UNIVERSITETS- OG HØGSKOLERÅDET

UNIVERSITETS- OG HØGSKOLERÅDET The Norwegian Association of Higher Education Institutions European Commission Internal Market Directorate General, Unit D-4 Rue de Spa 2, Office 06/014 1049 Brussels Belgium ).our referance: Our 10 '230-28 Our daw: 11.03.2011 Response from the Norwegian Association of Higher Education Institutions to the Consultation Paper by DG Internal Market and Services on the Professional Qualifications Directive Dear Madam/Sir; Reference is made to consultation paper by DG Internal Market and Services on the Professional Qualifications Directive of 7 January 2011 The Norwegian Association of Higher Education Institutions (UHR) is the most important cooperative body for Norwegian universities and colleges, whose purpose it is to develop Norway as a knowledge-based nation of high international standard. Our members are governmental and private higher education institutions holding an institutional accreditation granted by Norwegian Agency for Quality Assurance in Education. UHR aims to be a central supplier of ten-ns to the parliament and government and an important education and research policy player. The education and training leading to access to the harmonized professions as listed in the Directive 2005/36, are all offered in our member institutions. All of those programmes, including nursing and midwifery, are at graduate level. The view points in this document have been identified through a thorough process involving all our member institutions and professional units within our organisation. Our responses are framed within the scope of: human health and safety aspects animal health and safety aspects ensuring material values scientific and technological development developments in education and training the European Qualifications Framework (EQF) for Lifelong Learning adopted by the Commission and Diploma Supplement as a document within the Europass, and the Qualifications Framework for Higher education and the Diploma Supplement within the Bologna process Address: Phone: +47 22 45 39 50 Contact person: Pilestredet 46 B postmottak@uhr.no «Sbr_Navn» NO-0167 Oslo www.uhr.no «Sbr_Email» Org.no: 974 652 323 Phone: +47 «Sbr_Tlf»

the great variety between member states and EEA countries in terms of culture, educational systems, different health systems, distribution of tasks between groups of professionals and different qualifications requirements Our responses are limited to: aspects relating to education and training for accessing the harmonized professions the general system for mutual recognition of qualifications: As the higher education sector plays an important role in assisting the competent authorities with assessing individual applicants' qualifications and facilitating compensatory measures, we will also respond to these issues where relevant any other related business Introductory remarks Despite the intentions signalled by numbers 6 and 44 in its preamble, the directive appears to be more directed towards accommodating individuals' rights to access regulated professions than towards protecting health, safety and consumers. The current consultation paper strengthens this view and points towards even more rights for the individuals and deregulation as far as possible. At the time when the sector directives and the general directive were introduced, the EU was a smaller and more homogenous organization. The current picture of the EU is more of a vast patchwork, with very significant differences between the member states concerning e.g. culture, economy, education systems, scientific and technological development etc. The strong emphasis on the right of individuals must not become more important than the protection of health, safety and values. As part of the evaluation of the directive, each member state (MS) and the member states in the European Economic Area (EEA) should be encouraged to critically review which professions that still need to be regulated in order to sufficiently protect health, safety, consumers and material values. Mutual recognition is supposed to be established based on trust between the MS. A qualification leading to a specific profession in the home country should normally be sufficient to practice the same profession in a host country. Taking into account that the member states and the EEA countries make up a very heterogeneous mass, we consider this fundament valid only within geographical, cultural and economic regions with a certain degree of similarities. We have trust in that each qualification in each country is fit for serving local needs. The definition of local needs depends upon a number of factors, such as the state of public health, developments within the health sector, the economic development in each country, how the health services and other services are organized and which roles and functions the various professions are intended to fill in each country. We experience major differences in how well suited holders of a qualification in one country are to serve the purpose of the presumed same profession in a different country without any adaptation measures, thus sometimes creating significant challenges for employers and colleague. An example on challenges occurring through migration is that there are countries which still offer professional programmes as physiotherapy etc. at vocational college level. Nursing is even identified at secondary school level in some places. There is reason to question whether the candidates from vocational colleges and secondary schools are trained to the same level of independent practice as health professionals trained at higher levels in other countries. The training at secondary and vocational level is not research based (a certain change is identified in some cases for the latter), and students are consequently not trained in research theory or methodology, thus reducing the compatibility between the EU/EEA-countries. Furthermore, it reduces those professionals' capacity to keep their professional knowledge and competence updated to the level expected in a number of host countries.

