EUROPEAN UNION OF GENERAL PRACTITIONERS/FAMILY PHYSICIANS UNION EUROPEENNE DES MEDECINS OMNIPRATICIENS/MEDECINS DE FAMILLE

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1 EUROPEAN UNION OF GENERAL PRACTITIONERS/FAMILY PHYSICIANS UNION EUROPEENNE DES MEDECINS OMNIPRATICIENS/MEDECINS DE FAMILLE PRESIDENT: Dr. Ferenc Hajnal (Hungary) Dr. Eirik Bø Larsen (Norway) Dr. Francisco Toquero (Spain) Dr. Nena Kopcavar Gucek (Slovenia) Dr. Joseph Portelli Demajo (Malta) CONSULTATION PAPER European Commission DG Internal Market GREEN PAPER (COM(2011) 367 final) Modernising the Professional Qualifications Directive 16 September 2011

2 The European Union of General Practitioners/ Family Physicians (UEMO) is an organization of the most emblematic national, non-governmental and independent organizations representing General Practitioners/Family Physicians in the countries of Europe. Founded in 1967 by the national organizations in Belgium, France, Germany, the Netherlands and Italy, the UEMO quickly grew to encompass organizations from all current Member States of the European Union, from the countries of the European Economic Area (EEA) as well as other European countries. As one of its main objectives, UEMO aims to study and promote the highest standard of patient care, training, continuing medical education and continuing professional development, professional practice conditions within the field of the General Practice/Family Medicine throughout Europe, to keep up the role of General Practitioners/Family Physicians (hereinafter GP/FP) in the healthcare systems and to promote the ethical, scientific, professional, social and economic interests of European GP/FP and to secure their freedom of practice in the interests of the patient. We thank the opportunity to share our experience and suggestions during the process of public consultation on the modernisation of the Professional Qualification Directive carried out by the European Commission s Internal Market Directorate General. Under this topic, UEMO would like to mention one specific difficulty which arises with the growing number of Member States that have introduced Family Medicine as a medical speciality and the general practice rules as defined in the Directive 2005/36 /EC. UEMO very much agrees with the intention of the call for consultation to simplify the recognition procedure and facilitate mobility of professionals through the EU, namely mobility of GP/FP. Most parts of the acquis on professional qualification were agreed between six or nine Member States of the then European Economic Community. According to an UEMO survey, 21 out of the 27 EU countries recognize General Practice/Family Medicine as a speciality under the Title III of Directive 2005/036/EC, in 4 countries (Austria, Bulgaria, Italy and United Kingdom) GP/FP are not specialists, functioning under the Title IV, and in two countries (Belgium and Luxembourg) the status is currently under consideration. We have answered the questions of particular interest to UEMO: Question 1: Do you have any comments on the respective roles of the competent authorities in the Member State of departure and the receiving Member State? The competent authorities in both Member State of departure and the receiving Member State play a critical role in assuring doctors credentials, and ultimately their competence to practice. According to UEMO, it is essential that the competent authority in the host Member State is able to satisfy itself that the doctor is fit to practise and that his/her documents are valid. This is in order to maintain the integrity of the medical register. The host competent authority must not be prevented from carrying out these checks due to the existence of a professional card. The Internal Market Information (IMI) system should be the focus of this discussion and is the key tool utilised in the relationship between the Member State of departure and the one which is receiving the professional. The holding of a European Professional card would be less relevant for the medical profession. The main focus of this discussion should remain on the efficient communication between the competent authorities, and how this could assist in the process of automatic recognition. In case of existence of a professional card, while competent authorities of the home Member State should be responsible for verifying the original card, responsibility for the maintenance of the card once the physician starts practicing in another or several Member States needs to be identified, particularly in terms of recording continuing medical education (CME) and continuing professional development (CPD) as well as disciplinary/misconduct issues. The maintenance of information on the card, particularly in regards to the medical profession, needs to be mapped out to ensure the veracity of the individual practicing medicine. 1

