On the European workforce for Health

The European Council of the Liberal Professions (CEPLIS) is the inter-professional organisation representing  the liberal professions at the Community level. Its members are inter-professional federations of professional bodies in individual EU Member States and mono-professional organisations representing professional associations and regulators at EU level. CEPLIS does not represent individual practitioners. It is their professional or regulatory bodies that are members of, or are associated with, CEPLIS.

These bodies include the inter-professional federations of France (UNAPL), the UK (UKIPG), Spain (UP), Italy (CUP & Confprofessioni)), Ireland (IIPA), Belgium (UNPLIB), Romania (UPLR), Malta (MFPA), etc, who have within their membership the national organisations of most of the professions; as well as the organisations representing at the European level the professions of Nurse (FEPI), Psychologist (EFPA), Osteopath (FEO), Veterinarian (FVE), clinical Chemist (EC4), Podiatrist (CLPUE), etc.  At the same time, many national or oversight regulatory bodies of our professions, such as those of the Italian Physicians and  Dentists (FNOMCeO), the French Radiologists (FNMR), the United Kingdom Council for Healthcare Regulatory Excellence (CHRE) or the Nursing and Midwifery Council (NMC) of the UK participate in the activities of CEPLIS, as correspondent organisations.

               The professional or regulatory bodies active in the health sector, represented within CEPLIS, represent thousands of persons across the EU who contributes substantially to the efficiency and quality of the health services. 

CEPLIS recognises that in the words used, the Commission is seeking in the Green Paper, to achieve two objectives
·         to describe the challenges faced by the EU health workforce that are common to all Member States; and
·         to help to identify where the Commission considers further action can be taken to  address these challenges and to launch a debate

CEPLIS welcomes the initiative of the Commission to stimulate a debate on the important issues touched upon in the paper. Governments in all Member States will be expected by their citizens to provide affordable health services of high quality now and in the future. They have a right to assume that their governments and the European Union, where it can assist, will take steps to identify obstacles to such provision and address them positively in a timely fashion.

CEPLIS also welcomes the opportunity to participate in this important debate.

1.      General comments

With some reluctance, CEPLIS finds it necessary to suggest that some of the wording in the Green Paper is unclear, thus making it difficult to respond in a precise manner to some of the points. For example, we are not clear of the precise meaning of a sentence such as “Encouraging cross-border agreements on training and staff exchanges, which may help to manage the outward flow of health workers while respecting Community law” in Para. 4.4.

Secondly, we make the point that the Paper focuses on selected health professionals and appears to fail to recognise the important contributions made to the health and well-being of people, by professionals such as psychologists, podiatrists, osteopaths, physiotherapists and others. Some of these professionals can be expected to make an even greater contribution to healthcare generally, as the proportion of older people in populations increases, as the Commission recognises it will. The contribution to human health of veterinarians should also be recognised rather than ignored. They make a vital contribution to human health, for example in the control of zoonotic diseases and in ensuring food safety.

2.      Specific comments on issues raised

·         Demography and the promotion of a sustainable health workforce

Member States have to recognise that as people live longer demand for healthcare services is bound to increase and the nature of that demand will change as compared with the past and the present. The financial consequences of providing a large enough health workforce to meet this increased demand must be planned for.

CEPLIS agrees that it is vital to ensure both that sufficient facilities and resources are provided to educate and train new young practitioners and that there should be re-investment in the mature workforce, particularly in training in the development of necessary new skills for existing practitioners and in facilitating return to practice for those who have been out of the workforce for some time.

In regard to “return to practice” campaigns, it is important that the facilities provided are designed to stimulate confidence in those contemplating re-joining the health workforce that successful completion of a course, including any supervised practice, will indeed equip them to resume practising in a health environment that may be very different from that which they left. This will require a significant investment of resources by governments.

Those returning to practice will then, of course, be subject to the same requirements as their peers, for participation in continuing professional development (CPD) to ensure continuing competence in their specific sphere of practice. CEPLIS has concerns about the considerable differences in requirements for CPD for various health professionals in different Member States. This has implications for patients and the public in relation to cross-border movement of health professionals.

CEPLIS recognises that under the Directive on Recognition of Professional Qualifications, the need for CPD is specified but arrangements are said to be a matter for individual Member States. CEPLIS does not consider this to be acceptable from the point of view of patients when professionals are likely to move cross-border. We believe that there should be much greater co-ordination of CPD requirements for individual health professions at Community level.

