Recruitment and Retention of
Health Care Providers in
Remote Rural areas
Status report for ICELAND
Bjarni Jónasson
Einar Rafn Haraldsson
Hildigunnur Svavarsdóttir
Jón Helgi Þórarinsson
Sigurður E. Sigurðsson
Stefán Þórarinsson
Contents
1
Introduction....................................................................................................................... 3
2
Geography ......................................................................................................................... 3
3
Demography ...................................................................................................................... 4
4
The organization of the health care services .................................................................... 5
4.1
Primary health care ........................................................................................................... 6
4.2
Hospitals / Specialized service ........................................................................................... 6
5
Health care professionals .................................................................................................. 7
6
Urban area ......................................................................................................................... 8
7
Education and training ...................................................................................................... 9
7.1
Medical education ............................................................................................................. 9
7.2
Nursing education.............................................................................................................. 9
7.3
Pre-hospital education ...................................................................................................... 9
7.4
Other health care education ............................................................................................. 9
7.5
Continuing education ........................................................................................................ 9
8
Recruitment / Retention problems ................................................................................. 10
9
Summary ......................................................................................................................... 10
Attachment 1
Attachment 2
Attachment 3
Figure 2
Figure 1
Comparison of service between health care centres ...................................................... 11
Hospitals / Health care centres in North and East area .................................................. 12
Turnover rate in Akureyri hospital ................................................................................. 13
Age distribution of population .................................................................................................. 4
Health care region in Iceland..................................................................................................... 6
Table 1 Change in populations and regions .................................................................................................. 4
Table 2
Population distribution.............................................................................................................. 5
Table 3
Employment status last five years............................................................................................. 5
Table 4 Description of health care group................................................................................................... 7
Table 5 Distances ....................................................................................................................................... 8
Table 6 Population and population growth ............................................................................................... 8
2
1
Introduction
The aim of this report „Recruitment and Retention of Health Care Providers in Remote Rural areas“ is to
provide information about the situation in Iceland (north and east part of the country) regarding
recruitment and retention. The report will also provide baseline information for future comparisons and
work in order to produce accurate data on the motivating and de-motivating factors affecting
recruitment and retention of health care workers. The structure of this report includes general
information of the country, the organisation of the health care services and health care staff and finally
some discussion about the pertinent problems with recruitment and retention of health care workers.
2
Geography
Iceland is the second-largest island in Europe, approximately 103.000 km2. It is located east of Greenland
and immediately south of the Arctic Circle, atop the divergent boundary of the Mid-Atlantic Ridge in the
North Atlantic Ocean. About half of Iceland's land area, which is of recent volcanic origin, consists of a
mountainous lava desert (highest elevation 2,112 m above sea level) and other wasteland. Eleven
percent is covered by three large glaciers. Twenty percent of the land is used for grazing, and only 1% is
cultivated. The inhabited areas are on the coast,
particularly in the southwest; the central highlands
are totally uninhabited. Because of the Gulf
Stream's moderating influence, the climate is
characterized by damp, cool summers and
relatively mild but windy winters. In Reykjavík, the
average temperature is 11°C (52°F) in July and 0°C
(32°F) in January.
The defined area for the Recruit and retain project
covers North and East Iceland. The size of the
Northern regions (North-West/North-East) and
Eastern area is approximately 53.000 km2 or 51% of
Iceland. Common trends of the area are long
distances between settlements, often serious
difficulties in travelling by car during winter, due to snow and mountain roads. Public transport is not
sufficient.
The North-West region covers 12.800 km2 and the population is around 8.000 with 33% or 2.600 living in
Sauðárkrókur. Smaller villages (500+) are Blönduós (1.000), Hvammstangi (600) and Skagaströnd (500).
About 59% or 17.000 of the 29.000 inhabitants in the North-East region (22.000 km2) live in Akureyri, the
biggest town of the area. Smaller towns/villages are Husavik with 2.300 inhabitants, Dalvík (1.500),
Siglufjörður (1.200) and Ólafsfjörður (800). The Eastern Area is 22.700 km2 and populated with 10.200
people, 26% or 2.700 living in Egilsstaðir, smaller villages (500+) are Neskaupstaður (1.400),
Reyðarfjörður (1.100), Eskifjörður (1.000), Seyðisfjörður (670), Fáskrúðsfjörður (660) and Vopnafjörður
(530).