The Consultation Paper Provided the basis of our scope and limitation, we present responses to the questions we have selected as being of particular relevance to the higher education sector. 2.3 Mitigating unintended consequences of compensation measures Question 4: Do you have any experience of compensation measures? Do you consider that they could have a deterrent effect,.for example as regards the three years duration of an adaptation period? A condition for requiring an applicant to complete compensatory measures, is according to article 14 1. (a) - that "...the duration of the training of which he provides evidence under the terms of Article 13, paragraph 1 or 2, is at least one year shorter than that required by the host Member State:-. In cases where our training programmes takes three years to complete and the applicants' training all together has a shortage of one year, we find that the applicants' qualifications do not correspond to the qualifications in the host country and do not provide access to the regulated professions. In such cases, compensation measures are of little or no help in order for the applicant to become qualified. The one year rule is also considered to be a challenge for educational programmes lasting 5-6 years, in particular in cases where the applicant has limited work experience and is lacking postgraduate education or training. On behalf of the competent authority, the higher education sector facilitates compensation measures for individual applicants. One of the aims of the compensation measures is to ensure that the applicant possesses the required knowledge and skills in order to practice safely. Different kinds of competences and knowledge demand different kinds of compensation measures in order for the applicant to demonstrate required knowledge and skills. Our experience is that a number of the applicants need to do both compensation methods in order to demonstrate sufficient level of knowledge and skills in a safe way. As the current directive does not provide such an opportunity, the deterrent effect of the current system is that applicants may be turned down completely, because we lack the opportunity to make the best choice for compensation measures. By changing the directive in order to allow for a combination of the measures, the total time the applicant must spend on this may be shortened, and the number of applicants that currently are rejected may in a number of cases be reduced. Question 5: Do you support the idea of developing Europe-wide codes of conduct on aptitude tests or adaptation periods? No, we do not support the idea of developing Europe-wide codes of conduct on aptitude tests or adaptation period any further than what already exists. As mentioned in our reply to question 4, we believe that it should be up to the competent authority of each country to determine the most suitable compensatory measures. Question 6: Do you see a need to include the case-law on "partial access into the Directive? Under what conditions could a prolessional who received "partial access" acquire full access?

The directive should be designed to prevent the option of "partial access- on the grounds mentioned in the consultation document. In general, access to a profession should be granted only when an applicant has completed a qualification. If the differences are so large that they cannot be compensated for by compensatory measures, the applicants qualification is simply not the same qualification as that of the host country. In such cases the applicant can apply for -Accreditation of prior learning- and similar systems. and complement their training within a university or university college. This pathway requires solid documentation of the applicants' qualification from the home- or education country. In such cases applicants may have the opportunity to take parts of the education in the host country instead of a full programme. However, in some cases the differences will be too extensive to compensate for. Partial access should not be granted unless it is a part of the system for compensatory measures. If partial access is used as suggested in the consultation document, it will most likely not be of any use for the applicant in the long run, if the aim is to obtain full recognition. In many professions, it will be irresponsible to let employees with partial access work with anything else than what he/she is qualified for. A system of sufficient supervision and training opportunities would be costly and time consuming. This would be a challenge in several sectors where we already today experience a lack of capacity to facilitate for employees in systems of apprenticeship and clinical placements for students in health and social care education and training. A practitioner with partial access may at some point go beyond his/her clearly stated limitations for practice (as identified by the competent authority) due to unforeseen challenges occurring e.g. in a doctor-patient relation. Another challenge arising is how to plan work and execute management in health care, business etc., with an even more differentiated workforce where some members are holding partial qualifications only. 3.3 Offering consumers the high quality service they demand Question 15: What are your views ahout introducing the concept of a European curriculum a kind qf 28th regime applicahle in addition to national requirements? What conditions could he foreseen for its development? As the consultation paper describes this item, it is very hard to see how this could be implemented. It seems to complicate the picture more than it helps. The description indicates that there will be both a national curriculum and an EU curriculum which will function alongside, but which will not replace, the national curriculum. If country A has one curriculum for e.g. physiotherapy and country B has a different one, how could the EU curriculum that is different from at least one of the countries - perhaps both - be of any help? It seems that the only effect would be to complicate the situation. 4 INJECTING MORE CONFIDENCE INTO THE SYSTEM 4.1 Retaining automatic recognition in the 21st century 4.1.1.2 Need to update minimum training requirements

