Health Professionals: EEA and Non-EEA Citizens
(12 years, 8 months ago)
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Viscount Bridgeman
To call attention to the disparity in the authorisation procedures for European economic area (EEA) and non-EEA citizens who are seeking to practise as health professionals in the United Kingdom; and to move for Papers.
Viscount Bridgeman
My Lords, I am very grateful for the opportunity to initiate this debate and particularly grateful to those noble Lords who will speak, as notice only came last Thursday because of the Recess.
I call attention to the disparity of treatment of health professionals trained within the EEA and outside it. It is particularly marked in the case of nurses, but applies to a greater or lesser degree to all healthcare professionals. I am deliberately omitting mentioning doctors in great depth as I know distinguished doctors taking part in the debate will speak with authority on this subject. The Nursing and Midwifery Council—the NMC—is responsible for the registration of and setting standards for all nurses throughout the United Kingdom and the islands. There is no better way of viewing this disparity than through the eyes of the NMC and I make no apology for taking that route myself.
Let me summarise the main differences. Nurses from outside the EEA have to take the overseas nursing programme as part of registering. This is a comprehensive 20-day course invoking professional competency and, where applicable, a period of supervised practice of between three and six months in length. All applicants have to undergo the International English Language Testing System. The NMC is therefore in a position to exercise total control over the registration of these non-EEA applicants. Contrast this with healthcare professionals trained within the EEA, who are subject to the Commission’s mutual recognition of professional qualifications directive of 2005. Under this directive, healthcare professionals seeking to register and practise in another EEA member state have the right to do so provided that their qualifications meet the minimum standards as laid out in the directive. If these standards are met, the member states’ competent authorities—I shall refer to them as regulators, as it is rather easier—must automatically recognise the qualification and register those professionals as fit to practise in their countries. They have no option. Regulators are not allowed to undertake further competency checks, including checking whether practice competencies had been kept up to date or the applicant has basic communications skills in English.
Thus the directive does not require a migrating EEA nurse or midwife to demonstrate that they have kept their practice up to date since obtaining their training qualification. At the same time the NMC has no option but to register automatically EEA nurses and midwives, even those who may not have practised for, say, 20 years. Indeed, I am advised by the NMC that over the past year it had applications from over 1,400 EEA-trained nurses and midwives who have not practised for at least four years. Another proposal by the Commission—it is part of the revision of the directive, about which I will talk later—that causes concern is the principle of partial access. The Commission, in an otherwise well thought-out document, has suggested that professionals who have shortfalls in training that cannot be compensated by an adaption period should be registered with limits to their practice. This is simply not practicable in the case of nurses and midwives, who in the case of A&E nurses, for example, must often make ranges of critical clinical decision quickly and in pressured situations. I urge the Government to strongly resist this proposal.
I wish to cite a number of examples where, in the case of EEA applicants, the directive causes the registration process to be inadequate. First, member states’ training standards can vary greatly. For example, different countries put different emphasis on the importance of record-keeping. In inquiries that I made, I was amazed to find that several advanced countries did not have a tradition of patient notes such as we have in this country. While training in a large number is comparable to that in the UK, this is not the case with some of the newer accession countries. EEA standards for general nursing and midwifery date back three decades and do not account for fundamental changes in the professions over this time. Those changes include the use of new technologies and evidence basis, the shift from acute to community nursing and the move in some countries to a degree-level standard of training.
As regards language testing, as I said, under the directive EEA nurses and midwives applying for registration cannot be systematically tested for language competency. This is in stark contrast to the IELTS for non-EEA applicants, which includes even those from English-speaking countries. I consider that this is illogical and inefficient. Your Lordships will be aware that the directive places the onus of measuring language competency on employers rather than regulators. This has a number of practical defects, the first and crucial one being the lack of uniformity. For instance, hospital B may refuse an applicant on the ground of language competency, but that applicant may have come from hospital A where there was no problem. Not all hospital personnel departments are experienced in spotting language deficiency. A significant number of cases certainly slip through the net. The case of Dr Daniel Ubani is well known. In that case a patient died through an incorrect drugs dosage which was traced to the doctor’s inadequate command of English. Too much should not be made of this case as it was, after all, one isolated incident. However, for the reasons that I have just outlined, I suggest that there is another disaster waiting to happen. I know of one hospital where a number of consultant surgeons have refused to perform operations unless every member of the theatre team has English as his or her first language.
