Deliverable D042 on Mobility data Proposed structure of Draft Chapter 7 on Recommendations for discussion at the Rome WP4 WS 3/12/ 2014 with some selected background information material1

Recommendations at national and EU level - with high level assessment of the feasibility of the recommendations D042 Recommendations, main groups

● Technical recommendations - main focuses of the discussion2

● Policy recommendations - part of the discussion as applies

1. General issues (HWF mobility in a larger arena of labour mobility and related politics; Information synthesis; Influencing factors, including legal and education frameworks and state administration of Member States; etc. ) - Policy recommendations

The various types of HWF mobility are to be interpreted within the the larger arena of labour mobility and related politics both in the EU and globally34.

HWF mobility is part of the skilled migration that is in focus for EU as a whole and applies to all EU MSs, but in many different and sensitive ways. Attracting professionals with high level and the ’most wanted’ healthcare qualifications and skills is a priority in time of an ageing population and increasing healthcare and social care needs and demands. Five health-related professions (physicians, dentists, pharmacists, nurses and midwives) fall under the EC Directive 36/2005, and the automatic recognition of these qualifications also facilitate professional mobility. Some European states face severe loss of their domestic HWF (most of them mainly to other European states), while others struggle with dependence-reliance on foreign health workforce. Even in countries that are not affected by such mobility to a great extent from the viewpoint of health care provision, other HWF mobility related problems can occur, for example with regards to graduate and postgraduate training capacities. Background reasons and patterns of mobility include various factors, many beyond the healthcare sector and health labour market scope, and many beyond the potentials of individual countries. It is to be acknowledged that intra-EU HWF mobility across EU countries cannot be explored and discussed without taking into consideration health professionals’ flow between the EU and non (not yet) EU countries in Europe, and between the EU and the World outside Europe.

In addition, there are evolving tensions regarding immigration in some European countries. At the same time political trends and intentions thrive to diminish discrimination against the labour force of foreign origin and to respect severe HWF shortages outside Europe following the principles of the WHO Code of Practice on the

1 Planned structure and overview of D042 will be presented at the Rome Workshop. The current document is a draft, the list of recommendations is not complete.2 The D042 Deliverable will include both technical and policy level recommendations. Discussions at the Rome Workshop will focus primarily on the technical ones. 3 Buchan J., Wismar, M., Glinos, I. A. and Bremner, J. (eds.) (2013). Health Professional Mobility in a Changing Europe. New dynamics, mobile individuals and diverse responses. Observatory Studies 32. Available at: http://www.euro.who.int/__data/assets/pdf_file/0006/248343/Health-Professional-Mobility-in-a-Changing-Europe.pdf?ua=14 EC Feasibility study (2012). EU level collaboration on forecasting health workforce needs, workforce planning and health workforce trends - A feasibility study; Revised Final Report. Matrix Insight. Available at: http://ec.europa.eu/health/workforce/docs/health_workforce_study_2012_report_en.pdf

international recruitment of health personnel. These issues challenge the addressing of many aspects of HWF mobility and increase the need of clear political will to deal with this and elaborate its management.

Approach and methodology, synthesis and follow-up of HWF related research and studies, and connection of their results into health policy steps related to HWF mobility management is an especially important issue to deal with.

Experiences and findings of WP4 work (Activity 2: HWF mobility data mapping), including WP4 Questionnaire Survey5, interviews, and discussions on WP4 workshops6

showed that despite HWF mobility being a current, crucial topic, it is a challenge to evaluate its relevance regarding the quantity, composition and sustainability of HWF and health care provision both at national and international level. Grey economy is also present in HWF mobility especially in home-based care. Although this phenomenon is even more difficult to detect, there in no doubt that in many countries HWF mobility in certain professions and types of care is part of the overall picture, as well as the overlap of health and social care.

R1.1.HWF mobility and migration has to be explored and addressed in a comprehensive way, taking into consideration its broad contexts in the EU.

2. Objectives of HWF mobility information and its collection (HWF P)- Policy and technical recommendations

Despite the fact that HWF mobility is frequently addressed as one of the most sensitive and most discussed issues both at national and EU level, both at health policy and general political agenda, and the claim and request for accurate, valid, timely data/ indicator collection is evident, the objectives and potential utilization of mobilitydata and information is not clear. The connection and role of HWF mobility in HWF planning processes needs to be explored and clarified.

