Medical Issues in Europe

Volume 4 No 1 - 2000

Medical Issues Within a European Dimension [1]

Dr Jane Richards

Medical issues within Europe have been of considerable interest to the BMA for the past 25 years and it is only over the last 3 that we have had an International Committee as distinct from a European Committee, as we have now recognised the need to put our involvement in Europe into a global context. This will be reflected in some of the issues discussed below.

Firstly a bit of background:

The UK has the lowest ratio in Europe of doctors per 1000 head of population at 1.7 doctors for every 1000 people. The European average is 3.4, covering a range from our 1.7 to 5.5 in Italy. Other countries with a high ratio include Germany, Greece and Spain. No great surprises there. Professor Brian Jarman who is a statistically minded professor of General Practice, has estimated that our shortfall could be responsible for around 5000 deaths per annum in the UK. The NHS Plan paragraphs 5.22 to 5.24 has proposed recruitment from abroad to solve the NHS shortfall:

"To further boost NHS staff numbers in the short term, the Department of Health will work with the leaders of the professions and with other government departments to recruit additional suitably qualified staff from abroad where this is feasible, meets service priorities and complies with NHS quality standards. The NHS will not actively recruit from developing countries in order not to undermine their efforts to provide local healthcare"
"There are surpluses of trained doctors in some European countries"

"Carefully planned and targeted international recruitment for nursing and midwifery also remains part of our strategy".

As backup to the statement about surpluses I have figures that the GMC has collected on the number of doctors from Europe who have been granted registration to practice in this country under the provisions of the medical directives (of which more later) between 1977 and 1998.

Germany leads with

4702

Then Greece

3034

Ireland

2683

Italy

2099

And the Netherlands

2074

The largest contributors peaked in 1996 and the numbers appear now to be falling. So what are the European arrangements that will allow the NHS to recruit in Europe? They are Free Movement and Mutual Recognition of Qualifications.

Doctors were the first of the professions to be allowed to move freely within the EEC. The so-called "Doctors Directives" 75/362/EEC and 75/363/EEC were adopted in 1975 and have been in force since early 1976, well before the establishment of the Single Market. These entitle doctors to full registration in any EU member state if they fulfil certain criteria

They are citizens of a member state

They have completed primary training in a member state and hold a recognised qualification

Specialist recognition is more complex. If a doctor has completed specialist training in a specialty common to all member states and which is included in the list in the legislation, then he/she is entitled to be recognised as a specialist elsewhere in the community. There is also a list of specialties common to two or more states, but some areas of specialty recognised in the UK are not yet included and the whole process has been very protracted. Minimum training periods are specified for each listed specialty, but many of these are shorter than ours here. These discrepancies can cause mismatches in the practical experience of doctors with apparently equivalent qualifications.
A further directive covers the requirements for general practice 86/457/EEC, and this did not take full effect until January 1995. It was to correct the considerable imbalance between the requirements in various member states. All those wanting to enter general practice in a "social security system" such as the NHS and other publicly funded systems have to have completed a minimum of two years vocational training. Of course in this country all GP s have had to complete 3 years vocational training since 1981, or have a certificate of exemption,.

These three Directives have now been amalgamated into one with various subsequent amendments for different specialties and are covered by Directive 93/16/EC. In 1998 the European Commission presented a legislative proposal to update various EU directives relating to mutual recognition of professional qualifications. The so-called SLIM directive, part of Simpler Legislation in the Internal Market initiative, will include amendments to the Doctors Directive and those covering diplomas for nurses, midwives, dentists, vets and architects.

The European Union of General Practitioners UEMO, is taking the opportunity of the presentation of the proposed SLIM directive to lobby the European parliament to amend the doctors' directive to increase the EU wide minimum length of GP training to 3 years. On first reading in July 1998 the Parliament backed the UEMO amendments , however in March of this year the Council of Ministers rejected those amendments when it agreed its common position on SLIM. We are still pushing for it, and it is reassuring that the GP representatives of other member states in the UEMO want the longer training period to be mandatory.

