SOCIAL POLICIES AND CONSUMER PROTECTION SUB- COMMITTEE Safety First: Mobility of Healthcare Professionals in the EU Oral and written evidence

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1 SOCIAL POLICIES AND CONSUMER PROTECTION SUB- COMMITTEE Safety First: Mobility of Healthcare Professionals in the EU Oral and written evidence Contents Alliance Boots Written evidence... 3 British Dental Association (BDA) Written evidence British Medical Association (BMA) Written evidence Council for Healthcare Regulatory Excellence (CHRE) Written evidence Department for Business, Innovation and Skills (BIS) and the Department of Health (DH) Written evidence Department of Health and the Department for Business, Innovation and Skills Written evidence Department of Health Oral evidence (QQ ) Department of Health Supplementary written evidence European Commission Oral evidence (QQ ) European Commission Supplementary written evidence European Federation of Nurses Associations (EFN) Written evidence General Dental Council (GDC) Written evidence General Dental Council and General Pharmaceutical Council Oral evidence (QQ 1 40). 79 General Medical Council (GMC) Written evidence General Medical Council Oral evidence (QQ 54 81) General Medical Council Supplementary written evidence General Osteopathic Council (GOsC) Written evidence General Pharmaceutical Council (GPhC) Written evidence General Pharmaceutical Council and General Dental Council Oral evidence (QQ 1 40) 127 Dr Rory Gray Written evidence Dr Stuart Gray Written evidence Guild of Healthcare Pharmacists (GHP) Written evidence Health Professions Council (HPC) Written evidence Health Professions Council Oral evidence (QQ 41 53) Emma McClarkin MEP Written evidence Medical Protection Society (MPS) Written evidence National Association of LINks Members (NALM) Oral evidence (QQ ) National Association of LINks Members Written evidence National Clinical Assessment Service (NCAS) Written evidence NHS European Office Written evidence North East Scotland Faculty of the Royal College of General Practitioners Written evidence Nursing and Midwifery Council (NMC) Written evidence Nursing and Midwifery Council Oral evidence (QQ ) Nursing and Midwifery Council Supplementary written evidence Patients Association (PA) Written evidence Royal College of General Practitioners (RCGP) Written evidence

2 Royal College of Nursing (RCN) Written evidence Royal College of Physicians (RCP) Written evidence Royal College of Surgeons of England (RCS) Written evidence Royal Pharmaceutical Society (RPS) Written evidence Professor Howard Young Written evidence

3 Alliance Boots Written evidence Alliance Boots Written evidence Free movement Pharmacists, employers and customers benefit from the free movement of professionals across the EU. [p5] In market training It should be a requirement for any healthcare professional moving to work in another Member State to undertake a period of supervised training in that Member State before starting to practise unsupervised. [p6] Language testing Healthcare professionals should be required to demonstrate a high level of fluency in a relevant language before practising in another Member State. Regulatory bodies should be able to require proof of language competence before registration. [p6] Professional cards The introduction of professional cards may enhance free movement. Using the term professional passport would give a clearer indication of the purpose of the document. [p7] 3

4 Alliance Boots Written evidence About Alliance Boots Alliance Boots is a leading international pharmacy-led health and beauty group, which owns and operates pharmacies and full-line pharmaceutical wholesaling businesses in a number of EU and EEA countries. We are the largest pharmacy owner in the UK, with around 2,400 pharmacies situated were people live, work, shop and travel. As well as dispensing medicines, our pharmacies increasingly provide added-value services to the communities they serve, particularly in public health and supporting better use of medicines. We actively recruit qualified professionals, predominantly pharmacists, from across the EU for our business making use of the free movement principles of the Single Market and the Professional Qualifications Directive. 4

