The Belgian and Dutch legislatin gverning health care prfessins and task shifting Ellen Vanermen, KU Leuven, Belgium
1. Task shifting (TS)
Task shifting What? When tasks shift frm prfessinals belnging t ne ccupatinal grup t prfessinals belnging t anther (pssibly new) ccupatinal grup r subcategry theref E.g. frm physicians t (specialised) nurses, nurse practitiners r physician assistants There are ther definitins and related cncepts Task reallcatin, delegatin, substitutin, supplementatin
Task shifting Why? It is presumed by many that TS may have beneficial effects in terms f adressing capacity shrtages in ne/mre ccupatinal grup(s) reducing waiting times imprving career perspectives imprving efficiency f, access t, quality, cntinuity and affrdability f care
Task shifting Why? Wrld Medical Assciatin warns fr ptential risks (Reslutin, 2009) Decreased quality f care Increased demand n physicians Research n and mnitring the effects f TS are imprtant E.g. Gielen, S.C., Dekker, J., Francke, A.L., Mistiaen, P., Krezen, M. The effects f nurse prescribing: A systematic review. Internatinal Jurnal f Nursing Studies: 2013. E.g. Laurant M., Reeves D., Hermens R., Braspenning J., Grl R., Sibbald B. Substitutin f dctrs by nurses in primary care. Cchrane Database Reviews 2005, Issue 2. Art. N: CD001271. DOI: 10.1002/14651858.CD001271.pub2.
2. Task shifting frm a legal pint f view
Task shifting frm a legal pint f view Cmparisn between Belgian and Dutch legislatin gverning health care prfessins Which ne facilitates TS mre? In general Specific prfessins, specific tasks
Belgian legislatin Health Care Prfessins Act (HCPA, 1967) All medical, pharmaceutical, nursing and paramedical acts are reserved t legally designated prfessinals It is prhibited t perfrm thse acts unless ne is legally authrized Each regulated health care prfessin is authrized t perfrm certain reserved activities
Dutch legislatin Individual Health Care Prfessins Act (IHCPA, 1993) Everyne is allwed t perfrm individual health care acts, with the exceptin f 14 reserved activities It is prhibited t perfrm thse activities unless ne is legally authrized
Dutch legislatin Title prtectin Only thse wh meet certain requirements (registratin/educatin) may use a specific title A title hlder is deemed cmpetent fr certain activities Prtected titles as quality labels
Dutch legislatin Reserved activities (RA) 14 activities deemed t pse a cnsiderable risk t the health f the patient if perfrmed by anyne wh is nt qualified Surgical prcedures Elective cardiversin Obstetric prcedures Defibrillatin Endscpies Electrcnvulsive therapy Catheterizatins Lithtripsy Injectins Artificial inseminatin Punctures Prescribing medicatin General anesthesia Prcedures invlving the use f radiactive substances and devices emitting inizing radiatin
Dutch legislatin Reserved activities (RA) Art. 36 IHCPA determines fr each RA which prfessinals are allwed t assess whether RA is necessary perfrm RA themselves OR delegate RA t thers = Autnmus authrity Art. 36 a IHCPA: Experiment article Subrdinate legislatin may, by way f experiment, grant autnmus authrity t prfessinals wh did nt have such authrity befre, fr a trial perid f maximum five years
Which legislatin facilitates task shifting mre? Dutch legislatin is mre pen and flexible and facilitates TS mre Three reasns
1. Less reserved activities The Netherlands 14 medical activities are reserved t legally authrized prfessinals Belgium All medical, pharmaceutical, nursing and paramedical acts are reserved t legally authrized persns
1. Less reserved activities The Netherlands Belgium
1. Less reserved activities The Netherlands Belgium Mre restrictive E.g. Nursing aid Authrized t perfrm 18 nursing acts Hygienic care, measure temperature : free in NL Often, they illegally perfrm mre acts Oxygen applicatin, feeding persns having difficulties swallwing : free in NL
2. Open delegatin basis fr RA The Netherlands Legislatin nly determines wh is authrized t perfrm RA n his/her wn initiative Prfessinal with autnmus authrity may delegate t anther prfessinal He/she has t be qualified, n further details Open delegatin basis fr RA
2. Open delegatin basis fr RA Belgium Legislatin determines wh is authrized t perfrm medical, pharmaceutical, nursing and paramedical acts n his/her wn initiative r after delegatin by anther prfessinal N pen delegatin basis Mre restrictive E.g. injectin f insuline: delegatin t nursing aid is nt an ptin
3. Experiment article The Netherlands Subrdinate legislatin may, by way f experiment, grant autnmus authrity fr RA t prfessinals wh did nt have such authrity befre, fr a trial perid f maximum five years Intermediate stage befre amendment IHCPA Tl fr evidence based legislatin Physician assistant and nurse practitiner: autnmus authrity fr mst tested RA will be incrprated in article 36 IHCPA (amendment recently apprved) Belgium Granting autnmus authrity fr medical activities t a nnphysician requires amendment HCPA Less flexible Physician assistant and nurse practitiner absent in Belgian legislatin
Sme remarks TS is nt absent in Belgium E.g. midwives authrized t prescribe certain medicatin Legal basis 2006; implemented 2013 Intentin t revise Belgian HCPA thrughly Plicy plan federal gvernment 2014 N bill yet
3. EU law and regulatin f health care prfessins
Directive 2005/36/EC n the recgnitin f prfessinal qualificatins Art. 21 (6): Each Member State shall make access t, and pursuit f, the prfessinal activities f dctrs, nurses respnsible fr general care, dental practitiners, ( ) midwives and pharmacists subject t pssessin f evidence f frmal qualificatins referred t in pints ( ) f Annex V respectively, attesting that the prfessinal cncerned, ver the duratin f his training, has acquired, as apprpriate, the knwledge, skills and cmpetences referred t in Articles ( ). Is the Dutch system in accrdance with art. 21 (6)? The Netherlands: Title prtectin (= mde f pursuit, art. 1 Directive) & limited number f reserved activities
