Saudi Journal for Health Sciences

REVIEW ARTICLE
Year
: 2019  |  Volume : 8  |  Issue : 3  |  Page : 127--132

The economics of healthcare personnel shortage on the healthcare delivery services in the United Kingdom versus the Gulf Cooperation Council


Narendra Kumar1, Shaimaa Mustafa2, Cyril James3, Manish Barman4,  
1 Department of Cardiology, Manchester University NHS Foundation Trust, Manchester, UK
2 Department of Cardiovascular Medicine, Faculty of Medicine, Benha University, Banha, Egypt
3 Department of Cardiology, Wexford General Hospital, Wexford, Ireland
4 Hamad Medical Corporation; Department of Medicine, Weill Cornell Medicine University, Education City, Qatar

Correspondence Address:
Dr. Narendra Kumar
Department of Cardiology, Manchester University NHS Foundation Trust, Oxford Road, Manchester, M13 9WL
UK

Abstract

Most nations face a range of medical workforce challenges with questions over not only how to overcome public demand for healthcare and maintain a sufficient number of general practitioners but also how to fill shortages in particular hospital specialties and ensure an even distribution of doctors across the population. For both the Gulf Cooperation Council (GCC) and United Kingdom (UK), considering the growth in healthcare expenditure, growing hospital beds, and increasing population burdened by the aging population, the craving for more healthcare professionals can only worsen in the coming future. There is a lack of scientific data comparing the economic aspects of shortage of healthcare professionals in the GCC and UK. These geographically apart regions share a common problem, due to similar etiologies behind them, and both countries are coming closer together on various academic and nonacademic platforms to combat this situation together. We aim to identify various practice methods, decipher the complexities of the healthcare industry of respective local regions in relation to the availability of professionals in their respective economies. There are several recommendations and solutions to bring together the best global practices in each other's jurisdictions to solve the shortage of healthcare professionals.



How to cite this article:
Kumar N, Mustafa S, James C, Barman M. The economics of healthcare personnel shortage on the healthcare delivery services in the United Kingdom versus the Gulf Cooperation Council.Saudi J Health Sci 2019;8:127-132


How to cite this URL:
Kumar N, Mustafa S, James C, Barman M. The economics of healthcare personnel shortage on the healthcare delivery services in the United Kingdom versus the Gulf Cooperation Council. Saudi J Health Sci [serial online] 2019 [cited 2020 Feb 27 ];8:127-132
Available from: http://www.saudijhealthsci.org/text.asp?2019/8/3/127/272442


Full Text



 Introduction



The shortage of healthcare personnel in the healthcare sector is one of the most pressing global health issues of the 21st century.[1] There is a worldwide shortage of approximately 4.3 million healthcare professionals as doctors, nurses, midwives, and others. This problem was earlier presumed to be limited to middle- and low-income countries with common reasons blamed, including work environment, salary, knowledge upgradation opportunities, and life style.[2]

Recently, it has been highlighted that such problems are becoming a concern in all high-income members of the Organization for Economic Cooperation and Development (with the single exception of the Netherlands), including the United Kingdom (UK).[3] A global undersupply of such professionals threatens the quality and sustainability of health systems in not only poor countries but also the rich countries. It is widely agreed that the international migration of health workers exacerbates crisis and contributes to the widening global (health) inequality.[4] The European Union member states are relying increasingly on internationally trained health workers,[5] ranging from meager <5% (e.g., Italy and France) to significantly high levels (up to 37% in the UK).[6],[7] The UK has a long history as a destination country for migrating health workers.[5]

The nations: the UK of Great Britain and Northern Ireland referred as the UK in Western Europe unites England, Northern Ireland, and Scotland as one kingdom with an overall population of 63.7 million and gross domestic product (purchasing power parity) of $ 2.5 trillion. In 2012, the UK's total healthcare spending was $ 235 billion and is expected to rise to $ 292 billion by the year 2017, with the ratio of spending to GDP increasing to 10.3%.[8]