5 Alliance Boots Written evidence Response to consultation questions Fundamental principles 1. What benefits are derived by healthcare professionals and patients from mobility? 1.1. As one of the largest employers of pharmacists in the country we have around 4,500 working for the company in a wide range of store-based and head office roles Boots UK benefits from the flexibility of being able to recruit across the whole of the European Union (and the wider European Economic Area), not just the UK We take on about 1,000 new pharmacy graduates and fully qualified pharmacists each year. The majority of these will have trained at the UK s university schools of pharmacy. We also recruit from the EU to fill vacancies in our pharmacies Community pharmacies are legally required to have a pharmacist on the premises at all times when they are open. Hence, our customers benefit from our ability to maintain a full complement of staff by supplementing UK pharmacists with those recruited from the EU EU pharmacists benefit from being able to work in the UK pharmacy market. As well as providing the core dispensing service, pharmacists in the UK are also able to provide some of the most advanced clinical services to patients in the EU, including medicines use reviews, public health services and those which involve the supply of both prescription medicines and professional advice through our own patient group directions. 2. What risks have you observed arising from mobility and to what do you attribute those risks? 2.1. There are two main issues that overseas pharmacists working in the UK have to deal with: local (in-market) aspects of professional practice and language skills. Failures in either of these could lead to them making professional errors As an employer with a duty of care towards both our customers and our employees, we take steps to address both these issues. We believe that these approaches should be reflected in European law (see our submission to the European Commission at Appendix 1 for full details) In terms of in-market professional practice, we require our non-uk pharmacists to undertake a period of up to 12 weeks of supervised practice in one of our UK pharmacies before working unsupervised For language skills, we require potential recruits to demonstrate a high level of fluency in English [ILETS-7 or UBELT-3]. 3. Where do you think that the balance should lie between a regime covering the mobility of all workers with the objective of maintaining high standards of patient safety? 3.1. We believe that the balance must lie firmly in the interest of maintaining the highest standards of patient safety. In particular, circumstances that vary between 5

6 Alliance Boots Written evidence Member States, language and professional practice, need to be addressed before a health professional is allowed full registration and practice in other State Thus, in the interests of public health and safety, we feel that it is appropriate that health professionals operating in another Member State should receive appropriate in market training on legal and practice matters before they are allowed to work in an unsupervised capacity in that country The ability of professional regulatory bodies to require evidence of language competency before registration also needs to be addressed (see Q6, below). Automatic recognition 4. How content are you with the system of automatic registration? 4.1. In our experience, the current system works reasonably well, subject to the comments made under Q3 above However, since pharmacy practice continues to evolve across the EU, and in the UK in particular, with subsequent changes to professional education, care will need to be taken to ensure that recognition of updated qualifications is maintained. Administrative co-operation 5. To what extent do you consider that appropriate systems are in place for administrative co-operating between Member States, particularly as regards fitness-to-practise? 5.1. In our experience, there is adequate co-operation. However, information exchanged by regulatory bodies also needs to be cascaded to health care providers and employers if it is to be useful. Language competence 6. Are you content that [requirements for language competence] have been applied satisfactorily as regards health professionals and ought it to be strengthened? 6.1. In our view, the inability of healthcare regulatory bodies to ask for clear proof of high-level fluency in a relevant Member State s official language is a major loophole in the protection offered to patients At present, there are few opportunities to offer pharmacy services to the public through the NHS without being either a pharmacy contractor or an employee of a contractor or NHS body. This means that language testing falls predominantly to employers within pharmacy. However, this situation is different in other health professions, and may change for pharmacy in future As such, we believe that EU policy should be clarified or changed in order so that health regulatory bodies have the right to require applicants seeking registration through mutual recognition to demonstrate appropriate high-level fluency in a relevant language before registration. 6

7 Alliance Boots Written evidence European professional card 7. What is your response to the suggestion [of a European professional card]? 7.1. In general terms, we would find a professional card helpful, but we would require further information about how the process would work and where the costs of acquiring such a card might lie We suggest that the term professional passport gives a better indication of its use, and might allay fears among professionals in Member States that they would have to acquire such a card at personal expense simply to remain registered in their own country. 7

8 Alliance Boots Written evidence Appendix 1 EU Professional Qualifications Directive: a consultation by DG Internal Market and Services A response by Alliance Boots Alliance Boots is a leading international pharmacy-led health and beauty group, which owns and operates pharmacies and full-line pharmaceutical wholesaling businesses in a number of EU and EEA countries. Our Health & Beauty Division operates community pharmacies in the UK, Republic of Ireland, Italy and the Netherlands, as well as in Norway and Russia. These predominantly trade under the Boots brand. We are the largest pharmacy owner in the UK, with around 2,400 pharmacies situated were people live, work, shop and travel. As well as dispensing medicines, our pharmacies increasingly provide added-value services to the communities they serve, particularly in public health and supporting better use of medicines. Our Pharmaceutical Wholesaling Division operates full-line wholesale businesses serving community pharmacies, medical practices and hospitals in the UK, France, Spain, Italy, the Netherlands, Czech Republic and Germany, as well as Norway and Russia. We also have joint ventures in Switzerland, Turkey and Egypt. Alphega Pharmacy is a leading network of independent pharmacists in Europe. Launched in 2001, today it supports more than 3,000 pharmacies across six countries the Czech Republic, France, Italy, Russia, Spain and the UK. The central aim of Alphega Pharmacy is to help improve the quality of health in communities across Europe by developing a benchmark independent community pharmacy model. Central Homecare is a high quality provider of clinical homecare services throughout the UK. Its aim is to make the administration of medicines at home as simple and stress-free as possible for patients and their carers, and to meet the goals of healthcare clinical teams. We actively recruit qualified professionals, predominantly pharmacists, from across the EU for our business making use of the free movement principles of the Single Market and the Professional Qualifications Directive. 8

