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ARITAKE-WILD & WILKE, MAACK AND PARTNER

CEEP and ETUC Joint Project

“Anticipation of change in Public Services”

Sectoral Report

Education and Healthcare

Background report for the seminar to be

held at the offices of CEEP in Brussels

on 22nd and 23rd February 2010

Prepared by Anna Kwiatkiewicz February 2010

Project of the European Social Partners with the financial support of the European Commission


CEEP & ETUC “Anticipating change in public services” Education & Healthcare

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Sectoral Report – Education and Healthcare

Background report for the seminar to be held at the offices of

CEEP in Brussels on 22nd and 23rd February 2010

CONTENTS

Section one - Introduction and background

Section two – Education;

• The nature and extent of change and prospects for the future;

• The social impact of change; • The role of the social partners in the

anticipation of change; • Key themes emerging from the report.

Section three – Healthcare;

• The nature and extent of change and prospects for the future;

• The social impact of change; • The role of the social partners in the

anticipation of change; • Key themes emerging from the report

Section four – Reflections and themes for the sectoral seminar



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Sectoral Report – Education and Healthcare

Background report for the seminar to be held at the offices of

CEEP in Brussels on 22nd and 23rd January 2010

Section one - Introduction and background CEEP, working in partnership with ETUC and with the support of the sectoral social partner organisations in education, electricity, healthcare, postal services, public transport, railways and public administration have initiated a project designed to improve expertise in anticipation, preparation and social support during restructuring in public services or sectors of general interest (SGIs). The project is titled “Anticipation of Change in Public Services” and it is the intention of the social partner organisations to focus on this feature of the restructuring process. The project is intended to build on aspects of the previous CEEP project undertaken in 2007 and titled “Public Services Restructuring and Modernisation through effective social dialogue and human resource management”. In this sense the project will take significant steps forward by being “joint” in nature and by seeking to improve the outcomes of social dialogue by deepening the level of debate on the most important issues. The project involves the preparation of four sector specific background reports that will provide the core input for four sector seminars. At the end of the project an overall synthesis report will be produced and subsequently discussed at a European level seminar. At each seminar the sectors participating in the project will be combined in pairs as follows;

Seminar one • Postal services • Electricity

Seminar two • Railways • Public transport

Seminar three • Education • Healthcare

Seminar four

Public administration at the central and municipal level

The purpose of the sectoral seminars is to identity the most important issues in the anticipation and management of change in sectors of general interest (SGIs) and provide a forum where the social partners can discuss these themes in depth. Prior to each meeting, the expert report will be circulated to provide a basis for the discussions at the seminar. The output of each seminar will be the generation of ideas and proposals to improve social dialogue at the European level as it relates to SGI’s which will be captured and presented in the project synthesis report.

This paper is presented as an “expert report”. It represents the views of the individuals involved in its preparation and does not purport to represent the views, either individually or collectively, of CEEP, ETUC or the participating sectoral social partner organisations. Its purpose is to encourage discussion and debate amongst the social partners on the subject of anticipation of change in public services.



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The main body of the report is presented in three sections;

Section one - Introduction and background;

Section two – Education;

• The nature and extent of change and prospects for the future; • The social impact of change; • The role of the social partners in the anticipation of change; • Key themes emerging from the report.

Section three – Healthcare;

• The nature and extent of change and prospects for the future; • The social impact of change; • The role of the social partners in the anticipation of change; • Key themes emerging from the report

Section four - Reflections and themes for the sectoral seminar Each of the sectoral sections of this report will be briefly presented and discussed at the seminar to be held in Brussels on 22nd and 23rd February 2010. Finally, it should be noted that the report will not only serve as a discussion document for the specific sectoral seminar, it will also be made available to a broader audience through the social partner websites. The authors therefore apologise to the specialist sectoral participants at the seminar for providing elements of detail and background that may appear obvious or superfluous to them. The inclusion of this material is essential if cross sectoral comparisons are to be made and the broader information sharing objectives of the project accomplished.



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Section two – Education The nature and extent of change and prospects for the future The education sector is one of the biggest employers in the European Union. According to Eurostat, in 2007 there were 15,052m people working in education, which represents around 7% of the EU’s entire working population1. The disparities between the EU member states are significant. In 2007 in Sweden education staff accounted for 10.8% of the total workforce, while in Romania it was just 4.6%. On average, between 2001 and 2006 European governments spent a sum equivalent to 5.1% of national income on education every year. Expenditure on education in 2006 accounted for 11% of total public expenditure. The majority of the education budget is spent on employment costs. The annual cost per pupil/student increases with the level of education, so that a student in tertiary education may cost up to 5 times more than a pupil in primary education. Figure 1. Annual expenditure in public-sector institutions by pupil/student and educational level (PPS EUR) in thousands, 2006

Source: Eurostat, UNESCO/OECD/EUROSTAT (UOE) and National Accounts (June 2009). Currently national governments attempt to meet two conflicting objectives. The first is to contain public expenditure on education, and the second is to improve the performance of the education sector. In short, they generally want “to do better with less” or “more with the same”. Whilst there is a consensus that reorganisation of the system is the way forward, in some countries the direction taken has been to increase centralisation, in others, increased decentralisation, and in some, a combination of the two. In 2006 in the European countries’ teachers in primary and lower secondary education represented on average 2% of the active population. The countries with the highest proportion of the active population are Lithuania and Malta (3.2%). It has to be noted that these data should be treated with caution as a result of a very different organisation of education systems in the EU (in terms of the length of compulsory education and teachers’ working time). In 2002, the other 5% of

1 The material in this section of the report draws primarily on material from: Eurydice – the information network on education in Europe. Specifically, it uses Eurydice’s reports; Key Data on Education in Europe 2009; Reforms of the teaching profession: a historical survey (1975-2002) / Supplementary report - The teaching profession in Europe: Profile, trends and concerns. General lower secondary education. It also uses Eurydice’s profiles of the education system in individual EU Member States.



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the population engaged in education were managers and administrators, librarians, technicians and support staff etc. This shows that there is a significant proportion on non-teaching staff employed in support functions. An important feature of employment in the education sector is the domination of women in primary and secondary schools. This decreases significantly at higher education levels. In 2006 in all European countries (except for Greece, Luxembourg and Lichtenstein) over 60% of teachers in primary and secondary education (level of ISCED 1, 2 and 3) were women2. At the same time representation of women teachers in the tertiary level education (ISCED 5 and 6) is below 40% in half of the European countries. Only in Latvia and Lithuania do female teachers represent over 50% of the total employment. Such a discrepancy in employment at different education levels between female and male teachers is a feature typical not only for the EU countries, but is a worldwide trend. It was confirmed by the TALIS research, Creating effective teaching and learning environments3 conducted in 2007 and 2008, which showed that female representation in primary and secondary education varies between 80-85% in CEE countries (namely in Bulgaria, Estonia, Lithuania and the Slovak Republic). The TALIS research also referred to the existence of a “glass ceiling” in relation to senior management and promotion opportunities. This trend was observed in most of the countries researched and particularly in Austria, Belgium (Flemish Community), Ireland, Korea, Lithuania, Portugal, and Turkey, where the percentage of female school management staff is over 30% lower than the percentage of female teachers. The majority of teachers are “middle-aged”. In Germany, Italy and Sweden, teachers in primary education tend to be older. The two most strongly represented age groups are 40-49-year-olds and those 50 years old or over. At the same time there are countries with a younger teaching profile. In 12 countries (Austria, Belgium, Bulgaria, Finland, France, Greece, Hungary, Latvia, Lithuania, Poland, Portugal and Slovenia), the teaching population is relatively younger and age groups of 30-39 and 40-49 are the largest cohorts. Younger teachers account for almost 66% of teachers in Hungary and over 72% in Bulgaria, Greece and Slovenia. The youngest primary education teachers can be found in Cyprus and Malta where more than 60% of primary teachers are in the age group of 30 to 49. The only countries with a relatively balanced age distribution are Luxembourg and Romania where each group accounts around a quarter of teachers. In the majority of countries with the exception of Malta, teachers in secondary education are older than those in primary education. According to TALIS research only 15% of teachers are less than 30 years old and very few teachers were under the age of 25. This is strongly influenced by the lengthy process of acquiring necessary professional qualifications. At the same time more than a quarter of teachers are over 50 years old, providing clear evidence of an ageing teacher population. It is worth noting that in countries like Austria and Italy more than 40% of teachers are over 50 years old, while in Estonia and Lithuania some 10% of teachers are aged 60 or over. The general trend is that the higher the level of education, the older teachers are. The teaching profession used to be a prestigious career choice, perceived as a “socially sensitive” profession with a clear mission and responsibility. Teaching was often ranked alongside the role of doctors, lawyers or priests in society. It was also a predictable and stable career often linked with the status of civil servant. For those retaining this status today, employment can often be terminated only under particular circumstances. For teachers, the acquisition or loss of this status is a major contributor to perceived job (in)security. Today, in

2 The proportion of women teachers in some CEE countries is even higher: it reaches the level of 80% in Bulgaria, Estonia, Latvia and Lithuania). 3 In TALIS Research 23 countries participated: Australia, Austria, Belgium (Flemish Community), Brazil, Bulgaria, Denmark, Estonia, Hungary, Iceland, Ireland, Italy, Korea, Lithuania, Malaysia, Malta, Mexico, Norway, Poland, Portugal, Slovak Republic, Slovenia, Spain and Turkey.



