Licensing procedures and registration of medical doctors in the European Union
By Legido-Quigley, Helena | |
Proquest LLC |
ABSTRACT
The current proposals to update the
KEYWORDS: Registration, licensing, revalidation, directive on professional qualifications, professional mobility
Introduction
Doctors have long had the right to practise throughout the
The most recent directive, which came into force in 2007, is being revised in response to these concerns. A draft text was proposed by the
Methods
Key informants were identified in 14 EU member states:
1 definitions
2 regulatory basis
3 governance
4 the process of registration
5 the flow and quantity of applications for movement by doctors (Box 1).
This was supplemented by reviews of peer-reviewed and grey literature.
The questionnaire was developed in consultation with the
The analytical framework
The analytical framework builds on the model of policy analysis developed by
Results
Context
Legislative basis and mobility flow
The main contextual factors are the relevant EU legislation and the factors influencing professional mobility. Professional mobility within the EU has been discussed at length elsewhere.5 In brief, it arises from a combination of push-and-pull factors including differentials in salaries and opportunities for professional development. In general, movement has been from countries offering lower salaries and fewer opportunities to those offering more. Table 1 shows the numbers of newly registered medical doctors and newly registered medical doctors with foreign training in 2008-10 (or latest available year). Patterns of mobility are shown in Fig 1. These highlight the role of cultural and linguistic similarities and longstanding historical ties in determining patterns of mobility.5 The
Content
Defining licensing and registration
Licensing and registration are designed to ensure that professionals achieve minimum standards of competence, although the terminology is not always used consistently,6,7 in part reflecting definitional ambiguity. Licensing has been defined as 'the process of authorization or authenticating the right of a physician to engage in medical practice, its monitoring (regulation) and renewal or extension'.8 The same source defines registration as 'all the processes associated with the issuing of licences/authorisations to practise medicine and ensuring that the professional activities carried out under this authority maintain the professional standards on which it is based'. It is apparent that these definitions could be improved to provide greater clarity. Thus, registration can be considered to be the act of placing an individual on a list of medical practitioners by virtue of having obtained a qualification and possibly a licence (neither of which has been forfeited for any reason), whereas licensing means that that person has been assessed as fit to practise currently. These two may be combined (whereby being placed on the register confers a right to practise) or separate, when they can take place simultaneously (and in some cases automatically) or consecutively (ie only those on a register can be licensed, or vice versa - Table 2).
There are many variants, with the words used illustrating the terminological problems. In
In some countries medical professionals can be registered and/or licensed as general practitioners/medical doctors/ physicians and as medical specialists regardless of their status (active/inactive, eg
Governance and regulatory bodies
Regulation of the medical profession is undertaken by a diverse array of national bodies, many of which combine this role with others, such as professional standards or representation in negotiations on terms and conditions (Table 2). They vary from government ministries to self-regulating professional bodies, with varying degrees of statutory regulation. Medical chambers play a major role in the registration and licensing process in some countries (Fig 2). In federal countries the process may be devolved to regions, as in
In
Process
The transparency and complexity of the registration and licensing process
In all the countries studied, doctors must apply to be registered, except in
<p>In all countries, application for registration is in writing, but some also require the individual to appear in person (eg
The criteria for registration vary: only in
Graduates from outside the EU must demonstrate competence in appropriate languages, although this is not a requirement for registration by graduates of other EU countries. However, employers will normally wish to ensure that those they employ have the language skills necessary to do the job. For example, the
The stringency of the processes involved in registration varies. However, even in the absence of harmonisation, we could find no evidence of systematic discrimination against non-nationals. Rather, for historical reasons, in some countries bilateral agreements allow for a more favourable treatment of citizens from some countries than from others.
In most countries, medical registers are publicly accessible and can be accessed online. However, in
Rejection and appeal
The data supplied by key informants suggest that it is rare for an application to be rejected, with fewer than five cases in any country each year being rejected. Reasons include nonrecognised medical qualifications (
Discussion
This study reveals just how complex the systems of licensing and registration are within the EU, with different interpretations of even the basic terminology. The challenges facing doctors moving between countries and those responsible for their registration and licensing are apparent.14 However, concerns have been voiced in some member states that any simplification of recognition procedures could undermine patient safety.3 A particular concern is the need to balance freedom of movement with language competence, especially given the need for complex terminology in medicine and the nuances of patient communication. However, there is an argument that this issue should be addressed by recruitment procedures, not registration, because there will be some situations, such as laboratory medicine, where fluency in a language other than English may be of less importance. Another concern relates to the lack of transparency, with some countries refusing access to lists of registered professionals, and problems in ensuring that professionals barred in one country do not move across borders to practise somewhere else, a concern that could be addressed with an alert system for health professionals.1
Some patterns emerge from our data.
