We would be very happy to expand on this submission, orally or in writing, if the Committee so wishes.

NHS European Office response to House of Lords EU Social Policies and Consumer Protection Sub- Committee Inquiry into the mobility of healthcare professionals Introduction The NHS Confederation's European Office welcomes the opportunity to submit evidence to the House of Lords' EU Social Policies and Consumer Protection Sub-Committee's Inquiry into the mobility of health professionals. The NHS European Office was established in 2007 to engage with EU developments which have implications for the NHS and to seek to ensure that NHS views and concerns are taken into account when EU policy and law is shaped. It is part of the NHS Confederation, which is the independent membership body for the full range of organisations that make up the modern NHS. Attracting healthcare professionals from outside the UK is very important for the NHS and the EU Directive on the Mutual Recognition of Professional Qualifications has facilitated this. Working closely with the NHS Employers organisation, which represents NHS employing bodies in England on workforce issues, the NHS European Office responded to the European Commission consultation on the revision of the Directive earlier this year on behalf of the NHS. Our response to that consultation can be found attached at Annex A. The European Office will continue to engage with the revision of the Directive throughout the decision-making process, feeding in NHS views as appropriate. We would be very happy to expand on this submission, orally or in writing, if the Committee so wishes. More information about the work of the NHS European Office can be found at: www.nhsemployers.org/europe Elisabetta Zanon Director NHS European Office

RECOGNITION OF PROFESSIONAL QUALIFICATIONS - KEY POINTS FROM THE NHS EUROPEAN OFFICE RESPONSE TO THE EUROPEAN COMMISSION CONSULTATION The NHS European Office supports the principles of mutual recognition and free movement, but believes these mustn t be at the expense of safety and quality. In particular, we believe higher safety and quality standards need to apply to healthcare professions, as the risks are much higher and patients are vulnerable. We agree the Directive needs updating and would like to see the minimum qualifications updated, possibly to take account of outcomes (competences achieved) as well as hours put in. We welcome the suggestion that continuing professional development should be made a requirement for continuing registration and think Member States (MS) should be responsible for ensuring such arrangements are in place for healthcare professions. We also welcome the idea of extending the mandatory use of the Internal Market Information (IMI) electronic database system to health professions, and placing a duty on regulatory bodies to exchange proactive warnings about fraudulent or incompetent registrants. We are opposed to the idea of a professional card we think there are better alternatives, such as using IMI. We think a card would be open to abuse and are sceptical about the costs and benefits. We are also dubious about the concept of partial access for healthcare professions it would be very hard to monitor and ensure that individuals granted partial access only practised within the scope of their competence. We do not want checks on professionals providing services on a temporary and occasional basis to be relaxed, and would prefer that the term temporary and occasional should not be clarified in the Directive but left to the regulator s discretion on a case by case basis. Language competence we would prefer a more explicit statement in the Directive about the possibility of testing at the point of registration, though we maintain that primary responsibility for testing language competence remains with the employer (where one exists).

Responses to the Inquiry questions Turning specifically to the seven questions asked by the Inquiry: 1. Background: fundamental principles What benefits are derived by healthcare professionals and patients from mobility? 1.1 Freedom of movement is good for the NHS, and good for professionals and patients. The NHS has benefited greatly from the contribution of incoming migrants and has been able to use mobility across European borders to help match labour supply and demand. Professionals for their part also gain personally and professionally from working in new environments. 1.2 The healthcare sector faces particular challenges over the next few years and is already facing a gap in supply of skilled professionals that will widen in the future unless appropriate measures are taken to address it. The European Commission s Green Paper on the European Workforce for Health issued in December 2008, the follow-up report in December 2009 and the Council conclusions Investing in Europe s health workforce of tomorrow adopted in December 2010 all highlight the challenges facing European healthcare systems in the 21st century, such as increasing demand owing to the ageing population and technological advances, coupled with an ageing workforce and shortages of healthcare workers. In some Member States (MS) these shortages are severe. 1.3 The mobility of qualified, competent healthcare professionals is therefore an important feature in ensuring a responsive national healthcare system. 2. What risks have you observed arising from mobility and to what do you attribute those risks? 2.1 Concerns have been expressed for some time by eminent members of the medical and nursing establishments in England about the competence of some European health professionals both their clinical competence and their communication (English language) skills. There has also been a great deal of adverse publicity in the UK media around the issue of communication in particular. 2.2 It is important that patients, and their healthcare colleagues, have full confidence in migrant health professionals and the systems in place to facilitate their movement. 3. 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? 3.1 We are mindful that healthcare, by its very nature, carries a high degree of serious risk to the health and safety of patients from professionals who may lack training, clinical expertise, relevant experience or personal integrity. It is necessary therefore in this sector to balance the desire to streamline and simplify free movement with the need to maintain minimum quality and safety standards by checking the competence and suitability of professionals who will be providing services. 3.2 This point is worth reiterating at a national and European level during the review. We believe the case for these minimum quality and safety standards is a very strong one and must be reinforced.

