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Analysis of ENMCA on the European Professional card (EPC) implementation

Analysis of responses to ENMCA questionnaire on the European professional card

  1. In December 2013 the European Network of Medical Competent Authorities (ENMCA) issued a questionnaire to participating competent authorities (reproduced at Annex 1) to feed into the deliberations of the focus group on the European Professional Card (EPC).
  1. The findings have been collated below. For further information please contact: contact@enmca.eu

Overview

  1. A total of 14 competent authorities from 14 EEA countries replied to the questionnaire. A fifteenth responded to say that it was unable to complete the questionnaire until it had received further information on the new procedures that will be detailed in the European Commission secondary legislation.
  1. In general, respondents cautiously welcomed the possible introduction of the EPC for automatic recognition but outlined serious concerns with a number of issues that may impede the ability of competent authorities to safeguard patient safety and to carry out their duties effectively, especially with regards to the recognition of medical qualifications that fall within the general systems regime.

Summary of findings

Bureaucratic burden

  1. Competent authorities in 7 countries highlighted the added bureaucratic burden to competent authorities who would have to run two recognition systems concurrently, comply with tight deadlines and upgrade IT systems. All of which will require increased staffing levels and resources.

Fees

  1. Six respondents raised concerns over the fees that competent authorities would be able to charge for the production of the IMI file and for the verification of documents which, in the case of general systems, is often a lengthy and intricate process. Questions were also raised on how the fees would be divided between the home and host member states. The fees charged currently for recognition and registration vary widely across Europe. One respondent suggested possible fee levels whilst two respondents[1] called for the EPC to be free of charge.

General systems and complex cases

  1. Competent authorities in 11 countries raised serious concerns about the compatibility of the EPC with recognition under the general systems procedure and for complex cases. Many stated that they will be unable to process applications via general systems within the proposed deadlines as these applications often require an in-depth examination of training and experience and the contracting of external experts to evaluate compatibility with the requirements of the host member state. Moreover, in completing the IMI file, the home member state would need to be aware whether the application in question is subject to the general or the automatic recognition procedure and would need detailed knowledge of the requirements for the specific general system in each host member state. Situations are complicated even further if qualifications were obtained in a third country state and for acquired rights cases.

Definition of home member state

  1. Seven respondents highlighted the need for the home member state to be clearly defined. In cases where a doctor has undertaken training and obtained qualifications in a number of countries, it is not immediately clear which competent authority would be responsible for collecting the information and issuing the professional card. An example is the situation in Sweden where many students complete their basic medical training in Poland or Denmark and then complete their compulsory training in Sweden.
  1. One respondent suggested that the home member state should be defined as the most recent country to issue an EPC for the doctor, thus it could change as the doctor moves around Europe.

Online procedures

  1. Not all member states currently offer online applications so will find it challenging to implement the EPC as this will involve an upgrade of current IT systems and a re-organisation of current arrangements. A number of member states also highlighted the increased risks of fraudulent documents when relying on electronic copies (see paragraph 11). One country mentioned that any evidence submitted to their legal system must be in paper format only.
  1. Two respondents mentioned that it should be possible for competent authorities to download and save all relevant data and documents to their own systems in order to safeguard against documentation being lost if a doctor chooses to delete his/her IMI file. This would also be required if an investigation is required about the authenticity of documentation if questions are raised at a later date. In at least one country, information held by the competent authority is sometimes disclosed to the police authorities to assist with criminal investigations.

Tacit authorisation

  1. Five respondents raised concerns about tacit authorisation being incompatible with the protection of patient safety. This is especially true in those countries that have a one-step recognition procedure whereby recognition also grants access to the profession. These countries will need to re-organise their recognition and registration procedures if they are to safeguard patient safety by avoiding tacit authorisation.

