ID: 2014-10-231-R-4130

Novokreshenova I.G., Chunakova V.V.

State Budgetary Educational Institution of Higher Professional Education Saratov State Medical University im. IN AND. Razumovsky Ministry of Health of Russia

Summary

Improving primary health care is one of the priority tasks of national health care. The development of primary health care will increase the availability of this type of care for the population, and, consequently, the satisfaction of patients with the quality of medical care. An important role in the organization of primary health care is occupied by specialists with secondary medical education, who are currently given the opportunity to independently solve a number of medical and social problems in servicing patients within their competence.

Keywords

Primary health care, nursing staff, the role of a nurse

Overview

The nurse traditionally plays a significant role in the public health system. In the structure of medical personnel of medical institutions, nursing staff is one of the largest groups of medical workers. L.A. Berlova, 2006, notes that in most cases it is the nursing staff who is the first, last and most permanent medical worker in contact with the patient (in case of deterioration of the patient's health in a hospital, first aid, psychological support to patients and their relatives). ).

At the present stage of development of society, the profession of a nurse is considered not only as one of the most massive, but also as one of the most socially significant. In his works, N.N. Kosareva, 2008, analyzes nursing as a complex medical and sanitary discipline that has medical and social significance, since it is designed to maintain and protect the health of the population, as well as an essential component of the health care system, which has significant human resources. As foreign practice shows, the rational use of nursing personnel leads not only to a significant increase in the availability and quality of medical care, but also to its cost-effectiveness, more efficient use of financial and human resources in the industry.

It should be noted that over the past decades in Russia, nursing has not been given due attention, there has been a decrease in the prestige of the work of a nurse, her social status. These circumstances have led to a significant lag in this area of ​​public health from the development modern science and medical technologies. In the words of the eminent researcher and promoter of nursing in Europe, Dorothy Hall, "many of the problems facing national health services today could have been avoided if nursing had developed at the same pace as medical science" .

In the health care of our country, there is an outflow of qualified nursing personnel from the profession, as well as a shortage of nursing personnel in medical organizations. The imbalance in the ratio between doctors and nurses of inpatient and outpatient clinics, medical institutions serving the urban and rural population is increasing and, as a result, the quality of medical care may deteriorate. In Russia, the ratio between medical and nursing staff is 1:2, but WHO, as an international standard, recommends that states adhere to a ratio of 1:4-1:5, respectively, in which the public health system will function and develop effectively. So, in the USA the ratio between medical and nursing staff is 1:4.

At present, there is a need to re-evaluate the entire system of nursing care. Over the past decades, the role of the nurse has increased significantly in the health care of many European countries. According to A. Egorova, 2013, in the United States, a nurse is regarded as a full-fledged assistant to a doctor, exercising symptomatic control and maintaining the treatment process at the proper level, i.e. the nurse can independently identify the symptom and offer the doctor a way to treat it.

In our country, fundamental changes in the organization and evaluation of the activities of medical institutions begin in the 90s of the twentieth century and are also accompanied by an increase in the importance of a specialist with a secondary medical education. To date, active purposeful work is being carried out in Russia to restore the importance of the nursing profession. As part of the report of the Minister of Health of the Russian Federation at an expanded meeting of the collegium of the Ministry of Health of Russia “On the results of the work of the Ministry in 2013 and tasks for 2014”, it was noted that “there is a need to introduce new technologies in the activities of nursing staff with a differentiated expansion of its functions at different levels provision of medical care".

The designation of the role of a nurse in the field of public services is provided for by the Program for the Development of Nursing in the Russian Federation for 2010-2020. (hereinafter the Program), developed in accordance with the main objectives of the Concept for the development of the healthcare system in the Russian Federation until 2020. To achieve this goal, the Program notes the presence of such areas as reforming the existing legal framework that defines competencies and responsibilities, creating decent working conditions and social security, and increasing the prestige of the nursing profession. Active work continues to inform the heads and staff of medical institutions about new approaches to improving nursing practice (seminars, conferences, congresses of medical workers are held). The process of introducing modern nursing technologies into practical healthcare is actively underway.

In the course of ongoing reforms in the field of nursing, the role of nursing staff in the organization of preventive, therapeutic, diagnostic, and rehabilitation measures at all levels of medical care for the population is increasing, regardless of the profile of medical care.

Primary health care is the most important link in health care, since this type of care is the main, most accessible, economically and socially acceptable type of mass medical care. In accordance with the Order of the Ministry of Health and Social Development of the Russian Federation dated May 15, 2012 No. 543n “On Approval of the Regulations on the Organization of Primary Health Care for the Adult Population”, primary health care is provided on an outpatient basis, as well as in a day hospital, in including home hospitals. The main types of primary health care are primary pre-medical, medical and specialized health care. In the provision of primary pre-hospital health care, the main role belongs to specialists with secondary medical education in feldsher health centers, feldsher-obstetric stations, medical outpatient clinics, health centers, polyclinics, outpatient departments of medical organizations, departments (offices) of medical prevention, health centers. The special importance of nursing staff in the context of primary health care lies in the use of modern prevention technologies, including the formation of medical activity of the population.

V.N. Nozdrin and I.G. Grekov, 2008, note that, unlike Western countries in Russia, nurses working in urban outpatient clinics do not self-administration patients. To a greater extent, nursing staff in polyclinic offices of various profiles work together with the doctor. This circumstance testifies to the traditionally established idea of ​​a nurse only as an assistant to a doctor, performing only auxiliary functions. At the same time, in conditions of a shortage of personnel, the functions of junior medical personnel are often assigned to a nurse. Such an “expansion” of activities, due to the performance of work not included in the direct duties of a nurse, adversely affects the quality of medical care provided by nursing staff.

However, at present, there are examples of the organization of medical care for the population, where the leading role belongs to a specialist with a secondary medical education. Thus, the functioning of pre-medical reception rooms does not require qualified medical assistance; classes in schools for patients are conducted by nurses. Nursing personnel are responsible for providing education to the population in emergency care and methods of caring for sick and disabled persons (disabled, "lying" patients). This will facilitate the solution of priority and potential problems of the population and the patients themselves, as well as increase the efficiency of the activities of special services in emergency situations.

In his works, S.E. Nesterova, 2008, indicates that the reorganization of the provision of medical care on the basis of a general practitioner, carried out in recent years, gives the nurse a much more significant role than before. In the context of the increase in the volume of work of a general practitioner, a nurse cannot remain just an assistant to a doctor, an executor of his appointments. She must take on a certain amount of independent work and perform it professionally and with full responsibility.

Taking into account the current level of professional training of nursing personnel, namely the possibility of obtaining a higher nursing education, it is necessary to actively involve nurses in organizing various forms of community care: day hospitals, home hospitals, outpatient surgery centers and medical and social assistance, consultative and diagnostic services and services home care .

The day hospital is designed to provide medical care to persons in need of inpatient treatment that does not require round-the-clock medical supervision. E.B. Lushnikova, 2009, notes that in a day hospital, the duties of a nurse include providing information to patients about upcoming treatment, providing psychological support, monitoring the patient's condition before, during and after procedures, monitoring the readings of devices and systems, maintaining the necessary documentation . T.V. Konovalova, 2006, notes that the provision of obstetric and gynecological care by the nursing staff of the day hospital of the antenatal clinic has certain features, which are characterized by an expansion of the opportunity for independent work with patients, an individual creative approach to them, and an increase in responsibility for the quality of nursing services provided.

In an outpatient clinic in the Samara region, there is a one-day surgical hospital, where most of the work is done by nurses: they talk with the patient after the doctor determines the tactics of treatment, fill out medical documentation (medical history), check the patient's preparation for surgery, provide psychological support and care for patient in the postoperative period, etc. In the course of her work, the nurse is guided by protocols specially developed for the nursing staff of this institution. In accordance with the requirements of the protocol (discharge criteria), the nurse independently assesses the patient's readiness for discharge.

At present, in servicing the rural population, special attention is paid to the use of hospital-replacing technologies (active nursing patronage, beds, departments, nursing care facilities, feldsher-obstetric day care centers). L.N. Afanasyeva, 2008, argues that the need to develop hospital-replacing technologies is determined both by the population's need for this type of medical care, and by the rational and efficient use of financial resources and material and technical resources of healthcare. According to many authors, the shortage of medical personnel serving the rural population significantly affects the availability and quality of medical care. Given the qualifications and potential capabilities of nursing staff, it is possible to significantly expand the scope of treatment and diagnostic measures performed by nursing staff when servicing patients in district centers and rural settlements.

So, for example, active patronage of patients at home is an important part of the independent work of a nurse. The task of the nurse during patronage is to monitor the dynamics of the patient's condition, adherence to the diet and regimen, and the correctness of taking medications. In addition to standard activities (performing injections, procedures, measuring physiological parameters, examination), the level of professional training of a nurse allows her to be instructed to perform at home such activities as taking biological materials for research, taking an electrocardiogram, and performing physiotherapeutic procedures. An important component of nursing patronage is teaching the patient self-control over his condition and providing self-help when it worsens. The nurse teaches the patient's family members the techniques and rules of care, performing simple medical procedures and providing first aid when the condition worsens. Thus, the nurse must not only be proficient in manipulation techniques, but also help the patient adapt to new conditions.

In Russia, for a long time, the activities of nursing personnel were considered as secondary, having no independent significance. The main criterion for its evaluation was the correct performance of manipulations, medical prescriptions. Today it is recognized significant contribution, which this professional group contributes to the implementation of measures aimed at protecting the health of the population, and the need to improve nursing is more fully realized. The result of the activity of the entire healthcare system, the quality and quantity of medical services provided, the volume of financial and material and technical sources largely depend on the work of medical personnel.

One cannot but agree with I.G. Glotova, 2000, that high-quality nursing care facilitates the medical task, optimizes the diagnostic and treatment process and reduces its time. Medical practice and nursing are independent but complementary professions. The main tasks of doctors are the prevention, diagnosis and treatment of the disease. At the same time, the nurse focuses her attention on solving existing and identifying potential problems of the patient, thereby implementing all stages of the nursing process (collecting an anamnesis, making a preliminary diagnosis and subsequently constantly monitoring the patient's behavior, informing the doctor about all changes, participating in the bypass of patients by the doctor ). Doctors and nurses have common goals and strategic objectives and implement them using special methods and technologies that they possess by virtue of their education.

Thus, it can be argued that the organization of independent activities of a nurse at the level of primary health care contributes to increasing the availability and quality of medical care to the population, realizing the creative potential of a nurse and increasing the importance of specialists with secondary medical education in the health care system.

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Moscow
2 - Multidisciplinary clinic "House of Health", Pyatigorsk

Role of human health resources in realizing the policy of medical care quality
Popovich V.K. 1, Shikina I.B. 1, Turchiev A.G. 2 , Baklanova T.N. one
1 - City hospital №17, Moscow
2 - "House of Health" multi-purpose clinic, Pyatigorsk

Keywords: medical personnel, quality of medical care.

key words: human health resources, quality of medical care.

The quality of medical care is assessed according to three main components: structural, technological and productive.

Each of the listed components involves taking into account and analyzing such characteristics as finances and material and technical resources, the human resources potential of the healthcare industry and their compliance with the obtained (expected) results.

At the same time, quality management of medical care is a key healthcare problem that determines both current and strategic prospects for the activities of any medical institution (HCI) . An important role in this process is assigned to medical personnel, since the attitude to work of each employee has a direct, in some cases decisive influence on the results of the diagnostic and treatment process.

The leading role and importance of personnel in the activity of the industry is explained by the fact that the volume of financial and logistical support of the health care system, when the appropriate conditions are created, is formed and recreated faster than its human resources. Restoration, stabilization and effective use of personnel are realistically feasible only after several years and even decades.

Prospects for the development of health care in the Russian Federation largely depend on the state of the professional level and quality of training of medical and pharmaceutical personnel, their multi-stage improvement throughout their career, which is reflected in the "Concept of personnel policy in the health care of the Russian Federation" (2002), developed in accordance with the state policy to improve the health of the population.

The Concept emphasizes the main goal of the health personnel policy in the near future, which is to develop a system for managing the personnel potential of the industry. One of the key tasks is defined as "... carrying out a reform of the health personnel service in accordance with the principles and requirements of the modern theory of scientific human resource management."

The concept reveals the main content of the personnel policy in the health care of the Russian Federation:

• - priorities for the formation of personnel work in the industry in accordance with the directions of its reform;
• - principles of planning and use of human resources for health care based on the improvement of the range of specialties and the system of certification of specialists;
• - a strategy for the intensive development of human resources in healthcare based on the optimization of the system of medical and pharmaceutical education in accordance with the requirements of practical healthcare, medical science and sectoral management;
• - new principles of the system of remuneration of workers in the industry;
• - new principles for the development of social partnership with the involvement of public medical and pharmaceutical organizations in healthcare management.

