# EUR-Lex - 52012SC0093 - EN

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# 52012SC0093

**COMMISSION STAFF WORKING DOCUMENT on an Action Plan for the EU Health Workforce /* SWD/2012/0093 final */**

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COMMISSION STAFF WORKING DOCUMENT

on an Action Plan for the EU Health
Workforce

Accompanying the document

COMMUNICATION FROM THE COMMISSION
TO THE EUROPEAN PARLIAMENT, THE COUNCIL, THE EUROPEAN ECONOMIC AND SOCIAL
COMMITTEE AND THE COMMITTEE OF THE REGIONS

Towards a job-rich recovery

TABLE OF CONTENTS

1........... Introduction.................................................................................................................... 1

2........... Defining and measuring
healthcare jobs............................................................................ 1

3........... Key challenges facing the EU
Health Workforce.............................................................. 3

4........... Actions to promote a sustainable
workforce for health in Europe...................................... 8

5........... Delivering the actions.................................................................................................... 12

Disclaimer: This document is a European Commission staff working
document for information purposes. It does not represent an official position
of the Commission on this issue, nor does it anticipate such a position.

1.           Introduction

The healthcare sector constitutes one of
the most significant sectors in the EU economy with an important employment
potential due to an ageing population and increasing demand for healthcare.

However, the sector faces major challenges
which are similar to all Member States: the health workforce itself is ageing
with insufficient new recruits to replace those that are retiring, problems of
retention due to demanding working conditions and relatively low pay in some
health occupations. In addition, new care patterns to cope with chronic
conditions of the elderly and the rise in new technologies will require new
skills and competences.

Given the
current tough budget constraints, health expenditures are under strong pressure
to provide high quality healthcare cost effectively and to make fundamental
reforms in the way in which they deliver healthcare. EU health systems need to
find innovative solutions through new technologies, products and organisational
changes which depend on a high quality motivated health workforce of
sufficient capacity and with the right skills to meet the growing demands of
healthcare.

Recognising the European dimension of the
challenges at hand, Members States agreed on the added value of EU action and
European collaboration, inviting the Commission to propose an action plan to
assist Member States tackle the key challenges facing the health workforce in
the medium to longer term[1].

This Commission
Staff Working Document describes the contribution of the EU's health workforce
to meet the 2020 employment target of 75% for women and men aged 20-64. It
provides the rationale for measures proposed in the action plan, annexed to the
accompanying Communication
"Towards a job rich recovery", to assist Member States to address the
shortages of the EU health workforce and boost job creation in the sector.

2.           Defining
and measuring healthcare jobs

The healthcare
sector comprises workers primarily delivering healthcare services such as
health professionals (doctors, nurses, midwives, pharmacists and dentists),
allied health professionals, public health professionals, health management and
administrative and support staff. Many people also work indirectly for the
healthcare sector such as those employed in the healthcare industries and
support services, pharmaceutical, medical device industries, health insurance,
health research, e-Health, occupational health, spa etc[2].

Health
professionals can be salaried or self employed. In several countries[3] General Practicians and
outpatient specialists are mostly independent self employed with private
practices or are contracted by funds or hospitals to provide services.

The healthcare
workforce thus makes up a large part of the so-called "white jobs"
which also include professionals delivering social care services.

A modern and
innovative healthcare sector is a driver for economic growth as keeping people
healthy benefits productivity and competitiveness. The healthcare sector is
also a key driver for research and development and absorbs the highest amount
of innovative products and services.

Healthcare is a
highly labour intensive activity and one of the largest sectors in the EU: in
2010 there were around 17, 1 million jobs in the healthcare sector which
accounted for 8% of all jobs in EU-27[4].
The number of jobs in the sector increased by 21% between 2000-2010 creating 4
million new jobs. Even during the economic crisis, employment in the healthcare
sector has continued to grow: while overall employment
fell by 5 million people over the period 2008-2010, the healthcare sector
increased its share of total employment by half a percentage point, creating more than 770 000 new jobs[5].

