4.2 Human resources
4.2.1 Health workforce trends
In 2016, around 282 600 health professionals (according to the statistical classification of economic activities in the European Community (NACE) Q86: Human health activities) were employed in the Austrian health sector, which corresponds to 65% of total health and social care employment. Between 2007 and 2016, the number of professionals employed in the health sector increased by 16%. This increase is particularly pronounced for specialist physicians and medical technicians. In the same period total employment only increased by 8%. The health and social care sector accounts for around 10% of total employment in Austria and is thus the third largest sector of employment (Statistics Austria, 2017o). In 2016, more than three out of four health and social care professionals were female (Statistics Austria, 2018b). Table4.5 indicates the number of health professionals by professional group per 100 000 population since 1995.
More than 116 000 health professionals were employed in hospitals in 2016, which corresponds to 41% of all health professionals in the health sector. Nurses were the largest professional group, accounting for more than 50% of total hospital staff. Around one fifth were physicians (approximately 24 600), with about half of them being specialists and half being physicians in training (Statistics Austria, 2017b).
To date, the number of health care professionals outside hospitals has not been systematically recorded. However, the implementation of a public health care professions register is currently in preparation. From the second half of 2018, all health and care professionals, including LTC and nursing professionals, physiotherapists and speech therapists will be required to register (see section 2.8.3) (Gesundheitsberuferegister-Gesetz, 2016).
Austria has the second highest density of physicians (510 per 100 000 population) in the EU, far above the EU average of 350. Between 1995 and 2015, the number of physicians increased by 45%, faster than in any other OECD country (see Fig4.5). This increase was particularly pronounced for specialist physicians, namely in neurology and radiology. Between 1995 and 2015, the number of specialists more than doubled, while the number of general medical practitioners (GPs) only increased by 25%. As a result, only 15% of all physicians worked as GPs in private practice in 2015 (Table4.5). It should be noted that national statistics exclude double counts for physicians with more than one graduation (e.g. GP and medical specialization), therefore deviations from internationally reported numbers may occur.
In 2015, approximately 44 000 physicians were licensed to practise in Austria, with about two thirds of them working as employees (29 800) and more than half (24 000) working as employees in hospitals (Statistics Austria, 2016b). Ambulatory health care services are provided by around 17 000 independently practising physicians, whereof 10 300 practise without any additional employment. They either contract with one or more SHI funds (7 700 or 45% in 2015) and/or practise without SHI contracts (9 400 or 55% in 2015, Fig4.6). Most non-contracted independent physicians (5 400 or 60% in 2015) are employed in other settings, such as hospitals, and consequently spend less time providing ambulatory care than their contracted colleagues.
The increase in the number of ambulatory care physicians since 2000 was mostly driven by an increase in the number of non-contracted physicians. At the same time the number of contracted physicians has stagnated as shown in relative terms in Fig4.6. This development will be further exacerbated by future retirements of contracted physicians (see section 7.3.2).
In addition, the distribution of specialist physicians across regions and/or medical specialties is a challenge (see also section 5.3). In particular, there are considerable disparities for specialists. For example, there is a 2.5-fold difference between the two Länder with the highest and lowest density of neurologists and psychiatrists with SHI contracts, and the density of radiologists varies threefold across the Länder (OECD & European Observatory on Health Systems and Policies, 2017). This maldistribution is further exacerbated by the rising numbers of non-contracted (mostly specialist) physicians who are free to choose their practice location.
Nurses and midwives
In 2015, a total number of 69 500 nurses (general nurses and assistant nurses) were employed in Austrian hospitals. In the period 2006–2015, the number of nurses increased by 16%. However, nurse density in Austria (817 per 100 000 population) remained slightly below the EU average (see Fig4.7), and when compared with Switzerland and Germany, nurse density is quite low. This comparatively low number of nurses in Austria explains why the total number of physicians and nurses is in the middle field of western European countries (Fig4.8).
However, international comparisons are difficult because data on nurses working outside of hospitals remain unavailable. Furthermore, headcounts and full-time equivalents are not used consistently in data reporting across countries. Data on midwives are collected and presented separately by national statistics and refers either to midwives employed in hospitals or total numbers of midwives licensed to practise (see Table4.5).
