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ENMCA Response to the EC Green paper – September 2011
European Commission consultation on the professional qualifications Directive
The network brings together the medical competent authorities in the European Economic Area (EEA) responsible for the recognition of medical qualifications in accordance with Directive 2005/36/EC.
We welcome the opportunity to contribute to the European Commission Green Paper on Modernising the Professional Qualifications Directive.
Our response focuses on the key questions of relevance to the network and is informed by the fact that we all have considerable expertise and practical experience of the implications of high levels of professional mobility. Member states undoubtedly benefit from this mobility, receiving many dedicated medical professionals who contribute positively to healthcare in Europe and whose main responsibility is to provide safe and effective care. Mobility does however raise a number of challenges to the protection of the public, which the Directive’s review presents an opportunity to address. This response is in complement to individual responses from network participants.
1. The network notes with interest that doctors are one of the most mobile professions according to the European Commission’s Evaluation of the Professional Qualifications Directive.
2. In this context, network participants raised doubts about a European professional card would add value in facilitating the recognition of medical qualifications and the mobility of doctors. The network believes that any card should be voluntary for the competent authority.
3. Whilst we welcome greater involvement from the competent authority of establishment in the recognition process, we do not support the Commission’s suggestion that on presentation of a card, the host member state would no longer be required to check the migrating doctor’s documentation or see the originals. In order to guarantee patient safety the host competent authority must be able to carry out their own verification of the documents required for recognition, even if at times this might be considered to be resource intensive. There are also concerns that the competent authorities in the member states of establishment will find it difficult to cover the increased administrative costs that will result from a shift in responsibility for recognition.
4. For general systems, it would not be appropriate, for the competent authority of establishment to carry out a comparison of the training for the purpose of issuing a card. The network firmly believes that the host competent authority is best placed to establish whether the education and training of a migrant doctor is equivalent and whether compensation measures are required. Doubts were also expressed as to whether an IMI translation mechanism would provide accurate enough translations of complex documents such as specialist training curricula.
5. For temporary and occasional mobility, we do not support the Commission’s suggestion that the issuing of a professional card should replace the prior declaration and the current requirements of Article 7, which we believe are essential for public protection. The temporary and occasional provisions in the Directive should not serve as a route to evade regulatory scrutiny.
6. The network fully agrees that the recognition process could be improved through a more comprehensive use of the Internal Market Information System (IMI). This could be achieved by allowing competent authorities to exchange documents, including Certificates of Current Professional Status / Certificates of Good Standing, directly through IMI. Some participants consider that there may be merit in exploring the use of an individual identification number which could be used to ensure that the exchanged documents can be uniquely assigned to the migrating doctor. We also agree that IMI should be made compulsory and that users should be subject to enforceable deadlines to ensure that competent authorities respond to IMI requests in an effective and timely manner.
7. We also believe that IMI should remain a mechanism for the exchange of information. Suggestions that a register could be created within IMI to hold information would not be proportionate, would lead to duplication of information and, if not continuously updated, would be unreliable and could pose a risk to patient safety if a doctor is given authorisation to practise on the basis of outdated information.
8. Participants agree with the suggestion in the Green Paper that the deadline for automatic recognition decisions, on submission of a complete application, could be gradually decreased from three months. But remain doubtful that the deadline under general system should be reduced from four months to one month given the time and resources required to undertake a comparison of the training.
9. Participants do not support the inclusion of partial access for medical professionals in the Directive and believe that European Court of Justice jurisprudence is already clear in this area. To ensure patient safety competent authorities should only grant recognition and access to the profession to fully qualified medical practitioners. As there are different systems of regulation in member states, the network believes that it would be challenging to control partial access in a way that would not put patients at risk. It also has the potential to undermine member states’ own system of education, unless it is clearly defined.
National Contact Points
10. We agree that National Contact Points play an important role in signposting professionals to the appropriate competent authority and providing essential information on professional recognition. However, we do not believe Contact Points should become central access points and are concerned about the proposal to make them responsible for all administrative procedures relating to professional qualifications. The Contact Points will not have the necessary expertise to deal with each individual profession. Operating as an intermediary in the way proposed by the Commission may become an additional tier of bureaucracy and cost for both the professional and the competent authority. This could complicate procedures and may create delays and/or misunderstanding.