Question 22: Do vou see a need to modernise the minimum truining requirements? Should these requirements ulso include a lirnited set of competences? If so, what kind of competences should be considered? It is appropriate and reasonable to nourish a concern for the relevance of the minimum training requirements. The ongoing evaluation of the Directive 2005/36 has so far yielded data uncovering that a number of competent authorities suggest that the content of the directive related to the harmonized professions needs to be evaluated due to advances in the scientific and technological development that have taken place since the implementation of the directive. As pointed out earlier, there is a tension between the free movement of people, which is one of the EU's pillars. and at the same time the member statesurge to safeguard patient health, safety and material values. As long as the signals from the EU so strongly convey the emphasis on free movement of people, it is difficult to understand how numbers 6 and 44 in the preamble of the directive are to be interpreted. With regard to Article 22 a), we appreciate the opportunity to offer part-time training. As a country with a small and scattered population, the part-time option has proven to be a good tool for ensuring required competence within the rural districts. To the extent that particular parts of the health services are mentioned within the directive, hospitals are emphasized. The development in Norway and in several other countries is towards increased investment - in terms of money, organisation and professional development- in the community health services. We suggest that this aspect of the health service be included in the text where appropriate. The way we conceptualize education and training today has evolved during the more than 30 years' history of the oldest part of the sectorial regulations. The current content of the annex reflects a rather prescriptive way of educating and preparing for a career within a profession. The Bologna process has contributed to the huge development of higher education and training. The most recent development which is under implementation, is the qualifications framework and the description of learning outcomes. Generally speaking, Directive 2005/36 and the principles concerning academic recognition, qualifications frameworks and learning outcomes from the Bologna Process and the European Qualifications Framework (which also embrace vocational college and secondary school) should be harmonized as far as possible. As a minimum requirement for modernizing Annex V, the lists of prescribed content should be replaced with descriptions of learning outcomes. In order to describe the expected competence of a profession, it is important that the learning outcomes are described precisely and at a sufficiently detailed level, yet with the flexibility needed for the educational institutions to be able to keep their programmes updated and relevant. It is obvious that the minimum training requirements standard is far too low. Furthermore, there is no system in place for continuously supporting updates or improvements. The "one size fits approach may be considered a challenge in a Europe characterized by diversity also within health care provision and education and training. Input-output-based education and training The current standards for minimum training is input based. As previously mentioned, we suggest changing the paradigm from an input based to an output based description in the shape of learning outcomes as training standards. In the latter case, it is important to describe the learning outcomes at a sufficiently superior level in order to make it possible to implement. At the same time, it must sufficiently precise to be applicable.

