Critical Challenges: Revitalizing the Health
Professions for the Twenty-First Century
Executive Summary
A
Within
another decade 80-90% of the insured population of the
·
more managed with better integration of services and financing
·
more accountable to those who purchase and use health services
·
more aware of and responsive to the needs of enrolled populations
·
able to use fewer resources more effectively
·
more innovative and diverse in how it provides for health
·
more inclusive in how it defines health
·
more concerned with education, prevention and care management and less
focused on treatment
·
more oriented to improving the health of the entire population
·
more reliant on outcomes data and evidence.
The Impact on the Nation's
10 Million Health Care Workers
This
demand-driven system in health care and health professions practice will create
difficult realities for many health professionals and great opportunities for
others. Some of these realities will be:
CLOSURE
of as many as half of the nation's hospitals and loss of perhaps 60% of
hospital beds
MASSIVE
EXPANSION of primary care in ambulatory and community settings
SURPLUSES
in the supply of physicians - 100,000 to 150,000, as the demand for specialty
care shrinks; nurses - 200,000 to 300,000, as hospitals close; and pharmacists
- 40,000, as the dispensing function for drugs is automated and centralized
CONSOLIDATION of many of the over 200 allied health professions into
multi-skilled professions as hospitals re-engineer their service delivery
programs
DEMANDS
for public health professionals to meet the needs of the market-driven health care
system
FUNDAMENTAL
ALTERATION of the health professional schools and the ways in which they organize, structure and frame their programs of education,
research and patient care.
The Implications for the
System that Produces Health Professionals
Because
health care is a labor-intensive enterprise, the next stage in our present
cycle of change will demand a rapid transformation in:
·
how health professionals are prepared for practice
·
how that practice is regulated
·
the educational programs that prepare them for
practice.
The
knowledge, skills, competencies, values, flexibility, commitment and morale of
the health professional workforce serving the systems of care will become the
most important factors contributing to the success or failure of the system. In
response to these circumstances, the system that produces health professionals
and the structures in which they work will shift away from its supply
orientation and toward a demand-driven system. This situation will create four
challenges to the ways health professionals practice and are educated and
trained:
CHALLENGE 1: Redesigning the ways in
which health professional work is organized in hospitals, clinics, private
offices, community practices, and public health activities.
CHALLENGE 2: Re-regulating the ways in
which health professionals are permitted to practice, allowing more flexibility
and experimentation, but ensuring that the public's health is genuinely
protected.
CHALLENGE 3: Right-sizing the health
professional workforce and the institutions that produce health professionals.
For the most part this will mean reducing the size of the professions and
programs.
CHALLENGE 4: Restructuring education to
make efficient use of the resources that are allocated to it.
The Recommendations of the
Commission
This
report is intended to be a guide for surviving the transformation and thriving
in the emerging health care culture. It is an attempt to balance market-driven
realities, institutional prerogative and public need. Failure to take up these
challenges by institutional, professional or policy leaders is an abdication of
their responsibilities to their patients, their students and ultimately to the
public they are obligated to serve.
The Commission makes the
following recommendations for all health professionals:
A1:
All health professional schools must enlarge the scientific bases of their
educational programs to include the psycho-social-behavioral sciences and
population and health management sciences in an evidence-based approach to clinical
work.
A2:
While legitimate areas of specialized study should remain the domain of
individual professional training programs, key areas of pre-clinical and
clinical training must be integrated as a whole, across professional
communities, through increased sharing of clinical training resources, more
cross-teaching, more exploration of the various roles played by professionals
and the active modeling of effective team integration in the delivery of
efficient, high-quality care.
A3:
The next generation of professionals must be prepared to practice in more
intensively managed and integrated systems. Specifically, the clinicians of the
future will be required to use the sophisticated information and communications
technology to promote health and prevent disease, to sharpen their skills in
areas ranging from clinical prevention to health education to the effective use
of political reforms to change the burden of disease, to be more customer- or
consumer-focused and to be ready to move into new roles that ask them to strike
an equitable balance between resources and needs.
A4:
There is a substantial body of literature which concludes that culturally
sensitive care is good care. This means two things for all health professional
schools. First, they must continue their commitment to ensure that the students
they train represent the rich ethnic diversity of our society. Important
investments and many successes have been achieved, but this is an obligation
that must be continued at each institution until it is no longer an issue.
Second, diversifying the entering class is not sufficient to ensure understanding and appreciation of diversity. Cultural
sensitivity must be a part of the educational experience that touches the life
of every student.
A5:
Every professional school must be willing to develop partnerships and alliances
that have not been a part of education in the past - partnerships with managed
care for training, clinical research, and tertiary care referrals; with
computer and software companies to develop information and communications
systems; partnerships with integrated systems to support health services
research; and partnerships with state government to determine the best ways to
meet the health needs of the public.
A6:
All health professions must recognize that the current health professions
regulatory system needs to change. Health professionals must work with state
legislators and regulators to ensure that regulation is standardized where
appropriate; accountable to the public; flexible to support optimal access to a
competent workforce; and effective and efficient in protecting and promoting
the public's health, safety and welfare.
The Commission makes the
following recommendations for Allied Health:
B1:
Restructure the mission and organization of allied health education programs to
focus on local community health needs identified through partnerships with
delivery systems, professional associations, educators, regulators, consumers,
and the public.