Most
importantly, this positive trend is reflected across
all age groups and includes a 3% rise in the employment
of young people when youth employment fell by 11.3 % in the economy overall[6].

Figure 1:
Employment growth in health & residential care sector, 2008-10 by age
groups

Source: based on Eurostat Labour Force Statistics for
NACE Rev.2 sectors 86 and 87

As regards the level of education, the
health and social work[7]
sector employs a higher than average number of highly educated people.
According to Eurofound's data on working conditions[8], more than 55% of people
employed in this sector hold at least a post-secondary degree whereas the
average for all sectors is below 33%.

The
employment trend observed so far in the healthcare and social sector will
continue[9]. It
will remain a growing sector according to the forthcoming CEDEFOP skills
forecasts[10],
even though employment growth will be more modest compared to 2000-2010. More
than 1 million new jobs are expected to be created between 2010-2020. The
growth rate in this sector is projected to be 5%, which is higher than EU
average slightly above 3%. There will be about 7 million additional job
openings between 2010-2020 due to replacement needs. Together with net
employment change around 8 million of total job openings are projected. Most
jobs will require highly qualified people (more than 5 million) while the need
for medium qualified personnel will remain rather significant (around 3
million). Around 200 000 job openings will be for low qualified people.

3.           Key Challenges Facing the EU Health
Workforce

Labour
demand will increase as the population ages...

The demand for
healthcare will increase dramatically with Europe's ageing population. The
number of elderly persons aged 65 and over is projected to almost double over
the next 50 years, from 87 million in 2010 to 152,7 million in 2060[11]. Long-term
and formal care is likely to increase with an expected reduction in the
availability of informal carers, for example as a result of changing family
structures.

... with
consequences for future skills and competences...

These
demographic changes will have significant consequences on the way in which
healthcare systems respond to patient needs. The increasing numbers of elderly
people with multiple chronic conditions will require new
treatments and new care delivery models and necessitate changes in skill mixes
and new ways of working for health professionals.

... while the
number of health professionals decreases...

Most Member
States are currently facing critical workforce shortages - in certain health professions and medical specialisations
or geographic areas – which could be exacerbated if no action is taken. The retirement
bulge is drastically shrinking the EU's healthcare workforce. In 2009, about
30% of all doctors in the EU were over 55 years of age and by 2020 more than 60
000 doctors or 3.2% of all European doctors are expected to retire annually.
Based on data collected by some Member Sates[12]
the average age of nurses employed today is between 41-45 years.

Figure 2:
Number of physicians by age group in 17 EU member States in 2004 and 2008

Source: Eurostat, 2011. Absolute numbers. Data
available from 17 MS: AT, BE, CZ, DK, DE, ES, FI, FR, HU, IT, LV, LT, NL, RO,
SK, SE, UK – note that for F, NL and IT data refers to professionally active
doctors who may or may not have direct contact with a patient.

... and
difficulties to recruit and retain healthcare staff

This retirement
bulge risks not being offset by a sufficient number of new healthcare
professionals. Not enough young recruits are coming through the system to
replace those who leave: In Italy, 13 400 nurses were due to retire in 2010,
but only 8500 nurses graduated in 2008-2009. Germany is facing serious
difficulties in training sufficient number of graduates, Slovakia has
insufficient nurses, midwives, physiotherpists, radiological assistants and
paramedics and Hungary faces serious bottlenecks in supply caused by reductions
in nurse training. Unfilled specialist training places are reported in Romania,
France, Hungary and Austria[13].
The health labour market has to compete with other employers for the younger
generations making career choices. On the other hand, people who have recently
left the health workforce to take up other types of jobs, may consider
returning to the health sector because of greater job security.

