Health care labour shortages aggravated by professional turf wars

Shortages exist but it is the system’s structure that is preventing people from doing their jobs properly

Health care has been the subject of endless reform, but one thing that hasn’t been done very well is examining the people who are actually doing health-care jobs and the way in which they’re organized.

The health labour force is often categorized as burned out, overworked and plagued by personnel shortages. Shortages exist but it is the system’s structure that is preventing people from doing their jobs properly.

The first problem is the way the health professions are organized into self-governing colleges and professional associations. Here, the main issue is turf protection.

The second challenge is the way professions interact — or don’t interact — to provide primary care (the first point of contact between the patient and the health system). Here, the problem is how primary care is funded. This is compounded by turf protection.

A health profession is more than a job description in an HR department’s files. Each health profession is regulated by laws and by self-governing colleges, meant to protect the public interest. Their boards comprise people drawn from the professions and from the general public — but even if their intentions are good, these colleges can be so steeped in the traditions and interests of their professions that they end up spending time protecting professional turf, particularly when the professions overlap. The hold that colleges have over their professions is immense. The price paid by a professional who violates the rules laid down by her college can be severe, including the loss of the right to practice.

So, in Ontario for example, while there are 21 colleges, each dealing with its own profession, there is no entity dealing with all professions — other than the province’s government, which is often too enmeshed in political agendas to deal with the interaction among health professions.

Added to this is the power of many of the associations representing the interests of particular health professions. Organizations such as medical, dental and nursing associations often act as the professional equivalent of unions. However, their voices add to the din of turf-protection statements that can make teamwork difficult in health-care workplaces.

Few would argue for the abolition of self-regulating health professional colleges, since the alternative would be leaving it up to the government. However, there seems to be a need for greater transparency in these colleges, and a stronger presence for public (as opposed to professional) members of the colleges’ governing councils to ensure the public interest predominates.

A second challenge has to do with how health workers interact at the primary care level. It is the payment mechanism that impedes teamwork. It could be reorganized to allow health workers other than doctors to do the routine work, leaving doctors to do what they do best — heal.

Primary care, such as that provided in the family doctor’s office, is normally based on practitioners working on a fee-for-service or “piecework” basis. If a doctor or other fee-charging professional sees a patient, performs a procedure or refers someone he is paid for that “piece.”

This payment mechanism rewards doctors not for the quality of work, but for volume. Doctors earn the most money when they see the most patients in the shortest amount of time.

Fee-for-service, the payment mechanism for well over half of Canada’s doctors, does not allow doctors to be paid for work done by others — for the work of nurses or nurse practitioners, for example. Yet many visits to family doctors are for minor conditions that could be handled just fine by nurses.

Most health reform advocates say payment systems should foster team care, not just care provided by doctors. They also argue that payment based on the number of procedures performed should be replaced by other payment systems. Capitation (payment of an amount for each person registered as a patient with a clinic) is often cited as the preferred alternative, but with rates per person adjusted to reflect the complexities of care — more per person, for instance, for elderly patients or people with chronic conditions. Under capitation, doctors and other team members can concentrate on preventive measures. They are also encouraged not to under-serve their patients, since patients could leave a clinic’s roster and go to someone else if they feel they are not being well-served. And with capitation there is less demand on doctors to do almost everything, since payment is no longer linked to the act of a single professional.

Both doctors and patients seem to be ready for reform. Just 37 per cent of doctors responding to a 2002 Canadian Medical Association survey said they prefer fees-for-service, down from 50 per cent in 1995. And 54 per cent of Canadians polled in 2000 said they would be willing to see a general or specialized nurse working with a doctor for routine care. Of those polled in 1999, 74 per cent said they would prefer having a family physician working as part of a team rather than solo.

Reformed primary care would likely reduce the need for doctors, but it would not be a panacea. Doctors are not the only professionals in short supply, and more nurses and other health professionals must be trained if they take on expanded primary care roles.

But it’s a step in the right direction.

John Butler, president of the Agora Group, a Markham, Ont.-based HR and health-care management consulting firm, is a regular contributor to Canadian HR Reporter’s Insight Section. He can be reached at (905) 294-9762 or [email protected].

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