9 Alliance Boots Written evidence Executive summary In market training The European Commission should make it a requirement for any healthcare professional moving to work in another Member State to undertake a period of supervised training in that Member State before starting to practise unsupervised. [p10-11] Language testing Healthcare professionals should be required to demonstrate a high level of fluency in a relevant language before practising in another Member State. [p10] Professional cards The introduction of professional cards may enhance free movement. Using the term professional passport would give a clearer indication of the purpose of the document. [p11] Temporary services There should be a clearer definition of the phrase temporary provision of services. [p11] CPD The continuing professional development undertaken by healthcare professionals should be relevant to the territory they are operating in as well as to their field of practise. It should be equivalent to the CPD undertaken by registrants in the Member State they are working in. [p11] 9

10 Alliance Boots Written evidence Response to consultation questions NOTE: Not all of the questions posed are relevant to the businesses operated by Alliance Boots. We have supplied general answers to topics where we feel we have appropriate experience and understanding. Compensation measures and in market training The professional training for pharmacists can be divided into two elements: o The basic training on the physiology of diseases and the pharmacology of treatments which is broadly harmonised across Europe, through the Professional Qualification Directive and the licensing requirements for medicines, which are also underpinned by European Directives. o The second element is market specific. It relates to the practice of pharmacy in each Member State, along with the remuneration model and the legal and ethical requirements for each country. Thus, in the interests of public health and safety, we feel that it is appropriate that pharmacists operating in another Member State should receive appropriate in market training on legal and practice matters before they are allowed to work in an unsupervised capacity in that country. In addition, we also believe that pharmacists should be required to demonstrate a high level of fluency in the relevant Member State language (see Language testing below). When Boots recruits pharmacists from other EEA countries to work in our UK pharmacies, we require them to be able to show a high level of fluency in English [ILETS-7 or UBELT-3]. Assessing English language competency is extremely important for the candidate to be assured that they can communicate effectively with customers, patients, staff and other healthcare professionals. As an employer, we have a duty of care towards our customers in this respect. As a responsible employer, we require EEA pharmacists who pass the language testing, and who satisfy the other requirements of our recruitment process, then undertake supervised practice for up to 12 weeks within one of our pharmacies. This supervised period is based on a process similar to that required as part of the one-year preregistration training undertaken by UK pharmacy graduates wishing to join the Register of Pharmacists maintained by either the General Pharmaceutical Council (GPhC), the competent authority for Great Britain, or the Pharmaceutical Society of Northern Ireland. The supervised period concentrates on the differences in pharmacy practice in the UK, both legal and ethical, and on how to avoid the most common dispensing errors (such as those caused by medicines with similar product names). At the end of the 12-week period, the supervising pharmacist signs a declaration that the recruit is competent to practice unsupervised in the UK. We believe that it would be in the public interest for the European Commission to introduce the requirement for a similar period of in market supervised training for all healthcare professionals moving to work in another Member State. This would protect 10

11 Alliance Boots Written evidence public safety by ensuring that these professionals were fully aware of the healthcare environment they intended to practise in, and where this might differ from regulations or customs within their own countries. A European professional card In general terms, we would find a professional card helpful, but we would require further information about how the process would work and where the costs of acquiring such a card might lie. We suggest that the term professional passport gives a better indication of its use, and might allay fears among professionals in Member States that they would have to acquire such a card at personal expense simply to remain registered in their own country. It is also unclear whether this card would be used by those seeking temporary rather than permanent work in another Member State. Temporary movement for professionals At present, there are few opportunities for pharmacists to provide professional services in the UK outside of the context of being employed by a contractor to the National Health Service (NHS) or by an NHS body. Hence, we do not have much experience in this area. However, we share the concerns expressed by the public, professional and regulatory bodies about the potential for healthcare professionals using temporary service provision as a way of escaping restrictions placed on their practise by competent authorities in another Member State. We also share the concerns about making a distinction in practice between temporary and continuous service provision in the absence of any formal definition of temporary. We feel that this needs to be addressed. Continuing professional development Continuing professional development is now a mandatory requirement for registered pharmacists (and pharmacy technicians) wishing to remain on the GPhC register. It is something that the public expect. We share the concern felt by the public that an EU healthcare professional operating temporarily or permanently in the UK might not be required to undertake the same level of CPD as fully-registered UK professionals. CPD should be relevant to the field of practise, including the territory of practise. We feel that this should also be addressed. Alerting mechanisms for professional malpractice Where restrictions have been placed on a healthcare professional s practise by a competent authority, it is right that other authorities should be able to request or see this information. However, this information will not be of practical value unless it can be cascaded to known or potential employers, either directly or on request. 11

