Healthcare Worker Shortage a Silent Crisis
SNA (Tokyo) — The World Health Organization estimates that there will be a shortage of 18 million healthcare workers by 2030. This equates to a 20% gap in the global capacity to provide healthcare services. Japan, which is already grappling with an aging society and its attendant problems, is at the forefront of this crisis.
This, in part, is the message delivered by Dr. Mark Britnell, the global chairman and senior partner of health care, government, and infrastructure for KPMG, during his recent book tour in Tokyo.
The shortage in the healthcare workforce is felt worldwide, but Japan feeling it acutely. Britnell states, “If you want to see the future, go live in Japan… the pressures that Japan faces are greater than most other countries, but they are similar in nature if you think about the aging population in China, the aging population in South Korea, the aging population in Singapore.”
Britnell’s book Human: Solving The Global Workforce Crisis in Health Care also highlights the issues surrounding education and the training necessary for the medical industry. Britnell says that the problem is “educating enough healthcare staff, retaining enough healthcare staff, and then thinking about how long before healthcare staff retire.”
Japan has been putting some of its hopes into technology, such as the use of robotics. Britnell sees great potential in this approach: “Isn’t it cool that old people are piloting robotics before millennials in healthcare?.” Japan might be capable of not only developing incredible technological innovations which revolutionize the medical field, but also to export these technologies for its own economic gain.
As for the recent scandal at Tokyo Medical University, in which the test scores of female applicants were secretly lowered, Britnell comments, “Japan is and will always be one of the major economic powers in the world, but it also has to be one of the most progressive powers–and you can’t be progressive if you think men are better than women, or you load the dice for men against women.”
Encouraging women to join the medical workforce is tremendously beneficial to Japan and may help to alleviate to the healthcare worker shortage.
A full transcript of the interview is available below.
Mark Britnell: My name is Dr. Mark Britnell. I am the global chairman and senior partner for health care, government, and infrastructure at KPMG. This is my tenth visit to Japan over the past ten years or so. And this time I’m here to promote and launch my new book Human: Solving The Global Workforce Crisis in Health Care and my good friend and colleague Dr. [Yasuhiro] Suzuki, who is the chief medical officer and vice-minister of health for Japan, is here today to help me launch my book to health delegates from across the country.
Michael Penn: So why is your book getting such support right out the gate?
Mark Britnell: Well, first of all, for the last two or three years I’ve been working in about thirty-three countries a year. I have noticed that there is an increasing problem with workforce in healthcare. The World Health Organization estimates that we will be short of 18 million health workers by 2030. Which is roughly a 20% gap in the total capacity to care. And of course because Japan is the oldest population on the planet the pressures are seen here before anywhere else. But I think there is no doubt about it, make no mistake about it, that the workforce challenge in Japan for healthcare is simply enormous. As I found with other countries there is a great thirst and a desire to both understand the problem and also to start to think about implementing solutions as well.
Michael Penn: Well, not getting to Japan yet, speaking globally, why should there be any labor shortage in the healthcare market, it sounds like a place where people have good paying jobs, and there are a lot of people who need good productive employment, so why is it that this has happened?
Mark Britnell: You know, Michael, that’s a great question. And you’re right. When we look at the growth of workforce in healthcare, it’s the fastest growing industry in the world. In fact in the next two years, it’s projected to be the largest single sector of employment in the world. And precisely because it’s been growing so quickly as the population grows and the population ages, although they are increasing employment in healthcare it’s simply not being at a quick enough rate. And so more jobs are being created if I think about the United States now, they are projected to be 1 million nurses short by 2025 and 120,000 doctors short by 2030. In my own country, the United Kingdom, 1 in 10 clinical posts is now vacant. In India where they are now launching Modicare, the largest single movement towards universal healthcare, they are 4 million nurses and doctors short. And in China when they relaxed the one child policy, they forgot to tell the obstetricians and now they need an extra 180,000 obstetricians. So the point is, yes, it’s a great job, it’s a great profession, it’s a great vocation, the pay rates are decent, and your colleagues are wonderful, and what you do for patients is remarkable, but quite simply we’re getting too ill, too old, too quick and therefore we have not been able to play catch up with increasing employment needs.
Michael Penn: So, I mean, I’m thinking of what could the bottleneck be and I’m thinking probably education?