4. 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? 4.1 The experience reports collated by the European Commission show that the current recognition of professional qualifications arrangements work well on the whole, and in particular that competent authorities (in the UK and elsewhere) wish to retain the system of automatic recognition for sectoral professions. However they also highlight areas that could be improved. 4.2 These include practical difficulties in identifying the appropriate competent authority (for example in countries where professionals are registered by a multiplicity of regulatory bodies at regional or local level), delays by competent authorities in responding to queries, unnecessarily complicated procedures and/or requests for superfluous documentation, sometimes at a cost to the applicant. We believe that the automatic recognition system could be improved if the minimum training requirements were overhauled to take account of the differences in duration and curriculum content between Member States and to encourage greater transparency between regulators about these differences. 4.3 On the issue of whether automatic recognition should be extended, we would leave it to the individual professions to decide whether this should be the case. 5. Administrative cooperation To what extent do you consider that appropriate systems are in place for administrative cooperation between Member States, particularly as regards fitness to practise? 5.1 Insufficient cooperation between MS is a cause of concern for the NHS. Currently, lack of information about the content of training curricula for example sometimes makes it difficult for competent authorities to compare qualifications and to have confidence in the quality of training and education delivered. 5.2 The Internal Market Information (IMI) system in particular is an area where cooperation can and should be increased between MS. We consider that all competent authorities regulating healthcare professions should be required to register with and use the IMI system. We would welcome a proactive alert mechanism for health professions using IMI. We acknowledge however that there are differences between fitness to practise criteria between MS and that there would need to be discussion and agreement between competent authorities about the circumstances in which an alert should be triggered. 6. 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? 6.1 Competent authorities and employers in the UK have reported concerns that some registrants from other MS may not have the language skills necessary for pursuit of the profession in the host MS. This has sometimes led to misunderstandings and even errors.

6.2 We agree that it is the responsibility of employers to ensure that people they appoint to posts have the necessary skills, including language competence, to perform the tasks for which they are being recruited. However subtle deficiencies may not always be apparent at the stage of recruitment, in the case of health professions requiring an unusually high level of language competence in clinical situations. 6.3 There are also concerns about professionals who are self-employed and can practise immediately after recognition of their qualification and registration. 6.4 We would welcome a more explicit acknowledgement in the Directive that competent authorities may, if they wish, satisfy themselves that the applicant seeking registration has a knowledge of the host MS language sufficient for pursuit of the profession, providing this is done in a proportionate and non-systematic way. This would not commit MS to make any changes to their transposing legislation if they do not wish to do so. The details of how this would work in each MS would be for MS governments and competent authorities to decide in the light of domestic legislation and practice, respecting the overall principle of removal of unnecessary barriers to freedom of movement. 7. 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? 7.1 As stated above, we do not believe the case for the introduction of a European Professional Card as proposed has been made. We believe a great deal more thought needs to go into defining the purpose of such a card and, following this, looking at a range of possible ways of achieving the identified objectives. In particular, we are concerned that this proposal has been put forward as a solution without simpler, more cost-effective means of achieving the same objectives being considered first. 7.2 For example, the very successful IMI system could be adapted for this purpose, rather than introducing an expensive and risky new system which is potentially open to abuse. A full cost/benefit analysis should be conducted before any further work takes place on this initiative. NHS European Office June 2011