3
3
Demography
The general trend concerning migration has been that people are moving to the Capital region from the
countryside. At January 1, 2005 62,8% of the population lived in the Capital region and this figure has
increased to 63,3% at January 1, 2010.
Table 1 Change in populations and regions
Population
Distribution
2005
2010
Change
2005
2010
Change
Total population
293.577
317.630
8,2%
Capital region
184.244
200.907
9,0%
62,8%
63,3%
0,8%
Suðurnes
17.110
21.359
24,8%
5,8%
6,7%
15,4%
West
16.654
17.543
5,3%
5,7%
5,5%
-2,6%
6.643
6.305
-5,1%
2,3%
2,0%
-12,3%
North
34.843
35.178
1,0%
11,9%
11,1%
-6,7%
East
10.073
10.373
3,0%
3,4%
3,3%
-4,8%
South
24.010
25.965
8,1%
8,2%
8,2%
0,0%
North and East
44.916
45.551
1,4%
15,3%
14,3%
-6,3%
West fjords
Figure 1
Age distribution of population
Age distribution, Iceland,
2010
90
72
54
36
18
<1
-4,000-2,000 0
Women
Age distribution, Capital
region, 2010
Age distribution, N- and
E-Iceland, 2010
91
73
55
37
19
1
90
72
54
36
18
<1
2,000 4,000
Men
-2000
0
Women
2000
Men
-500
0
Women
500
Men
4
Table 2
Population distribution
January 1, 2010
Population aged 15 and below
Population aged 65 and above
Iceland
22,4%
12,0%
Capital region
21,9%
11,7%
North and East
22,8%
13,7%
Life expectancy at birth, years: men 79,4, women 82,9, average 81,2. Infant mortality rates, (deaths
per 1000 live births): 2,0
Table 3
Employment status last five years
Monthly unemployment - Iceland
Capital region
Suðurnes
West
West fjords
North
East
South
4
2005
2,1%
2,2%
2,3%
1,0%
1,8%
2,5%
1,0%
1,5%
2006
1,3%
1,2%
2,1%
0,7%
1,2%
2,0%
0,5%
1,1%
2007
1,0%
0,9%
2,5%
0,7%
0,9%
1,5%
0,4%
1,0%
2008
1,6%
1,5%
3,7%
1,4%
0,5%
2,0%
0,8%
1,5%
2009
8,0%
8,8%
12,8%
5,0%
2,1%
6,2%
3,6%
5,8%
2010
8,1%
8,9%
13,1%
5,0%
3,2%
5,8%
4,4%
6,0%
The organization of the health care services
The Icelandic health care system can be described as universal, comprehensive and mostly financed by
general taxation. The Health Services Act that came into force in 1978 accorded all citizens of Iceland
access to the best health care services at any given time for the protection of their mental, physical and
social health. Iceland is split into seven health care regions and this project deals with two regions i.e.
the north and the east region (see figure 1).
5
Defined area for the
Recruit and Retain
project
Figure 2 Health care region in Iceland
4.1
Primary health care
Each health care region has its own primary health care centres, some of which are run jointly with the
local community hospital. A health care centre is provided for each designated area of the country, and
all inhabitants are entitled to seek medical assistance at the health care centre most easily accessible to
them at any given time. Patient transport system from health care centres to bigger hospitals is in place
with transport by ground or air ambulances. See attachment 2, page 12.
4.2
Hospitals / Specialized service
Hospitals fall into a few categories according to Icelandic law. There are a few types of hospitals,
university hospitals, regional hospitals, and so-called general hospitals, with specialists in surgery,
medicine or general practice. Many of the general hospitals are now primarily nursing homes, with only a
few beds for observation and simple medical treatment. The main hospital is the National University
Hospital in Reykjavík which operates emergency departments with about 100.000 visits per year. They
operate the main triage group according to the contingency plan and this group can be ready to go
throughout Iceland if needed. There are a few hospitals / health care centres in the defined area:
In the North:



Akureyri hospital has 120 beds with specialized services.
Health care institution in Husavik (HÞ) has 12 beds intended for minor medical problems and
recovery from surgery. General Practitioner (GP) is on call 24/7. There is one medical specialist
(gastroenterologist) attending
Health care institution in Sauðárkrokur (HS) runs xx beds intended for minor medical problems
and recovery/rehab after surgery. Midwifes run a separate independent local services.
6





Health care centre in Fjallabyggð (HSF) runs a hospital in Siglufjördur. There are Xx beds intended
for minor medical problems and recovery/rehab after surgery.
