Patient safety and quality

Issues of patient safety do have a cross-border dimension, both for cross-border care and because health care-associated infections are one of the key potential threats to the safety of patients that can potentially cross borders with a patient.

The EU’s action is broader, although aiming to support improvements in best practice more generally, given the scope for mutual learning in this area, and best practices were distilled down into a Council Recommendation on Patient Safety, adopted in 2009.⁴⁸ While a variety of projects can and have been funded from

46 See European Commission. Digital agenda for Europe: ehealth and ageing. Brussels, European Commission, 2014 (http://ec.europa.eu/digital-agenda/en/life-and-work/ehealth-and-ageing, accessed 14 July 2014).

47 Commission implementing Directive 2012/52/EU. Official Journal, 2012, L 356, p. 68.

48 Council of the European Union. Council recommendation on patient safety, including the prevention and control of healthcare associated infections. Official Journal, 2009, C 151/1.

the health and research programmes on the issue of patient safety, it is possible that the most impact will come from improved, transparent and comparable data if the projects are able to deliver. This may also be supported by the Directive on Patients’ Rights in Cross-Border Healthcare, which obliges Member States to ensure transparency about quality and safety standards.

4.4 People

Health professionals who are EU citizens enjoy the right to seek employment or to establish themselves in another country of the European Economic Area.⁴⁹ The free movement of workers and self-employed persons is, alongside the free

49 The EU plus Iceland, Liechtenstein and Norway.

Clinical guidelines for chronic conditions in the European Union Edited by Helena Legido-Quigley, Dimitra Panteli, Josip Car, Martin McKee and Reinhard Busse European Observatory on Health Systems and Policies, 2013

http://www.euro.who.int/en/about-us/partners/

observatory/studies/clinical-guidelines-for-chronic-conditions-in-the-european-union Chronic noncommunicable diseases make up a large part of the burden of disease and make a huge call on health systems’ resources. Clinical guidelines are one of the ways that European countries have tried to respond and to ensure a long-term perspective in managing them and addressing their determinants.

This study reviews the various national practices relating to clinical guidelines in 29 European countries (the EU, Norway and Switzerland).

The book explores those guidelines and whether they actually affect processes of care and patients’ health outcomes. It analyses the regulatory basis, the actors involved and processes used in developing clinical guidelines across Europe as well as the strategies used to disseminate and implement clinical guidelines in various contexts. It explores innovative methods for cost-effective prevention of common risk factors, developing coordinated patient-centred care and stimulating integrated research. It also assesses the effectiveness of their utilization.

HOME CARE ACROSS EUROPECURRENT STRUCTURE AND FUTURE CHALLENGES

Chronic noncommunicable diseases make up a large part of the burden of disease and make a huge call on health system resources. Clinical guidelines are one of the ways European countries have tried to respond and to ensure a long-term perspective in managing them and addressing their determinants.

This book explores those guidelines and whether they actually have an impact on processes of care and patients’ health outcomes. It analyses

• the regulatory basis, the actors involved and processes used in developing clinical guidelines across Europe

• innovative methods for cost-effective prevention of common risk factors, devel-oping coordinated patient-centred care, and stimulating integrated research

• the strategies used to disseminate and implement clinical guidelines in various contexts and

• the effectiveness of their utilization.

This study reviews for the first time the various national practices relating to clinical guidelines in 29 European countries (EU27, Norway and Switzerland). It shows that while some have made impressive progress many are still relying on sporadic and unclear processes. The level of sophistication, quality and transparency of guideline development varies substantially across the region even when the system for producing guidelines is well established. There are nonetheless clear examples that – if shared – can assure and improve quality of care across Europe.

This study was commissioned by the European Commission’s Directorate-General for Health and Consumers. It also benefited from links with the ECAB/EUCBCC FP7-research project on EU Cross Border Care Collaboration (2010–2013).

The editors

Helena Legido-Quigley, London School of Hygiene & Tropical Medicine, London.

Dimitra Panteli, Department of Health Care Management, Berlin University of Technology, Berlin.

Josip Car, Global eHealth Unit, Imperial College London, and Imperial College Healthcare NHS Trust, London.

Martin McKee, London School of Hygiene & Tropical Medicine, and European Observatory on Health Systems and Policies, London.

