A Framework for Collaborative Pan-Canadian Health Human Resources Planning

I. The Case for a Collaborative Approach to HHR Planning

Where We've Been: Utilization-based Planning and Planning in Isolation

The traditional approach to health human resources planning in Canada has relied primarily on a supply-side analysis of past utilization trends to respond to short-term concerns. For example, faced with shortages in a certain profession, jurisdictions tend to add training positions; faced with surpluses, they cut training positions; faced with budget pressures, they cut or reduce full-time positions. This approach has a number of critical weaknesses:

• health care system needs are defined based on past utilization trends rather than emerging population health needs, so jurisdictions tend to plan for the past rather than the future
• planning is based on traditional service delivery models rather than considering new ways of organizing or delivering services to meet needs
• health human resources planning has tended to focus almost exclusively on physicians and nurses rather than the full range of health care providers
• planning has been based on weak data and questionable assumptions
• our planning models have tended to view health human resources as a cost rather than an asset that must be managed effectively (i.e., decisions made to respond to immediate budget pressures are not always assessed for their long-term impact on recruitment and retention)
• there has been insufficient collaboration between the education system, which produces health care providers, and the health system that manages and employs them, so the number and mix of providers the education system produces each year are often influenced by academic priorities rather than population health or service delivery needs (e.g., number of students required to maintain budgets, teaching programs and support research; educational trend to increasing specialization)
• in most jurisdictions, planning has not included effective strategies to ensure the availability of appropriate health human resources.

The negative impact of past planning approaches has been exacerbated by the fact that, historically, each province and territory in Canada has worked independently to design its service system, develop service delivery models and plan HHR. This has resulted in competition between jurisdictions for limited health human resources.

Risks Associated with the Status Quo

The status quo approach to planning has the potential to create both financial and political risks, to limit each jurisdiction's ability to develop effective sustainable health delivery systems and the health human resources to support those systems, and to fall short of the Canadian public's expectation (as reported by both Romanow and Kirby) of a seamless system from province to province.

Utilization-Based Planning

If jurisdictions continue to plan based primarily on past utilization, they will continue to experience:

• lack of capacity to anticipate and respond to changing population and health system needs
• cycles of over and under supply (i.e., peaks and valleys) of physicians, nurses, and other health providers
• high turnover and attrition
• destabilization of the health workforce
• greater competition for limited resources.

Traditional approaches to recruitment into the health professions and curriculum design will not allow jurisdictions to deliver on their commitment to improve the health status of Aboriginal peoples or to fulfill other health commitments, such as increasing home care.

Planning in Isolation

While each jurisdiction in Canada will continue to be responsible for planning and managing its health care system, it faces inherent risks if that planning is done in isolation, including:

• Unintended impacts. Decisions made by one jurisdiction can have unintended impacts on other jurisdictions. For example:
  • A change in one jurisdiction's health care system design could have a negative impact on the supply of certain providers for other jurisdictions. The risks are greater in the current reform environment where unilateral action by any one jurisdiction could undermine system stability and affect other jurisdictions' ability to deliver on health commitments (e.g., reducing wait times, improving the health status of Aboriginal peoples).
  • Not every jurisdiction has training programs in all health professions. If a jurisdiction that produces a significant proportion of a certain type of health provider for other parts of the country (e.g., medical perfusionists) reduces enrollment in that program, it may severely disadvantage other provinces.
  • If one province decides to increase the number of training positions for specialist physicians, it may draw students away from family medicine programs in other provinces, and exacerbate the current shortage of family physicians.
  • A decision to increase entry-to-practice requirements in one jurisdiction puts pressure on other provinces and territories to do the same. Changes to entry-to-practice requirements may have an impact on the quality and safety of health services, compensation, labour supply and distribution, the post-secondary education and health systems, and labour mobility ñ both within the jurisdiction where the change occurs and in other provinces and territories.
  • If one jurisdiction increases wages paid to health care providers, it may draw health care providers from other provinces and territories or trigger demands for higher wages that make it more difficult for other jurisdictions to manage health care costs.
  • Incentives offered by some jurisdictions can encourage inappropriate mobility, drawing providers from one under-serviced area to another.
• Mismatch between supply and needs. Insufficient collaborative planning between jurisdictions (and between the health system and the education system) contributes to the oversupply of some providers and undersupply of others.
• Costly duplication. All jurisdictions are investing resources in developing HHR data, forecasting/simulation models, and planning frameworks. Without collaboration, these efforts will result in unnecessary duplication as well as forecasting models that are unable to capture the impact of decisions in other jurisdictions.
• Inability to respond effectively to international issues/pressure. The international licensing and quality control issues created by both global competition for a limited number of providers and new technologies are often beyond the capacity of any one jurisdiction in Canada (e.g., digital teleradiology systems will give people in small, remote communities better access to MRIs and CT scans but there is a risk that the scans could be read by radiologists outside Canada who are not licensed to practice here). Canada may be at a disadvantage compared to other governments in presenting a united front on HHR issues if its jurisdictions are not collaborating on issues of international interest.

Where We Want to Be: Systems-Based, Collaborative Planning

Jurisdictions across the country want to give all Canadians timely access to high quality, effective, patient-centered, safe health services. To do this, they need a collaborative approach that supports their individual efforts to plan and design health systems based on population health needs, and identify the HHR required to work within their service delivery models. The appendix describes one example of a conceptual HHR planning model, which illustrates the range of factors governments must consider when designing their health systems and identifying their HHR requirements.