Fraud detection and verification of documents

  1. Six respondents voiced worries about the impact of the EPC on existing fraud detection procedures and expressed doubt in the system of trust which is inherent and central to the new EPC procedure. The host competent authority will have to rely on the robustness of fraud and verification checks made in the home member state. This is despite the fact that the host member state maintains responsibility for patient safety on its territory but will lose the ability to effectively monitor the suitability of doctors applying to practise medicine there.
  1. Three respondents gave examples of cases whereby fraudulent documents have been used in order to gain recognition and expressed concerns that home member states which export large numbers of doctors and which will be under an increasing administrative burden of processing large numbers of IMI files, may be unable to verify the high volume of documents they will be processing and maintain high standards in doing so.

Deadlines

  1. Almost all respondents (11 competent authorities) expressed concerns about the new deadlines introduced by the EPC, particularly for general systems and complex cases which often require a large volume of documents to be assessed on a case-by-case basis. For example, contacting employers or foreign competent authorities in order to verify documents before an IMI file can be produced can be very time consuming and home member states will have to rely on the responsiveness of third parties in order to comply with the EPC deadlines.
  1. Host member states will be forced to refuse an application if additional information is not or cannot be provided by the home member state within the deadline in order to avoid the risk of tacit authorisation. This poses a great disadvantage to the applicant. One respondent suggested that it should be possible for the host member state to request missing documents directly from the applicant and to agree on an extended deadline in direct consultation with the applicant.
  1. Another respondent suggested that the possibility of a ‘time out’ option should be built into the process in the case that an applicant is unable to supply the required information within the permitted timeframe and in order to avoid falling foul of the deadlines.

Documentation

  1. Almost all countries made suggestions as to the type of documents that should be required in order for the home member state to create the IMI file. These were mostly the documents that are currently required under the traditional system. The importance of continuing to provide a Certificate of Good Standing was highlighted by eight countries and also the importance of being able to undertake identity checks. These were introduced in a number of countries following incidents of individuals gaining a licence to practise as a doctor after claiming to be or stealing the identity of a medical professional.

Temporary and occasional

  1. Four respondents voiced concerns about the use of the card by applicants applying on a temporary and occasional basis. These stated that before any application for temporary mobility, or for the extension of an existing EPC, a competent authority must examine whether the planned activity really qualifies as temporary and occasional. One respondent stated that undertaking paid work for an unbroken period of 18 months is clearly neither ‘temporary’ nor ‘occasional’, particularly if the doctor then wishes to extend this period. Clarification must be given as to whether the home or host member state would be responsible for making this decision.
  1. Four countries also mentioned that competent authorities must be able to verify the language knowledge of temporary and occasional applicants and must be able to require a Certificate of Good Standing from such applicants.

ENMCA, January 2014

 

Annex 1

 

                                                                       Prepared for the ENMCA Copenhagen meeting

 2 December, 2013

 

 

Questionnaire on the possible implementation of the

European professional card (EPC)

 

The aim of this questionnaire is to collect ENMCA participants’ views on the process and implementation of the EPC should it be adopted for the medical profession. The answers will be used by the coordinators to feed into the European Commission’s (EC) focus group meetings likely to take place in December/January; and to influence discussions and preparations for the EPC’s implementing act.

The legal basis for the EPC is the text as adopted by the Council at its meeting on 15 November 2013 available here: http://register.consilium.europa.eu/pdf/en/13/pe00/pe00057.en13.pdf  (pages 36-55).

This questionnaire is based on article 4 of the revised Directive and the EPC workflow published by the EC and available at Annex A.

Please take the time to read both documents before answering the questions.

We would be grateful if you could take the time to think about the answers to the questionnaire ahead of the ENMCA meeting in Copenhagen as they will form the basis of our discussion on the card.

Following the meeting, we would appreciate written responses to the questionnaire by Friday 6 December. Please send your completed forms to contact@enmca.eu.

Thank you very much in advance for responding to this questionnaire.

ENMCA Coordinators

******

This questionnaire is divided into 4 sections:

I.       IMI file and applications. 6-5

II.      Procedures. 5-6

III.    Disciplinary actions and criminal sanctions. 6

IV.    Any other comments. 6

Preliminary comment

In general, what does your organisation think about the EPC recognition procedure created by the revised Directive? Please outline any challenges and opportunities and whether you would welcome the introduction of recognition with an EPC. 