Some health professionals are entitled to “mutual automatic recognition” under the terms of Directive 2005/36/EC, based on the holding of a specific original qualification. This is not satisfactory from the point of view of patients. There is a need for an arrangement for revalidation of qualifications, based on participation in CPD, to ensure up-to-date competence in providing professional services.

CEPLIS notes with interest the Commission’s recognition of the importance of developing possibilities for providing language training to assist in potential mobility of health professionals. We have been encouraging action on this theme for some time, at Community level. We would add that, alongside language training, there should be at the very least, an introduction to the differences in culture likely to be encountered in a Member State to which a professional is considering migrating.

·         Inter-disciplinary co-operation

It will also be very important, in the view of CEPLIS, to invest in research on how to achieve the best outcome for patients from the skill mix in multidisciplinary health practitioner practices. We believe that considerable benefits will accrue from research to identify best practices in this regard in various Member States and subsequent encouragement and facilitation for the adoption of these practices in all countries.

·         Raising awareness in schools about the wide range of available careers in the health and care sectors

CEPLIS welcomes the proposal for such an initiative to raise awareness of available careers across the whole healthcare sector. The approach will of course have to be professional and again this will require investment of adequate resources. The importance of the media, including television and the Internet in capturing the interest of young people will be recognised. There is good evidence that a successful TV series of a fictional nature can have more effect in stimulating the interest of young people in a specific profession in the health sector than advertisements or a documentary specifically intended to arouse such interest.

·         Public health capacity

The Commission has recognised the importance of successful health promotion and disease prevention initiatives in reducing future demand for treatment and care services. There has been talk in various Member States in recent years about changing the emphasis from a service that treats illness to one that helps people to avoid sickness and maintain good health. Unfortunately many governments appear to be unwilling to make the investment to turn the talk into action. This is perhaps understandable. It is bound to be difficult at a time when funds are not unlimited and there is pressure to provide more and better treatment facilities, to persuade a majority that significant investment of resources now in health promotion, will produce major cost benefits in, say, 20 or more years time. Thinking tends to be short term because of political factors. Nevertheless, in the view of CEPLIS, efforts must be intensified to seek to achieve a change in mindset in this regard, on the part of policy makers.

So far as health promotion campaigns themselves are concerned, there has sometimes been too much emphasis in the past in focusing publicity mainly or exclusively in medical practice premises and clinics linked to hospitals – locations likely to be visited when an individual is already unwell or feels unwell. It is, of course important that health promotion material should be prominent in such locations. However, the involvement of pharmacies should also be seen as vital and a major effort should be made to encourage enthusiastic participation in locations such as shopping centres, supermarkets and other places that people visit when they perceive themselves to be fit and well.

Such locations should also be considered for publicity about the wide range of interesting and fulfilling careers in health and social care.

·         Managing mobility of health workers within the EU

As is made clear in the first sentence of paragraph 4.4 of the Green Paper, “free movement of persons is one of the fundamental freedoms guaranteed by Community law.”  As far as professionals are concerned this in underlined in texts such as the European Action Plan on Professional Mobility and the Directive on Recognition of Professional Qualifications. The Green Paper makes it clear that health professionals move for a variety of reasons. The main drivers are career enhancement and the opportunity to achieve better pay and/or working conditions. These drivers will always exist while there are disparities within countries.

It is not clear to CEPLIS how there could be “cross border agreements on training to manage the outflow of health workers” without contravening Community law, from the point of view of the individual affected. Further information on what the Commission has in mind would be welcomed.

CEPLIS also considers that the proposed goal of “achieving self sufficiency” in health personnel, suggests the concept of “fortress Europe”. This would be neither desirable nor achievable in our view.

On the other hand CEPLIS fully supports the concept of promoting the “circular” movement of staff as envisaged in the Green Paper. This would have benefits for both the citizens of the “home” Member State and the individual professional, providing the rights of the latter on subsequent free movement are protected. One could perhaps envisage an arrangement under which funding is provided for training in new skills in a host Member State in return for an obligation to provide those additional services in the “ home” Member State for a specified reasonable minimum period.

·         Global migration of health workers.

CEPLIS fully supports the sentiments expressed in paragraph 4.5 of the Green Paper and the initiatives taken by the EU. The promotion of “circular migration” will be important in bringing benefits to developing countries.