There is one area where the profession in this country feels that the original directives have created an anomalous situation. You will remember that there are two criteria to be fulfilled for free movement; citizenship and primary qualifications. In the UK the profession includes a very significant number of doctors who have qualified in non-EU countries, particularly the Indian sub-continent, had their qualifications recognised and approved by the GMC and become citizens of the UK and invaluable labourers in the NHS. This is so in other countries too, particularly those with previous colonial responsibilities. Such doctors ask that if their primary qualifications have been recognised by the registering body in one member state such recognition should equate to obtaining their qualification in the EU and apply to all. Most of these doctors have further qualifications obtained in the UK.

We have been battling on their behalf for many years with minimal success. At last there is some progress. New legislation will soon come into force committing registration bodies to take into consideration experience acquired elsewhere, of doctors who are registered and practising in the EU area, so that cases can be considered on an individual basis. Apparently one of the countries most vehemently against any change to the principle is Portugal who are fearful of being overrun by South American Dentists whose qualifications are recognised by Spain and who might flood over the border. (This is anecdotal of course!)

This is probably the place to briefly explain the profession's own structures within Europe, as I have already mentioned UEMO. These are non-statutory and funded by subscriptions from member associations. The umbrella organisation is the Standing Committee of European Doctors or "Comite permanent" which was set up in 1956 by the original 6 signatories to the Treaty of Rome. It has of course expanded to include all the member states since then. Its current terms of reference are

To study and promote the highest standard of medical training, medical practice and health care within the European Union

To study and promote the free movement of doctors within the EU

To represent the medical profession of member states vis-a-vis EU institutions and other relevant organisations.

It is registered formally as an international association under Belgian law as there is a permanent office in Brussels. Linked to it, although each is an independent body in its own right, come the European Union of Medical Specialists, the UEMO, the Permanent Working Group of Junior Doctors. There is also an European Public Health Alliance. They all become known by their acronyms, with which medical Europe is awash!

The British Junior Doctors particular involvement in Europe over recent years has been with campaigning for the inclusion of juniors in the Working Time Directive which limits working hours to a maximum of 48 per week and from which junior doctors have been exempt. Our government have agreed to phase this in for them over the 13 years which is the maximum time stipulated in the recently adopted directive, and which is totally unacceptable as a transition period.

Another body involved is the European Forum of Medical Associations and WHO. This is a little different in that WHO 's European Region ( and that of the United Nations for that matter) extends to the countries of Eastern Europe and the former Soviet Union which adds a particular flavour to its deliberations. It promotes the Tobacco Control Resource Centre which works from BMA House in London with help of funding from the European Commission.

In each member state there is a recognised Competent Authority who has responsibility for the qualifications that are required for registration. Here this is the GMC for primary qualifications but also the Specialist Training Authority of the Medical Royal Colleges for entry to the Specialist registers and the Joint Committee on Postgraduate Training for General Practice for vocational training certification. There are two important Statutory Bodies:

Firstly the Advisory Committee on Medical Training, again set up in 1975 under the original doctors directives, to advise the European commission on training requirements. It consists of members of the practising profession, medical faculties of universities and competent authorities. As part of a recent streamlining exercise only one delegate per category per country has been allowed and alternates are not nominated by governments. This can sometimes mean that a whole area of expertise is missing from a plenary session . The Commission has also cut its resources so that it has not been able to meet as often as really necessary and we are concerned that sadly, the European Commission is more interested in free movement than in the quality of training that is needed to underpin it. This is also reflected in its response to the period of GP training to which I referred earlier. ACMT's remit in 1975 was "to help to ensure a comparably demanding standard of medical training in the community, with regard both to basic training and further training." I am not convinced that it is any longer able to deliver this if it continues to be emasculated and starved of funds by the Commission.