3 Question 2: Do you agree that a professional card could have the following effects, depending on the card holder's objectives? a) The card holder moves on a temporary basis (temporary mobility): Option 1: the card would make any declaration which Member States can currently require under Article 7 of the Directive redundant. Option 2: the declaration regime is maintained but the card could be presented in place of any accompanying documents. While this could be a beneficial tool to family doctors, UEMO position is, however, that due to the responsibility of physicians in terms of patient safety and care, it requires comprehensive security measures to ensure the integrity of the card. The introduction of a new card could lead to administrative duplication and difficulties around interoperability. Therefore, unless a fully interoperative and secure professional card is developed which provides a safe method for storing accompanying documents of doctors, it is essential that competent authorities continue to verify such documents. b) The card holder seeks automatic recognition of his qualifications: presentation of the card would accelerate the recognition procedure (receiving Member State should take a decision within two weeks instead of three months). c) The card holder seeks recognition of his qualifications which are not subject to automatic recognition (the general system): presentation of the card would accelerate the recognition procedure (receiving Member State would have to take a decision within one month instead of four months). The importance of a robust and efficient recognition process is predominantly an issue of patient safety. While timelines to process the professionals request for recognition are important to doctors moving from one Member State to another, the competent authority of the Member State of departure must be able to operate within a reasonable timeframe whereby it can undertake the necessary comprehensive communication and investigation between the relevant authorities. Meeting these responsibilities should be balanced with the professional s request of recognition. Question 3: Do you agree that there would be important advantages to inserting the principle of partial access and specific criteria for its application into the Directive? (Please provide specific reasons for any derogation from the principle.) In the opinion of UEMO, partial access should never be granted to medical professionals. Partial access is leading to unclear legal situations and is difficult to explain to the public. Its extension to the health sector could jeopardize patient safety. If the principle of partial access is inserted into the revised Directive, there must be a full derogation for healthcare workers. Only the full license/registration entitles the holder to unrestricted exercise of the practice of medicine. This is essential to ensure optimum patient safety and healthcare service delivery in Europe. Question 6: Would you support an obligation for Member States to ensure that information on the competent authorities and the required documents for the recognition of professional qualifications is available through a central on line access point in each Member State? Would you support an obligation to enable online completion of recognition procedures for all professionals? (Please give specific arguments for or against this approach). Yes, UEMO would support such an obligation. In our opinion, professional organizations at EU level could provide links to national websites which provide this information and add a section on frequently asked questions. Publishing experiences of members with the authorities ordered per country could give additional factual information. It is also highly important to inform members who want to work in another country that this is not an easy switch: any change of country has to be well planned in advance in order to be a success. Besides, migrant doctors should be made aware of the need of language skills for exercising the profession. The central on line access point could be useful to signpost migrants to the competent authorities. Moreover, 2