In 2015, there were 4906 dentists working in Austria (Statistics Austria, 2017f; BMGF, 2017j). Since 1995, the number of dentists increased by 77%. However, the dentist-to-population ratio remains below the average in the EU15 in 2014 (57.3 per 100 000 population compared to 70.5) and significantly below the density of dentists in Germany (85.3) (see Fig4.9). Of the comparator countries, only Switzerland has a lower ratio of dentists to population (51.4 per 100 000 population). The majority of dentists are self-employed and work in private practices outside hospitals (approximately 80% in 2015), either with or without a contract with a SHI fund. Employed dentists (approximately 20% in 2015) work mostly in hospitals or dental clinics.
Fig4.10 shows that the number of pharmacists in Austria increased continuously since 2000, to 66.1 per 100 000 population in 2014, which is, however, considerably below the EU average (85.1). In 2016, 5822 pharmacists worked in community pharmacies, with one out of four being self-employed. On average, four community pharmacists work together in one pharmacy. The majority of pharmacists are women (79.1%) and about 50% of pharmacies are owned and managed by a female pharmacist. Only 362 pharmacists were employed by the 45 hospital pharmacies in 2015 (Österreichische Apothekerkammer, 2017).
4.2.2 Professional mobility of health workers
Austria has long been a net importer of nurses and a net exporter of physicians. The main destination countries for physicians trained in Austria are Germany and Switzerland. Nurses move to Austria mostly from Germany and eastern Europe.
The share of foreign-trained physicians increased from 2.9% in 2006 to 5.1% in 2016. Due to the absence of language barriers, Austria is a main destination country for German physicians. In 2015, a total of 1084 German physicians worked in Austria (approximately 60% of all foreign-trained doctors). Conversely, Germany is also a major destination for Austrian physicians, mainly due to higher German pay grades. In 2015, in total 1977 Austrian physicians worked in the neighbouring country. Other sending countries are Hungary (244 physicians), Slovakia (105 physicians) and Czech Republic (77 physicians) (OECD, 2017j; OECD, 2017k).
After the European Court ruling on university admissions in 2005 that declared earlier restrictions illegal for discrimination towards non-national European citizens, the numbers of foreign students admitted to medical faculties in Austria increased. However, this significant intake of international students has put the education and training system under pressure. To stem the flow of foreign students (primarily from Germany), Austria decided in 2006 to reserve 75% of places in medical faculties for students with an Austrian high school diploma. This quota-based system aims to prevent a domestic shortage of doctors as foreign graduates potentially return to their country of origin.
In contrast to physicians, mobility patterns of nursing staff are characterized by a constant net inflow of foreign-born and foreign-trained nurses from neighbouring countries. Germany is the main source of foreign-trained nurses given that German diplomas are recognized and there are no language barriers. Also, Slovakia plays an important role due to its geographical proximity and the possibility for professionals to commute. Exact numbers of foreign-trained nurses will only be available after the implementation of the registry of health and care professionals.
According to census data, the share of foreign-born nurses in Austria in 2009/2010 was similar to the average across the 22 OECD countries from which data are available (14.5%; OECD, 2015). The number has remained stable since 2000/2001, except for a short peak following EU enlargement in 2004. The majority of foreign-born nurses come from EU15 and European Free Trade Association (EFTA) countries (36%) and new EU Member States (35%). Migration of nurses and carers also plays a major role in the LTC sector (see section 5.8.1), with about 30% of home-based caregivers being foreign-born in 2012/2013 and coming mainly from Romania and Slovakia (OECD, 2015). The full extent of health workforce migration is difficult to capture because data on foreign health professionals, especially for nurses, are not systematically reported and evaluated.
