The free movement of nurses and doctors within Europe provides new employment opportunities. But will it also perpetuate existing shortages? Glenn Gathercole provides the perspective of the Standing Committee of Nurses of the European Union.
The European Commission communication "New European Labour Markets, Open to All, with Access for All" (1) ensures that people are free to move throughout Europe to find work. The move promotes the single European market by liberating the movement of persons and skills from one country to another.
To assist the process, the European Commission is reviewing the system of mutual recognition of qualifications of all healthcare professionals (2) to simplify the system and encourage free movement whilst maintaining a regulated standard of education and training. Missions to countries applying for EU membership are taking place to assess levels of compliance with the current regulations and standards.
On the face of it, these developments should be welcomed. They will facilitate the free movement of healthcare professionals between Member States, and they may result in a redistribution of doctors and nurses from those countries with an oversupply of specialist health professionals to those countries which are experiencing shortages.
In theory, the result will be a Europe with a healthcare workforce, determined by supply and demand, providing equitable healthcare across the Union. The question is whether freeing the market for doctors and nurses in Europe will present more problems than solutions.
Nursing shortages
The International Council of Nurses (ICN) issued figures in 2001 (3), which describe an emerging global crisis and a worldwide shortage of nurses. In Europe, the Standing Committee of Nurses of the EU (PCN) confirms that nearly every country within the EU is reporting severe shortages of nurses. Qualified nurses are leaving the profession and the number of new entrants to nursing courses is falling. Demographically, the workforce is ageing, which implies that a further crisis is just around the corner.
When nurses choose to migrate between countries and health systems, it has significant implications for both the importing and exporting country. Without migration, the shortage of nurses might be expected to push up the salaries of nurses; with it, nurses’ salaries are unlikely to improve. Recruitment of nurses from countries with lower standards of living is likely to depress salaries within importing countries.
Poor countries lose
Nurses in poorer countries may leave home even though there are shortages in their own countries. Specialist nurses are likely to be in short supply in lower income countries, but this will not stop higher salaries in wealthier Member States attracting them away. In this case, market forces solve the problem for the wealthier states but poor countries are left with critical shortages and with no means of attracting the workforce back.
Within the accession countries, National Nursing Associations (NNAs) are concerned about the future impact of enlargement on their workforces. With the removal of borders, nurses may be tempted to migrate from Central and Eastern European countries, where working conditions and pay are relatively low, to Western European countries, where both standards of living and pay are higher. The nursing associations fear that if a trend in the migration of government-trained doctors and nurses becomes established, governments may cease to invest in medical and nursing education, possibly leaving the responsibility for the provision of healthcare to the private sector.
Lack of data
At present, making the case for or against migration is thwarted by a lack of statistical information. One of the major issues currently facing all the NNAs is the collection and accuracy of data on current cross-border movement. What exists is neither comprehensive nor reliable. At EU level, it is almost non-existent.
National registers of employed nurses within countries are not standardised. Most provide the numbers of registered nurses but do not indicate how or whether they are employed. There are currently no systems to assess how many nurses are leaving a country, where they have gone, what proportion are likely to return, and in what time period.
Many Central and Eastern European countries have so little data available that it is impossible to be certain whether shortages or surpluses exist. Elsewhere, incomplete information leads to disagreements. For example, while the Spanish government considers there to be a nursing surplus, the national nursing association says there are only surpluses in certain specialities.
The Standing Committee of Nurses of the EU (PCN) has proposed that a European workforce monitoring forum be set up. It would collect information about the movements of nurses and assist in workforce and health service planning.
Quality of health care
The all-important question is whether migration of healthcare professionals is adversely affecting the quality of care given to the patients.
In receiving countries, shortages may be alleviated but differing levels of training and education and different "packages" of skills may cause problems. Cultural and language barriers may create a sense of isolation among migrant workers that affects the quality of care they are able to give. Information supplied by employers or agencies about work permits, registration, career prospects and so on is often insufficient. Many know little about future living and working conditions before they leave home. Reports suggest that some are experiencing social hardship, including racism, within their new environment. Unpleasant surprises mean that the worker becomes disorientated, demoralised, and may even return home.
In exodus countries, migration may be the direct cause of workforce shortages at home, with adverse results on healthcare systems. However, cross-border migration cannot be blamed for all the problems. Personnel and skills are not always optimally spread even within countries.
For some time, PCN, ICN and other nursing associations have been well aware of the problems of migration, particularly those for both the receiving and exodus countries. At the European level, PCN has held several workshops and is developing proposals for collaboration between NNAs to identify and share successful recruitment and retention strategies, and to evaluate their transferability across Europe.
Several initiatives have already been introduced. For example, the Irish government is encouraging part-time degrees and increased financial support for nursing students. In Belgium, older nurses are now allowed to reduce their working hours, while maintaining their salary level, in the final years of their working life.
PCN is currently developing guidelines for the ethical recruitment of nurses from abroad. These will aim to set standards for employers and agencies to follow. International agencies are increasingly being used to recruit nurses from abroad and their practices need to be both fair and ethical. For example, all nurses recruited should be given full and accurate information on working conditions, salary, accommodation and so on. The agencies should not be involved in aggressive recruitment in developing countries, nor in countries experiencing their own workforce shortages and health system problems. Whilst many agencies are competent, standards and safeguards are needed to ensure that unscrupulous practices do not develop.
To achieve "Open to All, with Access for All" (1), healthcare professionals must have the freedom of choice to work wherever they wish within the EU. At the same time, the professional bodies, national governments and EU Institutions will need to work together to ensure that the Member States can provide healthcare systems that deliver quality care to patients.
Article written by Glenn Gathercole, Co-ordinator, Standing Committee of Nurses of the EU (PCN).
This article was prepared with contributions from PCN members - Annette Kennedy, Irish Nurses Organisation (INO) and Josie Irwin, Royal College of Nursing (RCN).
The Standing Committee of Nurses of the EU (PCN) represents more than 750,000 European Nurses and is the independent European voice of the profession. PCN is an EPHA member.
References:
(1) COM(2001)116 final
(2) MARKT/D/8131/3/2001 "European Commission Staff Working Paper on the Future Regime for Professional Recognition".
(3) ICN "The Emerging Global Nursing Shortage"
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