Here I come to the blunt instrument which will be familiar to those experienced in these matters. Until recently, the NMC required all applicants, including those from the EEA, to demonstrate at least 450 hours of practice in the three years prior to their application. However, over the past two years the Government have had no option but to request the NMC to drop this requirement as it affects nurses coming from the EEA on the ground that it is incompatible with the directive. I am told by the NMC that it has reluctantly had to comply.
On a more encouraging note, the Commission, the Department of Health and BIS are well aware of the urgency of the language and other competency risks I have discussed. Many of the risks to which I have referred could be mitigated through changes to the existing directive. A review of the directive is under way and is due to be completed by 2012. The NMC is leading a group of 25 European nurse regulators to co-ordinate their responses through the review process. As part of the review the European Commission released a Green Paper in June exploring changes to the directive. The Green Paper suggestions have gone some way to addressing concerns but they are still not clear enough. It is worth summarising what the NMC wishes to see in nurses from within the EEA registered in the United Kingdom. This is taken from its submission to Sub-Committee G—I am very pleased to see the noble Baroness, Lady Young of Hornsey, in her place—and is an excellent summary of what is expected from a nurse or midwife from the EEA seeking to practise in the UK. They should be trained to a level equivalent to that of training in the UK. They should be fit to practise within the scope of practice of the professions in the UK and they should be able to communicate effectively in English.
In the light of this the NMC has a “shopping list” which I respectfully bring to the Minister’s attention. First, minimum training requirements should be modernised to reflect the changing roles of nurses and midwives, potentially to a degree-level standard. I am talking about other EEA members here. Secondly, all EU regulators in the Community should be required to implement continuous professional development to ensure that competencies are kept up to date. Thirdly, the principle of partial access must not be applied to the healthcare professions. Finally, and most importantly—this is at the heart of this debate—regulators must be allowed to satisfy themselves of language competence at the point of registration, and employers should be allowed to undertake competency checks.
BIS, supported by the Department of Health, has recognised throughout the review process the unique position of healthcare professionals and supports many of the changes proposed by the NMC. I think that it also appreciates the urgency of the situation. The Government are to be commended for their recent efforts to strengthen a local-level system of language competency checks to be put in place at an early stage and operate until a full-scale revision of the directive is completed, which will take a number of years. I urge BIS to continue to reflect the concerns of the nursing profession in its submission to the Green Paper consultation, which closes on 21 September. I also urge the Government to continue this support when draft legislative changes to the directive are made later this year for consideration by the European Parliament and in due course by the Council of Ministers.
I hope that a feature of this debate will be patient safety. I hope that the Minister will be able to assure the House that he and his colleagues in BIS will keep up the pressure on the Commission not only to set up an interim regulatory system but to ensure that the directive as revised emerges as helping to maintain the traditionally high standards of nursing in the United Kingdom rather than acting as a hindrance, which it sadly does at present. As with any measures taken to prevent or minimise accidents, tomorrow may be too late. I beg to move for Papers.
Baroness Northover
My Lords, I remind noble Lords that this is a strictly time-limited debate and that therefore when the clock reaches four, noble Lords will have had their time. To go further will take either from the time of other noble Lords or of the Minister responding at the end.
Lord Winston
My Lords, in January 1944 the American VI Corps of the Fifth Army was engaged in a bitter struggle at the Anzio beachhead when a doctor, Henry Knowles Beecher, ran out of morphine. In his field station with these desperately wounded patients, his nurse in desperation decided to put up a drip for each patient and tell them that inside the saline drip was a powerful pain reliever. The remarkable effect on these soldiers was such that very few of them complained of the pain, the amputations and the other horrific surgery that they were undergoing. Beecher founded in consequence the randomised control trial, which—the Minister will be aware—led to our partial understanding of the placebo effect. It was very clear that the communication with those patients was the key issue.