The Concept states that the problems of personnel management should be solved by modern technologies for hiring and diagnosing personnel, competent placement of personnel, taking into account the requirements of the workplace, the criteria for matching the employer's expectations and the potential of the medical worker, ensuring the professional growth of the employee. On the basis of the Concept, normative legal documents are developed, industry programs, plans relating to various aspects of personnel policy. Its provisions are taken into account in the formation of strategic directions for the development of regional health care and the staffing needs of a particular health facility.

Thus, the personnel policy includes organizational, staffing, managerial, social, financial, information policies and is combined with the plans and concept of medical facilities for managing the quality of medical care.

Ensuring motivation for work focused on obtaining the final result, and for quality management is one of the main tasks on the way to improving the diagnostic and treatment process. For this purpose, both methods of economic incentives are used (a remuneration system taking into account the contribution of each employee to the result obtained) and moral incentives: career advancement, awards and other forms of encouragement.

When forming plans for the implementation of the policy in the field of quality of medical care in any inpatient medical facility, the leading role in strategic planning is assigned to the management of human resources, the qualitative composition of which largely determines the result of the treatment and diagnostic process.

The main objectives of the personnel policy of health facilities should be:

• ensuring high quality of human resources;
• maintaining the stability of the staff;
• creation of a system of continuous professional growth of employees;
• formation of a favorable socio-psychological climate in the team;
• social protection of medical workers;
• formation of corporate culture.

The efficiency of the healthcare industry, as well as the entire national economy, is largely determined by the knowledge, skills and abilities of managers at various levels. In this regard, the guarantee of the professionalism of each manager is his continuous education. Basic principles of professional education of a manager in modern conditions- consistency, continuity, scientific character, commitment, perspective, development of leadership qualities in a manager, individualization and differentiation of the educational process, a combination of organized learning with self-education.

The cornerstone task of the organizational and staffing policy of health facilities is staffing with highly qualified specialists in strict accordance with specific needs. For these purposes, a system of contracts is used with state educational institutions of higher and secondary vocational education for targeted training of specialists (radiologists, pathologists, anesthesiologists, resuscitators, etc.) in internship and clinical residency, training of paramedical personnel from among the employees of medical facilities.

In health care facilities, various methods of testing personnel for professional suitability are used. So, when hiring, a preliminary assessment of the future employee is carried out by the management and specialists of the personnel department of the healthcare facility, as well as the heads of structural divisions, taking into account compliance with the requirements vacant position. The assessment is carried out on the basis of the submitted documents, analysis of the submitted resume, personal conversation, questionnaire in order to identify professional training, justify the desire to work in a particular structural unit, as well as the reasons for dismissal from the previous job.

Increasing the responsibility of each employee for the quality of work performed within the framework of the treatment and diagnostic process and the ongoing medical services provided largely depends on the improvement of the system of training and retraining of personnel. It is necessary that professional development and improvement of health facility staff be carried out continuously.

Everyday training is necessary so that the staff has the opportunity to get acquainted with the latest achievements of domestic and world medicine directly at the workplace, and not by the "trial and error" method. This significantly reduces the time for the introduction of new technologies, the frequency of complications and, as a result, reduces mortality.

Advanced training is the process of preparing medical specialists for the implementation of planned innovations (for example, high technologies) and for working with new modern equipment (magnetic nuclear resonance tomography, etc.).

An atmosphere should be created in the healthcare facility aimed at stimulating the desire of each employee to master modern technologies, broaden their horizons, improve professional level. In the absence of sufficient material resources to encourage an employee, management can use other methods of motivation: sending an internship to Russian medical centers, providing an opportunity to master related medical specialties, creating conditions for scientific activity, etc.

The introduction of new medical technologies requires a new approach to the training of nursing staff, including universal training in modern standards practical activities nurse. Classes on this subject in subdivisions should be held separately with chief, senior, ward, procedural, dressing nurses.

Quality control required the introduction of new accounting and reporting documentation. To this end, in some health facilities, a special journal of nurses' defects was developed, which is maintained in each department by senior nurses with the notes of the chief nurse recorded during rounds. Each deviation from the standard has its own approved score.

Strict control over the implementation of standards in health care facilities leads to a decrease in the number of identified defects in the organization of medical care, primarily in patient care.

The introduction of new methods of care and performance of functional duties allow, along with other activities, to significantly improve the quality and intensify the treatment and diagnostic process, reduce the average length of stay of the patient.

An analysis of the effectiveness of training medical personnel is carried out regularly at meetings of the medical council of the institution, where an annual report on personnel work is heard, as well as reports from the qualification and certification commissions.

In daily work should be learned how business qualities employees and their observance of deontological principles. Managers (deputy chief physicians, chief nurses, heads of departments, head nurses) evaluate the quality of work of each employee, study their job satisfaction, competence in solving the tasks. An important criterion is the patient's assessment of satisfaction with the quality of medical care provided by this employee (anonymous survey).

The promotion of each employee should go in two directions, including career growth and advanced training. In order to make the right management decisions in the field of personnel policy in health facilities, the list of reserve employees for senior positions should be approved annually.

Based on the long-term plans for the development of medical facilities, the personnel department draws up a personnel development plan, which takes into account the need to open new departments, services, introduce new technologies, equipment modern equipment, and selects the appropriate team of subdivisions (Fig. 1).

Rice. 1. Structural diagram "Organization of the training process".

The information policy of health care facilities as an element of personnel policy is aimed at obtaining high-quality information on the needs of departments and bringing all administration initiatives and management decisions to employees.

The development of personnel abilities and qualifications is carried out through continuous internal and external training. Despite the difficulties with financing, health care facilities should set as one of the priorities of their personnel policy the mandatory advanced training of doctors and paramedical personnel once every five years with the receipt of certificates and certificates.

Doctors undergo professional retraining mainly at the faculties of postgraduate education of state educational institutions of higher professional education. The training of paramedical personnel is carried out in accordance with the schedule in state educational institutions of secondary and higher professional education.

The introduction of new medical technologies requires a new approach to the training of nursing staff. In this regard, the role of the deputy chief physician for nursing staff and / or the head nurse of the health facility is increasing.

Time has shown the need to develop modern nursing standards based on the assessment of the quality of medical care as the main factor in its improvement. The nurse must adhere to the standards of practical work in the performance of each type of activity in the same way as the doctor performs the standards of the diagnostic and treatment process for various pathologies.

Thus, providing adequate motivation for quality work and quality management of medical care is one of the main tasks of clinical management. Strategic planning for the use of human resources in the implementation of a policy to improve the quality of medical care can improve the clinical performance and economic efficiency of health facilities.

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7. Shikina I.B., Vardosanidze S.L., Voskanyan Yu.E., Sorokina N.V. Problems of ensuring patient safety in modern healthcare. // M., Publishing house: OOO "Glossarium". 2006. 336 p.
8. Cossutta R., Masserini A.B., Colombelli P. Evaluation of quality of life in patients with systemic sclerosis by the SF-36 questionnaire // Arthritis and Rheumatism. 2000 Vol. 9. P. 776.

References

1. Vardosanidze SL, Vorobev SV, Golovina SM, Gololobova TV, Gorbunkov VYa, Grigoreva TN, Gryaznova TYu, Daraev YuM, Devyatko VN, Dubodelova NK, Zhilinskaya EV, Kovaleva VV, Kozachenko OA, Lindenbraten AL, Magaev KA, Minin OG, Proshchenskiy BM , Ragoznyy AD, Soloveva NB, Timofeev LF, Timofeeva TA, Filippova VI, Shikina IB, Shipova VM. Economic metody v upravlenii zdravookhraneniem. Shchepin OP, editor. Moscow; 2006. 308 p.
2. Vardosanidze SL, Shikina IB, Sorokina NV. Motivatsiya meditsinskikh kadrov v usloviyakh mnogoprofilnogo statsionara. Manager zdravookhraneniya 2006;(10):44-49.
3. Mikhaylova YuV, Son IM, Sokhov ST, Danilova NV, Shestakov NN, Sasina NS, Takhtarova YuN. Sostoyanie i perspektivy razvitiya kadrovogo potentsiala sistemy zdravookhraneniya. Zdravookhranenie Rossiyskoy Federatsii 2008;(1):52-54.
4. Polesskiy VA, Martynchik SA, Zaporozhchenko VG, Martynchik EA, Kucherenko VZ. Evolyutsiya modeley sistemy kachestva: mezhdunarodnaya praktika. Ekonomika zdravookhraneniya 2005;(8):25-36.
5. Prikaz Minzdrava RF dated 07/03/2002 No. 210 "O kontseptsii kadrovoy politiki v zdravookhranenii Rossiyskoy Federatsii".
6. Upravlenie zdravookhraneniem. Kucherenko VZ, ed. Moscow: TEIS; 2001. 448 p.
7. Shikina IB, Vardosanidze SL, Voskanyan YuE, Sorokina NV. Problemy obespecheniya bezopasnosti patsientov v sovremennom zdravookhranenii . Moscow: Glossary; 2006. 336 p.
8. Cossutta R, Masserini AB, Colombelli P. Evaluation of quality of life in patients with systemic sclerosis by the SF-36 questionnaire. Arthritis and Rheumatism; 2000;9:776.

The main goal of personnel policy in the near future is to develop a system for managing the personnel potential of the industry, based on rational planning for the training and employment of personnel, the use of modern educational technologies and effective motivational mechanisms that make it possible to provide healthcare authorities and institutions with personnel capable of solving the tasks of improving quality of medical care to the population.

Exactly fifteen years have passed since the approval of the Concept of personnel policy in the health care of the Russian Federation (approved by order of the Ministry of Health of the Russian Federation of July 3, 2002 N 210). Over the past decade, some work has been done to strengthen the personnel potential of the industry, but many problems remain unresolved. And now, as before, the prospects for the development of Russian health care largely depend on the state of the professional level and the quality of training of medical and pharmaceutical personnel as the main resource of the public health system.

Priorities for the formation of personnel work in the industry in accordance with the directions of its reform and development;

Principles of planning and use of human resources for health care based on the improvement of the range of specialties and the system of certification of specialists;

The strategy for intensive development of human resources in healthcare based on the optimization of the system of medical and pharmaceutical education in accordance with the requirements of practical healthcare, medical science and sectoral management;

New principles of the system of remuneration of workers in the industry;

New principles for the development of social partnership, involvement of public medical and pharmaceutical organizations in healthcare management.

Educational institutions of the system of the Ministry of Health and Social Development of Russia graduate about 100 thousand young specialists with higher and secondary vocational education per year. About ½ million healthcare workers are annually trained in the system of additional professional education of industry specialists. Medical universities provide training in new health care specialties: nursing, general practice, economics, clinical psychology, social work, etc.

The system of admission to higher education is developing educational establishments on the basis of targeted contracts and the technology of the educational process is being improved. The contract system of employment of young specialists is becoming more widespread.

Systems of certification of healthcare professionals and licensing of medical activities are being formed. The number of specialists with higher and secondary vocational education who have received qualification categories in accordance with the achieved level of theoretical knowledge and practical skills is increasing.

At the same time, a number of problems in the field of human resource management remain unresolved. Among them are the following:

1. Inconsistency of the number and structure of personnel with the scope of activities, tasks and directions of reforming the industry.

2. The presence of disproportions in the structure of medical personnel:

Between general practitioners and narrow specialists, doctors and paramedical workers;

Between different territories, urban and rural areas;

Between specialized care facilities and primary care.

3. Imperfection of the legal framework.

4. Inconsistency of training of specialists with the needs of practical healthcare and the tasks of structural restructuring of the industry.

5. Lack of evidence-based methods for planning the number of medical personnel.

6. Insufficient social protection of healthcare workers.

7. Low level of remuneration, which is not conducive to attracting and retaining specialists in the industry.

8. Strengthening the trend of outflow of young professionals from the industry.

9. Low level of participation in solving personnel issues of professional public organizations.

The strategy of personnel policy in health care depends on the degree of social orientation of the state, the recognition by society of the high economic importance of health as an important component of the country's labor potential.

Personnel policy includes three interrelated areas:

Planning and optimization of the number and structure of personnel;

Improving staff training;

Health Human Resource Management.

The main goal of personnel policy in the near future is to develop a system for managing the personnel potential of the industry, based on rational planning for the training and employment of personnel, the use of modern educational technologies and effective motivational mechanisms that make it possible to provide healthcare authorities and institutions with personnel capable of solving the tasks of improving quality of medical and medicinal care to the population.

The main conceptual tasks for the implementation of personnel policy in health care are as follows:

1. Ensuring the further development of an integrated system for planning human resources, taking into account the structure of the needs of the industry, their rational distribution and effective use.

2. Raising the professional level of healthcare workers on the basis of further development of the system of continuous education, improvement of the system of state educational standards for training specialists.

3. Raising the standard of living of healthcare workers, bringing the wage system in line with the complexity, quantity and quality of medical care.