Evidence from
some countries shows an increasing turnover in the health professions. Low pay,
but also non financial factors such as long working hours, stress or difficult
work life balance constitute reasons for healthcare workers to leave their jobs[14]. Preliminary findings from one
the largest nursing workforce studies ever conducted in Europe and the USA, Nurse
Forecasting in Europe (RN4Cast)[15],
confirm that, despite considerable differences in health systems, all twelve European
countries studied face problems of nurse burnout and dissatisfaction due to working
conditions. Many European nurses report they intend to leave their hosptial
positions, from 19 % in the Netherlands, rising to 49% in Finland and Greece.

The issue of
work life balance is all the more relevant in the healthcare sector as the
participation of women in the workforce has historically been significant and
is increasing. Overall, there were more than 13,1 million women working in the
healthcare sector in 2010, making up up more than three quarters of the health
workforce in the EU[16].
In many Member States the intake of women to medical schools is now over 50%.
However, so far, this growing feminization of the healthcare workforce has not
always been properly reflected in measures to improve the reconciliation of
professional and private life. It is a factor which might increase the difficulties
to retain the healthcare workforce in the future.

Moreover,
although skill levels are relatively high and working conditions are often
demanding (for instance, night and shift work), overall wage levels in the health and
social services sectors tend to be lower than in other sectors of the economy.
This tendency, which is related to the high rate of female employment in the
sector and to the gender pay gap, is becoming more pronounced[17] and may be regarded as another
disincentive to work in this sector.

The working
conditions and the level of wages of the healthcare workforce may be affected
longer term by the current economic crisis. There is recent and worrying
evidence that the cost containment measures to reduce public expenditure is
profoundly affecting the recruitment and retention of healthcare staff and in
particular nurses, the largest health profession, in almost half of EU 27[18]. Maintaining an adequate
supply and quality of healthcare services under severe budget constraints is
thus a key issue to be addressed by policy makers.

... resulting
in worsening healthcare labour shortages

Without further
measures to meet these challenges, the Commission estimates a potential
shortfall of around 1 million healthcare workers by 2020 rising up to 2 million
if long term care and ancillary professions are taken into account[19]. This means around 15% of
total care will not be covered[20]
compared to 2010.

Potential
shortfalls might worsen the working conditions and increase pressures on the
healthcare workforce raising concerns over the impacts on patient safety and
quality of care.

Table 1: SHORTAGES
IN SELECTED EU MEMBER STATES

Country ||

Bulgaria || There is an acute shortage of nurses and medical specialists (in particular of anaesthesiologists, gynaecologists and paediatricians).

Finland || Shortages are particularly severe in health centres in remote rural municipalities. Significant shortage among dentists. 235,450 additional vacancies in the healthcare and social sector projected over the period 2008-2025.

France || Shortages of obstetrics and gynaecologists. Geographic misdistribution of physicians and nurses

Germany || Shortage of 17,000 doctors in 2010, rising to 45,000 doctors by 2020 and 165,000 by 2030. Projections for other health professions: 150,000 in 2020, rising to 800,000 in 2030. There is also a shortage of elderly care nurses.

Hungary || 19% of available posts of public health physicians were vacant and 13% of posts of physicians in 2008.

Netherlands || Shortages of doctors in the mental healthcare sector, dental surgeons, gastroenterologists, nuclear physicians, nurses in homes for the elderly and in nursing homes.

Spain || Forecasting shortfall of 14 % of medical specialists (including GPs) by 2025. Persistent shortages of specialists in anaesthetics, orthopaedic and traumatic surgery, paediatric surgery, reconstructive surgery, family and community medicine, paediatrics, radiology and urology.

UK || Severe shortages of 35 specific health-related professions, including medical practitioners, specialist nurses, midwifes and therapists. Vacancy rates pharmacy (5.3% vacancy rate), other physiological sciences (7.6%), and respiratory physiology (6%). Estimates for 2014 the average number of entry-level posts for specialty training will be around 6511. Unless training posts are revised accordingly, there might be a shortage of GP and medical specialists of more than 6,000.

