Flow analysis

Flow analysis captures the dynamic of health professional mobility, quantifying the phenomenon by counting the numbers of health professionals leaving and entering countries. It can also be presented in terms of the share of foreign health professionals among all health professionals newly entering the health system or the share of health professionals leaving as a proportion of all health professionals in the service.

Inflow analysis plays an important role in monitoring not only the numbers of incoming health professionals but also their professions, specializations and geographical distribution. Ethical reasons require monitoring of the source

Fig. 2.3 Reliance on foreign dentists in selected European and non-European OECD countries, 2008 or latest year available

Sources: Slovakia: National Health Information Centre, National Register of Health Professions; Germany: Federal Chamber of Dentists; France: National Order of Dental Surgeons; Poland: Polish Chamber of Physicians and Dentists;

Hungary: Office of Health Authorisation and Administrative Procedures; Finland: Statistics Finland; Belgium: Federal Database of Health Care Professions; Austria: Austrian Chamber of Dentists; Slovenia: Medical and Dental Register, Medical Chamber of Slovenia.

Notes: No data provided for Australia, Canada, Estonia, Ireland, Italy, Lithuania, New Zealand, Norway, Portugal, Romania, Serbia, Spain, Sweden, Switzerland, Turkey, United Kingdom, United States; ^a 2007; ^b 2009 (all indicators); ^c 2006.

5 10

Foreign-trained Foreign-national

Slovakia Germany France Finland Belgium Austria

15

0

Foreign-born

a a

20 25

b c

Poland Hungar y

Sloveni

a a

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country in order to avoid recruiting from countries facing workforce shortages.

Inflow analysis is an important tool for ensuring the accuracy of workforce planning.

Outflow analysis is also relevant for workforce planning. If not factored in adequately, workforce planners may underestimate annual losses of the workforce and the loss of specific skills, thereby producing inaccurate planning projections that may lead to inadequate decisions. Outflow analysis is also an early warning signal of health workers’ dissatisfaction with their working conditions, working environment and work content. The signal can help to attract the attention of policy-makers, health-care managers and professional organizations and enable timely responses.

From a long-term perspective, mobility and migration in Europe appear to have increased. With the exception of the United Kingdom, most of the EU-15 countries for which data were available show a rise in yearly inflows of medical doctors and dentists over the last 10 to 20 years. Trends among nurses are inconclusive because of the severe lack of data. Outflows from the EU-12 countries appear to have increased since the EU enlargements but on a smaller scale than expected (see section 2.4.1). Moreover, even some of the EU-15 countries have experienced increasing outflows. All three of these developments point towards increasing levels of mobility on the whole. However, a degree of caution is required as the findings are based on a relatively small number of countries providing time series data,⁵ often covering a shorter time period than requested⁶ and reflecting the paucity of evidence available to show time trends.

Inflows

This section provides an analysis of the inflows of medical doctors, nurses and dentists. A situation analysis of inflows in 2008 will be presented for each profession. This will be followed by an analysis of the increases or decreases since 1988. Finally the continuities and discontinuities of these trends will be analysed. Differences between the EU-15 and the EU-12 will be discussed throughout the section.

Although based on a limited sample, the situation analysis for medical doctors in 2008 clearly shows that the EU-15 have experienced higher inflows than the EU-12 in both absolute numbers and in relative terms. In 2008, inflow data for medical doctors were reported for Austria, Finland, France, Germany, Hungary, Lithuania, Poland, Slovenia, Spain and the United Kingdom.

In absolute numbers, the largest inflows of medical doctors were experienced

5 Data on time trends were retrieved from the 17 case studies and included in the analysis only when at least three points in time were covered.

6 Many case study authors could not provide data on long-term trends such as the 10 or 20 year time period requested and provided data for periods of only six to eight years (e.g. 2003–2008).

by Spain (8282 foreign degrees recognized), the United Kingdom (5022 foreign-trained newly registered) and Germany (1583 foreign-national newly registered). Lithuania reported the lowest absolute number – 11 work permits issued to new entrants. Only a handful of country case studies reported on the share of foreign health professionals within all newly registered medical doctors. Of these countries, the United Kingdom reported by far the highest proportion (42.6%) followed by Austria (13.5%), Hungary (4.7%) and Poland (2.7%).

For the purpose of presentation, the time-trend figures were split between countries with inflows of fewer than 1000 foreign medical doctors per year (Fig. 2.4) and those with more (Fig. 2.5).

