National recommendation for professional skill mix

• Abstract
• Purpose of health policy or idea
• Characteristics of this policy
• Political and economic background
• Purpose and process analysis
• Expected outcome
• References

Featured in half-yearly report: Health Policy Developments 11

Abstract

After 4 years of experimentation and public consultation, a national recommendation for developing cooperation (i.e. skill mix) between health professionals has been published by "Haute Autorité de Santé" and National Observatory of Health Professions in April 2008. The text recommends a number of reforms on education and training of health professionals, provides a regulatory framework for developing cooperation, and arguments for their necessity.

Purpose of health policy or idea

The main objective of this policy is to anticipate the future demand for health care professionals in a context of a decreasing number of doctors in the next ten years. The objective is to transfer some of the medical tasks from doctors to nurses and to other paramedical professionals, and create conditions of a more flexible healthcare provision. One important issue is to offer more attractive careers for different health profesionnals and particularly for nurses through a Masters Degree and new job opportunities.

The recommendation requires a clear engagement of policy makers to adapt a regulatory framework (i.e. definition of the scope of practice), to create a specific Master degree for nurses, and to develop cooperation through adequate salary scales and new modes of payment in hospitals and in ambulatory care. Thus, the recomendation supports a simultaneous change in the regulatory framework, the mode of payments and the development of education and training programs for non-medical professionnals.

Groups affected

Medical doctors, nurses, other health care professionals

Degree of Innovation	traditional		innovative
Degree of Controversy	consensual		highly controversial
Structural or Systemic Impact	marginal		fundamental
Public Visibility	very low		very high
Transferability	strongly system-dependent		system-neutral

The recommendation is rather innovative, recognizing the role of different health professionals which are traditionally dominated by doctors. Providing a larger perspective and clear career pathways for nurses, midwives, and other health professionals is important for satisfying future healthcare needs. Many countries have already recognized such evidence.

In France, the principle of public payment and private practice, in which fee-for-service is a central part, seems to slow down the promotion of skill mix. It might be necessary to change the model of remuneration. The government annouced that  experimentation will also be carried out in this field, which will certainly be linked to skill mix initiatives.

Political and economic background

The national recommendation is the result of a political process which has been promoted in 2003 to tackle the problem of a decreasing number of medical doctors in France. Four different health ministers succeeded since the kick off of this idea and the implementation of experimentations. The government policy has been reatively stable for four years, even if the process has been slow.

This skill mix or cooperation policy is also linked to the Bologne agreement on university diploma (Licence Master Degree) which gives an incentive to introduce university diploma for different health care professions. However, despite some marginal adjustment on specific topics like eye care, or vaccination by nurses, there is no specific policy program or engagement to implement this recommendation yet. So, it is not clear if there will be any  radical change for enhancing cooperation between health care professionals.  

Change based on an overall national health policy statement

This specific skill mix policy has been originally motivated by the perpective of a future medical shortage. The actual developpment of the policy of skill mix is also oriented to improve the quality of care and to create new jobs in health care.

Purpose and process analysis

Current Process Stages

	Idea	Pilot	Policy Paper	Legislation	Implementation	Evaluation	Change
Implemented in this survey?

Origins of health policy idea

The project of the skill mix policy is strongly supported by the president of the National Observatory of Health Professions. He has been a leader for the profession and he has been in office for four years despite the change of ministers every year. Since 2006, the project has been partly transferred to the "Haute Autorité de Santé" (High Health Authority) in order to produce a national recommendation both to policy makers and to health professionals.

The recommendation has been supported by the results of experimentations in pilots projects. These projects mainly consist of a formalization of informal practices which were already carried out by nurses or other healthcare professionals, in some cases for many years. Some examples are: abdominal echography by imagery technicians, reconduction of ambulatory chemotherapy for patients with brain cancer by nurses, follow-up treatment of patients with hepatitis C. Those pilot projects were driven by medical leaders mainly in hospitals on a voluntary basis for a limited period of time. The evaluation of those experimentations has been explained and largly communicated to doctors and to other stakeholders. The final recommendation has been submitted for public consultation.

Initiators of idea/main actors

• Government: The current Minister of Health is supporting this recommendation. The Minister of Education has not been consulted until now.

• Providers: Division appears in each professional group. The MD Chamber is conservative, the trade union of private MDs is divided. GPs' trade union is supportive and the positions of specialists vary. The private nurses' trade union fears a loss of autonomy by working as salaried employees in GPs' practices.

