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Original Article

Anaesthesia workforce in Europe

Egger Halbeis, C. B.*; Cvachovec, K.; Scherpereel, P.; Mellin-Olsen, J.; Drobnik, L.§; Sondore, A.

Author Information
European Journal of Anaesthesiology: December 2007 - Volume 24 - Issue 12 - p 991-1007
doi: 10.1017/S0265021507000762
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Abstract

Introduction

A sufficient number of anaesthesia providers is needed to ensure optimal care for surgical patients. During the last few years a growing demand for surgery has increased the demand for anaesthesiologists. However, the decreased supply of providers and expansion of the European labour market towards Eastern Europe have led to a major risk of human resources shortage in medicine [1,2].

The National Anaesthesia Societies Committee (NASC) of the European Society of Anaesthesiology (ESA) decided to conduct a survey study with the following objectives:

  • Review of the number of and activities by anaesthesia care providers;
  • Study of migration1 of anaesthesiologists in Europe;
  • Assessment of expected shortage of anaesthesia workforce by European national anaesthesia societies.

This study also updates workforce data from a similar survey study on the anaesthesia workforce in Europe that was performed in 1996 by the Union of European Medical Specialists (UEMS), section Anaesthesiology [3].

Methods

Survey

This study was approved by the Ethics Committee and the Research Board of the Departement Universitaire d'Anesthesie Reanimation et Medecine d'Urgence of the Lille University Hospital, France. The ESA designed a questionnaire with ten questions. The questionnaire was based on the previous survey from 1996 and questions related to migration and shortage were added. The questionnaire was sent to the president of the National Anaesthesia Society in each of the included European countries. We asked for the most recent data and to indicate for which year the data were provided for. Interviewees were also asked to indicate whether their answers relied upon statistics or on ‘best guess'. In case we had to follow-up on answers that were unclear, interviewees were contacted again by E-mail, fax or phone call. For all those countries where no reply was received by the timeline, reminder E-mails were sent.

Country grouping

We grouped European countries into three different groups based on each country's association to the European Union (EU) or the European Free Trade Association (EFTA) and the related access to (or barrier from) the EU-related labour market. This was done to study migration patterns and to determine differences in the anaesthesia team composition.

Group 1 represents EU and EFTA member states before 1 May 2004. Group 1 includes the following countries (N = 18): Austria, Belgium, Denmark, Finland, France, Germany, Greece, Iceland, Ireland, Italy, Luxembourg, The Netherlands, Norway, Portugal, Spain, Sweden, Switzerland and the United Kingdom (UK).

Group 2 includes countries entering the EU in 2004 (‘new member states') (N = 10): Cyprus, Czech Republic, Estonia, Hungary, Latvia, Lithuania, Malta, Poland, Slovak Republic, and Slovenia.

Group 3 includes EU candidate countries, potential candidate countries and non EU-related Eastern European countries (which were regarded as European as defined by the World Health Organization, WHO) (N = 14): Albania, Armenia, Belarus, Bosnia and Herzegovina, Bulgaria, Croatia, Israel, Macedonia, Moldova, Romania, Serbia and Montenegro2, Ukraine, Uzbekistan and Turkey. This is a heterogeneous group with respect to political and cultural issues and also the development of medicine.

Calculation of relative workforce figures and anaesthetics per anaesthesiologist

For country populations, the statistics of the United Nations' Population Division was used [4]. Only descriptive statistics were used (average, standard deviation, range). The numbers shown correspond only to the countries from which data were actually received. All relative workforce figures are given as per 100 000 of population. Group averages for relative workforce figures (e.g. number of anaesthesiologists per 100 000 population) were calculated by dividing each group's total number of anaesthesiologists by the group's total population times 100 000. This formula was chosen to better reflect the situation in the more populated countries. Also, group averages were calculated only for the actual subgroup of countries that use the respective type of workforce. For example, some of the European countries do not use anaesthesia nurses. These countries were not included to calculate the group average for the number of anaesthesia nurses.

From the number of anaesthesiologists and anaesthetics per year, the number of anaesthetics performed per anaesthesiologist was calculated for each country where both numbers were available.

