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).

The implementation of innovations in health care organizations is a complex process that is affected by many factors, positively or negatively (Fleuren, Wiefferink & Paulussen, 2004). Skill-mix innovation is particularly challenging, conceptually, technically and politically (Kernick & Scott, 2002). It is essential to identify the factors and strategies that influence the uptake of skill-mix interventions in organizations, in order to better inform policy and decision-making.

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.

Most European countries are faced with a chain of challenges in health care. Due to the ageing of the population and a growing number of chronically ill patients with multimorbidity, the demand for health care is higher than ever. At the same time, countries are confronted with current and forecasted health workforce shortages and maldistribution. Many countries have turned to interprofessional work and task substitution in response to these challenges (De Bont et al., 2016). Both concepts are interconnected and imply changes in the skills of health care professionals (OECD Health Division Team, 2018) as well as in the skill-mix of health care organizations (Dussault & Buchan, 2018). A key requirement for these changes to successfully take place, is that education and planning systems effectively and rapidly respond to the changing skill requirements at the workplace (Frenk et al., 2010).