HEALTH HUMAN RESOURCES
In our first report to Canadians, the Health Council stressed the importance of focusing on the health care workforce — both the recruitment of new professionals and the retention of those currently working in the system. We argued that without an appropriate health human resources strategy, all other health care
renewal efforts would fail.
What did governments promise?
The 2003 First Ministers’ Accord on Health Care Renewal committed governments to collaborative strategies to strengthen the evidence base for national planning, to promote interprofessional education, to improve recruitment and retention, and to ensure the supply of needed health providers. The 2004 First Ministers’ 10-Year Plan to Strengthen Health Care committed governments to increase the supply of health professionals based on their assessment of the gaps. The federal government agreed to expand the assessment of internationally trained graduates, to target efforts in Aboriginal communities, to reduce the financial burden on students, and to participate in health human resources planning with interested governments.  Teams Manage Chronic Disease
Where are we now?
Efforts to ensure that we have the right mix of health professionals must take into account that different aspects of the problem require different solutions. For example:
| - | We have real shortages of particular groups. The solution here is to train more workers.
| | - | We have shortages of services as a result of professionals spending time on activities that could be delegated to others. The solution here is to reorganize the
work to get the best use of the skills in our existing workforce.
| | - | In some areas, we have a sufficient pool of workers, but many are retiring early, changing careers or reducing their hours of work. The solution here is to focus on ways to reverse the exodus or provide alternative career tracks that prevent the loss of their skills and experience in health care.
| | - | We have access problems for certain services due to growing demands, some of which may not yield additional health benefits for individuals. The solution here is to eliminate inappropriate and redundant use of health services.
| | - | Some areas of the country have an adequate or even an over-supply of some types of workers, while others experience shortages. The solution here is to implement policies and practices to achieve a better distribution of personnel in relation to need. | The Health Council sponsored a national summit on health human resources in June 2005 at which we examined four themes:
| - | interprofessional education and training;
| | - | scope of practice;
| | - | issues in the workplace; and
| | - | planning efforts. | A full report is available on the Council’s website, www.healthcouncilcanada.ca.
Interprofessional Education and Training
There is an urgent need for interprofessional education that supports new models of primary health care delivery. Simply put, we need to change the way we are
educating and training health professionals. This will require different programs, an expansion of current approaches that are educating and training health professionals together, the creation of workplaces that support team-based care, new funding models, and the removal of barriers that prevent professionals from putting their skills to the best use.
A number of schools are on their way to introducing an interprofessional curriculum, and Health Canada has approved funding for the development of 11 collaborative programs. However, it will be some time before students will actually complete these programs and enter the workforce. The projects listed in Table 4 are all due to be completed by March 31, 2008.  Table 4. Plans for New Interprofessional Education Programs
Scope of Practice
It is impossible to achieve a sound workforce strategy in health care without addressing scopes of practice. In any industry, getting the division of labour right is crucial. Making the best use of the full spectrum of skills is key to primary health care renewal, recruitment and retention of providers, high-quality patient outcomes, cost-effectiveness and flexibility to meet community needs. Our own research on scope of practice shows that:
| - | There are no common definitions of scope of practice in Canada.
| | - | Scopes of practice are determined by a number of different players, including educators, legislators, regulators, employers, professional associations and providers themselves, and their perspectives and aspirations often collide.
| | - | Individual professions have worked on their own scope of practice issues, often isolated from what others are doing (Table B.3).
|  Simultaneously, the credentialing process in Canada is becoming increasingly complex. Self-regulating professions are setting “entry to practice” standards at higher and higher levels. For example, physiotherapists are proposing a master’s degree (MSc) to enter independent practice, and pharmacists are proposing a doctoral level (PharmD) entry credential. There are competing views about the justification for this trend. One view is that “credential enhancements” are based on concerns about patient safety and performance, and reflect the rising expectations of front-line health care. Others view the trend as “credential creep” and question whether it arises from professional self-interest and whether it may work against the development of team-based care by perpetuating professional isolation. In the Health Council’s view, a highly educated workforce and a commitment to lifelong learning are essential to support the delivery of safe and effective health care. However, increases in credential requirements should occur only when there is evidence that existing standards compromise the quality of patient care and therefore standards need to be raised. The provinces and territories have agreed to a standardized process for reviewing changes to entry-to-practice credentials for health professionals. Professions proposing a change in the entry-to-practice credential are required to complete a detailed submission outlining the rationale for and evidence supporting the change. Each proposal will be reviewed by an expert panel that will make a recommendation based on its findings. While the process is standardized, jurisdictions retain the authority to make their own final decisions. Critical Care Teamwork in Rural BC
Workforce Planning