FSA is a secondary hospital. All others are primary or less.
FSA runs on call duty 24/7 in surgery, medicine, psychiatry and Gynaecology / Obstetrics. All
others are serviced by GP 24/7.
There is a specialized reception outside the Akureyri hospital and health care centres.
Læknastofur Akureyrar (located in Akureyri) run operating services in day care i.e. orthopaedics,
urology and general surgery (3000 procedures/year). There are also receptions in neurology,
orthopaedics, ENT, GYN, psychiatry and rehab.
There is a visiting specialized health care professionals to the area (frequency, speciality)
o See attachment 1 (page xx).
In the East:



5
FSN hospital in Neskaupstaður, regional hospital with 23 beds, runs 24/7 in surgery, medicine
and maternity ward.
Health care institution in Egilsstaðir (HS) runs 4 beds intended for minor medical problems and
recovery/rehabilitation after surgery serviced by GP 24/7
There are visiting specialized health care professionals to the area (frequency, speciality). See
attachment 1 (page 11).
Health care professionals
Health care group
HSÞ
Pre-hospital
FSA /HAK
HSF/Dalvik
HSS
HSB
HAS*
14 with
manpower
of 22, in all 6
teams
On call 24/7
11 GPs on
call 24/7
5 GP´s
On call 24/7.
Medical
X ray 8-16.
Lab 8-16
A&E 24/7
with on call
medical
specialists
(~50) (surg.,
medic., GYNOB, psych.,
anesth/ICU).
3 GP´s
On call 24/7.
5 GP´
On call 24/7
2 GP´s
2 midw.
X-ray and lab
8-16.
On call 24/7
12 GPs, 5
consultants
(intern,
anaest.,
dermatol.
surgeon)
X-ray and lab
Nursing
46 FT eqv.
Allied health care
180 FT eqv.
Total
248 FT eqv.
Turnover rate
4,6% (att 3)
3-4%
*Eastern part of the country has combined health care services while the service in the northern part is still fragmented
Table 4
Description of health care group
7
6
Urban area
Reykjavík is Iceland´s capital. Reykjavík and its surrounding towns i.e. the Capital region will be used
for our comparison to the North and East areas. Reykjavík is the national centre of commerce,
finance, population and governmental activities. The Greater Reykjavík Area “the Capital region"
(marked red in the picture) is a name used collectively for Reykjavík and seven municipalities around
it. The area is the largest urban area in Iceland. Approximately 37% of the population lives in the
capital, and 63% in the capital and neighbouring communities. With a population of approx. 200
thousand, in an area of 1.062 km2 (density 187,4 pr. km2)
that is only just over 1% of the total size of the country.
Population of the area has been growing ahead of the
country´s population growth. Two universities with over
85% of Universities students, University of Iceland and
Reykjavík University, are both in the capital. Reykjavík is
the centre for most of the educational institutions for
healthcare professionals and is the location for Iceland´s
main hospital “Landspítali – The national University
Hospital in Iceland”. Next urban areas to the capital are overseas – England, Norway, Denmark
within 3 hrs flight from Reykjavík.
Table 5 Distances
Distance km, Greenland
Distance km, Faroe Islands
Distance km, Jan Mayen
Distance km, Scotland
Distance km, Norway
287
420
550
798
970
Table 6 Population and population growth
2005
2006
2007
2008
2009
2010
293.577
299.891
307.672
315.459
319.368
317.630
- growth from 2005
2,2%
4,8%
7,5%
8,8%
8,2%
- growth, prev. year
2,2%
2,6%
2,5%
1,2%
-0,5%
Total population*
Capital region
187.426
191.919
197.945
201.251
200.907
- growth from 2005
1,7%
4,2%
7,4%
9,2%
9,0%
- growth, prev. year
1,7%
2,4%
3,1%
1,7%
-0,2%
62,5%
62,4%
62,7%
63,0%
63,3%
% of total population
184.244
62,8%
*As of January 1.
8
7
7.1
Education and training
Medical education
The Faculty of Medicine is a leading teaching and research institution in the field of medical science
in Iceland. The Faculty has a strong connection to the Landspítali – The national University Hospital in
Iceland, giving the students opportunity to excellent training and work experience. The Faculty
graduates 40 doctors per year. To gain full licensure, medical students must complete 6 years of
undergraduate medical education, followed by a compulsory 12-month clinical training program.
