Using a Markov supply and demand forecasting model, we found that a strict regulation of foreign physicians admitted in anaesthesia training positions in Latin Switzerland would result in a progressive and significant shortage of 38 % in the number of anaesthetists in transition positions by the year 2024. When adding to the model the impact on favoured retirement age of the increasing female to male ratio and the progressive societal shift from full to part-time job, this gap could reach 50 % (95 % CI 42–59) by the end of the projection period. This could have a serious impact on public hospitals but more particularly on district hospitals, where nearly half of the European and extra-European anaesthetists are practising. This case study shows that in countries that heavily rely on foreign physicians to maintain their healthcare workforce balance, the implementation of restrictive policies such as strict quotas (i.e. Switzerland) or return policies (i.e. United States) are likely to cause a significant deficit in physician workforce, particularly in district areas.
While the impact of a restrictive policy on trained physicians’ immigration has not been assessed elsewhere, a number of related publications confirm our findings. In a study on Austrian psychiatrists, Riedel et al. found that the implementation of quotas for different nationalities at entry in medical school was one of the main contributor to the projected 5 % gap between demand and supply in 2030 . In another modelling study on optometric supply in Australia, Kiely et al. forecasted a 21.5 % decline in the proportion of optometrists in active practice if the number of national graduate and immigrants was going to decrease in the future .
Therefore, when the provision of locally trained physicians is insufficient to meet population needs, countries should engage in policies facilitating rather than impeding immigration. However, these should be considered only as temporary buffers as such policies are likely to further increase the brain drain already present in numerous countries [26, 27]. Western OECD countries are currently the main destination for medical migrants while developing and East European countries experience a progressive shortage of physicians due to emigration . The brain drain of physicians has a serious negative impact on healthcare systems of countries with a negative immigration balance [29, 30]. Therefore, a number of specific guidelines and codes of good practice have been developed to promote ethical, transparent, fair and mutually beneficial agreements between source and destination countries .
Some examples are the Commonwealth Code of Practice for International Recruitment of Health Workers  and the ‘Global Code of Practice on the International Recruitment of Health Personnel’ of the World Health Organisation . While such policies are laudable initiatives, their impact on the brain drain of skilled healthcare workers from developing countries remains marginal. Codes of practice are voluntary initiatives of the signatories and compliance is hardly monitored or enforced . Governance in the field of human resources for health remains relatively poor .
Interestingly, extensive policies aimed at limiting immigration, while integrating little ethical considerations, are likely to have a more significant impact on brain drain than codes of good practices. In our case study, we forecasted a 50 % (95 % CI 42–59) decrease (adjusted for part-time positions) within 10 years of the number of anaesthetists in intermediary positions (senior registrars), should strict immigration quotas for foreigners be implemented in Switzerland.
It could be argued that immigrants contribute to increase the size of the population and thus, a strict regulation of immigration could maintain the balance of the physician to population ratio. However, this ignores the increased demand of the population for care, particularly in the surgical area. In Switzerland for instance, between 2002 and 2008 there has been a19 % increase in the overall number of core surgical procedures (inpatient and outpatient) . A similar trend has been observed in most OECD countries where healthcare needs have increased , particularly for surgical procedures such as hip or knee replacement, with a 10 to 60 % raise between 2000 and 2010. As a result, limiting global immigration is likely to have no impact on the growing need for additional physicians.
To minimise reliance on foreign trained physicians and limit the brain drain of physicians in source territories, countries should engage in policies that increase domestic physician supply. These should not be done only through quota adjustments of medical students , but also through initiatives that tend to improve the retention of physicians in the workforce. This could be done by increasing retirement age and working hours. However, these should be in line with both the generation shift and existing laws defining retirement age and regulating the maximum amount of working hours authorized for physicians. In Switzerland, these are set at 50 h a week [38–40].
Another option, in the case of anaesthesia care, could be the implementation of independent anaesthesia nurse practitioners. In Switzerland, nurse anaesthetists are a significant part of the anaesthesia workforce and are allowed to perform a large number of procedures such as drug administration, tracheal intubation, patient monitoring and surveillance. These have to be performed under the strict supervision of a certified anaesthetist. In the near future, they could provide anaesthesia care without any assistance in low risk ASA 1 and 2 patients.
There is to date much controversy as to whether this approach would be detrimental or not to the overall quality of care [41, 42]. Professional organizations are still debating whether or not, they should engage in that direction. Furthermore, the recruitment of nurses can be quite difficult and many countries suffer from a nurses’ workforce shortage. As a result, Switzerland like many other European countries heavily relies on foreign trained nurses to care for its population .
Another alternative could be to increase productivity through technological innovation, financial incentives such as fee-for-service payments and the development of day care surgery [44, 45]. Some of these developments are already underway. For instance, an increasing number of surgical procedures in Switzerland are performed on a day care basis, increasing patient turnover in hospitals and overall productivity. Replacing cost-reimbursement by activity-based payments that reward efficiency is another possible method that could enhance productivity . This strategy should be balanced with the increased risk of jeopardizing the overall quality of the service provided, if patient turnover is escalated excessively. In healthcare, productivity cannot be increased perpetually and a minimum staff/patient ratio needs to be achieved in order to minimize the risk of adverse outcomes [1, 3]. This is especially true in anaesthesia, a high risk specialty [47–49].
There are a number of limitations to our study. First, in our model, we assumed that over the years, only fixed and constant quotas of non-Swiss trainees would be allowed to work and live in the country. While this is likely to be the case with the new law, the exact outline of the Swiss quota immigration policy is currently still under consideration. Our model is therefore only one of the several possible scenarios that may result from the new immigration policy. Secondly, the model included only data collected in the French- and Italian-speaking part of Switzerland, limiting the generalisability of study findings. Finally, we lacked information on anaesthetists working in intensive care and could not draw conclusions on this category of healthcare professionals although they contribute to post anaesthesia care. Despite these limitations, the present study is the first one to assess the possible impact of restrictions on skilled immigration in a case study of the specialty of anaesthesia. Future studies should explore the impact of such policies in other medical specialties and other OECD countries that heavily rely on skilled immigration to supply healthcare to their home population. It would also be important to perform such studies in nursing, midwifery and other allied healthcare workforce areas which also often rely on skilled immigration in many countries.