 Workforce planning in health care has been a challenge for policy makers for quite some time. Canada does not have a national health human resources strategy that is linked to a clear picture of future delivery models. Instead, provinces and territories are doing this work separately, often in isolation from one another. The good news is that some governments have joined forces to plan together on a regional basis. Every provincial and territorial primary health care plan refers to newer professions, but efforts to increase their numbers are lukewarm. For example, nurse practitioners have a 30-year history in Canada, but there are fewer than 900 of them in the country and they are not licensed in all jurisdictions. This lack of uptake inhibits the development of different models of delivery and compromises access in rural and remote areas where it is difficult to recruit physicians. Health human resources planning must take into account a number of factors, including changing practice patterns, appropriate scopes of practice, changing demographics and the delivery models of the future. This requires an abundance of good data with good models to project future needs and, most importantlyin our view, a desire to work together across jurisdictions. Work is underway to improve planning capacity; Table B.4 outlines specific activities in the jurisdictions. At the intergovernmental level, the federal/provincial/territorial ministers of health have released a Pan-Canadian Health Human Resources Planning Framework for consultation. The framework has some promising elements that will likely promote collaboration. These elements include articulating a common vision, setting goals and objectives, and linking these goals and objectives to desired outcomes. In addition, the framework identifies short-, medium and long-term activities and commits jurisdictions to plan on the basis of the health needs of their populations. However, the framework does not address the issue of coordination across governments and with other organizations such as provider groups, regulators, employers, unions and researchers. Their work needs to be integrated with that of governments. Jurisdictions were due to have released their separate action plans on health human resources by December 31, 2005. As of mid-January, eight had released plans: Saskatchewan, Ontario, Quebec, New Brunswick, Nova Scotia, PEI, Northwest Territories, and Nunavut. Steps are also being taken to get more and better data. CIHI is leading efforts to develop a minimum data set, which will ensure that all data collectors gather similar information about health care professionals. Currently, Canada has substantial amounts of usable data only related to nurses and physicians. Data on other professions is vital if interprofessional teams are to be the vehicle for primary health care delivery. In conjunction with efforts to improve data collection, governments are working on projection modelling – a set of tools that planners and policy makers can use to assess future demand for health care professionals. The work is being done under the auspices of a federal/provincial/territorial advisory committee. It would be useful for the committee to inform the stakeholder community about the models being developed, when they might be publicly available, and when they might have an impact on improving access to health care professionals. Greater self-sufficiency in producing our own health care professionals is an important national goal. In fact, it may be most prudent to develop a modest surplus in the supply of some types of health professionals to keep the system flexible, able to adapt to quickly changing demands. Part of these developing health human resources strategies will involve the use of internationally educated health professionals. It is important to recognize that Canada is a country that welcomes immigrants and that immigration policies in Canada facilitate the entrance of skilled workers. A clearly articulated role for these professionals is needed. At the same time, the Council believes that the active recruitment of health care professionals from countries that are experiencing their own shortages is not an ethical, long-term strategy. Other alternatives are required.
Where are the roadblocks?
| - | Current training programs and work environments, as well as planning models, are not geared towards interprofessional delivery of care. Without this directional shift, a population-based approach to health needs cannot take hold and the skills of other health professions cannot be fully tapped. Ultimately, health professionals will not be able to truly understand how they could work together differently.
| | - | The skill sets of existing health professions could be put to better use, but real and perceived legal and regulatory barriers are preventing progress.
| | - | Requirements for licensure and entry to practice vary widely across jurisdictions, making it difficult for jurisdictions and professions to plan collaboratively.
| | - | Planning efforts need to be coordinated across jurisdictions to reduce duplication and variability in supply. |
What needs to be done?
 | Focus aggressively on increasing the number of interprofessional education and training programs available in Canada. The Council recommends that:
| - | each university health sciences program in Canada offer an interprofessional education program. If we want health professionals to work together, they need to learn and train together;
| | - | education and training opportunities allow already-educated professionals to add skills without having to pursue extensive new training programs;
| | - | tuition subsidies be made available for students and post-graduate trainees to enter interprofessional programs;
| | - | a collaborative practice workplace fund be established to support primary health care settings that implement true interprofessional teams;
| | - | the shift to payment models that encourage interprofessional teamwork be accelerated; and
| | - | concerns about professional insurance schemes and liability be addressed by developing joint liability programs that would apply to a team rather than an individual. | Specific targets and timeframes for these recommendations are included in the Health Council’s November 2005 report, Modernizing the Management of Health Human Resources in Canada: Identifying Areas for Accelerated Change.4
|  | Clarify and report to the public on who will provide what services, especially in primary health care. Governments must take the lead in bringing together the necessary players to assess how scopes of practice align, complement or even duplicate each other, and to clearly articulate who is capable of providing different types of patient care. Those who need to be involved in this effort include health profession associations and regulators, unions and employers. Health human resources plans should be publicly available and specify clear targets and timelines so that local citizens can understand what type of professionals will be delivering care in their communities.
|  | Remove barriers to optimizing skills sets. Governments, health professions, employers, unions, educators and planners must work together to identify specific legislative, regulatory, financial and policy impediments to optimally using the knowledge and skills of all health professions. The focus must be to support, rather than prevent, interprofessional collaboration and teamwork.
|  | Integrate provincial, territorial and regional health workforce plans. Unless jurisdictions collaborate in their planning, there will continue to be competition for scarce human resources. Common approaches are needed to address such issues as barriers to mobility and the mismatch between training opportunities and forecasted needs. The education and practice environment for health care workers needs to become simpler, not more complex.
|  | Make decisions about supply in conjunction with addressing scope of practice issues. For example, changes in the number of training places in various programs should be related to developments in scope of practice to avoid serious under-supply or over-supply of needed health care providers. | 
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