Issues around the supply, demand and management of health human resources have been identified by providers, governments and the private sector as the first and foremost challenge in healthcare today. Numerous studies and expert panels have presented the issues from many different perspectives for several decades.Why is it, then, that this problem persists? At different times during the last 30 years or so, experts have predicted an oversupply or undersupply of almost every type of health professional; it is no wonder that health-planning efforts are not able to get it right.

Recognizing the importance of this subject, we invited Alvarez, Zelmer and Leeb from the Canadian Institute for Health Information (CIHI) to provide an overview of the available data on the current situation and future projections of health human resources in Canada. As the authors remark, many of the issues raised in their paper are not new. They have been raised at almost every forum or review of Canada's healthcare system. Yet the critical problems persist and are likely to get worse if we do not arrive at the right plan to move forward. CIHI has provided a wealth of information on what we know about the professional groups that provide health services in different settings in Canada. The authors give us the facts as far as they are available and indicate, for example, that over 30 different types of healthcare professionals are now licensed to practise in various parts of Canada. The largest of the professional groups is nurses. That group alone is predicting a crisis in the supply of trained professionals. However, it is clear from the analysis that, in theory, there may be a sufficient supply of many health professional groups, but that these groups are not always distributed geographically to the populations where they are most needed.

The authors comment on education and training, employment and work practice, payment, mobility and the evolution of the healthcare team. In fact, the organizing framework for the paper centres upon "the healthcare team," which may be an overstatement of the realities of how different occupational groups actually function. If team functioning is an ideal to be strived for, most observers would agree we are a long way from achieving it. At the conclusion of the paper, the authors refrain from passing judgment on the extent to which there are "enough" health professionals for the future but simply provide the data for further discussion. The interpretation of the implications of the data is left to our very able commentators.

Our commentators have done an excellent job in filling in gaps where no data are available and raising new but central issues to this complex human resources problem. Rowand, in his usual eminent style, places the problem not so much as one of insufficient data but more around how to facilitate the use of the data for better health human resources planning.He points out the limitations of, and frustrations with, previous efforts by universities, governments and professional associations in achieving a valid and implementable plan. He stresses that one of the most important problems we face is how to attract more young people into the health professions. Many young people do not see working in health services as a particularly rewarding or attractive career. Superficially, the tangible benefits to a career in the health fields are often few. The hours of work usually include evenings, nights and weekends and are difficult to fit with a normal family life. The workplace is frequently stress-inducing since much of the clinical work may be difficult, unpleasant and involve working with patients and families in crisis. The media does not always help matters by pointing out the limitations of Canada's health services such that healthcare does not appear to be a dynamic or optimistic environment in which to work. Rowand raises the very thorny issue of professional groups' vested interests that can interfere with rational planning and often promote the continuation of a less than adequate status quo.

From an international perspective, Buchan of Queen Margaret University College in Edinburgh provides us with some reassurance that these human resource issues are not unique to Canada but also exist in other developed countries. He describes the initiatives underway in the United Kingdom to sustain improvements in staffing levels, mix and motivation in the NHS. Buchan describes the Changing Workforce Program in the United Kingdom that focuses on steps being taken to encourage new roles and a new skill mix. In particular, he emphasizes the development of the role of nurse practitioners to free up physicians' time. This strategy is one that those of us in Ontario are quite familiar with, where nurse practitioner education programs have been in place for several years. At the present time, there are more graduates of education programs in Ontario than there are positions of employment for nurse practitioners. The situation is similar to the United Kingdom where there have been estimates that nurse practitioners could carry out at least 20% or more of the work being done by family physicians. Canada has led the way in the development of nurse practitioner roles that could drastically improve some of the distribution problems, but so far this has not happened. A second strategy described by Buchan is the development of the role of vocationally qualified healthcare assistants who would have the potential to ease the nursing shortage problem by taking up about 12.5% of nurses' current workload. Substitution of one category of worker by another is frequently resisted by professional associations in order to protect traditional turf.

Dower from the Center for the Health Professions, University of California, provides excellent examples of the interplay between health workforce data and policy-making. She notes that most of the research and policy in this area has focused on medicine, nursing and complementary and alternative medicine. She indicates that historically, the interest in medicine has been on generalist to specialist ratios which have typically shown that Canada has had a relatively higher ratio of family physicians to specialists than the United States. This comparison is usually interpreted to mean a shortage of family physicians in the United States. Dower provides an excellent review of the recent research controversy over the relationship between nursing and patient outcomes and the decision in California to propose minimum nurse-to-patient ratios. She outlines the limitations of data availability on practitioners of complementary and alternative medicine. Yet some states are moving ahead with legislation to either recognize or prevent practice by practitioners such as acupuncturists, chiropractors, homeopaths and so on.

Focusing on recruitment and retention, Rondeau provides an overview of policy issues and research attempting to address this issue in Canadian health services. His point is that health human resources planning is unlikely to succeed without more comprehensive improvements to the healthcare workplace. Much more research is needed to understand what types of workplace environments are likely to be optimal in ensuring that health professionals are satisfied with their work and less likely to move on to another organization that appears more conducive.

Haddad and Scully, representing Canada's physicians, contend that the situation regarding doctor shortages is critical and that current data collection on supply and professional activities is inadequate and underutilized. Citing the need for improved planning, they call, first, for a national forum to consider the challenges; and, second, for the establishment of an independent national advisory body that is mandated to focus on policy analysis and planning, and also developing priorities for data collection. Little, representing Canada's nurses, suggests it is critical to examine past patterns to find answers for today's dilemmas. She urges both an examination of past decisions and policies that have led to a loss of interest in nursing as a profession and also to a substantial decrease in graduates from nursing programs. She recommends investment in longterm strategies, such as increased educational opportunities, improving workplace health and increasing the number of full-time positions.

Krakauer, Cowling and Parker focus on the critical shortage of health technology professionals such as medical laboratory technologists, medical radiation technologists, respiratory therapists and other related groups. They point out the limited data available on who is practising where in Canada and the various interpretations of these roles. Clearly much more work is needed to fully understand this group of occupations and how they fit in the healthcare team.

Rochon writes that the failure to recognize the interdependence of health professionals has been short-sighted and unimaginative, and that to continue to focus on the supply of various professional groups fails to take into account existing and future healthcare realities. He urges us to explore the benefits of broadening the scope of professional practice, and to do so in collaboration with healthcare workers themselves. He strongly suggests engaging workers in making decisions that will establish the appropriate balance between the needs of patients and the capacity of staff.

Ward, who chairs a national advisory committee on health human resources, concludes the commentaries with a strong argument for the creation of an institute at arm's length from government that could oversee a national database of healthcare providers, including unpaid caregivers and educational programs, thereby matching resources with demand. He also advocates for a national strategy to facilitate integration of information. He urges the development and implementation of models to forecast the effects of new diagnostics and therapies and reminds us of the role of governments - as representatives of the public and funders of the system - in decisions and policy-making.

Decter, in the final response, elegantly summarizes the discussion with the recognition that there are two simple goals that we need to achieve - first, training and importing sufficient numbers of skilled professionals and, second, retaining them with more attractive work environments.

In summary, we have attempted to point out some of the limitations in what we know about who is working in the healthcare system in Canada currently and what the needs might be for the future. As illustrated over and over again, the problem is not simply the reliability and validity of the data but more the lack of attention to and the limited way in which this information is used by health policy-makers and other decision-makers across Canada.While there have been considerable strides made in data gathering and communicating the data in many different aspects of health services, there is still very little use of the evidence to actually change behaviour.We are optimistic that health human resources will be an important item for the Romanow Commission to tackle.

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