Source: European Commission
(forthcoming in 2012), Feasibility Study EU level collaboration on forecasting
health workforce needs, workforce planning and health workforce trends

Table 2: estimated shortage in healthcare sector by 2020

Many Member States also face the challenge of shortages caused by an
unequal distribution of health professionals within their country, raising
serious concerns over the availability of healthcare in certain regions. The EU
research project on Health Professional Mobility and Health Systems
(PROMeTHEUS)[21] provides evidence from 17 European countries, that there is an
undersupply of health professionals in rural and sparsely populated areas, for
example in Denmark, Finland, France, Germany, Romania, and an oversupply of
doctors in some urban areas, particularly in Germany, and an oversupply of nurses
in Belgium.

In addition,
the number of medical specialists is increasing much more rapidly than
generalist practitioners[22]. This trend is raising concerns about the access to care for
certain population groups. Many countries are therefore looking to improve the
attractiveness of general practice as well as the development of new roles
other healthcare providers.

With regard to
mobility of health professionals within the EU, the PROMeTHEUS research
concludes there are significant differences in cross-border movements with a
clear east-west asymmetry for doctors, nurses and dentists. While all 27 Member
States experienced migration of health professionals, western and northern
Member States are simultaneously receiving health professionals from other
countries. However, based on the limited data available, outflows have rarely
exceeded 3% of the domestic workforce, although there are serious shortages in
certain medical specialists in some countries.

The EU faces
competition from other countries as many health professionals migrate to non-EU
countries: for example, health workers migrate to the United States, Australia,
New Zealand and Canada and the inflows of foreign doctors with long-term
permits have also increased markedly in Switzerland (+70% between 2001 and
2008), mainly from Germany[23]. Forthcoming findings from the EU project Mobility of Health
Professionals (MoHPRof[24]) will improve understanding of the
complex phenomenon of international migration of health workers in 25 countries
with a focus on migration within, to and from the EU.

The high
outflow of health professionals ("brain drain") has provoked policy
debates on the impact on healthcare systems in some Member States, reinforcing
the need for accurate and comparable data on mobility and migration flows in
the EU to develop policy responses based on evidence.

Health workforce shortages in many Member
States have increased the reliance on the recruitment of healthcare
professionals from outside the EU. National patterns of migration flows of
doctors coming from outside the EU vary widely: out of 10 Member States, nearly
30% of all migrant doctors come from outside the EU in Austria, Belgium,
Denmark, Germany, Netherlands and Poland. This figure rises to 60% in France
and Italy and to 80% in Ireland and the UK[25]. To
mitigate the negative effects of migration on fragile health systems, Member
States are committed to the 2010 WHO Global Code on the international
recruitment of health personnel, currently in its implementation phase.

4.           Actions to
promote a sustainable workforce for health in Europe

Recognising the
European dimension of the above challenges, Member States agreed on the added
value of European cooperation to help tackle EU health workforce shortages and
invited the Commission to propose concrete actions in the following areas,
bearing in mind the Member States competence for organising and delivering
healthcare systems[26]:

· 
Forecasting workforce needs and improving
workforce planning methodologies

· 
Anticipating future skills needs in the health
professions;

· 
Share good practice on effective recruitment and
retention strategies for health professionals

These areas for action reflect feedback
from the Commission's public consultation on the Green Paper European Workforce
for Health[27] which drew over 200 responses from a wide range of stakeholders,
the majority of which saw added EU value in European collaboration to exchange
best practice, to foster European networks and to improve European data on the
health workforce.

4.1.        Forecasting Health Workforce
Needs

Across the EU there is growing interest in
the development of integrated health workforce planning and forecasting which
takes account of a number of factors – the age, gender, number, specialisations
and distribution of health workers, skills and competence mix, working
practices – to develop policy interventions and inform investment decisions in
education, training and recruitment to better match demand and supply of health
professionals while offering long-term job prospects for healthcare workers.