Mark Britnell: Yes, that’s one of the bottlenecks, essentially there are three problems. There is educating enough healthcare staff, retaining enough healthcare staff, and then thinking about how long before healthcare staff retire. The bottleneck in educating is that there is a massive growth now in universities across the world for medical schools and nursing schools and allied professional schools. And we know through global surveys when you’re sixteen, when people take surveys of what school kids want to be, their number one priority is to work in the health profession. But by about eighteen or nineteen that changes to law or business or accountancy. So we start to lose people through their perceptions of healthcare, but we still are educating enough. The problem is then whether we have got enough, sufficient, clinical facilities in our hospitals and clinics to train all of these students and sometimes that’s a bottleneck. And of course when people actually come into healthcare sometimes we see people not actually staying for as long as they want. So how we look after them, how we nurture them, how we mentor them, how we coach them, how we support them is important. And also towards the end of a career when we know that perhaps manual dexterity gets a little slower or is a little more compromised. Making sure we select the right jobs for people’s ages is also important. And you know we’ll come on to Japan as Japan now thinks about elongating its retirement age, frankly broadly in line with most of the developed world at 65 or so. You need to think about the balance between manual labor and mental labor. And making sure that you’ve got people that feel comfortable in doing a great job later on in their career. And that means simply healthcare employers need to become much more agile, and much more flexible, much more family friendly. And all of these lessons of course need to be learned and must be learned from Japan as well.
Michael Penn: What’s the problem with retention? Why are people leaving the industry?
Mark Britnell: Well, we know, if you survive five years in healthcare you’re likely to commit the rest of your career in healthcare. Sometimes I think early on in people’s career, especially we see it in nursing where the dropout rate is quite high because of the balance between the pay and the onerous nature of the duties. And partially that’s about perception and partially it’s about reality so I think in the early years it’s really making sure you have a good coach and a mentor to make sure you can make sense of the organization and the organization can support and be sensitive to your needs.
Michael Penn: Are you seeing a major variation between countries which have national health services like Britain and the US which is fully privatized?
Mark Britnell: That’s a great question again, Michael. First of all, sadly I’ve worked now in 79 countries on 330 occasions over the last ten years and I’m sad to say that no country does healthcare workforce planning particularly well. So whether you’re a free market system or a state-controlled system you still have problems. However, I would say that where you have got socialized universal health care where the state plays a more prominent role in shaping healthcare you have better planning and better direction of healthcare. It doesn’t make the problems go away but it actually does make them easier to manage. We know, for example, I was in, I was in Boston, Chicago, New York just last month talking about my new book, and I think Americans were surprised to know they had potentially 1 million nurse shortfall because of the fifty states in the United States. It’s fragmented. You’ve got a private sector and a public sector, no one has really got oversight or a purview of the problem, and that means the problem really is fractured and splintered across the free market in America and across the states. And that makes it very difficult for the federal government to plan with any degree of certainty whereas in other countries, such as Italy or Spain, the United Kingdom or even Japan, there is a more coherent appreciation of the problem, if not always the solution.
Michael Penn: Okay, now let’s pull it to Japan: Is Japan more or less just one of the countries that is having this problem or is it in a particularly deep crisis?
Mark Britnell: Well, I say to everybody when I travel the world if you want to see the future, go live in Japan, because for healthcare we know because of your aging population and because of your low dependency ratio between those who are in employment and supporting depending on either a young age or old age we know that you are at the pinch points of that pressure. So in one sense the pressures that Japan faces are greater than most other countries, but they are similar in nature if you think about the aging population in China, the aging population in South Korea, the aging population in Singapore. It’s not that different to the aging population in Germany, in Italy, or the United Kingdom. But the size of the problem is more profound in Japan, but it would be wrong to say, as I say in my book, that Japan hasn’t seen this coming. It has tripled the number of nurses from 550,000 to 1.7 million over the last thirteen years. But still is short of 250,000 care workers. And we know now that the government through it’s new health vision for 2030 wants to think about technology and robotics. It wants to think about new models of care, so moving care from hospitals into the home or primary care or community care. And also increasingly, and perhaps novelly for Japan, now thinking about the role that progressive immigration can play with nurses from Indonesia or the Philippines. These are all good solutions which are now being pushed by the Japanese government and of course today with 100 delegates coming from around Japan, listening to Dr. Suzuki and myself, I hope that we can explore these solutions further in Japan. I think Japan is making progress, but it is slow.
Michael Penn: What do you see as the Number 1 threat to Japan going forward? What could be the biggest mistake?