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many parts of Europe, teaching is no longer seen as the attractive career it once was. Alongside the growth in intellectual services, graduates have discovered a wider choice of job opportunities when they leave university and teaching today’s youth is no longer an “easy” career option. As a result, teaching has fallen down the league of preferred options. Some of those interviewed in the preparation of this paper believe that the change of the profession’s image has been caused by mass media and “tabloid-like” communication, easy access to alternative sources of information and knowledge (Internet) and the introduction of ICTs and networking tools such as Facebook, which break traditional relations between teachers and pupils based on distance and respect. The education sector in Europe divides into five levels: pre-primary (nursery), primary, general lower secondary, general upper secondary and third-level. Within this broadly recognisable structure, the management of the education systems varies widely across the European Union. Some countries have highly centralised systems, while in others, schools are managed at either a local or regional level. There is also an important split between public and private education, often correlated with a split between secular and religious systems. Another area of diversity is the education system’s connection (or lack of connection) with the labour market and use of the system of internships or similar programmes to equip pupils and students with relevant workplace skills. An example is the dual system of professional education in Germany. On the basis of the desk research and interviews conducted it can be suggested that the sector faces seven basic challenges:

• Reforming the education sector and decentralisation of management; • Growing competition among education providers; • An ageing workforce and challenges linked to work organisation; • Ensuring cohesion of education curricula and labour market skill requirements; • Challenges linked to lifelong learning and adult education; • New teaching methods and use of ICTs; • EU education policy.

i) Reforming the education sector and decentralisation of management Reforms in the education sector mirror the trend toward the more general marketisation of public services observed in many countries. The privatisation of supporting services like cleaning and food service provisions is common. The scale of the introduction of market-type mechanisms into the management of the education system is a particular feature of the Dutch and UK systems. The approach of developing a market economy in the education sector in the Netherlands, the United Kingdom and the Nordic countries contrasts sharply with the strategies adopted in other countries. For example, education in France remains an area of responsibility of central government and reforms have been primarily designed to establish new teacher education institutions. Reforms in the teaching profession have related mainly to teacher training and especially to in-service training. Like the UK, other countries have attempted to combine centralising and decentralising initiatives simultaneously. In Austria, between 1975 and 1988, the structure of education was reformed, the period of initial teacher education was extended for those intending to work in Hauptschulen, and a final ‘on-the- job’ training phase were built into the system, while compulsory in-service training was strengthened. Recent years have seen a number of moves towards decentralisation within the system with the aim of bringing teachers closer to local employers and the authorities responsible for teacher education. In most cases, decentralisation has occurred down to the level of the individual school, and teacher education institutions enjoy considerable autonomy in determining curriculum content and structure. In Denmark, Finland and Sweden, decentralisation has been extended to the local authority level, which may in turn decentralise its responsibilities to schools.



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One of the results of the reforms introduced in the education sector has been the change in the teacher’s employment status that has occurred in many countries. The exceptions to the general trend are the Czech Republic, Estonia, Greece, Cyprus, Austria, Poland, Slovenia, Finland and Romania. Unlike in other areas of the public sector, where moves have been almost exclusively to “private sector style” contracts, moves in education have been in both directions4. Throughout Europe, educational authorities have implemented a wide range of measures designed to bring about changes in teachers pay and working conditions. In most countries, significant changes have taken place in recent years in the management of salary structures. There were two key factors that drove salary structure reforms in the nineties - a strive to make the profession more attractive and tackle the problem of teacher shortages combined with efforts to improve and extend teacher responsibilities. There have also been reforms concerning working time, duties and professional codes. It is important to remember that the teaching occupation relies not only on “face time” in the classroom that can be easily measured, but on un-measurable preparation, personal development and pastoral activities. Despite difficulties of measurement, the general trend is towards growing pressure to control teacher’s working time and teaching is changing from being a “free profession” to a “regulated” one. Fifteen European countries have seen change in teaching time (time spent in class) in recent years. Outside of the classroom, in eleven countries, teachers’ job descriptions have been redefined in recent years to specify clearly the full range of activities required of teachers. In some cases they were precisely defined in terms of required time. In seven countries (Denmark, Italy, Malta, the Netherlands, Austria, Poland and Liechtenstein), new tasks were officially added to the regular work of teachers in general secondary education. Teamwork (as in Denmark, Poland and Liechtenstein), in-service training (Malta, the Netherlands and Austria) and the continuous assessment of pupils (Denmark) are just three examples. Introduction of all these measures has resulted in increased workload and longer working time. The number of teaching hours required weekly by teachers varies widely between countries. In 2006/07, the majority of teachers in Europe had to be actively engaged in teaching pupils between 18 and 20 hours a week, excluding normally planned breaks and any other contact time with pupils not involving teaching. For the majority of the EU countries, the time required to be spent in schools does not to exceed 30 hours, except in Portugal, the UK5 and Iceland, while “overall working time” is suggested to amount to between 35 and 40 hours per week. The increasing autonomy of schools, school heads and parents is worth noting. Autonomy, initially pursued as a basic principle in order to guarantee teaching freedom, to strengthen local school democracy and to complete the process of decentralisation, school autonomy has today, in most countries, become an instrument to achieve primarily educational goals. In other words, more freedom is given to schools and teachers in order to improve the quality of education. Although all countries now view the purpose of school autonomy largely in educational terms, there remain marked differences across Europe in the implementation of the school autonomy process as well as in the extent and nature of autonomy. Differences in the implementation of school autonomy policies also exist with regard to the body or individuals to whom powers are devolved.

4 In the countries such as Denmark, Italy and Latvia teachers are subject to general employment legislation, while in Hungary, Slovenia and Slovakia they moved the other way and became public servants. In Lithuania, teachers became public servants in 1998, and 4 years later this move was reversed. In Italy some teachers are considered as “normal employees” as a result of public service decentralisation, while others are employed by the central educational authority and retain public service status. 5 More precisely: England, Wales and the Northern lreland.



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Figure 2. School autonomy relating to human resources in the public sector compulsory education, 2006/07

ii) Growing competition among education providers While the co-existence of public and private schools has a long tradition in Western Europe, public education sector in Central and Eastern Europe has been characterised by growing competition between public and private schools in the last decade. A recently published report on higher education in Poland showed a significant increase in the number of students attending private institutions6. According to the OECD, the share of students in those institutions has reached 34%7. The increasing number of private higher education institutions is a result of the growing educational aspirations of young people and translates into larger numbers of students. It is worth noting that the position of private schools in the primary and secondary levels differ from that in tertiary level education. Being “richer”, private schools usually have better infrastructure and in general terms, better teachers are attracted by more generous remuneration. Private schools at the primary and secondary level are usually perceived to be of higher quality and there is a serious threat that they attract talented children from more affluent families. By contrast, public schools attract a generally less talented or privileged population resulting in the threat of education institutions polarisation. The situation is different in the case of private universities and tertiary level education institutions. Many new institutions have been created recently, but only very few are of a quality that allows them to compete with their public counterparts. In central and eastern Europe in particular, there is an overlap within the teaching body with many professors and assistant professors teaching in both public and private institutions to supplement income. As this phenomenon has become more

6 Diagnosis of the higher education condition in Poland, Ernst & Young Business Advisory, The Gdansk Institute of Market Economy, November 2009. (http://www.ey.com/Publication/vwLUAssets/Diagnoza_stanu_szkolnictwa_wy%C5%BCszego_w_Polsce/$FILE/Diagnoza_stanu_SW_fin.pdf). 7 OECD, Higher Education to 2030. Vol.1: Demography. Vol.2: Globalisation, 2008.



