The Concept of Skill Mix in the Health Economy
Several concepts and theories formulated address the need to improve service delivery and overall effectiveness and efficacy of health institutions (Jones et al, 2005). Skill mix acts as a solution to solving staffing problems and increasing overall patient care as practiced in a number of health institutions around the world. When looking at the benefits of skill mix, managers are concerned with the impact of the intervention on overall profitability of the health institutions and any notable change in the physician or nurse to patient relationship (Buchan, n.d.). Skill Mix is the concept of complementing or substituting a given skilled professional with a similar skilled professional. In the health economy, skill mix happens between nurses and doctors (Kernick & Scott, 2002a). This paper describes the concept of skill mix and evaluates its adoption in the health economy.
Health economy encompasses the function of health care as an extension of health. Therefore, health economy looks into demand for health, supply for health and factors that influence the equilibrium in the pricing of health care (Eastaugh 2004). Unlike other goods and services, health care does not fall into a specific category of consumer or producer role (Harris 2005). Each individual encounters health in four basic ways according to the Grossman model, as a consumer, manufacturer, as a public overseer and as a contributor to the provision health care (McGuire, Henderson & Mooney 1988). The management of the health economy looks into the satisfaction of the patient cure and elimination the factors that lead to the eventuality of poor health (McCormack & McCance 2010). Health economy deals with the allocation of resources in providing patient treatment and care. Therefore, the subject involves physicians and nurses as providers of health care and patients as measures of the effectiveness of health provision. Other than measuring effectiveness of provided cure, health economy extends to capture externalities arising from health choices made by practitioners or beneficiaries (Harris, 2005).
Description of Skill Mix
Arguments for or against skill mix concern the substitutions of doctors with nurses or the diversification of their roles and responsibilities (Banham & Conelly 2002). Assigning of specific roles for doctors and nurses in the past took gender dimensions. Gender roles in the traditional family where women support their husband’s careers shaped up the initial doctor nurse relationship. In a similar way nursing as a women’s profession support doctors (Banham & Conelly 2002).
In recent times, the idea of having a family like doctor nurse relationship is no longer viable. Nursing is no longer an exclusive profession for women. The claim for equality by women around the world has extended form their womanhood to their vocations (Banham & Conelly 2002). Nurses now are not just assisting doctors, but have their independence and perform holistic tasks in patient care. Such tasks include “production of complex theories that are based on sociology and psychology, the creation of a pseudoscience from assessing patients and finally writing of care plans during the nursing process” (Banham & Conelly 2002, p. 5). Women’s autonomy has pushed open communications between doctors and nurses. Now there are an increasing number of male nurses and female doctors. Focus has shifted from the hierarchy of doctors and nurses to the value of nurses (Banham & Conelly 2002).
Nurses now assume titles previously used only by doctors and other medical practitioners such as nurse consultants (Mason et al. 2006). Furthermore, nursing now encompasses an enhancement of the nurse’s competency such that nurses overlap doctors on day-to-day patient care tasks (Joint Commission on Accreditation of Health Care Organizations 2005). While previously nurses worked exclusively under doctors, their new autonomy puts them in competitive positions with doctors (Banham & Conelly 2002). As nurses’ work on roles previously administered by doctors, they reduce the doctors working hours and hence serve as a cost reduction because nurses’ pay is lower than doctors’ pay. Since nurses take on less complex tasks from doctors because of their limited profession expertise, it appears that nurses handle the boring task of doctors (Denny & Earle 2005). The traditional doctor-centred model of care where nurses contributed medical continuity is no longer forthcoming and now emerging is a shift aimed at multidisciplinary team methodology that is able to react rapidly to the changing health needs of patient and whose composition assigns the nurse a centre role (Coombs 2004).
When adopting skill mix as an efficiency improvement strategy, it is paramount that balance personnel within a staff area and between different staff groups are maintained. In the case of the health economy, this will involve balancing doctor and nurse numbers and the tasks assigned to doctors and nurses (Cribb 2005). Supervising roles are subject to equal division between the two professional groups. Therefore, a broad look into skill mix in the health economy will cover issues like the work force, workload requirements in the primary care of patients, how enhanced roles and boundaries between doctors and nurses are defined (Jenkins-Clarke et al. 1997). There exists no common entry point for the examination of inter-related issues of doctor nurse roles and skill mix (Buchan & Calman 2005). Different countries and regions exhibit separate variations in the mix of different health care professions. Each country or region’s adoption of a particular characteristic of skill mix is an upshot of several driving forces that are not equally important (Dyro 2004).