4.2.3 Training of health workers
In Austria, training for all health care professions is regulated by federal law. EU legislation (e.g. the Directive on the Recognition of Professional Qualifications (Directive 2005/36/EC)) has been transposed into national law (BMGF, 2017g). Non-academic training is regulated by the BMASGK. Higher education is regulated by the Federal Ministry of Education, Science and Research (Bundesministerium für Bildung, Wissenschaft und Forschung) (e.g. by the University Act (UG 2002)), with the BMASGK also establishing guidelines for the training of health care professionals at higher education institutions (BMGF, 2017aj). For health care professions with a legal representative body (e.g. a chamber), part of the responsibility for regulating postgraduate training also lies with the representative bodies (Hofmarcher & Quentin, 2013). Continuing education is compulsory for all health care professionals; however, the required contact hours are not always clearly defined. The following sections give an overview of training and respective requirements for all health professionals; however, physicians and nurses are covered in more detail due to recent changes.
Physicians, dentists, pharmacists and other health care professionals with university education
University education of physicians is regulated in the University Act 2002 and in the Medical Training Regulation 2015 (Ärzteausbildungsordnung, 2015). Medical study programmes (human medicine and dentistry) are offered at four public universities (Vienna, Graz, Innsbruck and Linz) with a total annual capacity of 1536 places for 2018/2019 (jku 2018; medizinstudieren, 2018) and three private universities in Salzburg (75 places), Krems (50 places in 2018/2019; 70 places from 2019) and Vienna (150 places) (Ärztezeitung, 2016; sfu, 2017; pmu, 2017; FH Krems, 2017). Training of medical doctors lasts for a minimum of 6 years, with the exception of the university in Salzburg that offers a 5-year study programme, equivalent to the 6-year programmes elsewhere. Study programmes of the medical faculties are not subject to detailed regulation (the University Act defines only length of studies and ECTS-points), structure and curricula differ by university.
Admission to the study of medicine was restricted in 2006 with the introduction of a standardized test at public universities (admission examination for medical studies, EMS). Private universities defined admission requirements individually. In addition, a quota system was set up in 2006 after Austria experienced a significant inflow of German students in 2005, granting 75% of the study places to students with an Austrian secondary school leaving qualification, 20% to EU citizens and 5% to non-EU citizens. The introduction of these contingents resulted in infringement of EU non-discrimination proceedings taken against Austria (starting in 2007), which were terminated in 2017, when the European Commission declared the quota system as justified (Miko, 2017).
Postgraduate medical training is regulated by the BMASGK (Ärzteausbildungsordnung, 2015) as well as by the Austrian Medical Chamber, according to their respective areas of responsibility. In 2015, postgraduate medical education underwent an important structural reform. Postgraduate medical education for GPs and specialist physicians now starts with a clinical training of a minimum of nine months, during which graduates obtain basic competences in surgical and conservative specialties. Thereafter they undergo training specific to their chosen specialty: those wanting to become GPs enter a 33-month period (2.75 years) of practical training in a recognized training institution, which they conclude with a final exam. Those wanting to obtain another specialization enter a 63-month training period (5.25 years) in a recognized training institution (including 15–36 months basic specialty training, followed by 27- to 48-month advanced practical training and a final exam) (BMGF, 2017g; BMGF, 2017aj). Training institutions have to meet quality criteria, which are defined in the Ärzteausbildungsordnung and monitored by the Austrian Medical Chamber, which in turn reports to BMASGK.
Continuing medical education with a defined number of contact hours is compulsory for all practising physicians. The Austrian Medical Chamber is responsible for regulating, promoting and supervising the continuing education of their members and for offering special diplomas, certificates and further training courses (e.g. in occupational medicine, public health, emergency medicine and alternative medicine).
The profession of dentistry was only separated from the medical profession in 2005 with the Dentist Act (2005). Before that, dentistry was a medical specialization followed after completion of general medical training. Training of dentists takes place at a medical university, lasts a minimum of 6 years and includes clinical training. Doctors specialized in dental, oral and maxilla-facial surgery are physicians (see training above), undergoing training for this specialty (BMGF, 2017aj).
University studies in pharmacy last nine semesters in Austria. Graduation from university is followed by a practical year in a pharmacy and a final examination which entitles graduates to work as employed pharmacists. Various laws are relevant to training requirements for pharmacists, the most important being the Pharmacy Act (1906, latest amendment in 2017) and the Chamber of Pharmacists Act (2001, latest amendment in 2017) (BMGF, 2017aj). The latter also regulates continuing education of pharmacists.