Survey questions

Interviewees were asked the following questions (Appendix 1):

  • Number of anaesthesiologists, anaesthesia physician trainees and anaesthesia nurses; their gender distribution;
  • Allocation of anaesthesia workforce to public and private practice;
  • Distribution of anaesthetic procedures performed: general anaesthesia (GA); regional anaesthesia (RA); combined anaesthesia procedures (CA).
  • Typical level of professional activity of the anaesthesia physician workforce in terms of % of a full-time equivalent (FTE), where 100% FTE represents a full-time working anaesthesiologist.3
  • How does the anaesthesia physician workforce allocate its work time to anaesthesia activity in the operating room (OR), critical care medicine, chronic pain services and pre-hospital emergency services.
  • The number of anaesthesia nurses and whether anaesthesia nurses are required to pass a formal training in anaesthesia and whether they work under the supervision of an anaesthesiologist or not.
  • Monthly gross basic salary (in Euros per month) for a board-certified anaesthesiologist.
  • Migration: The number of anaesthesiologists entering or leaving the respective country and the countries of origin or destination, independent of citizenship of anaesthesiologists or country where anaesthesia training was completed. Based on these absolute figures, the percentages of migrating anaesthesiologists were calculated based on the country's current total anaesthesia (physician) workforce. Also, each country's net change of workforce was calculated (as a percentage of current workforce).
  • Shortage: We asked whether a shortage of anaesthesia workforce is being anticipated.

Definitions

Anaesthesiologist: Any physician who has completed anaesthesia training and who has passed a national board certification (‘board-certified anaesthesiologist').

Anaesthesia nurse: Any clinically active non-physician anaesthesia care provider. In Europe, the workforce model of anaesthesia nurses (or nurse anaesthetists) is different to the US where the certified registered nurse anesthetist (CRNA) may completely substitute the anaesthesiologist. The anaesthesia nurse's autonomy and the degree to which the aspects of anaesthesia care are delegated to the anaesthesia nurse differ within and between countries [5].

Results

Return rate

The return rate was 78% for Group 1, 80% for Group 2 and 79% for Group 3. In Group 1, no data could be obtained from Austria, Belgium, Iceland and Portugal. In Group 2, no replies were received from Cyprus and Hungary. In Group 3, no data were received from Croatia, Macedonia and Ukraine.

Number of anaesthesiologists

Overall, for the 33 countries, there was a total of 69 860 anaesthesiologists4 (Tables 1, 2 and 3), and the average relative number was 11.7 per 100000 population.

T1-2
Table 1:
Number of anaesthesiologists, trainees, and anaesthesia nurses in Group 1.
T2-2
Table 2:
Number of anaesthesiologists, trainees and anaesthesia nurses in Group 2.
T3-2
Table 3:
Number of anaesthesiologists, trainees and anaesthesia nurses in Group 3.

In Group 1, there were 53 405 anaesthesiologists, the average number being 14.5 per 100 000 population (range 7 in The Netherlands to 19.9 in Germany). In Group 2, there were 6302 anaesthesiologists, the average number being 10.2 per 100 000 (range 7.3 in Poland to 20.7 in Estonia). If Groups 1 and 2 are taken together (i.e. EU and EFTA countries), the average relative number of anaesthesiologists was 13.9 per 100 000. In Group 3, there were 10 153 anaesthesiologists, the average number being 6.1 per 100 000 (range 2.7 I Turkey to 14.6 in Belarus).

Gender distribution (Tables 1, 2 and 3)

The average percentage of female anaesthesiologists in Group 1 was 37%, in Group 2, 54% and in Group 3, 50%. The largest percentage of the female workforce was found in Greece (74% female) whereas the lowest was in Armenia (19% female).

Number of anaesthetics per anaesthesiologist per year (Tables 1, 2 and 3)

The average number of anaesthetics performed per anaesthesiologist was 661 in Group 1, 518 in Group 2 and 571 in Group 3. The number of anaesthetics per anaesthesiologists ranged from 124 (Uzbekistan) to 1823 (Israel).