The Gulf Cooperation Council (GCC) was formed in the Middle East by Saudi Arabia, the United Arab Emirates (UAE), Kuwait, Qatar, Oman, and Bahrain in 1981, after Iran's Islamic Revolution, and the outbreak of Iraq–Iran war. Their population of 43.2 million has an economic output of around $1.4 trillion, with majority contribution from oil exports.[9],[10] It is estimated to grow at compound annual growth rate of 12.0% to US$ 69.4 billion by 2018 from an estimated US$ 39.4 billion in 2013.

 Shared Problems of the Gulf Cooperation Council and United Kingdom



[Figure 1] shows both regions are affected by the high rate of population growth and even higher rate of aging population. Moreover, due to the emergence of noncommunicable disease as the major health risk factor, the pattern of morbidity and mortality of the population has certainly changed in both regions.[11]{Figure 1}

At present, both regions are unable to produce sufficient number of healthcare professionals to provide adequate quality of care for its population. The percentage increase in the number of new medical and paramedical graduates that are becoming available in both regions in the nearby future is unable to keep pace with their native relatively exponential population increase. In spite of various short-term and long-term measures which are mentioned later in this article, their reliance on imported physicians and nurses continues.

A close look at the healthcare infrastructure in GCC reveals that it is not as developed as the infrastructure in developed countries like the UK. The availability of medical doctors to cater to the existing population is below the levels in developed nations. The physician density in GCC is lower than that in the USA and far lower than that in Europe.[12],[13]

As shown in [Figure 2], the average ratio of doctors to nurses/10,000 people in the GCC is nearly 26 and 49, respectively, and is insufficient to meet the growing demand for healthcare services.[14] The GCC region is highly dependent on foreign medical professionals, and this scenario has not changed much. Dependence on expat healthcare workforce is driven by as follows: (a) insufficient local medical students to cater to the population, (b) a huge rise in the incidence of lifestyle-related diseases, and (c) reluctance of local nationals to accept lower-paying jobs.{Figure 2}

Interestingly, the recent trend of medical graduates passing out of the newly opened medical schools in GCC region is moving out of their home region either in search of better education or even in search of better living conditions. Hence, increasing the capacity of medical colleges and attracting local youth to pursue a career in medicine would be key steps the governments could take to help build a larger pool of local physicians and cater to the ever-growing demand.

 The Reasons of Shortages



For the UK, there has been reductions in past, or failures to increase, the number of training places for several reasons, especially financial ones.

The biggest bottleneck problem for the National Health Service (NHS) today is not any of the financial constraints, but the shortage of healthcare professional resources, including the physicians, therapists, nurses, and other health professionals which keep the NHS in action round the clock.[15] The UK is short of doctors and nurses and the demand for doctors could increase by about 50% between 2005 and 2020.[16] The Wanless report projected that supply might increase by about 27% leading to a projected shortage of doctors of about 20% in 2020. These projections, however, may be challenged by more recent trends. On the other side, during 2014, 2,900 doctors applied for “certificate of good standing” which allows them to work at foreign destinations. The total number of doctors joining is 13,150, whereas 12,231 doctors left – “either through retirement, moving abroad, or quitting the profession altogether.”[17]

For training a doctor in the UK, it costs the local economy, a sum of £ 610,000 over 10 years to train. However, annually 3000 of them leave the UK for a “Sunny life” in lands of Australia and New Zealand. The departments worst affected are accident and emergency units and general practitioners surgeries.[17]

Moving abroad and retiring are the most common reasons for doctors stop working in the UK. Further, a significant 10% headed to Canada, 8% went to three countries in East Asia (Hong Kong, Malaysia, and Singapore), 6.7% went to Ireland, and 4.9% went to the UAE.[17] Since 2013, the dominance of Australia and New Zealand decreased by 10%; from 61% in 2008 dropping to 51% in 2013. On one hand, the percentage share of Canada, Ireland, and South Africa has also decreased a minimum; on the other hand, the share of the three East Asian countries (and other countries) has increased, suggesting an increase in the diversity of countries to which doctors working in the UK are choosing to go.