11. Instead competent authorities should be encouraged to become more transparent and provide clear information online about their accessibility and the recognition procedure in their member state. They could also be supported to develop online application processes available on their website to facilitate the mobility of professionals.
12. We agree with the European Commission that competent authorities imposing compensation measures should justify their decisions to migrating doctors and outline which “substantial differences” in training have been identified.
13. However, the network believes that it is essential for competent authorities to have the flexibility to devise compensation measures that are most appropriate for the doctor wishing to move, whilst at the same time ensuring the adequate protection of the public. We do not believe that the development of a mandatory Europe-wide code of conduct to define common approaches for the development and implementation of compensation measures would be helpful. Instead competent authorities should be encouraged to share best practice and experience for the benefit of the professional and the patient.
Partially qualified professionals
14. We understand the desire to facilitate the mobility of graduates across Europe. However, the network believes it is essential that only those at a comparable training level can gain access to the profession in another member state.
15. Competent authorities fully support the principle of non-discrimination and medical graduates can already access remunerated supervised practice in another member state, subject to approval by national training providers. Therefore, a decision of whether to recognise part of a qualification and / or grant access to a remunerated supervised practice abroad does not need to be enshrined in the Directive, which should focus on the mobility of fully qualified professionals.
Internal Market Information system
16. We agree that all competent authorities should be required to register with IMI and to respond to queries sent through the system. However, network participants believe that it may be impractical for all queries to be answered through IMI and that competent authorities should be able to use other channels of communication as well (i.e. direct contact via email, telephone and meetings).
17. We welcome the Commission’s suggestion that an IMI alert mechanism should be incorporated in a revised Directive, allowing competent authorities to share information about decisions taken against a doctor’s registration in line with national and European data protection requirements. The current system is not sufficient to prevent a small minority of doctors avoiding or evading regulatory sanctions by moving across jurisdictions.
18. We also reiterate our call on the Commission to consider whether the alert mechanism could be used to support the exchange of intelligence about individuals that try to register with fake diplomas or false identities.
19. For reactive information exchange, the network also highlights the need to implement Article 56 to ensure patient safety, at the point of first recognition.
20. The network welcomes the suggestion in the Green Paper to strengthen the language requirements in the Directive but remains concerned that the options proposed might not be sufficiently robust to ensure public protection and patient safety.
21. We would like to highlight that access to the profession should not rest solely on the recognition of professional qualifications. A doctor’s fitness to practise, including their ability of a professional to communicate with their patients, colleagues and the wider healthcare system must also be part of the process. It is therefore essential that competent authorities are able to assess the language of migrating doctors before granting registration regardless of whether they have direct contact with patients.
22. We do not agree with the suggestion that under general system “submitting an application in the language of the host member state” is sufficient to assess the language competence of a migrating professional. We believe that the Directive should include a derogation to allow medical competent authorities to assess the language of migrating doctors as part of the recognition process. This requirement should apply to both automatic recognition and general system cases.
Modernising automatic recognition
23. We welcome the Commission’s intention to modernise the minimum training requirements. The criteria for automatic recognition have not been reviewed for over thirty years and the network is of the view that they should reflect current practice in medical education and training.
24. The network believes that to ensure trust and confidence in the automatic recognition system, the process of modernisation needs to transparent, objective and inclusive, formally involving the competent authorities.
25. In this context, we would suggest that the network play a key role in reviewing the existing requirements, to ensure that they are genuinely comparable, and is involved in further developing the criteria for automatic recognition.
26. The network also questions whether the use of ECTS will genuinely facilitate automatic recognition and suggests that for the moment it would not be appropriate to make its use mandatory. We look forward to the outcome of the external study on the impact of educational reforms.