Directive 2005/36/EC n the recgnitin f prfessinal qualificatins Art. 59 (3): Member States shall examine whether requirements under their legal system restricting the access t a prfessin r its pursuit t the hlders f a specific prfessinal qualificatin, including the use f prfessinal titles and the prfessinal activities allwed under such title, referred t in this Article as requirements are cmpatible with the fllwing principles: (a) requirements must be neither directly nr indirectly discriminatry n the basis f natinality r residence; (b) requirements must be justified by verriding reasns f general interest; (c) requirements must be suitable fr securing the attainment f the bjective pursued and must nt g beynd what is necessary t attain that bjective. MS bliged t assess the prprtinality f their prfessinal regulatins
Directive 2005/36/EC n the recgnitin f prfessinal qualificatins Reprting bligatins fr MS regarding assessing prprtinality f their prfessinal regulatins Art. 59 (5): By 18 January 2016, Member States shall prvide the Cmmissin with infrmatin n the requirements they intend t maintain and the reasns fr cnsidering that thse requirements cmply with paragraph 3. Member States shall prvide infrmatin n the requirements they subsequently intrduced, and the reasns fr cnsidering that thse requirements cmply with paragraph 3, within six mnths f the adptin f the measure. Art. 59 (6): By 18 January 2016, and every tw years thereafter, Member States shall als submit a reprt t the Cmmissin abut the requirements which have been remved r made less stringent. Art. 59 (7): The Cmmissin shall frward the reprts referred t in paragraph 6 t the ther Member States which shall submit their bservatins within six mnths. Within the same perid f six mnths, the Cmmissin shall cnsult interested parties, including the prfessins cncerned.
Directive 2005/36/EC n the recgnitin f prfessinal qualificatins Transparancy & mutual evaluatin exercise, 2014-2016 MS had t carry ut a screening f all their legislatin n all prfessins regulated in their territry EU Cmmissin: Lack f clarity as regards the criteria t be used when assessing prprtinality Uneven scrutiny f measures It has nt prevented the intrductin f new restrictive measures withut bjective and cmprehensive analysis since Fllw-up initiative (art. 59 (9)): Prpsal fr a Directive n a prprtinality test befre adptin f new regulatin f prfessins (January 2017)
Prpsal fr a directive n a prprtinality test Art. 1 - Subject matter : This Directive lays dwn rules n a cmmn framewrk fr cnducting prprtinality assessments befre intrducing new legislative, regulatry r administrative prvisins restricting access t r pursuit f regulated prfessins, r amending existing nes, with a view t ensuring the prper functining f the internal market
Prpsal fr a directive n a prprtinality test MS are bliged t cnduct an ex-ante prprtinality assessment substantiated by qualitative, and wherever pssible, quantitative evidence (art. 4 (1) and (3)) MS have t mnitr the prprtinality f their prvisins n a regular basis (art. 4 (4)) Befre intrducing new r mdifying existing prvisins restricting access t r pursuit f regulated prfessins, MS have t assess whether the prvisins are: Justified by public interest bjectives (art. 5 (1); (2) lists justificatins) Necessary and suitable fr securing the attainment f the bjective pursued and d nt g beynd what is necessary t attain that bjective (art. 6 (1))
Prpsal fr a directive n a prprtinality test Art. 6 (2) sets ut the main criteria t be cnsidered when assessing necessity and prprtinality Nature f risks Scpe f activities reserved t a prfessin Link between qualificatin required and activities Degree f autnmy in exercising a regulated prfessin Ecnmic impact f the measure The pssibility t use less restrictive means t achieve the public interest bjective Cumulative effect f restrictins Art. 6 (3) insists n assessing whether the bjective f the regulatin culd be attained by the prtectin f the prfessinal title withut reserving activities Lack f clarity as t the extent t which a specific apprach fr health prfessinals culd be justified (Rita Baeten) T what extent wuld the Belgian HCPA pass a thrugh prprtinality assessment?
Prpsal fr a directive n a prprtinality test MS have t infrm stakehlders befre intrducing new measures r amending existing nes and give them the pssibility t express their views (art. 7) MS have t encurage exchange f infrmatin with cmpetent authrities f ther MS (art. 8)
Prpsal fr a directive n a prprtinality test Different actrs advcate the exclusin f health care prfessins frm the prpsed directive Draft pinin Cmmittee n the Envirnment, Public Health and Fd Safety (EP) Draft reprt Cmmittee n the Internal Market and Cnsumer Prtectin (EP) Fedcar Standing Cmmittee f Eurpean Dctrs Pharmaceutical Grup f the EU Cuncil f Eurpean Dentists Rita Baeten: This exclusin shuld be accmpanied by a specific legal framewrk applying the free mvement rules t natinal regulatin n health prfessins and health services Baeten, R. (2017) 'Was the exclusin f health care frm the Services Directive a pyrrhic victry? A prprtinality test n regulatin f health prfessins, OSE Paper Series, Opinin Paper N. n 18, Brussels, Eurpean Scial Observatry, April, 25 p.
4. Cnclusins
Cnclusins TS may be a strategy t adress certain challenges Dutch legislatin facilitates TS mre than the Belgian legislatin Hw much margin f appreciatin d MS have in regulating health care prfessins?
Thank yu fr yur attentin Questins? Experiences with/views n -task shifting? -legislatin gverning health care prfessins? ellen.vanermen@kuleuven.be