Throughout the COVID-19 pandemic, the confined population constantly praised the work of health professionals who worked tirelessly every day to make sure patients received the care they needed.
However, as the lockdown came to an end and we returned to a semblance of normalcy, the scarcity of healthcare staff in Luxembourg has become more and more pronounced, leading to heightened tensions within healthcare organisations in the Grand Duchy and neighbouring countries, further reducing the capacity to care for patients.
Those tensions have existed for a while though, especially the demographic tension as 65% of healthcare workers* in Luxembourg are residents of neighbouring countries. While this isn’t surprising given that cross-border workers account for 46% of the country’s workforce, this “dependency” can be perilous, in particular when facing a pandemic.
In the initial days of the COVID-19 crisis, the Grand Duchy faced a significant risk of lacking essential resources to combat the pandemic because of the possibility of cross-border health workers not being allowed to cross borders due to security concerns.
Consequently, there was a risk that these crucial health professionals would be constrained to work within their respective countries of residence, addressing local health needs rather than contributing to the Grand Duchy’s pandemic response.
The outlook to solve the demographic issue isn’t encouraging, making it difficult, if not impossible, to achieve the health system resilience objectives the World Health Organization set in 2021.
Assessing the state of Luxembourg’s healthcare sector workforce
In light of the numerous challenges regarding Luxembourg’s healthcare sector workforce in the post-COVID era and in perspective with the action plan of the new government, we decided to independently launch in 2023 a study titled ‘The state of Luxembourg’s healthcare workforce: Findings, challenges and prospects’.
The study consists of quantitative and qualitative data collected through interviews and an online survey with the participants. Additionally, we examined the existing literature on the topic to put the collected data into context.
Participants to the study represent 70% of the entire Luxembourg health sector including hospitals, elderly care homes and home care institutions, laboratories, as well as public sector institutions and associations.
According to all the healthcare representatives we met during this study, the situation is all the more urgent to address as the population is growing (over 81% since 1980 and over 35% expected until 2050), living longer, in greater numbers and developing chronic illnesses that need to be treated throughout life. Statista (2022) predicts that 18.4% of Luxembourg’s population will be aged over 65 in 2030 (compared to 14.4% in 2021) and 26% in 2050.
In this blog, we examine the main outcomes of the study revolving around Luxembourg’s healthcare sector workforce, highlighting issues such as personnel shortages, training capacities, high dependency on neighbouring countries, and work-life balance.
Based on insights from the study participants, we also provide possible solutions, including an international training project, task-shifting, digitalisation, and the coordination of patient pathways.
1. An insufficient number of doctors to guarantee the population’s good health
Luxembourg’s 2023 National Health Plan foresees the need to renew and recruit more than 1,200 doctors by 2030. The objective is quite ambitious—meaning, difficult to achieve—for a number of reasons.
One of them is the fact that medical studies at the University of Luxembourg are only able to provide six semesters of training for medical students, when in fact the full training takes between 10 and 12 years to complete. This means that after the six semesters, students have no other option but to go abroad to continue their medical study.
Moreover, 65% of doctors in Luxembourg are expected to retire by 2034, and 30% of medical students who go to train abroad—because, as aforementioned, they are obliged to do so—don’t return to Luxembourg.
The absence of a university hospital centre in Luxembourg also constitutes an obstacle to the development of skills in the country and even leads young Luxembourgish doctors to stay abroad.
It is the doctors residing abroad (for instance, France, Germany and Belgium) who cross the border every day to provide care in the Grand Duchy that are making up for the current and emerging difficulties. In fact, more than 26% of doctors practising in Luxembourg are non-residents, compared to 16% in 2008. But as we have seen, this isn’t sustainable.
In addition, healthcare personnel and organisations interviewed express that the medical profession also faces numerous practical difficulties, including:
- Too much administrative work and not enough use of digital and technological solutions to facilitate their work with patients.
- Too many on-calls and on-call duties for a generation of doctors who no longer wish to work as many hours as their elders.
- Pathways that are too hospital-centric and insufficiently coordinated with independent healthcare professionals.
Furthermore, according to some human resources (HR) managers we met, for equivalent work, they “need more doctors today because they tend to work eight hours and no longer 12 hours as before”.