Not all countries could provide data for the whole reporting period starting in 1988. Based on the available data, inflows to EU-15 and EU-12 countries indicate diverging trends. The trends in Slovenia and Hungary are more difficult to interpret as the former covers only six years (since 2003) and the latter only five (since 2004). However, yearly inflows have decreased during these periods.

The numbers for Lithuania are so low that no conclusions can be drawn.

Fig. 2.4 Inflows of foreign medical doctors (countries with annual inflows below 1000) 1988–2008

Notes: Austria: newly registered foreign-national medical doctors (Austrian Medical Chamber); France: newly registered foreign-national medical doctors (National Medical Council); Hungary: newly registered foreign-national medical doctors (Office of Health Authorisation and Administrative Procedures); Lithuania: work permits issued to foreign health professionals (Lithuanian Labour Exchange); Slovenia: foreign-trained newly registered medical doctors (Medical Chamber of Slovenia).

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In most EU-15 countries for which data were available, the inflows of foreign medical doctors appear to have increased or peaked. Inflows to Austria reached their highest numbers in 2004 and 2007 but showed an overall growth in total numbers in comparison to 2000. France reported stark fluctuations in yearly inflows, but yearly inflows between 2002 and 2006 were higher than in 1988. Inflows to Germany increased from 2000 and peaked in 2003 but did not decrease substantially over the following years. Spain has experienced a continuous and, since 2004, an increasingly rapid growth in inflows. Inflows to the United Kingdom grew rapidly and must have peaked in or before 2003.

A key reason for this is the change in recruitment policy from international recruitment to self-sufficiency (see section 2.8).

The situation analysis of inflows of foreign nurses in 2008 is based on data reported for Austria, Belgium, Finland, France, Hungary, Italy and the United Kingdom. Italy reported the highest number of foreign-trained nurses (9168), followed by the United Kingdom (3724). Finland reported a small number of foreign-born nurses (97). The share of foreign nurses among all newly registered nurses was markedly highest in Italy (28%), followed by the United Kingdom (14.7%) and Belgium (13.5%). In Hungary, only 2.4% of all newly registered nurses were foreign nationals.

Fig. 2.5 Inflows of foreign medical doctors (countries with annual inflows above 1000) 1988–2008

Notes: Germany: newly registered foreign-national medical doctors (Federal Chamber of Physicians); Spain: foreign degrees in general medicine recognized in Spain, not including speciality degrees (National Statistics Institute database, Ministry of Education); United Kingdom: newly registered foreign-trained medical doctors (General Medical Council).

0

Data on time trends for nurses showed major limitations and were available in only 4 of the 17 case studies: Austria, Belgium, Hungary and the United Kingdom. These cover time periods of four to six years⁷ with the exception of the United Kingdom for which data dating back to 1988 were available.

Austria and Belgium showed a clear upward trend of yearly inflows (Austria:

428 in 2003 to 773 in 2008⁸, Belgium: 205 in 2005 to 565 in 2008⁹).

A decreasing trend emerged in Hungary, where numbers dropped from 439 in 2004 to 190 in 2008. In the United Kingdom, the effects of changes in its recruitment policy are clearly reflected in flow data: yearly inflows increased substantially from 1988 to 2004 (from 2808 to 15 065 foreign-trained nurses and midwives) and decreased considerably thereafter (to 3724 in 2008). Yet, given the limited country coverage of time series data on nurses, no conclusions could be drawn on the patterns between EU-12 and EU-15 countries.

The situation analysis for dentists in 2008 is based on data reported from Austria, Belgium, Finland, Hungary, Poland, Slovenia and Spain. Analogous with the results for medical doctors, EU-15 countries experienced higher inflows than those in the EU-12, both in absolute numbers and in the share of foreign dentists among all newly registered dentists (Fig. 2.6). The highest absolute inflow number of foreign-trained dentists was reported in Spain (421), followed by Austria (100). All other countries reported much lower inflow numbers;

Hungary reported the lowest (18). In Austria, newly registered foreign-national dentists made up 40.8% of all newly registered dentists, followed by the United Kingdom (33.7%), Belgium (19%), Hungary (9.7%) and Poland (3%).

The analysis in Fig. 2.6 shows increases in the inflows of foreign dentists to Spain, Austria, and Belgium although there is a lack of trend data. The absolute numbers for Estonia, Hungary and Slovenia are so low that no conclusions on the trends can be drawn.