Discussions on HWF mobility are in a way “simplified” (despite the growing evidence of research, channelling the results to debates remain a challenge); debates use HWF related information and terms, like “HWF mobility” and “HWF mobility monitoring” as if these were evident terms and issues, while the picture is complex. In reality, agreed and accepted clarification, understanding and interpretation of the phenomenon, its aspects and related terminology - and consideration of which type is crucial for a given country or situation - are impaired or missing, in many cases both at national and international level. It endangers any further steps, including to define and clarify objectives, because terminology issues at the roots are not clear. Different HWF types allow and claim for different objectives, and may need different approach regarding data and indicator collection, data process management, analysis and utilization of results.

5 The WP4 Questionnaire Survey was sent to partners in September 2013 and the indicated deadline for returning the filled in forms was December 2013. In total 14 country responses were received.The objective of Section 2 was to explore, reveal, and clarify the details of health professional mobility, mobility data mapping. WP4 collected information on the relevance of HWF mobility; the availability, interpretation and use of mobility data, and the objectives of mobility data collection in your country. WP4 also aimed to map views on the comparability of mobility data and gather information of the use of the currently available European Union databases, processes and recommendations. Furthermore, in the last part of the QS we asked recommendations on any further steps at EU level on mobility data-related issues.6 Please note ‘Experiences and findings of WP4 work’ in this document from now on refers specifically to the findings of the WP4 Questionnaire Survey, interviews with HWF experts and stakeholders, and the four Workshops WP4 conducted so far.

Experiences and findings of WP4 work showed that HWF mobility data collection is mostly used for monitoring at national level. There are intentions and claims to use mobility data also for HWF planning and forecasting in most countries, and even in some countries without definitive HWF planning, HWF policies aim to manage retention to address severe loss of domestic HWF. Only some countries can give evidence of using HWF mobility information in planning and forecasting, but it is may not always be easy to follow how this practice is built up.

R2.1The starting and most important point of any HWF related discussion and measure should be to clarify the type of HWF mobility in question, as well as the reasons, and the objectives addressed by the given type of HWF mobility. This is to specify the reasons to collect and analyse related data/indicator/information. The connection between HWF mobility in question and HWF planning process has to be explored and clarified. This is also the essential prerequisite of cooperation and compliance of involved stakeholders, both at national and international level. Mutual interests and benefits have to be clear and be in focus from the beginning.

R2.2Mobility of health students during graduate training and mobility of graduated HWF in postgraduate professional training for specialisation is an increasing phenomenon that should be monitored and studied in detail. As this mobility type can challenge country level stakeholders of HWF planning and have implications at EU level, related indicators should be channeled into HWF planning.

R2.3HWF mobility has a strong relevance to HWF Planning. Accurate information on HWF mobility could be directly channeled into HWF planning. As intra-EU mobility data is of limited use on its own within the framework of global HWF mobility, non-EU mobility should be included in the data collections and used for HWF planning.

R2.4Monitoring HWF mobility gives opportunity for policy makers to include HWF mobility information into HWF planning, and establish focused/targeted recruitment and retention interventions/strategies for balancing inequalities and managing the composition of HWF (HRH management).

3. Terminology and its relevance (It is not only HWF mobility types related issue, also relevant regarding indicators!) - Policy level and technical recommendations

Terminology issues are the bottlenecks of proper quality HWF mobility data/ indicator and information collection, and it even often remains unmarked, out of the scope of considerations. There are many types of HWF mobility. Albeit there is no proper type of classifications fully covering all possible aspects, there is available research work in this field. EC feasibility study introduces the approach distincts professional and geographical flows, focusing on their direction, and identifies international and national level in case of geographical migration. Aside from this the length of stay is

considered7. WP4 Questionnaire Survey8 - following the EC Feasibility Study framework- provided a definition in order to reach a common understanding of the term “mobility” as: the term “mobility” in this Survey is used for geographical, international cross-border HWF mobility (inflow and outflow), - both across European countries and from and to non-European countries. Volume 2 of Prometheus project Chapter 69 provides a twin typology approach, considering both the aspect of mobile health professionals and the meanings of borders, to define six most representative HWF mobility types taking a variety of factors into account: “motivations for and purpose of migrating, conditions (circumstances) in the home country, conditions in the destination country, personal profile, likely direction of move and likely length of stay abroad”(see Table1)10.