4. Ensuring the legal and social protection of an employee of the industry, the development of state and social insurance, increasing the effectiveness of labor protection measures.

5. Carrying out the reform of the health personnel service in accordance with the principles and requirements of the modern theory of scientific management of human resources.

The implementation of the tasks set should ensure an optimal balance between the processes of updating and maintaining the quantitative and qualitative composition of the industry's employees, the development of human resources in accordance with the needs of practical healthcare, the requirements of current legislation and the state of the labor market.

Improving the planning and use of human resources

The planning of the number and structure of health personnel should be built in accordance with the Program of State Guarantees of Free Medical Care for Citizens of the Russian Federation, based on a long-term forecast of the population's need for medical, medicinal and sanitary and hygienic provision, built taking into account the demographic situation, the dynamics of public health, and the natural movement of personnel , the nature of migration processes and the tasks of structural restructuring of the industry.

It is advisable to improve planning on the basis of the development and use of staffing standards.

The current standards should become an effective tool for leveling regional, social (urban-rural, center-periphery) and structural (by types of assistance, types of institutions and specialties) disproportions in the distribution of human resources, as well as ensure proportionality in the development of primary and specialized types of medical care, treatment and prevention.

Perspective standards should form the basis of plans for admission to educational medical institutions, be taken into account in the professional orientation of graduates, retraining of specialists, the formation of state (federal) and target (subjects of the Russian Federation and municipalities) orders for the training of specialists.

Improving planning is ensured by the development of criteria for assessing the state of human resources and evidence-based approaches to determining the need for specialists of various qualifications, the further development of the range of specialties of health workers.

The main directions for increasing the efficiency of using human resources in health care are:

Elimination of duplication of functions;

Redistribution of functions between various professional groups of medical personnel;

Transformation of the structure of medical personnel on the basis of the formation of the "Institute of General Practitioner";

Streamlining the job structure of healthcare institutions based on the use of a progressive regulatory framework;

Modernization of workplaces, increasing the technical equipment of labor.

Increasing the importance of nursing staff in providing medical and medico-social care, in organizing and managing nursing requires taking measures to improve the training of specialists with secondary vocational education, to develop new organizational forms and technologies of nursing care to the population, and legal regulation of nursing activities.

Raising the professional level of specialists is ensured by the creation of a certification system for specialists based on the development of professional standards.

Professional standards will make it possible to form common approaches to the development of standards for various sections of medical care and will contribute to the rational use of human resources in health care.

Improving the training system

The successful implementation of personnel policy largely depends on the quality of training of industry employees and the creation of the necessary conditions for their further professional growth.

The selection of applicants from professionally oriented school graduates contributes to the stabilization of the personnel potential. In this regard, it is necessary to expand the network of lyceums, medical classes in general education schools, introduce alternative forms of military service and involve high school students to work during holidays in healthcare institutions.

The learning process, methodological approaches, content of curricula in the main disciplines should be constantly improved, respond flexibly to changing health care needs, and focus on training specialists in new areas.

The methodological basis for improving the system of continuous education at all levels in the context of industry restructuring should be the industry qualification requirements of healthcare professionals and managers. Volumes must be determined for each specialty necessary knowledge, including a reasonable set of theoretical questions and practical skills.

In accordance with modern requirements imposed on the professional level of medical personnel, it is necessary to improve the entire interconnected system of documents regulating the educational process of educational medical and pharmaceutical institutions:

Qualification characteristics of specialists;

State educational standards;

Curricula and curricula in the disciplines of the curriculum;

Educational materials.

The use of modern technologies of multidisciplinary and problem-targeted teaching methods will ensure an increase in the effectiveness of the educational process.

In the process of learning, it is necessary to carry out professional adaptation, using for these purposes the passage of industrial practices at the place of future work.

The system of quality control of training of specialists at all stages of continuous education should be further developed.

Continuous education provides for the improvement of the system of self-learning, the development of which should be aimed at scientific and research organizations that prepare appropriate training programs, expert systems and methodological materials, develop modern systems for transferring knowledge using telemedicine methods, distance education technologies, etc.

It is advisable to combine the spread of the system of orders for the training of specialists in educational medical and pharmaceutical institutions with a change in the procedure for their financing. State return subsidizing will solve the problems of training specialists of the required profile and in the right quantity, will contribute to the development of targeted training and the provision of young specialists with work on the basis of contracts (contracts).

The problem of restructuring the industry requires new approaches to solving complex socio-psychological problems in the field of rational use of labor resources related to the retraining and employment of released qualified specialists, which should be the focus of institutions of additional professional education.

It is necessary to constantly strengthen and update the material and technical base of educational institutions. Particular attention is required to the training and advanced training of teaching staff.

Purposeful and systematic training of highly qualified scientific and scientific-pedagogical personnel in the future remains one of the priority tasks of the Ministry of Health and Social Development of the Russian Federation.

For these purposes, it is expected:

Improving the system of postgraduate training in postgraduate and doctoral studies;

Further formation and development of scientific schools in priority areas of medicine;

Integration of scientific institutions and universities in a single university complexes;

Expansion of the operational exchange of information on research in the field of medical science and on the introduction of new technologies into practice.

The quality of the working environment. Moral and material motivations

Improving the quality of the working environment includes issues of wages, the creation of appropriate working conditions and the use of working time.

The current situation with a low level of wages hinders the further development of human resources, negatively affects the state and quality of medical care to the population. It is necessary to take measures to significantly increase the remuneration of health workers, ensure the growth of real wages and eliminate the unjustified gap in wage levels in the real sector of the economy and the public sector. The solution of this problem is impossible without the creation and improvement of the regulatory framework and the reform of the existing conditions of remuneration on its basis.

Deterioration specifications medical equipment, employers' failure to comply with basic labor protection requirements, the lack of relevant services and a number of other reasons lead to an increase in occupational injuries and occupational diseases.

In addition, the unsatisfactory state of the working environment is becoming an important factor in the destabilization of personnel potential, contributes to the outflow of specialists from the industry, the emergence of unprestigious jobs, increases unproductive compensation costs for the medical rehabilitation of people who have suffered as a result of an industrial injury and suffered Occupational Illness, reduces the possibility of their subsequent employment.

In this regard, it is necessary to revise the normative documents on labor protection in force in the industry, bring them into line with modern safety requirements, organize administrative control over the state of working conditions at the workplace, conduct training for managers and personnel of healthcare institutions.

Implementing a unified policy for the protection of workers in special conditions, it is necessary to carry out certification of workplaces everywhere for compliance with labor safety standards in accordance with the current regulations in this area.

In order to reduce and prevent occupational injuries, it is necessary to ensure the development of territorial programs to improve working conditions and labor protection, as well as similar programs directly in healthcare institutions.

It is necessary to develop and put into effect a mechanism for exercising the rights of industry workers to compulsory personal insurance, in the case when the performance of official duties is associated with a threat to life and health.

The solution of important tasks facing the industry requires increased attention to the social problems of medical personnel related to ensuring a decent standard of living, increasing the authority of industry workers, and maintaining their health.

In order to improve the social protection of medical workers in their professional activities, it is necessary to create a system of state social liability insurance in case of an error and in the event of a risk of medical intervention.

It is necessary to provide a system for stimulating medical activities for specialists employed in the most important prospective and priority areas(general practitioners, phthisiatricians, narcologists, oncologists, etc.), as well as for people working in difficult domestic, natural, environmental and other adverse conditions.

One of the main tasks related to the solution of social issues is to increase the role of tariff agreements and collective agreements, which are designed to ensure the optimal combination of the interests of workers and employers in regulating the issues of wages, material incentives for high-quality and efficient work, improving working conditions and labor protection.

In modern conditions, the importance of the factors of preserving and consolidating labor potential is sharply increasing. This should be facilitated by an effectively functioning system of moral and material incentives: solving social and domestic issues, creating modern jobs, promoting professional growth through targeted training in clinical residency, postgraduate studies, and retraining.

The contests "Best Doctor of the Year" and "Best Nurse of the Year" should help raise the prestige of medical professions.

Health Human Resource Management

The solution of strategic tasks of personnel policy in health care depends on the organization of labor resources management in the industry.

The new conditions for the functioning of health care impose increased requirements on the potential of the personnel service, the functions and responsibilities of which should be significantly expanded.

The most important condition for the effectiveness of the personnel policy and modern personnel management is the strengthening of the personnel service in government and healthcare institutions on the following principles:

1. The number of full-time positions of personnel service specialists is determined by the number of employees.

2. Established human resources positions should be staffed by specialists who have received training in the field of personnel management.

3. The professional and official composition of personnel service specialists is determined by a list of tasks that need to be addressed in modern conditions.

The main tasks facing the health personnel service are:

1. Forecasting the need for personnel in specific specialties and planning their training.

2. Recruitment, selection, training, development and motivation of personnel for the effective performance of work; assessment of the quality of work performed; remuneration, promotion, transfers, demotion, dismissal of staff.

3. Maintaining optimal relationships between employers and employees based on compliance with the law, ensuring a fair wage system, social protection of employees, creating favorable industrial relations and a healthy climate, ensuring labor protection and other conditions that positively affect the quality of work and the quality of life of employees.

4. Promoting the employment of health workers through increasing the professionalism and competitiveness of the workforce in the labor market.

5. Interaction with other departments, organizations and institutions on labor and personnel issues.

Legal regulation of the structure of the personnel service of health authorities and health care institutions is carried out by regulating all aspects of its activities, determined by the regulations on the body and structural divisions, professional job descriptions, staffing tables, etc.

The fulfillment of functional duties and the solution of modern problems of work with personnel requires managers and specialists of the personnel service to possess multidisciplinary professional knowledge(legal, economic, pedagogical, psychological, etc.), as well as skills and abilities in the field of modern personnel technologies.

The problems of personnel management should be dealt with by professionals who are able to navigate the labor market well, perform analytical work, own modern technologies for hiring and diagnosing personnel, competently participate in the placement of personnel, taking into account the requirements of the workplace and the potential of the employee, ensuring the professional growth of employees.

It is necessary to release personnel officers from functions that are unusual for them, increase wages, conduct systematic training and retraining, work out the issues of organizing certification and attestation of specialists, staff and strengthen the material and technical base for the full implementation of the tasks of the service.

The development of a model of a personnel service specialist, containing a list of the necessary personality traits and professional job requirements, is a task of paramount importance. The system of training and advanced training of both personnel service specialists and heads of health authorities and institutions in the field of personnel management requires further improvement.

It is necessary to strengthen the interaction of personnel services with the heads of institutions, raising their status to the level of deputies for personnel management.

The personnel management system is obliged to take into account and use the intellectual potential of the employee as the most valuable national asset. This will require a certain freedom for the heads of healthcare institutions in choosing and using forms of remuneration, incentive mechanisms, in organizing the professional recognition of a specialist, and ensuring his career growth.

A particularly important area in the human resources management system of the industry is maintaining a high professional level of the management team. The right choice of a leader largely determines the success of a business.

It is necessary to form an effective reserve of executives, carry out special work to develop organizational skills among managers, as well as improve knowledge in economics, finance, law, and management.

It is necessary to encourage managers to obtain a second education on the basis of leading Russian universities, to regularly conduct internships for executives in leading domestic and foreign centers.

For the purpose of broad practical training of the reserve, it is possible to use the methods of current rotation of managers at the municipal, regional and federal levels.

The selection and appointment of a candidate for a managerial position, as well as the certification and attestation of managers, should be carried out regularly in strictly regulated terms in strict accordance with uniform national criteria and requirements.

It is advisable to revise the procedure for coordinating candidates for appointment to managerial positions.

It is necessary to strengthen the interaction of the personnel service with trade union organizations, professional associations, social protection authorities, etc.

Creation needed effective system collection, processing, storage and transmission of personnel information for making informed management decisions. Information policy should be directed, on the one hand, to the improvement of statistical accounting, and, on the other hand, to the creation of regional, interregional databases.

The creation of a multi-level system for monitoring the development of personnel will make it possible to manage the movement of personnel, take timely measures to preserve personnel potential, select specialists and plan retraining programs.

To ensure the employment of medical workers and their rational distribution throughout the country, it is advisable to create a database of vacancies in institutions and organizations of the industry, as well as use the capabilities of the Internet system.

Thus, the current situation in the industry involves urgent and profound changes in the field of human resource management, without which it is impossible to improve the quality and efficiency of the entire healthcare system.

The specifics of personnel work in health authorities and institutions lies in the fact that the scope of these organizations is under state control regardless of the organizational and legal form of the institution.

Personnel work in healthcare institutions includes the following areas of activity:

1. Planning the organization's need for personnel.

2. Selection and admission of workers.

3. Development of employee incentive programs.

4. Evaluation of personnel performance.

5. Organization of training, advanced training of employees, certification.

6. Development of personnel adaptation programs.

7. Documentary support of personnel work at the enterprise Posherstnik S. The work of personnel services in health care institutions / / Personnel business. - No. 7. - 2003, p. fourteen .