12 Alliance Boots Written evidence In addition, there may be problems in directly replicating specific restrictions on practise, depending on the nature of local legislation or pharmacy operations. For example, narcotics and other medicines subject to abuse may have different levels of legal control in different Member States. Language skills Healthcare decision making requires that the patient and professional are able to exchange information clearly and freely. Misinterpretations and misunderstandings can have serious consequences. As mentioned above, we believe that it is reasonable on grounds of public health and safety that healthcare professionals who wish to work in another Member State should be able to demonstrate advanced-level fluency in an appropriate language. We believe that healthcare regulatory bodies and competent authorities should be in a position to request suitable proof of such fluency before registering them. 14 June

13 British Dental Association (BDA) Written evidence British Dental Association (BDA) Written evidence 1. The British Dental Association is the representative organisation for dentists in the UK, with over 19,000 dentist members and nearly 4,000 student members. 2. We responded to the European Commission s formal consultation on the professional qualifications directive which ended in March This is attached for information. 3. Below are our comments on the specific questions of this enquiry. These are based on our response to the Commission where appropriate. Background: fundamental principles What benefits are derived by healthcare professionals and patients from mobility? 4. Mobility enhances life choices. Healthcare professionals can benefit from improved choice for job search and career progression, including postgraduate training. Experience of living and working in another country is also a good way of broadening one s individual horizon. There is also the opportunity of cross-fertilisation of ideas, advances and skills. 5. Patients can benefit from improved access to services, particularly in areas where there may be a shortage of dentists. What risks have you observed arising from mobility and to what do you attribute those risks? 7. Communication is a major issue as health professionals must be able to explain treatment options and receive informed consent from the patient for any treatment they propose. Regulators are not currently permitted to test the language competence of the health professional. While there are provisions for this in the UK through the NHS system, the possibility to ascertain language competence at registration level would provide reassurance to the public and help avoid communication problems in patient care. 8. On a very anecdotal basis, problems have been raised with a lack of training in some minimum training standards due to different treatment modalities in other countries. For example, it was found that it was not routinely the practice in one country to take radiographs to aid dental diagnosis. The problems were not addressed through the compensation measures, but rather through additional training in the UK. A risk would result in such circumstances if the health professional was tempted to work outside their competence, rather than addressing the shortcoming through training. There should be the opportunity for compulsory induction periods so that professionals can learn about the requirements in the host country. 13

14 British Dental Association (BDA) Written evidence Where do you think the balance should lie between a regime covering the mobility of all workers, including non healthcare workers, with the objective of maintaining high standards of patient safety? 9. Health professionals are different from other service providers. While they do provide a service, this provision is not in the first instance based on competition or business, but on improving the health of the individual. The Commission is undertaking the review of the directive with a view to reviving the Single Market, and is therefore considering this issue from a competition and mobility point of view. It is, however, necessary for the health professions to retain certain safeguards in the system to ensure appropriate regulation, quality, safety and redress for patients in cases of error or neglect. 10. With some exceptions, we believe the professional qualifications directive generally works well in dentistry. The minimum training standards provide the baseline for recognition, and healthcare professionals on the whole are conscientious practitioners who put their patients interests first. They also accept an ethical responsibility to continue their professional development throughout their working life. CPD is, however, variable across the EU, and we have suggested in our response to the Commission that the directive might benefit from stronger guidance on this issue. 11. In addition, we have already highlighted our concern about the lack of language testing (see also below) and suggested the introduction of induction requirements. Automatic recognition How content are you with the system of automatic recognition as currently applied to doctors, general care nurses, dentists, midwives and pharmacists? What suggestions do you have for improvements? Should it be extended at all to any other healthcare professionals? 12. The system has generally worked well in the UK. Registration for dentists in the UK is straightforward, and the use of compensation measures after several new countries joined in 2004 also provided a largely appropriate safety net. An online registration approach for those subject to automatic recognition could facilitate ease of movement, but appropriate safeguards, such as the provision of original documents and proof of language competence would be essential. 13. We refer once again to the suggestion for induction requirements. 14. Anecdotally, we have received comments from dentists who hope to work in other EU countries who have found the process more difficult once they have made contact with the authorities, often due to devolved arrangements in the host state. The problem could be addressed by all regulators and dental associations providing full information on procedures in their country on their websites. 15. With regard to other health professionals, within UK dentistry there are six categories of dental care professionals (dental nurses, hygienists, therapists, dental technicians, clinical dental technicians and orthodontic therapists). Not all these 14