Over the past several decades, the perception has been growing among UK youth that the healthcare profession options are unattractive and not well paid. Suboptimal pay scale, especially for nurses and paramedical staff members and differential payment of staff in various specialties, has been blamed as another significant reason.

There has been a steady increase number of malpractice suits which make them less attractive to recruits. Greater work pressure, demanding nature of profession, and increased demands of the healthcare industry have further pushed the staff leaving employment.

There have been growing global trends toward lesser working hours and earlier retirement which is further aggravating shortage of healthcare professionals.

GCC healthcare expenditure will reach a total of US$ 60 billion by the year 2025,[18] which is an underestimate considering the giant leaps in the allocation of Kuwaiti and Saudi healthcare budgets. According to the Alpen capital 2015 report, the demand for the number of hospital beds in GCC is expected to be 93,992 in 2015 which is 10% higher than 2010.[14] Although this is in line with the current GCC mean but surely below the European and USA numbers.[19]

Unlike most high-income countries, including the UK, whose healthcare systems have evolved over decades and centuries, GCC has experienced exponential growth and development over the last few quarters of the century. Most countries in GCC have significantly higher percentage of imported healthcare systems from other countries unlike the UK and currently struggling to mold the imported foreign systems to the unique indigenous Gulf culture.[14]

The limited availability of medical education options in the region and high dependence on expatriates tends to worsen the issue.[20] After aggressive hiring by Qatar, the availability of physicians rose from 24/10,000 populations in 2002 to 28 by 2011, the highest in GCC.[12],[15],[16],[21]

 Economic Implications



All the GCC nations (except Saudi Arabia) witnessed nearly 7% annual rise in healthcare expenditure 2014, that is much higher than that of Europe's 4%,[22] but the situation is worsened by falling oil prices.

The GCC governments spend on an average between US$ 0.1 and 0.5 million on every single patient, which may easily surpass US$ 1.5 million for some.[23] More than US$ 400 million was spent in 2011 on outbound medical tourism by Saudi Arabia. Similarly, in 2014, alone health authority in Dubai spent approximately US$ 120 million toward overseas treatment for its citizens.[23] However, with the local availability of better quality medical professionals, such funds will be less spent which can be invested further in developing the healthcare resources of the region. The Saudi Arabian government spent over US$ 266.6 million) for the overseas treatment of locals in 2014.[24]

The cost of the outflow of health workers can be considerable. When low-income nations pay to educate their healthcare workers only to have them leave the county, they are, in effect, subsidizing a wealthier nation; this makes the rich nations richer and the poor nations poorer and is a curse for economic development.[25] Importing expertise from high-income countries to compensate for the brain drain, costs low-income countries a huge pressure on a financial budget.[26]

In the UK, a physician's training and studying costs from medical school to a consultant costs NHS nearly £ 0.7 million and requires £ 8 billion budget for Health Education England.[27] A single emigrating African professional represents a loss of $184,000 to Africa.[28],[29],[30] The staff shortage is so acute that NHS trusts in England have been aggressively recruiting doctors from nearly 27 countries. Official figures show 32 of the 160 hospital trusts in England spend £ 2.6 billion every year on agency and temporary staff.[31]

Families and communities of the home countries benefit significantly from the remittances sent by healthcare professionals. For 2012 alone, the World Bank estimated that remittance flows to the Global South reached US$ 406 billion. However, remittances cannot compensate for the negative effects of health worker migration since they primarily benefit individual households and not health systems.

Source countries health systems can also benefit from the introduction of new skills and knowledge when migrating health workers return to their home country, i.e., in the case of circular migration.