These drivers are “skill shortages, cost containment, quality improvement, technological innovation; new medical interventions, new health sector programs or initiatives, health sector reform and changes in legislative/regulatory environment” (Buchan & Calman 2005, p. 18). For skill mix to addresses the above issues, however, it is not the panacea solution. In addition, skill mix has to have a proper configuration in the system to realize maximum benefits in efficiency improvement (Jenkins-Clarke et al. 1997).Skill mix as a concept ensures that clinical presentations match interventions constructed on the most suitable level of expertise (Kernick & Scott 2002a). In consideration of the different skillsets of doctors and nurses, skill mixing works best in team settings (Hall & Buch 2009). Health professionals working in teams can easily contribute their unique expertise to the attainment of a common goal of the team (Kernick & Scott 2002a).
Kernick and Scott (2002b) identify three relationship types within teams using the skill mix in their structure. Coactive relationship types where there is delegation of activity. This relationship assumes that one team member has more authority than other team members have and can choose what to delegate. This type of relationship is the most common in the provision of primary health care. Secondly, there is the competitive team relationship where parties work on competing goals or similar ones. Doctor and nurse relationship in the U.S. fall under this category because nurses perform the same tasks as doctors of prescribing medicine and issuing hospital admittance rights. Finally, the interactive team relationship exhibits a sharing of responsibilities and equal collaboration. Practitioners have individual skills in the team however; their specific skill contribution does not have a demarcation as in the case of coactive relationships (Kernick & Scott 2002b)
In the formation of teams, leaders or the team appointing authority, seek to have team members who have skills needed in accomplishing the designated tasks for the team (West 2004). Team composition therefore encourages diversity to be fully competent in the tasks (Harris 2005). A skill review ensures that there is a balance in the skill mix of teams. The skill review consists of a discovery of the activities that the team will carry out, the persons that are currently performing the activities and the new assignees of the activity, and the skill levels of the assignees in relation to the minimum skill required to perform the tasks (Harris 2005). Additionally, a skill review looks at the possibility of combining activities to come up with new activities and group formations within the team. Emphasis is laid on identifying technical skills required in the team that are absent or currently offered at a high cost when creating or adjusting team compositions to improve efficiency and reduce costs (Harris 2005).
Buchan and Dal Poz (2002) in their review of the evidence of skill mix in the health care workforce conclude that there are a limited number of empirical studies in the topic of skill mix in the health workforce. Studies that have moved beyond the description of skill mix in health care are constrained by weak methodologies, inappropriate evaluations of outcome and cost and their use of small sample sizes (Buchan & Dal Poz 2002). Limitations of the conclusion by Buchan and Dal Poz (2002) in their study include the fact that the authors examined evidence from a majority of studies conducted in the USA. Their findings do not reflect the whole spectrum of available literature worldwide and therefore are only usable when examining the case scenario in the USA. The authors note that the concept of mixing qualified and unqualified practitioners was publicly adopted in the 1990s to contain costs in North America was a pioneer concept and it resulted to the re-examination of nursing skill mix in many countries, organization and sectors (Buchan & Dal Poz 2002). Findings of the study highlight the misgivings of nurses when they are replaced or when their skills are undervalued and argue that cheaper substitution strategies in skill mix are not guaranteed to be cost effective. The authors cite negative externalities associated with the adoption of cheaper skill mix such as higher absenteeism associated with less qualified personnel and their reduced turnover rates. They note that cheap skill mix increases the levels of staff unproductive times as the care givers are not autonomous and only act on the direction of their supervisors. Furthermore, cheap skill mix increases the possibility of care assistants to harm patients when their jurisdiction extends beyond their skill capacity (Buchan & Dal Poz 2002).