  1. IMI file and applications
  1. Information: Have you given any thought to how your organisation will inform the applicant about the choice between recognition with the EPC or the existing procedure? If yes, how will you envisage this to work? Do you foresee any difficulties (please outline any implications for staffing, information system, your fraud detection procedures as well as financial implications)?
  1. Applications: Do you currently accept e-applications? Do you foresee any advantages or disadvantages with a recognition system based on e-applications vis-à-vis written applications?
  1. IMI file: According to Article 4a.5 and Article 4b.1, the competent authority (CA) in the home Member State (MS) will be in charge of creating and completing an IMI file after receiving an application from a doctor wishing to move to another MS.
    1. Do you foresee any challenges? If so, please outline them briefly below.
  1. The doctor wishing to move will be provided access to IMI through an individual file but will not be able to modify the file.  What you think about that?
  1. Documents:
    1. Which documents should be required for the creation of the IMI file (see Article 4b.2.)? In responding to this question, please think about both general systems and automatic recognition cases.
  1. Do you foresee any difficulties with the authentication of the EPC and the supporting documents exchanged through IMI? What security features do you think will be required to ensure the information contained on the EPC is accurate?
  1. Issuing the card: Article 4e.7 foresees that employers, customers, patients, public authorities and other interested parties may verify the authenticity and validity of a European Professional Card presented to them by the Card holder. What are your views of this requirement?
  1. Implementation: Article 4a.6 stipulates which CA will be in charge of the IMI file and the issuing of the card. Most of the responsibility lies with the home CA who will be responsible for collecting, verifying and submitting the information to the host CA via IMI. For general systems applications, there are likely to be a large amount of documents to verify. How will you deal with this new requirement?  Please outline below the operational impact this is likely to have for your organisation.
  1. Fees: Recital 6 and Article 4a.8 stipulate that the fee for the EPC shall be reasonable, proportionate and commensurate with the costs incurred by the home and the host MSs and shall not act as a disincentive to apply for an EPC. What do you envisage charging for an EPC?

8. Special scenarios: There are some scenarios which may not be as straightforward to deal with should recognition with a card come into force for doctors. For example, a doctor registered in 2 MSs wishing to move to a 3rd; or a doctor with a basic qualification from country X, and a specialist qualification from country Y, who wishes to move to country Z – it is not immediately clear which competent authority would be responsible for collecting the information and issuing the professional card. Can you think of other scenarios where recognition with a card may create some challenges?

  1. Procedures

As stated in the workflow, there are three different procedures. For temporary mobility (and only for automatic recognition cases), the home MS is in charge of verifying the application and supporting document and issuing the EPC (Article 4c.1). On the contrary, for establishment and for temporary and occasional general system cases, the host MS is responsible for verifying the authenticity and validity of the supporting documents in the IMI file and issues the EPC (Article 4d.1).

  1. Deadlines: Do you foresee any difficulties in complying with the new deadlines for recognition with an EPC?
  1. Temporary mobility: How do you envisage dealing with doctors wishing to continue to provide temporary and occasional services after the 18 months stipulated in Article 4c.3?
  1. Verification of original documents: Should the host MS be able to see the original documents and to complete an identity check before granting recognition? Please explain.
  1. Justified Doubts: The Directive stipulates that competent authorities may request certified documents from the applicant in cases of justified doubts (Articles 4b.3 and 4d.2).
    1. Will this create any difficulties with your existing registration requirements and fraud detection practices? If yes, please outline the reasons below.
  1. Are Articles 4b.3 and 4d.2 compatible with the statement in Recital 4 that the EPC should complement rather than replace any registration requirements associated with access to a particular profession? Please give reasons.
  1. Disciplinary actions and criminal sanctions
  1. Do you think there would be value in including information on the EPC about disciplinary action or criminal sanctions as mentioned in Article 4.e.2? This procedure is also covered under Article 56a on the alert mechanism and already exchanged by some CAs though the Certificate of Current Professional Status. Please explain.

IV.   Conclusion    

  1. Do you have any other suggestions to improve the rules, procedures and working of a card?

 

 



[1] Although one of these respondents  also acknowledged that as they do not offer a full medical education course, they are very rarely classed as a home member state