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widespread, regulations have been introduced to limit the number of schools in which a person can be employed. These “atypical” employment practices and associated workload increases bring the subject of ensuring quality and standards of education in private schools into sharper focus. As a result of the Bologna process (i.e. the separation of B.A., M.A. and Ph.D. level education, introduction of the European Credit Transfer Systems and the promotion of studies abroad and ensuring funds for this) there is increasing competition from foreign universities. A real threat for CEEC universities is the loss of students in favour of foreign universities, whilst attracting foreign students is a substantial challenge linked to education quality and language delivery. iii) An ageing workforce and challenges linked to work organisation Among teachers the predominance of permanent employment contracts means that long professional careers are not a surprise. According to TALIS research almost two thirds of teachers have ten or more years of experience8. The teaching population tends to retire early, often citing stress as a decisive factor. In virtually all European countries, there is an official age of retirement which sets the limit beyond which teachers may no longer work, except in special circumstances. This upper age limit is in most cases 65 years of age. It is 60 in Greece and Poland (in the case of women), and is 64 in Liechtenstein and 67 in Norway (for both sexes in case of both countries). In some countries (mainly in CEECs) the practical age of retirement is lower as teachers may cease their occupational activity and secure a pension early. The “early retirement” option is usually linked to reaching a lower age limit and fulfilling certain conditions, normally the length of employment. Whenever possible, teachers tend to take this option. In countries where longer work results in a higher pension teachers tend to work longer. Examples include Italy, the Netherlands, Austria, Latvia, Lithuania and Slovakia. It is worth noting that the length of time in service required to generate a “full pension” varies from 30 years in Spain, 35 years in Austria and 40 years in Belgium. In Malta and the majority of CEE countries it remains possible for women to retire earlier than men although there are plans either to minimise the difference or abolish it all together. Another feature of the careers in the education sector is that the teaching population tends to work part-time more frequently than other occupations. In some European countries9, between 1998 and 2002 the growth in part-time work was particularly marked. Part-time work was widespread in Belgium, Germany, Latvia, the Netherlands, Sweden, Iceland and Norway, concerning around a quarter or more of teachers at the three levels of education. By contrast, in Italy and Cyprus, fewer than 5% of teaching staff (irrespective of the level concerned) worked part-time. In general, the proportion of teachers who work part-time tends to increase with the level of education but this is not consistently the case. For example in Germany and the Netherlands, the proportion of teachers working part-time is highest in primary education. An important issue relevant to some EU countries (e.g. the UK or the Netherlands), has been the introduction of teaching assistants and the associated segmentation of the teaching role. Whilst the impact of teaching assistant on education quality is a subject of debate, it is clear that they play an important role in facilitating teaching in the ethnically diverse classes.

iv) Ensuring cohesion of education curricula and labour market skill requirements In the context of rapid qualitative and quantitative changes in the labour demand, especially in the more “high tech” and innovation driven sectors, education and training systems need to become more open and relevant to the needs of labour market, society and the general public. They should equip all young people for preparedness for continuous learning in working life and more

8 According to the research 29% teachers worked between 3 and 10 years, 27% worked between 11 and 20 years and over 36% taught for over 20 years. 9 This is true for these countries from which the data was available for 1998 and 2002.



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attention needs to be given to skills and attitudes to work, flexibility, adaptability, motivation, than technical content which becomes obsolete very quickly. This type of education is one of the basic factors to facilitate ongoing employability of workers. One of the main assumptions of the Bologna Process is that education is facilitating gaining initial employment, maintaining people in work and aiding labour market mobility. Coherence between education curricula and current and future labour market demands can be ensured by engaging the diverse interested partners in the education system involving labour market analyses at the regional and local level, ensuring social partner input and a supporting dialogue between employers and education and training institutions on the content of education curricula. This can be observed for example in the German dual system, where theoretical knowledge is combined with the intensive system of apprenticeships in enterprises. It allows the introduction of young people with a theoretical background to the world of enterprises and facilitates the acquisition of practical skills at an early stage. The dual system guarantees companies an influence on the content and organisation of education system and the graduates’ competence of labour market entrants. This kind of “constant dialogue” between the world of education and the labour market is not however typical for all member states and a specific feature of particular countries including Germany, Austria and Denmark. v) Challenges linked to lifelong learning and adult education Europe faces challenges that require a fundamental change in the perception of the role of education. The economic development of the BRIC countries (Brazil, Russia, India and China)10 is based on the production of labour-intensive goods and Europe must strengthen its position as a knowledge-based economy in order to face the competition. To compete successfully in a knowledge-based economy with a world dominated by new technologies, it is crucial to develop and update skills continuously as well as to acquire new ones. Continuing development is the basic assumption of the lifelong learning concept. In the context of an ageing population, large migration flows and increasing global competition, the idea of lifelong learning faces the challenges of transferability of skills, tackling diversity and dealing with skill deficits. The future workforce of Europe will be recruited increasingly from an older population, which in turn raises the need for improved ongoing training and learning systems. The performance of this older workforce will define to a large extent economic growth in Europe. Older workers are less inclined to training and generally less educated than young people11. As a result, there is a need to find efficient ways of encouraging them to take part in further training as well as to adapt curricula and methods of teaching to their abilities and learning preferences. In the context of changing labour markets and the constant need to adapt to new developments in technology and working methods, the acquisition of transferable skills have become increasingly valuable in the workforce12. The value of specific or technical skills reduces as they become obsolete increasingly rapidly and the value of narrow vocational qualifications is diminishing in the light of technological innovation. Transferable skills are not tied to any particular firm, sector or work process, but they are applicable to a wide range of professional situations and they generally line up with a set of key competences indicated in the European Framework for Key

10 Projections made by OECD indicate that, within the next 40-50 years, the overall GDP of the BRICs could exceed those of the largest EU countries, US and Japan (see: OECD Employment Outlook, OECD, Paris 2007). 11 This problem is the most evident in Southern Europe, where 60% of people aged 35-54 – which will be aged 48-67 in 2020 – has attained at least upper secondary education in Spain, Portugal, Greece and Ireland (see: The Future of European Education and Training Systems: Key Challenges and Their Implications, Analytical Report for the European Commission prepared by the European Expert Network on Economics of Education (EENEE), 2008, p. 5). 12 It is worth noting that according to the recent works of the CEDEFOP (preliminary findings were published at the CEDEFOP website on February, 4, 2010) the skills required on the market are rather a combination of transversal skills with job specific ones, so there may be again a paradigm shift from the idea of equipping workers with broad skills to the idea of equipping them with a mix of the broad and specific ones.



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Competences for Lifelong Learning13. It is crucial to ensure that education and training systems equip people in this skillset. vi) New teaching methods and use of ITCs New technologies are changing ways of teaching and learning fundamentally. New teaching methods, such as module, blended and distance learning have appeared, widening access to education on the one hand (i.e. via e-learning), but creating new challenges on the other (i.e. developing appropriate teaching materials). They also contribute to the fact that knowledge is increasingly produced outside universities and transmitted outside formal education systems. Teachers and trainers not only have to gain new skills related to the use of ICTs, but have to constantly update them as the technologies change. For example e-learning is no longer today’s hot topic in the training industry and a new revolution is forecast by the introduction of mobile-learning (m-learning) resulting from the widespread access to the internet in mobile devices. Younger and adult learners alike will demand a different, more flexible and learner-centred type of education in the future, making learners active participants or “co-producers”. The challenge for teachers is to provide education and training courses in new ways, using interactive methods and new tools. Keeping in touch with new technologies results in the need to invest greatly in education infrastructure, ensuring access to ICTs for all. ICTs influence the workload for teachers at all levels of education system. The wide-spread use of ICTs and changed working and family life patterns often result in a situation while e-mail or SMS are major communication tools for teachers, pupils and parents. Teachers are increasingly expected to be accessible almost 24/7 to answer parents’ questions immediately. The issue of managing parents’ and students’ expectations impacts on “out of class” working time and the work-life balance of the teaching community. vii) EU education policy14 As the education field has been largely left to the discretion of national government, there is no overarching European driver of change in the education sector and there are no European Union liberalisation or deregulation Directives impacting on the sector. However, EU policy triggers some processes that require adaptation of education institutions’ management systems, human resource management and teaching curricula. This “bottom-up” approach to change encourages programmes and initiatives that result in a positive outcome at the Community level. Cooperation in the area of education started as late as in 1976 and its result was the first community plan on education, in which six priorities for actions were defined. Soon, Community actions started with pilot projects, study visits and exchanges of information. Cooperation was difficult in the early years due to the lack of a legal basis for action at the Community level and limited resources. The next step in the development of cooperation in the education field at the EU level was a great number of programmes such as COMETT, ERASMUS, PETRA or FORCE that appeared in the 1980s. Co-operation accelerated with the implementation of these programs, with budgets far larger than those for the first action program15.

