Providing Care at Less Cost – the Great Skill-mix Debate

Health care professionals do not all receive the same emoluments. In all countries doctors are paid the most. They carry the greatest responsibility for making decisions that affect people and they are the most likely to be sued – so their differential pay seems fair. But the other side of the coin is that non-doctor health professionals can do many things equally well, or perhaps better. Similarly, there are things that Community Health Workers can do as well or better than nurses, and again at lower unit cost. There are many types of skill mix initiative, and the most widely used classification emanated from Bonnie Sibbald,[1] herself a previous CLAHRC director:

Sibbald’s Skill-Mix Classification

Changing roles

  • Extending roles
  • Substituting – exchanging one type of worker for another
  • Delegation
  • Innovation – creating new jobs

Changing structures at the interface between services

  • Transferring service from one setting to another
  • Relocation
  • Liaison

There are a number of systematic reviews on skill-mix summarising a great many articles. However, review authors agree that there is little clear evidence on effectiveness or cost-effectiveness. Many studies concentrate on skill substitution, usually comparing doctors and nurses.[2] However, the subject is hard to study, and deriving generalisable conclusions is always going to be difficult because of differences in context – especially training. One cadre that has received a lot of attention over the last two decades involves innovation more than substitution – the use of Community Health Workers. They have a valuable role in prevention (e.g. malnutrition/vaccination), maintenance of therapy (e.g. HIV, TB and hypertension), and frontline care (e.g. rehydration therapy), as discussed in previous News Blogs.[3-5]

— Richard Lilford, CLAHRC WM Director

References:

  1. Sibbald B, Shen J, McBride A. Changing the skill-mix of the health care workforce. J Health Serv Res Policy. 2004; 9(s1):28-38.
  2. Antunes V & Moreira JP. Skill mix in healthcare: An international update for the management debate. Int J Healthc Man. 2013; 6(1): 12-7.
  3. Lilford RJ. Lay Community Health Workers. NIHR CLAHRC West Midlands News Blog. 10 April 2015.
  4. Lilford RJ. An Intervention so Big You Can See it from Space. NIHR CLAHRC West Midlands News Blog. 4 December 2015.
  5. Lilford RJ. Between Policy and Practice – the Importance of Health Service Research in Low- and Middle-Income Countries. NIHR CLAHRC West Midlands News Blog. 27 January 2017.
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