ANNEX A NHS European Office Response to Consultation Paper by the European Commission s DG Internal Market and Services on the Professional Qualifications Directive The NHS European Office who we are and who we represent 1. This response has been prepared by the NHS European Office, working closely with the NHS Employers organisation, which represents NHS (National Health Service) organisations in England on workforce issues. The NHS European Office represents the English National Health Service in Europe, including representing the NHS in the EU social dialogue through the European social partner organisations CEEP and HOSPEEM. 2. In order to inform our response to the current consultation we called for views and input from employers across the NHS, and this paper reflects these inputs. There was a high degree of consensus from our respondents about the messages they would wish us to convey to the Commission on behalf of the NHS, which is one of the largest employers in the world, with well over a million employees in more than 350 different careers, both within and ancillary to healthcare. Introduction and context the healthcare sector 3. We agree with the Commission that now is a good time to review and update European legislation on mobility of professionals, some of which dates as far back as the 1960s. Increasing mobility across European borders is an important element of matching labour supply and demand and thereby contributing to meeting the Europe 2020 targets for sustainable and inclusive growth. 4. The healthcare sector faces particular challenges over the next few years. The sector is already facing a gap in supply of skilled professionals that will widen in the future unless appropriate measures are taken to address it. The European Commission s Green Paper on the European Workforce for Health issued in December 2008, the follow-up report in December 2009 and the Council conclusions Investing in Europe s health workforce of tomorrow adopted in December 2010 all highlight the challenges facing European healthcare systems in the 21 st century, such as increasing demand owing to the ageing population and technological advances, coupled with an ageing workforce and shortages of healthcare workers. In some MS these shortages are severe. 5. It is therefore critical for MS to be able to attract and retain healthcare professionals, and we agree that there should not be unnecessary barriers to free movement that would hamper MS in providing adequate healthcare for their populations. However we are also mindful that healthcare, by its very nature, carries a high degree of serious risk to the health and safety of patients from professionals who may lack training, clinical expertise, relevant experience or personal integrity. It is necessary therefore in this sector to balance the desire to streamline and simplify free movement with the need to maintain minimum quality and safety standards by checking the competence and suitability of professionals who will be providing services. 6. The experience reports collated by the Commission show that the current recognition of professional qualifications arrangements work well on the whole, and in particular that

Question 1 competent authorities (in the UK and elsewhere) wish to retain the system of automatic recognition for sectoral professions. However they also highlight areas that could be improved. We welcome this timely opportunity to make positive suggestions about how the current regime could be updated. Do you have any suggestions for further improving citizens access to information on the recognition processes for their professional qualification in another Member State? 7. The current contact point system appears to work well in signposting incoming migrants to the appropriate UK competent authority. We are fortunate in the UK that all of the regulated healthcare professions are dealt with by a small number of competent authorities, each of which (with the exception of the pharmacy regulator) covers the whole of the UK. Each of the UK competent authorities maintains a website containing the information migrants need to know, and applicants are encouraged to apply online. 8. Health professions are excluded from the provisions of the Services Directive and we would not wish this to change. Question 2 Do you have any suggestions for the simplification of the current recognition procedures? If so, please provide suggestions with supporting evidence. 9. In the case of healthcare professionals, we feel the current recognition procedures, correctly applied, provide an adequate balance between simplicity and safety. Question 3 Should the Code of Conduct become enforceable? Is there a need to amend the contents of the Code of Conduct? Please specify and provide the reasons for your suggestions. 10. No. We are strongly of the opinion that the Code of Conduct should not be made enforceable : it is useful guidance but should not be made legally binding. We do not think that it is appropriate for a document containing this level of administrative detail to become a legally binding instrument. 11. We are especially concerned that the code should not inadvertently make it easier for the small minority of practitioners who may attempt to submit fraudulent documentation, for example by supplying photocopies (which may have been tampered with) rather than original documentation, which is more difficult to forge. 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? 12. We understand that the UK competent authorities are submitting detailed replies to these questions, and feel they are best qualified to do so. However in general we believe that, where there is a substantial difference in the applicant s level of training and experience which requires a compensation measure, this measure should not be diluted simply because it may have an unintended deterrent effect. Compensation measures play an important part in ensuring that integration of the migrant is facilitated as well as the safety of patients is safeguarded, so is beneficial to both parties. Periods of adaptation help migrants to