In this regard, the Commission should consider the possible implications of Directive 2003/109 and COM(2007)637 final. On the face of it, these have the effect of increasing mobility of third country nationals within countries of the EU rather than encouraging “circular migration”.

The goal of supporting the WHO in its work of developing a global code of conduct for ethical recruitment will have the full backing of organisations of health professionals world-wide. The difficulties of achieving the desired aim of preventing “brain drain” of health professionals from developing countries should not be underestimated. Ethical recruitment by public sector employers can be undermined by recruitment activities of the private sector.

The Commission may wish to seek input from the World Health Professions Alliance on this topic.

·         Data to support decision making

The absence of up-to-date data as described in paragraph 4.6 of the Green Paper is undoubtedly a barrier to effective planning of health services. This must be addressed.

For the regulated health professions, there should be a co-ordinated system of data collection. The number of practising professionals on the register of an individual health professional should be known at all times, as should the number of students and those engaged in pre-registration activities. So far as migration is concerned, the number of those seeking registration to practise, by virtue of a qualification gained in another Member State, should be recorded. If it is a requirement for such individuals to notify addresses on annual re-registration, information should be available on whether individuals have returned to their country of origin.

Recording of such data electronically to enable analysis should be feasible.

The harmonisation and standardisation of health workforce indicators for the regulated health professions should be vigorously promoted.

The difficulties are much greater when a health profession is not regulated in some Member States. This is a matter to which the Commission should give some consideration if the goal is to achieve a comprehensive standardisation of health workforce indicators in EU Member States.

·         The impact of new technology: improving the efficiency of the health workforce.

CEPLIS fully supports the statements about the benefits that accrue from the effective use of new technologies, as set out in paragraph 5 of the Green Paper. The comment about the need to gain the acceptance of the health workforce for its use is particularly welcomed.

However, bearing in mind the principle of subsidiarity, CEPLIS wonders if effective action can be taken at Community level. Encouraging Member States to take action to ensure inter-operability of new information technology could be a more realistic solution.

·         The role of health professional entrepreneurs in the workforce

CEPLIS has concerns about the goal of encouraging more entrepreneurs to enter the health sector in order to improve planning of healthcare provision.

Firstly, it is not clear how entrepreneurs will improve planning of healthcare provision. Secondly the very special nature of healthcare services has to be recognised as well as the need to ensure that health professionals must always be guaranteed conditions that enable them to exercise their responsibilities with independence and impartiality. The involvement of “entrepreneurs” may not guarantee such conditions.

Earlier in this submission, we promoted the benefits of encouraging health professionals to operate in multidisciplinary practices. This would create new jobs. The professionals would decide the ethos of the practice. That should be the way forward for the benefit of patients and the public, as well as the health professionals themselves.

·         Cohesion policy

CEPLIS fully supports the goals of Member States making more use of the support offered by structural funds to train and re-skill health professionals, improving the use of structural funds for the development of the health workforce and enhancing the use of these funds for infrastructure to improve working conditions.

POSITION OF THE EUROPEAN COUNCIL OF THE LIBERAL PROFESSIONS (CEPLIS) ON THE COMMUNICATION FROM THE COMMISSION TO THE COUNCIL,

THE EUROPEAN PARLIAMENT, THE EUROPEAN ECONOMIC AND SOCIAL COMMITTEE AND THE COMMITTEE OF THE REGIONS “THINK SMALL FIRST” A “SMALL BUSINESS ACT FOR EUROPE”