Other health professionals with a university education include health care psychologists, clinical psychologists, veterinary surgeons and exercise therapists. Different academic degrees can be obtained (Bachelor’s, Master’s, Dr, PhD), which are mostly followed by education and training in a clinical setting (Aistleithner, 2017).
Training and further education of nursing professionals is regulated by the Nursing Act (2007/amendment 2016). Until 2016 nursing professionals included the professions of general nurses and assistant nurses. In July 2016, following a lengthy evaluation period of the existing law (2009–2012), the Austrian Parliament passed an amendment to the Nursing Act (2007). A new profession of assistant nurse with more competences was created, named “second level assistant nurses” (GuKG-Novelle, 2016). The previous profession of assistant nurse was thereafter renamed “first level assistant nurse”. First level assistant nurses require a 1-year full-time training, while second level assistant nurses follow 2-year full-time education in nursing schools.
The reform also adapted the professional profiles to a changing environment of service provision and requirements of the skills mix of health professionals. The overall aims of the reform of the Nursing Act were thus:
- to increase the importance of competences of care workers rather than of activities performed;
- to increase the number of nursing staff;
- to allocate the workload more evenly across the different professional groups; and
- to promote the attractiveness of the nursing profession both for young people graduating from high school as well as those already qualified to remain in their jobs.
Several studies projected that, in the absence of reform of the nursing profession, Austria would face a lack of nurses and assistant nurses in the future (Rappold et al., 2017; Zsifkovits et al., 2013).
Training as a general nurse (as of July 2018 with mandatory registration in order to practise) can be pursued both at universities of applied sciences (since 2010) and nursing schools and requires three years to complete. Currently around 80 nursing schools (usually located at hospitals) and about 10 universities of applied sciences offer nurse training programmes and/or further education (oegkv, 2017a; oegkv, 2017b; oegkv, 2017c). In addition, two private universities offer university training in cooperation with nursing schools. By 2024, all training of nurses will be gradually transferred to the tertiary educational sector. From 2024 onwards, a qualification in nursing training can only be obtained at universities of applied sciences through a Bachelor’s degree (three years, 180 ECTS), which corresponds to international standards.
Completion of continuing professional development for nursing professionals is compulsory and the responsibility of both the professional and his or her employer. Requirements for continuing development courses stipulate 60 contact hours within 5 years for general nurses and 40 hours for first and second level nurse assistants.
Other health care professionals
Other health care professionals who undergo training at universities of applied sciences (Bachelor’s degree programmes lasting for 3 years) include midwives, higher medical-technical professionals (physiotherapists, biomedical analysts, radiological technologists), dietitians, occupational therapists, speech/logopedic therapists and orthoptists.
Training of psychotherapists is varied and mostly offered by private institutions (associations, universities). Education is divided into two phases, general and specialized training. Regarding specialization, a large range of psychotherapeutic methods are recognized in Austria. Music therapists undergo training (Bachelor’s, Master’s degree programme/s) at an Austrian (public) university or an Austrian University of Applied Sciences.
Training settings and qualification periods of paramedical assistants vary. Qualified cardio-technicians undergo their training within a defined framework of employment over the course of 18 months. Medical assistants (disinfection assistant, plastering assistant, laboratory assistant, assistant prosector, operating theatre assistant, doctor’s surgery assistant, radiology assistant and qualified medical assistant) attend the school for medical assistants or a course of 650–2500 contact hours.
Masseurs train as medical and/or therapeutic masseurs. Paramedics also have a clearly defined training course ranging from first level- and second level-training (1690 to 2490 contact hours) to special emergency qualifications. Dental assistants attend a course within a 3-year training employment framework.
4.2.4 Doctors’ career paths
After completing postgraduate medical education as a GP and/or specialist physician, physicians have several career options. Requirements to practise as a physician are regulated in the Physicians’ Act (1998/2017). Physicians can either work in medical or in nonmedical settings. The latter include positions in consulting, the pharmaceutical industry, the public sector (federal, Länder, and municipal health services as well as police or military), SHI funds or schools and so on. Occupational physicians, emergency medicine specialists and doctors working for public health institutions, the police or the military service mostly follow special career paths with different entry requirements and defined (further) training.