15 British Dental Association (BDA) Written evidence professional categories exist in all EU countries, however, and where they do exist they are not necessarily registered or formally regulated. Training standards are not defined across the EU, and therefore these professionals are assessed with regard to their skills, knowledge and experience before they are registered in the UK. Without defined minimum training standards accepted throughout the EU, automatic recognition of these professionals would be difficult to develop. Administrative cooperation To what extent do you consider that appropriate systems are in place for administrative cooperation between Member States, particularly as regards the fitness to practise? 16. The BDA is not the dental regulator and therefore has no first-hand experience of the EU s Internal Market Information System (IMI). We understand that the system exists to facilitate the exchange of information between regulators, but that usage of the system is variable across EU member states and professions. We believe, however, that it could appropriately address the need for administrative cooperation if used by all those entitled or required to do so. This is particularly important with regard to sharing results of fitness to practise proceedings, so that professionals who have been sanctioned in one country cannot easily transfer to another member country. Language competence Article 53 of Directive 2005/36/EC requires those benefiting from mobility under the Directive to have a knowledge of languages necessary for practising the profession in the host Member State. Are you content that this requirement has been applied satisfactorily as regards healthcare professionals and ought it to be strengthened? 17. The requirement should definitely be strengthened. The BDA would advocate an appropriate, clear yet flexible language testing regime. Many of the fitness-to-practise cases in the UK are based on a lack of appropriate communication skills. It would be in the interest of both patients and professionals to have some form of language testing system for all professionals. The testing is necessary to find employment/work in most cases, so having this as part of the registration regime might actually make it easier for professionals to move forward with their professional life in the host country. Many even expect it to be a prerequisite of registration. 18. The implications of a dentist or DCP not being able to communicate appropriately with patients are of major concern. Patients may not be able to give informed consent to treatment if the treatment options are not outlined appropriately by the professional, which can result in complaints and in fitness-to-practise cases which can devastate a professional s life. A requirement to show competence through a variety of tests would be an appropriate way forward. 15

16 British Dental Association (BDA) Written evidence European Professional Card The Commission refers in its consultation paper to the possible introduction of a European Professional Card. What is your response to this suggestion? Under what conditions would it be helpful for healthcare professionals and patients? 19. The BDA believes that better communication between the professional regulators is essential to improve movement of professionals. We are not, however, convinced that a professional card would address the issue in a useful way. 20. If the card were to be used to facilitate registration, it would presumably need to contain registration details such as registration number, name, address, qualification details, and information on any investigations by the home regulator into fitness to practise. 21. There are concerns about the currency of the information on the card. There would be a need to ensure that the professional card was issued within a certain timeframe and contained an expiry date. The home regulator would need to be able to cancel the card if fitness-to-practise issues were identified after issuing the card. Introducing such a system across all EU regulators would constitute a major cost and workload. 22. In conclusion, we believe that a professional card would add little to facilitate migration, due to the safety issues and the expected cost. The IMI system, used appropriately by all regulators, and the creation of online registers in all member states would address the related issues in a faster, easier, safer and more costeffective way. 17 June

17 British Medical Association (BMA) Written evidence British Medical Association (BMA) Written evidence The British Medical Association (BMA) is an independent trade union and voluntary professional association which represents doctors and medical students from all branches of medicine all over the UK. With a membership of over 145,000 worldwide, we promote the medical and allied sciences, seek to maintain the honour and interests of the medical profession and promote the achievement of high quality healthcare. The BMA has closely followed developments around professional mobility for over ten years. It has submitted a response to the European Commission's recent public consultation and is pleased to contribute evidence to the House of Lords Sub-Committee inquiry. Executive summary The BMA supports the principle of free movement of professionals but recognises that the Directive on the Recognition of Professional Qualifications (2005/36) requires updating in order to meet the demands of modern medicine It is essential that a robust system of checks and balance remains in place The BMA believes that basing a decision on fitness to practise on the length of time individuals have trained rather than on the skills they have acquired is not appropriate for the continued development of a modern healthcare system The BMA believes that continuous professional development (CPD) must be enshrined in the Directive Medical regulators should be legally bound to share registration and fitness to practise information proactively with other regulators in Europe It is essential that doctors are able to communicate appropriately with their patients and colleagues The BMA is unconvinced of the necessity of a Professional Card and is concerned that the card could lead to administrative duplication and difficulties around interoperability Fundamental principles 1. The BMA supports both the free movement of doctors in the EU and the principle of recognition of professional qualifications. The UK health system has benefitted from EEA and international doctors practising in the UK. EEA doctors are important feature in workforce planning in the UK NHS; whilst UK trained doctors are able to enrich their careers by practising in another EEA state. 2. Despite these benefits, the BMA believes that there are a number of risks arising from mobility. Due to the changing nature of modern medicine, the BMA is concerned that Directive 2005/36 is no longer fit for purpose in its current state. It is essential that the system is updated in order to emphasise a healthcare professional s continuing fitness and suitability to practise in the host member state. It is essential that EEA doctors who exercise their right to free movement are able to demonstrate regularly to the host competent authority that they are fully qualified and fit to practise. Some of the most important risks (inadequate checks and balances, 17