The European Council of the Liberal Professions (CEPLIS) is the inter-professional organisation representing the liberal professions at Community level. Its members are either inter-professional federations of professional bodies in individual EU Member States or mono-professional organisations representing professional associations and regulators at EU level. CEPLIS does not represent individual practitioners. It is their professional or regulatory bodies that are members of, or are associated with, CEPLIS.
These bodies include the inter-professional federations of France (UNAPL), the UK (UKIPG), Spain (UP), Italy (CUP & Confprofessioni)), Ireland (IIPA), Belgium (UNPLIB), Romania (UPLR), Malta (MFPA), etc, who have within their membership the national organisations of most of the professions; as well as the organisations representing at the European level the professions of Surveyor (CLGE), Engineer (ECEC & FEANI), Nurse (FEPI), Psychologist (EFPA), Notary (FANE), Veterinarian (FVE), Osteopath (FEO), etc.  At the same time, many national or oversight regulatory bodies of our professions, such as those of the Italian Physicians and Dentists (FNOMCeO), the French Radiologists (FNMR), the Nursing and Midwifery Council in the UK (NMC) or the Italian Industrial Experts (Consiglio Nazionale dei Periti), participate in the activities of CEPLIS, as correspondent organisations.
Counting some four million European citizens amongst their members, the professions represented within CEPLIS act as employers to millions of persons across the EU and contribute substantially to the realisations of the Lisbon goals aiming at making the Union the most competitive and dynamic knowledge-based economy in the world.
CEPLIS has received the European Commission’s Communication on a “Small Business Act
for Europe” and has very carefully reviewed its content, aware of the fact that a great number of professionals are exercising jointly with colleagues coming from the same or similar disciplines and with other collaborators, in forms quite resembling those of regular Small or Very Small Businesses.   
In the light of the provisions of the Communication in question, the European Council of the
Liberal professions wishes to express its concern that the European Commission does not seem to have taken into account the specific professional characteristics of its members and their activities in its plans to encourage investment, employment and growth at the “Small” scale.  
We have observed in fact that some of the proposed provisions in the ‘Act’ might be adaptable to the practice of the Liberal Professions: An eloquent example is that of the principle of ensuring “that honest entrepreneurs who have faced bankruptcy quickly get a second chance”. For our sector this principle is closely related to professional requirements. A professional who is facing bankruptcy is often in need to become updated to the scientific evolutions related to his/her skills and to raise the level of his/her CPD: A waiting period after bankruptcy is indeed necessary for the professionals in order to act as warrant for the quality of their services. We feel that one year is not a sufficient enough period for that. CEPLIS would like to attract attention on the dangers and damages that a professional who does not meet the necessary requirements to exercise his/her tasks, or is not fit to practice, can cause to patients, clients and the general public.  
At the same time, as the European Parliament has underlined in several resolutions relating to our category, the liberal professions, because of their role as “the expression of a democratic fundamental order based on law”, even when they are exercising their activities in the form of a small enterprise continue to be obliged to register with regulatory bodies and to abide by rules and codes of conduct, specifically designed to ensure the impartiality, competence, integrity and responsibility of every profession and to guarantee the quality of their services to the benefit of their clients, of the society in general and of public interest (see for example EP Resolution of December 8, 2003 on Market Regulations and Competition Rules for the Liberal Professions; see also the  “Common Values of the Liberal Professions in the European Union”, attached to this position).  
Characterised by a high level of specialised knowledge, the liberal professionals are also distinct from other service providers and small entrepreneurs by the fact that they are very often act as agents of the public authority and are thus obliged to follow regulations aiming at preventing conflicts of interest and at safeguarding their proper practice, and this despite of the inherent restrictive effects on competition, such as for example a number of limitations to advertising, that may result from such regulations (see for example EP Resolution of March 26, 2006 on the Legal Professions and the General Functioning of the Legal System).
The European Council of the Liberal Professions welcomes and indeed supports many of the initiatives envisaged by the SBA. However it is clear from the foregoing, that there is an important distinction to be made between the activities exercised by our professions and those the European Commission’s communication is aiming at supporting.
There remains however the pressing need to promote the same goals that govern the Commission’s principles for the Small Enterprises in our own field as well: As an important generator of employment, knowledge and growth, our professions are in need of a Community encouragement to investment in their field and of a broader recognition of their role for Europe’s economy and society.
The European Council of the Liberal Professions is convinced that this recognition needs to take the form of a distinct Communication from the European Commission on a “European Liberal Professional Act”, establishing the principles that should govern the relations of the professions with the European institutions and proposing a number of supporting mechanisms and measures to promote these principles.
Such a “Liberal Professional Act” should take into consideration the risk that liberal professionals take - a risk not relevant to SMEs - because of the professionals’ direct and total liability, as well as other issues such as the tax status of the professions. The Act should also reflect the fact that the liberal professions are exposed to a triple control: civil, penal, and deontological – under the codes of conduct of their regulatory bodies, and are characterized by independence of professional decision making and action.
In that framework, CEPLIS calls upon the Council, the European Parliament and the Commission to also consider the designation of an interlocutor of our category at the Union level, by attributing the responsibility of our portofolio to a member of the College of Commissioners.