27. Some participants consider that revising the minimum training requirements for basic medical training would not be expedient, particularly in the context of ongoing shortages of medical professionals across the EEA. Several member states have established intensive graduate-entry or fast-track programmes which meet high quality standards and are compliant with the current Directive. Any change to Article 24 would undermine the flexibility necessary to organise medical education and training in line with national healthcare needs and workforce requirements. Others support a clarification of the minimum requirements for basic medical training so that the six years and 5500 hours apply cumulatively.
28. Participants welcome the Green Paper’s suggestion to improve the notification system for the inclusion of new diplomas in the Annexes of the Directive. We also support the proposal for a compliancy document to accompany new notifications to ensure that amended qualifications continue to meet the minimum training requirements. Furthermore the extension of automatic recognition to new specialties should not be imposed on member states, even if the specialty exists in their jurisdiction.
29. The network believes that a positive way of improving confidence and transparency in the automatic recognition system would be to clarify the process by which new specialties are included in the Directive. We note the suggestion to lower the threshold of member states required to extend automatic recognition. Participants suggest that, before deciding whether to lower the threshold, the Commission should ensure that the process is made more transparent than the current comitology procedure and is based on objective criteria for inclusion.
30. The network also notes the Green Paper proposals on partial exemptions for specialist training. Participants are not aware that the current framework represents a significant barrier to mobility. We consider that the organisation of medical education and training is the competence of member states and automatic recognition should rest on the basis of a completed qualification rather than periods of training. Participants noted that the general system already provides an effective route for competent authorities to take periods of training and experience into consideration.
Clarifying the status of professionals
31. The network considers that it would be impractical to impose minimum CPD criteria given that member states have developed (or are developing) competence assurance mechanisms that reflect their own professional requirements.
32. However, we believe that host competent authority need better assurances that incoming doctors have kept their skills and knowledge up to date since the award of their qualification.
33. As a first step, we support the suggestion that a doctor needs to be established to benefit from automatic recognition. We therefore call on the Commission to extend Annex VII of the Directive to include a document certifying that the migrating doctor fulfils all legal requirements in the member state of establishment to exercise the medical profession.
Third country qualifications
34. The network is concerned about the Green Paper’s suggestion to facilitate recognition for third country qualifications and believes that the current regime for third country nationals with third country qualifications should not be simplified.
35. Participants do not support the suggestion that competent authorities should automatically recognise EEA nationals with third country qualification that have already gained recognition in an EEA country.
36. Furthermore, we would not support reducing the number of years required for a EEA national with a third country qualification to benefit from recognition in another member state. Three years of lawful, full-time and relevant professional experience are essential to prevent professionals from ‘forum-shopping’ to circumvent the more stringent entry requirements in some member states which are necessary to ensure patient safety.
 A template for the certificate was developed by the Healthcare Professionals Crossing Borders (HPCB) in 2005 and is included in the Edinburgh agreement.
 See page 71 of the European Commission Evaluation of the Professional Qualifications Directive, 5 July 2011.
Competent authorities in support of this response
|Belgium||SPF Santé publique, Sécurité de la Chaîne alimentaire et Environnement/ FOD Volksgezondheid, Veiligheid van de Voedselketen en Leefmilieu|
|Cyprus||ΙΑΤΡΙΚΟ ΣΥΜΒΟΥΛΙΟ ΚΥΠΡΟΥ|
|Czech Republic||Ministerstvo zdravotnictví|
|Finland||Sosiaali- ja terveysalan lupa- ja valvontavirasto, Valvira|
|France||Conseil National de l'Ordre de Médecins|
|Hungary||Egészségügyi Engedélyezési és Közigazgatási Hivatal|
|Italy||Ministero della Salute|
|Latvia||Latvijas Ārstu biedrība|
|Luxembourg||Ministre de la Santé|
|The Netherlands||Koninklijke Nederlandsche Maatschappij tot bevordering der Geneeskunst|
|Norway||Statens autorisasjonskontor for helsepersonell|
|Portugal||Ordem dos Médicos|
|Romania||Colegiul Medicilor din Romania|
Ministry of Health
Zdravniška zbornica Slovenije
|UK||General Medical Council|