Since that time, Dr Bensing in the health service’s research department in Utrecht has looked at the growing tendency in medicine towards the business-like interview between patient and doctor, and has taken video tapes over some 20 years showing that. They show a gradual deterioration in the kind of care that is going on—probably throughout Europe. Bensing’s work is really very interesting. This is not due simply to a placebo effect. There is a very important publication from as long ago as 1976 by Patel and Daley showing that 77 per cent of hypertension patients’ condition improved simply by talking to the doctor and the doctor listening to them in great detail. It is obvious that this was not a placebo effect because in the main these patients did not require drugs afterwards to suppress their hypertension. Most of them required at least a reduction in drugs and some needed no drugs at all. What is impressive about the study is that that effect continued for at least six months or a year.
That is something that we will come back to during our discussions on the health Bill. Communication between the patient and the professional is vital. We run the risk of losing it with nurses who cannot speak English and who have been trained in a different way. I am particularly concerned about nurses coming from the eastern bloc of Europe—for example, from Romania or Bulgaria. Having been extensively in the far east of Europe when we were still in the Cold War with my research, I am well aware of the limited communication even in their own language that healthcare professionals had. If we are not careful we will increase that in our health service.
I hope that we will make sure that that, plus the fact that record-keeping is not fully understood by those nursing staff, are aspects that we will fight on in the European Union. I know that the Minister is caring and responsible, has high integrity and communicates and listens brilliantly. I understand that it is not entirely his problem because he has to communicate with BIS to represent our views in Europe. As he knows, Europe has already threatened our health service in other ways and I hope that we can make the strongest case possible to ensure proper communication between patient and carer.
Baroness Hussein-Ece
My Lords, I thank the noble Viscount, Lord Bridgeman, for securing this very important debate.
Since the inception of the NHS in 1948, it has relied heavily on overseas-trained nurses and staff to bolster its workforce. The NHS was built with the help of immigrant workers and professionals from across the world when the call went out around the empire that the UK needed their labour. Thousands of doctors and nurses migrated here from the West Indies, as it then was, Pakistan, India, and elsewhere during the 1950s, 1960s and 1970s. They were recruited in response to a health service in desperate need of health professionals in the post-war years. The value of their huge contribution has always been recognised, and it is that diversity on which the NHS was based and is now run. It has been a success story.
We know that more than 30 per cent of NHS professionals were born overseas. Without them, the NHS would come to a standstill. In some cases the NHS is now less reliant on overseas trained professionals to deliver services, but international recruitment has been regularly used as the main option for employers trying to fill vacancies in both health and social care, and in professions and specialisms with recognised shortages. Many Asian and black health professionals have been the backbone of the NHS, often concentrated in the lowest paid roles, the least glamorous specialisms, and in the least popular parts of the country. Some have faced racism and, for many, there has been slow promotion in their working lives.
There are legitimate concerns that the countries from which the nurses and midwives are recruited suffer from a knowledge and skills drain, reducing their capacity to provide healthcare to their own populations. But there have been huge advantages when professional staff have returned to their country of origin, taking with them the skills and development that they have acquired here. No one is advocating uncontrolled immigration but the introduction of a cap on non-EU health workers is insulting to those doctors and nurses who came to work in Britain’s hospitals. Many of them have faced difficult circumstances but have made enormous contributions. In light of the increasing evidence of how reliant we are on migrant workers, the cap could have unintended consequences by blocking much needed specialist workers from settling in Britain when they are vital for our economy and public services.