It is crucial to be aware of the existence of different HWF mobility types and their different relevance and possible way of addressing and collecting information on. It is critical to consider what types of HWF mobility can be and should get priority at the national and EU agenda. Different methods of monitoring, and different interventions can be appropriate for each mobility types.

Other HWF category terminology issues also strongly affect and link to HWF mobility terminology, first of all the ones relate to HWF activity (for example LTP, Professionally Active, Practising categories, or FTE) as HWF mobility is considered in relation of active, practising, actually working HWF. It obviously has important implication for indicators in which ratios are used11.

Experiences and findings of WP4 work showed that terminology associated rather with HWF mobility indicators at first (mainly regarding foreign trained, foreign born, foreign nationality, recognition/ certification/ admission of diploma, conformity certification, etc.), several types of HWF mobility come up after it. But in discussions it is often realized that depending on many factors (country, profession, time perspective, role of the stakeholder, etc.) different understanding and priorities on the HWF mobility types exist, with different classifications in mind. Discussion and agreement on HWF mobility types and definitions are characteristically missing at national level.

R3.1Terminology issues have to be considered. It is necessary to raise awareness in this field, and to identify main HWF mobility types, and prioritize them both at national and EU health policy agenda.

7 EC Feasibility study (2012). EU level collaboration on forecasting health workforce needs, workforce planning and health workforce trends - A feasibility study; Revised Final Report. Matrix Insight. Chapter 5.0, 5..1-2-3, p83-87.Available at: http://ec.europa.eu/health/workforce/docs/health_workforce_study_2012_report_en.pdf8 The WP4 Questionnaire Survey was sent to partners in September 2013 and the indicated deadline for returning the filled in forms was December 2013. In total 14 country responses were received.The objective of Section 2 was to explore, reveal, and clarify the details of health professional mobility, mobility data mapping. WP4 collected information on the relevance of HWF mobility; the availability, interpretation and use of mobility data, and the objectives of mobility data collection in your country. WP4 also aimed to map views on the comparability of mobility data and gather information of the use of the currently available European Union databases, processes and recommendations. Furthermore, in the last part of the QS we asked recommendations on any further steps at EU level on mobility data-related issues.9 Buchan J., Wismar, M., Glinos, I. A. and Bremner, J. (eds.) (2013). Health Professional Mobility in a Changing Europe. New dynamics, mobile individuals and diverse responses. Observatory Studies 32., p129-151. Available at: http://www.euro.who.int/__data/assets/pdf_file/0006/248343/Health-Professional-Mobility-in-a-Changing-Europe.pdf?ua=1

10 Please note that this most comprehensive and holistic classification will be used to support group work discussion on terminology issues.11 HWF terminology problems were subject of WP4 Activity 1 - Terminology Mapping. Findings of this activity were summarized in WP4 Deliverable 041.

R3.2HWF mobility terminology is to be handled together with other HWF terms, especially the ones aiming to describe HWF activity.

4. Indicators (including potential HWF mobility indicator minimum set) - Technical recommendation

There is a variety of HWF mobility indicators. The clear challenge is that even in case of inflow, but surely in case of outflow the indicators are proxy indicators at the best. The basic three types of inflow indicators: foreign trained (FT), foreign born (FB), and foreign national (FN) are used in different extent and sometimes in different way in Member States. Reliance on foreign health professionals is also an important indicator regarding health professional mobility, although its reliability and comparability is affected by the different calculation methods.

Next to these ones, many other indicators can support HWF mobility monitoring, depending on the type of HWF mobility and the objective of data collection. For instance, student mobility became a crucial issue in health training requiring a different approach to indicators as well.