A three year EU joint action on
forecasting health workforce needs for effective planning in the EU will be
launched by the end of 2012. This joint action, as foreseen in the 2012 work
plan of the Health Programme[28], will create a partnership of Member States and professional
organisations to share good practice and to develop methodologies on
forecasting health workforce and skill needs, workforce planning methods and to
improve EU wide data availability on mobility and migration trends of health
professionals.

To assist Member States with forecasting
scenarios on the future training needs for health professionals, a study will
be carried out, in cooperation with the OECD, on the structure and training
capacities in the EU. Moreover, the Commission will work with partners in the EU
joint action on workforce planning to produce guidance to develop effective partnerships
to make best use of training capacities and to help respond to recent
European Court of Justice cases on the mobility of medical students[29].

4.2.        Anticipating skills needs in the health professions

Anticipating future skill needs for health
professionals to meet new healthcare demands is a further challenge. Member States need to act swiftly to avoid skills mismatches and
gaps in the healthcare sector to ensure tomorrow's health professionals are
equipped with the right skills.

While national health authorities are
responding to the challenge of delivering high quality healthcare in different
ways, there are nonetheless common trends in the EU which are changing the way
in which health professionals work and creating new employment opportunities in
healthcare:

The development of new integrated care
delivery models - with a shift from care in hospitals to the delivery of
primary care closer to home - to cope with elderly patients with multiple
chronic conditions, such as heart disease and diabetes, requires different
skill mixes and, new ways of working within a wider interdisciplinary team.

The growth of new technologies, new
medical appliances and diagnostic techniques, requires technical know-how
in addition to clinical knowledge. The expansion of e-health, which enables
distant diagnostics services, is leading to new ways of working and a new mix
of skills including technical and e-skills. The expansion of telemedicine, to
improve access to specialised health services will require doctors to work
beyond the boundaries of face-to-face counselling and to be trained to work in
a technological environment.

The operation of e-health systems such as
telemonitoring for nurses or teleradiology will change work patterns and open
new job opportunities in the healthcare sector, including the need for ICT
specialists.

Figure 4: Health
Professionals in Europe: New Roles, New Skills

Source:
European Hospital and Healthcare Federation (2009), Health Professionals in
Europe: New Roles, New Skills

At the same time the increased use of
telemedicine will help address shortages of health workers and secure better
healthcare coverage in remote areas as it will enable medical specialists to
provide quality services to more patients in different care settings and across
different Member States.

Member
States need to adjust their education and training curricula to fast moving
changes in healthcare and to equip people with the right skills for the job
market and improve their employability. These changes require increased
coordination between education/training providers and employment to assess and
anticipate the different mix of skills and competencies needed in the
healthcare sector in the future.

At EU level, there are several actions under
development to assist Member States to better anticipate skills' needs and
competences in the healthcare sector: an EU skills council in the area of
nursing and care, which will review the competence profiles of the nursing and
care sector, and a pilot health care assistants expert network and database[30] which will examine the scope of skills
and competences required from healthcare assistants for uptake by national
education and training programmes. In addition, the EU joint action on health
workforce planning (cf. 4.1.) will develop European guidelines on forecasting
methodologies and analyse future skills need in the healthcare sector.

The outcomes from these initiatives will
contribute to the EU skills panorama[31] to be
launched by the end of 2012 will provide a comprehensive overview of emerging
skills needs as they evolve up to 2020. Furthermore, the common multilingual
classification of occupations, qualifications and skills (ESCO), will
provide a resource for education and training providers in the healthcare
sector. The outcome of these initiatives needs also to be aligned with the
proposal on the modernisation of the Professional Qualifications Directive once
agreed by the Council and the European Parliament.

To help bridge the gap between education
and employment, a pilot EU sector skills alliance in the healthcare sector
will seek to investigate the feasibility for developing new sector–specific
curricula and innovative forms of vocational teaching and training[32].

