Skill-mix initiatives focus on changing professional roles - directly and indirectly.They change roles directly through extension of roles or skills, delegation, andthe introduction of a new type of worker; they change them indirectly throughmodifications of the interface between services - that is, where care isprovided.Skill-mix initiatives may be motivated both by qualitative considerations (such asquality improvement, professional development and quality of work-lifeconcerns) and quantitative considerations (such as shortages, maldistributionand cost-effectiveness).Policy instruments that support the effective implementation of skill-mixinitiatives include:• modifying or introducing new professional roles through the developmentof different organizational and regulatory arrangements, includingregulating professional scopes of practice and overcoming institutionalbarriers;• supporting new or enhanced professional roles through collectivefinancing and altered financial incentives; and• ensuring the educational foundations (competence and capacity) for thenew and expanded professional roles.Across all initiatives, it is essential that the professional organizations affectedand the government support new professional roles.Skill-mix initiatives must be driven by need and must be sensitive to the healthsystem and health professional; one-size-fits-all approaches are not helpful.Optimal skill mixExecutive summaryThe first step towards determining and implementing an optimal skill mixwithin a health system involves defining the skill mix and achieving clarity aboutthe key policy problems for which it is envisioned as a solution.Skill-mix initiatives focus on changing professional roles directly or indirectly.Direct initiatives look at enhancement (by extending roles or skills), substitution,delegation and innovation (by introducing a new type of worker). Indirectinitiatives, however, modify the interface between services - that is, where careis provided; they consider transfer (by moving the provision of a service fromone health care setting to another), relocation (by shifting the location of aservice without changing the people who provide it) and liaison (by usingspecialists in one health care sector to educate and support staff working inanother sector).

The problems for which skill mix can be a potential solution include:

shortagesof certain provider groups and their maldistribution; rising health care costs andthe related desire to improve the cost-effectiveness of health care servicedelivery; and quality improvement, including addressing professionaldevelopment and quality of work-life concerns.The optimal skill mix has been determined in different ways in differentEuropean contexts and has been implemented in diverse ways, according to thecontext. Skill-mix initiatives have sometimes been driven by the need or desireto change the professional roles of established professions or to introduce newprofessional roles. At other times, the initiatives have been driven by the needor desire to pursue a new strategic direction for health systems that required ashift in existing professional roles. Among five European countries thatrepresent different types of welfare and health care systems - Finland,Germany, Spain, the Russian Federation and the United Kingdom - the mostextensive deployment has taken place in the United Kingdom, followed byFinland; in Germany, Spain and the Russian Federation, it has taken place to amuch lesser extent. Across all five countries, the initiatives that targetedchanges in professional roles typically included modifications to structuralfactors - particularly, legislation, regulation of the scope of practice,certification, education and training (usually the first to be modified), and oftenalso collective financing and the public provision of services.The development and implementation of advanced practice nursing in theUnited Kingdom provide useful insights that are applicable to other Europeanhealth systems. With significant support from government and a lack ofopposition from the dominant medical profession, this initiative has beenwidely implemented in the United Kingdom. Arguably, the relative success ofthis initiative is dependent on conducive contextual factors in the UnitedOptimal skill mixKingdom. The enabling contextual factors in the United Kingdom, however, arecritical to a better understanding of the viability of various skill mix approachesin other countries.The contextual factors that influence the implementation (and potential scalingup) of skill-mix initiatives include sensitivity to existing professional roles, theneeds of the health system, and support from government and relevantprofessional associations or unions, and these differ from country to country.

These factors can operate at several levels:

the structural (macro) level; theinstitutional (meso) level; and the interactional (micro) level. Policy instrumentsthat address skill-mix issues thus need to deal with:• modifying or introducing new professional roles through the developmentof different organizational and regulatory arrangements;• supporting new (or enhanced) professional roles through collectivefinancing and changing financial incentives; and• ensuring the educational foundations (competence and capacity) for newand expanded professional roles.In all cases, the support of the professions affected and the government isessential.As findings from studies of skill-mix initiatives are often difficult to generalize,two multistep approaches that move from identifying the problem and initiativeneeds to providing the capacity to undertake change and the choice of option -both of which reinforce the importance of the contextual elements - arehighlighted in the concluding section of the policy brief. These multistepapproaches can help health system managers and policy-makers determinewhether and which skill-mix initiatives should be undertaken. Overall, however,changing services, which may require a shift in skill mix, may be a moreeffective approach than changing the skill mix directly.