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European Observatory on Health Systems and Policies

Spain


Health Systems in Transition (HiT) profile of Spain

4.2 Human resources

4.2.1 Trends in the health workforce

According to the latest figures, the primary health care workforce has remained stable since 2010. Regarding primary health care physicians and nurses, figures in 2014 slightly exceeded those in 2010 – from 75 to 76 physicians per 100 000 assigned insurees and from 62 to 65 staff nurses per 100 000 assigned insurees. The same observation is applicable to other specialist physicians working in hospitals and outpatient specialized settings; specialist physicians have increased from 176 per 100 000 inhabitants in 2010 to 189 per 100 000 inhabitants in 2014. In turn, staff nurses working in hospitals and specialized outpatient premises have remained stable at 320 staff nurses per 100 000 inhabitants (MSSSI, 2017b).

Interestingly, the number of women accessing staff positions as doctors has clearly increased since 2010: in 2015, the proportion of women reached 55.7% (5% points more) in primary health care and 49.5% in hospital settings (6.2% points more). The percentage of women in the case of staff nurses has remained stable in the same period, with 80% in primary care and 90% in specialized care (MSSSI, 2017b).

In comparison with other countries, the number of physicians in Spain follows the same growing trend as other EU countries, but far above the EU average (Fig4.2).

In the case of nurses, however, the rate remains far below the EU average (Fig4.3). According to OECD data, the ratio of nurses to doctors in 2014 is one of the lowest among the OECD countries (1.4) (OECD/EU, 2016). However, it is worthwhile highlighting that OECD data do not include nurse assistants, which in Spain have similar tasks to those attributed to associate professional nurses in other countries.

For dental care, the SNS has converged with the EU rate of dentists per 100 000 inhabitants over the past 25 years (Fig4.4), surpassing the EU average rate in 2013 with 70 dentists per 100 000 people.

Although one of the highest rates in the EU, the rate of pharmacists in Spain has increased substantially since 2010 (20%), reaching 112 pharmacists per 100 000 inhabitants in 2013, far above the EU average (82.8 pharmacists per 100 000 inhabitants) (Fig4.5).

See Box4.2 for the geographical distribution of health workers.

Finally, the rate of formal long-term care workers of 4.2 workers per 100 people aged 65 and over in 2013 is below the OECD average (6.1 per 100 people aged 65 and over) and far below that of Sweden (12.3 per 100 people aged 65 and over), the OECD country with the highest rate (OECD, 2015b).

4.2.2 Professional mobility of health workers

The most recent data on the mobility of health workers reflects the situation in 2011. At that time, 9.4% (of the 207 042 doctors) had been trained in foreign countries, most of them in Latin America, Germany and Italy. With regard to nurses, 2.1% (of 250 277) had been trained abroad, basically, Latin America, Portugal and Romania (OECD, 2017c).

In the aftermath of the economic crisis, the budgetary and personnel reduction policies translated into an increasing outflow of doctors and nurses seeking employment abroad. The SNS as a single employer was not able to absorb the number of health workers trained in the country, and the rate of unemployment rose in the health sector. As indirect evidence from the Medical Council, the number of physicians requesting a “competence certificate”, which is required to work in other EU countries, has increased up to 2016: 1380 physicians in 2011; 2405 in 2012, 3279 in 2013; 3300 in 2014; 2917 in 2015 and 3500 in 2016 (Medical Council Organization, 2017). However, many doctors ask for their competence certificate but do not then move so the exact number of migrant physicians is unknown. As countries of destination, physicians looked for employment in the United Kingdom, France, Germany, Ireland and Belgium (Medical Council Organization, 2017). Similar behaviour was observed in the case of nurses; between 2010 and 2013, 4580 nurses requested their “competence certificate” from the Ministry of Education; in 2014, 8000 nurses were working abroad. In this case, main destinations were the United Kingdom, France, Italy, Portugal and Belgium (Galbany-Estragués & Nelson, 2016).