Social care is another area which is being hit by these procedures. It remains one of the lowest-paid sectors, and it is notoriously difficult to recruit for here in the UK. The National Care Association paints a rather stark picture of the policy's impact on social care. It is already complaining that the care sector cannot get the workforce needed to deliver services in this country. It is estimated that 1 million extra workers will be needed to support the UK's ageing population by 2025. In 2007, one in three care workers was recruited from outside the UK, while an estimated 60 per cent of London care workers were non-EU migrants. Meanwhile, we have the same problem with children's services where there has also been a cap, putting vulnerable children at risk because of the shortage of qualified and experienced social workers in some parts of the country, particularly in London. While measures put in place to train people from the UK and EU for roles now filled by non-EU migrant workers will help, it will take more than three years to have enough suitably qualified candidates to fill these positions.
I believe that successive Governments have failed to put the compelling case to the UK public that communities, from hospitals to schools, right through to local authorities, need to be encouraged to develop a more realistic understanding of immigration matters in this respect, and of how reliant we are on skilled migrant workers for our public services. In addition, we need to shape a practical, common-sense approach to this issue, one that reflects our heritage and our values.
Baroness Young of Hornsey
My Lords, I, too, am grateful to the noble Viscount, Lord Bridgeman, for securing this debate, as it gives me an opportunity as chairman of EU Sub-Committee G on Social Policies and Consumer Protection to let your Lordships know of the some of the aspects of the inquiry the committee has just completed. I very much look forward to seeing the noble Viscount, Lord Bridgeman, on our committee in the near future.
We launched this inquiry into the mobility of healthcare professionals in June and received a substantial amount of written and oral evidence which has informed our response to the Commission’s Green Paper—mentioned by the noble Viscount—on the modernisation of the directive which governs intra-EU mobility of professionals. The report has not yet been debated by Select Committees, and we anticipate publishing it some time in early October. I am going to draw on some of the evidence we have received to point to the particular aspect which the noble Viscount has drawn to our attention.
The inquiry heard from the major regulators of healthcare professions in the UK, including the General Medical Council and the Nursing and Midwifery Council. They expressed serious concerns that discrepancies in a number of areas were forcing them to admit to their registers individuals who did not meet what they considered the necessary standards for safe practice, thereby putting patients at serious risk. For example, the Nursing and Midwifery Council said it had concerns about the decisions it was forced to take in favour of certain EU applicants, and that it was absolutely certain that many of these would not have been admitted to the register if they had been UK applicants. Similarly, the GMC pointed out how countries joining the EU changed the requirements for doctors applying to work in the UK. Whereas previously applicants would have had to take an exam, which many of them failed, once they were from member states, the GMC’s ability to question their language, knowledge and skills was severely restricted.
It is right that there be some differences between EEA and non-EEA applications. For example, automatic recognition of professions is based on the fact that there are harmonised, minimum training requirements for these professions which do not exist for third countries. The majority of witnesses felt that the problem was not one of differences per se, but that the system lacked the necessary flexibility to take account of the specific nature of the healthcare professions, and did not reflect the nature and requirements of modern practice.
In certain areas, regulators argued that they should be able to apply the same standards to EU and non-EU applicants—for example, systematic language testing, as has already been indicated—at the point of registration. Others simply wished for greater freedom to decide what was appropriate in each case; for example, the ability to test more widely when they had doubts.
The fact that the Commission is looking at the issue is clearly welcome. However, there will need to be some far-reaching changes to ensure that intra-EU mobility of healthcare professionals maintains the confidence of patients and professionals alike. Mobility can bring significant benefits: exchange of ideas, new treatments, and so on. But as has been emphasised by all the witnesses, patient safety is the most essential thing and should be the priority over mobility.
Lord Colwyn
My Lords, I am delighted to follow the noble Baroness, Lady Young. I spent many years on Sub-Committee G and I regret not being there while she was chairman.
Professionals holding specific qualifications and currently registered with a competent authority in one member state can register to practise in any other member state without having to satisfy further tests or formalities. Automatic recognition of qualifications under the directive 2005/36/EC is about granting access to professional registration, not about suitability to undertake a particular job. It is up to employers to ensure that the applicant has the necessary skills and competencies to perform the role for which they are applying. In the limited time available I will make some general remarks about issues that affect the dental profession. I declare an interest as a former dental practitioner.
