The following question was asked to HOPE members:
In the context of the financial and economic crisis, what have been the direct interventions and/or e indirect effects on healthcare professionals (wages reduction, stop recruitment…)?
Mrs Ulrike Schermann-Richter
Federal Ministry of Health
To date, no major consequences of the crisis can be highlighted concerning healthcare professionals. The number of hospital staff (Full Time Equivalent) is constantly increasing. However, more rigorous negotiations on contracts between public health insurance funds and healthcare providers regarding tariffs, budget caps or any other commitments and measures on cost containment are taking place, which lead to an increase in work-loads and working pressure.
Mrs Eva M. Weinreich-Jensen
To curtail spending and keep spending within budgets in 2011–2012, several regions have been forced to lay off healthcare workers, including healthcare professionals. This has been the consequence of both the financial crisis and the need to scale down healthcare spending to achieve long-term fiscal sustainability. However, employment is slowly growing again in 2013. The crisis and the low growth in public expenditure have, however, not led to a debate about prioritising in healthcare expenditures even as, for instance, the expenditures for hospital medicine increased by 10% in 2012.
Mr Urmas Sule
In 2010, healthcare providers were forced to diminish the wages of healthcare workers because of the budget cuts in the end of 2009 and beginning of 2010. In 2011, the wages were increased to the same level as 2008 and in the autumn of 2012 Estonia experienced the first strike of healthcare workers in its history. As the budget of HIF has increased during 2011–2012, the doctors, nurses and nursing care workers decided to demand a rise of minimum wage and proposed to sign a very voluminous collective agreement between Hospitals Association and Health care workers unions.
The strike lasted 25 days and ended with a collective agreement that states: from 1 March 2013, the minimum wages of doctors will increase by 11%, nurses by 17.5% and nursing care workers by 23%. In addition to the wage increases, according to the agreement, healthcare workers and hospitals would assemble a working group to discuss and agree on a recommended work load for doctors and nurses. Healthcare workers demanded, for example, to increase the time spent on a patient during the first visit by 20% and to increase time spent on a patient in a hospital bed by 16%. All this was, of course, supposed to be calculated into the HIF budget. This working group has been working throughout the year 2013 and has already achieved some first results.
Mrs Aino-Liisa Oukka
Oulu University Hospital
The healthcare workforce has increased steadily since the end of 1990s. However, in the near future, we will experience a deficit of the workforce through ageing. Because of the crisis, most hospitals and primary care units have to limit the recruitment of temporary work force. Some municipalities and hospital districts have considered wages reduction, not succeeding thus far. Pay free leave and temporary lays off are frequent actions.
Mr Yves-Jean Dupuis
French Federation of Non-Profit Hospitals
Mrs Pascale Flamant
UNICANCER (French Federation of Comprehensive Cancer Centers)
Mr Gérard Vincent
French Hospital Federation
The various measures undertaken to reduce public spending has resulted in shortening the money devoted for hospitals, which has immediate consequences on unemployment. In 2011, 2012 and 2013, many hospitals had to cut their workforce in order to reduce expenses: more and more public hospitals were forced not to replace staff. Meanwhile, the salaries in the public sector are frozen. In the private non-profit sector, the crisis has led to many layoff plans, and even in a few cases to hospital closure.
The cost-containing measures have dramatic impacts on the workforce organisation, with a risk of damaging health care quality. Even if French healthcare system will benefit from the policy implemented to increase the “numerus clausus” for doctors, geographical inequalities are more and more striking both within and between regions.
Mr Joe Caruana
Ministry of Health, the Elderly and Community Care
The increase in public recurrent expenditure has allowed the recruitment of new graduates in nursing and other healthcare professions. As described above, the government is committed to ensuring that financial resources available are well spent and therefore, in this area, action is being taken to ensure that the overtime expenditure is better controlled and that work practices are improved through a process where health workforce representatives are fully engaged.
Mr Robbert Smet
NVZ Ereniging Van Ziekenhuizen
Hospitals see their volume growth trends reduced to 2.5% per year in the period 2012 to 2015. From 2015 onwards, the Government wants to further reduce growth to 2% per year. In order to be able to digest this further reduction, hospitals are expected to control the number of treatments, fight overtreatment, reduce excess capacity and combat spills of resources. Furthermore hospitals are expected to concentrate complex treatments in fewer locations in order to increase quality and reduce costs.
The salary of medical specialists will be reduced and the length of training shortened to the European minimum of five years. In a plan that was withdrawn, medical specialists would have been taxed a certain annual amount as compensation for the public costs of their specialist training. The Government has taken, or will take, cuts on:
- the coverage of collective funding, for example, diet advising, programs for quitting with smoking, speech therapy, medicines, physiotherapy
- coverage of mental health therapies
- tariff cuts on general practitioners
- cuts on innovation funds, patients organisations, project subsidies
Mrs Sara Pupato Ferrari
Institute for Health Care Management
A package of measures was adopted in 2010 to cut expenditure by €15billion between 2010 and 2011 through:
- reduction of staff salaries by 5% in 2010 (in proportion, there have been more cuts in higher salaries, including a discount of 15% of payroll for members of the Government) and freezing of staff salaries in 2011
- reduction of the replacement rate: for every ten retirements, only one employee can be replaced in healthcare services
The wages of doctors and nurses have been reduced since 2010. In 2012, in real terms, it is said that this reduction could be approximately of 15% (taking into account the inflation rate). The wages of professionals, as well of other civil servants, will stay frozen in 2014, as they were in 2013. The staff reductions are difficult to quantify due to differences between regions, although it can be estimated at 5%. Other measures have been taken on healthcare professionals in 2013:
- cut in the number of days of vacation by seniority and reduction on additional days by personal issues (free use)
- mandatory retirement at 65 years with rate of null replacement
Mr Erik Svanfeldt
International Coordinator Health and Social Care Division Swedish Association of Local Authorities and Regions (SALAR)
The purpose of the temporary increase of government grants to the local government sector was to help the municipalities and county councils/regions to retain personnel despite strained economic conditions, and, in that way, maintain key welfare services such as schools, healthcare and elderly care during the recession. Nonetheless, some county councils/regions have adopted restrictive policies concerning new recruitment of staff, appointment of substitutes and further education for professionals. Wage cuts have not been considered in Swedish health care.
Mr Mike Farrar
CBE Chief Executive
Salaries have been frozen for public sector workers earning over about €24,650 per annum and this will continue until April 2014. NHS Employers has called for no pay increase across the board for 2014 and for further reform of the incremental pay system. Changes to the NHS Pension scheme have now been implemented following agreement with the NHS Unions in 2012. These changes reduce the long-term cost of the scheme, which is an employer- and taxpayer- funded defined benefit scheme run on a ‘pay as you go’ basis.
The Government, NHS Employers and the unions are working on a partnership basis to deliver changes to retirement ages through the ‘Working Longer Review’. As part of overall controls on expenditure, employers have been looking at how to control and reduce labour costs, including by reducing staff numbers. The headcount for the NHS, including primary care, was 1,358,295 in August 2012. There has been a fall of just under 30,000 NHS employees since 2010, with around 63% of these coming from the infrastructure support category and 21% from qualified nursing. The NHS is developing tools to help employers set safer staffing levels at local level. There is growth in the use of non-NHS providers to provide NHS services through a range of initiatives, including Any Qualified Provider. At present, this mostly affects community and mental health services.
Treatment of staff following transfer to new providers remains a big issue and recently rules have been amended to allow staff to remain in the NHS pension scheme. The impact of recent legal changes to the TUPE regulations is yet to be seen.