The number and composition of people working in hospitals in OECD countries varies depending on the roles and functions that hospitals play in health systems, as well as on how different types of support services in hospitals are provided and accounted for. The roles and functions of hospitals vary notably regarding the extent to which outpatient specialist services are provided in or outside hospitals. In most countries with universal health coverage funded by the tax system (national health service‑type systems), outpatient specialist services are typically provided in public hospitals. This is the case, for example, in the United Kingdom, Nordic countries, Portugal and Spain. In other countries such as Australia, Austria, Belgium, Canada, France, Germany, Switzerland and the United States, most outpatient services are provided outside hospitals. In some Central and Eastern European countries (such as Estonia and Slovenia), most outpatient specialist services are provided in public hospitals, whereas these are provided in public multi-specialty clinics in others (such as Poland) or in private solo practices (as in the Czech Republic).
In 2021, the number of people working in hospitals relative to the overall size of the population was at least twice as high in Switzerland, the United Kingdom, Norway, Denmark, the United States, Iceland and France as in Mexico, Chile, Korea and Hungary (Figure 8.18). However, it is important to bear in mind that in the United States, 45% of people working in hospitals are non-clinical staff (administrative and other support staff), and this proportion is over 30% in Switzerland, France and Iceland.
In all countries, nurses represent the largest category of care providers in hospitals. Nurses and midwives account for 37% of all hospital employment on average across OECD countries. In some countries, including France, Portugal and Spain, healthcare assistants (or nursing aides) also represent a large category of hospital workers. Doctors account for one in seven (14%) hospital workers on average across OECD countries, although in several countries this number underestimates the number of doctors who work at least part time in hospitals, since self-employed doctors with dual practices outside and in hospital are not counted.
The number of full-time equivalent (FTE) nurses in hospitals is lower than the headcount because a significant proportion of nurses work part time. On average across OECD countries, the number of FTE nurses in hospitals is 13% lower than headcount. This gap is larger in some countries like the Czech Republic, Germany and Iceland, where FTE nurse numbers are about 25% lower than headcounts. Looking at trends over time, the ratio of FTE nurses to headcount remained relatively stable between 2011 and 2021 in many countries (e.g. France, Lithuania, New Zealand and the United States), while it decreased in some countries (e.g. the Czech Republic, Estonia, Iceland and Israel), indicating that the average working time of hospital nurses has decreased. By contrast, in some other countries (e.g. Ireland, the Netherlands and Norway), this ratio increased, meaning that the average working time of nurses has increased, although it remains well below 100%.
In some countries like Canada, Germany and the United States, the number of nurses working in hospitals increased fairly steadily between 2011 and 2021, both before and after the pandemic. The growth started a few years later in Portugal and Spain, but picked up both before and during the pandemic years. By contrast, the increase was more modest in France before the pandemic, and there was no increase in the employment of hospital nurses during the pandemic. In Italy and the United Kingdom, there was no increase in the number of nurses working in hospitals between 2011 and 2019, but the number increased at least slightly in 2020 and 2021 (Figure 8.19).
The pandemic stimulated the development of new plans to increase recruitment of hospital staff and to improve working conditions to retain staff. For example, in France, the government introduced a new multiyear plan in July 2020 to strengthen public hospitals, including significant pay rises to increase staff recruitment and retention, especially for nurses (OECD/European Observatory on Health Systems and Policies, 2021[1]).
