Health services in most European countries were developed to meet the needs of demand-led health care. Although they still focus mostly on treatment, cure and care (Beaglehole & Dal Poz, 2003), the growing burden of noncommunicable diseases, along with newly emerging communicable diseases and increasing antimicrobial resistance, create strong and shifting demands on these services. At the same time, the growing prevalence of multimorbidity and the widening health inequalities pose additional threats to health systems that do not give enough attention to the factors that produce health. To address these challenges, it is necessary to reorient health services towards more preventive, people-centred and community-based approaches, with a more prominent role for disease prevention and health promotion, integrated within the wider health system.

Worldwide, countries are seeking strategies to strengthen their health workforce to ensure health systems are sustainable and resilient and to reach universal health coverage (World Health Organization, 2016). In Europe, a 2019 expert opinion focused on task shifting, which is one – among several – examples of skill-mix innovations (European Commission, 2019). However, to date, a systematic analysis of skill-mix innovations and their effects on outcomes has been missing. Skill-mix changes have been suggested to be of high relevance to respond to changing patient needs (for example, for patients with chronic conditions and multimorbidity), unequal access to services (for example, for vulnerable groups), skill gaps (for example, in long-term and palliative care) and changes among the health workforce (shortages and maldistribution) (see Chapter 1).

Access to and the quality of health services are closely linked to the density and skill-mix of a country’s health workforce (OECD, 2016; World Health Organization, 2006, 2016). High rates of chronic conditions and multimorbidity, new treatment options, and technological advances and economic pressure have led to fundamental changes to health systems and have impacted on the daily work of health professionals. Many countries worldwide are experiencing a shortage of primary care providers, particularly in rural or socially deprived urban areas (OECD, 2016; World Health Organization, 2013). Primary care systems face the challenge of ensuring a sustainable workforce to allow timely access to services, high-quality care and person-centred services (Kringos et al., 2015a, 2015b).

Timely access to long-term care and palliative care that takes patients’ individual choices into account has been an area of concern to policy-makers in many European countries. The majority of Europeans wish to receive long-term care in their homes for as long as possible (European Commission, 2007). They are often primarily cared for by their families and supported by health and social care professionals. Moving to a nursing home or a similar institution is the first preference of only approximately 10% of Europeans. As to palliative care, the majority of patients prefer to stay at home under the care of the regular health care providers with whom they often have longstanding relationships.

Many countries across Europe are considering implementing skill-mix strategies to better meet the needs of their patients, against the backdrop of changing service delivery models, new technologies and financing as well as payment policies. Implementing skill-mix changes in a country, region or setting is a complex intervention and impacts on the education and training of providers, multiprofessional collaboration, work flow and service provision, and ultimately, the patients and families. Skill-mix reforms are often highly controversial and prone to self-interests, influenced by various stakeholders, including different professional associations, payers, regulators or trade unions. Managing the process of implementation therefore requires a good understanding of the influencing factors, potential barriers and pitfalls involved. It also requires anticipating and actively fostering potentially facilitating factors in the process.