Table 4 Primary healthcare workforce action

NHS systems

Denmark

1. Major problems include a shortage of all PHC groups, and regional mismatches with more pronounced shortages in rural areas

2. A PHC reform was introduced and additional funding was made available to increase HCW staffing levels. Efforts are underway to create new models of PHC beyond general practice, thereby blurring the boundaries between hospitals and general practice/out-patient care. These models and related funding efforts are driven by the municipalities that focus on care for elder patients, aiming to avoid hospital admissions

3. A national health reform is pending, but there are a wide range of regional and local efforts to improve recruitment and retention in PHC, reflecting the decentralised PHC organisation. Coherent coordinating of PHC across general practice, municipalities and hospitals has been established

4. The WHO PHC model is recognised but does not provide a systematic basis for policy reform and is not connected to the SDGs

Portugal

1. Major challenges include: HCWF shortages, geographical imbalances, an increase in private sector employment in areas covered by the NHS, limited data and planning, and the growing dissatisfaction of HCWs. Slow and poor implementation of the PHC reform, and gaps between centralised–decentralised governance are also considered problematic

2. Political rhetoric to protect HCWs is strong but lacking action. Some action has been taken to strengthen the position of nurses through an increase in salaries, and through new tasks and responsibilities but the results vary strongly between organisations

3. There are no interventions to improve recruitment, retention and mental health. Policy implementation is poor and strong drivers for change are missing. In addition, coherent transsectoral and multi-professional coordination is lacking

4. The WHO PHC model does not play a relevant role beyond rhetoric, and the SDGs are largely absent from policy discourse

UK/England

1. Major challenges are shortage of GPs, nurses and other relevant PHC staff, poor recruitment and retention in rural areas, HCW stress/burnout, and unsustainable levels of international recruitment

2. Policies have been introduced to improve education, recruitment and retention, focusing on increasing HCW numbers through international recruitment, introducing new roles, and strengthening task-shifting, team approaches, and mental health support. The NHS Long Term Workforce Plan 2023 provides significant funding for additional education/training places for physicians, nurses, dentists and other HCWs. The Additional Roles Reimbursement Scheme encourages recruitment and inclusion of additional practitioners (e.g., physiotherapists, pharmacists, paramedics) in PHC teams

3. PHC interventions focus on education, professional development, skill-mix, and some organisational change; yet, coherent coordination mechanisms and governance are lacking. Implementation is poor, structural interventions are generally weak, and organisational and professional action are poorly coordinated. Initial evidence shows that new roles have not been effectively implemented into PHC teams

4. The WHO PHC model and SDGs model have little impact on policy and implementation

Established SHI systems

Germany

1. Major challenges include shortages of physicians and medical assistants coupled with geographical mal-allocation, large retirement waves, strong medical hierarchy, weak academisation of nurses, and an expansion of for-profit companies that weaken public control

2. The PHC workforce is not a policy priority and a systematic strategy for improving recruitment and retention is missing. Policies focus predominately on physicians with the aim of increasing the recruitment of foreign-trained physicians and making PHC more attractive

3. PHC interventions are largely physician-centred, including a comprehensive increase in medical training capacity, quotas with prioritised access to medical education for those planning to work in PHC in rural areas, incentives for GP specialisation and PHC providers (shorter education, some recognition of other qualifications). Multi-professional workforce development is lacking, but organisational changes are present seeing an increase in large private PHC centres with multi-professional provider groups supporting skill-mix and team approaches

4. The WHO PHC model and the SDGs are largely missing from the workforce debate

Netherlands

1. Major challenges include (regional) shortages of GPs and nurses, increasing complexity of services and user needs that cause overburdened physicians, and for-profit organisations taking over GP practices and enhancing change through organisational restructuring without mandate/public control

2. The PHC workforce is among the key policy priorities. There are new policies aiming to align specialised and GP care and improve transsectoral coordination between hospitals, ambulatory care, elder care/nursing homes