Type of practice: public vs. private

In Group 1, the median number of Anaesthesiologists in private practice as a percentage of the total workforce was 20% (range 2-74%). In some Northern European countries (Denmark, Norway, Finland, Ireland, UK), only a very small fraction of anaesthesiologists work in private practice (2-5%). The private sector represents a high percentage of anaesthesiologists in Luxemburg (74%) and The Netherlands (50%), and a moderate percentage in France, Germany, Greece, Italy, Spain and Switzerland (20-39%). In Group 2, private practice plays only a minor role (median 5%, range 1-12%) except for Poland where some moderate private activity (12%) can be found. In Group 3 (median 2%, range 0-29%), moderate private activity can be found in Armenia, Bulgaria, Serbia and Montenegro, and Turkey (18-29%). In all other countries, the public anaesthesia practice dominates.

Distribution of anaesthetic procedures

In Group 1 (Fig. 1), 63% of all anaesthetics were GA, 26% RA and 11% CA on average. France, Luxembourg and the UK have a comparably low percentage of cases in which RA techniques are applied whereas in Finland and The Netherlands, RA techniques are used more often. In Group 2 (Fig. 2), there is a smaller percentage of cases performed with RA techniques: on average, 72% of all anaesthetics were GA, 22% RA and 6% CA. In Group 3 (Fig. 3), a picture very similar to Group 2 can be found: 73% of anaesthetics were GA, 21% RA and 6% CA.

F1-2
Figure 1:
Distribution of anaesthetic procedures in Group 1.
F2-2
Figure 2:
Distribution of anaesthetic procedures in Group 2.
F3-2
Figure 3:
Distribution of anaesthetic procedures in Group 3.

Level of professional activity

In Group 1, anaesthesiologists in public practice work 96% of a FTE on average. Interestingly, in Germany and The Netherlands, there was a relatively high percentage of part-time working anaesthesiologists (female: typically 60% FTE, male typically 80-90% FTE). For Group 2, data were available from the Czech Republic and Malta only. In the Czech Republic, female anaesthesiologists work typically 80% FTE but both Czech and Maltese male anaesthesiologists work 100% FTE. For Group 3, only Israel and Turkey provided data for this question and all anaesthesiologists work close to 100% FTE.

Areas of professional activity

In Group 1, anaesthesiologists in public practice were involved in anaesthesia for 71% of their working time, on ICU duties for 19%, in chronic pain for 5% and in emergency medicine for 5% (Fig. 4). Data relating to private anaesthesia activity was further analysed for Group 1 countries where 5% or more of the anaesthesiologists work in private practice (Fig. 5). Anaesthesia activity in the OR was more important in private practice (average 84% of working time).

F4-2
Figure 4:
Areas of professional activity in Group 1 (public practice).
F5-2
Figure 5:
Areas of professional activity in Group 1 (private practice).

In both Groups 2 and 3, non-OR commitments by anaesthesiologists tend to be larger than those in Group 1. In Group 2, anaesthesiologists were involved in anaesthesia for 61% of their working time, in intensive care medicine for 31%, in chronic pain for 3% and in emergency medicine for 5% (Fig. 6).

F6-2
Figure 6:
Areas of professional activity in Group 2 (public practice).

In Group 3, anaesthesiologists in public practice were involved in anaesthesia for 63% of their working time, on ICU duties for 31%, in chronic pain for 3% and in emergency medicine for 3% (Fig. 7). Private practice activities in Armenia, Bulgaria, and Bosnia and Montenegro mainly include anaesthesia.

F7-2
Figure 7:
Areas of professional activity in Group 3 (public practice).

Trainees

For all 33 countries, a total of 20 082 anaesthesia physician trainees were recorded (Tables 2-4). The absolute and relative number of anaesthesia physician trainees as well as the duration of anaesthesia training are shown in Table 4.

T4-2
Table 4:
Trainees and duration of European anaesthesia physician training programmes.

In Group 1, the average percentage of female trainees in anaesthesiology was 47% in Group 1 (range 20% in Denmark to 63% in Greece). In Group 2, the average percentage of female trainees was 59% (range 52% in Estonia to 90% in Latvia). All Group 2 countries had more than 50% female trainees. In Group 3, the average percentage of female trainees was 53% (range 14% in Uzbekistan to 81% in Romania).

Anaesthesia nurses

In Group 1, Greece, Ireland, Italy, Spain and the UK report no use of anaesthesia nurses5. The average relative number of anaesthesia nurses for all other countries was 15.8 per 100 000 population. Except for Luxembourg and Switzerland, all anaesthesia nurses have passed a formal training in all Group 1 countries.