B2:
Focus allied health curriculum on related discipline clusters, multi-skilling and interdisciplinary core curricula.
B3:
Improve student and professional articulation and career ladders within
disciplines and between professions.
B4:
Improve education-practice linkages with diverse care delivery environments,
such as managed care, home health care, and ambulatory care, for the benefit of
both faculty and students.
B5:
Increase recruitment of minority, disabled and disadvantaged students and
practitioners.
B6:
enhance faculty leadership skills and competence in clinical outcomes and
effectiveness research.
B7:
Establish innovative collaborations among professional associations.
B8:
Improve the collection, evaluation and dissemination of data and innovations
related to allied health education, training, practice, and regulation.
The Commission makes the
following recommendations for Dentistry:
C1:
Maintain the entering dental school class size at its 1993 level (4,001
students).
C2:
Create the opportunity for a post-graduate year of training for all graduating
general dentists. New opportunities should be developed in private practice and
managed care settings.
C3:
Accomplish the training for a dental degree and the one year of post-graduate
training in four years of post-baccalaureate training.
C4:
Create adequately funded, managed dental care partnerships between dental
schools and their clinics and the emerging integrated health care system.
C5:
Change the clinical training of dentists to reflect a broader orientation to
the efficient management of quality dental care.
C6:
Integrate dental education more thoroughly with that of the other health
professions.
C7:
Increase the productivity of dentists through the efficient and effective use
of dental hygienists and dental assistants.
C8:
Decrease the tuition dependency of dental schools, and subsequent student
indebtedness by developing efficiently managed dental school clinical models
and the creation of endowments, scholarships and loan programs for students.
The Commission makes the
following recommendations for Medicine:
D1:
Decrease the number of graduate medical training positions to the number of
D2:
By 2005 reduce the size of the entering medical school class in the
D3:
Change immigration law to tighten the visa process for international medical
graduates, ensuring that they return to their native countries for service upon
completion of training.
D4:
Redirect graduate medical training programs (6,951 programs as of 1991) so that
a minimum of 50% of them are in the primary care areas of family medicine,
general internal medicine and general pediatrics by the year 2000.
D5:
Move training of physicians at the undergraduate and graduate levels into
community, ambulatory and managed-care based settings for a minimum of 25% of
clinical experience.
D6:
Create a public-private payment pool for funding health professions education
that is tied to all insurance premiums and is designed to achieve policy goals
serving the public's health.
D7:
establish an enlarged National Health Service Corps to attract graduate
physicians into service roles currently being met by the excessive number of
residency positions
The Commission makes the
following recommendations for Nursing:
E1:
Recognize the value of the multiple entry points to professional practice
available to nurses through preparation in associate, baccalaureate and masters
programs; each is different, and each has important contributions to make in
the changing health care system.
E2:
Consolidate the professional nomenclature so that there is a single title for
each level of nursing preparation and service.
E3:
Distinguish between the practice responsibilities of these different levels of
nursing, focusing associate preparation on the entry level hospital setting and
nursing home practice, baccalaureate on the hospital-based care management and
community-based practice, and masters degree for
specialty practice in the hospital and independent practice as a primary care
provider. Strengthen existing career ladder programs in order to make movement
through these levels of nursing as easy as possible.
E4:
Reduce the size and number of nursing education programs (1,470 basic nursing
programs as of 1990) by 10-20%. These closings should come in associate and
diploma degree programs. These closings should pay attention to the reality
that many areas have a shortage of educational programs and many more have a
surplus.
E5:
Encourage the expansion of the number of masters level
nurse practitioner training programs by increasing the level of federal support
for students.
E6:
Develop new models of integration between education and the highly managed and
integrated systems of care which can provide nurses with appropriate training
and clinical practice opportunities and which can model flexible work rules
that encourage continual improvement, innovation and health care work
re-design.
E7:
Recover the clinical management role of nursing and recognize it as an
increasingly important strength of training and professional practice at all
levels.
The Commission makes the
following recommendations for Pharmacy:
F1:
Reduce the number of pharmacy programs (75 schools and colleges in 1995) by
20-25% by the year 2005. These closings should target institutions exclusively
offering the professional baccalaureate degree.
F2:
Recognize the need to evenly distribute these closings to accommodate
underserved areas, but to close those programs that remain oriented toward the
Bachelor of Pharmacy degree.
F3:
Focus professional pharmaceutical training even more on issues of clinical
pharmacy, system management and working with other health care providers.
The Commission makes the
following recommendations for Public Health:
G1:
Create new public health education programs that bring together the traditional
public health disciplines with the clinical professions. These programs should
be created in conjunction with state governments, local governments, managed
care organizations and other non-academic institutions.
G2:
Develop partnerships to apply population health management skills to the
problems that are now faced by highly managed and integrated systems of care.
These partnerships should include research, service and training components.
G3:
Build programs at the federal, state and managed care organization levels to
continue and enlarge the support base for a broad range of
psycho-social-behavioral research and training.
G4:
Reframe public health as a basic science in the personal and clinical health
sciences and incorporate the new knowledge, skills and competencies related to
the analysis of health care as a system, and to the re-design of work for the
continual improvement and innovation of care.
G5:
Recognize the obligation at the state and federal level to adequately fund
public health education and practice institutions, particularly in an era of
market-driven health care.
http://www.futurehealth.ucsf.edu/summaries/challenges.html