13 OJ L 394, 30.12.2006, p.10. The key competences (9) are the following: communication in the mother tongue, communication in foreign languages, mathematical competence and basic competences in science and technology, digital competence, learning to learn, social and civic competences, sense of initiative and entrepreneurship, cultural awareness and expression. 14 Based on: The European Higher Education Area booklet, http://www.ond.vlaanderen.be/hogeronderwijs/bologna/documents/Bologna_leaflet_web.pdf, In the finishing straight: From Copenhagen to Bordeaux, CEDEFOP, http://www.cedefop.europa.eu/etv/Upload/Information_resources/Bookshop/515/8027_en.pdf as well as the European Commission, DG Education & Training website: http://ec.europa.eu/education/index_en.htm; the official Bologna Process website 2007-2010, http://www.ond.vlaanderen.be/hogeronderwijs/bologna/ 15 Between 1990 and 1994 funding for all the programmes accounted for €1bn, compared with 10 years earlier, when €14m had been earmarked for the first action programme implemented between 1980 and 1984.



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Further EU integration and the adoption of the Maastricht Treaty in 1992 provided grounds for strengthening cooperation in the education field. Education started to be perceived as an increasingly important sector, especially as a result of globalization and the development of the information society. At present, education is seen as an integral part of a knowledge-based economy, and lifelong learning as the basis for employability of workers. The following developments of in EU level cooperation in the education field can be noted;

• The launch of the Bologna process in 1993 with a view to creating convergence between national higher education systems and the creation of the European Higher Education Area by 2010 to facilitate mobility of students and academic staff;

• The Lisbon Strategy in 2000 and its revision in 2005 made education and continuing learning and training areas of key importance to the EU;

• The Copenhagen process in 2002 sought to enhance cooperation in vocational education and training across Europe to ensure transferability, transparency and mobility in the field of education;

• The popularisation of the lifelong learning concept as vital for innovation, competitiveness and sustainable development;

• The adopting of the “Education and Training 2010 Work Programme” and definition of five overriding benchmarks for education to be reached by 2010;

• Adopting “Education and Training 2020” in May 2009, which is a new strategic framework for co-operation between EU and members states to reform their own education and training systems; to monitor the reform six overriding objectives were defined, which are to accompanied by five benchmarks and indicators.

One of the important goals of the Bologna process was ensuring transparent and comparable university degrees. In order to realise this goal the Bologna process has brought significant changes to the structure of higher education implying that the education process is structured along three cycles (B.A. M.A. and Ph.D.). This affected both study cycles in national systems but also curricula (i.e. the creation of a national qualifications framework). Another achievement of the Bologna process was the establishment of joint degrees, which stimulated student and staff mobility. This is greatly facilitated by the European Credit Transfer and Accumulation System (ECTS) and the Diploma Supplement. The Copenhagen process is the process supporting implementation of the Lisbon strategy and focused on strengthening vocational education and training (VET). The core of the Copenhagen process was the development on common European frameworks and tools such as European Qualifications Framework (EQF) or Europass. The social impact of change The main social impact of change in the education sector relates to factors associated with the positioning of the teachers’ profession, job security, growing demands on teachers’ education levels and competences, the changing nature of employment contracts and shortages of teaching staff. As a result, the overall social effects of change can be examined under four sub- headings:

• The profession’s image and job security; • Challenges linked to the remuneration system; • Ageing and the shortage of teachers; • The emergence of new skills requirements.



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i) The profession’s image and job security Teaching has been viewed traditionally as offering a stable career with strong job security. However, in a number of countries concerns have appeared relating to a decline in security, associated with an increase in contract-based employment, particularly of a short-term nature and the negative impact of higher teacher turnover16. In Belgium, Germany, Latvia, the Netherlands, Sweden, Iceland and Norway short-term contracts concern around a quarter of teachers at the three levels of education. Another issue related to the overall security is the challenge the profession faces associated with psychosocial hazards such as work-related stress (which is above the average for other industries, services and society in general) and is often linked to violence, bullying (mobbing), harassment, and unacceptable student behaviour17. According to the ETUCE survey, few countries include work-related stress and other psychosocial hazards in Health and Safety provisions for the education sector. The Nordic countries tend to be more advanced in this area and teaching unions in other countries are working towards the integration and acknowledgment of work-related stress in their national health and safety legislation for the education sector18. ii) Challenges linked to the remuneration system Teacher’s salaries are usually fixed with reference to a salary scale generally determined at national level and pay ranges are generally compressed. Maximum and minimum levels generally differ by less than a factor of two, based on the number of years of service, additional qualifications and merit, etc. According to the OECD data in 2006, the statutory salaries of teachers with 15 years of experience were, on average across the OECD countries, 35% higher than starting salaries for lower secondary teachers19. This fact, together with the incidence and impact of salary increases, may explain why teaching may be more attractive at some stages of a career than at others. The absolute level of pay and the impact of pay compression appear to limit the interest in pursuit of the teaching profession among young graduates, who would like to see salary increase earlier in their careers. As a result, those who work in the education sector can be generally classified into two categories - they are either “enthusiasts” or a “negative-selection” cases who become teachers as they cannot not find a preferred job elsewhere. In this context the issue of competition between private and public education arises, as private schools are usually able to offer better conditions for their employees. It is suggested that feminisation of primary and secondary education depresses pay levels for the whole profession. Currently, in most countries teachers’ pay increases mainly with length of service and modernisation of the remuneration system with closer linkages to performance and activity is an important challenge. iii) Ageing and the shortage of teachers Some European countries face shortage of teachers in the years immediately ahead as substantial numbers will reach the retirement age (often early retirement age) within a relatively short time. This trend can be already be observed in the Netherlands and according the Eurydice data20, only in Cyprus and Malta are teachers evenly represented across different age groups. Germany and Italy will experience teacher retirement on a very large scale in the near future with almost 70% of teachers scheduled to retire within the next 20 years. The negative impact of 16 Creating effective teaching and learning environments. First results from TALIS, OECD, 2009, p. 29. 17 European Agency for Safety and Health at Work, E-fact 31, Prevention of work-related stress in the education sector, 2008 (see: http://osha.europa.eu/en/publications/e-facts/efact31). 18 ETUCE second interim report on the project “teacher’s work related stress: implementing the ETUCE Action Plan and the European Autonomous Agreement on Work Related Stress”, ETUCE, 2009, p. 16, available at: http://etuce.homestead.com/publications2009/06.2009_II_ETUCE_report_WRS_EN.pdf. 19 Creating effective..., op.cit., p. 28. 20 Eurydice, Key data on education 2009, p.187.



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teachers’ shortages will be reduced by demographic changes, but in coming years, these concern only pre-school and early school teachers and this is more than offset by the increase of demand for adult education. These trends create a serious challenge for the recruitment of new teachers, and their retention in the profession. There are a number of new initiatives in place such as “Teach First” in the Netherlands where talented students are encouraged to teach for a year before looking for a job in other sectors of the economy. Students are also encouraged to undertake some teaching activity during their studies. Attracting people to the sector and competing for good people with other sectors of the economy is, and will continue to be, a serious challenge. Another important issue linked to hiring staff is attracting more men and making the profession more gender-balanced, especially at the primary and secondary school level. There is also an urgent need to recruit a more ethically diversified teaching population better able to cope with the growing diversity of pupils/students. iv) The emergence of new skills requirements Education, as most employment sectors, faces increased demand for higher education levels of staff. There is a general tendency to ensure that all teachers have a postgraduate degree and can further develop during their professional career. Additionally teachers need to possess new skills and competences. During interviews, education sector experts indicated the need for such competences as:

• ICT skills – teaching and using;

• Competence-based teaching and promoting a problem solving approach to teaching require different skills;

• Interpersonal skills and aptitudes;

• Intercultural sensitivity and ability to effectively manage diversity;

• Cross-border education and training;

• Customer-and client orientation;

• Ongoing learning, skill and qualification upgrading. The role of the social partners in the anticipation of change21 At present there is no formal EU-level sectoral social dialogue committee in the education sector. Whilst the teachers' unions and other representative organisations have very substantial membership it is difficult to identify the “employers” in the sector. In the education sector employer status is held by several players: the national public authorities in charge of education, regional and local authorities, local management bodies ("education councils", "organising entity", etc.) and headmasters. Each of these players can, under different circumstances, carry out the tasks of an employer and be responsible for pedagogical programming, recruiting staff, drafting and signing work contracts, defining remuneration, executing sanctions etc. This wide variety of employer representatives makes the creation of an overall, European-level employers’ representative body difficult. A peculiarity of employee representation in the education sector is that it almost entirely concerns the teaching profession. This is important as teachers represent only around one third of those employed in the sector. At the EU-level the European Trade Union Committee for Education (ETUCE) gathers 118 teachers' unions from the 28 EU and EFTA countries. It was created in 1975 and is composed of national organisations of teachers and other education sector staff. The

21 Based on the material available at http://edudialogue.homestead.com; http://www.eurofound.europa.eu/eiro/ and from publications of the European Trade Union Committee for Education (ETUCE).