Registration of non-UK dentists with the GDC is dependent both on the individual's nationality and the country in which they qualified. Dentists who are EU citizens with degrees obtained within the EU benefit from automatic registration based on the rules of free movement of EU citizens. Subject to proof of identity, degree and good standing in the home country, dentists are able to register with the GDC without further exams. A directive defines the minimum training standards required within the EU. All degrees of current EU countries comply with these requirements, although some member states require their dentists to undertake a period of clinical work experience in addition to the degree before they can work independently. In these cases, the requirement may apply also to registration with the GDC.
There are regulations for dentists who are EU citizens with degrees obtained outside the EU; regulations for dentists with a qualification gained before and after 01/01/01 from Hong Kong, Singapore, Malaysia, South Africa, New Zealand and Australia; and regulations for dentists who are not EU citizens but who have obtained degrees within the EU. I would like to have had the time to explain this more fully. The regulations are considered to work well, both with regard to the minimum training standards and the compensation measures for those countries that joined the EU more recently and did not at the beginning comply with the directive. A consultation is currently taking place with a view to modernising the directive.
The main concerns for dentistry have been the lack of language testing at registration points and the lack in some countries of practical training involving seeing patients. In the current review there is a welcome option for more formal language testing. I suggest that there is also a need to update the minimum training standards in accordance with the latest science.
Another concern that is not directly related to registration with the GDC is the fact that dentists from Europe are exempt from the requirement to undertake vocational training. UK-qualified dentists as well as non-EU dentists are required to undertake this training, while EU dentists are able to register without further training on a local performer list. All dentists should be required to undertake such training. However, to ensure fairness of the system all places would have to be funded. EU dentists are eligible to apply for foundation training but, if allocated a place, take it away from a UK graduate. There is high competition for these training places across the UK.
The overseas registration exam for non-UK dentists is designed as a competency test set at the level of a UK undergraduate. The pass rate is not high. Concerns over the exam remain with regard to appropriate provision of exam places, as there continues to be a waiting list. Dentists who are not EU citizens are required to undertake vocational training or foundation training through an equivalence route before they can become independent performers. My time is up: I look forward to hearing from the Minister.
Lord Kakkar
My Lords, I join other noble Lords in congratulating the noble Viscount on having secured this important debate. I will confine my remarks to medical practitioners and declare my interest as a practising surgeon.
For practitioners who have qualified outside the European Union, the situation is clear: our national regulatory body, the General Medical Council, is obliged to test their language skills and competency and is fully entitled to inquire into the content and quality of their medical education and training. For practitioners from the European Union, this is not the case: the GMC is not able to test language skills, is unable to make an assessment of their competency and is unable to inquire into their training and education. Clearly this is not acceptable, but the situation is worse even than that because, for practitioners who are registered elsewhere in the European Union and who, as we have heard, are entitled to come to the United Kingdom and practise, and for whom the General Medical Council is obliged to provide the opportunity for automatic registration, there is no obligation on the part of their home regulatory bodies to report any concerns that they may have about the practice of the individual—whether they have been suspended or whether there are any inquiries into their practice. That is an intolerable situation. It is not right for fellow practitioners who have to work with these individuals, but most of all it is not right for the citizens of our country who, at times when they are unwell and are becoming patients in our healthcare system, need to be absolutely certain that the practitioners to whom they are exposed are competent, meet the standards required of medical practitioners in our country and therefore can, with certainty, provide the quality of care that citizens in our country deserve.
There is a simple way forward. On language testing, I understand that a change in domestic legislation will allow immediately for the General Medical Council to move forward and assume responsibility for ensuring language competence. On professional competence, there will need to be changes at the European level. I know that the General Medical Council—and I am sure medical practitioners in our country—would warmly encourage the Government to pursue discussions at a European level of professional competence training, but in the mean time it would be most helpful if Her Majesty’s Government would consider looking at language testing and determining whether a change to domestic legislation could ensure that that particular problem is overcome. Ultimately this should not be a matter of politics or even of European relations: it is simply a matter of patient safety and providing for the people of our country the certainty they deserve in knowing that when they are unwell, the practitioners who will look after them all meet the same standard, whether they have been trained in the United Kingdom, in a European country or elsewhere in the world.