4 the competent authorities could facilitate access to information by providing their website content in a common European language in addition to their home language UEMO would support a full system of online completion of recognition procedures for doctors ONLY if the authenticated documents required as part of recognition procedures for physicians can be verified with absolute certainty, including meeting all legal data protection obligations. Question 11: Would you support extending the benefits of the Directive to graduates from academic training who wish to complete a period of remunerated supervised practical experience in the profession abroad? (Please give specific arguments for or against this approach.) This is a very complex question and UEMO agrees that countries should make arrangements to ensure that those graduating in medicine from their home universities can complete the basic elements of training. However, the movement of new graduates in the specific training should be facilitated. There is evidence that traineeships abroad helps to improve doctor-patient relationship in intercultural contact. This is an accepted practice throughout Europe with many Junior Doctors seeking training abroad and returning afterwards to the country of origin. UEMO believes that the sheer number of young physicians who complete part of their training in other EU Member States is a proof of the fact that there are no major constraints and that the recognition of knowledge, skills and training periods acquired in other EU Member States is not a problem. Question 12: Which of the two options for the introduction of an alert mechanism for health professionals within the IMI system do you prefer? Option 1: Extending the alert mechanism as foreseen under the Services Directive to all professionals, including health professionals? The initiating Member State would decide to which other Member States the alert should be addressed. Option 2: Introducing the wider and more rigorous alert obligation for Member States to immediately alert all other Member States if a health professional is no longer allowed to practise due to a disciplinary sanction? The initiating Member State would be obliged to address each alert to all other Member States. UEMO supports option 2. Our position is that the Directive should be revised in order to introduce a legal duty on all medical regulators to share registration and fitness to practice information proactively. Data protection issues which prevent some EU Member States from doing this must be addressed and resolved as a matter of urgency. In addition to the proactive sharing of data when regulatory action is taken against a doctor (an alert mechanism ), the IMI system must be made compulsory for all EU competent authorities so that they can be confident of receiving a timely and reliable response to any justifiable concerns they may have over an applicant. The instances that are currently being highlighted (professional malpractice issues) should certainly trigger an alert to all other Member States, however there must be safeguards to ensure that this is used in appropriate circumstances and clear standards and criteria should be developed around this procedure. Question 13: Which of the two options outlines above do you prefer? Option 1: Clarifying the existing rules in the Code of Conduct; Option 2: Amending the Directive itself with regard to health professionals having direct contact with patients and benefiting from automatic recognition. UEMO recommends option 2, but a balance needs to be achieved to ensure that competent authorities are not (directly or indirectly) using language tests as a discriminatory tool. Although it is fully justified to require different levels of language knowledge depending on the profession and on the level of contact with the population, the system has proven that Member States could have very diverse positions on this issue. As a 3

5 consequence, depending on the host country, the person could be refused the right to practice his/her profession. These potential discrepancies are not justifiable for the migrants. At the same time, the level of language knowledge required should be justified and appropriate in order to allow the migration of physicians within the European Union. And to further facilitate this migration, there should be various means of proving language skills. In addition, information on the level of language competency required and the forms of acceptable proof should be made available to physicians wishing to migrate. Moreover, limiting the control of the necessary language skills to health professionals who have direct contact with patients would not be suitable. Sufficient knowledge of the host Member State s language(s) is a necessary prerequisite for cultivating a relationship of trust between patients and physicians. But, in addition, it is vital that doctors are able to communicate with colleagues, with the healthcare team and with outside organisations who may be involved in the treatment of their patient. Question 14: Would you support a three-phase approach to modernisation of the minimum training requirements under the Directive consisting of the following phases: - the first phase to review the foundations, notably the minimum training periods, and preparing the institutional framework for further adaptations, as part of the modernisation of the Directive in ; - the second phase ( ) to build on the reviewed foundations, including, where necessary, the revision of training subjects and initial work on adding competences using the new institutional framework; and - the third phase (post-2014) to address the issue of ECTS credits using the new institutional framework? UEMO supports a dual approach of minimum training time and competencies to ensure a much more balanced approach to medical training in Member States. Currently, there can be significant discrepancies in training standards. Through the three-phase approach, a comprehensive review can be undertaken to best devise a course of action to ensure that the harmonisation of training standards can be achieved. However, it should be up to national competent authorities to maintain their independence in delivering such training. The three proposed phases for the modernisation of the minimum training requirements are closely linked and a comprehensive review of the Directive encompasses actions under all of them. UEMO therefore calls for the Commission to ensure that all the 3 steps are undertaken and are not optional. For doctors, the minimum training conditions to ensure that certain levels of medical education and training have been achieved for qualifications to be recognised are currently laid down in Annex V of Directive 2005/036/EC. It is UEMO s view that the text in this Annex needs to be amended and updated to reflect current medical and education principles. Question 15: Once professionals seek establishment in a Member State other than that in which they acquired their qualifications, they should demonstrate to the host Member State that they have the right to exercise their profession in the home Member State. This principle applies in the case of temporary mobility. Should it be extended to cases where a professional wishes to establish himself? (Please give specific arguments for or against this approach). Is there a need for the Directive to address the question of continuing professional development more extensively? UEMO believes that professionals should always demonstrate to the host Member State that they have the right to exercise their profession in the home Member State, whether they apply for temporary mobility or they wish to establish on a permanent basis. There must be greater understanding between competent authorities on fitness to practise and disciplinary procedures in order to avoid the unfair treatment of doctors. 4