assimilate to the culture of the host MS (for example the expectation in the UK that a nurse will practice as an autonomous practitioner alongside medical colleagues, rather than under medical supervision). 13. The outcomes of the TUNING project and progress in developing a European curriculum that supplements national training programmes would help in this respect. Question 5 Do you support the idea of developing Europe-wide codes of conduct on aptitude tests or adaptation periods? 14. It would certainly be helpful for competent authorities to be able to exchange examples of good practice and to learn from each other in developing aptitude tests and adaptation periods. We would not want to see a rigid or prescriptive code of practice, but we would welcome transparency and sharing of best practice between MS. This would save duplication and unnecessary reinventing the wheel, especially as it is likely that applicants from certain MS will have similar shortfalls from standards in other host MS regarding their training and experience. Question 6 Do you see a need to include the case-law on partial access into the Directive? Under what conditions could a professional who received "partial access" acquire full access? 15. We have concerns about the principle of partial access to a profession. Whilst practitioners would have a responsibility not to practise beyond the scope of their competence, it could be difficult for employers to supervise them to ensure they are not put in this position and are only performing tasks they have been trained to do. We consider there may be valid reasons in the case of health professionals to argue that the risk is too great and that partial access is not in the public interest. 16. Should partial access be granted, it would be the responsibility of employers to ensure that staff they recruit have been trained to do the tasks they have been recruited to perform, and to train them if there is a shortfall in their training, clinical expertise or experience. They could thus in due course expand the scope of their practice. Question 7 Do you consider it important to facilitate mobility for graduates who are not yet fully qualified professionals and who seek access to a remunerated traineeship or supervised practice in another Member State? Do you have any suggestions? Please be specific in your reasons. 17. We can see that this proposal could cause difficulties in relation to domestic workforce planning, especially in specialties where this could exacerbate a shortage of places for other applicants. We can however also see that there are merits in encouraging cross-fertilisation between graduates from different healthcare systems and cultures. Question 8 How should the home Member State proceed in case the professional wishes to return after a supervised practice in another Member State? Please be specific in your reasons. 18. We leave this question for competent authorities and educational bodies.

Question 9 To which extent has the requirement of two years of professional experience become a barrier to accessing a profession where mobility across many Member States in Europe is vital? Please be specific in your reasons. 19. In the case of the great majority of healthcare professionals this situation cannot arise, as the majority of healthcare professions are regulated in all MS. Where it does arise, we consider that two years experience is a reasonable requirement. Question 10 How could the concept of "regulated education" be better used in the interest of consumers? If such education is not specifically geared to a given profession could a minimum list of relevant competences attested by a home Member State be a way forward? 20. Again, we consider this question is best addressed by competent authorities and educational bodies. Questions 11 to 14 What are your views about the objectives of a European professional card? Should such a card speed up the recognition process? Should it increase transparency for consumers and employers? Should it enhance confidence and forge closer cooperation between a home and a host Member State? Do you agree with the proposed features of the card? What information would be essential on the card? How could a timely update of such information be organised? Do you think that the title professional card is appropriate? Would the title professional passport, with its connotation of mobility, be more appropriate? 21. We consider that these questions are premature. A great deal more thought needs to go into defining the purpose of such a card and then looking at a range of possible ways of achieving the identified objectives. We are concerned that this proposal has been put forward as a solution without simpler, more cost-effective means of achieving the same objectives being considered first. 22. For example, the very successful IMI system could be adapted for this purpose, rather than introducing an expensive and risky new system which is potentially open to abuse. 23. A full cost/benefit analysis should be conducted before any further work takes place on this initiative. Question 15 What are your views about introducing the concept of a European curriculum a kind of 28th regime applicable in addition to national requirements? What conditions could be foreseen for its development?

24. We have not yet formed a firm view on this suggestion. However we are interested in exploring the idea of a possible European curriculum based on agreed competences, which would not preclude MS from retaining individual approaches to delivering national training programmes. 25. There are still significant variances before more unified outcome measures are achieved that are valid in all MS. We would not want such a regime to settle for legitimising or ossifying old-fashioned programmes of training. We will listen with interest to the outcomes from the professional working groups set up by the Commission to examine educational issues. Question 16 To what extent is there a risk of fragmenting markets through excessive numbers of regulated professions? Please give illustrative examples for sectors which get more and more fragmented. 26. We agree that there are too many regulated professions, and that ideally regulation should be determined by the level of risk posed by practitioners to the public. However this is not really an issue for the health professions, who have strong health and safety grounds for regulation. Question 17 Should lighter regimes be developed for professionals who accompany consumers to another Member State? 27. No. However, this is not generally a big issue for healthcare professions. Where it arises (for example doctors or sports physiotherapists accompanying athletes to competitions) the rules on provision of temporary and occasional services would normally apply. However we are mindful that in the case of healthcare practitioners, safeguards need to be in place in case such an individual wishes to treat other patients during their stay in the host MS. Question 18 How could the current declaration regime be simplified, in order to reduce unnecessary burdens? Is it necessary to require a declaration where the essential part of the services is provided online without declaration? Is it necessary to clarify the terms temporary or occasional or should the conditions for professionals to seek recognition of qualifications on a permanent basis be simplified? 28. Yes, it is necessary to require a declaration in the case of healthcare professions, in view of the health and safety considerations and the vulnerability of patients. The terms temporary and occasional should not be clarified but should be determined on a case by case basis at the discretion of the competent authority. Question 19 Is there a need for retaining a pro-forma registration system? 29. Yes, for the reasons given above. Question 20 Should Member States reduce the current scope for prior checks of qualifications and accordingly the scope for derogating from the declaration regime?