Transnational mobility offers access to new
jobs and new training opportunties to enhance skills. Intra-EU professional
mobility, facilitated by the Directive 2005/36/EC on the mutual recognition
of professional qualifications, can help address the mismatches between
labour supply and demand, while offering health professionals new career and
training opportunities or better pay and conditions. The Commission proposal to
modernise the Directive[33] aims to simplify rules and make it easier
for health and other regulated professionals to practise in other EU countries.

The EU funding programmes Erasmus and Leonardo da Vinci[34] and its proposed successor programme Erasmus
for All 2012-2014[35] provide support for cross-border
education and training, also for medical students and healthcare workers. More
promotion could help raise the visibility of these programmes in the healthcare
sector

Access to lifelong
learning and continuous professional development (CPD) plays an
important role to update professional competence and also to motivate and
retain staff. The Directive on the mutual recognition of professional
qualifications obliges Member States already since 2005 to ensure that
individuals are able to keep abreast of professional developments to the
extent necessary and the Commission's recent proposal would require Member
States to report to the Commission and other Member States on their continuing
education and training procedures related to the regulated health professions[36].

CPD systems and regulations vary
significantly across Member States and country specific data remain scarce. A
majority of stakeholder respondents and the European Parliament[37] suggested that, while lifelong learning is a competence of the
Member States, European collaboration in sharing good practice on CPD approaches
and accreditation systems would also help improve mutual understanding between Member States.

4.3.        Share good practice on effective recruitment and
retention of health professionals

To ensure a sustainable health workforce in
the EU crucially depends on atttracting people to work in the healthcare
services as well as retaining qualified experienced staff in a highly
competitive global labour market.

Member States need to step up efforts to
attract and recruit young people into the health professions and raise
awareness in schools on the high employment potential of the healthcare sector
and the wide variety of careers available in the healthcare sector requiring
different skills and levels of qualifications. Moreover, return to work
campaigns are important to attract experienced older health workers back into
the professions.

While wage levels play a crucial role,
non-financial factors such as a supportive and safe work environment are
important to recruit and retain health workers, particularly women[38], Moreover, recent evidence from the project Nurse forecasting in
Europe (RN4Cast) suggests that low cost approaches to improve the hospital
work environment, through nurse participation in decision-making or
managerial support for nursing care for example, can retain staff. Workforce
planning should therefore factor in an analysis of the work environment as it
influences recruitment, retention, mobilty, performance and ultimately health
outputs and quality of care[39].

The European Social Dialogue in the hospital
and healthcare sector[40] has led to several agreements aimed at
improving working practices, among which Council Directive 2010/32/EC on the
prevention of sharp injuries in the hospital and healthcare sector, the Code of
Conduct on the Ethical Cross-Border Recruitment and Retention in the Hospital
Sector, and the Framework of Actions on Recruitment and Retention. Working
conditions are an important factor to retain workers in the health professions
as they grow older and the Commission is working closely with the social
partners, European Federation of Public Service Unions (EPSU) and European
Hospital and Healthcare Employers Association (HOSPEEM), on the EU Social
Dialogue Committee to develop common guidelines in relation to the ageing
workforce As set out in the Commission's White Paper on sustainable pensions[41], Member States need to adapt work place and
labour market practices to improve opportunities for older workers.

Feedback from
stakeholders and Member States[42] suggest that the EU could assist in further exploration of factors
that contribute to a supportive working environment and that European
cooperation could help promote good practice on innovative and effective
recruitment and retention strategies in the EU.

4.4.        Addressing the ethical recruitment of health
professionals

There is a range of EU policies in the
fields of education, development aid and migration policy which support the
implementation of the WHO Global Code on the international recruitment of
health personnel and reinforce Member States' commitment to the Code to help
reduce the negative impact of migrants' flow on fragile healthcare systems.