Let us consider in more detail these areas of activity of personnel services in healthcare institutions.

The planning of the need for personnel of a healthcare organization is carried out by the personnel service on the basis of the staffing table approved by the head of the organization, as well as based on the actual staffing of medical workers.

Also, the planning of the number of personnel of a healthcare organization is carried out on the basis of separate regulations, for example, Order of the Ministry of Health of Russia dated June 9, 2003 N 230, which approved the staffing standards for employees and workers of state and municipal healthcare institutions and employees of centralized accounting departments at state and municipal healthcare institutions.

A new employee is accepted into the staff of an organization or institution in accordance with the staffing table (unified form No. T-3, approved by the Decree of the State Statistics Committee No. 1), which contains a list of structural units, positions, information on the number of staff positions, official salaries, allowances and monthly payroll fees. The staffing of an organization, institution is approved, changed by order of the head or authorized person “Positions, tariff categories, qualification characteristics in medical and educational institutions”, ed. A.Yu. Kibanova. - St. Petersburg: Peter, 2005, p. 125.

The position to which the employee enters is indicated strictly according to the Qualification Handbook. In the absence of a job title in this directory, use All-Russian classifier professions of workers, positions of employees and wage categories (OKPDTR).

The qualification handbook was developed in accordance with the accepted classification of employees into three categories: managers, specialists and other employees (technical performers). The assignment of employees to one category or another is carried out depending on the nature of the work that is mainly performed and constitutes the content of the worker's work (organizational-administrative, analytical-constructive, information-technical).

The names of the positions of employees, the qualification characteristics of which are included in the Qualification Handbook, are established in accordance with the All-Russian Classifier of Occupations of Workers, Positions of Employees and Wage Categories OK-016-94 (OKPDTR).

This Qualification Handbook consists of two sections. The first section contains qualifications industry-wide positions managers, specialists and other employees (technical performers), which are widely distributed in institutions and organizations, including those on budget funding. And the second section presents the qualification characteristics of the positions of employees who are employed in research institutions, design, technology, design and survey organizations, as well as editorial and publishing divisions.

Qualification characteristics in institutions and organizations can be used both as normative documents of direct action, and serve as the basis for the development of internal organizational and administrative documents - job descriptions that contain a specific list of job responsibilities of employees, taking into account the characteristics of the organization of production, labor and management, as well as their rights and responsibilities. If necessary, the responsibilities that are included in the description of a particular position can be distributed among several performers.

Since the qualification characteristics specified in the Qualification Handbook apply to employees of institutions and organizations, regardless of their industry affiliation and departmental subordination, they present the most typical work for each position.

The position must be indicated with an indication of the category, qualification, category, and the structural unit in which the employee is accepted is indicated in accordance with the organization's staffing table. The presence of the slightest deviation from regulatory documents in such documents as an employment contract, staffing organization, work book, as well as in the employee's job description can lead to adverse consequences (for example, litigation regarding the correction of violations).

Salary of healthcare workers.

To date, there are many regulations governing the remuneration of employees of healthcare institutions.

Conventionally, they can be divided into three groups: regulations regulating general approaches to the organization of the system of remuneration of employees of all budget institutions, including health care, regulations on the system of remuneration of only employees of health care institutions and departmental regulations.

The main document regulating the remuneration of employees of health care institutions is the Regulation on remuneration. It provides for unified principles of remuneration for employees of health care institutions that are funded by the budget. According to this provision, the wages of healthcare workers include:

Salary (the Regulation on wages provides for the conditions for its increase);

allowances;

Surcharges.

On fig. 1. The salary structure of medical personnel is presented in accordance with the regulation on remuneration.

Figure 1. Salary structure of medical staff.

The salaries of employees of health care institutions are determined on the basis of the Unified Tariff Scale (UTS), which includes 18 categories.

The regulation on remuneration defines the conditions that affect the establishment of the salary, namely the position of the employee, the area in which he works (rural, urban), skill level, academic degree or title.

The regulation on remuneration identifies factors that increase the level of remuneration of medical personnel (see Fig. 2).

Figure 2. Factors that increase the level of wages

Thus, medical workers working in rural areas are given higher salaries (rates) compared to the salaries (rates) of specialists engaged in these types of activities in urban areas. An increase in salaries is allowed by 25% (clause 2.3 of the Regulation on wages).

For deputies, salaries are set at 10-20% lower than the salary of the corresponding manager, taking into account the qualifications of this deputy, provided for by the ETS. If a specialist has a high qualification, confirmed by a certificate, and he is engaged in important and responsible work, in accordance with paragraph 2.5 of the Regulations on remuneration, he can be set a tariff rate based on 9-10 UTS categories.

When determining the amount of remuneration for the head of a healthcare institution, the number of estimated beds for which the institution is designed should be taken into account.

The indicators and the procedure for classifying healthcare institutions as groups for the remuneration of managers are given in Appendix No. 1 to the Regulations on Remuneration.

When honorary titles are awarded to medical workers, advanced training, changes in continuous experience, the amount of salary also increases (clause 2.7 of the Regulations on Remuneration). So, when a doctor is awarded the title of "Honored Doctor", his salary for his main job increases by one category, and when he is awarded the title "People's Doctor" - by two categories. If a doctor has two honorary titles, only one is accepted as a basis for increasing his remuneration (clause 3.12 of the Regulations on Remuneration).

In addition, salaries may be increased for employees of healthcare institutions if there are other conditions (section 4 of the Resolution on wages):

Particularly difficult and dangerous working conditions for health (if an employee of healthcare institutions (their structural divisions) is involved in the treatment of AIDS patients, HIV-infected, leprosy, mentally ill, tuberculosis patients). Their salary is increased by 60, 40, 30, 25 and 15% according to the List approved by the Ministry of Health of the Russian Federation in agreement with the Central Committee of the trade union of health workers of the Russian Federation, given in Appendix No. 2 to the Regulation on wages;

Work in hospitals for war veterans and special departments of hospitals (provided that departments in hospitals are used by at least 90% for the treatment of war veterans and persons equated to them in terms of benefits), as well as Rehabilitation Therapy Centers for internationalist soldiers. Salaries for medical and pharmaceutical workers of these institutions are increased by 15%, and for other employees - by 10%.

Other conditions.

According to sect. 5 of the Regulations on remuneration for employees of healthcare institutions, the following types of additional payments are made:

For work at night;

For work with the division of the shift into parts;

For combining professions;

For work in the specialty to medical directors and their deputies;

For work related to the provision of TB care;

Other types of surcharges.

Additional payments provided for medical staff by the regulation on remuneration are presented in Fig. 3.

Figure 3. Additional payments to medical staff

Work at night. The order of work at this time of day is regulated by the norms of Art. 96 of the Labor Code of the Russian Federation, according to which the time from 22 to 6 hours is considered night. The duration of work (shift) at night is reduced by one hour without subsequent working off. However, night work for medical workers is not subject to reduction. This follows from Art. 96, 350 of the Labor Code of the Russian Federation and Decree of the Government of the Russian Federation of February 14, 2003 N 101 "On the duration of the working hours of medical workers, depending on the position held."

The amount of additional payment for work at night is established by clause 5.1 of the Regulations on wages and is:

50% hourly rate ( official salary) for each hour of night work. At the same time, this additional payment is paid to workers at the rate of the hourly tariff rate (salary), taking into account the increase for work in dangerous and especially difficult working conditions. And for medical, pharmaceutical workers, specialists and employees - based on the official salary for their position;

100% hourly tariff rate (official salary). In this amount, the surcharge is established for medical personnel engaged in the provision of emergency, emergency and emergency medical care, field personnel and communication workers of stations (departments) of emergency medical care.

Work with the division of the shift into parts. Employees of health care institutions, with their consent, may be introduced a working day with the division of the shift into parts. The right to establish such a working time schedule is established by Art. 105 of the Labor Code of the Russian Federation. According to the norms of the mentioned article, when dividing the working day into parts, the total duration of working time should not exceed the established duration of daily work.

Additional payment for work with the division of the shift into parts is made on the basis of the official salary for the position held. The list of positions of employees who can be given the specified surcharges, and the amount of surcharges are determined by the head of the institution in agreement with the elected trade union body (clause 5.2 of the Regulations on wages).

Work with a combination of professions. The conditions and procedure for establishing an additional payment for combining professions (positions) or performing the duties of a temporarily absent employee are established in collective agreements(clause 5.5 of the Regulations on remuneration). In this case, the combination of professions is understood as the performance by an employee in the same healthcare facility within the working day, along with his main job, stipulated by an employment contract, additional work in another position (profession) or the performance of the duty of a temporarily absent employee without releasing his main job. .

Work in the specialty of a doctor by managers and their deputies. In accordance with paragraph 5.3 of the Regulations on remuneration, doctors - heads of health care institutions and their deputies are allowed to work in the institutions in which they are employed, work in their specialty within the working hours of their main position. In this case, the additional payment will be up to 25% of the official salary of a doctor in the relevant specialty. The exact percentage of the additional payment is established by the order of the head of the institution.

Work related to the provision of anti-tuberculosis care. Medical and other employees of healthcare institutions directly involved in the provision of anti-tuberculosis care, whose activities are associated with the risk of infection with mycobacterium tuberculosis, in accordance with clause 5.6 of the Regulations on remuneration, an additional payment is established in the amount not exceeding 25% of the official salary (monthly tariff rate).

Allowances

The regulation on remuneration for employees of healthcare institutions establishes the following types of allowances (Section 6 of the Regulation on remuneration):

For the duration of continuous work in healthcare institutions;

For working conditions;

Stimulating nature.

The list of allowances provided for by the regulation on remuneration is presented in fig. 4.

Figure 4. Allowances provided for by the regulation on the remuneration of medical workers

Continuous work in healthcare facilities. Depending on the position of the medical worker, the period of his continuous experience and the type of medical institution in which he works, the amount of the bonus to the official salary is established (clause 6.1 of the Regulations on Remuneration).

Allowances for working conditions. The amount of allowances paid for working conditions and the procedure for their payment are established in clause 6.3 of the Regulations on wages. They are paid in the following amounts:

30% to the salary (rate) of medical and pedagogical staff of psychiatric hospitals (departments) of a specialized type and forensic psychiatric departments for persons in custody;

20% to the salary (rate) of employees of health care institutions that diagnose and treat HIV-infected patients.

In accordance with Art. 146 of the Labor Code of the Russian Federation, remuneration of employees is made at an increased rate, not only in the implementation heavy work, work with harmful, dangerous and other special working conditions, but also when performing labor functions in areas with special climatic conditions. Employees of medical institutions performing work in areas with special climatic conditions, Art. 10 of the Law of the Russian Federation of February 19, 1993 N 4520-1 "On State Guarantees for Persons Working and Living in the Far North and Equivalent Areas" establishes the amount of the percentage premium and the procedure for its payment.

Incentive bonuses. For the application of the achievements of science and advanced labor methods, high achievements in work, the performance of particularly important or urgent work (for the period of their implementation), as well as labor intensity, employees of healthcare institutions may be paid incentive bonuses (clause 6.4 of the Regulation on wages ). They are accrued on the salary (rate) and are not limited to maximum sizes. Allowances are established by order of the head for a certain period, but not exceeding one year. In case of deterioration of indicators in work or the completion of especially important or urgent work, allowances are canceled.

For the heads of healthcare institutions (chief physicians, directors, heads, chiefs), allowances are established by the decision of a higher healthcare management body for work aimed at developing the institution, applying advanced methods of diagnosing and treating patients, new patients in the practice of the institution. medicines and medical equipment, advanced methods for ensuring the sanitary and epidemiological well-being of the population.

Due to the specifics of their activities, doctors and paramedical personnel are on duty at home. They are introduced within the limits of the balance of working time of the relevant employees for the accounting period, as a rule, a month, for the main position and the position held in combination.

According to paragraph 7.1 of the Regulation on remuneration, the time spent on duty at home, both day and night, is taken into account as half an hour for each hour of duty. If it becomes necessary to call a doctor or senior staff specialist on duty at home to provide medical care, then the time spent on providing assistance is paid at the rate of the official salary of the doctor or paramedical worker for the hours actually worked, taking into account the time of the move.

Characteristics of health care personnel

According to the Decree of the Ministry of Labor of the Russian Federation of August 27, 1997 No. 43 "On the harmonization of pay categories and tariff and qualification characteristics for the positions of healthcare workers in the Russian Federation" (hereinafter referred to as the Decree of the Ministry of Labor No. 43), the following categories of positions are used in medical institutions:

1. Leaders.

2. Specialists:

2.1. Specialists with higher medical education;

2.2. Specialists with higher professional education;

2.3. Specialists with secondary medical education (middle medical staff);

3. Junior medical staff.

4. Other personnel of medical and labor workshops at health care institutions.

The main characteristics of the personnel of health care institutions also include general characteristics of the classification of employees, such as gender, age, education, work experience, marital status, etc.