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ETUCE is recognised as the Industry Federation for Education and Training of the ETUC and is, as such, the representative voice of the teachers' unions in relation to the European Union22 and has the following objectives:

• Promoting the interest of organisations of teachers and education employees and of the education sector within the EEA through consultation with all relevant EU and EFTA institutions and through other trade union actions;

• Promoting the social dimension of the EEA in association with the European Trade Union Confederation (ETUC);

• Promoting assistance programmes by serving as the liaison between the European institutions and the Committee's member organisations with regard to national and European programmes sponsored by the EU institutions.

ETUCE believes that the “education sector is well placed on the agendas of political discussions conducted at European level, particularly since the launch of the Lisbon strategy and of its European programme concerning education - “Education and Training 2020”. These policies concern all the players in the sector and have an impact on the evolution of national education systems. The main achievements of ETUCE activity in years 2003-2009 were the following23;

• Initiating and carrying on social dialogue on education;

• Engaging in the activities related to health and safety at work;

• Promoting equality in education;

• Analysing ICTs use in education;

• Assisting in creating the education sector employer organization – the European Federation of Education Employers (EFEE)24.

In the area of social dialogue, ETUCE initiated a European level dialogue with the European Centre of Employers and Enterprises providing Public Services (CEEP) and Council of European Municipalities and Regions (CEMR). They organised a series of social dialogue conferences, regional seminars and debates for joint discussions on the prospects for a future sectoral social dialogue committee at EU level, in which representatives of CEEP and CEMR took part. In addition to this ETUCE organised training seminars for its members from the New Member States. Another important contribution to the social dialogue was the preparation and conduct of two surveys among ETUCE member organisations on the state of social dialogue in education, which resulted in two reports on the formal aspects social dialogue (collective bargaining systems, the agenda of negotiations and social dialogue practices) and on mapping the employers in all levels of education in the EU and outside (share of public vs. private employers) as well as on possible obstacles for employers to assume the mandate to enter into collective bargaining. ETUCE has completed EU level projects aiming at training teacher trade unions in social dialogue and the Lisbon process, discussing guidelines for national strategies in these fields, as well as involving employers' organisations together with ETUCE member organisations in establishing a sectoral Social Dialogue in education. In the context of the global financial and economic crisis ETUCE launched project to measure its impact on industrial relations in the education sector in the EU-27 countries. Other activities of ETUCE, related to health and safety at work and promoting equality in education.

22 Information based on the information from ETUCE website (http://csee-etuce.org/) 23 Ibidem. 24 More on the European Federation of Education Employers (EFEE) - see the paragraph below.



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In December 2005 ETUCE adopted an “Action Plan on Strengthening Social Dialogue in Education”. The plan represents a political agreement between ETUCE members on working towards establishing a sectoral dialogue, and sets out concrete steps to be taken, not only at the EU level, but also to strengthen the social dialogue in the education sector at the national level. A tangible result of ETUCE’s activity in these areas was its engagement in setting up the European Federation of Employers in Education (EFEE) that started to be operational in February 2009. EFEE gathers 15 countries out of the EU-27 and aims at working for ensuring quality in education, dealing with challenges posed by demographic change and engaging in implementing the “Education and Training 2020” initiative. EFEE also engages in the issue of creating the most “healthy” links between education and labour market to ensure that the education system provides pupils/students with qualifications needed by labour market, but at the same time fulfils a more general role of preparing people to functioning in the society and enjoying its rights as aware citizens and cultivated individuals. Following the establishment of EFEE, the creation of a sectoral social dialogue committee has become possible and this is slated for March 2010. Independent of it, the voice of education sector is substantial at the EU-level and this is regarded by the social partners as a major success. ETUCE and EFEE have already managed to publish their first joint statement concerning the consequences of the financial crisis for the education sector and the two organisations jointly protested against cutting spending on education. Both partners believe that using education as an easy area to cut spending is very dangerous given the high level of education and professional skills that are the basis for the modern EU economy. Despite the fact that the two organisations are forward looking and sensitive to future challenges and its consequences, there is no formal body that has the responsibility of anticipating change in the education sector. Nonetheless, ETUCE has analysed ICT use in education and taken steps to disseminate good practices and initiated the European eLearning Forum for Education (ELFE). An interesting national initiative is the Norwegian partnership of multi-stakeholders (the Ministry, employers, trade unions, universities and student representatives) to create a platform on trends and the future of education. It was driven by the Ministry as the founding force, but later the responsibility for its development and functioning was embraced by all the partner organisations. Key themes emerging from the report The purpose of this section of the report is to suggest areas that might be discussed jointly at the national seminar where a limited number of the most important themes can be addressed in more depth. In the final “post seminar” report, this section will be replaced by a longer segment dealing with the content and outcomes of discussions. The themes are offered on the basis of the desk research undertaken and interviews carried out during the research phase of this project and are all referred to in the preceding text. At the sectoral seminar it will be for the participants to select from the list below, or add new topics or themes. We will have the time to discuss the exact question to be addressed under each heading.

What progress can be made in the education sector European social dialogue – particularly in the area of

anticipating change and dealing with it?

Can specific initiatives be undertaken with a view to preparing social partners jointly for anticipating change

and identifying an agenda?



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What can be done together to contribute to the European Commission initiative skills and jobs

for 2020.

How can the social partners at he European level deal with representation of those with employment

responsibilities and the education community outside if teachers? What are the opportunities and constraints

in this area?

Given the central nature of education and lifelong learning to Europe’s future, how can the European level education dialogue engage with the broader

social dialogue?

Anticipating change in the aftermath of the economic and financial crisis.



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Section two – Healthcare The nature and extent of change and prospects for the future25 Health care is one of the most important sectors in any economy and is generally one of the largest employers in developed countries. The output of the healthcare sector accounts for about 7% of GDP in the EU-15, larger than the roughly 5% accounted for by the financial services sector or retail trade sector. Trends in productivity and efficiency in healthcare have a large impact on the competitive performance of the European economy as a whole, via their effect on labour costs, labour market flexibility and the allocation of resources at the macroeconomic level. The final output of this sector – ensuring a healthy population – has a crucial impact on the productive capacity of the economy and quality of life. One of the three key determinants of the UNDP quality of life indices26 is the length and quality of life. In a very real sense the functioning of the health sector has a direct and important impact upon the broad standard of living of Europe’s citizens. With more than six million workers, health and welfare constitute one of the most significant sectors of the economy in the EU. According to the Eurostat, the share of persons employed in the health and social sector represented 8.8 % of all people employed in the EU-15 and 9.3 % of all those employed in the EU-25 in the second quarter of 200327. Health care is extremely labour-intensive, perhaps more than any other public sector activity. In Central and Eastern Europe the health sector has an even greater role in employment due to the relative underinvestment in capital, resulting in a more labour-intensive model of service delivery28. Approximately 70% of health budgets are allocated to salaries and other charges related directly to employment. As a result, any cuts in healthcare budgets will almost always influence the situation of employees. Health care employment tends to be female-dominated – women account for 77% of the health care workforce in Europe. The share of women differs significantly among health care occupations – while the nursing profession is strongly feminised, the share of women in physicians is much lower (41.5 % in 2006)29. However, gender balance at higher levels is becoming more favourable for female workers. Recently more female doctors have been employed in traditionally male dominated health care roles. The proportion of female physicians rose steadily during the 1990s to a level of 36.6 % in 1998. Females dominate employment in the New Member States and Finland, where they account for over 60% of physicians. It should be noted, that the biggest increase in female physicians is observed among younger workers. Last, healthcare is subject to a high degree of government intervention. Governments intervene both directly, through provision and funding, and indirectly, through regulation. Moreover, they have to balance the often conflicting goals of equity and efficiency of healthcare provision. On the basis of the desk research and available materials it can be stated that the healthcare sector faces six basic challenges:

• Conflicting paradigms – equity versus efficiency; • Ageing society and demand for new services; • Ageing workforce and migration of staff; • Technological progress;

25 This part is greatly based on the report: Public services restructuring and modernisation through effective social dialogue and human resource management, ARITAKE-WILD, 2007, pp. 25-43. 26 United National Development Projects Development Index 27 Data 2003, based on the report: The Contribution of health to the economy in the European Union, European Commission, 2005, p. 68 (see: http://ec.europa.eu/health/ph_overview/Documents/health_economy_en.pdf) 28 The Contribution of health to the economy in the European Union, European Commission 2005. 29 Eurostat data, Population and social conditions/Health/Public Health (December 2009).



