• Skill mix

Skill mix

One of the major challenges for health care organisations is to find the right mix of personnel. This article, taken from the ‘Bulletin of the World Health Organisation’, reviews publications that examine the skill mix in health care. Much of the literature is based on experiences from the USA, although analyses from other countries are used, where available.

The paper gives a brief overview of the determining factors that should be taken into consideration when assessing and adjusting skill mix. It then summarises the main findings from a literature review, highlighting the evidence on skill mix that is available to inform health system managers, health professionals, health policy-makers and other stakeholders.

There are a number of important findings that emerge from the review although the authors counsel against drawing general conclusions since many studies are marked by methodological weaknesses. Findings include:

• Meta-analyses reveal evidence that, in settings where there is actual or potential role overlap between registered nurses and doctors, there is scope for a cost-effective increase in the role and deployment of the former.
• Data surveys at the macro level show that larger proportions of registered nurses in the workforce lead to a decrease in the occurrence of adverse events.
• Substitution of cheaper care assistants for more expensive nurses may be no more cost-effective because of the hidden costs associated with skill dilution (such as higher absence and turnover rates of less qualified staff).
• Evidence relating to the impact of introducing unlicensed assistants in the USA is mixed: some reports show there to be a positive impact on health outcomes, others have found the opposite.
• Studies examining the substitution of doctors by nurses show that patients reported higher levels of satisfaction for the latter. Costs may be the same since nurses tended to spend more time with the patients.

The implications of these findings are that:

• In many countries, the scope for nurses to substitute for doctors is unrealised. The delivery of care in maternity units is one example where substitution would be preferable.
• Studies on skill mix have tended to be focussed on the USA and on substitution from and into nursing. There is therefore a need for broader research in this field.
• There is also a need for more robust guidelines on staff mix, as well as better dissemination of good practice, to expand the evidence base and support informed decision-making in this area.

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