18 British Medical Association (BMA) Written evidence continuing professional development and language issues) are addressed later in our response. 3. The BMA supports the principle of mobility and welcomes the mutual recognition of professional qualifications as a framework for encouraging mobility. It is important that healthcare workers continue to have separate rules and processes from the rest of the professions. This is due to the unique responsibility that healthcare professionals have towards patients. Patient safety is more important than the ability to cross borders without administrative burden. 4. It is vital that any simplification of the Directive does not dilute the checks and balances that enable competent authorities to regulate doctors effectively and to ensure patient safety. The system must remain robust in order to safeguard patient safety and to protect the functioning of the national health system. 5. An example of where specific derogations for healthcare workers should be maintained is the principle of partial access. The European Court of Justice laid down the principle of partial access in a 2006 ruling 1 where it stipulated that partial access to a profession must be given if there are no valid public interest reasons to prohibit it. 6. The BMA believes that patient safety constitutes a valid public interest reason. Under no circumstances must partial access to the medical profession be granted to a doctor whose training or qualifications do not merit full recognition. It is essential that this is codified into the new revised Directive in order to protect patient safety. Automatic recognition 7. The BMA welcomes the principle of automatic recognition but warns that it is necessary to maintain a robust system of checks and balances in order to protect the integrity of the medical register and to ensure that doctors are fit to practise. There are a number of ways in which the system of mutual recognition can be improved. 8. The BMA strongly believes that basing a decision on fitness to practise on the length of time individuals have trained rather than on the skills they have acquired is not appropriate for the continued development of a modern healthcare system. Competent authorities and employers must be able to satisfy themselves that a doctor possesses all of the necessary clinical skills in order to undertake their job successfully. 9. It should be noted that although the regulatory authorities are required to register EEA doctors, it remains the responsibility of doctors employers to determine whether they possess a sufficient level of competence to undertake the activities for which they are employed. Employers should provide full induction and training to doctors who may not have a full knowledge of the specificities of the healthcare system they wish to work in. 1 Case C-330/03 of 19 January

19 British Medical Association (BMA) Written evidence 10. Education and training are vital components in creating a modern, efficient health workforce. Continuous professional development (CPD) must be enshrined in the EU health workforce in order to ensure that doctors have up-to-date professional skills and are knowledgeable about the latest treatments and developments in medical technology. The current Directive does not allow the competent authorities to satisfy themselves that a doctor has kept their skills and competences up to date in the years following their qualification. 11. Whilst the BMA is wary of imposing minimum CPD requirements in the revised Directive, we believe there should be a way for competent authorities to verify the CPD status of applicants and, if necessary, to impose additional requirements before a doctor can take employment in the host country. 12. The BMA is concerned that standard fitness to practise checks cannot be made on EEA doctors who apply to practise on a temporary and occasional basis in the UK. Patients have a right to the full protection of the medical regulatory system in the UK whether their doctor practises in the UK permanently or on a temporary basis. Article 7 must not be seen as an easier route for doctors to enter the UK medical system. 13. In addition to the above, the term temporary and occasional itself is ambiguous and the BMA would welcome further clarification from the European Commission on what it envisages is the maximum time allowed under this distinction. Despite the European Commission s view that setting an arbitrary time limit may go against the integration of markets as foreseen by the Single Market, we believe that patient safety must take precedence. 14. The BMA questions whether temporary or occasional healthcare services that are provided online should be exempt from an annual declaration. We argue that regulatory requirements should apply to both electronic and non-electronic healthcare Administrative cooperation 15. It is essential that the competent authorities in member states are able to verify that doctors applying to join the medical register are fit to practise medicine. 16. The Directive should be revised in order to introduce a legal duty on all medical regulators to share registration and fitness to practise information proactively with other regulators in Europe. Data protection issues which prevent some EU member states from doing this must be addressed and resolved as a matter of urgency. 17. In addition to the proactive sharing of data when regulatory action is taken against a doctor (an alert system ), the Internal Market Information system (IMI) must be made compulsory for all EU competent authorities so that they can be confident that they will receive a timely and reliable response to concerns they may have over an applicant. 18. The above regulatory requirements should apply to both electronic and nonelectronic healthcare. EU member states should ensure that the use of e-health and 19