The average number of anaesthesia nurses in Group 2 was 14.3 per 100 000. No anaesthesia nurses exist in Lithuania. In Latvia, Malta, Poland and the Slovak Republic not all anaesthesia nurses have formal training. The total number of Polish anaesthesia nurses was as high as 3980, but the percentage of those having passed a formal training was only 57%. Anaesthesia nurses work under supervision in all Group 2 countries.

In countries of Group 3, the average number of anaesthesia nurses was 13.4 per 100 000. In Bosnia-Herzegovina and Israel, anaesthesia nurses are not deployed. In Armenia, Bulgaria, Serbia and Uzbekistan, formal training was not mandatory for anaesthesia nurses. Anaesthesia nurses work under supervision in all Group 3 countries.

Salaries

Monthly salaries tend to increase the more north-western a country is and to decrease towards the south-east (Table 5). In Group 3, three countries (Armenia, Moldova and Uzbekistan) pay anaesthesiologists less than €100 per month. The majority of Group 3 countries (8 out of 10) pay €500 or less per month for an anaesthesiologist.

T5-2
Table 5:
Monthly salary for Board-certified anaesthesiologist in Europe (€ per month).

Migration

In Group 1 (Fig. 8), the majority of countries have gained in anaesthesia workforce by a few percentages. The relatively high net increases in Switzerland and Luxembourg are partly due to small population sizes. The only country in Group 1 with a net efflux of anaesthesiologists is Germany: the 3% loss corresponds to an absolute number of 500 emigrating anaesthesiologists. In Group 2 (Fig. 9), all countries except Malta and Slovenia showed emigration of anaesthesiologists. The smallest change could be found in the Czech Republic, the biggest in the Slovak Republic. Poland lost the largest number of anaesthesiologists in absolute terms (340 anaesthesiologists).

F8-2
Figure 8:
Migration in Group 1.
F9-2
Figure 9:
Migration in Group 2.

A mixed situation was found in Group 3 (Fig. 10). Serbia and Montenegro, Moldova, Bulgaria, Albania and Uzbekistan had net losses of 150, 138, 80, 31 and 25 anaesthesiologists, respectively. For Moldova, this translated into −30% of its anaesthesia workforce. Israel and Romania are the only countries in Group 3 that had a net influx of anaesthesiologists.

F10-2
Figure 10:
Migration in Group 3.

Group 1 anaesthesiologists migrated within Group 1 or moved to the US. Immigrating anaesthesiologists from outside Group 1 countries into Group 1 have their origin in Eastern European countries, the Middle East or South-East Asia. In Group 2, the countries mentioned most often as destinations were those in Group 1.

Group 3 countries had migration with Group 1 (France, Germany, the UK), with the Middle East (Emirates, Israel, Kuwait, Yemen), with Russia and, especially Israel, and also with the US.

Shortage of anaesthesiologists

The countries for which no shortage of the anaesthesia workforce is being anticipated are Germany, Italy, Luxembourg, Norway and Switzerland in Group 1, Czech Republic in Group 2 and Albania, Armenia, Belarus, Bosnia-Herzegovina, Romania and Uzbekistan in Group 3.

Only a few of the countries provided estimations and forecasts of the number of anaesthesiologists over the next 15 yr. In France, it is estimated that the number of specialists will decrease from 9700 in 2005 to 6000 in 2020. In the UK, a further increase of workforce up to 8500 is expected but it was felt that this supply will not be sufficient to meet demand. In Group 2, for Poland and Slovenia the number of anaesthesiologists is expected to fall to 900 (from 2800) and 160 (from 180), respectively. In Group 3, Bulgaria expects a shortage in the range of 5% for the years 2010 and 2015. Israel and Serbia anticipate a decrease of the number of specialists down to 490 and 300, respectively, by the year 2020.

Data quality

In all three groups (especially Group 3), most of the questions were answered. If an answer was missing, incomplete or obviously erroneous, it was excluded from data analysis. For example, if the percentages given for the four different areas of activity did not add up to 100% these data were excluded from analysis. Therefore, groups do not include the same countries for all analyses.