The EU Blue
Card Directive which facilitates the admission of highly qualified migrants in
the EU also allows Member States to reject applications in order to ensure
ethical recruitment from countries suffering from a lack of qualified workers[43], for example in the health sector. Member States using this
possibility must communicate to the Commission and the other Member States the
countries and sectors involved[44]. The Commission must present a report on the application of the
Directive in 2014, which will be an occasion to look at how, and to what
extent, these provisions on ethical recruitment have been used.

5.           Delivering
the Actions

Implementation
of actions to tackle the challenges facing the EU health workforce requires enhanced
cooperation - between the Commission, the Member States, stakeholders,
social partners - and improved coordination across a range of policies - health,
education, social policy, employment, internal market, development and cohesion.

Member States are urged to maximise the
use of European funding instruments to support
actions to tackle health workforce shortages and to boost job creation in the
healthcare sector:

In line with the Common Strategic Framework[45], the proposed Cohesion
and Structual Funds 2014-2020 could be used for investments in jobs in
the healthcare sector, for example to support measures for upgrading skills and
training as well as counselling on long-term employment opportunities in the
healthcare sector.

The EU programmes Leonardo da Vinci[46] and Erasmus[47] and the proposed successor "Erasmus
for All"[48]
support cross-border education and training projects to help healthcare workers
to develop new skills and to support schemes to attract young people into the
healthcare sector.

The proposed Health for Growth
Programme 2014-2020[49]
puts the contribution of innovative and sustainable health systems to
economic growth as a key objective. The programme proposes to help Member
States to develop common tools and mechanisms at EU level to address shortages
of resources and to facilitate the uptake of innovation in healthcare.

[1]               See conclusions of the 3053rd
EPSCO Council meeting, Brussels, 7 December 2010, Investing in Europe's
health workforce of tomorrow: Scope for innovation and collaboration.

[2]               Alcimed (2010), Study on
Healthcare Services, Sectors and Products in Europe for the European
Commission, Final Report February 2010

[3]               AT, BE, DK, FR, DE, EL, NL, LU,
SK – European Economy, Joint Report on Health Systems, December 2010cf. p. 111

[4]               Eurostat (2011) NACE Rev.2 categories 86 & 87

[5]               Eurostat (2011) NACE Rev.2 categories 86 & 87

[6]               Eurostat (2011)

[7]               Disaggregated data for the
healthcare sector only are not available

[8]               Eurofound (2010)

[9]               Disaggregated data for the
healthcare sector only are not available

[10]             Based on new CEDEFOP skills
demand and supply forecast in 2012
(http://www.cedefop.europa.eu/EN/about-cedefop/projects/forecasting-skills-demand-and-supply/skills-forecast.apx)

[11]             Eurostat: Europop2010 population projections (online data code:
proj_10c2150p)

[12]             Based on data collected from 6
MS: DE, DK, IE, FR, SE, UK. (http://www.euro.who.int/en/what-we-do/health-topics/Health-systems/health-workforce/facts-and-figures,
http://www.icn.ch/images/stories/documents/pillars/sew/DATASHEET_SUMMARY_NURSING_PROFILE_2011.pdf

[13]             M. Wismar, C. B. Maier, I. A. Glinos, G.
Dussault and J. Figueras (eds., 2011), Health professional mobility and health
systems. Evidence from 17 European countries, Observatory Study Series No. 23,
European Observatory on Health Systems and Policies, WHO Regional Office for
Europe, Copenhagen. (http://www.euro.who.int/__data/assets/pdf_file/0017/152324/e95812.pdf)

[14]             More detailed analysis can be found in the
Employment in Europe 2009 report and the Second Biennial Report on social
services of general interest, 2011 (http://ec.europa.eu/social/main.jsp?catId=794&langId=en&pubId=5940&type=2&furtherPubs=yes).

