We are all well aware of the social and demographic changes affecting the population, and their consequences. An ageing population and ageing workforce, increases in life expectancy, affecting the use of health and social services and migration of labour, ask for attention on a European level. However, it is not only the general population that is changing. The healthcare workforce is subject to the same changes. The healthcare workforce is ageing; the number of health workers above 45 years of age has increased by over 50%,1 and health care has become less popular as a career choice. Health professionals move between member states of the European Union (EU) and globally from less to more affluent countries, making health workforce issues even more pressing.

The European Commission recently called for action through its Green Paper on the European Workforce for Health.[1] As is common procedure with green papers, the European Commission has launched a consultation. The European Forum for Primary Care (EFPC) has responded to the consultation, which is published at the EFPC website.[2] Why a response by the EFPC? We feel that a number of problems related to the quality and quantity of health workers can be solved by strengthening primary care. That is why we launched our own consultation of the members of the EFPC on the urgent challenges the health workforce is facing in their country. This editorial provides a summary of the results of this consultation.

The problem is easy to summarise. There is an increasing demand for health care, for increasingly complex health problems, with fewer people to provide this care, and an unbalanced situation between European countries.

Of course solutions are less easily summarised. However, the EFPC highlights the role of primary care as part of the solution of the current and future workforce problem. A multidisciplinary approach is required as a response to changing healthcare needs, and primary care is well suited to provide this. Integrated care for people with chronic illness is needed, with a strong emphasis on horizontal integration instead of vertical programmes. Strong primary care is one of the conditions for horizontal integration.[3] Shifting tasks from more specialised and longer educated personnel is part of the solution of workforce shortages, but again strong primary care is a condition.

The burden on the healthcare system is growing. As workforce problems gain prominence every day, a new approach is needed. Scarcity of healthcare professionals may put equity and accessibility of the system under pressure. We have to redistribute this burden on the various parts of the healthcare system. Strong primary care, with a multidisciplinary approach, can contribute to the solution of the problems that lie ahead. It is necessary to invest in public health integrated with primary care and to invest in substitution fromhospitalbased to community-oriented care. We have to move from the traditional solo to a multidisciplinary approach with integrated, community-oriented primary care and optimised skill mix. A multidisciplinary approach is the only feasible way to provide a complex range of services within primary health care and to maximise subsidiarity of care delivery.

In our response to the green paper we have suggested that European Structural Funds be used to improve community-oriented primary care. This includes training the necessary healthcare workforce and through this, strengthening social cohesion at population level within the European member states.

As part of multiple chronic disease management, other professionals (occupational therapists, physiotherapists, social workers, psychologists, nutritionists, nurse practitioners and public health experts) have to be involved and integrated in interdisciplinary care. At the moment, the impact of professions allied to medicine and supporting personnel is undervalued and neglected. They have high potential, as they will optimise the quality of care and can reduce the workload of physicians by taking over tasks and givingmore specialised personal care. Skill mix initiatives focus on changing professional roles, extending roles or skills.

Developments within thismultidisciplinary approach should be focused on task shifting and task delegation between primary healthcare professionals. The role of the nurse needs to be redefined. New professions will be developed and will contribute positively to address the needs of the population. This will contribute to a more efficient and effective healthcare system.

The integration of these professions into a smoothly organised healthcare system is very important. This is only possible if a multidisciplinary approach is already part of the education of health professionals. It needs to be taken up in the curriculum of basic training for healthcare professionals. The undergraduate curriculum should focus on generalism and comprehensiveness, and not on reductionism and superspecialism. In this way, the different healthcare professionals learn each other’s strengths andweaknesses before entering practice and respect each other in providing best quality care to the patient and the community, and this will influence task sharing and improve patient outcomes and provider satisfaction. The Bologna-measures should create a framework for interprofessional education and stimulate learning outcomes related to comprehensive interprofessional action.

Public health, health promotion, disease prevention and self-management support have the potential to reduce future demand for treatment and care services. Within multidisciplinary care and within strong primary care, these activities should be incorporated with a focus on empowerment of individuals and communities and building more social cohesion. The broadening of public health activities within primary care is thus part of the solution.