Interviewees were asked to provide information on whether their answers were based on national statistics or on an ‘educated guess'. The analysis of data accuracy shows that in Group 1, the percentage of data based on statistics is 30%, i.e. 70% of all answers were estimated by interviewees (‘educated guess'). The best availability of statistics was on the number of anaesthesiologists (63%) whereas for the question about anaesthesia subspecialty fields, almost all data (94%) were estimated. In Group 2, 43% of answers were based on statistics. Statistics were available in 88% for the question about the number of anaesthesiologists, whereas for none of the countries were statistics available for the question about shortage. In Group 3, 28% of data were based on statistics. The most accurate data were on number of trainees (55% of responders); statistics about possible shortage of anaesthesiologists were nonexistent.

Discussion

During the last decade, several factors have affected supply and demand of anaesthesiologists in Europe. With the accession of the ‘new member states' into the EU on 1 May 2004, the European labour market is becoming more integrated towards the east. Under the ‘2 + 3 + 2-yr scheme' allowed for by the Accession Treaty, each of the old member states (EU-15 countries) has the right to decide how fast they are going to open their labour market to the new member states [6]. In this ongoing process, skilled labour (e.g. anaesthesiologists) may migrate to countries with more competitive salaries and working conditions. Eastern European countries, especially, may face an emigration wave. In Western European countries, working time directives (WTD) have increased the demand for all physicians, including anaesthesiologists. However, several reports from different Western European countries have suggested an imminent shortfall of anaesthesiologists due to an ageing physician workforce and central control of and restricted access of trainees to the medical profession [2,7,8].

Number of anaesthesiologists

We found an average number of anaesthesiologists of 14.5 per 100 000 population in the old EU member states (Group 1), 10.2 for the new member states (Group 2) and 6.1 for other Eastern European countries (Group 3). The mean relative figure for the old EU member states is higher than that in 1996, which was 10.8 per 100 000. This increase in the anaesthesiologist head count may be explained by several factors: (1) an increase in supply of anaesthesiologists; (2) an increase in the number of procedures that require anaesthesia services due to population ageing and the introduction of new procedures (e.g. interventional radiology) and (3) a rising percentage of part-time working staff which reduces the amount of available FTE-working workforce (e.g. Germany).

Supply in Group 1 countries may have been increased at least partially due to migration of anaesthesiologists, especially from Eastern European countries (Group 1) joining the EU in 2004 (see below).

For those countries for which both historical and current data are available, we compared the trend of absolute numbers of anaesthesiologists. In those countries the number of anaesthesiologists increased by 43%. Except for Italy (which has a stable absolute number of anaesthesiologists) all other countries have increased their pool of anaesthesia specialists from 1.15-fold (The Netherlands) up to 2.3-fold (Ireland).

Gender distribution

There was a majority of male anaesthesiologists in Group 1 although women represented more than 50% in Groups 2 and 3. It is possible that this could be explained by selection bias. There may be a correlation between the male : female ratio and salary as in countries with low salaries, there was a higher proportion of females. Factors that may influence the feminization of an anaesthesia and physician workforce, in general, are the preference for primary care medicine, for working opportunities in urban areas and for part-time work and the possibility for early retirement [9].

Is there evidence for the feminization of anaesthesiology in Europe over time? In Canada for example, the number and percentage of women in anaesthesiology has been gradually increasing [10]. We are able to compare historical data for the Czech Republic, France, Germany, Norway, and Switzerland with data from this study. In the Czech Republic, the percentage of female anaesthesiologists decreased from 55% in the year 2000 to 47% in 2005 [11]. Since 1998, the percentage of women among anaesthesiologists in France stayed relatively stable at roughly 35% [2]. In Germany, the percentage of female anaesthesiologists decreased from 59% in 1996 to 40% in 2005 [3]. In Switzerland, we can see an increase from 29% to 37% over the last decade [3]. In Norway, the percentage of the female anaesthesia workforce saw a remarkable increase from 13.9% in 1995 to 22.6% in 2005 [12]. Based on the figures of these five countries, there is no clear evidence for a feminization of the anaesthesia workforce in Europe during the last decade. For a definitive conclusion however, systematic and comprehensive data would be required and gender distribution in anaesthesiology should be compared to that of the physician workforce in general.

