C ONCLUDING REMARKS

Literature and experience tell us that healthcare workforce planning is a necessary but difficult activity. Public debate has developed in last years, but there are still many ambiguities and different positions.

Here we will give only some brief concluding remarks.

The first problem is about trust in the market rationality and, on the other side, on planning possibilities (Jacoby and Meyer, 1998; Feldstein, 2002; Grumbach, 2002). Market failures in healthcare explain public intervention and workforce planning. Nevertheless, it is not clear if planning gives better results – in terms of absolute shortages, economic efficiency, costs control, etc. – than the invisible hand of market forces. Of course, answers depend on personal values and, in any case, the effective equilibrium is in between the two extremes.

Second, the internationalisation of health labour market raises difficulties for a national workforce planning. This is especially true for workforce exporting countries, whose attempts to retain skilled workers have often failed, by now. This globalisation of the healthcare workforce has led to relevant efforts by the international institutions – WHO, ILO, IOM, WB, EU, OECD,

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etc. – to standardize and gather data, to discuss global policies, do develop conduct codes for regulating the international flows and protect less developed countries from brain drain.

Third, much ambiguity is about the notions of shortage and surplus. Economic theory, which usually deals with those subjects, suggests using the notion of (relative) scarcity. This could improve the debate. In any case, many definitions and measures of scarcity exist, and that could add frustration in research and policymaking (WHO, 2002; Zurn et al., 2002).

A fourth difficulty can refer to political cycles. Their length, usually limited to three-to-five years, can partially explain the relatively short-term view that has so long prevailed in workforce planning, where longer approaches could lead to better results.

A major issue remains the need (or clinical need) approach. This is quite specific of healthcare, and must be considered as a positive element of the debate. By now, the problem has been that many times the clinical needs approach has been the main – or only – element of such debates, leading to misunderstandings, hypocrisies, and economically irresponsible behaviours between the various stakeholders involved in the policy arena: clinical professionals, politicians, regulatory agencies, etc.

Planning difficulties highlight a special feature of the healthcare system: i.e., the pivotal role of health professions in running the systems and in defining the labour division. Codified professions do form separate labour markets and do hinder – if not forbid – the shift of competences and activities between different professions. Moreover, this leads to separate workforce planning for each profession, with the consequent need of a supplemental coordination effort and the final result of making difficult to discuss or envisage possible skill mix change.

This last point is particularly relevant. It refers to the past and future developments of the professions. In most countries, the number of recognised health professions has grown in last decades, often accelerating in the very last years. In several cases, this was the result of actions and pressures explained with particular interests, more then with the general interest and public protection (Davies, 2004: S55-6). It is now time to assess the structure of the system of

3. THE MIXED EVIDENCE OF NURSING SHORTAGE IN ITALY

3.1. Object and goals

In the last decade, the Italian healthcare system has experienced for the first time a major perceived nursing shortage, receiving widespread attention by mass media.

In particular, the IPASVI (Italian federation of nursing colleges)⁸ and the mass media report a shortage of 60,000-100,000 nurses in the Italian healthcare system (for example, Corriere della Sera, 2006). In order to appreciate this claim, it should be noted that registered nurses in Italy at the end of 2007 were 360,874, that registration with the Nursing College is mandatory for practicing, and that not all registered nurses are actually active as nurses. This makes clear that, if correct, the claimed shortage – which ranges from 17 to 28% of registered nurses today – would represent a major and structural constrain to the healthcare provision in the country. So, it is worth to see how the claimed shortage is usually quantified and to look at its main characteristics.

Instead of discussing the various possible definitions and causes of workforce imbalances (for a review, see Zurn et al., 2004), here we will focus on perception and tentative explanation of nursing shortages in Italy. Here, measures of the shortage refer both to national and comparative analyses.

National data refer to:

- the gap between official staffing needs of NHS Local Health Authorities and Hospital Trusts⁹, and the actual staff, totalling around 25,000¹⁰;

8 The Federazione dei Collegi IPASVI (www.ipasvi.it) represents Italian nurses on a national basis. The national Federation coordinates the Provincial Colleges, non-profit bodies established by law in 1946 and 1950. In Italy there are 100 IPASVI Colleges, the first ones being established in 1954.

9 For a description of the Italian NHS structure, see France et al. (2005). Here and elsewhere, staff data is given in terms of headcounts.

46 - the gap between the requests done each year by IPASVI when the Ministry of

Education has to define the numerus clausus for nursing education¹¹, and the actual number of students who each year successfully attend the courses. In the period between the mid-eighties and the mid-nineties this gap has summed up to around 35,000¹².

International comparisons have usually considered Italy relatively poor in nurses. This was the case until the 2006 report by OECD (2006) and the 2007 report by WHO (2007). There, the number of practicing nurses per 1000 inhabitants in Italy was reported to be 5.4 in 2003, while the OECD average was around 6.9. Thus, in order to align with the OECD average, Italy would had to add further 70,000 nurses.

However, those analyses have several weaknesses, discussed in next section. Section 3 presents shortly the possible determinants of nursing shortage. Sections 4 and 5 present policy and managerial responses to shortage, respectively. Section 6 presents the experience of a major public hospital coping with the shortage in Milan. Finally, section 7 presents some conclusions.