To substantiate this assertion, more evidence in various contexts needs to be collected. Health services research is needed to provide more evidence on the conditions under which prevention and health promotion will reduce the need for health care and community social care.

Besides the introduction of a multidisciplinary approach, immediate action should be taken to solve urgent problems relating to human resource policies. Serious investment in education and retraining of the healthcare workforce, to attract more young people and to improve conditions to retain and attract staff should be taken. Greater focus should also be given to improve childcare facilities to increase the participation of women and create the image of health care as an attractive workplace. Primary care is unpopular in some member states; due to better conditions in other countries, general practitioners (GPs) and nurses tend to leave. ‘If working conditions in primary care will improve, the attraction to this part of health care will be greater and this will solve some of the manpower problems’; ‘There should be stimulating methods, like improved working conditions for them not to leave the country’; ‘In some countries the position of primary care and family medicine in the healthcare system is still unclear’ and ‘GPs are overworked’ are reactions from our members.

Regarding migration and mobility of the healthcare workforce, we believe that positive measures and compensation mechanisms between countries will contribute to sustainable solutions and a balanced situation. Ethical recruitment and circular movement, enabling return to the home country after having served for a period abroad, are therefore important principles to be addressed.

Migration and mobility of the healthcare workforce has the potential to improve quality of care, expand knowledge and increase the experience of healthcare workers. New skills and experiences from abroad may improve the quality of care in the home country. This is an opportunity to learn from each other. The circular movement of primary care professionals within Europe is a very important way of continuous medical education.

However, it is always important to prevent an excessive ‘brain drain’. Healthcare workers migrating to other countries form a loss of investment in education for their home country. According to several of our members, primary health care suffers from migration more than other healthcare sectors. Special attention should be paid to migration of (primary) healthcareworkers fromdeveloping countries (Africa, Asia) to Europe. This brain drain is unethical.

Migrating healthcare workers also pose specific problems to primary care in the receiving countries, as our members noted: ‘well-trained health workers but not culturally adapted; cultural adaptation is more important in primary care than in other sectors of health care’ and ‘high levels of communication skills are needed’. Integration programmes for health workers to secure a high-quality level of care are needed.

There is a lack of good information on manpower issues in the EU member states. Information on issues of migration and mobility is largely lacking. The monitoring of migrant health workers, in the home country as well as in the host country and the border areas, and short-term mobility need to be improved. In addition, case studies would provide insight and enable us to understand the problem better.

Conclusion of the recommendations to the European Commission

Urgent plans of action are needed; strong primary care with a multidisciplinary approach and integration with public health is part of the solution. This is the only feasible way to provide a complex range of services within primary care. This approach will contribute to the current needs of the growing elderly population and the needs of people with multiple chronic conditions. These changes need to be incorporated in the undergraduate curriculum to have optimal results.

Migration and mobility of the health workforce could cause some serious shortcomings between regions and countries. Circular movement, ethical recruitment and balancing mechanisms should be facilitated, advised and supported by the European Commission to prevent serious workforce problems resulting. Lack of data makes it difficult to analyse and to understand the situation. Therefore more and comparable information is needed.

Finally, the European Cohesion Policy should contribute to the improvement of community-oriented primary care and therefore strengthen social cohesion.

We suggest that structural funds can be used to improve the training of the European health workforce to enable them to work in community-oriented primary care, and by this strengthen the social cohesion at population level within the European member states.

Peer Review

Not commissioned; not externally Peer Reviewed.

Conflicts of Interest

None.

References

1. Commission of the European Communities.Green Paper on the European Workforce for Health.COM/2008/0725.Brussels:Commission of theEuropeanCommunities, 2008. https://ec.europa.eu/health/ph_systems/docs/workforce_ gp_ en.pdf (accessed 3 September 2009).
2. European Forum for Primary Care. Response on the EC Green Paper, On the European Workforce for Health, by the European Forum for Primary Care (EFPC), 31st of March 2009. https://www.nivel.nl/oc2/page.asp?PageID=10915 (accessed 3 September 2009).
3. Gress S, Baan CA, Calnan M et al. Co-ordination and management of chronic conditions in Europe: the role of primary care – position paper of the European Forum for Primary Care. Quality in Primary Care 2009;17:75–86.