Thus, the personnel of health care institutions is characterized by various characteristics. The specificity of the classification of this category of personnel lies in the legislatively fixed list of positions, according to which the salary category of the employee is established. But on the basis of the category and tariff-qualification characteristics, the amount of salary, as well as allowances and additional payments to an employee of a healthcare organization, is established.

Thus, in this chapter, the theoretical aspects of personnel management, scientific ideas and approaches to this problem were considered.

The features of personnel work in healthcare organizations are considered, the characteristics of the personnel of healthcare institutions are given.

Keywords

annotation scientific article on health sciences, author of scientific work - Sheiman Igor Mikhailovich, Shevskiy Vladimir Ilyich

Currently in Russian health care many serious personnel problems have accumulated, among the main ones are the low level of personnel planning, the shortage of many categories of workers, and serious disproportions in their composition. The purpose of this article is to look at Russian problems through the prism of global staffing processes. health care. Three directions of development are taken as a basis: 1) increasing the efficiency of using medical resources, 2) searching for the optimal level of specialization of medical activity, 3) changes in division of labor between individual professional and qualification groups of industry workers. Such a comparison makes it possible to single out different types of development of staffing in Russia and abroad, and from these positions to look more critically at the main conceptual documents of the Russian health care. It is concluded that there is a significant deviation in the trends in the development of human resources in the Russian health care from the strategies that are dominant in Western countries. First, there are significant differences in the position of physicians in the system health care in Russia and abroad, the size and structure of wages, forms of employment, organizational and legal status. They largely determine the lag of our country in terms of the quality of medical care and the efficiency of the use of industry resources. Secondly, efforts are being made in Western countries to overcome the over-specialization of medical work, especially in the field of primary health care. In Russia, the process of specialization continues, giving rise to serious structural imbalances in human resources and an unsatisfactory state of primary health care. Thirdly, in foreign health care intensifies the process division of labor between doctors and paramedical personnel, as well as new categories of workers, which reduces the volume of routine functions performed by doctors. In the Russian health care this process is much less intense. The identified trends give grounds for practical advice for personnel policy in Russian health care.

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Health labor policy: comparative analysis of Russian and international developments

The text of the scientific work on the topic "Personnel policy in health care: a comparative analysis of Russian and international practice"

PERSONNEL POLICY IN HEALTH:

COMPARATIVE ANALYSIS OF RUSSIAN AND INTERNATIONAL PRACTICE

Sheiman I.M., Shevskiy V.I.*

annotation

At present, many serious personnel problems have accumulated in Russian healthcare, among the main ones are the low level of personnel planning, the shortage of many categories of workers, and serious disproportions in their composition. The purpose of this article is to look at Russia's problems through the prism of global health workforce processes. Three areas of development are taken as a basis: 1) increasing the efficiency of using medical resources, 2) searching for the optimal level of specialization of medical activity, 3) changes in the division of labor between individual professional and qualification groups of industry workers. Such a comparison makes it possible to single out different types of development of staffing in Russia and abroad, and from these positions to look more critically at the main conceptual documents of Russian healthcare. The conclusion is made about a significant deviation of the trends in the development of human resources in Russian health care from the strategies that dominate in Western countries. First, there are significant differences in the position of doctors in the health care system in Russia and abroad - the amount and structure of remuneration, forms of employment, organizational and legal status. They largely determine the lag of our country in terms of the quality of medical care and the efficiency of the use of industry resources. Secondly, efforts are being made in Western countries to overcome the over-specialization of medical work, especially in the field of primary health care. In Russia, the process of specialization continues, giving rise to serious structural imbalances in human resources and an unsatisfactory state of primary health care. Thirdly, in foreign healthcare, the process of division of labor between doctors and paramedical personnel, as well as new categories of workers, is intensifying, which reduces the volume of routine functions performed by doctors. In Russian healthcare, this process is much less intensive. The identified trends provide grounds for practical recommendations for personnel policy in Russian healthcare.

Key words: healthcare; personnel policy; human resource management; doctors; paramedical personnel; division of labor; organizational legal status of a doctor.

* Sheiman Igor Mikhailovich - Candidate of Economic Sciences, Professor of the Department of Economics and Health Care Management, National Research University Higher School of Economics, Honored Economist of Russia. Address: National Research University Higher School of Economics. 101000, Russia, Moscow, st. Myasnitskaya, 20. E-mail: [email protected]

Shevskiy Vladimir Ilyich - HSE consultant, Honored Doctor of Russia. Deputy Head of the Health Department of the Administration of the Samara Region in 1971-2001. Address: National Research University Higher School of Economics. 101000, Russia, Moscow, st. Myasnitskaya, 20. E-mail: [email protected]

The key direction in the formation of an effective healthcare system is to ensure a higher human resources potential of the industry. At present, many serious personnel problems have accumulated in Russian healthcare, among the main ones are the low level of personnel planning, the shortage of many categories of workers, serious disproportions in their composition, and the low professional level of a significant part of doctors. Discussions do not stop regarding the correspondence of the number of doctors to the real needs of the population, the ratio of certain professional and qualification groups, and, in a broader sense, the correspondence of the state personnel policy to new challenges to the health care system associated with the complication of medical technologies, an increase in the population's need for medical care.

A number of works defend the point of view that the shortage of doctors in Russia is "man-made" in nature. It is the result of many imbalances in the structure of human resources and reflects the continuation of the traditional course towards their extensive development. A change in the structure of personnel, combined with a change in the structure of medical care, can solve the problem of a shortage of doctors (Sheiman, Shevskiy, 2014). In other works, the emphasis is on the lack of financial resources, which leads to a shortage of personnel (Ulumbekova, 2011).

With all the diversity of points of view on the problems of human resources for health care, they, as a rule, are not based on an analysis of foreign experience in solving similar problems. Meanwhile, this experience makes it possible to identify stable development trends that should be taken into account in personnel policy, of course, taking into account the specifics of the organization of Russian healthcare.

The purpose of this article is to look at Russia's problems through the prism of global health workforce processes. Three directions of development are taken as a basis: 1) increasing the efficiency of using medical resources, 2) searching for the optimal level of specialization of medical activity, 3) changes in the division of labor between individual professional and qualification groups. These areas, in our opinion, are the most relevant for improving the personnel policy in Russian healthcare. Comparisons are based on WHO and OECD data, primarily for Western countries, and in some cases for post-Soviet countries.

Such a comparison makes it possible to single out different types of development of staffing in Russia and abroad and from these positions to look more critically at the main conceptual documents of Russian health care - to highlight in them what corresponds to the emerging global trends, what contradicts them, and what is simply ignored.

The position of the doctor in the health care system

A doctor in Western healthcare is an expensive resource. His primary training is of a "piece" nature and lasts more than ten years,

Sheiman I.M., Shevskiy V.I. Personnel policy in health care: a comparative analysis...

and in the future there is a constant updating of knowledge. The state and the professional medical community place high demands on the level of qualification and responsibility of a doctor. In the public mind, the attitude towards the doctor as a professional elite of society has long been established. Hence the high level of payment for his work.

The salary of doctors in Western countries significantly exceeds the average salary in the economy. General practitioners in the main part of these countries receive 2-2.5 times more than the average worker in the economy, narrow specialists - 3-4.5 times. Many countries in Eastern Europe have also exceeded the doubling of doctors' salaries. For example, in the Czech Republic narrow specialists - 2.3 times, in Estonia - 2.1 times, in Poland general practitioners - 2.2 times (OECD, 2013).

Having such an "expensive" doctor, the governments of a number of Western countries have long pursued a policy of curbing the admission of students to medical schools, in which they were actively supported by medical associations - in order to limit the influx of new doctors and maintain their high salaries. But the rapid growth in the need for medical care, which was especially pronounced at the end of the twentieth century. under the influence of new medical technologies and the aging of the population, forced to abandon this policy. In the last 2-3 decades, in almost all Western countries, the number of doctors has grown both absolutely and per inhabitant. A similar upward trend in the provision of the population with doctors is also observed in the post-Soviet countries, including Russia (Fig. 1).

Picture 1

Provision of the population with doctors (excluding dentists) per 100,000 population in individual countries and groups of countries

in 1990-2012

(without Russia)

Germany

EU, "old" members, until May 2004.

EU, "new"

members, since May 2004.

the Russian Federation

The number of jobs for doctors in Western countries is determined based on the fundamental premise of the high cost of medical work. Considers-

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It is also the fact that the number of highly qualified doctors is limited due to the high requirements for their training. Therefore, the opening of additional jobs is always linked to the availability of worthy candidates and the financial capabilities of the healthcare system. As will be shown below, a course is being actively pursued to support and replace a doctor through new jobs for paramedical personnel.

The dominant form of employment for a physician in Western countries is a single job with a high level of remuneration. Work on a part-time basis (part-time work) is very common, but part-time work in the Russian understanding of this phenomenon is very poorly developed, i.e. work on multiple positions. In the United States, Canada, and a number of European countries, it is common practice for private practitioners to combine outpatient appointments with work in a hospital. But unlike Russian practice, this is not a form of additional income through working at several rates, but a mechanism for ensuring the continuity of patient management: the doctor first sees them in his waiting room, and then, if necessary, continues treatment in the hospital. The main motives for such a combination are to attract patients and improve the qualifications of the doctor himself: working in a hospital allows an outpatient specialist to expand his professional horizons, gain additional experience and ensure the continuity of patient management. The state encourages this approach in every possible way, seeing in it, on the one hand, a means of improving the qualifications of doctors, and on the other, an opportunity to reduce the need for medical personnel.

The organizational and legal status of doctors in Western countries differs significantly depending on the place of their work. As in Russia, they are most often employees in hospitals, but in the field of outpatient care, the main business entity is usually a private practitioner. It operates as part of individual or group practices and provides the bulk of medical care at the expense of public funds within the framework of the compulsory health insurance system or the budgetary system. The status of a private practitioner has become widespread in many post-Soviet countries, for example, in Estonia, the Czech Republic, and Slovakia. in these countries in the 1990s. traditional Soviet polyclinics were transformed into a network of private practitioners' offices. In subsequent years, the course towards the privatization of medical practice was somewhat adjusted (individual practices began to be combined with each other to increase the level of cooperation of individual doctors), but the status of independent economic entities was preserved (Ettelt et al., 2009).

This status ensures broad autonomy of doctors in solving medical, organizational and economic problems. At the same time, it determines the sole responsibility for the results of medical activities - the doctors themselves (and not their organization) are responsible for proven medical errors. This employment model dramatically expands the scope of competition - not only large medical organizations are drawn into it -

Sheiman I.M., Shevskiy V.I. Personnel policy in health care: a comparative analysis...

tions, but also specific doctors. They are trying to attract more patients, including by expanding working hours. In the UK, for example, the average working week for a general practitioner is 74 hours (Barkalov, 2011). Such a doctor is responsible for his patients even during his absence. To do this, he cooperates with other doctors or hires an assistant.

The structure of his remuneration also corresponds to the high price of a doctor's work. In recent years, the pay-for-performance system has become widespread, providing for incentive payments for the achieved indicators of the process and result of medical care. For example, in the UK, since 2004, general practitioners have received bonuses based on their performance in 168 indicators. There are numerous pay-for-outcomes programs for inpatient care (Appleby et al., 2012). Although the importance of these programs is growing, nevertheless, the share of incentive bonuses rarely exceeds 10% of the total salary of doctors, most often it is 3-5%. There is widespread concern about the imperfection of incentive indicators and the risk of “measurement” (Busse & Mays, 2008). The basis of remuneration remains its basic part, established depending on the accumulated experience and competencies, the complexity of the work performed, determined by the results of multi-stage and uncompromising certification. Informal requirements at the level of medical organizations, established taking into account competition in the labor market, are also taken into account.

These are, in the most general form, the characteristics of remuneration, employment, and the organizational and legal status of a doctor in Western countries. Consider the same characteristics in Russian health care.

The salary of doctors in our country for decades was at the level of 100-120% in relation to the average for the economy. Doctors are a relatively cheap resource, so they perform many auxiliary and routine functions that are unusual for them. Unresolved problems of providing medical care are solved primarily by increasing the number of jobs, and the issues of rational use of medical personnel remain in the background. Doctors "close" any innovations of managers: each new function is carried out mainly through the creation of new medical positions. The best example in this sense is the far from undisputed initiative to set up numerous health centers to expand prevention. Its implementation was not along the path of expanding the functionality of existing primary care physicians with a corresponding increase in their remuneration, but by creating new medical positions that were obviously difficult to staff, not to mention the possibility of attracting qualified specialists.