Reinhard Busse, European Observatory on Health Systems and Policies, and Berlin University of Technology, Berlin.

Edited by Nadine Genet, Wienke Boerma, Madelon Kroneman,Allen Hutchinson, Richard B Saltman

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movement of goods, services and capital, a fundamental policy stipulated in the TFEU and indispensable for the functioning of the single market.⁵⁰ The policy entails the abolition of all forms of discrimination between workers on the grounds of nationality with regard to employment, remuneration and other conditions of work and employment. Moreover the TFEU provides a mandate for legislation that facilitates cross-border professional mobility by flanking it with all necessary social security measures.⁵¹

Consequently, medical doctors, nurses, midwives, dentists, pharmacists and other allied health professions are crossing borders seeking employment and business opportunities as livelihood migrants, career-oriented professionals, backpackers or commuters.⁵² Some countries have welcomed these professionals filling gaps in their workforce and some have even actively recruited from abroad, while others have raised concerns regarding the magnitude of qualified health workers leaving their country.⁵³

Free mobility, however, is based on the portability of qualifications, which implies that the qualifications obtained in one country are similar enough to the qualifications required in another country. To this end, a system of mutual recognition was developed in the mid-1970s and the latest major revision took place in 2014. Five health professions are mentioned explicitly in the European Commission Directive on the Recognition of Professional Qualifications: medical doctors, general care nurses, midwives, dentists and pharmacists.⁵⁴ They can take advantage of the so-called automatic procedure that provides for recognition if the minimum requirements of number of hours and theoretical/practical train-ing are met or, dependtrain-ing on the profession, if certain competencies are taught according to the curriculum. The recognition procedure is guaranteed to be completed within a three-month timeframe.

For those health professions and specializations not covered by this Directive, the “general system” applies. It requires national competent authorities to assess the qualifications of individuals on a one-by-one basis. In that case, the Member

50 TFEU, Article 45ff.

51 TFEU, Article 46.

52 Glinos IA, Buchan J. Health professionals crossing the EU’s internal and external borders: a typology of health professional mobility and migration. In: Buchan J et al., eds. Health professional mobility in a changing Europe. New dynamics, mobile individuals and diverse responses. Copenhagen, WHO Regional Office for Europe for the European Observatory on Health Systems and Policies, 2014:129–158.

53 Maier et al. Cross-country analysis of health professional mobility in Europe: the results. In: Wismar M et al., eds. Health professional mobility and health systems evidence from 17 European countries. Copenhagen, WHO Regional Office for Europe for the European Observatory on Health Systems and Policies, 2011:23–66; Ognyanova D et al. Mobility of health professionals before and after the 2004 and 2007 EU enlargements: evidence from the EU PROMeTHEUS project In: Buchan J et al., eds. Health professional mobility in a changing Europe. New dynamics, mobile individuals and diverse responses. Copenhagen, WHO Regional Office for Europe for the European Observatory on Health Systems and Policies, 2014:65–94.

54 European Parliament and Council. Directive 2005/36/EC of 7 September 2005 on the recognition of professional qualifications. Brussels, European Commission, 2005.

Health professional mobility

Health professional mobility in Europe has become a fast-moving target for policy-makers as it increasingly affects the performance of health systems. It is evolving rapidly in direction and magnitude as a consequence of fundamental change caused by EU enlargement and the financial and economic crisis.

Health professional mobility and health systems.

Evidence from 17 European countries

Edited by Matthias Wismar, Claudia B. Maier, Irene A. Glinos, Gilles Dussault and Josep Figueras

European Observatory on Health Systems and Policies, 2011 http://www.euro.who.int/en/about-us/partners/observatory/

studies/health-professional-mobility-and-health-systems.-evidence-from-17-european-countries

Health professional mobility in a changing Europe.

New dynamics, mobile individuals and diverse responses

Edited by James Buchan, Matthias Wismar, Irene A. Glinos and Jeni Bremner

European Observatory on Health Systems and Policies, 2014 http://www.euro.who.int/en/about-us/partners/observatory/

studies/health-professional-mobility-in-a-changing-europe.-new-dynamics,-mobile-individuals-and-diverse-responses The PROMeTHEUS project, funded under the EU’s seventh Framework Programme for research, aimed at identifying and filling the gaps in knowledge about the numbers, trends, impacts and policy responses to this dynamic situation.