3. PHC interventions include new regulations to force specialised care providers to work in PHC, strengthening a community-based approach, and increasing funding for medical PHC provision. However, strong market and corporatism hamper the governing power of the Ministry of Health, increasing complexity and uncertainty in implementation

4. The WHO PHC model and SDGs are largely missing from public debate and their impact is unclear

Switzerland

1. Major challenges include shortage of GPs, large retirement waves, high shares of part-time work, growing shortage of Medical Practice Assistants (MFAs), negative attitudes towards integrated care and barriers to implementation, lack of attention for MFAs in PHC reform and new HCWF policies

2. PHC is not considered in the Health Strategy 2030, but recent policies and governance innovation may impact the organisation of care and professional roles. This includes new insurance contracts with family doctors as gate-keepers, an increase in GP group practices, improved skill-mix and new professional roles of nurses, and some task-shifting to physiotherapists (direct access)

3. PHC policy interventions and reform modes focus on organisational change to establish integrated care, larger centres and multi-disciplinary group practices. PHC policy interventions ignore the labour market conditions, are not responding to the HCWF crisis, and efforts are not monitored

4. The WHO PHC model is not explicitly connected to PHC and the same applies to the SDGs

Emergent SHI systems in Central Eastern/ Eastern Europe

Kazakhstan

1. Major problems include shortages of PHC staff including teaching staff, geographical maldistribution, poor retention in rural/remote areas (especially for young professionals), a general lack of medical student interest in PHC, the growing privatisation of medical education with poor regulation and quality control, and the poor and uneven implementation of national skill-mix guidelines

2. PHC and the workforce play an important role in health policy. There is a bundle of policy efforts, including increasing the share of GPs/family medicine in relation to specialist services (improved education, retraining of GPs, specialisation of physicians and nurses, improvement of work conditions, increase in salaries), increasing the attractiveness of working in rural areas (financial benefits; social support/housing, etc.), and establishing a multidisciplinary team-based PHC model that expands biomedical approaches towards a more holistic public heath approach

3. Policy interventions are characterised through multi-level trans-sectoral action, the connection of professional and organisational innovation, and a multi-professional focus on the HCWF and skill-mix/teams. Some pilot projects have been established but an overview of its impact is missing

4. The WHO PHC model is a strong driving force for comprehensive system-based policy and PHC transformations including the human resources. The role of SDGs is less clear

Romania

1. Major challenges include insufficient staffing levels and shortages of physicians and nurses, especially in rural areas, low career attractiveness of PHC for students and early career professionals, poorly regulated scope of practice, high out-migration of physicians, some overproduction in the education system, and inconsistencies in training policies, funding, and access to resources for PHC staff

2. There are some policy efforts to improve education and working conditions through the provision of financial incentives. In additions there are efforts to foster interdisciplinary collaboration within PHC teams (including between family doctors, community nurses and social workers in rural areas) and policies being introduced to strengthen digitalisation

3. A new Recovery and Resilience Plan pays some attention to recruitment and retention, but sector-specific needs of PHC staff are not addressed. Coherent governance and coordination between corporatist stakeholders are lacking, and implementation is not monitored and hardly predictable

4. The WHO PHC model and the SDGs provide some guidance at national-level policy development

Serbia

1. Problems are mostly a result of general policy failures and a lack of planning. There is an overproduction of well-educated HCWs (physicians and nurses) with high out-migration, underfunding and understaffing of the public sectors, poor work conditions in PHC, a lack of mental health support, low salaries, geographical and sectoral mismatches with strong PHC staff shortages and large cohorts of HCWs nearing the retirement age

2. A national PHC workforce plan is lacking, and the responsibility is delegated to the operational level of organisations. The Midterm Health Strategy of the Ministry of Health (2022–2025) includes the development of HCWF planning, but without attention to the PHC workforce. Some efforts are underway to improve the situation in future, including the Network Plan, digitalisation of the PHC workforce, and the introduction of a PHC model based on family medicine that is led by WHO

3. Policy interventions are generally poor and largely absent for the PHC workforce

4. The WHO PHC model and SDGs provide some guidance but implementation is poor if not absent