Changing work structures in healthcare settings

November 10, 2014


November 10, 2014

Zoe Tabary


Zoe is an Editor with Amnesty International whose role entails researching and producing reports on human rights issues. Before this Zoe was an Editor with The Economist Intelligence Unit's Thought Leadership team for almost four years. In that time she managed research projects for a number of clients across the energy, healthcare and sustainability sectors. Prior to joining The Economist Intelligence Unit she worked as a journalist in France and the UK. She holds a Master of Science in Marketing and a Bachelor’s degree in Political Science from Sciences Po Paris, and is fluent in French, Spanish and German.


How can traditionally cash-strapped and risk-averse healthcare institutions adapt their work structures and ultimately improve patient outcomes?

Global healthcare systems are confronting a period of dynamic change, which is forcing governments and healthcare systems to look for operating models that promote greater efficiency, while at the same time improving outcomes for patients. This combination of evolving healthcare structures and cost concerns is having an impact on the way human resources are deployed across healthcare systems.

New incentives

Globally, there is a growing tendency to scale back so-called “fee for service” remuneration, in favour of paying doctors a set price for treating patients for the whole course of an illness or operation, or tying payment to outcomes, such as reducing hospital readmission rates.

Medical professionals have welcomed the trend towards adapting salaries in line with providing a more comprehensive and integrated care-management system that gives physicians greater autonomy. Such systems are part of “enabling people to do the job that they trained for,” according to Dr Murray Ross, director of the Institute for Health Policy at US health provider and insurer Kaiser Permanente.

A World Bank study has found that the use of performance-based remuneration can be an especially effective way of retaining public-sector health staff. The study, which focused on developing countries, showed that output-based contracts led to an increase in salary for 80% of physicians in a Romanian pilot project; the researchers also found that salary hikes were more effective when tied to performance goals.[1]

Meanwhile, some healthcare systems are looking to improve other aspects of the environment in which their medical staff work, in an effort to reduce both occupational stress and staff attrition and enable them to attract top talent. In 2000 the UK National Health Service (NHS) introduced Improving Working Lives, an initiative designed to offer flexible working, access to childcare and carer support and other programmes designed to encourage health and wellbeing at work.

Flexible workers

The healthcare systems with most flexible workforces are likely to be the most successful at deploying resources efficiently in the future. This will mean doctors collaborating both with one another and with other healthcare professionals, such as physiotherapists and nurse practitioners.

Co-ordinated care can create cost savings by reducing uncertainty and diagnosing certain health conditions earlier. For example, a breast cancer patient may have a group meeting with a surgeon, medical oncologist and radiation therapist within 24 hours of diagnosis, and this team-based care can save valuable time as well as money, observes Dr Thomas Lee, the former chief executive of PartnersHealthCare[2], a US-based healthcare provider. “The advantage is that there are no mixed messages; when people walk out of the room, everyone knows what is going to happen next,” he says.  

Such initiatives can lead to greater engagement on the part of healthcare workers, which in turn can contribute to greater job satisfaction and improved patient care, US researchers have found.[3] Yet it is also important for healthcare systems to maintain an open dialogue with their employees in order to avoid the morale problems that can undermine changes within a workforce. The NHS, for example, has conducted an annual staff survey for the past 12 years: its 2013 survey found that although 79% of NHS employees reported overall satisfaction with the support they receive on the job, just 41% said that they felt the organisation valued their work.[4]

Redefining roles

For such integrated care models to work well implies a redefinition of professional roles, whether between nurses and doctors or between direct health providers and team managers.

At Kaiser Permanente, doctors retain full responsibility for medical decision making, which aligns professionalism and commitment, according to Dr Ross[5]. “Because the collaboration between the health plan and medical group is purely on an organisational level, our physicians have substantial autonomy and they answer to their peers, not to the health plan,” he explains.

UK-based health provider and private insurer Bupa[6] conducts in-house medical reviews amongst its own teams of physicians to determine appropriate treatment, a factor that helped 4,500 of its patients avoid potentially unnecessary surgery between May 2011 and May 2013, according to Dr Paul Zollinger-Read, chief medical officer at Bupa.   

While more flexible and integrated health workforces can help medical teams work more efficiently, there is, however, less evidence that they can compensate for staff shortages, one of the biggest stresses facing hospital workforces. One article looking at nursing staffing shortages in the US compared “short-term” strategies, such as the use of internal agencies to meet temporary staff shortages with “long-term” strategies such as investments in nursing education and changes in roles. The study found that short-term solutions were not likely to be sufficient on their own to reduce employee stress levels.[7]

Many healthcare providers are already adjusting their care models to this new environment. Those that fail to adapt could face a bumpy ride.

This article is part of a series managed by The Economist Intelligence Unit for Sodexo. 


[1] Vujicic, M., “How you pay health workers matters: a primer on health worker remuneration methods,” World Bank, September 2009.

[3] See Peltier J. and Dahl, A., “The Relationship between Employee Satisfaction and Hospital Patient Experiences,” Forum for People Performance Management and Measurement, Northwestern University, April 2009.

[7] May, J. H., Bazzoli, G. J. and Gerland, A. M., “Hospitals’ Responses to Nurse Staffing Shortages,” Health Affairs, Vol. 25, No. 4 (July 2006).

The views and opinions expressed in this article are those of the authors and do not necessarily reflect the views of The Economist Intelligence Unit Limited (EIU) or any other member of The Economist Group. The Economist Group (including the EIU) cannot accept any responsibility or liability for reliance by any person on this article or any of the information, opinions or conclusions set out in the article.

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