6 Regarding the question of continuing professional development, UEMO believes that a process should be launched with health professionals in order to see how to encourage continuing medical education and training of higher quality. The current Directive does not allow the competent authorities to satisfy themselves that a doctor has kept their skills and competences updated in the years following their qualification. Education and training are vital components in creating a modern, efficient health workforce. But continuing medical education (CME) and continuing professional development (CPD) must also be taken into account in order to ensure that doctors have up-to-date professional skills and are knowledgeable about the latest treatments and developments in medical technology. Question 16: Would you support clarifying the minimum training requirements for doctors, nurses and midwives to state that the conditions relating to the minimum years of training and the minimum hours of training apply cumulatively? (Please give specific arguments for or against this approach.) As stated in our answer to Question 14, the introduction of quality criteria for post-graduate training is necessary. Basic (undergraduate and postgraduate specialist) medical training standards need to be outlined in the Directive to ensure that throughout Member States training can be undertaken in full confidence that a high standard of doctors are delivered. By establishing these competencies along with a timeframe, a comprehensive framework can provide competent authorities with the trust which is currently lacking behind the qualifications that are automatically recognised. Besides, in order to simplify and optimize the current recognition procedure, UEMO suggests recognizing General Practice/Family Medicine as a speciality. Question 17: Do you agree that Member States should make notifications as soon as a new program of education and training is approved? Would you support an obligation for Member States to submit a report to the Commission on the compliance of each programme of education and training leading to the acquisition of a title notified to the Commission with the Directive? Should Member States designate a national compliance function for this purpose? (Please give specific arguments for or against this approach.) Yes, in the opinion of UEMO the system for notifying new diplomas must be able to react faster and more flexibly to changes at a national level, as well as to possible current mistakes. Member States should be obliged to notify the Commission of all new programmes of education or training. This is essential for a good functioning of the Directive and for the procedural safeguards of graduate students. Currently, there are large discrepancies between education degrees and training programs. A level of harmony should be reached through communication by appropriate bodies in the Member States, to ensure that comparable ground is available for the professions. Member States should designate a national compliance function and, where appropriate, notify existing competent accreditation bodies taking on this role. Question 18: Do you agree that the threshold of the minimum number of Member States where the medical speciality exists should be lowered from two-fifths to one-third? (Please give specific arguments for or against this approach.) Yes, UEMO believes that reducing the threshold to one-third would facilitate the recognition of medical specialities that have a significant establishment in EU medical practice. The main challenge is less the number of Member States (the threshold) than the decision process for adopting a new speciality. Member States should be obliged to report recognised specialities using a simple common procedure to a single central source in Brussels. Moreover, in order to simplify and optimize the current recognition procedure, UEMO suggests recognizing General Practice/Family Medicine as a speciality. 5

7 Question 19: Do you agree that the modernisation of the Directive could be an opportunity for Member States for granting partial exemptions if part of the training has been already completed in the context of another specialist training programme? If yes, are there any conditions that should be fulfilled in order to benefit from a partial exemption? (Please give specific arguments for or against this approach.) If transferable competencies between specialities are implemented, the overarching principles should be that the training has been assessed as satisfactory in the previous programme and that this assessment is of competencies and experience (and not just of experience or length of training). Question 24: Do you consider it necessary to make adjustments to the treatment of EU citizens holding third country qualifications under the Directive, for example by reducing the three years rule in Article 3 (3)? Would you welcome such adjustment also for third country nationals, including those falling under the European Neighbourhood Policy, who benefit from an equal treatment clause under relevant European legislation? (Please give specific arguments for or against this approach.) For UEMO it is essential that the three years rule is maintained and no change is required to this point of the Directive. The three-year rule, along with the current arrangements for recognising qualifications, are adequate and provide reasonable safeguards, particularly when looking at areas of patient safety. 6