The doctor will see you now (if you turn on the video)

health workforceMark Pearson, Deputy Director, OECD Directorate for Employment, Labour and Social Affairs. Also published by Europe’s World

An elderly man with cardiovascular disease tests his own blood pressure, and sends the results to an online application that his doctor can access. Another patient with depression living in a rural area far from health services tells a psychiatrist how he is feeling via a video connection. All of this occurs without the patients leaving their homes.

These scenarios may sound like something scripted by writers of science fiction, but such ‘telehealth’ has the potential to bring high-quality and specialised care to previously underserved populations. Studies indicate patients respond positively to using the technology, and it increases access to health services. Health professionals report that it reduces the need for patient visits, and assists with clinical decision-making. There is also evidence suggesting that telehealth can improve patients’ ability to manage their own health, not to mention lower the cost of healthcare through fewer hospitalisations.

Despite this clear advantage, health systems have yet to abandon their hospital-centric approach to care. If telehealth is such a good idea, why is not being given wide support? One of the most intractable problems holding the service back is a much-needed rethink of the types of workers we will need in future health systems.

Up until now, much of the discussion on the healthcare workforce has centred on the shortage of doctors or nurses. It’s true that many doctors in particular are approaching retirement and will soon need to be replaced. An OECD report released this month shows that countries have substantially increased their training of doctors and nurses, and the numbers are growing. But this is an expensive approach. A recent report by the UK’s National Audit Office has indicated it takes three years and costs about £79,000 to train a nurse, ten years and £485,000 to train a general practitioner, and 14 years and £727,000 to train a specialist. These huge investments deliver healthcare professionals with astonishing skills, but regrettably we do not always take advantage of these skills wisely.

There is evidence of a considerable skills mismatch in the health sector, with a large proportion of health workers over-qualified for the work they do. The 2011-12 OECD Programme for the International Assessment of Adult Competencies survey showed that between 70-80% of doctors and nurses report being over-qualified for some aspects of their work. This suggests an inefficient use of their time and a waste of human capital. To be blunt, is it really worth ten years of training someone to spend much of their day looking into children’s ears to confirm that they are a little bit red and might require some basic antibiotics? Is there not a way their skills could better serve the population’s health?

At the same time, after all that training, about 50% of doctors and 40% of nurses report being under-qualified for some of the tasks they have to do. Education and training programmes need to transform so as to make health workers ‘fit for practice’. The outlook at present is discouraging, as many health programmes teach little about the skills we know to be needed in future systems such as ICT and people management.

Perhaps the biggest challenge will be to rethink ‘who does what’ – or ‘scopes of practice’ in the health jargon. This means letting appropriately-trained clinicians perform tasks they were previously not permitted to. The most common example of this is the nurse practitioner. In some countries, these more advanced nurses, who usually have a Master’s qualification, can prescribe limited medication and order diagnostic tests under controlled conditions. An OECD review in 2010 showed that advanced-practice nurses are able to deliver the same quality of care as doctors for a range of patients. Most evaluations find high patient satisfaction, mainly because nurses tend to spend more time with patients as well as provide more information and counselling.

Is it so difficult to imagine that diabetes workers, when backed with strong ICT support and clear protocols about what to do when symptoms are not within a prescribed range, can be trained to ensure that treatments are followed correctly, leaving those with more expertise to focus their attention on problematic cases? The barriers to realising this vision remain considerable. There are strong lobbies against change, particularly by professional associations. Policymakers need to engage these groups boldly, so they too can begin to see change as the tremendous opportunity to gain new skills and focus on what they do best, rather than succumbing to the impulse to feel threatened.

Traditional roles and responsibilities need to transform, and alongside them so do the antiquated ways of thinking. The evidence base for change is growing, but it needs to be matched by a growing political will. The question is, are governments bold enough to meet the challenge?

Useful links

OECD health statistics

OECD health workforce project

Health workers with right skills in right places needed

Health policies and data from the OECD

Skilled, unskilled, too skilled?