Given this skills “debt” owed by the Global North to the source countries of the South, Mensah et al.(2005) and Mackintosh et al. (2006) have reasoned that destination countries have an obligation to compensate source countries, though the payment of a restitution called “perverse subsidy.” Such compensation could be either paid as government-to-government transfers or in the form of a restitution fund used to address the push factors for the migration in source countries.

 Current Practical Strategies of the Gulf Cooperation Council and United Kingdom



Majority of healthcare delivery in the Middle East is by public sector institutions. A key challenge facing the GCC is to provide an environment that enables the participation of the private sector significantly in the healthcare system. Increased private sector participation could help the region achieve its overall goal to improve access and quality; however, creating such a framework is likely to require policy changes, industry restructuring, and new incentives.

Abu Dhabi and Dubai health authorities have proposed to hire and retain highly skilled medical workforce and to construct several hospitals, 3 medical colleges, and 5 nursing schools.[32] In addition to specialty hospitals, these medical centers and cities house the educational and research centers.

In October 2015, the UAE Ministry of Health started a campaign to attract more nationals to pursue a nursing career. The campaign focuses on awarding hospitals for incentivizing the profession, changing the perception of the profession, and introducing nursing in early education and career guidance program.

The German Neuroscience Center, based in Dubai Healthcare City, has partnered with Vivantes Hospital Group, Germany's largest government healthcare group.[33],[34],[35] The association aims to invite leading neurologists to Dubai Healthcare City to offer medical treatment and conduct programs in the areas of education, training, knowledge transfer, and patient therapy.[32]

Since October 2015, the Oman government started framing the next 5-year NHS (2017–2022) that emphasizes on health and well-being of workers.

Sidra Medical and Research Center at Qatar with a budget of US $ 2400 million is the second-largest project in GCC region, which involves the construction of 400 beds tertiary care center along with the research and education institutions.

Several GCC members have engaged the top-notch educational institutions, including Cleveland Clinic, Imperial College London, Royal College of Surgeons of Ireland's postgraduate facilities, Royal College of Surgeons of Ireland's postgraduate facilities in Bahrain, and John Hopkins Medicine International to set up healthcare facilities and are also seeking international affiliations for the regional institutions to improve the overall quality.

Currently, the UK has increased the overall number of hired healthcare professionals. Moreover, keeping an eye on long term gains it is making strategic alliances in the setup of different academic institutions globally. Some of the most remarkable ones are mentioned below.

The UAE-based Gulf Medical University partnered with the UK-based University of Salford for knowledge transfer as well as staff and student exchange programs in the area of genomic diagnostics.[36] In November 2015, the UAE-based VPS Healthcare entered into a strategic partnership with Penn Medicine to conduct educational conferences, enhance patient care standards, and provide healthcare education for industry professionals such as physicians and nurses.[37]

A total of 11 Indo-UK Institutes of Health will be started with the investment of around £ 10 billion and will include “multispecialty NHS-branded hospital for healthcare delivery, clinical support services, NHS e-health, staff accommodation, a medical college, a nursing college, R&D facilities, medical manufacturing facilities, and a medical mall,” the statement added.[38] The medical and nursing colleges will train 15,000 new medical doctors and 20,000 nurses.

NHS has been playing a key role for various healthcare professionals friendly measure, e.g., measures to retain staff by increasing the support for staff has been encouraged openly by NHS and encouraging more flexible working arrangements.

 Recommendations and Solutions



An overall shift from curative care to preventive care is the need of the hour. Focus on the prevention of diseases will not only improves the public health profile but can also help reduce healthcare expenditure and enhance the quality of care. Furthermore, points are mentioned below.

Create a greater supply of health workers by

Increasing the training capacities, especially with the inclusion of rural centers, for example, by posting medical residents during training at community health centersImproving overall working conditionsMoreover, making the jobs of nursing and other healthcare professionals more incentivized and attractive to the domestic ones.

