Cahiers de sociologie et de demographie medicales最新文献

In France, ambulatory care is provided to patients mostly by independent physicians, GPs and specialists, paid on a fee-for-service basis. A national agreement between the Sickness Insurance Fund and the medical associations sets the price of different medical services. Due to the numerus clausus imposed upon the medical schools since the 70's, the yearly number of new graduates has sharply decreased and a feeling of manpower shortage has spread throughout the health system, in the public hospitals and the ambulatory care sector as well. Moreover increased dissatisfaction has been perceived among independent practitioners (they were 56 % of all the medical profession in early 2004). In this context, an opinion survey was undertaken among a sample of 3000 independent doctors whose one thousand have answered to the postal questionnaire.

In France, most of the physiotherapists providing ambulatory care are in private practice: they are paid on a fee-for-service basis by the patients who are reimbursed by the Sickness Insurance Fund. A survey on a sample of 2000 (out of 40,000) private practitioners was undertaken in early 2004. As concerns their workload, only 4% think that it is "not sufficient" whereas 66% estimate it "certainly sufficient". Such a feature is noteworthy, as private practitioners are most often fearful of lack of work. In the coming years, one physiotherapist out of 10 envisages to increase his workload, whereas 27% are in favour of a reduction. Furthermore, the survey shows that more than one third of private physiotherapists plan to offer to patients services which are not listed in the contractual agreement document signed by their profession and the Sickness Insurance Fund. The trend is most noticeable among the young practitioners. As the feeling of medical doctors shortage is currently widespread in France, the public debates are focused on the issue of task delegation. After the survey, 54% private physiotherapists are in favour of task delegation, 24% have an opposite opinion and 22% do not express a clear-cut position. However, an in-depth analysis of the written answers to the question shows that a large majority do not accept to replace medical doctors for performing the tasks which are of a subordinate level, are not significant or are time-consuming (e.g. filling out the administrative forms). The question of vocabulary is fundamental in the matter. Moreover, a process of task delegation implies that certain tasks carried out by an overburdened profession are transferred to an other profession less heavily surcharged. Is it the case of French private physiotherapists whose two thirds declare that "their workload is certainly sufficient"?

In the French health care system, most nurses work in hospitals as salaried, but a number are also salaried in health centers or operate in their private offices. About 48,000 are private practitioners, they provide nearly all the ambulatory nursing care to the population. A survey undertaken in early 2004 shows that on the average, their weekly working time is 40 hours: 10 hours are devoted to injections, 9 to dressings, 17 to nursing care and 4 to other activities. Out of 10 nurses in private practice, 3 think that their workload is too heavy. Moreover, 19% declare that they are willing to leave private practice over the 3 coming years. If all the individual plans become reality, more that 9000 private nurses would disappear during the coming years from a workforce of 48,000:2900 would retire, 2700 would become salaried in hospitals, 3200 would take up an other job and 400 would become temporary workers in interim companies. Will the tasks they let be carried out by their remaining colleagues? No doubt that this will not be the case only 7% of the surveyed professionals declare that they are willing to increase their workload. As nurses shortage in French hospitals is evident nowadays, it seems that shortage in ambulatory care is unavoidable. The surveyed nurses point out 3 important difficulties they are encountering. One nurse out of 4 complain about the heavy administrative procedures i.e. the numerous and complex forms they have to fill out. One out of 6 complains about the lack of locum tenets. Furthermore, one out of 15 are in favour of suppressing the official "Nursing Care Approach" which was promoted recently, precisely to highlight the importance of their professional work.

The Symposium was held in Barcelona, Spain, with the Institut d'Estudis de la Salut acting as host. It gathered 51 participants working in 34 institutions based in 18 countries. The main objective of the Symposium was to create an opportunity for assessing the past trends and forecasting the future developments of health workforce within the various national health systems. The Symposium was composed of 5 sessions devoted to presentations of the papers freely contributed by the participants and 5 discussion sessions devoted to the following themes : (i) Supply of and demand for health workforce, (ii) Future trends and forecasting methods ; (iii) Strategies for managing and planning health workforce ; (iv) Health workforce in underserved areas; (v) International migration of health workers. Each discussion session was conducted by a discussion leader whose the synthesis report is displayed here below.