Trainees

All European countries included in this study except Luxembourg offer physician anaesthesia training programmes. For countries where both current data and historical data are available, we analysed each country's anaesthesia workforce planning. Pairs of data are available from the following Group 1 countries: Denmark, Finland, France, Germany, Greece, Ireland, Italy, The Netherlands, Norway, Spain, Switzerland and the UK. Except for Denmark, all countries have increased their absolute numbers of anaesthesia physician trainees by 1.3-fold (Spain) up to 2-fold (France and The Netherlands). In Denmark, the absolute number of trainees has decreased by 35%. The relative number of trainees varied greatly between- and within-study groups. The ratio of trainees to specialists was 0.32 in Group 2 and 0.25 in Group 3. In Group 1, this ratio was 0.29 and has been stable since 1996, which indicates that the number of anaesthesiologists increased at the same rate as the number of trainees.

Countries with longer anaesthesia physician training programmes than others tend to have a larger number of physician trainees (per 100 000). For example, anaesthesia physician training takes 7 yr in both Ireland and the UK. This relatively long programme translates into a considerable anaesthesia physician trainee workforce of 8.2 and 8.1 per 100 000, respectively. On the other hand, anaesthesia training lasts 4 yr in both Italy and Spain, and the relative number of trainees is only 2.1 and 2.5, respectively. In addition to the duration of the training programme, factors affecting the number of trainees may include cultural differences, the extent to which anaesthesia nurses are deployed and the extent to which trainees are used to substitute anaesthesiologists to allow them do external work.

Compared to board-certified anaesthesiologists, the average percentage of female trainees in anaesthesiology was higher in all three groups which suggests two things: (a) feminization of the anaesthesia specialty (as for medicine as a whole) has started only recently and (b) more women than men leave the workforce once they are fully trained [9].

Anaesthesia nurses

The availability of anaesthesia nurses varied widely between- and within-study groups. There is no obvious relationship between the relative number of anaesthesiologists and the number of anaesthesia nurses. The vast majority of anaesthesia nurses have completed a formal training in anaesthesia, especially in Group 1 countries. However, anaesthesia nurses across Europe run different training programmes as shown in previous studies [8]. Also, our study confirms that in Europe, anaesthesia nurses usually administer anaesthesia under the supervision of a board-certified anaesthesiologist. We did not investigate the scope of duties of anaesthesia nurses (pre-hospital ambulance service, PACU, etc.).

In many European countries, anaesthesia nurses traditionally play an important role within the anaesthesia care team. It is assumed that the presence of anaesthesia nurses may decrease demand for anaesthesiologists.

Anaesthesia procedures

It has been previously reported that European anaesthesiologists performed RA techniques to free themselves for other tasks (ICU, chronic pain services) by having the anaesthesia nurse monitor and manage the patient [5]. However, it may also be possible that labour intensity of the anaesthesia workplace increases with a higher percentage of RA techniques which then may contribute to a higher demand for anaesthesiologists in these countries. The results of this survey study gave evidence of important differences in the distribution of anaesthetic procedures between- and within-study groups. There are countries like Finland and The Netherlands with more than 50% of anaesthesia procedures in which regional techniques are used. In general, Group 1 countries are more likely to use RA techniques for their surgical patients than Group 2 and 3. However, we found no obvious relationship between the percentage of regional anaesthetics and the size of anaesthesia workforce. It is unclear to what extent the use of anaesthesia techniques might influence the anaesthesia workforce. A French analysis of the evolution of the anaesthetic workload over the last two decades showed that the percentage of regional anaesthetics increased from 4% to 23% [1]. The skills needed to successfully perform RA may seem attractive to an increasing number of anaesthesiologists and creates opportunities for pain specialists. Cultural differences may also play an important role with respect to differences in the distribution of anaesthetic procedures.

Professional activities

It seems that anaesthesiologists engage in multiple roles in the care chain for surgical patients throughout Europe. In some Eastern European countries (Belarus, Czech Republic, Moldova, Romania, Slovak Republic, Uzbekistan and Turkey), but also in Italy, Germany, Norway and the UK anaesthesiologists are heavily involved in intensive care (30% or more of their professional activities). In the UK, in Greece, but also in Turkey, anaesthesiologists provide a remarkable proportion of chronic pain management (10%). In addition, anaesthesiologists also provide pre-hospital emergency and ambulance services in many European countries. Anaesthesiologists in Luxembourg, Greece, Norway and the Slovak Republic spend 10% or more of their time on this activity.