Experiences should be drawn from the project "Tuning Educational Structures in Europe" when the training requirements in the process of modernizing the training requirements. As stated on the web page of the project: The main aim and objective qf the project is to contribute significantly to the elaboration of a framework qf comparable and compatible qualifications in each of the (potential) signatory countries qf the Bologna process, which should be described in terms of workload, level, learning outcomes, competences and profile. The Tuning project has developed a methodologv and a common language, rellected in the Berlin Communiqué (19 September 2003), which can serve as a common basis, and will make it possible to develop an overarching European,framework of qualifications. htt ://tunin.unideusto.or hunin eu/index. h?o tion=content&task=view&id=3&itemid=26 Challenges related to migration of health personnel - experiences from Norway We experience a relatively significant difference between health professionals and veterinarians trained in countries from the EU compared to those trained in Norway. In general it can be argued that personnel holding 5-6 years training generally appears as skilled professionals. Perhaps the biggest challenge for the doctors, dentists, pharmacists and veterinarians is lack of knowledge of the Norwegian system for human and animal health care, the society and culture as well as communication and local language. As for the nursing and midwifery professions, the picture is more complex. Training to the long professions takes place in academic institutions in most countries within EU. However, while training to nurse and midwife takes place at university level in Norway, there are several examples of training courses at vocational college and some places even in secondary school levd within EU countries. Those who hold qualifications from vocational colleges and secondary schools appear to be technically skilled, but are usually not trained or expected to possess the skills to conduct independent practice including advanced patient evaluations. Education to nurse and midwife (access to education as midwife requires a background as registered nurse) in Norway is - just as education to doctor or veterinarian - research based, while this is normally not the case for vocational college and secondary school levels. In some countries, specialist training for nurses takes place at the same level as for general nurse. Automatic approval must be reserved for education in general nursing only. The same principle must be employed in relation to other professions were relevant. Challenges related to the duration of the study programme Academic Year Length varies from country to country which means that the actual length of educational programs varies. For instance in dentistry, the academic year lasts only 7 month for some countries. This example demonstrates a need for a more precise definition of duration and suggest weeks as the measure unit. Quality Assurance Automatic approval should require that the institution issuing the diploma is accredited by a governmental quality assurance body for education. This will strengthen the system of automatic recognition. Organization of the directive The distribution between the provisions covered by the articles in the Directive, and the content of the Annex V should be revised. We suggest that the directive only should confirm the programs covered by the scheme for automatic approval, their names, admission requirements, educational level, duration and other formal issues. The annex V may specify learning outcomes, information about the ratio of and other relevant information concerning theory/practice. The reason for a more informative Annex than -directive body- is that the

current regulations make it easier to keep the annex updated. Provisions of the Directive on minimum standards for education and other issues mentioned in the annex V should be evaluated at least every 10 years. European test For the long professional education, it is conceivable to introduce a system with a European test to ensure that graduates of programs actually meet the academic level the directive signals. The proposal has a background in the e.g. the U.S.A. where one has achieved this across the 50 states. Such arrangements are sidelined for the nurse and midwife as long as the training programs are offered at different educational levels. Education level for nurse and midwife Both the nursing and midwifery education are currently offered at different educational levels: university level, vocational college and secondary school. Nurses and midwifes trained at different levels are not trained for the same profession. This is due to differences in task distribution between professions, level of responsibility and independent practice and differences between the ways the countries have organized their health services. A very clear example is the British nurse practitioners who are responsible for the assessment and the medical care for certain patient groups and holds the right to prescribe drug treatment. Other countries offer nurse education at college level at a far more general basis. In Norway, nurses are trained at university level. Midwifes are trained at postgraduate level (qualifications as nurse must be obtained first) and is now in the process of being established as a master's degree. It is fairly obvious that the midwives from Norway and midwives from countries where they are trained at vocational college level will practice independently on different levels. Doctors of Medicine Article 24.2: The directive operates with two set of standards concerning the duration of the study programme. We suggest that only one standard is set, and prefer six year full time study programme. Basic medical education should also include knowledge and skills in quality assurance and doctor- patient communication. Health care services must be developed and improved continually because society, medical knowledge, skills and technology are continuously changing and developing. Also, patients' expectations change. Services do not always function as intended, and may not be so safe and secure as they ought to be and as they could be. The best way of improving health care is to train future health care workers in communication skills and quality assurance. The regulations for doctors of medicine differ from the other harmonized professions in that there is no specification of training requirements in Annex 5. The impact is that the profession with the potentially highest risk for causing harm to patients is the least regulated. If the system with automatic recognition for doctors of medicine is meant to continue, specific learning outcomes must be identified and included into the directive in the same way as suggested for the other harmonized professions. Nurses responsible for general care As mentioned in the consultation paper, some competent authorities have suggested increasing the admission requirements to university level. We strongly support this suggestion. In addition, we suggest that Article 31 include that nursing education and training shall be provided at bachelor's level at universities or other institutions accredited for the purpose. Consequently, article 31 2 last section must be removed.