[15]             RN4CAST (forthcoming 2012), Nurse
forecasting: Human resources planning in nursing. 12 European countries
(Belgium, UK, Finland, Germany, Greece, Ireland, Norway, Poland, Spain, Sweden,
Switzerland and Netherlands) and also USA, China, Botswana and South Africa

[16]             Eurostat (2011), NACE Rev.2
categories 86 & 87

[17]             More detailed analysis can be found in the
Employment in Europe 2009 report and the Second Biennial Report on social
services of general interest, 2011 (http://ec.europa.eu/social/main.jsp?catId=794&langId=en&pubId=5940&type=2&furtherPubs=yes).

[18]             European Federation of Nurses
(2011), Caring in Crisis: The Impact of the Financial Crisis on Nurses and
Nursing, A Comparative Overview of 34 European Countries

[19]             These figures are subject to several assumptions and hypotheses.

[20]             An Agenda for new skills and
jobs: A European contribution towards full employment, COM (2010) 682
final.

[21]             M. Wismar, C. B. Maier, I. A. Glinos, G. Dussault and
J. Figueras (eds., 2011), Health professional mobility and health systems.
Evidence from 17 European countries, Observatory Study Series No. 23, European
Observatory on Health Systems and Policies, WHO Regional Office for Europe,
Copenhagen.
(http://www.euro.who.int/__data/assets/pdf_file/0017/152324/e95812.pdf)

[22]             OECD report 2010 "Health
at a Glance", http://www.oecd.org/health/healthataglance/europe

[23]             OECD policy brief on the
migration of health workers, February 2010, www.oecd.org/publications/Policybriefs

[24]             EU project, Mobility of Health
Professionals (MoHPRof), http://www.mohprof.eu/LIVE/

[25]             Gilles Dussault, Inês Fronteire
and Jorge Cabral (2009) Instituto de Higiene e Medicina Tropical, Lisbon,
Migration of health personnel in the WHO European Region.

[26]             Council Conclusions (7 December
2010), Investing in Europe's health workforce of tomorrow: Scope for innovation
and collaboration.

[27]             Commission report on the open
consultation on the Green Paper on the European Health Workforce, 2010

[28]             Commission Implementing Decision (2011/C/ 358/06

[29]             C-73/08; C-417/03

[30]             http://www.hca-network.eu

[31]             Communication "Towards
a job rich and inclusive recovery, COM add ref 2012

[32]             Erasmus Programme
2012

[33]             EC Directive on the mutual
recognition of professional qualifications, 2005/36/EC.

[34]             http://ec.europa.eu/dgs/education_culture/index_en.htm

[35]             Erasmus for All, the EU
Programme for Education, Training , Youth and Sport, COM (2011) 787 final

[36]             Article 22, EC Directive on the
mutual recognition of professional qualifications, 2005/36/EC.

[37]             EP Report on the implementation
of the Professional Qualifications Directive, Committee on the Internal Market
and Consumer Protection (2005/36/EC) (2011/2024(INI)).

[38]             WHO Policy Brief How to create
an attractive and supportive working environment for health professionals,
Health Evidence Network and the European Observatory on Health Systems and
Policies, 2010

[39]             Interview with RN4Cast
coordinator, http://www.rn4cast.eu/en/index.php

[40]             http://ec.europa.eu/social/main.jsp?catId=480&langId=en&intPageId=37

[41]             White Paper "An agenda for
adequate, safe and sustainable pensions", COM (2012) 55 final

[42]             Council Conclusions Scope of
innovation and collaboration, 7 December 2010

[43]             Article 8(2) and recital 22

[44]             Article 20

[45]             Common Strategic Framework

[46]             Leonardo Da Vinci Programme, http://ec.europa.eu/education/programmes/leonardo/leonardo_en.html

[47]             Erasmus Programme, http://ec.europa.eu/education/lifelong-learning-programme/doc80_en.htm

[48]             COM(2011) 787 final
Communication from the Commission to the European Parliament, the Council, the
European Economic and Social Committee and the Committee of the Regions Erasmus
For All: The EU Programme for Education, Training, Youth and Sport

[49]             Proposal for a Health for
Growth Programme 2014-2020, COM (2011) 709 final of 9.11.2011