Public practice is the backbone of activities for all European anaesthesiologists. Moderate private anaesthesia activities are only seen in Western European countries. Nevertheless, the importance of the activity (in terms of workload) is not reflected by the distribution of anaesthesiologists among public and private anaesthesia practice. Workload may often be higher in private than in public practice as suggested by France where private practice occupies approximately 40% of the anaesthesia workforce but about as much as 60% of anaesthetics [13].

We were able to assess the level of professional activity, i.e. the degree to which the anaesthesiologists work full-time, for Group 1 countries. The vast majority of anaesthesiologists work nearly full-time. Only Germany and The Netherlands have significant part-time working activities. Part-time labour has an influence on available staff because more specialists are needed to do the same job [14]. For example, based on the survey data from Germany (60% FTE for female and 90% FTE for male anaesthesiologists), the number of available female anaesthesiologists would come down from 6589 (40% of 16 473) to 3953 FTE's and the number of male anaesthesiologists would decrease from 9884 to 8896 FTEs. Ultimately the total number of 100% FTE-working German anaesthesiologists would need to be adjusted down to 12 849, and the relative number of anaesthesiologists would decrease from 19.9 to 15.5 per 100 000 population (which is only slightly higher than the average of 14.5 in Group 1).

Migration of anaesthesiologists

This is the first study to address migration of anaesthesiologists in Europe. With the accession of the ‘new EU member states' in spring 2004, free labour movement within the EU and EFTA countries was granted to a much larger geographical area than before. However, a common European diploma of anaesthesiology, although already existing under the aegis of the ESA, is not yet accepted in all European countries.

With the exception of Germany which has lost about 500 anaesthesiologists (3% of the workforce in 2005), Group 1 countries are typically workforce recipient countries. Migration of anaesthesiologists also seems to be an important phenomenon among Group 1 countries, where Spain, Switzerland, France, the UK and Scandinavia seem to be popular migration destination. A previous study has found that countries sometimes rely heavily on an ‘import' of medical workforce. For example, almost two-thirds of Switzerland's and a third of Norway's physician workforce graduated in Germany [15]. Also, it has been recognized that some countries ease immigration of skilled healthcare worker in order to alleviate their supply shortage [16]. Group 2 countries typically are source countries of a migrating anaesthesia workforce with net losses up to 20% (Slovak Republic). Anaesthesiologists from Group 2 countries seem to migrate in Group 1 countries, mostly to Germany, Scandinavia and the UK. This migration most probably reflects the opening of labour trade barriers with the accession of these countries to the EU and the ability to work abroad in high-salary countries. The differences in salary seem to be more than 50-fold between Eastern (e.g. Moldova) and Western countries (e.g. the UK). This may well explain why Moldova has lost 30% of its anaesthesia workforce.

In more than half of the European countries included in our study, a shortage of the anaesthesia physician workforce is expected to develop within the next decade. Some of the results are surprising given the trainee and migration level - both of which highly influence the workforce. For example, although Germany has experienced a net loss of anaesthesiologists in 2005, a shortage is not expected. The high number of Group 2 countries expecting a shortage is not surprising given the increasingly open access to the ‘old EU member states'. The Czech Republic may represent an exception because of its high number of anaesthesia trainees and a steady influx of Slovak anaesthesiologists. Migration of Slovak anaesthesiologists may be explained by the proximity of and better salaries in the Czech Republic and minimal language barrier. It seems obvious that the rationale for migration and expected shortage of anaesthesiologists is different for each country.

Supply of anaesthesiologists is often controlled by governmentally enacted healthcare regulations. In France for example, specialist supply in medicine is annually determined by the Ministry of Health region by region, creating substantial supply imbalances in anaesthesia between regions. Determination of workforce supply is used as a main tool to control healthcare-related expenses. Due to the uneven age distribution of anaesthesiologists (which peaks around the fifties), the French anaesthetic workforce can be expected to decrease within the next decade if control on entrants into the anaesthetic workforce is maintained at the present level [17].