Some of these indicators are health sector and specifically HWF related, but can be interpreted and analysed in connection with other indicators that are beyond the health sector (for example the ones on actual employment, taxation, private and public proportion of health care facilities, health and social insurance data, etc.). If the possible objectives of data collection and HWF planning aspects are considered, it is also clear that other data can add much value to get a comprehensive picture, like some general data (gender, age, etc.) and some profession related data (speciality, type and geographical localisation of health care provision in country, etc.).

Clear, comprehensive views and picture on the range of potential indicators to consider, including the existing, available ones both at national and international level are needed. That also presumes open professional communications (in health and between health and other sectors) on the definition, content, validity and use of HWF mobility indicators. The indicators are also to address “stock”, “flow” and “trend” aspects regarding HWF mobility.

Experiences and findings of WP4 work showed that regarding HWF inflow FT (first qualification), FN and FB indicators, with more than one available in some countries, and recognition of certificates are used, while for outflow, conformity certificates as proxy indicators are available in most of the regular HWF databases. There are some countries, where research projects and labour market surveys also ensure some additional information for instance on the motivations to leave, or expected working conditions, etc., occasionally or in a regular basis. It is evident for stakeholders of HWF mobility data collection that all these are proxy indicators. Connecting them to HWF activity and employment data can ensure better value in case of HWF stock inflow, but outflow data needs to be verified by countries of destination. Even linking HWF mobility indicators to HWF activity and employment data is reported to be a challenge in most countries, albeit good practices and initiatives are available in other countries. Only some countries report to have contact with similar authorities of other states, and mostly the use of Internal Market Information (IMI) system12 is considered, but

12 Please note, that IMI regarding HWF mobility will be mentioned in frame of the DG Markt database presentation at the Rome WP4 Workshop. http://ec.europa.eu/internal_market/scoreboard/performance_by_governance_tool/internal_market_information_system/index_en.htm

only used to follow problematic cases. Some countries elaborate occasional verification of outflow proxy data with some defined countries of destination, and via bilateral cooperation with the competent authorities.

R4.1Potential HWF mobility indicators have to be mapped and considered according HWF mobility types. HWF activity indicators have to get a special focus regarding HWF mobility indicators.

R4.2Open and regular professional discussions, revisions, and joined developments are needed both within healthcare and between health and other sectors, both at national and EU level.

R4.3Optimally each of the basic HWF mobility inflow related indicators (FT, FB, FN) should be collected on a timely basis. It should be essential part of the HWF data and intelligence systems.

R4.4AThere is a common minimum HWF mobility indicator set all EU countries can agree on and be able to collect and provide (for the identified EU relevant HWF mobility types). The connection with HWF activity related indicators has to be defined and clarified. The common denominator(s) have to be found or developed considering feasibility and sustainability aspects in each MS.

R4.4 BA common HWF mobility indicator set is to be agreed upon that all EU countries are able to collect and provide. This indicator set should monitor the most relevant types of HWF mobility regarding healthcare provision, and also should ensure the estimation of reliance on foreign HWF and the hazard of health workforce outflow for the healthcare provision. R4.5Regular professional consultations and knowledge exchange between countries face similar HWF mobility challenges next to EU level discussions could support good quality indicator identification and related data collection.

R.4.6Awareness rising is needed and should be fostered regarding the value and limitation, with potential utilisation of HWF mobility indicators. These issues have to be discussed, and related information, research results are disseminated. High level, simple, clear, brief publications to reach policy and decision makers, and the public on the results of HWF mobility research have to be in focus and managed properly (both at national and EU level).

R4.7Data categories and indicators can be identified, agreed and shared at EU level to monitor and follow the training mobility of health students and graduated health professionals.

5. Methodology of data collection (national>>>regional>>>EU level) - Technical recommendations

a. Quality of datab. Data managementc. Data analysisd. Data utilisation and feedbacke. “Traditional” approaches versus Projects/ survey based mobility data collection

Currently HWF mobility can be estimated by proxy indicators at the best. No country is able to monitor and follow, thus assess mobility of its HWF without close cooperation with other countries. Information and data flow and exchange at international and EU level mean the prerequisite of having better quality data and indicators on HWF mobility, even considering good quality proxy indicators. At national level, the prerequisite of that is to have ONE defined HWF database and/ or establish communicating databases that can be linked together. According to findings of WP4 work that remains a challenge in many countries, partly due to the lack of real comprehensive general (at state, government level) and health policy strategy (and political will, commitment) to address HWF mobility issues in many MSs.