Lord Hunt of Wirral
My Lords, I declare an interest as a practising solicitor and partner for more than 40 years in the international commercial law firm Beachcroft. This debate gives me a wonderful opportunity, first, to thank my noble friend Lord Bridgeman for having introduced such an important subject, and also to support my chairman on Sub-Committee G and say to my noble friend Lady Young of Hornsey that I warmly applaud everything she has said. I am delighted that our overall chairman, the noble Lord, Lord Roper, is listening to this, because I think that everyone agrees that this directive needs modernising and urgently so. I agree with many of the points already made. There is, sadly, insufficient confidence among patients, professionals and regulators in the current framework. I think that everyone agrees with that, so what are we going to do?
There are two areas of concern upon which I agree with my noble friend Lady Young of Hornsey. The first is the diversity of regulatory systems and approaches to registration right across the European Union. The second is the variation in the competencies of individuals, even where they hold the requisite qualification. I agree with the noble Lord, Lord Kakkar, that right at the heart of all this is patient safety. In the limited time I have, I want to make two points. First, I am concerned about the lack of what is called continuous professional development. There must, surely, be a CPD requirement. I agree with the Nursing and Midwifery Council that the idea that we have automatically to register all EU nurses and midwives who meet EU minimum requirements, even those who may not have practised for 20 years, makes it sound as though there is something fundamentally wrong. We need to get this right. Secondly, as I complete six years as chairman of the English Speaking Union, I have to refer to communication skills. I do so by quoting from the Guardian. An article in the Guardian recently said:
“As Good Medical Practice makes clear, communication skills are fundamental to a doctor’s work and the success of many doctor-patient relationships is often determined by the doctor’s ability to communicate effectively with patients, particularly when obtaining consent or if something goes wrong”.
I am very grateful to the Medical Defence Union for making me aware of the statistics. Its journal of June 2011 revealed that around 30 per cent of complaints notified to the MDU by its GP members involved allegations of poor communication. This is such an important subject, and it is about time that we started to make sure we get it right across the European Union.
Baroness Thornton
My Lords, I thank the noble Viscount, Lord Bridgeman, for bringing this important matter to your Lordships' House. Although this is a short debate, it is none the less of huge importance. I am very keen to identify these Benches with the need to resolve this matter. A Health Select Committee report last year looked at the death of David Gray as a result of Dr Daniel Ubani and said then that this is a matter of great importance and urgency. How much more so now? That report stated that if the GMC had been able to carry out language and competence tests on EEA doctors wishing to practise as GPs then that life and perhaps other lives would have been saved. The Select Committee was keen to see the issue resolved then.
We know that the Government need to press for change to the relevant EU directive to enable the GMC to test the clinical competence of doctors and to undertake systematic testing of languages. I was very pleased to see that Sub-Committee G of our European Union Committee has taken evidence on this matter and will be reporting. That helps to strengthen the case. It would possibly have been helpful if it had reported before the deadline for the Green Paper, which is 21 September, but the fact that the evidence that has been given to it has been made public is very important. I knew that it was considering these matters, but I read with alarm some of the reports about the evidence that it had received. Dickon Weir-Hughes said to our Select Committee that the Nursing and Midwifery Council had to operate a two-tier system because of EU rules on the free movement of workers. In evidence to the same inquiry, the GMC revealed that a foreign doctor’s husband had contacted it on her behalf to register her for work because she could not speak English. It went on to report that the Nursing and Midwifery Council is now admitting people who have not been near a patient for 20 years, as the noble Lord, Lord Hunt, said in his speech.
We know that the GMC and the NMC have huge responsibilities for patient safety and we know that we must listen to them about this problem because this is about risk to patients. The problem we face is that this directive is an overarching document based on the principle of freedom of movement in the internal market and applies to several hundred professions, not just to those in the healthcare sector. While we on these Benches of course support the principle of freedom of movement and recognise the positive contribution of European Union nurses, midwives and doctors in the provision of healthcare in the UK, as the noble Viscount said, freedom of movement should not take precedence over patient safety. That is the challenge facing the UK Government in these negotiations.