Mix of workers in an institution make it productively efficient and in the case of the health economy, mixing of health leads to significant impacts on the delivery of health care services (Fulton et al. 2011). The production process of health care uses health care inputs such as facilities, equipment, systems, pharmaceuticals and other non-health care inputs necessary for any organization’s proper functioning. Combinations of skill mixes produce health services in different settings (Fulton et al. 2011). Fulton et al. (2011) examined health workforce skill mix in relation to the patient health outcome, costs and quality. The authors studied the creation of new cadres designed to boost productivity and make it possible to scale operations rapidly to improve patient access and reduce wage bills and worker training costs (Fulton et al. 2011). Task shifting is a substitution of tasks among professionals and the delegation of tasks to lower level trained professionals and creation of new cadre as well as task delegation to non-professionals (Shumbusho et al. 2009). Their study findings indicate that the training of lower cadre professionals in specific important patient handling skills is a cost effective way of increasing workforce to cater for special patient needs that would otherwise require extra commitment in time and money for formal training of nurses. Secondly, the authors find out that in implementing skill mix, supervision and training form the most important component for quality health care. Therefore despite the ease of scalability (Gaist 2009) when using lower trained personnel, management need to ensure that highly skilled professionals handle the delegation of duties and supervise their implementation to maintain quality and facilitate skill transfer (Fulton et al. 2011).
The benefits of shifting of task from the traditional professionals’ cadres to new ones such as care of specific patient categories form nurses to community health workers are noticeable when an analysis of cost effectiveness is used to make appropriate comparisons (Hongoro & McPake 2004). The context of the application of skill mix dictates the success or failure if the skills mix policy. These contextual factors are political support, available infrastructure, leadership and training offered and finally the living conditions of the patients and the practitioners (Fulton et al. 2011). The authors Fulton et al. (2011) acknowledge that their literature review only focused on studies published in 2006 but also confirm that main findings in their study offer substantial evidence that downplays the omission of other studies in their literature review. Other limitations offered of their study are publication bias and reporting bias of the articles examined in their literature review and the authors do not offer an estimate of the potential bias (Peat, Mellis & Williams 2002). Finally the authors indicate limitations of small study samples and different educational requirements for health practitioners in different countries create a challenge in establishing a control when comparing studies from different countries (Fulton et al. 2011).
The examination of skill mix effectiveness should consider the impacts of new technologies such as e-health and telemedicine. Fulton et al (2011) note that use of these and similar technologies provide positive externalities in terms of skill transfer and scalability (Fulton et al. 2011). In Britain, the Health Committee of the House of Commons found out that poor conceiving or skill mix changes does not lead to any improvement in productivity or a reduction in cost (Health Committee 2006-07). The Health Committee further noted that nurses generate the same quality of care as doctors but use more resources than doctors. Therefore, the savings provided by low nurses’ salary are eaten up by the resources needed (Health Committee 2006-07).
Fixing of attention on the health economy benefits of skill mixing in terms of cost savings limits the overall economic evaluation of the concept (Cowen & Moorhead 2006). The review of benefits does not put into consideration the unique nature of the health economy as compared to other economies (Culyer & Newhouse (eds.) 2000). The provision of health care is an obligation of health practitioners as well as of individuals, such that choices made by individuals to observe disease preventive measure positively affect other individuals by reducing the incidence of disease in a locality and hence reducing the overall cost of disease cure as in the case of infectious diseases (Maynard & Scott 2003). Managerial analysis of skill mix has to be pragmatic putting into account that stoppage of individual work towards shared goals by nurses and doctors to participate in care-teams might downgrade and make labour routine, thus lowering quality of health worker and patient experience while fitting financial goals of the institution (Buchan & Calman 2005).
Successful economic evaluation of skill mix offers a comparison in alternative interventions (Yoder-Wise 2003). Economic evaluation assists to note effectiveness of the skill mix intervention and it ensures that there is a maximum output for a given resource level or a minimum cost is endured to get a desired benefit level. Inefficiency implies that patient benefits are not maximally harnessed from available resources (Dierick-van Deale et al. 2010). Economic evaluation of skill mix looks at efficiency of using inputs like doctors or general health practitioners to obtain a specific output (Maynard & Scott 2003). In the health economy inputs are comprised of doctors, nurses, professions allied to medicine, the premises used in administering health care and the equipment used (Kernick & Scott 2002a). Outputs include clinical benefits of the patients like blood pressure, health status and the quality of life where this can be generic quality or disease specific quality, non-health benefits brought about by the health care such as choice and reassurance, accessibility and approachability of health care and finally continuation of the care (Kernick & Scott 2002b).
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