The past three decades have seen the number of international migrants double, to reach the unprecedented total of 175 million people in 2003. National health systems are often the biggest national employer, responsible for an estimated 35 million workers worldwide. Health professionals are part of the expanding global labour market. Today, foreign-educated health professionals represent more than a quarter of the medical and nursing workforces of Australia, Canada, the United Kingdom and the United States. Destination countries, however, are not limited to industrialised nations. For example, 50 per cent of physicians in the Namibia public services are expatriates and South Africa continues to recruit close to 80% of its rural physicians from other countries. International migration often imitates patterns of internal migration. The exodus from rural to urban areas, from lower to higher income urban neighbourhoods and from lower-income to higher-income sectors contributes challenges to the universal coverage of the population. International migration is often blamed for the dramatic health professional shortages witnessed in the developing countries. A recent OECD study, however, concludes that many registered nurses in South Africa (far exceeding the number that emigrate) are either inactive or unemployed. These dire situations constitute a modern paradox which is for the most part ignored. Shared language, promises of a better quality of life and globalization all support the continued existence of health professionals' international migration. The ethical dimension o this mobility is a sensitive issue that needs to be addressed. A major paradigm shift, however, is required in order to lessen the need to migrate rather than artificially curb the flows.

Rationale: There is well-founded concern about the current and future availability of Health Human Resources (HHR). Demographic trends are magnifying this concern -- an ageing population will require more medical interventions at a time when the HHR workforce itself is ageing. The lengthy and costly training period for most health care workers, especially physicians, poses a real challenge that requires planning these activities well in advance. Hence, there is definite need for a good HHR forecasting model.

Objectives: To present a physician forecasting model that projects the Full-Time Equivalent (FTE) demand for and supply of physicians in Nova Scotia to the year 2020 for three specialties: general practitioners, medical, and surgical. The model enables gap analysis and assessment of alternative policy options designed to close the gaps.

Methodology: The methodology for estimating demand fo physician services involves three steps: (i) Establishing the FT for each physician. To this end we calculate the income of each physician using Physician Billings Data and then identify the 40th and 60th percentile income levels for each of the 40 specialties. The income levels are then used to calculate the FTE using a formula developed at Health Canada; (ii) Calculating the FTE for each service by distributing the FTE of each physician at the service level (i.e., by patient age, sex, most responsible diagnosis, and hospital status group); and (iii) Using Statistics Canada's population projections to project future demand for three broad medical disciplines: general practitioners, medical specialist, and surgical specialists. The supply side of the model employs a stock/flow approach and exploits time-series and other data for variables, such as emigration, international medical graduates (IMGs), medical school entrants, retirements, mortality, and so on, which in turn allow us to access a host of policy parameters.

Results: Under the status quo assumption, demand for physician services will outstrip the growth in supply for all three specialties.

Conclusions: The model can simulate supply-side policy changes (e.g. more IMGs, delayed retirements) and can also reflect changes in demand (e.g. a cure for leukemia; different work intensities for physicians). The model is highly parameterized so that it can accommodate shocks that may influence the future requirements for physicians. Once a future requirement is determined, the supply model can identify the policy levers (new entrants, immigration, emigration, retirement) necessary to close the gap between demand and supply. The model is a user-friendly tool made for policy makers to formulate appropriate physician workforce planning.

With the collapse of the Soviet Union, countries in Eastern Europe and the Newly Independent States inherited a physician workforce that was often too large, dominated by specialists, and poorly prepared for the transition to primary health care and the addition of the family/general practice specialty. We examine attempts in selected countries to plan the future physician workforce, while attempting to reduce the size of the workforce and train physicians to lead the transition to primary health care (PHC). We look the impact these efforts have had on the current workforce and will have on the future physician workforce. With few exceptions, the first move after independence was to reduce the inputs into the physician workforce in an attempt to reduce the size of the workforce, considered large by western standards, in 1990 between 350 and 400 per 100, 000 population compared to the EU average of 299. These reductions often did not result from planning and ignored the lengthy physician training process, leading to concerns for the future supply of physicians and the conclusion that many other factors were influencing the number of physicians. At the same time, two methods were being employed to rapidly prepare physicians for PHC, retraining of existing physicians for the short-term and the establishment of training programs in the faculties of medicine to train family/general practitioners (GPs) for the long-term. GPs per 100,000 population remained at about 102 throughout the period in the original EU countries, but in the new EU countries went from 51 in 1991 to 63 in 2002. The success of the programs was varied and often depended on the overall organization of the physician workforce, the status of the new family physician within the workforce and the commitment at the national level to the transition to PHC. After over a decade of independence, there is still a struggle to have a physician workforce with the right numbers, the right specialty mix, and practicing in the right locations.

Australia, Canada and the United States have large land masses containing many sparsely populated regions. Each of these countries has experienced difficulty in meeting the physician recruitment needs of its rural and remote regions. This paper reports on a study of selected Australian, Canadian and American medical education programs designed to meet the health professional needs of rural and remote areas. The study is based on published material from the institutions studies, supplemented by a series of interviews with senior academic officials in the institutions involved. The paper focuses on a range of strategies, from recruitment and admissions policies, to exposure to rural clinical practice and modified curricula, each designed to produce medical graduates with a strong orientation to rural practice. The study highlights the important role played by special government funding targeted at rural medical education initiatives and discusses the challenges that such initiatives face.