This situation worries healthcare organisations and laboratories, especially since things among non-medical personnel, nurses, radio technicians, among others, aren’t much better.
2. The demographic prospect for nursing staff isn’t favourable either
A need for 3,800 nurses by 2030
The professional associations and hospital federations are categorical: “We already have vacant positions, and with future retirements the needs (3,800 nurses by 2030 as announced by the Ministry of Health) will be difficult to satisfy”.
They add that nurses’ current roles and tasks are no longer adapted to modern medicine: “They could be more useful in more technical activities with higher added value for patients […]. Moreover, Luxembourg is 30 years behind on outdated roles and responsibilities.”
The question of the “tout-infirmier”—a term used in Luxembourgish public discourse to describe the health system’s reliance on nurses to perform all sorts of jobs even if these could be performed equally well by profiles with lower qualifications such as caregiver—has become an acute problem given the current need for reinforcements in all sectors of health, hospital, independent healthcare practices, and in aid and care organisations. Unsurprisingly, this point was quickly raised during the interviews.
Mainly structured around the nursing profession, the care of patients in health institutions requires the availability of large and reinforced teams of nurses. However, the caregiver role at the hospital isn’t properly defined as it’s more common in care homes or disability and dependency care facilities.
Two-thirds (65%) of healthcare workers are non-residents of Luxembourg: A dependence that is a source of fragility for the health system
Beyond the large share of cross-border workers working in healthcare organisations in Luxembourg, it’s easy to understand that the cost of living (housing, daily expenses, among others) can also be an obstacle to the long-term settlement of trained personnel in Luxembourg.
Without being able to find accommodation close to the workplace, staff are subject to transport constraints that make up the daily life of cross-border workers – such as waking up at dawn, traffic jams, delays, stress – and eventually give up working in the Grand Duchy.
A necessary review of the healthcare profession to meet the aspirations of staff looking for a better work-life balance
Since the end of the COVID-19 pandemic, societal developments have led people to seek activities with fewer constraints and a better work-life balance, and the health sector is no exception.
The new generations’ tolerance to the weight of constant care and professional activities on weekends, nights and public holidays is decreasing. And yet this situation comes up against the urgent need to ensure continuity of round-the-clock care.
Insufficient training to address the system’s significant resource needs
One of the major points when it comes to the workforce issues is training, where there is a need for the harmonisation of programmes and practical training courses between the countries that form the Greater Region. However, the main concern is the size of the student cohorts.
According to the Ministry of Health, 60 general care nurses are trained each year. To this number we should add the specialised personnel (operating room, anaesthesia, childcare) whose training was introduced in September 2023 at the University of Luxembourg.
These measures go in the right direction and aim to increase the contingents trained in Luxembourg to reduce dependence on foreign countries. But this rate remains insufficient to reach the 3,800 nursing staff expected in 2030, and it won’t be able to increase drastically simply because of the small size of Luxembourg’s population.
Several stakeholders interviewed summarise the situation as follows: “The convoy to train nurses for 2030 has already left, but this is not an argument for ignoring the subject of their training. We know what we need now but we lack a plan.”
So, continuing to recruit resources trained abroad thanks to high salaries is a possibility, but the collateral risks of this policy are major.
The risk of pursuing a policy of acquiring resources from abroad and dependency constitutes a risk of disruption to the provision of care in Luxembourg, and the Greater Region.
Given what we mentioned above, Luxembourg, and more generally the Greater Region, face a risk of disruption in the provision of care in all areas: hospital, medico-social but also independent healthcare practice.
Such a situation will lead to major tensions around competition on remuneration between the four countries. These tensions will have collateral effects on the financial and workforce capacities of the Greater Region’s health system.
By offering higher salaries, Luxembourg’s needs can probably be met, at least periodically, but this will be at the cost, on the one hand, of an increasing staff turnover because of the country’s cost of living, and on the other hand, a depopulation of the hospital supply in the regions close to the Luxembourg border (Moselle, North of Meurthe et Moselle, Sarre, and Belgian Ardennes).
Once healthcare organisations in these regions have lost their resources and skills, the populations will have no other choice than to head towards the centres remaining open. They will, therefore, go to Luxembourg, a country that will have been able to recruit, thanks to attractive salaries, some of the staff that were previously working in the establishments in their country of residence.