While this is not the easiest and cheapest solution, it is the only one that can effectively tackle global undersupply while also being fair and sustainable to other countriesMore direct investment in the training and support increased capital inflowA national plan for the healthcare professionals supported by regional and state-level planningRecognition of medical degrees of more countries to allow more medical graduates to practice medicine in the host countryProtection and fairer treatment of health workersDecreased incentives for early retirementReassignment of health workers to areas in needTraining and development of career pathways to promote service in the rural and remote areasBetter strategies to more actively engage communities and patients in their own healthcare [Figure 3]Insightful use of technology, for example, telemedicine, telehealth services, and information technology to promote efficacious usage of available talentImprovement in payment and reimbursement policies, especially in remote, rural, and underserved areas, for example, by reducing the payment difference of professionals on the basis of their job location.{Figure 3}

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Naicker S, Plange-Rhule J, Tutt RC, Eastwood JB. Shortage of healthcare workers in developing countries – Africa. Ethn Dis 2009;19:S1-60-4.
2World Health Organization. The World Health Report: 2006: Working Together for Health. World Health Organization; 2006.
3Taylor AL, Hwenda L, Larsen BI, Daulaire N. Stemming the brain drain – A WHO global code of practice on international recruitment of health personnel. N Engl J Med 2011;365:2348-51.
4Mills EJ, Kanters S, Hagopian A, Bansback N, Nachega J, Alberton M, et al. The financial cost of doctors emigrating from Sub-Saharan Africa: Human capital analysis. BMJ 2011;343:d7031.
5Wismar M, Maier CB, Glinos IA, Dussault G, Figueras J. Health professional mobility and health systems. Evidence from 17 European countries. WHO Regional Office for Europe; 2011.
6Glinos IA, Buchan J, Wismar M. Health professional mobility in a changing Europe: Lessons and findings. In: Health professional mobility in a changing Europe; 2014.
7Dussault G, Perfilieva G, Pethick J. Implementing the WHO Global Code of Practice on International Recruitment of Health Personnel in the European Region. Copenhagen: World Health Organization; 2012.
8Bond S, Elston JA, Mairesse J, Mulkay B. Financial factors and investment in Belgium, France, Germany, and the United Kingdom: A comparison using company panel data. Rev Econ Stat 2003;85:153-65.
9Prasad A, Espinoza, RA. Monetary policy transmission in the gcc countries (No. 12-132). International Monetary Fund; 2012.
10Sultan N. The challenge of shale to the post-oil dreams of the Arab Gulf. Energy Policy 2013;60:13-20.
11World Health Organization. World Health Statistics 2010. World Health Organization; 2010.
12World Health Statistics; 2013. Available from: http://www.who.int/gho/publications/world_health_statistics/2013/en/. [Last accessed on 2016 Apr 13].
13Clark PF, Stewart JB, Clark DA. The globalization of the labour market for health-care professionals. Int Labour Rev 2006;145:37-64.
14GCC Healthcare Industry. Available from: http://argaamplus.s3.amazonaws.com/1903ef8f-13b5-4762-af78-00420fabc74f.pdf. [Last accessed on 2016 Apr 13].
15Plan N. The NHS Plan: A Plan for Investment: A Plan for Reform. Norwich: HSMO; 2000.
16Wanless D. Securing our Future Health: Taking a Long-Term View. London: HM Treasury; 2002. p. 16.
17Gauld R, Horsburgh S. What motivates doctors to leave the UK NHS for a “life in the sun” in New Zealand; and, once there, why don't they stay? Hum Resour Health 2015;13:75.