If the automatic recognition of nurse and midwife should be continued, all countries should offer education and training of nurses and midwifes at the same level. Nurses should be trained at level d pursuant to Article 11, and midwives should be trained at level e (post nurse graduation). If the EU does not want to actually harmonize midwifery, automatic approval should apply only between the countries that have organized midwifery training at equal levels. In light of the major developments in nursing education in Europe, with a considerable number of countries now offering bachelor degree, it is timely to state that the educational level should correspond to Article 11 d and be specified at bachelor level. If this is not possible to achieve within a reasonably short time frame, a plan for transition plan should be developed. The relative balance between the theoretical and clinical training stems from the time when nursing education was mainly a vocational qualification. The health services have advanced strongly since the text in this section was written. The rapid developments in health research, technology, organization and patient expectations and behaviour demand a much more advanced nurse today. The nurse's function in general has evolved into a much more autonomous function with a wider range of responsibilities. To cater for the development the nurse need both theoretical and clinical skills of a high standard. (S)he is trained to take responsibility for her/his own professional development, and is engaged in research. That is also why there is such a high number of nursing programmes within EU/EEA now offered at bachelor's level. We suggest that the theoretical training is provided with more time, and the clinical training with less time. The terms theoretical and clinical training are defined in Article 31.4 and 31.5. The definitions are very specific and rigid and create an artificial gap between the two terms. The interrelationship between theory and practice in contemporary professional education make article 31.4 and 31.5 irrelevant and is an obstacle to making use of the best possible ways to facilitate education and training. Instead of strict definitions and allocation of proportions of time spent within the programme on theory or practice, it is more helpful to describe learning outcomes that include elements from both theory and practice. In order to enhance the quality of clinical training, it should be stated that the clinical training must be evidence based. Contemporary nursing education and training covers the topics for theoretical education as stated in Appendix 5.2.1. When it comes to clinical instruction, greater challenges arise. If the expectation is that students are supposed to know the field well and obtain some level of clinical skills, we will have shortfalls concerning child care, paediatrics and maternity care. This is due to how health care for these groups are facilitated, which to a large extent is outside of hospitals. At the time when the text in the annex 5.2.1 was made, the situation within health care was different. The public health status has changed, as has the way we provide health services. E.g. child nursing has become a very small niche activity in hospitals compared to how it was 20 years ago, and this makes it impossible to provide clinical placements for more than a limited number of students. Maternity care also is different today and nursing schools are facing almost the same challenges with regard to child care and paediatrics. A number of nursing programmes in Europe seems to have entered higher education and are offered at bachelor level. This implies that teaching has to be research based and practice

should be evidence based. Consequently, the students must learn research theory and methods. Midwile Midwifery education and training in Norway is in line with Article 40, 1 (b). In Norway, this option requires a bachelor's degree in nursing before a two year full-time training to midwife. As a result of the implementation of the Bologna process, education and training to midwife is a cycle 2 programme and is on its way to be transformed into a master^s degree programme. Upon completion of the midwife education, the practitioner has achieved a qualification of five years study, corresponding to article 11 (e). The Norwegian midwifes are highly qualified and they are expected to practice independently. The large diversity in midwife education and training throughout Europe may represent a threat towards patient safety unless automatic recognition for this profession is abandoned or training requirements are to be harmonized within one model at the same level. Phannacists The field of pharmacy has changed substantially since the latest revision of the directive. This evolution of the profession requires new competences for pharmacists. In particular the following topics should be added to the list of training required for pharmacist: - social pharmacy - pharmaceutical care - communication skills - pharmaceutical biotechnology - molecular biology In spite of the suggestions above, also for pharmacy we recommend to replace the input based model with descriptions of learning outcomes. Dental practitioners Articles 34 and 35 in the directive are general in character and therefore easy to adopt and follow for the Norwegian dental schools. However, the emphasis on certain elements in the education may give different profiles to the dental practitioners within and between countries in the EU system. The directive in its present form has focus on training length and general requirements for the institutions providing the education. The requirements for expected knowledge are rather general, and use terms like "adequate knowledge". A focus on expected skills and achieved attitudes may be a better guideline in this respect. These problems are highlighted in documents prepared by the Association of Dental Education in Europe (www.adee.org). Exchange of students may be difficult as the curricula may vary between universities. Harmonization of the curricula in the EU system would be beneficial in this respect. Veterinary surgeons The competence of veterinarians trained in Europe varies extensively. With a free labour market for veterinarians in the EU/EEA area, further harmonization of veterinary education is needed. The veterinarian's role in ensuring the safety of exports and imports of animals and animal products also requires a greater degree of harmonization of veterinary expertise in Europe. Over 100 European institutions are member of EAEVE (European Association of Establishment for Veterinary Education). EAEVE has described the minimum requirements