Given the relatively small number of health education programs across the country and the mobility of health human resources, jurisdictions across Canada are already highly interdependent in health human resources. It is in everyone's best interests to participate in a more collaborative approach to HHR planning.

Experience with HHR Collaborations to Date

Canada has already had some experience and success with collaborative HHR planning, including collaboration between different ministries at both the regional and pan-Canadian levels. For example:

• The Atlantic Provinces (Nova Scotia, Newfoundland & Labrador, Prince Edward Island, and New Brunswick) are working together to develop current and future HHR requirements for 30 major health occupations. Through the Atlantic Advisory Committee on Health Human Resources (AACHHR), Atlantic government departments responsible for health and post-secondary education are assessing the adequacy of health education and training programs in the region in relation to the demand. Each province has completed a labour market analysis to determine current and future supply and demand for major health occupations based on the current health care system of the four Atlantic Provinces. This work will provide an HHR simulation model that will allow the provinces to identify the possible impact of policy decisions on HHR requirements, gaps and major issues. These projects were supported by a financial contribution from Human Resources and Skills Development Canada (HRSDC). As a result of these initiatives, the provinces will have: supply and demand data, an inventory of both pre-service and continuing education and training programs, an environmental scan of education and training issues, and a scenario-based education and training program forecasting tool. Regional collaboration has enhanced the work that each province does individually, improved the region's ability to predict future health education and training needs, helped develop strategies to maintain a skilled, adaptable health workforce, provided opportunities for jurisdictions to share information, and strengthened the region's capacity to address labour market and health human resource issues.
• Since 2002, the ministries of health and post-secondary education in the Western Provinces (British Columbia, Alberta, Saskatchewan, and Manitoba) and the Northern Territories (Yukon, Northwest Territories and Nunavut [since 2005]) have been collaborating within the Western & Northern Health Human Resources Planning Forum. The Forum, which was initially established as an information sharing process, has been transformed into an active regional collaborative body. All members were acutely aware of the growing need for cross-jurisdictional work in HHR planning and met the challenge by establishing a Secretariat. The Forum has now undertaken 20 regional projects (each one involving a number of jurisdictional partners) with funding from Health Canada's HHR Strategy. All projects have committed to sharing the outcomes among the members, with some having pan-Canadian implications. Projects have included initiatives such as: developing a standardized approach to describing core competencies for licensed practical nurses (LPNs; developing best practices for clinical education; establishing a health science clinical placement network; developing an assessment process for international medical graduates; and holding a national meeting on physician compensation.
• Through the Canadian Task Force on Licensure of International Medical Graduates, the provinces, territories and federal government have developed a series of recommendations designed to create a "nationally integrated approach to the assessment and training of international medical graduates" (IMGs) that maintains rigorous standards for licensure while giving all jurisdictions greater access to foreign-trained physicians. The recommendations ñ which include a standardized evaluation process, more supports and programs to train IMGs, and a national database to increase capacity to recruit and track IMGs) ñ have been approved by the Conference of Deputy Ministers and are now being implemented. The process was so successful that it is now being applied to the assessment, training and licensure of internationally educated nurses and allied health professionals, beginning with those professions with severe supply problems (i.e., pharmacists, medical laboratory technicians, medical radiation technology, occupational therapists, and physiotherapy).
• In October 2004, federal, provincial and territorial Ministers of Health announced the creation and implementation of a pan-Canadian process to manage proposals for changes in entry-to-practice credentials for medical and health professions. The aim is to determine whether proposed changes are based on sound evidence and serve the interests of patients and the health care system. The Coordinating Committee on Entry-to-Practice Credentials analyzes each proposed change and prepares a report for provincial and territorial governments summarizing its strengths and weaknesses as well as its impact on patients, quality and safety of health services, labour supply and distribution, the post-secondary education and health care systems, and labour mobility. (The province of Quebec is not participating in this initiative, but continues to collaborate by sharing information.)
• At the request of the Advisory Committees on Population Health and Health Security and Health Delivery and Human Resources, a subcommittee ñ with representatives from the federal and provincial governments, the public health delivery system, and academics ñ worked together to create a framework that sets out goals, key objectives, and proposed strategies for collaborative public health human resources planning. The framework is designed to help all jurisdictions develop a vibrant sustainable public health workforce. In June 2005, the Deputy Ministers of Health approved the framework in principle and asked the Pan-Canadian Public Health Network and the Public Health Agency of Canada to take the lead on pan-Canadian aspects of public health human resources planning, to refine the strategies, to determine priorities and required resources, and to address dissemination and implementation issues.

The Benefits of a Systems-based, Collaborative Approach to Planning

A more collaborative, pan-Canadian approach to certain aspects of planning would have immediate benefits, including:

• greater capacity to implement policies and priorities to improve both access to and quality of health care services at a cost Canadians can afford
• greater capacity to influence the factors that drive the health care system, determine health human resource needs, share best practices, and affect health status and system outcomes
• less costly duplication in planning activities, and better forecasting/simulation models
• improved information sharing to support compensation and related collective bargaining processes
• better understanding of the interjurisdictional and national picture of the workforce (through a common minimum data set) and greater capacity to address common HHR issues
• greater workforce stability in all Canadian jurisdictions, and more appropriate labour mobility
• health systems that are less vulnerable to global pressures, and better able to retain providers educated in Canada and compete in a global market for skilled health care workers.