Registers are important tools in workforce planning, especially given increased professional mobility which, in some countries, is leading to severe shortages of doctors in particular specialties and settings.14,15 However, the data must be accurate and available in a timely manner. It is not clear that this is always the case.
This survey has enabled the authors to identify seven areas where action is needed. The first is to agree on the terminology and, especially, to ensure consistent usage of the words registration and licensing. Second, there is no argument that a doctor must be able to communicate in a work setting, although what this means in practice may vary. Thus, there is a need to have a full and frank debate about language competence, clarifying who is responsible for assessing it and, specifically, the roles of the registration or licensing authorities or the employers, and the oversight of those in independent practice. The third is to reach agreement on at least the principle of whether registration or licensing should be time limited and what processes should be used to renew this status. There is widespread agreement on the importance of engaging in continuing professional development but not about any sanction for failing to undertake it. In practice, only very few member states have revalidation mechanisms (see Table 2) and those that exist, such as that in the
In summary, the systems of licensing and registration of doctors within the EU/EEA are extremely complex and confusing. Measures to bring clarity to them are long overdue.
Acknowledgements
We thank all questionnaire respondents who took time to generously provide us with the requested information. We particularly wish to thank all the institutions participating in the study:
Box 1. Five dimensions of registration and licensing.
1 Definitions: Is there a difference between registration and licensing, eg are these distinguished? What is the difference between licensing and registration in your country? Are registration and the licence to practise time limited? What do doctors have to do to maintain registration and the licence to practise? Are revalidation, re-registering and re-accreditation regulated?
2 Regulatory, legislative basis: Is there a government document or statute that includes requirements regarding licensing and registration? Is there any law establishing the functions of who is responsible for licensing and registration?
3 Governance - regulatory bodies: Which body/bodies in your country are responsible for registration and issuing licensing? How is this organisation funded and structured? Are registration and licensing governed centrally (eg through an arm's length body) or is there any government agency or professional association that deals with registration, licensing and authorisation? Is there a government document or a statement by an arm's length body or quasi-official agency that coordinates these issues?
4 The process of licensing and registration - EEA and non-EEA countries: When and how are licensing and registration initiated? What does the process of registration and licensing look like? What kind of mandatory steps do medical professionals have to follow in order to receive the licence to practise? What application documents have to be filled in? Are applicants from different countries/origin treated differently from national applicants? How does recognition of qualification work in case of EEA and non-EEA countries?
5 Flow and quantity of applications: What are the annual numbers of new registrations? What is the current number of medical doctors in the register? What is the volume of foreign health professionals getting registered?
EEA = European Economic Area.
References
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5 Wismar M, Maier CB, Glinos IA, Dussault G, Figueras J (eds). Health professional mobility and health systems. Evidence from 17 European countries.
6 Legido-Quigley H, McKee M, Walshe K et al. How can quality of health care be safeguarded across the
7 Greenwood MJ,
8 Rowe A, García-Barbero M. Regulation and licensing of physicians in the
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10 Albreht T, Pribakovic Brinovec R, Stalc J. Cross-border care in the south:
11 Albreht T. Addressing shortages:
12 Jesse M, Kruuda,
13 Kuusio H, Koivusalo M, Elovainio M et al. Changing context and priorities in recruitment and employment:
14
15 Jesilow P, Ohlander J. The impact of the national practitioner data bank on licensing actions by state medical licensing boards. J Health Human Services Admin 2010;33:94-126.
16 Hawkes N. Revalidation seems to add little to the current appraisal process. BMJ 2012;345:e7375.
Authors: Eszter Kovacs,A Andrea E Schmidt,B Gabor Szocska,C Reinhard Busse,D Martin McKeeE and Helena Legido-QuigleyF
Authors: Aassistant professor,
Address for correspondence: Dr
Email: [email protected]
Copyright: | (c) 2014 Royal College of Physicians |
Wordcount: | 3869 |
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