It is well known that non-financial factors like opportunities for professional training, appeal of centres of medical and educational excellence and better employment opportunities may attract a physician workforce [16,18]. In a WHO study about the role of wages in the migration of healthcare professionals from developing countries, domestic salaries in the source countries have been recognized as important determinants of labour migration [19]. However, non-wage factors like working and living conditions seem to be more important if wage differentials are small. Also, it seems that migration of healthcare workers is demand-constrained. Therefore, it was concluded that ‘source countries may want to initiate demand-side policies like tailoring training programmes to domestic needs, encouraging recipient countries to increase their training capacity and making destination countries pay some form of compensation to source countries'. For source countries, problems identified with physician migration are lost investment in education and lost human capital [15]. Also, in the scope of labour migration in anaesthesiology, practice variations and the delivery of anaesthesia care at different levels of appropriateness can be anticipated. Therefore, it would be interesting to learn whether there is sufficient performance management of anaesthesia staff and systems, i.e. European-wide outcome measurements. Also, is there adequate access to information and systematic and adequate measurement of health outcomes and medical errors and adequate continuing education and re-accreditation of anaesthesiologists?

Limitations

This study has a number of weaknesses and limitations. The results of this survey study heavily rely on estimated workforce data provided by the national anaesthesia societies. The availability of reliable, systematic, country-wide workforce statistics in general is poor throughout Europe. Also, all survey studies suffer because subjects potentially are prone to different biases. In addition, sometimes there were no data available for certain questions for individual countries. However, we estimated that asking the presidents of national anaesthesia societies would be the most feasible method to solicit the information we were looking for. Furthermore, our questions may have been asked in a way that failed to produce the best and truest answers and could be interpreted differently by different individuals.

Another factor affecting workforce supply is age distribution of anaesthesiologists, which we did not assess. However, it is questionable whether this type of information would be able to be supplied because of the lack of systematic data. Our study lacks regional information about anaesthesia workforce figures within the same country. Future workforce studies should incorporate age and regional distribution as well as accurate working hours of anaesthesia providers.

Conclusion

Our study found that each European country has its own, unique workforce constellation and practice pattern. Differences in salary are remarkable which might at least partially explain westward migration of anaesthesiologists from those countries that have access to the EU labour market. Shortage does not seem to be a problem unique to the new EU member states or to Non-EU Eastern European countries. Implications of our findings are that there is a European-wide lack of systematic, comparable data about the anaesthesia workforce, which makes it even harder to accurately assess supply of anaesthesiologists. Finally, our study indicates that there is a considerable disparity in the duration of anaesthesia physician training programmes and the related pool of trainees between European countries in terms of length of training. As anaesthesiologists from countries with relatively short programmes are allowed to move within the EU labour market without restraint, it is unknown how migration of those anaesthesiologists might affect the quality of care in countries with relatively long anaesthesia training.

Acknowledgement

Alex Macario, MD, MBA, Professor, Department of Anesthesiology, Stanford University School of Medicine, Stanford, California, reviewed the manuscript and made most helpful suggestions prior to submission.

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Appendix 1

FAU1-2
Figure

1 Migration is defined as an anaesthesiologist moving from one country to another, independent of citizenship.
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2 Serbia and Montenegro were politically separated by a recent referendum after the survey reply had been received.
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3 100% FTE was not further defined on hours per week worked.
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4 Interviewees used different statistics to provide the number of anaesthesiologists in their country. For example, in the UK, only full specialists were considered as ‘board-certified anaesthesiologists' excluding the non-certified career grade (NCCG) anaesthesia staff, which has been estimated as 1200. If these anaesthesiologists were added to the number of ‘Board-certified' anaesthesiologists in the UK, the total number of anaesthesia physician specialists would be 6500 and hence, the relative number of anaesthesiologists would increase from 8.1 to 10.9 anaesthesiologists per 100 000 population.
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5 For the UK, the operating department practitioner (OPD) is not included.
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Keywords:

MANPOWER; ANAESTHESIOLOGY; EMIGRATION AND IMMIGRATION; EUROPE

© 2007 European Society of Anaesthesiology