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• Globalisation and service provision liberalisation;

i) Conflicting paradigms – equity versus efficiency Potential conflict between equity and efficiency makes shaping and managing the national healthcare agenda a highly sensitive issue and it often influences the result of the elections. Moreover, political considerations are fundamental to understanding both the development of systems of provision and attempts to reform them. It is therefore useful to place the development of the health care system in an historical context. The development of the sector can be divided into a number of stages. In most cases, access to the majority of medical care was accessible for all citizens. However, together with the medical progress (new technology, new medicaments – i.e. antibiotics, etc), which enabled more efficient medical treatment and contributed to awareness rising among patients on the benefits of medical interventions, the overall costs of medical care systems have risen significantly. These factors have led to increasing tensions between equity and efficiency goals. Governments’ commitment to complete equality of access have been limited by the rapid increase in medical care system expenditures. As a consequence, many countries have placed regulations on costs, reduced provider fees and ration access. This in turn has resulted in an increase in waiting time and dissatisfaction of consumers. In responding to the problem a number of countries oriented the medical care system towards the market, moving away from public solutions. However, this has led to reduced equity, as the poor have limited access to private services. These tensions will probably continue to increase in the future and manifest themselves in different ways. For example, there are barriers for more affluent patients to a full transition from public into private medical care as some of the medical equipments or surgeries cannot be afforded by commercial operators and public healthcare provides the best alternative. At the same time, private clinics are serious competitors in providing routine checkups and interventions. ii) Ageing society and demand for new services Demographic trends pose one of the most fundamental challenges to healthcare sector. According to the EUROPOP2008 projections the EU27 population will be rising gradually from 495.4 million in 2008, reaching 520.7 million in 2035 and thereafter gradually declining to reach 505.7 million on 1st January 2060. It is also projected to become older: the media age is to rise from 40.4 years in 2008 to 47.9 years in 2060. The share of people aged 65 years or over in the total population is projected to increase from 17.1% to 30.0% and the number is projected to rise from 84.6 million in 2008 to 151.5 million in 2060. Similarly, the number of people aged 80 years or over is projected to almost triple from 21.8 million in 2008 to 61.4 million in 2060. Table 1. Projections for 2020

Name of the category 2020 Total population on 1st January (in thousands) 513 837.6 Population aged between 0 and 14 years old ( in thousands) 78 898.1 Population aged between 15 and 64 years old (in thousands) 331 887.3 Population aged between 65 years old or over (in thousands) 103 052.2 Population aged between 80 years old or over (in thousands) 29 281.1 Young age dependency ratio (%) 23.77 Old age dependency ratio (%) 31.05 Total age dependency ratio 54.82 Share of the total population aged 65 years or over (%) 20.06 Share of the total population aged 80 years or over (%) 5.70 Source: Eurostat, EUROPOP 2008 convergence scenario; K. Giamakouris, Population and social conditions, „Eurostat. Statistics in focus” nr 72/2008.



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Graph 1. Projected total population change over the projection period 2008-2060 (2008=100) for the EU Member States, Norway and Switzerland

Source: Eurostat, EUROPOP2008 convergence scenarios. The longevity of the worlds’ population is increasing and is one of the factors that contribute towards Europe’s ageing population profile. This indicator has gradually risen for males and females in Europe and the trend is expected to continue. In 2004 life expectancy of a boy at birth in the EU-27 was 75.2 years, while the life expectancy of a newborn girl was just over six years higher at 81.5 years. In 2008 it was respectively 76.1 and 82.1 years30. This is a result of the increase in the quality of life, resulting in part from better and more sophisticated medical treatment. At the same time increased longevity creates considerable pressures on health systems as more people require more treatment and the nature of the required treatment changes. Although generally the population is healthier, an increase in complexity of health problems is observed with age. More people suffer from multiple chronic conditions and more people need assistance in the case of limited mobility or ‘paramedical’ assistance, i.e. mental stimulation and physical activisation. In general terms more prevention measures are needed. Finally, demand for medical and paramedical treatment increases with the access to information and the average level of health-related knowledge. Patients today are better informed, are aware of new treatments potentially available to them, and want to have a say or even participate in choosing them.

iii) Ageing workforce supply and migrating staff Demographic change and greater longevity causes a “greying” of the healthcare workforce, especially nurses. Countries such as Denmark, Iceland, Norway, Sweden and France are witnessing this phenomenon where the average age of employed nurses is 41–45 years. In the United Kingdom, one in five nurses are aged 50 or older and nearly half are over 4031. A major concern is the decline in the number of younger nurses. In the United Kingdom between 1988 and 1998 the proportion of nurses aged under 30 fell from 30% to 15%32. Similar trends can be observed in the medical profession. In 1998 more physicians were under 44 years old compared with those aged over 45 - 53.8% vs. 46.2%. The numbers had reversed by 2006 with 40.8% of physicians under 44 years old, compared to 59.2% over 45. The greatest

30 European Commission, The 2009 Ageing Report: p. 22, (available at http://ec.europa.eu/economy_finance/publications/publication13782_en.pdf). 31 J. Buchan, The 'greying' of the United Kingdom nursing workforce: implications for employment policy and practice. Journal of Advanced Nursing, No 30(4), 1999; B. Finlayson, J. Dixon, S. Meadows, G. Blair, Mind the gap: policy response to the NHS nursing shortage, British Medical Journal, No 325, 2000. 32 United Kingdom Central Council for Nursing Midwifery and Health Visiting, Annual Report. London, UKMCC, 1998.



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number of those over 45 can be found in France (70.2%), Latvia (68.2%), Lithuania (67.2%) and Italy (66.7%). In the United Kingdom (65%), Ireland (57.8%) and Romania (53.2%) physicians aged under 44 prevail. These figures are generally in line with the trend to a lengthening of the working age of the entire population. Although EU policy (Lisbon Strategy) is oriented on active ageing and limiting early exit from the labour force, there still remain challenges to reach the desired rate of older workers’ employment. In 2008 the rate was only 45.6 % in the 27 Member States (47.4% for EU-15) and this figure is substantially lower in, for example, Belgium, Luxembourg, France, Malta, because of advantageous early-retirement schemes. In the healthcare sector early retirement has been very popular however, recently the number of physicians aged 65 or older is growing slowly in the majority of EU-27 countries. Migration can be an answer to workforce shortages caused by ageing employees. During the ten years through to 2007, net migration was the main driver of population change in the EU-27. Population growth across the EU-27 of 2.4 million persons in 2007 comprised a positive net migration of 1.9 million persons compared to natural population increase of 0.5 million persons. In some countries, especially form New Member States (Poland, Lithuania, Bulgaria and Latvia) net migration was negative. The migration of health workers has been particularly important to “gaining” and "losing” countries. Some authors argue that migration plays a more important role since new member states joined the EU, as international recruitment of health workers has become a ‘solution’ to the health professional skill shortages33. Due to the fact that training takes a long time, it is easier and to hire people and in such a way to increase the speed of supply and to decrease training time and costs. Migrating staff is, in turn, attracted by better paid jobs and, more opportunities to develop their skills and to assure an improved quality of life in general. In addition, the number of graduating doctors has declined over the period 1985 to 200534. This decline in graduation makes the inflow of foreign workers even more important to meet the demand needs. iv) Technological progress Technological innovation influences strongly the European healthcare sector, determining the types of services that health workers can perform, the settings in which they deliver them and their practice structures. Technology has broadened the scope of diagnosis (diagnostic services are becoming more international, especially in markets where privatisation is more widespread), treatable illnesses, shifted focus from care to prevention and altered the range and nature of healthcare provision, resulting in change of workforce demand. For example there is an increased need for occupations related to biotechnology or genomics and a reduced requirement for clerical staff. At the same time new opportunities for information and computer professionals has appeared. New information technology (e-health) has made mobility of professional knowledge higher. Another issue related to technological change in healthcare is a predicted increase in specialisation in those areas where more sophisticated technology has been introduced, such as surgery or transplantation. It is possible to take certain equipment away from hospitals, enabling provision of some services closer to patients. Finally, the technology is changing patients – they are becoming increasingly well informed about their diseases, whether through popular self-help guides or the Internet35. This has increased patients’ expectations from healthcare staff and means that they see themselves as partners in, rather than subjects of, treatment. 33 J. Buchan, Health worker migration in Europe: assessing the policy options, Eurohealth 13, 2007, pp. 6-8. 34 Investing in the Future of Jobs and Skills. Scenarios, implications and options in anticipation of future skills and knowledge needs Sector Report Health and Social Services, DG EMPL project VC/2007/0866, 2009, p. 31 (see: http://ec.europa.eu/social/main.jsp?langId=pl&catId=89&newsId=583&furtherNews=yes) 35 In the EU in 2002, the number of households with internet access was reported at 40%, with the number of web users estimated at around 150 million, similar to the United States and compared to a total of 404 million users worldwide. There is also increasing usage in central and eastern Europe with an estimated rise to 27% by 2006.