for the contents of a veterinary education and prepared "day one skills" which are the minimum qualifications a graduate veterinarian needs in order to be in line with the requirements of EU Directive. EAEVE is responsible for a volunteer system for accreditation of European veterinary institutions. Due to the large differences concerning the quality of the training programmes, we suggest that the EU require membership in EAEVE for the training facilities. Training facilities which are members of the EAEVE are a part of the organization's accreditation system. Furthermore, the directive should authorize the EAEVE to formulate minimum requirements concerning content and learning outcome of a veterinary program. This will facilitate harmonization between training programmes and a dynamic process to ensure that the content reflects the needs of the European communities. Accordingly, we find that Annex 5 should be reviewed and modernized. For example, agricultural and basic sciences appear to be too dominant. Besides the basic sciences and clinical veterinary disciplines, there is a need for increased focus on veterinary public health like e.g. zoonosis, risk assessment/risk communication and interface between human and veterinary medicine etc., in line with developments in the veterinary profession and society's needs. The relative importance between subjects should also be indicated. Alternatively, it should be left to EAEVE to formulate minimum training requirements leading to accreditation of a training programme. 4.2 Continuing professional development Question 27: Do you see a need Ibr taking more account qf continuing prqkssional development at EU level? Ifyes, how could this need be reflected in the Directive? Apart from the General Practitioner, Norway has no system for surveying individual health personnel concerning continuous professional development. Through the Health Personnel Act 1999, each health professional is individually responsible for being fit for practice and professionally updated. At the same time, employers are responsible for facilitating for the employees' continuous professional development. The numbers relating to malpractice or other forms of violations of the Health Personnel Act or the PatientsRights Act is held to be low. However, work life becomes even more complex as the scientific and technological development evolves. The need for a stronger focus on CPD is considered to be there. Even if numbers of negative incidents are claimed to be low, there is another important side of the coin: the trust of the consumers. This is crucial when it comes to health and probably other sectors as well. 4.4 Language skills Question 30: Have you encountered any major problems with the current language regime as foreseen in the Directive? The regulations to the Health Personnel Act clearly places responsibility for language skills on the individual health worker and the employer. For health personnel running their own business on a contract with e.g. local administration or a hospital, the contract partners are responsible.

The overall purpose of the directive is to ensure as free movement as possible amongst the member of the workforce within regulated professions. In most cases, a primary reason for regulating a profession is to keep potential risks and threats towards people, animals, nature, material values etc. at an acceptable levd. When it comes to health professionals, the main concern is patient safety. Language skills are an extremely important and integrated part of the execution of professional conduct. In order for the doctor to determine correct diagnoses and appropriate treatment (s) he/she must be able to understand the patient. For the patient to understand the diagnoses and treatment, the doctor must be able to communicate this clearly in the local language. This principle is valid for most health professionals. However, the degree of fluency in language skills may vary. We consider language to be an integrated part of the professional qualification. Practical solutions where e.g. the dental secretary actually writes the journal for a dentist who is no sufficiently skilled in the local language, makes it impossible for the dentist to be responsible for what is written in the patient journal. Consequently, proof of required language skills should be presented together with all other documents relevant for the application for recognition. Being skilled in local language is just as important in relation to temporary service as in cases of permanent settlement. We realize that with 4 600 regulated professions; there are probably several professions where language requirements can remain minimal. However, in a number of professions, the language is to be considered as a part of the qualification. The code of conduct mention only one example speech pathologist. This is obvious. However, this is just as obvious for doctor, nurse, primary school teacher etc. If the professional is unable to speak with and understand patients, pupils, public authorities, supervision boards etc., the person is simply not qualified. Documentation and/or testing of sufficient language skills should be an integrated part of the recognition process. Other comments: As for pharmacy, Norway as a few other countries in Europe offers training to pharmacist both at a masters level qualifying for automatic recognition and a bachelors degree. The bachelors degrees in pharmacy within Europe differs substantially. At present, we do not want to see a process leading to a system of automatic recognition for the bachelor level. Yours sincerely la ave secretary general or RyUii senior adver Torp