Due to low pay rates, Russian doctors are forced to combine work in several places, and the policy of artificially inflating staff creates the conditions for this. Heads of health care institutions

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The changes often “knock out” new medical positions without much chance of finding the right doctor, with the goal of creating a “vacancy fund” for additional wages. According to our estimates, the number of full-time positions in healthcare institutions in 2012 was 10% higher than the number of occupied positions and 70% higher than the number of individuals. For 2000-2012 regular positions grew steadily, and the number of doctors decreased by 19 thousand. This multidirectional dynamics led to an increase in the part-time ratio - from 1.44 to 1.54. Only in recent years has this figure stabilized.

In Russia, doctors worked for decades as "soviet employees", in the 1990s. options for the privatization of medical institutions were discussed, but all of them were rejected. In the following decades, many private medical organizations appeared, but their employees are most often the same employees as employees of state institutions, with no less dependence on "bosses" and low wages.

We are far from thinking that privatization would solve the problems of improving the quality of medical care, but there is one area in which it could be effective - this is the area of ​​general medical practice. The low popularity of this profession among doctors significantly limits the effectiveness of conventional personnel policy mechanisms. In this situation, the opportunity to work independently, freedom from petty control by the administration could increase the attractiveness of this profession for university graduates. And for patients, such a doctor would be popular. In the post-Soviet countries that have implemented this strategy, a high level of satisfaction with primary health care has been achieved. For example, in Estonia in 2007, 42% of patients were "very satisfied" with their general practitioner's work, and 50% were "satisfied". For comparison, we note that, according to a survey by Roszdravnadzor, in Russia in 2009 only 15% of the population were satisfied with their district doctor (Sheiman, 2011). It is unlikely that these figures will change in subsequent years.

The idea of ​​a doctor as a cheap resource has been reconsidered in recent years. By Decree of the President of the Russian Federation of May 7, 2012 (Decree N 597), the task was set in 2018 to increase the salary of doctors to the level of 200% of the average salary in the region. According to Rosstat, in September 2014 this figure was 142.5%2. This trend indicates a fundamental change in the attitude of the state to medical work. The doctor is gradually becoming an expensive resource, which should significantly change his place in the healthcare system. To do this, the course to increase the doctor's wages should be accompanied by measures to increase its efficiency. Much remains to be done to establish the principle of "not by number, but by skill", so that the increase in wages is linked to the real labor contribution of the worker.

The basis of this strategy is the transition to an effective contract, which provides for an increase in the stimulating role of wages, and at one workplace. Such a statement of the problem is completely justified, but its simplified understanding as an increase in the share of wealth is questionable.

Sheiman I.M., Shevskiy V.I. Personnel policy in health care: a comparative analysis...

simulating part of the wage fund. Foreign practice, as noted above, gives completely different benchmarks for the ratio of basic and incentive wages.

It seems to us that within the framework of an effective contract, all components of the salary of physicians should work to improve the efficiency and quality of their services. The traditional perception of the base salary as a reward for staying in the workplace should be a thing of the past. The size of the base salary, being a reflection of the accumulated achievements of employees, should have the main stimulating function, and periodic incentive payments should act as an additional motivational mechanism. The path to a decent base pay should be through new performance appraisal mechanisms, and to high incentive bonuses through a quality management system at the institution level. Thus, "non-stimulatory" payment in health care should not be at all.

A study of the work motivation of medical workers, conducted at the National Research University Higher School of Economics, leads to the conclusion that stimulating only current achievements is not enough. With this procedure for increasing wages, only about 30% of Russian doctors and no more than 25% of nurses would increase their labor productivity (Shishkin et al., 2013). Therefore, a course should be taken to increase the share of the base part of the salary, at least up to 70-80% of the wage fund. This will increase the attractiveness of the work of a doctor, stimulate the growth of qualifications and increase the competition of doctors for a job. As for the incentive part, it should perform the function of fine-tuning the amount of wages - to encourage the initiatives of employees and their current achievements in medical and preventive work (according to established quality indicators). At the same time, profound changes are needed in the mechanism for attestation of workers: the establishment of a new procedure for the formation of attestation commissions, an increase in the level of openness of their work, and an expansion of the criteria for assigning qualification categories for different groups of workers.

Thus, there are significant differences in the position of a doctor in the healthcare system in Russia and abroad. These are differences in the system of remuneration, and forms of employment, and organizational and legal status. They largely determine the lag of our country in terms of the quality of medical care and the efficiency of the use of industry resources. Changing the paradigm of the use of medical work is a strategic task of personnel policy.

Finding the optimal level of specialization

Throughout the 20th century the dominant process in the system of division of labor in foreign health care was the growing specialization of doctors. The intensive increase in medical knowledge, the rapid development of new medical technologies, the interest of doctors in the development of narrow medical "niches" that provide a higher personal income - all this contributed to the emergence of new medical specialties.

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This process seemed objective and irreversible for a long time. However, in the last 2-3 decades, it has acquired new dimensions under the influence of the aging of the population and the associated spread of chronic and concomitant diseases. Changing the structure of diseases has significantly increased the requirements for the complexity and continuity of medical care. These properties are by no means always provided by narrow specialists - due to the episodic nature of their contact with patients. There is a growing need for doctors with broad clinical thinking, able to assess the state of the body as a whole (and not its individual organs), constantly manage patients with complex and combined pathologies, and sometimes even combine the efforts of individual narrow specialists.

In recent years, a large number of studies have appeared in the Western literature proving that from the perspective of a patient with several interrelated diseases, it is better to deal with a single physician with a broad clinical mindset (Harrold et al., 1999; Nichols, 2003; Berman et al., 2013 ). The result of multidirectional factors of specialization was the emergence of new categories of doctors in the structure of medical personnel: surgeons, general practitioners, pediatricians of a general profile - generalists.

This trend is especially noticeable in the field of primary health care (PHC). Here, too, there is a long-term process of specialization of doctors. But recently, in many Western countries, efforts have been made to curb this process and strengthen the position of the general practitioner as the main institution of PHC. This policy is based on a large amount of empirical evidence of the high contribution of these doctors to population health outcomes. Mortality rates from cardiovascular disease, asthma, and bronchitis are lower in countries with higher availability of general practitioners. There is also a direct correlation between the content of their activities (a set of organizational and therapeutic functions) and the mortality rate of the permanently served population (Macinko et al., 2003). It is general practitioners who are responsible for the prevention of diseases, are responsible for their early detection, monitor the chronically ill, organize the provision of specialized care, and sometimes coordinate the work of narrow specialists. Their activities create the "roots" of the health care system, without which it cannot develop successfully.

This course is delivered in varying degrees of sequence. First, one has to take into account the strong pressure from medical associations interested in supporting, first of all, narrow specialists; secondly, behind the political rhetoric about the priority of PHC often hides the idea of ​​general practitioners as doctors of lower qualification compared to narrow specialists.

A number of tools for strengthening the institution of a general practitioner in foreign practice are used: planning the training of a growing number of them, stimulating postgraduate education of graduates in this medical specialty, creating new economic incentives aimed at overcoming the traditional gap in the level

Sheiman I.M., Shevskiy V.I. Personnel policy in health care: a comparative analysis...

wages of general practitioners and narrow specialists. In the United States, for example, as part of the health care reform initiated by President Obama (the Affordable Care Act), the PHC service is expected to be significantly strengthened. Scholarships and loans alone for college graduates ready to become general practitioners are expected to spend $1.5 billion over five years (US Department of Health and Social Services, 2013).

The course towards strengthening the institution of a general practitioner has been clearly outlined in most post-Soviet countries. In the Baltic states, the Czech Republic, Slovakia, Poland, Hungary, the countries of the former Yugoslavia in the 1990s. a profound reform of the district service was carried out. A local doctor (general practitioner or pediatrician) with a limited set of therapeutic and organizational functions has given way to a general practitioner who is able to treat patients with a fairly wide range of diseases. In these countries, the district service has long been almost 100% staffed by general practitioners3.

The quantitative parameters of the process of specialization of medical personnel differ markedly. The results of a comparison across OECD countries (Fig. 2) show that the undisputed leader in terms of specialization is the United States, where the development of new medical technologies is proceeding at the fastest pace. In this country, 80 specialties and almost 120 narrow specialties are officially recognized. The group of countries with a high level of specialization also includes Australia, Great Britain, Romania, Sweden, Italy, and Germany. At the other extreme are Canada, the Netherlands, Estonia, Belgium.

Figure 2

Number of medical specialties and subspecialties in various countries in 2010

Source: General Medical Council, 2011.

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In Russia, the process of specialization of medical practice in the XX century. followed the global trend. But already in the 1970s. the intensity of this process in Russia turned out to be higher than in most Western countries, at least in the field of outpatient care. New specialties of polyclinic doctors appeared, while the scope of the traditional district doctor, on the contrary, narrowed - both as a medical one and as an organizational one. The Institute of General Practitioner did not receive mass development.

Today, there are 92 specialties and sub-specialties in Russian healthcare4. The number of medical specialties includes such categories that in other countries do not belong to medical specialties: laboratory genetics, medical and social genetics, physiotherapy, sanitation, etc. Graduates of medical universities in the course of training in internship and residency try to master, first of all, narrow specialties. In this they do not differ from their Western counterparts. But the path to a narrow specialty is relatively shorter and easier for us. Firstly, according to the current qualification rules, the presence of the main specialty and practical skills in the main specialty is not a prerequisite for becoming a doctor of a narrow specialty5. In most Western countries, you first need to be certified in a major and have practical work experience (Policies and Procedures, 2014). Secondly, the duration of residency and internship in Russia is 2 years, and in Western countries - 3-6 years (depending on the country and specialty). Thirdly, in our country, a clinical resident and intern is practically “doomed” to receive a specialist certificate, regardless of the skills acquired, while in foreign clinics he performs a large amount of medical work and “on the way out” passes a serious certification.

There has been a trend towards artificial fragmentation of medical functions. Diagnostic studies are delegated to specialists in functional diagnostics and endoscopy. Doctors of the main specialties are losing their skills in conducting diagnostic studies, which negatively affects the quality of diagnosis and patient management.

To compare the indicator of the share of general practitioners in Russia and abroad, the OECD statistics in the field of health care were used. The number of general practitioners referred to the total number of physicians in the countries considered. As follows from the data in Table 1, the share of these doctors in Western countries for 2000-2012. tended to decrease. But this reduction was insignificant, and the absolute value of this indicator remains high. For example, in Canada and France, the share of general practitioners in 2012 accounted for about 47% of all doctors, in the UK - 29%. In the US, this figure remains much lower - 12-13% throughout the entire period. In the post-Soviet countries, there is a trend towards an increase or stabilization in the share of general practitioners, although its absolute value remains much lower than in Western countries.

Sheiman I.M., Shevskiy V.I. Personnel policy in health care: a comparative analysis...

In Russia, this indicator6 is significantly lower than in most Western countries (with the exception of the United States), and tends to decrease from 12.03% in 2006 to 10.53% in 2013. Moreover, the absolute number of such doctors has decreased over this period by 10%.

Table 1

Dynamics of the share of general practitioners in the total number of doctors in selected OECD countries and Russia for 2000-2012, in %

Country^"^^^ 2000 2005 2008 2010 2011 2012

UK 32.94 30.21 29.31 29.3 29.37 29.11

Germany 20.31 19.53 18.39 17.66 17.21 16.82

Canada 47.54 48.13 47.84 47.01 46.98 47.15

US 12.92 12.44 12.33 12.3 12.14

France 49.45 49.29 49.05 48.68 47.28 46.9

Czech Republic 21.57 20.4 19.86 19.57 19.31 19.12

Estonia 12.51 21.9 21.48 22.67 22.76 22.68

Russia - 12.03* 11.96 11.75 11.5 10.53**

Calculated from: OECD Health Data: Health care resources, http://stats.oecd.org/viewhtml. aspx?datasetcode=HEALTH_REAC&lang=en# TsNIIOIZ for the corresponding years.

The trend of absolute and relative decrease in the number of primary care physicians has serious negative consequences. The medical work of district doctors turned out to be limited to a small circle of pathologies, which generates a massive demand for specialized care. In essence, the function of district doctors as organizers and coordinators of medical care provided by narrow specialists of outpatient care and hospitals has been lost, which negatively affects the continuity of treatment. Responsibility for the health status of the population served at the polyclinic level is increasingly becoming collective, and therefore blurred. Despite constant declarations about the special role of primary healthcare, this sector remains the weakest link in Russian healthcare, which is an important factor in its unsatisfactory state.

Directions and forms of division of labor

In foreign health care, a doctor is the top of the personnel pyramid, at the base of which there is a large number of workers who free the doctor from routine functions and provide

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his clinical work. The share of doctors in the total number of people employed in health care tends to decrease in favor of other professional groups of workers (Fig. 3).

