Changes to health worker pay and numbers

This section focuses on changes affect ing health worker pay and numbers.

Health worker pay

Sixteen coun tries repor ted changes to health worker pay, almost all in direct response to the crisis (Table 5.13). In some coun tries, espe cially those with EAPs, pay cuts have been quite substan tial (Box 5.4).

Health worker numbers

Eleven coun tries repor ted meas ures to reduce the number of health sector workers, almost all in direct response to the crisis (Table 5.13).³

126 Economic Crisis, Health Systems and Health in Europe

Table 5.13 Reported meas ures to change health worker pay and numbers, 2008–13

Policy responses Countries

Health worker pay

Reduced salar ies Cyprus, Greece, Ireland, Latvia, Lithuania, Portugal, Romania, Serbia (privately contracted support staff), Spain

Salary freezes Cyprus, Portugal (2010), Slovenia, United Kingdom (England, Northern Ireland, Scotland for staff earning over a certain amount, Wales)

Limited rate of increase of salar ies Austria, Denmark, Italy, Slovenia Increased pension contri bu tions or

reduced bene fits Greece, Montenegro, Portugal, United Kingdom (England)

Cut over time or night shifts or lengthened shifts that require fewer staff and costs

Cyprus, Iceland, Ireland, Portugal

Health worker numbers

Staff cuts Iceland, Ireland, United Kingdom (England,

Wales)

Freezes on new recruit ment Ireland, Italy (some regions), Portugal, Romania, Slovenia replacement of staff on sick leave or retiring

Greece, Ireland, Spain (some regional governments), Sweden (some county coun cils and applied select ively)

Offering volun tary redund an cies and

incent ives for early retire ment Ireland, Italy (some regions), United Kingdom (Scotland)

Making retire ment compuls ory for

those meeting specific criteria Slovenia Source: Survey and case studies.

Policy impact and implic a tions

Some coun tries repor ted overall reduc tions in health worker numbers. A notable example is Ireland, where the Health Services Executive shed 10,000 staff members between March 2009 and November 2012, with an addi tional gross reduc tion of 4000 full- time equi val ent posi tions required in 2013 to meet employ ment ceiling targets. In Iceland, approx im ately 10 per cent of total staff lost their jobs at the National University Hospital between 2007 and 2010, while in England, from March 2010 to July 2012, the overall full- time equi val ent staff level in the NHS fell by 2.8 per cent, with the biggest reduc tion being a fall of 18 per cent in the number of managers (although the salary levels of this group also increased slightly).

Box 5.4 Examples of changes to health worker pay

Cyprus: The salar ies and over time rates of all public sector health profes-sion als were reduced in 2011, with further salary cuts of 10 per cent in 2012; addi tional scaled reduc tions for all public sector employ ees were imple men ted from the end of 2012, with cuts ranging from 6.5 per cent for those earning €1,001–€1,500 per month to 12.5 per cent for those earning over €4000 per month.

Greece: Salary reduc tions of 20 per cent were applied to all health care staff in 2010, and almost all subsidies and productiv ity bonuses were removed in 2011.

Ireland: Starting salar ies for new entrant consult ant medical staff were cut by 30 per cent (2012); plans for 2013 included hiring 1000 gradu ate nurses and midwives at around 80 per cent of the exist ing pay rate.

Latvia: After a cut of 20 per cent in 2009, salar ies subsequently rose slightly from 2010.

Lithuania: Health worker salar ies were cut by 13 per cent between 2008 and 2010, with gradual recov ery to 2009 levels in 2011.

Portugal: Health workers in the NHS lost two of their 14 annual payments (2012), and reduc tions in over time compens a tion (10 per cent) were imposed in 2012 and again in 2013; proposed income tax increases in 2013, changes in income brack ets and alter a tions to labour condi tions (hours, mobil ity) also affected staff pay.