20 British Medical Association (BMA) Written evidence other telemedicine services adhere to the same quality and safety standards as those in use in non-electronic healthcare provision. They should also offer adequate protection to patients notably through the application of regulatory requirements for telemedicine practitioners, wherever their location, identical to those in use for nonelectronic healthcare provision. Language competence 19. There remains confusion, particularly in the UK, as to the extent to which competent authorities can verify the language abilities of EEA doctors under Article 53 of the Directive. 20. The BMA strongly believes that it is important that doctors are able to communicate appropriately with their patients and colleagues and that the regulatory authorities are able to assess the fitness to practise of each doctor in their jurisdiction. 21. It is currently the responsibility of employers to ensure that they recruit people with the skills necessary for the job. This means that employers have a duty to verify the language and clinical skills of EEA doctors who wish to take up employment after their medical qualification has been recognised by the regulator. The BMA believes that employers must take this role very seriously. 22. Following correspondence with the European Commission and in light of the outcome of the Haim case (C ), some UK health stakeholders believe that the dilemma of whether the regulator can verify the language skills of an EEA doctor lies at UK national level. It is believed that the UK Medical Act 1983 gold-plated the 2005/36 Directive and thus prevents the UK competent authority from language testing EEA doctors where a concern over their ability is raised. It is believed that by amending the UK Medical Act 1983, some degree of informal language testing would be permitted thus bringing national legislation into line with Directive 2005/36. Further investigations need to take place at national level to verify this. The BMA encourages the UK government to address this issue as a matter of urgency. 23. If the Directive is amended to allow competent authorities to test the language skills of EEA doctors, this must not replace the powers and responsibilities that employers have to ensure that they employ suitable candidates. European Professional card 24. The introduction of a professional card has been proposed as a tool for facilitating the free movement of doctors. The BMA remains unconvinced and is concerned that the card could lead to administrative duplication and difficulties around interoperability. The information contained on a professional card would be held already by the competent authorities in the doctor s home member state. 20

21 British Medical Association (BMA) Written evidence 25. The BMA argues that the Internal Market Information system (IMI) should be strengthened and made compulsory thus enabling competent authorities to exchange regulatory data on doctors without the need for the introduction of a professional card. If an additional system for facilitating free movement was deemed necessary, the BMA believes this should be in the form of an online, European Professional Registry rather than a card which would be open to potential fraud and which would incur a cost for healthcare professionals who would need to purchase and then update the card regularly. 10 June

22 Council for Healthcare Regulatory Excellence (CHRE) Written evidence Council for Healthcare Regulatory Excellence (CHRE) Written evidence We are grateful to have the opportunity to contribute to the Committee's Inquiry into the mobility of healthcare professionals within the context of the European Commission's review of the Professionals Qualifications Directive. This submission closely reflects our submission to the Commission's consultation which ended in March this year. The Council for Healthcare Regulatory Excellence (CHRE) promotes the health and wellbeing of patients and the public in the regulation of health professionals. We scrutinise and oversee the work of the UK's nine regulatory bodies that set standards for training and conduct of health professionals. We also share good practice and knowledge with those regulatory bodies, conduct research, and promote the concept of right-touch regulation. We advise the four UK government health departments on issues relating to the regulation of health professionals. We are an independent body accountable to the UK parliament. We are monitoring developments in the review of the Professional Qualifications Directive closely, given the potential risks to patient safety that arise from the increasing mobility of health professionals. While we support the Commission s aim of supporting economic recovery through the removal of unnecessary or arbitrary impediments to mobility, we are concerned to ensure that this does not result in any risks to patients. Please note that we have not sought to answer all of the questions in the call for evidence, focussing on matters of principle rather than operational detail, as this is where we feel can make the most helpful contribution to this review. Question 3 - balance between professional mobility and maintaining high standards of patient safety Our view is that the purpose of statutory professional regulation should be to protect the safety of the public. It should protect the public from serious risks to their well-being, in circumstances where they are at risk of harm. There is an imbalance of power between members of the public and the professionals whom they consult, not least because of the greater specialist knowledge of the professional. The aim of statutory regulation should not be confused with that of registration of individuals for the purposes of consumer protection. We would argue that a proper assessment of risk should always be the touchstone in determining the nature of the regulation that is required in any situation or for any particular professional or occupational group. For those groups whose work presents a low risk to the safety and well-being of the public, the full force of statutory regulation should not apply. They should be free to seek work in other member states than their home states without having to apply to a competent authority for assessment and possibly having to undergo adaptation periods. CHRE is preparing to assume a new power (subject to Parliamentary approval) to accredit voluntary registers as an alternative to statutory regulation for lower risk professional and occupational groups which could provide a model for other countries. For these reasons we believe that the criteria for the use of statutory regulation have 22