But it is also clear that many data could be available in most countries to have a better picture on HWF mobility at the level of proxy indicators, but comprehensive approach and effective management of data collection processes, communication between stakeholders and data bases are all challenging issues, even in the health sector, and pose bigger challenge beyond health care. It is also partly due to lack of resources, including human resources. But these challenges are evident at the EU level as well. Elaborating a comprehensive, beyond sectors approach (that fits into a national and EU HWF strategy), addressing and closing the gaps in the CURRENT HWF mobility related data collection and process management itself could add much to improve HWF mobility information. There are some countries that could provide potential best practice examples on that.

Sequence of steps (considering the previous main groups of recommendations beforehand):

● Improvement of the quality of data, including the terminology issues ● Revision of existing, current data collection and review of the process of data

management (BPR13 type approach for instance) and reorganisation if needed – it has to be considered that legal aspects are also in the picture

● Any further steps: completion of data collection with new elements/ set up new system, etc.

It is also true that in many countries the analysis of data and their utilisation is not approached in a strategic and systematic way, and seems to be a gap between some, or most of the HWF mobility stakeholders, including the mobile health professionals and their representative professional organisations. It seems to be a challenge at EU level as well. Regular and mutual connections and feedbacks, including the objective and way of use of data analysis results, between involved stakeholders seem to be a problem. Identification and communication of mutual benefits are often neglected aspects. Some potential good practices can be observed in this field as well. But the time and resources to manage these relationships and communication seem to be

13 Business Process Reengineering

underestimated, and this need is not calculated, included into the “task lists”, often resulting in a bottleneck in the data management process14.

Special and important professional challenge in respect of utilisation is to get to, and communicate conclusions, or use them as policy steps support that the quality of the indicator and/or data collection should not allow and cannot verify. As HWF mobility issues are high at the political agenda, it means risk.

Next to regular, traditional HWF data collection projects/ survey based mobility data collections can have a special role in HWF mobility data collection, as these could be more feasible, effective and efficient in some cases, and/or add additional valuable information occasionally. Professional HWF organisations (international representatives) and EU has a crucial role here. Proper planning and scientific approach of projects/ survey based HWF mobility data collections is a bottleneck to address.

R 5.1 Cooperation between countries in a regulated way is a prerequisite of HWF mobility data collection.

R 5.2 With the valid data of recognition of foreign diplomas in all European countries the mobility flows - based on foreign training (FT) - might be followed at European Union level. The existing tools (DG Markt database, IMI system), in coordination with and potential link to other existing EU level databases could provide option to develop a good HWF mobility database, integrated into an EU level HWF intelligence system.

R 5.3By providing benefits for MDs in their Continuing Professional Development (CPD)- whether obtained abroad - MDs’ interest should be governed to update their multiple registration and licences. CPD completed abroad should be mutually recognised between Member States.

R 5.4 Various types of data/indicator and methodology may be important to gain at least estimations on HWF mobility. Qualitative methods (e.g. interviews with hospital leaders, fieldwork at institutes, units) should be incorporated into the process of gaining a deeper understanding of HWF mobility at national level. Proper quantitative methods should be identified at least for estimating HWF outflow.

R 5.5Data protection should allow the tracking of individual data, since using aggregated data does not make HWF mobility monitoring satisfactory or possible at all.

R 5.6.Legally regulated, automatic direct information exchange between Member States is essential to monitor HWF mobility in a timely manner. Any HWF mobility data collection can be effective only with two-way communications, and incentives that demonstrate mutual benefits.

-----------------------------------------Please note that the Annex of the Final D042 will also include the following parts related to the recommendation chapter:

14 Information flow problems are also discussed in WP4 Deliverable 041.

● Potential best practices based on country examples: policy level and technical recommendations

● European Union level support of HWF mobility data collection; Utilisation/development of existing EU tools (DG Markt) and plans for new tools -reasoning!- at EU level - policy level recommendations

● Practicalities, feasibility - policy level and technical recommendations