For example, many medical departments at the hospital in Thionville, France, or Saarbrücken, in Germany, have been closing completely or partially for several years due to the lack of resources, often recruited in Luxembourg.
The risk of collapse of hospital supply in the Greater Region, including in Luxembourg, therefore constitutes a major political issue that calls for strong and concerted action at the Greater Region level.
We, at PwC Luxembourg, propose an approach that incorporates some of the ideas suggested during the interviews, but we have also defined a vision to change the Grand Duchy’s healthcare system, which should be part of a broader and more ambitious action plan for the Greater Region.
3. The necessary commitment to a global action plan
The new Luxembourgish government, formed in 2023, has already envisaged a number of measures to transform the health sector to make it more robust and resilient. While these measures seem to be steering it in the right direction, we wonder if the pace of change is fast and efficient enough to meet the challenges.
As mentioned, we took up several proposals from stakeholders in the field, who were able to express their vision as well as expectations for the new government through our study. What is clear is that beyond the 2023 National Health Plan, we need a commitment to a global action plan, covering the challenges of both Luxembourg and the Greater Region. It includes four major pillars:
A university partnership project for the Greater Region, to build a common training programme and increase the number of personnel trained
Investing in medical training across the Greater Region.
Train, and quickly. This is the main objective put forward by all the healthcare representatives we met. There aren’t enough professionals available to cover all the vacant positions, so more need to be trained.
Given the quantitative objectives, a common action by the four countries of the Greater Region appears in the interviews as the most likely solution to meet the increasing needs of healthcare personnel in the region. The stakeholders unanimously support this vision, which they consider ambitious and pragmatic. But how can it be done?
This highly political commitment calls for at least a common position from the Ministries of Health and Social Security, and of Research and Higher Education of Luxembourg, but also the collaboration between the neighbouring countries’ governments, which should meet annually in an intergovernmental committee.
If several scope and implementation models can be considered, contracted and financed, the target could be the following:
1.Train more doctors in the Greater Region by creating:
- Additional places financed by Luxembourg in the universities of the Greater Region (Luxembourg, Lorraine, Liège and Hombourg);
- A common educational project, and a path allowing young people trained in the Greater Region to come or return to Luxembourg.
2. Identify within the Greater Region organisations hosting medical students to provide practical training courses. It’s then appropriate to define specifications and expectations in terms of training to determine which organisations are eligible for the project and for welcoming students, while guaranteeing that this international internship is valid for the student’s study programme, and not counted in the 12 months of compulsory international training.
As part of this project, Luxembourg could also consider making one of its healthcare facilities a university hospital, such as the ‘Centre hospitalier de Luxembourg’, for example, which is already in a close partnership with the University of Luxembourg for medical training. This commitment towards a true university label would be a major step to strengthen medical training in Luxembourg.
Towards a European school of health training.
In September 2023, the University of Luxembourg set up four specialised training courses for healthcare professionals: Operating Room, Anaesthesia, Psychiatry and Pediatrics. Over the coming years, the plan is to reinforce this offer for the professions of Laboratory, Imaging, and Comfort Care for patients (caregiver), which should bring the number of nurses in training to 140 every year.
However, as we have seen, the current trend, although encouraging, doesn’t meet the target of 3,800 nurses by 2030. To increase the contingent of future professionals to be trained, it appears difficult to limit the commitment to training only candidates living in Luxembourg, due to its total population of 660,000 inhabitants.
In this context, health stakeholders agree that a project coordinated across the Greater Region is the path to take, aligned with universities and hospitals in the region. The University of Luxembourg already encourages students to complete one or more practical internships in healthcare facilities in the Greater Region. Additional action could consist of opening more training places for general care nurses in Luxembourg and welcoming training candidates from other countries.
In addition, harmonising educational training programmes, in line with the European standards, could contribute to standardising professional good practices across the Greater Region. Luxembourg’s national association of nurses supports this, in particular to “improve the working conditions of field teams, preserving the technicality of their profession and modernising their working conditions”.
