LAUSR

There is a growing consensus that most Organisation for Economic Co-operation and Development (OECD) nations have more than enough doctors to meet health needs, but that some need is not met because of the distribution of these doctors, from a training to service perspective, and demographically, ethnically, geographically and disciplinarily. Most governments, health administrators and media do not appear to understand the situation well as the usual response is to advocate for and to increase the overall doctor supply. This is expensive, distracts funding from processes to understand the health need, and the consequent development of innovative models of care, such as virtual healthcare approaches, may compromise the quality of doctor experiential (i.e. apprenticeship) training and actually reduce health system efficacy, and, with three probable exceptions, has not been successful. Canada and Australia are current examples of a consequent over-supply of doctors viewed from a system learnerand employment-capacity viewpoint. The ‘mal-distribution’ consensus is largely presumptive, at least in part because the need for doctors is not known explicitly for any health system and given that the need for doctors is entirely dependent on what the doctors actually do. There is certainly no basis for arguing that there is a global shortage of doctors in the OECD nations. For example, unmet health need is measured explicitly in the European Union (EU). In countries such as France, Germany, the Netherlands, Sweden, Switzerland and the UK, most unmet health need is due to nonhealth system factors. In addition, comparing doctor to population ratios and capitated health funding for these countries, strongly suggests that significantly increasing the total number of doctors or the global health budget, in isolation, would not reduce the unmet health need arising due to service affordability, accessibility, availability and acceptability factors. Doctor to population ratios, considered regionally, ethnically or socio-economically, provide only weak support for the case that there is a ‘mal-distribution’ of doctors. The weakness arises, as the desirable ratio is unknown such that perceived shortages may be artificial constructs given that the comparative norm might represent an actual over-supply. More impressive support for a ‘mal-distribution’ is derived from considering disparities in: disease detection and intervention rates; outcomes such as survival and morbidity; unemployment rates due to health issues; and, even in gross measures, of which life expectancy is the most obvious. Three conclusions are possible. First, an explicit understanding of health need and the generators of unmet need are essential for any sensible health investment. Second, the role of the doctor needs to be a positive construct and not a deconstruction of current roles, which too often results in doctors surrendering functions that they find undesirable and/or unprofitable. A noteworthy, but yet to be published, experience in a region of apartheid-era South Africa, was that effective public health was provided for as many as 4 million people by 40 doctors or less. The role of these doctors was constructed by way of identifying only those tasks that someone who was a doctor could undertake – eventually largely confined to patient differentiation and making clinical decisions under conditions of uncertainty. The subject of this editorial is the third conclusion. There are at least seven steps, which will ‘redistribute’ doctors to meet health needs better and it is probable that all seven will require attention for any likely success. What is also apparent is that although an oversupplied medical labour market creates a desirable milieu for changing how medical services are funded and will reduce reliance on international medical graduates, it will not, by itself, generate a desirable redistribution of doctors. The seven steps will be discussed here in chronological career order, rather than in any order of likely impact. Step 1: Recruit medical students who are most likely to take up ‘desirable’ careers and to work in locations where there is a high level of unmet health need. The best data in this context exist for preferential admission schema for regional and rural-origin students and subsequent uptake of careers with a general scope of practice in regional and rural settings. However, the three most impressive examples of this – the Northern