Figure 3

The share of doctors (without dentists) in the total number of people employed in healthcare in selected countries and Russia in 1990-2012, in %

“ ^ h1e,6 J3.9_ J3,8„ - -°

10 10,3 10,2 9,9 9,7 9,6 9,6 9,4

8 6,8 6,9 6,7 7,2 6,9

6 5,9 5,9 6,0 6,2

5,3 5,3 5,3 5,2 00<><>0C^<>0<>«<>00 5,2 5,2 5,3

4 4,8 4,8 4,6 4,4 4,3 """"4,3 4,3 4,3 4,3 4,3 4,4

Germany

UK

Russia

1995 2000 2005 2006 2007 2008 2009 2010 2011 2012

Calculated based on: OECD Health Data, 2014; Rosstat of Russia for the corresponding years.

At the same time, two groups of factors were clearly identified that significantly changed the system of division of labor between individual groups of workers in the industry. The first is to increase the importance of the service component of medical care. The growing number of patients with chronic and multiple diseases as the population ages increases the need for constant monitoring of their condition. The importance of a set of measures for the management of chronic diseases is increasing, aimed at reducing the frequency of their exacerbations and, accordingly, at reducing the need for expensive inpatient care. Helping the terminally ill is turning into a special area of ​​activity.

The result of these processes is an increase in the need for nurses. The main burden falls on nurses who are able to combine the clinical and service components of medical care. New types of services appear, the functionality of medical personnel expands. For example, in the UK, nursing clinics are being established as part of general medical practices, providing

Sheiman I.M., Shevskiy V.I. Personnel policy in health care: a comparative analysis...

Additional services management of chronic patients, including at home. The work of nurses in this case complements the work of a doctor (Dubois et al., 2006).

The second trend is the advanced training of nursing staff, which makes it possible to delegate some of the traditional functions of doctors to them. The category of the most qualified nurses in Western countries not only performs medical appointments and conducts preliminary examination patients, but also independently treats some simple diseases. This process can be called the physician substitution effect.

These two processes determine the growth in the provision of the population with nurses. Comparative estimates7 show that in the EU countries (both “old” and “new”), after the decline in this indicator in the 1990s. there is a fairly stable trend of its growth (Fig. 4).

Figure 4

Availability of nurses (nurses, feldshers, midwives) (per 100,000 population) in the EU and Russia in 1990-2012

IIIIIIIIIIIIIIIM CIS

(without Russia)

France

Germany

EU, "old"

members, until May 2004.

oooo EU, "new" members, from May 2004.

Russian

Federation

Calculated based on: WHO Regional Office for Europe, 2013; Rosstat of Russia for the corresponding years.

In Western literature, there are a large number of assessments of the possibility and effectiveness of replacing a doctor with a nurse when performing certain medical interventions. Overview of 730 results for-

Issues of state and municipal management. 2015. No. 1

milestone publications on this issue, conducted by NRU HSE Professor V.V. Vlasov (Higher School of Economics, 2014), gives reason to believe that delegating the routine functions of doctors to nursing staff does not harm the quality of medical care: most of these functions are performed by nurses no worse than doctors, while ensuring a higher level of patient satisfaction. This effect is not so much due to the special competencies of nurses, but to the large amount of time they devote to patients, compared with the time devoted to patients by doctors. The feeling of constant and longer contact during treatment is highly appreciated by patients.

However, the economic effect of delegating medical functions, as shown by most studies, is often small or non-existent, which is associated with the need to attract additional work of nurses. The expansion effect is, in most cases, greater than the substitution effect, even if nurses' salaries are lower than doctors' salaries. That is, these studies generally confirm the hypothesis that in certain cases doctors can be replaced by nurses without compromising the quality of medical care, but the economic effect of such a replacement remains unproven.

Another important trend in the division of labor in foreign health care is the emergence of new professions related to the maintenance of medical and information technology, the organization of medical care, and in-depth patient care. These so-called "allied professionals" are essential complements to the work of the doctor and nurse. For example, there are more than 200 allied professions in the US, accounting for about 60% of healthcare workers (AAHS, 2012).

In contrast to the sphere of material production, where the new division of labor functions is aimed at increasing labor productivity and reducing costs, the reverse process of increasing the labor intensity of services dominates in health care, especially in hospitals. In all Western countries, there is a clear trend towards an increase in the number of hospital workers per hospital bed (Table 2). In some of them today there are 6-7 workers per hospital bed. Such a high labor intensity of services makes it possible to treat patients faster with a high clinical result. At the same time, there is a direct relationship between labor intensity and terms of hospitalization. Thus, in the United States, there are 6.43 workers per hospital bed, in Denmark - 7.11 (the highest figure), and the duration of hospitalization, for example, for myocardial infarction, is only 5.4 and 3.9 days, respectively. Countries with lower hospital labour-intensiveness (at the level of 2–4 workers per bed) have longer hospital stays for myocardial infarction (5.5–8 days) (OECD Health at a Glance, 2013).

Sheiman I.M., Shevskiy V.I. Personnel policy in health care: a comparative analysis...

table 2

Number of hospital workers per hospital bed in selected OECD countries and Russia

in 2000-2012

Country^^^^^^ 2000 2005 2008 2012

UK - 6.45 7.27 7.56

US 5.3 5.94 6.3 6.43

Canada - 5.43 6.16 6.24

Israel 3.12 3.34 3.67 3.66

France 2.27 2.7 2.82 3.14

Estonia - 2.47 2.57 2.65

Slovenia 1.68 2.01 2.17 2.26

Czech Republic - 1.74 1.87 2.01

Hungary - 1.29 1.38 1.43

Russia 1.25 1.26

Source: OECD Health at a Glance, 2013; Rosstat of Russia for the corresponding years.

In Russia, the effect of these factors also manifests itself, but to a much lesser extent than abroad. The effects of replacing doctors and expanding the functionality of nurses are much weaker here, and the burden on doctors is correspondingly higher. Their share in total employment in health care is 14%, which is 2-3 times higher than in Western countries (Fig. 3). Due to the poor development of support staff, the level of labor intensity of hospital care in Russia is 2-5 times lower than in Western countries, and 1.5-2 times lower than in Eastern European countries (Table 2), which is a sign of a lower intensity of medical care in the hospital.

The provision of the population with paramedical personnel in the USSR was higher than abroad, primarily due to the development of the mass profession of paramedics. In the 1990s this provision decreased sharply - from 1151 per 100 thousand of the population in 1990 to 964 in 2000. In subsequent years, this process slowed down, and in 2012 the provision with paramedical personnel was approximately at the level of the "old" EU countries, although slightly higher than in the "new" ones (Fig. 4). The loss of leadership in this indicator was associated, firstly, with a significant increase in the role of the nurse in Western countries, and secondly, with the slowdown in the training of nurses and the refusal to train paramedics in Russia. The latter is difficult to assess positively, since the work of a paramedic can significantly complement the work of a doctor, especially in rural areas.

There are currently 1.8 nurses per doctor in Russia, while the OECD average is 2.8. USA, Canada, Yes

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In Switzerland, this figure is 4.3-4.5, and in most countries it is between 2 and 4 (OECD at a Glance, 2013). This lag reflects not so much a lower provision with nurses as a higher provision with doctors, which, according to WHO (excluding dentists), in Russia is 447 per 100,000 population against 368 in the “old” EU countries and 275 in the “new” countries. »8 (Fig. 1).

The structure of related specialties in Russia is dominated by administrative personnel, while in Western countries it is technical. The decision to increase the salaries of physicians does not apply to administrative staff, they are the first victim of healthcare optimization. Until now, mass training of specialists in medical technology in specialized universities has not been established, the corresponding rates are most often filled by all kinds of "craftsmen". Insufficient development of non-medical personnel increases the burden on medical and nursing staff, leads to inefficient use of medical equipment and its frequent failure. Such a situation should be assessed as the most important personnel imbalance that negatively affects the effectiveness of medical care.

New horizons of personnel policy in Russian healthcare

To what extent are the considered global processes of development of human resources for health care taken into account in Russia? It can be argued that the “cheap doctor” policy, which has been dominating for many decades, has begun to be revised in recent years. Crisis processes in the country's economy may slow down the increase in the salaries of doctors, but it is unlikely that the priority of this task will decrease. We can also expect an increase in the dependence of the amount of wages of physicians on the volume and quality of their work. So far, this process has not been very consistent (Shishkin et al., 2013), but the realities of narrowing financial opportunities are likely to limit the scope for mechanical salary increases for all employees and force the heads of medical institutions to rely primarily on the most qualified and necessary specialists, employed at the same workplace, in full accordance with the idea of ​​an effective contract.

As for other aspects of personnel policy, there are no special grounds for optimistic forecasts yet. It is enough to look at the main policy documents for the development of health care.

Prospective directions for the development of human resources in healthcare are contained in the Decree of the Government of the Russian Federation dated April 15, 2013 N 614-R “On a set of measures to provide the healthcare system of the Russian Federation with medical personnel until 2018”. It is proposed to plan personnel taking into account a complex of new factors, including taking into account changes in the structure of medical care. There is a growing understanding of the need to move from an extensive increase in the number

Sheiman I.M., Shevskiy V.I. Personnel policy in health care: a comparative analysis...

laziness of doctors to the strategy of intensive development. But so far, this new strategy is not sufficiently specific, including on personnel planning. The personnel planning methodology adopted by the Russian Ministry of Health9 concerns only physicians and completely ignores other categories of specialists. In addition, we are talking about planning only the current, and not the long-term needs, which does not allow taking into account the long-term processes discussed above.

Some global trends in the development of human resources are taken into account in the State Program "Health Development", approved by the Decree of the Government of the Russian Federation of April 15, 2014 N 294. The task is to increase the number of trained specialists in institutions of secondary vocational education by 50% and, on this basis, nurses per doctor, from 2.2 in 2013 to 3 in 2020, i.e. reach approximately the level of most Western countries. To improve the quality of training and qualification of medical workers, it is planned to create a system of admissions to medical activities based on new professional standards and a new system of accreditation of specialists. It is planned to cover the system of accreditation of all specialists in 2022.

Despite the importance of these documents, it should be recognized that they do not address many acute personnel problems in Russian healthcare and do not sufficiently take into account global trends in the development of human resources.

First, the problem of overcoming the excessive specialization of personnel is not raised. This problem is widely discussed among healthcare organizers, but has clearly fallen out of program documents. Of particular concern is the lack of any clear position regarding the development of the institution of general practitioner. Will he be the main subject of primary medical care, or will the model of a district doctor, a specialist in a very limited range of diseases, that has repeatedly proved its inefficiency, continue to be preserved? How to overcome the shortage of primary care physicians and reach the indicators of their share in the total number of doctors comparable with other countries? How to improve the skills of existing district doctors? How to encourage students to master the specialty of a general practitioner? These and similar questions remain unanswered. It looks like primary care staffing will remain the weakest link in Russian healthcare over the next decade. The aforementioned "roots of the system" will remain stunted.

Secondly, there is no clear prospect of the possibility of overcoming the existing personnel imbalances between: doctors in hospitals (there is a surplus of these doctors) and polyclinics (an acute shortage); doctors of certain specialties (a shortage of some specialties coexists with an excess of others - primarily those that are oriented to effective demand); the number of doctors in urban and rural areas

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sti, between doctors and paramedical staff (Sheiman, Shevskiy, 2014). Mechanical reduction in the number of doctors without changing their structure - a process that has already begun in a number of regions of the country - is fraught with serious social damage, and therefore is hardly possible on any noticeable scale. One gets the impression that the parameters proposed in the regulatory documents for reducing the provision of the population with medical personnel (from 41 per 10 thousand of the population in 2013 to 40.2 in 2010) are nothing more than an arithmetic exercise aimed at reaching the desired savings figures funds to increase the wages of physicians.

Thirdly, the problem of reducing the combination of personnel, which is the content of the process of transition to an effective contract, has not been touched upon. The terms of this contract should provide a higher level of remuneration when working at one rate, i.е. you should pay not for the amount of time worked at several rates, but for the complexity of the work performed, the expansion of functional duties, the effective use of medical equipment and, of course, for the results of clinical activity. If the current practice of increasing staff positions continues, this problem will not be solved.

Fourthly, the emerging trend in global health care towards the expansion of related categories of workers who provide services for medical and information technology and support the work of a doctor has gone unnoticed. On the contrary, the prevailing point of view is that it is possible to save money on such personnel - they become the first victim of staff cuts. It is not clear where and how these personnel will be trained. This ignores a serious factor that lays the foundation for the technological and organizational development of the industry.

Last, but perhaps most important, even at the conceptual level, the task of changing the organizational and legal status of a doctor, aimed, on the one hand, at realizing the creative nature of his activity, and on the other hand, at increasing personal responsibility for the health of patients who trusted him, is not set.

Conclusion

In foreign healthcare in recent decades, there have been new trends in healthcare staffing. The process of specialization of medical personnel continues, but it is not inevitable and irreversible. It is opposed by new factors of social development, primarily the aging of the population. Western countries respond to new factors in an attempt to reverse the trend towards specialization, and especially in the field of primary health care. In Russia, such a task has not yet been set. The inhibition of the process of specialization observed in Western practice has remained practically unnoticed in Russian healthcare.