I hope that this debate will help the Minister in his representations to BIS on behalf of the Department of Health about why this review is so important and why we have to stand firm on it. I join other noble Lords in urging BIS to continue to reflect our concerns in its submission to the Green Paper consultations and I urge the Government to continue their support when the draft legislation changes are made later this year for the consideration of the European Parliament and Council of Ministers.
We also know that the wheels of European directives move exceedingly slowly, which is why the points made by the noble Lord, Lord Kakkar, and others about addressing this issue in the mean time, if we possibly can, are also important. I would also like to identify these Benches with the call to do that.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, my noble friend Lord Bridgeman deserves our thanks for tabling this very useful debate and for introducing the subject so ably. As he and other speakers have rightly indicated, there is considerable disquiet about the implications of European law in respect of the free movement of healthcare workers. I should particularly like to congratulate the noble Baroness, Lady Young of Hornsey, on her committee’s very helpful report and on her concise remarks today in support of it.
Several healthcare professional regulatory bodies have expressed concerns about whether we have the right safeguards in place to check whether European Economic Area migrants wishing to work in the UK are fit to practise. They have called for new powers for checks on such migrants. Under European directive 2005/36/EC, many EEA migrants will automatically have their professional qualifications recognised by the relevant UK regulatory body, whereas healthcare workers from countries outside the EEA will generally be subject to checks upon their competence and communications skills before they are allowed to register.
Any EEA national whose qualification is automatically recognised must hold a European qualification which conforms to the standards set out in the directive. Picking up the point so well made by the noble Lord, Lord Winston, this should ensure that, for example, a general care nurse’s qualifications broadly attest to his or her competence, but it is then up to whoever employs, or contracts with, the nurse to make sure that the individual in question has the right skills and qualifications for the role. My noble friend Lord Colwyn made this point very well in the context of dentists.
The UK system of health professions regulation largely treats registered professionals equally, regardless of their nationality and background. The differences lie primarily in entry to the profession—that is to say, entry into the register. In looking at the directive, our view is that elements of it need strengthening but overall the system for mutual recognition is effective. I can, however, reassure my noble friend Lord Hunt that we are absolutely committed to making the European system as strong and robust as it can be.
This summer we have been working constructively with other government departments and the health regulators themselves to formulate our response to the European Commission’s Green Paper on reforms to the directive. On that Green Paper there is very little on which the department and our partners disagree regarding areas of the directive that need strengthening. We agree that the harmonised training standards underpinning automatic recognition need updating and that a mechanism for regular updates is required. We would also like to see a focus over time on competencies in training rather than particular length of training.
My noble friend Lord Hunt referred to continuous professional development. We think that all member states should be required to have a system of CPD in place for the healthcare professions on their territories. Out-of-date training for the health professions can pose a much greater risk than for other professions covered by the directive. We agree that that issue needs to be tackled in a revised directive. We would want to ensure that EEA migrants subject to CPD requirements in their home state are obliged to demonstrate they meet such requirements when they register in another member state.
My noble friend Lord Bridgeman mentioned the principle of partial access. We share his concerns. The concept exists in European law through case law, whether we like it or not. The current case law allows that partial access can be denied if there are overriding reasons of public interest. We would argue that this means that it is not applicable to the health sector, particularly where harmonised training requirements apply. However, to avoid doubt about this, we wish to see explicit provision in the directive to clarify this point.
My noble friend and the noble Lords, Lord Winston and Lord Kakkar, referred to the issue of language checks. In fact, I think all speakers did so. Article 53 of the directive also states that those benefiting from automatic recognition,
“shall have a knowledge of languages necessary for practising”,
in the relevant member state. However, case law from the Court of Justice of the European Union precludes systematic language testing at the point of registration, and European Commission guidance states that the lack of language knowledge cannot be a ground for refusal of recognition of qualifications. So while a competent authority could test the communications skills of a healthcare worker from a non-EEA country, it could not routinely or systematically do the same for an EEA healthcare worker. Furthermore, such checks could not act as a barrier to recognition of their professional qualifications. However, both the directive and case law support language checks before a professional takes up a particular role provided that checks are not systematic, are proportionate and reflect individual circumstances.