The second body is the Committee of Senior Officials in Public Health affectionately known as CSOPH. This is a committee of governmental representatives, from departments of Health and health ministries, and does not contain members of the practising professions, although a few of the civil servants involved are qualified doctors. The UK is always represented by a medically qualified mandarin. This body is being used, I believe wrongly, to do some of the work that should be under the jurisdiction of the training committee.

The next area I wish to address is that of health care itself. The recent WHO Annual Report on Health Systems ranks the UK 18th in the world, out of 190, and 9th in Europe, in the first ever league table of world health care. France tops the league and Sierra Leone came bottom. UK is behind other EU countries such as Greece but ahead of Germany. In fact the Mediterranean countries, which include France, Italy and Spain, are rated higher than the rest. UK spends 6% of GDP compared with France's 9.8%. But is this the significant factor ? I believe that it is, as a country that is spending more overall is better resourced from both the manpower and equipment standpoints and is therefore able to give it's population a better service.

There are broadly two different models of health care systems in Europe. The tax-based NHS type such as our own and the insurance-based models as in Germany, France, Belgium and Luxembourg. There are also mixtures of the two such as in Holland. Some of the characteristics of the insurance based systems are that there are no gatekeepers, like our traditional referral system via GP s, and patients can access whichever part of the service they wish directly. The system is therefore expensive, but popular with patients. However there are now moves in some of the insurance based systems to adopt the British pattern of referral from generalists as the gateway to specialist care.

Earlier this year the European Commission published its new Health programme, a follow up of the Communication in 1998 which was consulted upon widely. The programme is intended to:

fulfil the expectations of the public for protection of their health

Address new health challenges and priorities brought about by expansion of the Eu and demographic change

Produce a more ambitious Community Health strategy

By focussing on:

Improving health information and knowledge and development of a comprehensive system to provide key health data, ( if this is to include outcomes, I wonder who they expect to do the collection and whether anyone will believe the data after the problems that we have had with league tables)

Rapid responses to health threats i.e. communicable diseases such as diphtheria and TB from Russia

Addressing health determinants and the underlying causes of ill-health. Poverty is not actually mentioned

There is also discussion of what we in this country call Health Impact Assessment, exploring the effects of the policies of other departments of government on health and health strategies, a very welcome move.

Under the provision of care, - a series of cases are before the European Court of Justice regarding the free movement of services which could have consequences for the NHS. The Dutch consider that they should be able to compete with Belgian insurers to provide services in Belgium and vice versa. This would alter the present position which is based on the Treaty of Rome that explicitly directs member states to set their own priorities and fund their health care systems accordingly, not looking across their borders. There can be no EU intervention at present. This may have to change with increased movement of services after the ECJ judgement expected this autumn.

Currently BMA policy is to oppose any EU involvement in funding or administration of member states health care systems. Discussions between the European Parliament and the Commission in March this year produced agreement to some movement in EU policy. It was accepted that where markets exist in health care the rules of the Internal Market should apply, as Holland would wish, but went no further. It was also agreed that sharing and exchanging experience and cooperation in health care provision could be a good thing. For instance setting up centres of excellence for rare diseases: but which member state would be allowed to have the one and only centre for the 1 in 6 million cases of Bloggins Neuroma?

There is still strong opposition to harmonisation of health care systems and concern about two-tier care if there was really free movement of patients. Inappropriate decisions for local communities made too far from the patients concerned on a EU wide basis is the other end of the spectrum from our equally unsatisfactory post-code prescribing. There are many other aspects of medical care which are covered by EU directives such as Medicines Control and interprofessional working.

Notes:

[1] This paper was first given as a Lecture for European Movement, Devon Branch, Wednesday August 30, 2000.

Copyright © 2000 Intellect Ltd, PO Box 862 Bristol BS99 1DE, UK

Germany leads with	4702
Then Greece	3034
Ireland	2683
Italy	2099
And the Netherlands	2074