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v) Globalisation and service provision liberalisation Globalisation and service provision liberalisation are having a substantial impact on health sector workers, affecting education and licensing, as well as the distribution, working practices and organisation of health professions. Many of the key issues facing the future health care workforce will have a global dimension that must be taken into consideration by policy-makers at both the national and international levels. One of the issues related to globalisation is increased international movement of health professionals, facilitated by development of common educational standards, harmonisation or mutual recognition of qualifications as well as liberalisation processes. In addition, technology has changed forms of learning and teaching, resulting in greater access to initial and continuous education of health professionals. Globalisation has also contributed to the introduction of major reforms in the healthcare sector through the need to create efficient and competitive systems. Although health care is organised on national scale, international competition plays an increasingly important role resulting in changes in the healthcare system. Firstly, more patients use facilities in other countries due to the shortages existing in their home countries or due to better quality of certain services provided abroad (example being “patient commuting” between Denmark and Germany). Cross-border care is increasingly popular. Secondly, globalization facilitates the offshoring of occupation previously tied to specific locations. Globalisation is shaping new forms of regulation of health professionals. There is an increasing move towards the organisation of professional bodies at supra-national levels, replacing self-regulation at the national levels. In 1999, the public health article was amended and a role for the EU was defined in complementing national policies. Latest developments relate to patients’ rights in cross-border health care as these services become increasingly popular with patients. In 2006 1% of total health care expenditure was spent on cross border care, compared to 0.3% in 1993 and this share is expected to increase and further stimulate international competition36. A new health strategy for 2008-2013 aims to provide, for the first time, an overarching strategic framework spanning core issues in health as well as health in all policies and global health issues. Despite internationalisation trends, service provision barriers still exist in the sector37. There is no free entry for companies, specialists, care institutions and hospitals in some countries, due to legal, economic and qualitative barriers. Entry processes are often regulated and lengthy. Many countries minimise budgets to keep healthcare expenditure under control, which in turn, extends waiting time for treatment. Flexible and quick reactions to changes in demand are sometimes obstructed due to the regulations relating to the training of new practitioners. In response to these challenges, EU countries are continually reorganizing their healthcare systems.

The social impact of change The main social impact of change in the healthcare sector is characterised by the processes of ageing of both the general population and workforce, the introduction of new technology, organisational reforms in the sector at the national level and the influence of Europe. These factors result in changes in the healthcare workforce composition, new skills requirements, new work organisation and the changed nature of employment relations towards more flexible internal and external arrangements. The main social effects of change can be examined under four sub- headings:

• The emergence of new skills requirements; 36 Investing in the Future of Jobs… , op.cit., p. 31. 37 Ibidem, p. 33.



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• Changing nature of jobs and new work organisation; • Ageing workforce and staff shortages; • Managing outsourcing and sub-contracting.

i) The emergence of new skills requirements

Demographic changes, technological progress, modern work organisation and increased competition result in an urgent need for training and the acquisition of new skills by healthcare sector employees. Increasing longevity of the population has significant implications for the health care workforce and its skills. New requirements are strongly related to certain professions, such as those, who work on the interface between health and social care, as older people generally need to have more assistance at a time when traditional family support structures are weakening. This is also the case of changed life-style of the population resulting in an increased demand for care provided by people other than close family members on a commercial basis. The demand for health-care professions like home-care workers, nurses, community health nurses and physiotherapists is increasing38. This shift in the nature of required services results in changed demand for skills and a need for qualifications corresponding to the increased cure and care of older people together with social and activisation techniques. It is probable that women will take the needed positions on the interface between health and social care, as female labour force participation increases over time. In European OECD countries the number of women aged 15–64 years in the labour force increased on average from 55% in 1990 to 65.3% in 2008, and male participation declined from 80% to 78.6% during the same period. Women’s employment in the sector has other social impacts. More women in the medical profession can be associated with more breaks during the working lifetime and an increase in demand for part-time work. Another factor influencing the changed demand for skills is fast-changing technology that places new requirements on the healthcare workforce. This applies not only to medical doctors, but also to nurses and related professions, who have to embrace ICT use in diagnostics and new forms of communication with patients and clients (via the internet and in dealing with electronic patient dossiers). In dealing with more information, need new skills in information management to base medical interventions on the best available evidence. Increased the mobility of patients and the growing number of cross-border services requires significant changes in staff skills. Foreign language and intercultural skills amongst healthcare staff are becoming more important, as patients and clients bring new demands and national workforces become increasingly ethnically diversified. As pensioners become more mobile, some care providers are expanding their services to the countries/regions, where older people choose to retire are retiring. This is the case of the Netherlands, where providers started offering services in Spain39. This need is likely to increase in the future. Across all jobs in the healthcare sector soft skills and the ability to acquire new knowledge and competences are becoming more and more important. An important trend is the growing importance of personal adaptability and a relative decrease in the importance of predefined technical knowledge capabilities40.

38 According to OECD data total nursing home expenditure per nursing home bed rose at an average rate of 3.8% per year in real terms between 1995 and 2005 (OECD, Health at a glance, Paris, 2007). 39 P.F. Driest, Long term care in Europe in: J. Hassink, M. van Dijk (eds.), Farming for Health, 101-106 Springer, 2006. 40 European Commission, Investing in the Future Jobs and Skills, Sector report, Health and Social Services, May 2009; available at http://ec.europa.eu/social/main.jsp?langId=pl&catId=89&newsId=583&furtherNews=yes).



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ii) Changing nature of jobs and new work organisation Changes in the healthcare sector have brought about a change in the nature of jobs and the need for new forms of work organisation. More emphasis is placed on the delivery of cost-effective solutions. Models of care promoting home care have been introduced, alongside the further development of primary care services. Each has implications for the organisation of work, the division of labour and particularly the boundaries between occupational groups. New approaches to working related to the development of new technologies blur traditional demarcations between different occupation within the sector and challenge traditional hierarchical structures (like virtual forms of work organisation, which substitute hierarchies through a horizontal network/team co-ordination). At the same time new forms of interaction between staff are emerging, such as the creation of multidisciplinary teams, group practices replacing solo practices and professional practices being de-compartmentalised. Certain occupations, such as nursing are becoming more independent, as more responsibility for diagnosis and treatment in emergency care, preventive care and chronic disease management is associated with this profession. In this context, pure secretarial and administrative functions are taken away from nurses and occasionally outsourced. When employment patterns are taken into account, it can be seen that they have become increasingly variable. More part-time jobs have appeared as a result of the increase in the number of women in the sector. Shift work is a key feature of health care. 83% of Belgian nurses, 75% of British nurses and 48% of hospital workers in Germany work shift systems41. This means that high flexibility is achieved only at the expense of overtime or extended unpaid hours and job stability is no longer the rule in public services. A lifetime career is increasingly built around a variety of employment arrangements, including part-time employment, short-term contracts, on-call work, multiple employments and independent contracting. The impact of the tendency toward increased intensification of work creates new, often stress related and other physical health hazards. According to research, the work-related accident rate in the health care sector is 34% higher than the EU average42. The sector has the second highest incidence rate of work-related musculoskeletal disorders, after construction. iii) Ageing workforce and workforce shortages The “greying” of the healthcare and greater longevity of “customers” of the healthcare sector have serious consequences. As the demand for healthcare work increases and changes, labour supply also changes and becomes smaller. There is a need for continuing training programmes for older workers and introduction of innovative HR practices to accommodate their physical limitations and expectations. While taking into account the entire of jobs in the healthcare sector the tendency is likely to be toward a shift in demand for jobs rather than a general job reduction. iv) Managing outsourcing and sub-contracting Internal reorganisation designed to improve competitiveness of healthcare institutions by cutting costs has resulted in the outsourcing of activities which were formerly performed within the sector. This trend applies not only to the non-core services, such as washing, cleaning, security and catering, but also to the standard procedure operations, diagnostics, ambulance care and specialists. Outsourcing requires new divisions of work between the operations/activities that stay within the institution and those that are outsourced. It also implies more monitoring and control over the outsourced functions.

41 R. Verschuren, B. de Groot, S. Nossent, Working conditions in hospitals in the European Union. Dublin, European Foundation for the Improvement of Living and Working Conditions, 1995. 42 Based on the information from the European Agency for Safety and Health at Work website, data from 2003 (see: http://osha.europa.eu/en/press/press-releases/030228).



