Health Professionals: EEA and Non-EEA Citizens

Debate between Viscount Bridgeman and Baroness Northover

Thursday 8th September 2011 Lords Chamber

[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.