Sheiman I.M., Shevskiy V.I. Personnel policy in health care: a comparative analysis...

The general trend in the development of health care in foreign countries is the strengthening of the division of labor between individual qualification and professional groups of workers. The number and functions of paramedical personnel and numerous categories of related workers in the industry are growing, which makes it possible to reduce the burden on doctors and reduce their share in total employment in health care. There are indications that this process does not reduce the quality of care, although it does not result in cost savings. In Russian healthcare, a course has also been taken for the accelerated development of nursing staff compared to the number of doctors, but it has not yet been sufficiently specified. As for the new categories of workers, the task of their training has not yet been set - this trend has also been out of the attention of the planning authorities of the healthcare system.

There have been certain shifts in the conceptual understanding of the need to overcome the fundamental differences in the position of doctors in Russia and abroad - a significant increase in their wages. But even at the conceptual level, the task of changing the organizational and legal status of medical practice, changing the forms of employment, changing the ratio of the basic and stimulating part of wages has not yet been set.

The use of foreign experience in the formation of personnel policy in the selected areas could increase the efficiency of the use of human resources in Russian health care.

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LITERATURE

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2. NRU HSE. Report on the research work "Modeling and forecasting the needs of the health care system in human resources." Code: TZ-128. 2014.

3. Rosstat of Russia. Health care of Russia. Moscow. For 2007, 2009, 2010, 2011, 2012, 2013, 2014 URL: http://www.gks.ru/wps/wcm/connect/rosstat_main/ rosstat/en/main/ (accessed 20.02.2015).

4. Ulumbekova G.E. How does the bill "On the fundamentals of protecting the health of citizens in the Russian Federation" respond to the challenges to the healthcare system. M.: Litterra, 2011. -104 p.

5. Shishkin S., Temnitsky A., Chirikova A. Transition strategy to an effective contract and features of labor motivation of medical workers // Economic policy. - 2013. - No. 4. - S. 27-53.

6. Sheiman I.M. Estonian healthcare reform experience: what is interesting for Russia? // Healthcare. - 2011. - No. 5. - S. 69-78.

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8. TsNIIOiIZ Ministry of Health of Russia. Resources and activities of medical healthcare organizations. Moscow. For 2007, 2009, 2010, 2011, 2012, 2013, 2014 URL: http://www.mednet.ru/index.php (date of access: 20.02.2015).

9. AAHS (2012). Association of Allied Health Schools, Definition of Allied Health Professionals. Available: http://www.asahp.org/ (accessed: 20 February, 2015).

10. Appleby J., Harrison T., Hawkins L, Dixon A. (2012). Payment by results. How can payment systems help deliver better care? 1st ed. London: The King's Fund.

11. Berman B.W. (2014). The Generalist-Specialist Interface: Not a Zero-Sum Game. Clin Pediatrician (Phila). July. no. 53. P. 719-720. Available: DOI: 10.1177/0009922813500341 (accessed: 20 February, 2015).

12. Busse R. & Mays N. (2008). Paying for chronic disease care In: Nolte E. & McKee M. (Eds). Caring for people with chronic conditions. A health system perspective. Berkshire: Open University Press.

13. Dubois C., McKee & Nolte E. (2006). Analyzing trends, opportunities and challenges In: Dubois, C., McKee, M. & Nolte, E. (Eds). Human resources for health in Europe. Berkshire: Open University Press.

Sheiman I.M., Shevskiy V.I. Personnel policy in health care: a comparative analysis...

14. Ettelt S., Nolte E., Mays N., Thomson S. & McKee M. (2009). International Healthcare Comparisons Network. Capacity planning in health care: a review of the international experience. Copenhagen: European Observatory on Health Systems and Policies.

15. General Medical Council (2011). Specialties, Sub-Specialties and Progression through Training the International Perspective, Aug. Available: http://www.gmc-

uk.org/Specialties_subspecialties_and_progression_through_training_______the_

16. Harrold L., Field T., & Gurwitz J. (1999). Knowledge, Patterns of Care, and Outcomes of Care for Generalists and Specialists. Journal of General Internal Medicine. no. 14. P. 499-501.

18. Policies and Procedures for Certification and Fellowship (2014). Aug. 2014. Available: http://www.royalcollege.ca/portal/page/portal/rc/common/documents/credentials/policy_procedures_e.pdf (accessed: 20 February, 2015).

19. Machinko J., Starfield B., & Shi L. (2003). The contribution of primary care providers to health outcomes within OECD countries, 1970-1998. Health Services Research. no. 38. P. 831-865.

20. Nichols F. (2003). Generalist or Specialist. Which do I consult? distance consulting. Available: http://www.nickols.us/generalist.pdf (accessed: 20 February, 2015).

22. WHO Regional Office for Europe (2013). European Health for all database. Copenhagen, Regional Office for Europe. Available: http://data.euro.who.int/hfadb/shell_en.html (accessed: 20 February, 2015).

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NOTES

Ministry of Health of Russia. Reporting statistical form 47 "Information about the network and activities of health care institutions."

Rosstat of Russia. Wages of certain categories of workers in social institutions and science (see: http://www.gks.ru/wps/wcm/connect/rosstat_main/rosstat/ru/statistics/wages/).

European Observatory on Health Systems and Policies. Health Systems in Transitions (HITs) for the respective countries.

Order of the Ministry of Health and Social Development of Russia dated April 23, 2009 N 210n “On the nomenclature of specialties for specialists with higher and postgraduate medical and pharmaceutical education in the healthcare sector of the Russian Federation”.

Includes community internists, community pediatricians and general practitioners.

To ensure comparability of data for the EU and Russia, the category of nursing staff was used, which in Russia includes not only nurses, but also feldshers and midwives.

It should be taken into account that in European countries, when calculating the number of doctors, not only dentists are taken into account, but also some other categories of doctors who are traditionally included in the medical staff in Russia, making this comparison not completely correct (for more details, see: Sheiman, Shevskiy, 2014 ).

Order of the Ministry of Health of the Russian Federation of June 26, 2014 N 322 "Methodology for calculating the need for medical personnel."

HEALTH LABOR POLICY: COMPARATIVE ANALYSIS OF RUSSIAN AND INTERNATIONAL DEVELOPMENTS

PhD in Economics, Professor of Economics and Health Management HSE, Honored Economist of Russia.

Email: [email protected]

Shevsky Vladimir I.

HSE Consultant, Honored Doctor of Russia. Deputy Head of the Department of Health Administration of Samara Region in 1971-2001.

Address: National Research University Higher School of Economics.

20, Myasnitskaya Str., 101000 Moscow, Russian Federation.

Email: [email protected]

The Russian health sector has accumulated a lot of serious labor problems, the most important of which are: a low level of labor planning, the shortage of physicians and other medical workers, substantial disproportions in their structure. The objective of this paper is to compare some aspects of health labor policy in Russia and Western countries. Three major developments are addressed: 1) the ways to enhance physicians’ efficiency, 2) the search for the optimum level of physicians’ specialization, 3) the changes in division of labor between various professional groups of medical workforce. The comparison of these developments allowed to determine substantially different types of health labor strategies in Russia and Western countries and to look more critically at the major strategic and regulatory documents in the Russian health sector. First, Russia differs much in terms of the size of physicians’ remuneration, its structure (the share of basic part is lower), as well as in the legal status of outpatient doctors. Second, contrary to Western countries where some efforts are made to overcome the excessive specialization of physicians, in Russia this process is escalating, particularly in primary health care. The overspecialization of PHC contributes much to its understaffing, low quality and dissatisfaction of patients. Third, the process of division of labor between physicians, medical nurses and allied health workers is intensively developing in Western countries, while in Russia this process is very slow. Some new categories of medical workers that support physicians are not known in Russia. Therefore the need for physicians is very high. Practical recommendations for health labor policy are made regarding each of the above developments.

Keywords: health care; labor policy; labor management; physicians; medical nurses; division of labor; physicians' legal status.

Citation: Shevskiy, I.M. & Sheiman, VI. (2015). Zarubezhnyi opyt kadrovoy politiki v zdravookhranenii. Public Administration Issues, n. 1, pp. 143-167 (in Russian).

Public Administration Issues. 2015. No. one

1. Barkalov, S. (2011). Analiz sotsialnogo statusa i sotsialnoi roli vracha obshcheyprakti-ki. Osnovnye napravleniya sotsialnoy raboty v sisteme zdravookhraneniya - problemy i perspektivy razvitiya. Available: http://maxpark.com/user/855238061/content/696870 (accessed: 24 February, 2015).

2. HSE. (2014). Report on nauchno-issledovatelskoy work "Modelirovanie i prog-nozirovaniepotrebnosti sistemy zdravookhraneniya v kadrovykh resursakh" . Code: TK-128.

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4. Ulumbekova, G.E. (2011). How otvechaet zakonoproekt "Ob osnovakh okhrany zdo-rov' ya grazhdan v RF" na vyzovy sisteme zdravookhraneniya. Moscow: Litterra, 2011

5. Shishkin, S., Temnitsky, A. & Chirikova, A. (2013). Strategy perekhoda k effek-tivnomu kontraktu i osobennosti trudovoy motivatsii meditsinskikh rabotnikov. Economic Politika, n. 4, pp. 27-53.

6. Sheiman, I.M. (2011). Opyt reformirovaniya zdravookhraneniya Estonii: what in-teresno dlya Rossii? . Zdravookhranenie, n. 5, pp. 69-78.

7. Sheiman, I.M. & Shevskiy, V.I. (2014). Pochemu v Rossii ne khvataet vrachei? . Economic Politika, n. 3, pp. 157-177.

8. Federal Research Institute for Health Organization and Informatics of Ministry of Health of RF. (2007, 2009, 2010, 2011, 2012, 2013, 2014). Resursy i deyatelnost meditsinskkih organizatsiy zdravookhraneniya. Available: DOI: http://www.mednet.ru/index.php (accessed: 20 February, 2015).

9.AAHS. (2012). Association of Allied Health Schools, Definition of Allied Health Professionals. Available: http://www.asahp.org/ (accessed: 20 February, 2015).

10. Appleby, J., Harrison, T., Hawkins, L. & Dixon A. (2012). Payment by results. How can payment systems help deliver better care? 1st ed. London: The King's Fund.

11. Berman, B.W. (2014). The Generalist-Specialist Interface: Not a Zero-Sum Game. Clin Pediatrician, July, n. 53, pp. 719-720. Available: DOI: 10.1177/0009922813500341 (accessed: 20 February, 2015).

Shaiman Igor M., Shevsky Vladimir I. Health labor policy: comparative analysis of Russian...

12. Busse, R. & Mays, N. (2008). Paying for chronic disease care. In: Nolte, E. & McKee, M. (Eds). Caring for people with chronic conditions. A health system perspective. Berkshire: Open University Press.

13. Dubois, C., McKee, M. & Nolte E. (2006). Analyzing trends, opportunities and challenges. In: Dubois, C., McKee, M. & Nolte, E. (Eds). Human resources for health in Europe. Berkshire: Open University Press.

14. Ettelt, S., Nolte, E., Thomson, S. & Mays. N. (2009). International Healthcare Comparisons Network. Capacity planning in health care: a review of the international experience. Copenhagen: European Observatory on Health Systems and Policies.

15. General Medical Council (2011). Specialties, Sub-Specialties and Progression through Training the International Perspective, Aug. Available: http://www.gmc-uk.org/Spe-

cialties_subspecialties_and_progression_through_training_____the_international_

16. Harrold, L., Field, T., & Gurwitz, J. (1999). Knowledge, Patterns of Care, and Outcomes of Care for Generalists and Specialists. Journal of General Internal Medicine, n.14, pp. 499-501.

17. OECD (2013). Health at a Glance 2013. OECD Publishing. Available: DOI: 10.1787/ health_glance-2013-en (accessed: 20 February, 2015).

18. Policies and Procedures for Certification and Fellowship. (2014). Aug.2014 Available: http://www.royalcollege.ca/portal/page/portal/rc/common/documents/credentials/ policy_procedures_e.pdf (accessed: 20 February, 2015).

19. Machinko, J., Starfield, B. & Shi, L. (2003). The contribution of primary care providers to health outcomes within OECD countries, 1970-1998. Health Services Research, n.38,pp. 831-865.

20. Nichols, F. (2003). Generalist or Specialist. Which do I consult? distance consulting. Available: http://www.nickols.us/generalist.pdf (accessed: 20 February, 2015).

21 U.S. Department of Health and Human Services (2013). Health Resources and Services Administration, National Center for Health Workforce Analysis. Projecting the Supply and Demand for Primary Care Practitioners Through 2020. Rockville, Maryland.

22. WHO Regional Office for Europe. (2013). European Health for all database. Copenhagen, Regional Office for Europe. Available: http://data.euro.who.int/hfadb/shell_en.html (accessed: 20 February, 2015).