided by more professionals.

So, how is Canada doing in its drive to achieve a high-performing health system through its people?

I will present three pressing policy challenges, each of which stems from a mismatch between our health care needs and our supply of health professionals – and what may be needed to solve them from re-occurring.

Reliance on internationally-trained professionals 

 

Canada has long relied on internationally trained doctors and nurses to staff our health care systems, particularly in rural and remote areas. While recent data are hard to come by, it is clear that our system is reliant on international graduates. In the 2010 National Physicians Survey, about 1 in 6 physicians reported that they completed their medical education outside Canada or the US. This in itself is not bad, but when we rely continuously on foreign nationals to meet our needs, then we and their governments have a problem.

Does Canada aim to become self-sufficient in its supply of health care professionals or will we continue our system of international recruitment? If we continue to recruit, how will we direct international graduates to where they are most needed?

The solution is a commitment to self-sufficiency with both the health and education and training sectors developing a joint plan to help Canada achieve this.

Underutilization of specialist physicians 

 

The second issue is one that was unheard of even five years ago: under- and unemployed specialist physicians. It takes large amounts of resources to train a medical specialist, which yields a “zero return” if they cannot practice due to a lack of capacity in acute care or other systems. We’re hearing stories in the media of eager young surgeons who can’t get operating room time, while patients wait for care.

A number of stakeholders are calling for better national human resource planning and better information for medical students to give them a clearer picture of their chances of landing a job in particular specialties, and in specific regions of the country.

The solution is better modelling of provincial needs and matching with specialist supply. Medical school seats and post-graduate training slots are adjusted accordingly.

Struggle to recruit a workforce for home care

 

The final issue speaks to our ability to care for the growing number of Canadian seniors. In our recent report we found that that seniors and their families want to receive care at home, most provincial systems are investing in home care services. Canada certainly needs to boost its home care services, as they are integral to a high-performing health care system today. But staffing these services presents huge challenges that run the gamut of human resource issues. From compensation, to education and training, to quality assurance and working conditions, the home care sector struggles to find staff to meet their clients’ needs.

Personal support workers (aka community health workers or continuing care assistants) provide most home care services, particularly for long-term clients. Personal support workers are unregulated and their training currently varies between provinces and territories.

The solution is to designate this sector as a growth sector, allocate additional training funds, upgrade quality improvement programs and realign the compensation and benefits regime to give this sector a higher status within the health care system.

Canada’s goal remains a high-performing health care system. To arrive there we need to tackle our health human resource challenges in a way that is strategic. In saying that, any approach has to be explicit, proactive, measured and bolstered by a common evidence base.

In my next blog post I’ll outline some of the steps we, as a country, need to take to improve the management of our health human resources with the goal of attaining the high-performing health care system that all Canadians want.

Progress on HHR issues?

Ivy Lynn Bourgeault, PhD, is a Professor in the Interdisciplinary School of Health Sciences at the University of Ottawa and the Canadian Institutes of Health Research Chair in Health Human Resource Policy. She is also the Scientific Director of the pan-Ontario Population Health Improvement Research Network and the Ontario Health Human Resource Research Network both housed at the University of Ottawa. Dr. Bourgeault also leads the pan Canadian Health Human Resources Network. Dr. Bourgeault has garnered an international reputation for her research on health professions, health policy and women’s health.

Can our progress towards more effective and efficient use of health human resources (HHR) be seen as a case of a glass half full or half empty – or is it that any progress should be seen as only a drop in the bucket of what is actually possible?  The conclusions that the Health Council of Canada has reached in regards to HHR issues in its Progress Report are correct.  We in Canada have ‘succeeded’ in increasing the supply of HHR (indeed to the point where we are hearing calls of surpluses and underemployment of some medical specialists [see http://spph.ubc.ca/sites/healthcare/files/Media/BelluzDoctorSupplyMedPost-Jan2012.pdfhttp://spph.ubc.ca/sites/healthcare/files/Media/BelluzDoctorSupplyMedPost-Jan2012.pdf]), but we have done so while neglecting to attend to the appropriate mix of HHR and other measures to ensure that existing, highly trained health professionals are working to their full scope of practice. 

The issue of scope of practice is increasingly being highlighted at important policy tables, the Council of the Federation being just one [see http://www.hhr-rhs.ca/index.php?option=com_content&view=article&id=185&lang=en]. Being able to work to full scope is not only important for the productivity of the health workforce, it is a critical element in efforts to retain highly qualified staff (yet another neglected issue). We have also improved collaborative practice and education initiatives – through the investment and successful efforts of the CIHC,  which is no longer being funded – but there has been little interprofessional planning of HHR supply and distribution. That is, any improvements in planning models are still limited by geographic and professional isolation. So we’ve done much less than we could in strengthening the evidence base for national planning and even less to foster closer collaboration across sectors critical in the planning process. 

We are disappointed that repeated calls to establish a pan-Canadian HHR observatory – echoed by all stakeholders and members of the Parliamentary Committee on Health in 2010 – has not been heeded 

[see http://www.parl.gc.ca/content/hoc/Committee/403/HESA/Reports/RP4631326/hesarp06/hesarp06-e.pdf]. Such an observatory would, as described by the WHO, collect, analyze and translate data and information on the health workforce, facilitate a dialogue among HHR stakeholders, and contribute to policy development and a broader understanding of HHR issues.  It is in this vacuum that we have been attempting to create some much needed research and knowledge exchange tools at the pan-Canadian HHR Network, with pilot funds received from Health Canada and the CIHR.  It is our intention to make evidence more accessible to those making critically important HHR decisions and to help sustain our publicly funded health system.