Elsevier

Health Policy

Volume 54, Issue 1, 1 November 2000, Pages 45-64
Health Policy

Mobile medics? The mobility of doctors in the European Economic Area

https://doi.org/10.1016/S0168-8510(00)00097-XGet rights and content

Abstract

The Treaty of Rome seeks to generate a common European market whereby all barriers to the free movement of produce, capital, services and labour are removed. Current EU policy on the free movement of labour requires that healthcare workers, who are EU citizens and meet certain training criteria, have the right to register to practice in member states other than the one in which they trained. This policy is underpinned by the EEC Directives. For example, the Medical Directive 93/16/EEC describes the framework for the mutual recognition of medical diplomas, certificates and other evidence of qualifications through out the European Economic Area (EEA). The potential impact of this for health policy is clear-workforce planning and the demand for doctors, (and also nurses and other health care professionals), could be particularly affected by new forces impacting on their supply. This paper reports on the reality of labour mobility today, and on the factors upon which mobility depends, by the means of a case study which, investigated the movement into UK of doctors from the EEA. At a formal level there is mutual recognition of diplomas, certificates and other evidence of qualifications. However, formal and ‘real life’ recognition could be in tension equating in policy terms to an implementation deficit. As a result, there is a ‘mixed picture’ which makes predicting the future (both for individual countries and for the European Union) even more difficult. Furthermore, different policy objectives have to be reconciled. Do we want high mobility; or do we want to preserve national manpower planning?

Introduction

The roles and responsibilities of the EU in relation to health are often unclear and not always understood. There are three main reasons for this confusion. Firstly, the European Union is a complex organisation with complex decision making processes. Responsibility for health is not held within a single unit of the EU, but rather dispersed between 13 of the 24 Directorate Generals.

Secondly, the focus of the European ‘health policy’ has, hitherto, been that of public health and not explicitly of health services. The exclusion of the latter has led to the conclusion that health services should, (in line with the principle of subsidiarity), be left to the responsibility of individual member states. The need to respect this responsibility was made explicit for the first time in the 1997 Amsterdam Treaty. Up until this time, parts of European treaties that affected health services did so indirectly and at a general level through the four freedoms of movement (goods, services, capital and labour). This gave the impression that health services were excluded from the remit of European institutions [1].

Finally and somewhat related, is the uncertainty regarding the process and outcome of transposition into British law, of EU law relating to health matters. In UK, and generally across Europe, transposition is not easily transparent and there is no clear procedure for this process. This has generated an impression of EU regulations and directives that are seemingly distant and irrelevant, with matters relating to health, (whatever they are and wherever they come from), ‘invisibly’ integrated into the domestic system.

The EU does, in fact, have clear roles and responsibilities in relation to health and these have the potential to impact on health services in number of ways. Firstly, through public health measures, especially in the areas of agriculture, social protection, environmental policy and consumer protections; and secondly, through the Health Policy mandate introduced by article 129 of the Maastricht Treaty (amended by article 152 of the Amsterdam Treaty). This focuses on issues of prevention, drugs, cancer and health promotion. In line with the principle of subsidiarity the task of the EU here is to undertake programmes that cannot be undertaken by individual member states. Thirdly, the EU has an agreed framework of research (for example in the field of biotechnology). Fourthly although the EU recognises member states’ autonomy in financing and organising health services, it has evolving interests in ‘intermediary’ areas such as quality, pathways for care, and technology assessment (in the broadest sense of the term). Finally, European integration can impact on health services through the internal market and therefore, the freedom of movement of: individuals; goods; services; and, capital when considered in a health context.

This paper reports on one aspect of the internal market, the free movement of individuals, specifically doctors. It describes a UK case study that has investigated healthcare labour mobility (as part of a BioMed Concerted Action programme. This programme aims to assess the impact of the EU internal market on health services through case studies in four countries: UK, Sweden, Germany and Spain).

Section snippets

Labour mobility of healthcare professionals.

As one of the largest employers in Europe, health services clearly have the potential to be affected by the impact of labour mobility on the demand for and supply of doctors, nurses, and other health professionals. Health service workforce planners in Europe have traditionally overlooked this potential impact. Integrated workforce planning that adopts a European dimension is an undervalued but increasingly important process.

In the UK, for example, adopting a European dimension to workforce

A case study on labour mobility

To address the questions identified above, a case study on labour mobility of doctors into the UK has been undertaken. The aims of the case study were to:

  • Describe the EU legislative framework for the free movement of individuals and its impact on labour mobility.

  • Enumerate the number of physicians from other EEA member states working in the UK.

  • Identify the number of physicians from other EEA member states in one health region of the UK (North West Region).

  • Investigate the reasons for mobility;

Policy framework for free movement of individuals

The Treaty of Rome lays the foundations for the free movement of labour within Europe. Key articles that facilitate freedom of movement are illustrated above in Table 1.

European directives (75/362/EEC and 75/363/EEC), passed in 1975, aimed to facilitate the entry of doctors into member states other than the ones in which they trained. They specified that immigration rules do not apply to a national of the European Economic Area (EEA), (or the family member of a national), who is entitled to an

Identifying EEA doctors and nurses in the UK NHS

The policy framework that underpins the movement of health care professionals has been defined. The next question, therefore, is to what extent are people actually moving? Earlier studies on labour mobility [13], [14] are rare. The lack of previous research into labour mobility among healthcare professionals in Europe is not surprising when considering the inherent challenges in doing so.

Investigations for this study support earlier observations [15] that there is little systematic collection

Labour mobility

The EEA doctors were asked how easy or difficult it is to get permission from the UK authorities to come to the UK and train/practice. They were also asked how easy or difficult it is to actually get a training position once they had obtained their GMC registration number. Of those who responded to the questionnaire, 89% found it was very easy or easy to get permission to train in the UK, whereas only 51% found it to be very easy or easy to get a job here. In addition 14% found it difficult or

Conclusions

This paper has focused on the experience of EEA doctors in the NW region of the UK, against the background of labour mobility across Europe and the associated regulation with respect to mutual recognition. The UK case study has, of necessity, been selective and we have not reported on all the findings. Rather, the emphasis has been upon an understanding of the factors behind labour mobility, in particular, of the EEA doctors into the UK and on the actual experience of those doctors once they

Policy implications

This brief case study has shown some of the ‘informal’ barriers to EU-wide mobility in training and employment. The (implicit) assertion is that labour mobility is ‘a good thing’. Clearly, in an economically and socially homogeneous Europe, which is a super-national political entity, such mobility is likely to be considered as a basic human freedom.

Yet, in a Europe ‘at the crossroads’, there may be unpredictable effects upon individual countries. If, for example, doctors are in shortage

Acknowledgements

We would like to thank the NHS Executive (North West) who funded this research and also the doctors and clinical tutors who participated in the interviews.

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