Who said this?

“We don’t have enough doctors. We don’t have enough nurses. We don’t have enough psychologists or counselors for addiction. We don’t have enough pharmacists.”

Was it:

a. Cyril Ramaphosa, President, South Africa
b. Kyriakos Mitsotakis, Prime Minister, Greece
c. Zahid Maleque, Minister of Health, Bangladesh
d. Bernie Sanders, Senator, USA, or
e. Dr. Tedros Ghebreyesus, Director-General, World Health Organization?

The correct answer is D, Bernie Sanders. But all of them could have said it; they probably did at some time and so could many others.

So, here is a senior politician in the world’s richest country lamenting a shortage of health care workers. Where does this problem come from? Is it a problem of supply, as Senator Sanders suggests, or a problem of demand? In a period where life expectancy is rising and infant mortality falling, how can it be that we need so much more health care than before? Are we actually sicker, or have we massively increased expectations of lives free from pain, illness or disability and so have increased our consumer demands? Are the brightest and best young people rejecting work in health care in favor of being engineers, lawyers, airline pilots, programmers, or politicians? Why the growing gap between need and provision of health care when overall we have never been healthier?

Maybe no one wants to work in the health sector anymore? But in the U.K. at least, a record number of students applied to study nursing at university in 2022. That year a total of 26,730 nurses were due to start training. In medicine and dentistry, the number of students was also up 16% in 2020 to 11,220 – the highest for at least a decade. Of course, an increase in numbers training doesn’t fill current workforce shortages because it takes several years to train a health professional.

Another explanation is that large numbers are leaving health occupations to take other jobs as part of ‘a public sector exodus.’ I’m a bit skeptical about this. Just what other jobs are they moving to? They are not qualified to be engineers, lawyers, or airline pilots. Of course, they could become journalists or politicians, for which you need no qualifications, but there are not that many vacancies for either.

Many surveys, such as the one reported in a recent edition of Ascend, report that up to 50% of physicians, nurses, and care workers are ‘thinking of leaving their profession.’ Well, who isn’t? I read the same of farmers, truck drivers, and teachers. These surveys are nearly always conducted by unions or professional associations so report a self-selected group of respondents who have a vested interest in expressing dissatisfaction. Thinking of leaving a job is not the same as doing it.

For example, a survey of doctors by the Royal College of Physicians in the U.K. reported that 45% had decided to retire at a younger age than previously planned, with 86% of them citing pension concerns as one of their reasons for this decision. This threat resulted in the U.K. government removing the pension tax threshold for already well-paid people to stem the supposed tide of early retirements. In fact, just 105 doctors left the NHS for voluntary early retirement in 2021/22. That figure was 561 among nurses and 20 for health visitors. The top recorded reasons given by NHS leavers were reaching the end of a fixed-term contract, hitting retirement age, or relocating. There are about 165,000 doctors and 360,000 nurses employed in the NHS. It doesn’t seem likely that having to pay tax on their already generous pensions is causing many doctors to retire early. I eagerly await next year’s survey reporting that doctors are retiring early to enjoy their new, even more generous pensions. If the size of the workforce is still growing, is it demand that is the problem?

So, I return to the increased demand for health care in already prosperous countries. When I travel, I watch TV in hotel rooms around the world. I find the advertisements for health products very revealing. The French, it seems, have digestive problems. The Americans need painkillers. Canadians, as they get older and stiffer, take drugs so they can bicycle up mountains or go paragliding with their grandchildren. The English, of course, have colds. Endless advertisements for pills, ointments, dietary supplements, cosmetic surgery, hair replacement, and dental enhancements all tell us that we are not as well as we should be, that our lives are imperfect, and that medicine will solve our problems. Like all advertising, much of it is aimed at telling us we have problems we didn’t know about and that they can sell us a remedy.

There is an old fable of a king who, when told by one of his ministers that he must do something about the health of his people, banished all the doctors from his land. Doctors, he said, keep diagnosing more and more illnesses. Get rid of the doctors and you get rid of the illnesses was his solution. That king had a point, although I’m not actually recommending it as an approach.

Of course, the solution to the mismatch between demand for health care and its supply is multi-factorial and we need to think about both sides of the problem. Are our demands for health care reasonable or unreasonable? How do our behaviors contribute to ill-health? Are the working conditions and pay of health professionals adequate to compete with other comparable occupations? Are we investing in training? Is over-regulation restricting supply? Do different funding models in different jurisdictions affect supply and demand? These are just some of the questions we need to consider. The problem does seem to be global, but its manifestation is local. The old adage ‘Think global, act local’ may well apply.

Harry Cayton is a sought-after global authority on regulatory practices who created the Professional Standards Authority (PSA) and pioneered right-touch regulation. He is a regular Ascend Voices contributor.