Mark Britnell: Well, I think there is one immediate threat and one potential pitfall the immediate threat is what we call ‘a nice problem to have’ or a ‘wicked problem’ because japan is nearly at full employment thanks to its sound economic growth over the last decade or so, the opportunities to recruit young people or old people into health care are diminished. So I think that is a problem for Japan. There are ways around it, you can think about including more females to participate in healthcare and also thinking about what older people do in their retirement. And perhaps having a more mixed portfolio of work, and rest, and play. I think that the real danger for Japanese healthcare is it’s very hospital dominated. We know that you have three times as many hospital beds as the OECD average. I don’t know whether your viewers would know the Japanese see their doctor more than anybody else in the world, along with South Korea. So on average Japanese citizens see their doctor thirteen times a year, in Great Britain it’s five, the OECD average is six. So what you are doing with your fee for service system, your hospital dominated system. You’re allowing patients to flock to hospitals, so your doctors are overworked, your hospitals are stretched, and because they are relatively small you’re not thinking of solutions at scale, and what I find paradoxical, and perhaps even ironic, and I say this in my book, for the country that gave us lean manufacturing through their Toyota production system, elsewhere in the world now in healthcare you have lean and [inaudible] systems that are perfecting operational excellence and flow, but that is still not widespread in Japan. I find that strangely ironic because forty years ago, you gave the world the slickest production system, but still in healthcare in your own country, you’re still playing catch up. And that is because the unit of delivery is too small. So you don’t get the speed and adoption of spread.
Michael Penn: You mentioned a gender balance in the healthcare field and you may or may not be aware that there has been a really big scandal about this recently with Tokyo Medical University secretly lowering the scores of women to keep women out of the profession.
Mark Britnell: I talk about it in my book.
Michael Penn: Ok, then I guess you do know about it. What are the policy and larger ramifications of this kind of discrimination?
Mark Britnell: Well, first of all, I was saddened I think along with the rest of the world to learn of the Tokyo Medical University scandal where the results seemed to be lowered for females. I am very pleased to read on my way over this week that actually now the scores are being recalibrated and, as we suspected, the females scored higher than males. So I think that’s sweet victory, and it’s in line of course with most of the developed world. There are now more females at medical schools than there are males. Often their grades are better than males. And therefore I think in terms of Japan correcting the actions of the university. I think that’s important for three reasons. First of all, Japan is and will always be one of the major economic powers in the world, but it also has to be one of the most progressive powers and you can’t be progressive if you think men are better than women, or you load the dice for men against women. That’s the first point. Secondly, it’s completely self defeating for Japan. Japan needs full female participation in the labor force. It doesn’t need to load the dice against females because by doing so it will actually thwart its own economic development, and then, as you said, there’s the moral case simply that we live in an age of equality whether its sexual or religious or economic equality, and I think it’s important that Japan thinks about female participation rates because, quite frankly, where you’ve got full employment now or near full employment you need to bring females into the workforce and you need to bring old people back into the workforce. You need to be pulling at every single lever at your disposal to make sure that your country can continue to grow and prosper. So it was a sad indictment, but I’m glad it has been corrected, and I think it’s a matter of sweet justice that the females have come out on top.
Michael Penn: Another issue which you already somewhat alluded to is the care workers programs coming mostly from Southeast Asia. In the past, so far, the Japanese government has generally not met its own quotas on this because of very high standards of language learning being imposed on the care workers before they come, and very few of them have been able to meet that hurdle. It seems to many observers that this is another case of Japan defeating itself. Where do you come down on the actual language needs for these care workers compared to the demand in the country?
Mark Britnell: Well, it’s a very important question, and actually I am sympathetic to both sides. Let me explain why. First of all, for centuries Japan has been largely hermetically sealed, it’s got a very homogeneous culture and it’s proud of its culture, and therefore I know, as I have traveled the world, how immigration poses opportunities and challenges. So first of all I’d say the fact now that the Japanese government has recognized that it needs immigration to support its farms, its factories, and its healthcare institutions is a good start. It is a marathon not a sprint. This cultural change is profound in Japan. And the reason why I say that, of course, being British, is that we just celebrated seventy years of a ship called Windrush, coming from the Caribbean bringing black Caribbean health workers into England when we needed them. And, of course, that caused a great deal of controversy at the time, but of course overtime people become acclimated to immigration. And let me say, of course, the history of human development is the history of human migration. We wouldn’t be where we are today if it weren’t migration in one form or another. In England we have our own language test, it’s called a PLAB test; and this is where I’m going to answer your question. It is right and it is legitimate for patients to be able to understand their care workers, giving care and receiving care is a deeply personal experience. Therefore you have to assume the care worker has a certain level of competence when speaking Japanese or English. We had concerns in England about patients not understanding foreign workers and therefore we raised the standards of our PLAB or English tests. That did stop some foreign workers coming in to the country, so I think there is a balance. I’ve been told that Indonesian care workers or Filipino care workers have to try and learn Japanese in three months. I’m sure that’s not true. I don’t even know whether it’s possible to learn Japanese in three months, perhaps thirty years. So I guess I would say all parties would have to be patient and respectful, but this trend will not stop. And therefore to embrace it early, to think about the successes and failures and to learn from them, is the most important thing the Japanese government and society can do.