• Payers: For the National Health Insurance Fund there is a risk that overall health expenditure might go up with duplication of tasks by different health professionals rather than substitution. This rises the issue of introducing a more performance based contract with health professionals.

• Patients, Consumers: Patients generally support this policy.

Approach of idea

The approach of the idea is described as:
new: The recommendation proposes a substantial adaptation of the regulatory framework of health professions (e.g. scope of practice for nurses which could be defined by missions and limits instead of actual definition by very precise and limiting list of acts)

Innovation or pilot project

Pilot project - 16 pilot projects have been carried out and assessed. Only two of them concerned ambulatory care (general practice and eye care). They involved mainly transfering of technical procedures, follow up of chronic patients with hepatitis or prevention.

Actors and positions

Government
Ministry of Health	very supportive		strongly opposed
Ministry of Education and Research	very supportive		strongly opposed
Providers
Medical doctor chamber	very supportive		strongly opposed
Medical trade unions	very supportive		strongly opposed
Medical academic	very supportive		strongly opposed
Nursing trade union	very supportive		strongly opposed
Other professional trade unions	very supportive		strongly opposed
Payers
National Insurance Fund	very supportive		strongly opposed
Patients, Consumers
Patients/consumers	very supportive		strongly opposed

Influences in policy making and legislation

The Minister of Health annouced that the different elements of the recommendation will be implemented in different laws in summer and autumn 2008. Concrete proposals will be developed in law to change the regulatory framework for health professions. At the moment very little is known about the precise content of the government project. The main opposition will probably come from the Ministery of Education.

Actors and influence

Government
Ministry of Health	very strong		none
Ministry of Education and Research	very strong		none
Providers
Medical doctor chamber	very strong		none
Medical trade unions	very strong		none
Medical academic	very strong		none
Nursing trade union	very strong		none
Other professional trade unions	very strong		none
Payers
National Insurance Fund	very strong		none
Patients, Consumers
Patients/consumers	very strong		none

Positions and Influences at a glance

Adoption and implementation

Medical bodies are crucial stakeholders for the implementation of this policy, that is the application of recommendations. Three main actors have to be motivated and convinced: Doctors and Nurses associations, Parliament and the Minister of Education.

Monitoring and evaluation

There is no monitoring tool to follow the implementation of the law. The translation of the recommendation into law will mean the success of the recommendation.

Expected outcome

The recommendation aims to tackle future problems of Human Ressources for healthcare in the next ten years and to further and to improve efficiency of healthcare provision. However, it is generally assumed that this reform will not help to reduce increasing healthcare expenditures.

Impact of this policy

Quality of Health Care Services	marginal		fundamental
Level of Equity	system less equitable		system more equitable
Cost Efficiency	very low		very high

The skill mix policy in itself is not able to promote more equity or more cost-efficiency. The institutionalization of new skills, new levels of competences, new jobs or new models of healthcare delivery is a condition to maintain equity in access to care and in some cases to improve quality of care in an efficient way. But this condition is not sufficient by itself and other policies to finance and monitor the level of equity and quality are required.

References

Sources of Information

• ALL DOCUMENTS available at www.has-sante.fr/portail/display.jsp?id=c_497724.
• Délégation, transferts, nouveaux métiers… Comment favoriser des formes nouvelles de coopération entre professionnels de santé ? - Recommendation.
• Guide méthodologique pour réaliser un cahier des charges (193.83 KB)
• Etude qualitative du CNEH - Rapport final.
• Les pratiques actuelles de coopération: analyse des témoignages des professionnels de santé.
• Enjeux économiques des nouvelles formes de coopération entre professionnels de santé.
• Les aspects juridiques des nouvelles formes de coopération entre professionnels de santé.
• La formation des professionnels : pour mieux coopérer et soigner.
• Rapport d'étape Délégation, transferts, nouveaux métiers. www.sante.gouv.fr/ondps/rapport_cinq_experim_juin2006.pdf.

Reform formerly reported in

Observation and monitoring of Health Professionals Process Stages: Implementation, Policy Paper, Legislation

Author/s and/or contributors to this survey

Bourgueil, Yann

www.irdes.fr/EspaceRecherche/Equipe/Bourgueil.htm

Suggested citation for this online article

Bourgueil, Yann. "National recommendation for professional skill mix". Health Policy Monitor, April 2008. Available at http://www.hpm.org/survey/fr/a11/1