Outflows

Outflows reflect the numbers of health professionals leaving a country. They can be expressed in absolute or relative terms, the latter analysing the share of health professionals lost from the workforce. Measurement of outflows is a key challenge for workforce planners and policy-makers and in most countries the numbers are unknown and subject to speculation.

Outflows can be measured against registry data from receiving countries.

However, not all countries hold registry data for all health professions and not

7 Austria: 2003–2008, Belgium: 2005–2008, Hungary: 2004–2008, United Kingdom: 1988 and 2003–2008.

8 Foreign-trained nurses having applied for diploma validation.

9 Newly licensed foreign-trained nurses.

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all countries identify newly registered health professionals. Intention-to-leave data are used as proxies but do not equal actual cross-border mobility. The term

“intention to leave” is self-explanatory, signalling health professionals’ intentions to move as evidenced by active requests for confirmation of entitlement to practise abroad. These are data on requests for diploma recognition in other countries following the procedure of Directive 2005/36/EC on the recognition of professional qualifications. However, there are two main reasons why these data have limited accuracy. Firstly, the Belgian and Slovak case studies reported that not all countries systematically request these certificates and this may lead to an underestimate of actual outflows. Secondly, health professionals may apply but do not actually move or individuals may apply more than once and cause overestimates of actual flows.

Outflows are one of the most contentious policy issues in health professional mobility. The term brain drain was used widely to describe the exodus of health professionals from countries already facing labour shortages in the health system.

Outflows are also a high-profile policy issue in the EU, since EU-12 countries are worried about systematic loss of their workforces to EU-15 countries.

Sources: Austria: newly registered national dentists in Austria (Austrian Chamber of Dentists); Belgium: foreign-trained newly licensed dentists (Federal Database of Health Care Professionals); Estonia: practising foreign-foreign-trained registered dentists in Estonia (Health Care Board); Hungary: foreign-national newly registered dentists in Hungary (Office of Health Authorisation and Administrative Procedures); Slovenia: foreign-trained newly registered dentists (Medical Chamber of Slovenia); Spain: non-EU and EEA degrees recognized in Spain (National Statistics Institute).

0 Fig. 2.6 Inflows of foreign dentists 1988–2008

According to the case studies, mobility has increased over time in terms of outflows too. However, the substantial lack of data on emigrating health professionals means that outflow data are only approximate – based on certificates of diploma recognition or certificates of good standing (CGS), which should be interpreted as outflow intentions.

Outflows from Estonia, Hungary, Poland, Romania, Slovakia and Slovenia increased substantially at the time of EU enlargements and then decreased but remained at a higher overall scale than before EU enlargement. Recent (2009 or 2010) data from Estonia, Hungary and Romania point towards new increases in outflows, possibly showing the effects of the global economic crisis.

Some of the large destination countries, such as Austria, Germany, Italy and the United Kingdom, also experienced increases in actual outflows and the outflow intentions of their workforces (discussed in detail in section 2.4). Between 1988 and 2007, the number of Austrian medical doctors on the German medical registry increased from 260 to 1613. Data on outflows for Germany are available only since 2000. Between 2000 and 2008, the annual outflows of German medical doctors almost tripled (from 1097 to 3065), mostly to Switzerland, Austria, the United States and the United Kingdom. Some sources estimate much higher outflows. A rise in outflows cannot be confirmed for nurses in either country: numbers decreased in Austria and the German data are inconclusive.

The Italian data also suggest increasing outflows of medical doctors, as measured by Italian nationals registered in Germany and the United Kingdom. In the latter, the number of Italian general practitioners notably increased. This trend is also reflected for Italian nurses. Interestingly, while the United Kingdom is a major destination that absorbs high numbers of internationally trained health professionals it also loses increasing numbers of health professionals.

However, the scale of outflows or outflow intentions is not comparable to that of inflows. Finland and Spain reported a declining trend in outflows and in outflow intentions (as well as important numbers of returnees), whereas time trends in Belgium and France remained inconclusive.

Both EU-12 and EU-15 countries are losing health professionals. But, unlike EU-12 countries, many EU-15 countries are simultaneously receiving health professionals.

Analysis in this section on quantifying mobility in Europe has been built on limited data, collected directly from the data sources in the respective countries and complemented by OECD data. Comparisons were made on a less than robust basis as the following section will argue.

36 Health Professional Mobility and Health Systems