Within hospitals, physicians usually work as employees. They start their hospital career as interns (Turnusärztinnen/-ärzte), both those in training to become GPs and those to specialize in a certain field. Physicians having trained as GPs may continue to work as assistant physicians in hospitals, usually being assigned to a ward. Specialist physicians may become “senior physicians” (Oberarzt/Oberärztin). The way in which this title is awarded is not regulated by law but is usually based on professional qualification and length of service. Sometimes senior physicians head defined wards. A specialist physician employed within a department is subject to the supervision of the department chair (chief physician, Primarärztin/Primararzt). The next career step is the position of the first senior physician (Oberarzt), who is usually appointed by the chief physician and/or hospital owner. The chief physician is responsible for a department and usually requires certain professional qualifications (in the field of medicine and management) as well as a defined background of professional experience (Mossialos et al., 2006). Chief physicians are able to supplement their income by treating patients with private supplementary insurance (“special fee class”) although reimbursement mechanisms vary considerably by medical specialty and hospital.
Specialists outside hospitals usually work on a self-employed basis in private practice with or without SHI contracts. Specialist physicians are, with few exceptions, restricted to practise within their obtained specialization. To contract with an SHI fund as a physician, defined criteria have to be met, which are agreed upon between the relevant regional medical chamber/s and SHI fund/s. Free posts are advertised via the Medical Chamber. Physicians mostly work in individual or group practices. Criteria for physicians wishing to work in primary health care units are defined by the Austrian Medical Chamber and the HVB in a contractual agreement from 2018 onwards.
4.2.5 Career paths of other health workers
Other health professionals may also work in nonclinical settings, including consultancy, research, teaching, public services, social insurance and/or for the pharmaceutical industry. The recent shift of education to universities of applied sciences has increased the relevance of research for a number of health professionals.
Due to tertiarization (shift from primary and secondary education to tertiary education) but also increased demand, new specialist and advanced roles for health professionals are developing (e.g. respiratory physiotherapy, family health nursing, advanced nursing practice or advanced occupational therapy). These are usually, as in other countries, not regulated by law.
Pharmacists can work on an employed or self-employed basis, in community pharmacies or hospital pharmacies. Five years of employment are required to obtain a licence to own and manage a community pharmacy (new or existing pharmacy). The professional licence is issued by the Austrian Chamber of Pharmacists. Further training and education is overseen by the Chamber of Pharmacists.
Nurses are responsible for the immediate and indirect care of people of all ages, families and population groups in all forms of care settings (primary health care, ambulatory (extramural) specialist care as well as hospital care) (Gesundheits- und Krankenpflegegesetz, 1997; Habimana et al., forthcoming; Weiss, 2014). They can either work on employed or self-employed basis, except for assistant nurses who cannot be self-employed. After graduation, nurses can undergo further training to specialize in a number of fields, such as psychiatric nursing and paediatric nursing, intensive care, hospice and palliative care, anaesthetic care, intensive paediatric care, renal nursing, surgical nursing, hospital hygiene, wound management and stoma care and psychogeriatric nursing (BMGF, 2017aj). Entry-level specializations as paediatric nurse or psychiatric nurse in the third year of general nurse were abolished. Potential further career options and steps for nurses involve managerial positions (e.g. as head of departments, wards or, on a higher level, as a nursing director within a hospital or a nursing home), teaching and/or lecturing or research. Also public (health) institutions and private health institutions offer career options.
Midwives can exercise their profession in various ways, working either on a self-employed basis and/or on an employed basis in hospitals, institutions of prenatal and postnatal care, for medical doctors or in medical group practices.
Most health professionals working in a therapeutic field (e.g. physiotherapists, psychotherapists, speech therapists) work on an employed and/or a self-employed basis, with sole or shared responsibility. Several of them are entitled to provide services to patients insured with SHI funds. However, patients require a referral (from a physician) for the respective services to be covered by SHI.
Masseurs can work on a self-employed or employed basis (in hospitals, in other establishments under medical management or supervision, in doctors’ practices or group practices or for physiotherapists).