Michael Penn: You already mentioned robotics, as we know many industries are going to be revolutionized by this. Probably the driving, truck driving, taxi, we can already see this on the horizon. But medical care seems to me, a little bit harder to imagine how robotics is going to massively change the number of medical care admissions and others that are needed. Do you see this idea of robotics really reducing a need for labor…
Mark Britnell: That’s another great question, Michael, and as you can see from my cover, we’ve got the hand of God and the hand of a robot. Well, first of all, let me say that healthcare is different to other industries, fundamentally (as I say in my book) you need the kind heart and warm touch of a human being when you’re ill. Nothing will ever replace kindness. A robot cannot replace kindness and empathy when you’re ill. But there is a lot that robots can do. Our best guess is by 2030, 36% or so of tasks in healthcare could be supported by robotics, artificial intelligence, cognitive augmentation, and blockchain. And the real issue now is to demystify jobs and to look at the actual tasks that humans do and then decide what tasks can be aggregated and grouped together and supported by robotics. So for example we’ve already seen now robots cleaning floors, we’ve seen robots dispensing pharmacy prescriptions, we’ve seen robots in Japan give exercise classes to older people, we’ve seen robots now perform surgery in terms of prostate cancer. So, the field of robotics is growing and speeding up, we know now in artificial intelligence that for pathology and radiology and ophthalmology actually now in tests between artificial intelligence in humans, artificial intelligence is as good, if not better. And we also know with blockchain where we think about large scale medical records or financial transactions, we’ve seen in other industries where blockchain has revolutionized transactions. So I am not a digital or robotic zealot. I believe in the supremacy of human beings and the subordination of machines. I do however believe that we have been slow to realize the potential. And one thing I do say in my book, and this is where Prime Minister Abe has been clever, is that you and 5,000 of your nursing homes are piloting robots, and you are staring now to think about robotics in healthcare as an export. So for example in March this year I was in Singapore, and I saw Japanese business and healthcare people try to sell their robotics into Singapore. Now Singapore as you know is a pretty smart country, it’s a very smart country, it’s an advanced country. And yet it’s learning from Japan. I actually think, and I say this in my book, isn’t it cool that old people are piloting robotics before millennials in health care? And I just think that’s cool.
Michael Penn: Finances. As we know whenever we talk about healthcare, money comes up and the amount of money is enormous, especially when we’re talking about so many people and society. A large percentage of society, huge debates in the United States and I think in other countries as well. So, to what extent is the amount of finances that is needed a roadblock for some of these reforms that are needed.
Mark Britnell: I don’t know of a system in the world that doesn’t need more money, and doesn’t want more money. We know on average globally that the average GDP per country is 10.4% of GDP spent on healthcare, in Japan, it’s 10.8%, but also Japan was one of the first countries to introduce new social insurance for old people back in 2000. By the way, that reform in 2000 when you didn’t have political consensus, was a bold reform which many other countries in the world including my own are now learning from. So sometimes when Japan politics and society plays at the top of its game it can be very progressive in terms of its reforms. In terms of financing for Japan, you have a fee for service model which creates a lot of healthcare inflation, you don’t have a primary care system where patients can go and see primary care doctors first. We know that’s cheaper and more efficient and more effective. So there are efficiencies that can be made in the Japanese system, but of course with your aging population we know that once you get over 65, especially when you get to 75, your consumption of care almost doubled overnight. Therefore, I’m not going to pretend it’s going to be easy in Japan. You’re going to have to continue to spend more money. I think your government has indicated that it will do, especially in age care. But I think all health systems, as I say in my book, can become more productive. Healthcare is only half as productive as other elements of industrial society. And my book basically presents ten solutions as to how we can improve productivity, which raises national health, which creates more wealth which in turn can be spent on healthcare. If you like my book, it’s the perfect recipe for a virtuous circle of health improvement and national development.
Michael Penn: Last question, what should I have asked you that I didn’t ask you?
Mark Britnell: Can Japan do it? Can Japan provide care for all of its citizens, over the next fifteen years with the demographics being as they are.
Michael Penn: Okay, answer?
Mark Britnell: I don’t know, I hope so.
Michael Penn: Okay, let me ask you that question, with Japan’s mountain of aging and challenges facing it. Can it really meet the challenges that it is facing now.
Mark Britnell: Well, the way it is meeting its challenges at the moment is by asking doctors in particular to do enormous amounts of overtime. I think in other parts of the world now we would consider the amount of work your doctors are doing is being unsustainable and unsafe. Well, we know the government wants to phase out long working hours for doctors by 2023. That’s right and proper. So I guess my answer is, if you’re pushing me, which you are, and I will answer, which I am. It’s that basically you have ten years in which to change the skill mix in your healthcare workers, change the models from being hospital centric to being community focused, introduce new technology in robotics. And do it with high levels of employment and healthcare. If you can meet those four challenges, you will meet the demographic pressures that this country is facing. And if you do manage to do that you will indeed be truly a world leader.
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