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The role of the social partners in the anticipation of change

European sectoral dialogue in healthcare is currently limited to the representatives of employers and direct employees of hospitals. The EU level sectoral social dialogue committee on hospitals was officially established on 20 September 2006 by the European Federation of Public Service Unions (EPSU) and the European Hospital and Healthcare Employers Association (HOSPEEM). Prior to setting up the committee, informal social dialogue processes took place within the framework of the Joint Representative Taskforce.

EPSU, the European Federation of Public Service Unions43, is the largest federation of the ETUC and comprises eight million public service workers from over 250 trade unions. EPSU organises workers in the energy, water and waste sectors, health and social services and local and national administration in all European countries. EPSU is the recognised regional organisation of Public Services International (PSI). EPSU represents 3.5 million health and social services workers across Europe representing professions from social worker to doctor, hospital cleaner to medical secretary or nurse. EPSU is the recognised European social partner organisation for workers in the hospital sector throughout the European Union.

HOSPEEM is the European hospital and healthcare employers' association44. HOSPEEM was set up in 2005 with a view to representing the interests of European Hospital and Healthcare Employers on employment and industrial relations issues. The Association was created by members of the CEEP who felt the need to provide a separate, distinct voice on health workforce issues at European level.

In the last three years the social partners in the healthcare sector have signed two documents. The first was the declaration on health services (December 2007), in which they presented a common position on healthcare sector management; supported member states’ autonomy in funding, organization and delivery of health services, while retaining European Community responsibility to promote public health; the organisation of health care on the basis of common European social values including solidarity, social justice and social cohesion and principles of general interest, like universality, accessibility and quality.

The second agreement signed in 2008 is titled “Code of conduct and follow up on Ethical Cross-Border Recruitment and Retention in the Hospital Sector”. Its aim was to promote ethical practices in the cross-border recruitment of health workers. The European social partners agreed to implement it with a help of their respective members within a period of three years after signing. During this period, the social partners committed themselves to monitor the situation and report at least once a year to the Social Dialogue Committee about the progress made. By the end of the fourth year a report will be issued on the overall implementation of the agreement. The key principles and commitments included in the document are high quality health care, accessible for all people in the EU; workforce planning; equal access to training and career development; open and transparent information about hospital vacancies across the EU; fair and transparent contracting; registration, permits and recognition of qualifications; proper induction, housing and standards of living; equal rights and non-discrimination; promoting ethical recruitment practices; and freedom of association.

Outcomes of the work undertaken by the hospital sector social dialogue committee reflect current and future challenges faced by the sector. The following priorities can be found in the work programmes for the years 2006-2007 and 2008-2010:

• Recruitment and retention: Identifying common positions for cross-border recruitment of hospital personnel; developing a sectoral initiative, promoting cross-sectoral reconciliation of work and family life via appropriate work organisation;

43 Based on information from the EPSU website: http://www.epsu.org/. 44 Based on information from the HOSPEEM website: http://www.hospeem.eu/.



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• Ageing workforce in the hospital sector: Identifying national and regional initiatives to promote realistic active ageing policies; creating specific instruments to face challenges of an ageing workforce through ad hoc projects;

• New skill needs in the hospital sector: Defining existing categories of hospital professionals and workers, identifying successful training initiatives, collecting and exchanging practices and experiences in the field of education and training, management of health care, and interaction between technology, ICT, skill needs and/or workforce planning and assessing the consequences of the different developments for work organization and workers, with specific focus on education and training, skill mix and healthcare management45.

In the work program for 2008-2010 two issues were added. Developing an adequate response to third party violence and strengthening hospital social dialogue structures, using a social partnership approach in capacity building and cooperation towards the launch of joint social dialogue projects at different levels as well as encouraging and supporting national affiliates to make use of available resources for social partnership funding under ESF.

There is no platform or a regular procedure or mechanism to exchange views on the management of change or the anticipation of it. However, the European social partners in the healthcare sector have contributed to the debate on skill needs in the health sector and organised a workshop together with CEDEFOP to define key trends, future skills and occupational requirements in the health care sector. In particular it looked at the interaction between technology, ICT and skill needs, the management of health care and education and training needs in the sector with the attempt to enhance evidence based development and policy-making at the national and European level. Key themes emerging from the report. The purpose of this section of the report is to suggest areas that might be discussed jointly at the national seminar where a limited number of the most important themes can be addressed in more depth. In the final “post seminar” report, this section it will be replaced by a longer segment dealing with the content and outcomes of discussions. The themes presented below are offered on the basis of the desk research undertaken during the research phase of this project and are all referred to in the preceding text. At the sectoral seminar it will be for the participants to select from the list below, or add new topics or themes. We will have the time to discuss the exact question to be addressed under each heading.

How effective is the healthcare sector European social dialogue at anticipating change and how can it

be improved?

What new initiatives can be undertaken with a view to better prepare social partners for anticipating change?

Continuing work on skills and lifelong learning in the context of the European Commission initiative skills

and jobs for 2020.

45 For a more detailed description of the work program 2006-2007 and 2008-2010 visit: http://circa.europa.eu/Public/irc/empl/sectoral_social_dialogue/library?l=/hospitals&vm=detailed&sb=Title



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How to strike a balance between equity and efficiency in healthcare management?

How to tackle challenges related to a changing workforce which manifests itself in ageing, labour force

shortages and growing diversity?

Addressing the demand for new professional skills in an ageing and rapidly changing sector.

Managing the relationship between European and national social dialogue

The impact of the current financial and economic crisis on the future of the sector



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Section four – Reflections and themes for the sectoral seminar It is not the intention of the project at this stage to link different sectors in order to identify similarities and differences in approaches. However, during the course of the four seminars covering eight sectors, a progressive discussion of tentative overall themes will be encouraged, in particular identifying what, if any, actions should be taken by the social partners at the European level representing workers and employers in all SGIs. It is worth recalling the conclusions of the previous CEEP project that was a part of the genesis of the current work;

“The enormity of the change taking place in the public services deserves more attention and study. In restructuring analyses, public services are often “overshadowed” by the volume of research into change in the private sector. In reality, the changes taking place in both quantitative and qualitative terms in the public services are at least as great as the more frequently reported outsourcing, offshoring and international relocation activities of international private companies; The nature of change differs by sector and by country. In certain sectors major job losses predominate and in others internal transformation has been more important. In the healthcare and education sectors, staff shortages and the haemorrhage of skilled employees are major challenges. In each of the above circumstances there is a distinctive common denominator which is the proactive and effective engagement of staff and their representatives. Organisations have to invest heavily in better management; giving staff the confidence in their ability to change; and minimising the causes of insecurity that manifest themselves in opposition. It is a fact of public sector employment life that trade unions are important interlocutors on behalf of staff and effective social dialogue will be crucial to effective delivery.”

In anticipating change there are a number of similarities in the two sectors;

• Both face the problem of ageing workforces that will need to adapt to ongoing changes in technology, customer needs and operating demands. These changes have already resulted in job enrichment and increased intensity of many sector’s workers. Positive employee engagement combined with lifelong learning initiatives will be important;

• Both sectors are “female dominated” and both sectors experience predominant female employment at the lower levels of the professional career: primary and secondary schools (education sector) and nurses and lower medical staff (healthcare sector);

• Attracting men to the profession will require significant efforts and innovative promotional techniques, and later innovative HR practices to retain them in employment;

• Both sectors have experienced significant changes in their image: from a respected profession, offering stable careers to careers that are looked down as difficult, poorly paid and that loose with other sectors of the economy to attract good employees;

• Change has, and will continue to, proceed at different paces in different countries. This means later developers can learn from those who have already trodden the path;

• Neither sector has yet focussed on the impact on government spending of the current financial and economic crisis, however both fear that it can have a serious negative effect of their operation, workload and employee satisfaction;

• In both sectors trade unions are well organised – however, they usually unite only the core staff (teachers in education sector and medical staff in healthcare sector), while employers are represented in smaller numbers and have a smaller coverage;



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• Both sectors have to face the challenge of growing internationalisation of customers (foreign pupils/students in education sector and cross-border patients in healthcare sector);

• Both sectors are very sensitive to public opinion and decisions are often made not only on pure financial/competition basis;

• Employees of both sectors have to cope with stress, potential third party violence and psycho-physical risks related to the performance of their profession. The professions demand patience, personal engagement and devotion, entail close relations with people and very often personal responsibility goes beyond the professional one;

• Both sectors have to cope with better informed, more aware and more demanding “customers” who have increasing expectations for the quality and timeliness of the provided services;

• In both sectors career development is time based and requires many years of training and practice. Pay increases can generally be expected later in the career, which is a factor negatively affecting the attractiveness of the profession to new entrants.

• Both sectors will have to accommodate the needs of ageing customers (adult learners in education sector and older patients in healthcare service sector).