Better distribute activities between healthcare staff and encourage delegation of care
While this practice has become commonplace in certain countries, such as France, Belgium and Great Britain, Luxembourg hasn’t yet introduced the advanced practice model requiring revised competencies and responsibilities to better distribute them between healthcare staff.
This would involve entrusting specifically trained nurses with tasks previously carried out by doctors, such as prescription renewals, certificates of fitness to play sports or more technical monitoring activities, and supervision of chronic patients (diabetes, chronic kidney disease or cancer). In this way, doctors could focus on more complex activities, and save precious time.
Now you will probably think that this measure is contradictory with the lack of nurses described throughout this blog entry. Well, not at all because the delegation and revision of the scope of skills also needs to concern nurses, since a large part of their tasks could be assigned to other professions, such as caregivers.
By transferring simple, non-technical tasks, care would become more efficient and the number of nurses per department would be reduced. As a professional association exemplified, “a simple dressing could be done by a caregiver who has just washed the patient. No more need for a nurse for this care.”
Good news: As of this writing, if this transfer of tasks hasn’t yet been written in full in the coalition agreement, we expect the Ministry of Health to do so in the coming months.
New digitalisation tools to reduce the burden of administrative tasks and gain efficiency
In the era of artificial intelligence and medical activity traceability software, administrative burden is no longer acceptable for the healthcare teams we interviewed. Investing in tools to improve performance and save time with patients is a real expectation of staff.
Without being exhaustive, the implementation of digital tools in healthcare could thus positively impact several areas such as in the management of dealing with patients in emergency departments or in the standardisation and automation of medical reports.
New technologies offer numerous possibilities to modernise and simplify the daily lives of teams and improve their working conditions, not to mention all these connected devices that everyone has and which provide very useful health data to exploit.
Better coordinated care pathways between the independent healthcare practice and the hospital, and placing prevention at the heart of a new system
Finally, workforce issues can’t be measured simply with quantitative indicators. An efficient use of the resources should also be part of their positioning throughout the patient journey.
Therefore, and as already included in the 2023–2028 coalition agreement, in-depth work on the coordination of patient pathways and the increase in the share of independent healthcare practice and home care activities will contribute to a more efficient use of the resources and a reduced need for hospitalisation or institutionalisation.
This point also places prevention issues at the heart of the system’s evolution so that caring for the patient is no longer simply synonymous with seeking to cure them. As mentioned in our blog entry “Public health and prevention: don’t wait until it’s too late!,” avoiding disease through prevention and individual responsibility actions constitutes both a national and European challenge.
This transition calls for some major structural changes headed by the financing model of healthcare professionals, who are currently not financially incentivised to perform prevention activities.
Ultimately, our study confirmed the seriousness of the situation and the obvious concerns of teams on the ground, from hospital management to service care staff. The situation isn’t unique to Luxembourg and a change in the model of European health systems is taking place painfully.
To renew and reignite this system that gave so much to the population in the darkest hours of the COVID-19 crisis, we will need to make health policy sustainable and have the courage to make difficult, perhaps costly, decisions, across borders and certainly disruptive for certain difficult achievements. It isn’t just a demographic problem to which we need to find demographic solutions. It’s time to change the model, to transform the system—literally.
As it is the case in all European countries, the government’s action in this area will be carefully evaluated by commentators and experts, but also by the population. Beyond treating the wounds, and without reform and rapid action, the Luxembourg healthcare system will no longer just be up against the wall, it will have crossed it and will be hard-pressed to extricate itself from it.
*Marie-Lise Lair Hillion, 2019. Etat des lieux des professions médicales et des professions de santé au Luxembourg.
What we think
Addressing workforce issues in the healthcare sector needs to be a priority for the new Luxembourgish government, and will find its solution in an ambitious national policy at the Greater Region level. Those issues are not just a demographic medical problem which has to find solutions in the number of people to train to complete the health workforce. It’s really time to change the model.Dr. David Larivière, Director, Health and Public Sector, at PwC Luxembourg
Societies are constantly evolving and so does the healthcare sector. A successful transformation will depend on the collaboration between the different healthcare parties in Luxembourg and focusing on the healthcare professionals forming the backbone of the healthcare system.Constantin Keith, Associate, Health and Public Sector, at PwC Luxembourg