4.2.3 Training of health personnel

Since 2010, a significant change of health personnel training was debated and has materialized in the RD 639/2014, affecting postgraduate medical internship programmes and regulating nurses’ specialization. Unlike the current system, with 46 medical specialties having separate medical internship programmes, the reform sought to establish a common 2-year training programme for postgraduate trainees before splitting into subspecialties for most of the medical specialties. This reform aimed to provide a common holistic base of knowledge for all health professionals in a way that improves their response to their patients’ complexity, mitigating care fragmentation and overcoming the current silo mentality that impedes flexibility in human resources management. The reform raised much controversy as some medical specialties were strongly opposed to entering the core modules of the medical or surgical specialties. The reform process has ended up in the courts of justice with a Supreme Court ruling declaring the RD 639/2014 void, leaving the current previous legislation in place (see section 5.2 in García-Armesto et al., 2010).

4.2.4 Health workers’ career paths

Very minor changes have been observed with regard to health workers’ career paths in the last 10 years. Notably, the upgrading mechanisms foreseen in Law 44/2003 on Regulation of Health Professions that implied salary complements endured strong restrictions as a consequence of austerity policies, although unevenly across ACs.

Meanwhile, it is worth noting that new regulation on the role of nurses in prescribing was issued in 2015 through RD 954/2015, which has not yet been implemented.

In the context of a shortage of some medical specialties, the Interterritorial Council mandated the Spanish Ministry of Health to increase the vacancies for the Medical Internship Programme (MIR), the nation-wide specialisation programme which provides entitlement for practicing in the NHS. Consequently, there will be up to 7,512 MIR vacancies in 2020, representing 715 more positions than the previous year (10.5% increase). The largest medical specialty will be Family and Community Medicine with 2,205 vacancies (15% increase), followed by Paediatrics with 481 vacancies (11%), Anaesthesiology with 382 (11%) and Internal Medicine with 353 (6%).

Besides, the number of vacancies for nurse training are expected to increase by 35%, reaching 1,463. As in medicine, the greatest nursing specialty will be Family and Community Medicine with 521 vacancies (a 54% raise), followed by Gynaecology-Obstetrics with 401 (6%) and Paediatrics with 188 vacancies (41%).
Accordingly, all the Autonomous Communities have increased their offer of training positions. Those experiencing the greatest increase are the Balearic Islands (40% increase), Navarra (32%), Extremadura (28%), Castile Leon (27%) and Aragon (22%).

More information (in Spanish):
https://www.mscbs.gob.es/profesionales/formacion/necesidadEspecialistas/doc/20182030EstimacionOfertaDemandaMedicosEspecialistasV2.pdf
http://www.mscbs.gob.es/gabinete/notasPrensa.do?id=4624

A new legal text has been approved (Royal Decree 1302/2018) regulating nurse prescribing after the difficulties in the implementation of RD 954/2015 (see Reform Log 04.12.2017). 

According to the new legislation, which has become effective 24th October, nurses are now entitled to make the indication, utilize and provide prescription drugs, subject to the existence of protocols and clinical guidelines that should specify in which cases prior medical validation is needed. Those protocols and clinical guidelines will also detail both the specific responsibilities for doctors and nurses as well as the collaborative ones, to guarantee patients’ safety and continuity of care.

Additionally, nurses will be generally able to prescribe those vaccines included in the official vaccination calendar or those related to specific vaccination campaigns.

In order to prescribe, staff nurses will be required to obtain an accreditation by the corresponding Regional Health Authority in their Autonomous Community. This entails either demonstrating professional experience of at least one year in the corresponding health care sector, or having passed a specific training programme.

More information (in Spanish):
https://www.boe.es/diario_boe/txt.php?id=BOE-A-2018-14474

According to the last report released by the Royal College of Physicians and the Spanish Council of Medical Colleges, the number of medical schools in Spain has increased substantially in the last 8 years, from 28 in 2010 to 46 in 2018. These figures have resulted in 7,000 new graduates every year in the country.

However, the number of new graduates does not match the number of vacancies in Medical Internship Programmes (Médico Interno Residente, MIR), the nation-wide specialisation programme that provides entitlement for practicing in the National Health System. As a consequence, in 2017 around 14,448 graduates applied to access the MIR programme while there were only 6,513 vacancies.

This is concurrent with an unbalanced replacement rate – doctors that will get into the MIR system to doctors in retirement – that is feared to result in a shortage of medical doctors for some specialties if the mismatch between number of graduates and number of MIR vacancies persists, as well as a paradoxically increasing the migration flow of new graduates. 

More information (in Spanish) here: http://www.cgcom.es/sites/default/files/estudio_demografia_2017