Although Icelandic medical students must complete 7 years of training to receive full medical
privileges, they are granted an attenuated license to practice as general practitioners after their fifth
year. This license gives them full prescribing privileges (except for specific medications restricted by
specialty) and allows them to work during their summer vacation. Many choose to work in a rural
part of the country and take over the practice of a small-town physician.
7.2
Nursing education
There are two schools of nursing in Iceland, one in the University of Akureyri and one in the
University of Iceland. Studies in nursing require four years and lead to completion of the B.Sc.
degree. You can study nursing at a master´s level at both universities and University of Iceland has
also doctoral programmes. A programme in Midwifery is also available at the University of Iceland.
Currently nursing is taught only on the spot in the University of Iceland (located in the capital) but
the University of Akureyri offers also distance learning available to students which means that
students from rural areas have had the opportunity to study at the faculty. It has become evident
that graduated nurses from the University of Akureyri are more like to settle and work in the rural
areas compared to graduated nurses from the University of Iceland.
7.3
Pre-hospital education
The Centre for Emergency medical technicians is located and operated from the Akureyri hospital
since November 2002, previously and initially run by the Red Cross since 1996. The main aim of the
Centre is to provide the best basic, continuing and further education for the Icelandic EMT´s. The
basic education takes 128 hours and then after 3 years of work they can add 317 hours to their basic
education. The Centre offers distance learning available to students which mean that students from
rural areas have the opportunity to train as EMTs and that has made a huge difference for the rural
areas.
7.4
Other health care education
Other types of health care education can be studied in Iceland, mainly at the University of Iceland.
Most of the health care professionals are trained at a university level apart from auxiliary nurses,
secretaries etc. Most university studies take minimum 4 years at Bachelor level.
7.5
Continuing education
It differs between health care professionals how strong continuing educational support is. Most
professionals can seek support, financially by their professional union / association.
9
8
Recruitment / Retention problems
Organisations of health-care professionals and the Directorate of Health have reported “Shortage of
health-care professionals” in the coming decade. There may be a shortage of professional and expert
knowledge among health-care workers such as nurses, nurse assistants, laboratory technicians and
general practitioners. It is of vital importance that these organisations, the authorities and educational
institutions find a solution to this problem. There are also signs that health-care workers are seeking
work abroad because of better wages1. In shortage the rural areas suffer first. It might be considered
that there is a change in the education of doctors and even nurses with increased specialisation so the
“all-round” surgeon or medical doctor is disappearing.
9
Summary
Specialised health care professionals seem to be migrating from rural areas. In the northern part of
Iceland during the last two decades, specialised doctors locally have all disappeared from the smaller
communities. In the only specialised care hospital in the area there is a chronic shortage of doctors in
some specialities for example paediatrics and pathology. In other specialities there is intermittent
shortage on regular bases solved with short term hiring when possible. The nursing situation is
considerably better especially after the establishment of the nursing faculty in the University of Akureyri
(established 1988). Midwifery service has changed in the rural area from delivering babies in the past to
providing anti- and postnatal care.
1
ANNUS MEDICUS 2009. ICELAND. EXTRACT FROM THE ANNUAL REPORT OF THE DIRECTORATE OF
HEALTH 2009. August 2010
10
Attachment 1 Comparison of service between health care centres
11
Attachment 2 Hospitals / Health care centres in North and East area
Hospitals (Secondary hospital in Akureyri) / Tertiary in Reykjavik
Health care centres with hospital beds
Primary health care centres / nursing homes
Small hospitals with specialised service – on call 24/7
12
Attachment 3
Turnover rate in Akureyri hospital
2010
FSA – all
professions
2009
2008
Turnover
rate
Mean nr of
staff
Turnover
rate
Mean nr of
staff
Turnover
rate
Mean nr of
staff
4,6%
587
9,0%
602
10,6%
650
FT employers
equiv.
FT employers
equiv.
FT employers
equiv.
Nurses
4,2%
165
9,7%
170
8,4%
179
Consultants
3,8%
52
9,4%
54
7,5%
52
13
2010
FSA – all
professions
2009
2008
Turnover
rate
Mean # of
staff
Turnover
rate
Mean # of
staff
Turnover
rate
Mean # of
staff
4,6%
587
9,0%
602
10,6%
650
FT employers
equiv.
FT employers
equiv.
FT employers
equiv.
Nurses
4,2%
165
9,7%
170
8,4%
179
Consultants
3,8%
52
9,4%
54
7,5%
52
14