A first country case study volume specifically looked at the scale and characteristics of health professional mobility, the motivations of a mobile workforce, the impacts on health system performance and the policy responses. It analysed the situation in Austria, Belgium, Estonia, Finland, France, Germany, Hungary, Italy, Lithuania, Poland, Romania, Serbia, Slovakia, Slovenia, Spain, Turkey and the United Kingdom.

The second volume goes well beyond situation analysis as it presents practical tools such as a yardstick for registry methodology, a typology of mobile individuals, qualitative tools for studying the motivation of the workforce and a set of concrete policy responses at EU, national and organizational levels, including bilateral agreements, codes and workplace responses.

HEALTH PROFESSIONAL MOBILITY AND HEALTH SYSTEMSEVIDENCE FROM 17 EUROPEAN COUNTRIESEdited by Matthias Wismar, Claudia B. Maier,Irene A. Glinos, Gilles Dussault, Josep Figueras

Health professional mobility affects the performance of health systems and these impacts are assuming greater significance given increasing mobility in Europe, a process fuelled by the European Union (EU) enlargements in 2004 and 2007. This volume presents research conducted within the framework of the European Commission’s Health PROMeTHEUS project. This research was undertaken in order to address gaps in the knowledge of the numbers, trends and impacts and of the policy responses to this dynamic situation.

The following questions were used to provide analytical guidance for the 17 country case studies reported here: from Austria, Belgium, Estonia, Finland, France, Germany, Hungary, Italy, Lithuania, Poland, Romania, Serbia, Slovakia, Slovenia, Spain, Turkey and the United Kingdom.

•What are the scale and characteristics of health professional mobility in the EU?

•What have been the effects of EU enlargement?

•What are the motivations of the mobile workforce?

•What are the resulting impacts on health system performance?

•What is the policy relevance of those impacts?

•What are the policy options to address health professional mobility issues?

The editors

Matthias Wismar is Senior Health Policy Analyst at the European Observatory on Health Systems and Policies.

Claudia B. Maier is a Technical Officer at the European Observatory on Health Systems and Policies.

Irene A. Glinos is a Researcher at the European Observatory on Health Systems and Policies.

Gilles Dussault is a Professor at the Instituto de Higiene e Medicina Tropical, Universidade Nova De Lisboa.

Josep Figueras is Director of the European Observatory on Health Systems and Policies and Head of the WHO European Centre for Health Policy.

Evidence from Cover_WHO_nr23_Mise en page 1 20/10/11 14:30 Page1

ISBN 9289050258 9789289050258 HEALTH PROFESSIONAL MOBILITY IN A CHANGING EUROPENEW DYNAMICS, MOBILE INDIVIDUALS AND DIVERSE RESPONSES Health professional mobility in Europe has become a fast moving target for policy makers. It is evolving rapidly in direction and magnitude as a consequence of funda-mental change caused by EU enlargement and the financial and economic crisis.

Health professional mobility changes the numbers of health professionals in countries and the skill-mix of the workforce, with consequences for health system performance.

Countries must factor-in mobility if they are forecasting and planning their workforce requirements. To this end they need clarity on mobility trends and the mobile workforce, and effective interventions for retaining domestic and integrating foreign-trained health workers. Health professional mobility remains an unfinished agenda in Europe, at a time when the repercussions of the financial crisis continue to impact on the European health workforce and its patterns of mobility.

This book sheds new light on health professional mobility in this changing Europe.

It is the second volume of the PROMeTHEUS project, following the previously published country case study volume. The 14 thematic chapters in this book are grouped in three parts:

•The changing dynamics of health professional mobility

•The mobile individual

•Policy responses in a changing Europe

The book goes well beyond situation analysis as it presents practical tools such as a yardstick for registry methodology, a typology of mobile individuals, qualitative tools for studying the motivation of the workforce and a set of concrete policy responses at EU-, national and organizational level including bi-lateral agreements, codes and workplace responses.

The editors

James Buchan, Professor, School of Health, Queen Margaret University, Scotland.

Matthias Wismar, Senior Health Policy Analyst, European Observatory on Health Systems and Policies, Belgium.