30. No, in the case of healthcare professions, because of health and safety risks to the public. Questions 21, 22 and 24 Does the current minimum training harmonisation offer a real access to the profession, in particular for nurses, midwives and pharmacists? Do you see a need to modernise the minimum training requirements? Should these requirements also include a limited set of competences? If so what kind of competences should be considered? Should the current scheme for notifying new diplomas be overhauled? Should such notifications be made at a much earlier stage? Please be specific in your reasons. 31. These questions are largely for educational bodies and competent authorities to answer rather than employers. However we agree that the minimum training requirements certainly require updating. The hours specification should be retained, but we think that professions should also work together to see whether minimum outcome-based competences could also be required. Qualifications should be based on agreed and explicitly stated outcomes in addition to minimum inputs expressed in terms of time (number of hours spent on education). Question 23 Should a Member State be obliged to be more transparent and to provide more information to the other Member States about future qualifications which benefit from automatic recognition? 32. Yes. Currently, lack of information about the content of training curricula sometimes makes it difficult for competent authorities to compare qualifications and to have confidence in the quality of training and education delivered Questions 25 and 26 Do you see a need for modernising this regime on automatic recognition, notably the list of activities listed in Annex IV? Do you see a need for shortening the number of years of professional experience necessary to qualify for automatic recognition? 33. Not applicable to healthcare professions. Question 27 Do you see a need for taking more account of continuing professional development at EU level? If yes, how could this need be reflected in the Directive? 34. Yes. The revised Directive could helpfully contain wording to the effect that all MS should have mechanisms in place whereby competent authorities should require CPD in order for professionals to remain up to date, fit and safe to practise and to maintain their registration. 35. Only professionals who satisfy the CPD requirement in their home MS should be able to benefit from automatic recognition when they migrate. Question 28

Would the extension of IMI to the professions outside the scope of the Services Directive create more confidence between Member States? Should the extension of the mandatory use of IMI include a proactive alert mechanism for cases where such a mechanism currently does not apply, notably health professions? 36. Yes and Yes. We consider that all competent authorities regulating healthcare professions should be required to register with and use the IMI system. We would welcome a proactive alert mechanism for health professions using IMI. We acknowledge however that there are differences between fitness to practise criteria between MS and that there would need to be discussion and agreement between competent authorities about the circumstances in which an alert should be triggered. Question 29 In which cases should an alert obligation be triggered? 37. This needs to be worked out by collaboration between the competent authorities and in the light of the very different standards across MS. Question 30 Have you encountered any major problems with the current language regime as foreseen in the Directive? 38. Yes. Competent authorities and employers in the UK have reported concerns that some registrants from other MS may not have the language skills necessary for pursuit of the profession in the host MS. This has sometimes led to misunderstandings and even errors. 39. We agree that it is the responsibility of employers to ensure that people they appoint to posts have the necessary skills, including language competence, to perform the tasks for which they are being recruited. However subtle deficiencies may not always be apparent at the stage of recruitment, in the case of health professions requiring an unusually high level of language competence in clinical situations. 40. There are also concerns about professionals who are self-employed and can practise immediately after recognition of their qualification and registration. 41. We would welcome a more explicit acknowledgement in the Directive that competent authorities may, if they wish, satisfy themselves that the applicant seeking registration has a knowledge of the host MS language sufficient for pursuit of the profession, providing this is done in a proportionate and non-systematic way. This would not commit MS to make any changes to their transposing legislation if they do not wish to do so. The details of how this would work in each MS would be for MS governments and competent authorities to decide in the light of domestic legislation and practice, respecting the overall principle of removal of unnecessary barriers to freedom of movement. NHS European Office March 2011