BMJ Career Focus 2004;328:99 (6 March)
European views about accession
Ioana Vlad finds out what our European colleagues think about workflow between member states come 1st May
The United Kingdom is gearing up for an "invasion" of doctors from the accession states (Cyprus, the Czech Republic, Estonia, Hungary, Latvia, Lithuania, Malta, Poland, the Slovak Republic, and Slovenia) come 1 May,1 but what are the views from the rest of Europe? Differences in training, numbers, and pay and work conditions are stacked up against the accession states and member states might not want their new colleagues to contribute to their workforce.
Merte Bosch, delegate to the European Union of General Practitioners (UEMO) from the Hartmannbund—German Medical Association—sets the scene: "It is not absolutely clear yet to what date salaried doctors from countries that are to join the EU [European Union] will enjoy the free movement following the EU directives. We suppose that for doctors who want to open a practice this will be possible with the entry into the EU of their country."
Differences in numbers
Among the current EU member states there are already differences in the number of practising doctors per 1000 inhabitants and also in the demand for doctors.
In Greece, for example, between 1990 and 2000 there were an average of 3.94 practising doctors per 1000 inhabitants. In Belgium in 2002 there were 3.2 active registered doctors for 1000 inhabitants. There were 3.88 registered doctors (including dentists, excluding training doctors) per 1000 inhabitants in Austria, 3.1 registered doctors per 1000 inhabitants in Malta, and 4.002 per 1000 in Lithuania.
"We have a shortage in training posts so that students after having finished their medical studies have to sometimes accept long waiting times before being able to enter a training post," says Dr Felix Wallner, legal adviser of the international department of the Austrian Medical Chamber. He adds: "The migration will certainly change as up to May 2004 there was almost no migration from those Austrian neighbouring countries such as the Czech Republic, Hungary, Slovenia." He explains that the only way Austria can restrict an unwanted invasion is to postpone permission to work in an employed situation (hospitals) for doctors coming from these countries. At present, most exchange of doctors or migration of doctors is between Austria and Germany.
According to Dr Martin Balzan, general secretary of the Medical Association of Malta, an accession state: "There are enough doctors in Malta. However there is a slight shortage of junior doctors and GPs [general practitioners] in the public health service as many doctors opt for the private GP market. There are enough specialists in most specialties in the public sector; however, many are kept at senior registrar grade. The private sector is saturated and in some specialties even oversaturated."
The Danish Medical Association expects an important movement of doctors (both junior doctors and specialists) from the new EU countries towards Denmark. "Denmark has a lack of medical specialists and Danish hospitals have approximately 800-900 vacant positions," says Michael Møller, from the health policy department of the Danish Medical Association.
Differences in income
There are also big differences in pay for European doctors, depending on the country in which they practise. In Finland, monthly income of a senior physician (specialist) is €2998-3994 (£2017-2687, $3765-5015), while in Ireland the average yearly income of a specialist is €133 051. "Young German doctors like to go to Great Britain or to Switzerland because of the pay and the way colleagues communicate," says Merte Bosch. She adds: "We do not think that the income of doctors will change because of a larger EU and as we do not have enough doctors, we do not feel that doctors from Poland or other countries could be a threat."
In Denmark, consultants and practising medical specialists (praktiserende special-læger) have an average yearly income of DKK 780 000 (€104 000), while doctors in training and staff specialists have an average yearly income of DKK 456 000 (€60 800).
A third of (younger) Lithuanian doctors would like to practise medicine abroad. This is understandable when you compare European salaries with those of Lithuanian doctors, who earn on average Lt737 (€214) a month.
These differences will be bigger with the new member countries and might be the main reason behind a suspected migration towards the countries with higher incomes. Malta is one of the accession states with the highest incomes. The maximum wage of a senior registrar working in Malta is €2000 a month. Even so, "many junior doctors move to the UK because of better salaries and better career prospects," says Martin Balzan. He adds: "Once Malta joins the EU, it is expected that more junior doctors who have completed membership/fellowship will move for higher specialist training in the UK, and as the salary structure and the career prospects are much better, most are expected to settle in the UK. The net outflow is expected to worsen with EU accession."
Preliminary monitoring reports
In November 2003 the European Enlargement Commission released monitoring reports regarding the state of preparations for membership. These reports raise serious concerns about the mutual recognition of qualifications in the healthcare sector in most of the candidate countries. So far only Malta and Hungary have released and implemented specific legislation regarding the mutual recognition of qualifications. Cyprus, Lithuania, and Slovakia have administrative delays in implementing the legislation regarding the recognition of qualifications, while Estonia, the Czech Republic, Poland, and Latvia still have to work out the laws and regulations. Slovenia needs to amend its Medical Services Act.
Apart from the legislative and administrative structures, all candidate countries are encouraged to step up their efforts to introduce educational and training programmes in order to guarantee the level of competence of qualified professionals required by the EU directives. It is up to the regulatory authorities of the candidate countries to ensure that all their professionals, including those who qualified before harmonisation, meet the European requirements and can therefore benefit from professional recognition throughout the EU.
The situation is slightly different for doctors from the Baltic States, the Czech Republic, Slovakia, and Slovenia who qualified while their country was part of the territory of another country (for example, USSR, Czechoslovakia, and Yugoslavia). Their diplomas must be certified as equivalent to the relevant existing national qualification and individuals will have to prove that they had been practising for three consecutive years in the candidate country during the five years preceding the application for recognition.
In Lithuania the licensing system is different. "Our doctors have to renew their licences every five years. They have to undergo 200 hours of refresher course, 60% in formal institutions, specialty conferences, and give documents confirming that they had been practising for no less than three years in [a] five year period," says Aiste Sivakovaite, Lithuanian Medical Association Secretary.
The brain drain
Contrary to the high workforce influx that the rich countries expect, the new member countries need to prevent a brain drain that might impede their economic and scientific progress. The Medical Association of Malta has already thought about ways of encouraging Maltese doctors to remain and practise in the country. It has proposed to the government a three point basic plan, which is still being negotiated. Martin Balzan describes the three basic points: "(1) An increase in basic pay to offset the loss of income with the possible introduction of the working time directive; (2) The full implementation of structured postgraduate training programmes in as many specialties as can be supported by the local infrastructure; (3) A gradual expansion in the consultant grade to improve the long term career prospects."
Ioana Vlad, junior doctor