18Mourshed M, Hediger V, Lambert T. Gulf Cooperation Council Health Care: Challenges and Opportunities. Global Competitiveness Reports; 2006.
19Economist Intelligence Unit. Healthcare Briefing and Forecasts: Middle East/Africa Healthcare Outlook. Economist Intelligence Unit; 2013.
20GCC Heathcare Sector; 2014. Available from: http://angloarabian-healthcare.com/wp-content/uploads/2014/04/GCC-Healthcare-Sector_22-April-2014-final.pdf. [last accessed on 2016 Apr 13].
21Health Statistics Healthbook. Available from: http://www.moh.gov.sa/en/Ministry/Statistics/book/Documents/1433.pdf. [Last accessed on 2016 Apr 13].
222012 Global Workforce Study-Saudi Arabia; 2013. Available from: https://www.towerswatson.com/en/Insights/IC-Types/Survey-Research Results/2013/05/2012-Global-Workforce- Study-Saudi-Arabia Findings. [Last accessed on 2016 Apr 13].
23Report: Dubai Clinical Services Capacity Plan 2015-2025; 2014. Available from: https://www.dha.gov.ae/Documents/HRD/DCSCP-Report.pdf. [Last updated on 2014 Nov 27; Last accessed on 2016 Apr 14].
24Show Report SMT; 2014. Available from: http://www.saudimedicaltourism.net/brochure/report.pdf. [Last accessed on 2016 Apr 15].
25Kuehn BM. Global shortage of health workers, brain drain stress developing countries. JAMA 2007;298:1853-5.
26Grubel H. Immigration and the welfare state in Canada: Growing conflicts, constructive solutions. Vancouver: The Fraser Institute. Public Policy Series 2005:84.
27Wild JR, Fitzgerald JE, Beamish AJ. Health education England, local education and training boards (LETBs) and reform of healthcare education: Implications for surgical training. BMC Surg 2015;15:3.
28Oyowe A. Brain drain: Colossal loss of investment for developing countries. Cour ACP EU 1996;159:59-60.
29Medical migration and inequity of health care. Lancet 2000;356:177.
30Feder G, Katz T. Brain drain and health professionals. J Clin Epidemiol 1999;52:631-6.
31NHS Hires up to 3,000 Foreign-Trained Doctors in a Year to Plug Staff Shortage; 2015. Available from: http://www.theguardian.com/society/2015/jan/28/-sp-nhs-hires-3000-foreign-doctors-staff-shortage. [Last accessed on 2016 Apr 15].
32Healthy, Wealthy & Wise; 2015. Available from: https://www.thebusinessyear.com/uae-abu-dhabi-2015/healthy-wealthy-wise/review. [Last accessed on 2016 Apr 15].
33Araujo EC, Evans TG, Maeda A. Using economic analysis in health workforce policy-making. Oxford Rev Econ Policy 2016;32:41-63.
34Scheffler RM, Liu JX, Kinfu Y, Dal Poz MR. Forecasting the global shortage of physicians: An economic- and needs-based approach. Bull World Health Organ 2008;86:516-523B.
35GNC Announces Partnership with Germany's Largest Public Healthcare Group 2015. Available from: https://www.zawya.com/story/GNC_Announces_Partnership_with_Germanys_Largest_Public_Healthcare_Group-ZAWYA20150122064642/. [Last accessed on 2016 Apr 15].
36New Partnership Signals Major Boost for UAE Medical Education 2015. Available from: https://www.zawya.com/story/New_partnership_signals_major_boost_for_UAE_medical_education-ZAWYA20151007130600/. [Last accessed on 2016 Apr 15].
37Penn Medicine & VPS Healthcare Set for Strategic Partnership 2015. Available from: http://www.businesswire.com/news/home/20151102006099/en/Penn-Medicine-VPS-Healthcare-Set- Strategic-Partnership. [Last accessed on 2019 Aug 01].
38British NHS-Led Consortium to Invest Rs 10,000 Crore in 11 Hospitals 2015. Available from: http://timesofindia.indiatimes.com/business/india-business/British-NHS-led- consortium-to-invest-Rs-10000-crore-in-11-hospitals/articleshow/ 49770913.cms. [Last accessed on 2016 Apr 15].