Romania: In 2010, the salar ies of all public sector employ ees, includ ing hospital phys i cians and other hospital person nel, were cut by 25 per cent, also lower ing the volume of contri bu tions paid into the health insur ance fund (public sector employ ees make up approx im ately 35 per cent of the fund’s contrib ut ors); salar ies rose in subsequent years and reached 2010 levels at the end of 2012.

Spain: In 2012, national meas ures redu cing the salary of workers (by 7.14 per cent and abol ish ing one of their 14 annual payments) and increas ing the stat utory number of working hours were added to regional meas ures, includ ing restric tions to salary supple ments and the removal of P4P incent ive schemes.

Source: Survey and case studies

Staff remu ner a tion and working condi tions (work–life balance, promo tion and oppor tun it ies for train ing) play an import ant role in attract ing and retain ing skilled health workers, keeping motiv a tion and morale high and incentiv iz ing improve ments in productiv ity and perform ance (Buchan 2008; OECD 2011).

Changes to recruit ment policies, expe cially where they are part of broader plans to reduce the numbers of public sector staff, should there fore be imple-men ted as select ively as possible (Dussault et al. 2010). Substantial cuts to the skilled health sector work force may have a negat ive impact in the longer term,

128 Economic Crisis, Health Systems and Health in Europe

leading to staff short agews. This is also an area in which revers ing cuts and rein vest ing in health sector human resources as economic condi tions improve may be highly chal len ging and incur addi tional costs asso ci ated with recruit-ment, invest ment (and time- lags) in train ing and the use of agency staff on a tempor ary basis (Alameddine et al. 2012).

Health worker salar ies vary widely across Europe (Figure 5.6). In coun tries with relat ively high health worker salar ies (compared to the national average) there may have been scope for effi ciency savings in redu cing remu ner a tion.

However, cuts to staff pay need to be balanced against effects on worker morale, productiv ity and reten tion rates. In coun tries where health worker salar ies are already very low, such as Romania and Greece, further reduc tions may be damaging for the workers concerned and for patients, who may end up paying inform ally to supple ment low wages. Large numbers of health sector workers may also leave the work force in response to cuts, as happened in Greece (pay cuts announced in 2012 exacer bated nurse short ages) and Portugal (in 2010 cuts to phys i cian expenses related to travel and over time led to an unex pec ted increase in early retire ment of nearly 600 doctors).

Such meas ures can have other effects. In some coun tries, across- the- board public sector salary cuts as part of wider auster ity meas ures led to large- scale demon stra tions and indus trial unrest (Parry 2011). As a result, govern ments were some times forced to make conces sions. For example, in the Czech Republic, where phys i cian salar ies are below EU aver ages, follow ing phys i cian strikes in 2011 the Ministry of Health agreed to increases in the pay of hospital

Figure 5.6 Remuneration of salar ied doctors and nurses (US$ PPP), 2008 (or latest avail able year), selec ted European coun tries

Source: OECD (2011).

Note: Data are not avail able for all categor ies or coun tries; coun tries ranked from high to low by size of special ist salar ies.

Table 5.14 Reported changes to HTA to inform cover age decisions, 2008–13

Policy responses Countries

Introducing HTA to inform cover age

decisions Whole bene fits package: Cyprus (EAP,

planned), Spain (planned) Inclusion of drugs in posit ive lists:

Belarus, Croatia, Russian Federation, Spain

Procurement of expens ive equip ment:

Belarus

Systematic disin vest ment: Spain

Establishing a new prior ity- setting agency:

Denmark, Montenegro

Strengthening networks: Spain (regional HTA agen cies to define bene fits) Applying HTA to new areas Belgium, Hungary, Romania, Turkey Adding new criteria to HTA France, Germany, Switzerland

Other Norway: Regional author it ies carried out

mini HTAs to slow the intro duc tion of new tech no lo gies (2013)

Source: Survey and case studies.

phys i cians in return for agree ment on the intro duc tion of DRGs and a freeze in hospital spend ing (Roubal 2012).

5.7 Changes in the role of health tech no logy assess ment (HTA)