23 Council for Healthcare Regulatory Excellence (CHRE) Written evidence become confused, and that too many occupational groups have been drawn in to unnecessary statutory regulation. We were struck by the statistics quoted at the Commission's public hearing held on 21 February of this year that there are 800 professions currently regulated across the members states and that of those, 25% are only regulated in one country. Clearly there is hugely discrepant practice between member states in the professions that are regulated, which is creating unnecessary complexity and impeding the movement of European citizens seeking work away from their home state. There is therefore great scope for simplification, which could make a significant contribution towards economic recovery by removing unnecessary barriers to the mobility of professionals. Questions 4 and 5 - improving existing systems Our answer to these questions should be read in conjunction with our answer to question 7, below. We believe that the starting point to improving the existing systems across Europe should be to review how the concept of a profession is understood. As we commented in answer to Q3 above, we believe there is confusion between statutory regulation for professionals and registration for the purpose of consumer protection. We believe that statutory regulation should be applied to professions because of the greater risk they present to the safety of the public. We commend a definition of a profession set out in 'the System of Professions: An Essay on the Division of Expert Labour' (Andrew Abbott, University of Chicago Press, 1988). In this work Abbott moves away from earlier definitions of a profession which focussed on the existence of, for example, standard qualifications and registers. Abbott argues that professions are defined by their diagnosis of complex social challenges in the areas of greatest ambiguity, and their offer for how those social challenges should be addressed. Successful professions are those that define their offer to society in abstract terms such that as new problems arise they can apply their expertise to solving those new problems within their professional jurisdiction. Under this definition, professions are those who are solving the most difficult and ambiguous social problems in areas of uncertainty, and therefore by definition those consulting them are most likely to be at risk of harm. As a practical way forward from this point to reforming regulatory structures, we commend our work on defining 'Right-touch Regulation' ( In this document we set out our views on when statutory regulation is required and when other approaches might be more appropriate. We believe that right-touch regulation is consistent with and complementary to the approach set out in the Commission's publication 'Smart Regulation in the European Union' (October 2010) and with the Better Regulation Executives Principles of Good Regulation (insert reference). Right-touch regulation means always asking what risk we are trying to regulate, being proportionate and targeted in regulating that risk or finding ways other than regulation to promote good practice and high-quality healthcare. It is the minimum regulatory force required to achieve the desired result. The concept has developed through our oversight role of the health professional regulators. It builds upon the principles of good regulation referenced above: proportionate, consistent, targeted, transparent and accountable. To this we added a sixth principle of agility. Agility in regulation means looking forward to anticipate change rather than looking back to prevent the last crisis happening again. 23

24 Council for Healthcare Regulatory Excellence (CHRE) Written evidence In practice we have identified the following eight elements that sit at the heart of right-touch regulation: Identify the problem before the solution Quantify the risks Get as close to the problem as possible Focus on the outcome Use regulation only when necessary Keep it simple Check for unintended consequences Review and respond to change For health professionals, we believe that the application of Right-touch Regulation principles confirms that we should concentrate on improving existing systems for recognition and information sharing, which we comment on further below. Question 7 - European Professional Card For health professionals we would argue that a professional card would be an unnecessary and expensive duplication of existing systems, if its purpose is to provide information on the registration status of a health professional. Registration status can be ascertained by a competent authority through the use of online registration data. A more focussed and efficient approach than a professional card would be to continue to work to improve the accessibility and reliability of competent authorities' websites across all member states, supported by further development of the Internal Market Information system. In effect we believe that the proposed card fails the first test of right-touch regulation: it is a solution looking for a problem. We are aware that proposals for improvement to IMI have recently been published by the Commission and we support this initiative. Additionally at CHRE we are working with the London School of Economics to develop an online International Observatory on the Regulation of Health Professionals which will provide competent authorities with analytical information on how health professional regulation works in other countries, in order to support regulatory improvement and development. 17 June