Fixing the health workforce crisis in Europe: retention must be the priority

Health and care workers in all parts of Europe are experiencing overwork, with high levels of burnout.1 They describe feeling undervalued and disaffected and are losing trust in the systems in which they work.23456

Strikes by health workers should be seen as red flags, pointing to serious underlying problems, but they are now taking place in several European countries.78 Less visible is the steady loss of skilled workers, with many attracted by the improved work life balance and better conditions offered by other careers or in health systems beyond Europe, or by early retirement. Yet, these problems have arisen in a situation when ever more health workers are being trained. Numbers of doctors and nurses have increased in relation to population by 13.5% and 8.2% respectively over the past decade.9 The European region now has the highest density of health workers among WHO’s six regions, with none of its member states having a critical shortage of health and care workers, as defined in a recent WHO report.10 So why are health workers so disillusioned at a time when their numbers have never been higher and what can be done about it?

We can identify several reasons for their unhappiness. The changing nature of healthcare is placing them under more pressure than ever. Healthcare is becoming more complex due to changing patterns of diseases, such as the growth of multimorbidity in ageing populations, as well as the ever increasing opportunities to intervene, for example with precision medicine. The health workforce is ageing too. In 11 of the countries in the European region for which data are available, at least 40% of doctors are over 55 years of age and will be retiring in the next decade.9 Meanwhile, older workers are being joined by those with young families in questioning what can be an unhealthy work-life balance. In some countries the financial rewards are being eroded, as pay rises lag behind inflation and costs, such as student debt, accumulate. This can too easily create a vicious spiral, as difficulties recruiting and retaining staff worsen conditions for those who remain, a particular problem in some socially deprived rural and peri-urban areas. And then there is the legacy of covid-19, in which many health and care workers lost their lives or were left with long term physical or mental disability.

The first step in addressing this situation is to reach a correct diagnosis. The stock of health workers is the sum of recruitment and loss. However, each acts over different time scales. A decision to increase training places taken today will not produce any more medical specialists for a decade. The lag is shorter for other health workers, but it cannot be the mainstay of a meaningful policy response. It also assumes that those highly pressurized workers now in post have capacity to provide the clinical training required. A more immediate solution is to recruit from elsewhere, but this raises important ethical issues. The obvious conclusion is that policies should prioritise retention of existing staff, with increased training offering only a partial, and long term answer. But how?

Health professionals are highly educated people. They have other options if they feel undervalued. Public sector pay restraint is an easy option for governments facing financial pressures, but is ultimately unsustainable. In some countries, health workers compensate by seeking informal payments, but this is obviously unsatisfactory.11 But the problems extend beyond pay. The digital transformations seen in many other sectors often seem to have passed much of healthcare by. Much of the work of healthcare staff, such as ordering of tests, is unnecessarily complicated. This is not just a problem for health workers. Patients, used to organising their holidays on the internet, puzzle as to why it seems so difficult to book an appointment. The pandemic has brought some improvements, such as greater use of remote consultations,12 but there is still a long way to go. Then there are the more personal aspects of working conditions, such as flexibility around rotas and family-friendly policies, where health systems again often lag behind other sectors.

The European Regional Office of WHO has recognised both the urgency of fixing these problems, but also the challenges involved in doing so. In 2022, it published a major report entitled “Health and care workforce in Europe: time to act.” This set out, in graphic detail, the scale of the challenge facing the 53 countries across the region and committed the Regional Office to 10 key actions to support governments to strengthen the health and care workforce.9 Consistent with the analysis set out above, many involve measures to improve working conditions and thus retention. Now, it has taken this process one step further. It convened representatives from 50 member states, along with professional associations and researchers, in Romania in March 2023. Emphasising the commitment to engage with those on the front line, one of the plenary speakers was a junior doctor who set out, in detail, the challenges she and her colleagues are facing.13 The resulting Bucharest Declaration offers an ambitious but comprehensive roadmap to move forward. It places health and care workers at its heart, recognising that failing to engage them in the search for solutions is pointless.14

The next step, in Tallinn, Estonia, in December 2023, is to embed these principles in wider health system reform. The challenge, which the ministers present will confront, is how to rebuild trust, by patients, health workers, and politicians, in health systems and transform services to make them truly person centred.15 This will only be possible with an engaged and motivated health and care workforce.