Irene A. Glinos, Senior Researcher, European Observatory on Health Systems and Policies, Belgium.

Jeni Bremner, Director, European Health Management Association, Belgium.

New dynamics, mobile individuals

Edited by James Buchan, Matthias Wismar,Irene A. Glinos, Jeni Bremner

Cover_WHO_Health Professional Mobility_DRAFT_Mise en page 1 22/04/14 19:47 Page 1

State where the individual has sought employment is not obliged to automatically recognize the qualifications and could impose, as appropriate, compensating measures such as an aptitude test or an adaptation period.⁵⁵

Overall, the Directive has been deemed as functioning by the members of the network of the competent authorities and because, without the automatic proce-dure, authorities would not be able to cope with the requests for recognition on an individual basis. Some worries regarding mutual recognition were addressed in the 2014 revision of the Directive. For example the right to check adequacy of language to ensure quality and safety of care was strengthened. There are, however, some worries that could not be addressed by the Directive. Continuous professional development is often disrupted when changing countries. Another worry is that of mobility asymmetries. With the enlargements since 2004, the EU has become more diverse in terms of salary levels, career opportunities and working conditions. This has provided strong pull factors drawing health pro-fessionals from less affluent EU Member States to move to wealthier countries.

A precondition for a well-functioning labour market for health professionals is to have the right numbers and the right skills. But this is being jeopardized because as the EU population ages and shrinks, so does the health workforce. The European Commission has, therefore, tried to forecast future workforce supply and demand and has projected a shortage of two million health and social workers by 2020.⁵⁶ The supply of nurses is a particular concern. In addition to numbers, the skills and skill-mix of the workforce give rise to growing concerns. As Europe’s popula-tion is ageing, chronic disease and multiple comorbidities have been increasing, requiring new technologies and increasingly coordinated and integrated forms of health service provision. More health promotion, prevention, rehabilitative and social services need to be developed. This implies that different cadres of health professionals will need to collaborate and communicate more effectively with each other and with the patients and their social environment. To facilitate this devel-opment, new skills and new skill-mixes are needed in the workforce. To address these challenges, the European Commission has launched a host of initiatives.

The European Commission has developed a comprehensive Action Plan for the EU Health Workforce.⁵⁷ This Action Plan has accompanied the EU sector-wide strategy for job-rich recovery and is, therefore, a centrepiece of actions confronting

55 Peeters M, McKee M, Merkur S. EU law and health professionals. In: Mossialos E et al., eds. Health systems governance in Europe: the role of European Union law and policy. Cambridge, UK, Cambridge University Press, 2010:589–634.

56 Testori Coggi P. Foreword. In: Wismar M et al., eds. Health professional mobility and health systems evidence from 17 European countries. Copenhagen, WHO Regional Office for Europe for the European Observatory on Health Systems and Policies, 2011:ix.

57 European Commission. Staff Working Document SWD(2012) 93 final: an action plan for the EU health workforce. Luxembourg, Publications Office of the European Union (http://ec.europa.eu/dgs/health_

consumer/docs/swd_ap_eu_healthcare_workforce_en.pdf, accessed 18 July 2014).

the recession and the financial and economic crisis. The Action Plan focuses on four topics including improving health workforce planning and forecasting, better anticipation of skills needs, stimulating exchange on recruitment and retention, and supporting ethical recruitment. To implement the Action Plan, the Commission commissioned a host of projects. This includes first and foremost the Joint Action on Health Workforce Planning and Forecasting. This is intended to create a European platform to share good practice and to develop methodologies on forecasting health workforce and skills needs.⁵⁸ The European Commission has also funded a project creating a pilot network of nurse educators and regulators.

The project focuses on health care assistants defined as “persons working within healthcare with a qualification below the standard of registered nurses”. The pur-pose of the project is to exchange best practices to improve the qualifications of health care assistants, with a particular emphasis on cross-border mobility. Other activities include an EU skills council in the area of nursing, and a care pilot EU sector skills alliance in the health care sector will seek to investigate the feasibility for developing new sector-specific curricula and innovative forms of vocational teaching and training. The implementation of the Action Plan and general workforce issues uses Member States’ resources and a multitude of Commission instruments coming from a range of programmes under different DGs.⁵⁹