A report from High Fliers Research published in February found that half the UK final year college students they interviewed believe they’ll have to take any job they’re offered, and a quarter say they’ve been forced to apply to employers that they aren’t really interested in.

We hear stories from most countries of people taking jobs they’re over-qualified for in any recession. The Insights blog asked Glenda Quintini and Paul Swaim of the OECD’s Employment Division what the impacts were on firms, workers and the economy as a whole.

Insights: Do employment data confirm what the High Fliers report implies – graduates are taking jobs they’re over-qualified for?

Paul Swaim: There’s anecdotal evidence of course, but it’s actually quite tricky to measure the extent of over-qualification, or under-qualification or the wrong qualification, come to that. Researchers have used various proxy measures to estimate how many workers hold  qualifications that appear to be a poor match for their jobs, but no real consensus view has emerged concerning how pervasive skills mismatch is in the economy as a whole. It is even harder to assess the extent to which the recession is increasing the number of graduates moving into jobs that don’t make full use of their qualifications, because detailed labour market data only become available with a considerable time lag.

Insights: How about for an individual employer – surely getting extra human capital on the cheap is a boost?

Glenda Quintini: That’s certainly what you might expect, but you have to ask what “human capital” actually means. Qualifications are one aspect, but that’s not the same as skills. A worker who’s learnt on the job, over the years, may have skills that aren’t reflected in any formal qualification. On the other hand, university graduates may vary in the skills they possess and some of them may be just as skillful as somebody who quit formal education after high school. Several studies argue that it is the less-skilled university graduates that end up in jobs that require a high school diploma.

Paul Swaim: You also have to look at the relation between earnings and productivity. If you assume that earnings do in fact reflect productivity on the current job, then there is some evidence that workers who are “over-educated” for their jobs earn somewhat more than “correctly-educated” workers in the same type of job. On the other hand, they’re probably earning less than if they were in a job normally associated with their level of education.

So employers who can hire workers who are satisfied to work in jobs they are over-qualified for may attain higher productivity than they would have got by recruiting less educated workers. While it seems likely that some employers profit from being able to hire over-qualified workers during a recession, it is hard to pick up that phenomenon in the labour market data available to us. In addition to the delay in the availability of data, which I mentioned earlier, there is also the complication that recessions tend to reduce labour productivity and profitability through a number of channels that could easily swamp any gains from an increase in over-qualification.

Glenda Quintini: Another thing you have to remember is that graduates might be happy to take any job when they’re unemployed and there aren’t so many jobs going, but once they actually start working, their attitudes can change, especially if the labour market picks up. Many studies have shown that qualification mismatch affects job satisfaction and whether people intend to stay with the firm. You could argue that mismatch damages productivity through lower job satisfaction and higher turnover.

Insights: Could productivity in the economy as a whole be affected?

Paul Swaim: Yes, but in several different ways making it hard to predict the overall effect. In the short run, it certainly is more productive for graduates take jobs they are over-qualified for rather than remaining idle. However, we should not lose sight of the fact that most of these workers would be even more productive in jobs that made full use of their qualifications and thus provide a better return on the money spent on educating them. Productivity is thus likely to suffer over a longer time horizon unless these workers move into jobs that better match their qualifications. Unfortunately, the evidence is quite mixed about how often this sort of “catching-up” occurs, once the economy begins to recover.

Insights: Any final thoughts?

Glenda Quintini: Going back to Paul’s point on wage effects, a study that derives the productivity loss economy-wide in Australia from the wage penalties experienced by mismatched workers estimates a cost of mismatch of up to 2.6% of GDP in 2005 (the paper by Mavromaras et al. (2007) is available online at as discussion paper No. 2837).

Useful links

Employment and the crisis from the forthcoming Insights From crisis to recovery

OECD Insights on Human Capital

FAQ: the crisis and employment

OECD Policy Brief on qualifications and lifelong learning

OECD work on recognition of non-formal and informal learning

The educationtoday blog has a post about the impact of recessions on graduate employment and earnings