In the UK, we have implemented a system of checks at a local level through duties on primary care trusts and guidelines to local NHS employers. The noble Lord, Lord Winston, is totally right to say that this is an issue of major importance for the quality of patient care. We have already taken steps to strengthen the system, and since January all designated bodies have been required to nominate or appoint a responsible officer—for example, a medical director in an NHS trust. In England, the responsible officer’s duties include ensuring that medical practitioners have the qualifications and experience necessary for the role and that references are checked. However, we think that we can and should do more, so we are working with the GMC to develop further proposals that will build on these existing duties.
Work is currently focused on the medical profession because risks there are perhaps most acute, especially in the context of general practice. However, we will also work with the relevant healthcare professional regulatory bodies and the European Commission to explore how a strengthened system of proportionate local checks might be introduced for other professions where there is evidence of justified concerns about patient safety.
The noble Lord, Lord Kakkar, referred to the unfairness to migrants from non-EEA countries. I think the issue here is that regulators have to reconcile the need for fairness and reasonable treatment of migrants seeking registration with their principal objective of protecting public health and safety. International migrants, as the noble Lord said, may undertake training in a very different cultural context—for example, in relation to child protection. For that reason it is essential that robust checks on professional competence are undertaken. At the point of entry to the UK, the regulator may seek confirmation from the home member state, if it is an EEA candidate, that there are no known concerns about the individual. Our concern relates more to the need for a proactive duty to share information when concerns actually arise.
My noble friend Lord Colwyn spoke about dentists in his customarily authoritative way. We consider that there is an opportunity here in the context of the proposal to update the minimum training standards in the directive to address the long-standing concerns that some newly qualified EEA dentists do not have the same level of practical training at the point of qualification. It will, however, remain essential that PCTs and other contracting or employing bodies ensure that any person they appoint to their performers list is appropriately trained and qualified for the role to which they will be appointed.
On the issue of our interaction with the EU Commission and the efforts by my department and those of the Department for Business, Innovation and Skills, I can reassure noble Lords, in particular the noble Baroness, Lady Thornton, and the noble Lord, Lord Winston, that the two departments have been working very closely together on the production of a response to the Green Paper. The closing date for responses to the Commission is 20 September. The Government’s response is being finalised more or less as I speak.
My noble friend Lady Hussein-Ece was correct in what she said. There is no question that, overall, the UK healthcare system benefits from the free movement of professionals and has done for many years. Thankfully, the NHS is moving more and more towards self-sufficiency in terms of its workforce but her point was very well made.
However, perhaps I may conclude by re-emphasising one issue. It is essential that there are effective checks on the suitability of all healthcare professionals for the specific jobs that they are going to undertake. In that context, there has to be, as there is now, a key role for those employing or contracting with healthcare professionals in undertaking those same checks.
Viscount Bridgeman
My Lords, I am most grateful to noble Lords who have taken part in this debate. I am slightly disappointed by the Minister. I understand that he is hamstrung by the requirements for the language testing. However, I draw the attention of your Lordships to the Green Paper where a number of quite constructive options are set out. I hope that, with tremendous support, the Government will pursue these with great vigour. I am particularly grateful for the Minister’s reassurance on the question of partial access. I think noble Lords will be reassured on that.
Turning to my noble friend Lady Hussein-Ece’s point, it is essential that the free movement of all health professionals is not impeded. I am confident that in due course satisfactory checks as to suitability and language will emerge. I should also like to thank the noble Baroness, Lady Young, for her kind words of welcome and I very much look forward to serving on that committee with my noble friend Lord Hunt. I have seen the submissions, which are of very high quality. We can expect some very interesting results. I beg leave to withdraw the Motion.