REPORT FROM THE COMMISSION ON SPECIFIC TRAINING IN GENERAL MEDICAL PRACTICE PROVIDED FOR BY TITLE IV OF COUNCIL DIRECTIVE 93/16/EEC OF 5 APRIL 1993 TO FACILITATE THE FREE MOVEMENT OF DOCTORS AND THE MUTUAL RECOGNITION OF THEIR DIPLOMAS, CERTIFICATES AND OTHER EVIDENCE OF FORMAL QUALIFICATION
Date: 1996-09-09
Institutions: European Commission
Subjects: freedom to provide services, medical training, physician, recognition of diplomas, right of establishment

COMMISSION  OF THE EUROPEAN  COMMUNITIES 

Brussels, 09.09.1996 
COM(%) 434 final 

REPORT FROM THE COMMISSION! 

ON SPECIFIC TRAINING IN GENERAL MEDICAL PRACTICE 

PROVIDED FOR BY TITLE IV OF COUNCIL DIRECTIVE 93/16/EEC 

OF 5 APRIL 1993 TO FACILITATE THE FREE MOVEMENT OF DOCTORS 

AND THE MUTUAL RECOGNITION OF THEIR DIPLOMAS,  CERTIFICATES 

AND OTHER EVIDENCE OF FORMAL QUALIFICA TION 

INTRODUCTION 

This  report  relates  to  the  application  of  Title  IV  of  Council  Directive 93/16/EEC  of  5 
April  1993  to  facilitate  the  free  movement  of doctors  and  the  mutual  recognition  of  their 
diplomas, certificates  and  other evidence  of formal  qualifications1. 

'Doctors  Directive')  constitutes 

This  Directive  (hereinafter  referred 
the 
to  as  the 
codification  of  all  the  directives  adopted  between  1975  and  1993  regarding  the  mutual 
recognition  of  doctors  qualifications  and  containing  measures  designed  to  facilitate  the 
effective  exercise  of  the  right  of  establishment  and  the  free  provision  of  services  as  well 
as those  designed  to  co-ordinate  the  legislative,  regulatory  and  administrative  provisions 
concerning  the activities  of doctors. At the time of the consolidation  of these directives, it 
was judged  appropriate  to  incorporate  Council  Directive  86/457/EEC,  of  15  September 
1986,  relating  to  specific  training  in  general  medicine2.  It  is  this  Directive  which  now 
constitutes  Title  IV of the  Doctors  Directive. 

Title  IV  of the  Doctors  Directive  provides  that  the  Commission  is to present  two  reports. 
Article  33  reads  as  follows:  "On  the  basis  of  experience  acquired,  and  in  the  light  of 
developments  in training  in general  medical practice,  the  Commission  shall  submit  to  the 
Council,  by  I  January  1996  at  the  latest,  a  report  on  the  implementation  of Articles  31 
and  32." 

Article 40  provides  that  "On  the  basis  of  experience  acquired,  and  in  the  light  of 
developments  in training  in general  medical practice,  the  Commission  shall  submit  to  the 
Council  by  1 January  1997 at  the  latest  a report  on.the  implementation  of  this  Title  and, 
if  necessary,  suitable  proposals  with  a  view  to  appropriate  training  for  every  general 
medical  practitioner  in order  to satisfy  requirements  of general  medical  practice.  " 

During  the  work  conducted  within  the  framework  of  the  Advisory  Committee 
on 
Medical  Training  (ACMT)  with  a  view  to  the  preparation  of  the  report  envisaged  by 
Article  33,  it  quickly  became  obvious  that  the  examination  of  the  content  of  specific 
training  in  general  medicine,  the  minimum  requirements  of  which  are  contained  in 
Article  31, must  be  placed  in  a  more  general  context.  This  position  is  supported  by  the 
reasoning  behind  Directive  86/457/EEC,  from  which  it  is  clear  that  the  introduction  of 
specific  training  in general  medicine must be achieved  progressively. 

1  OJn°L  165, 07.07.1993, p.L 

2  OJ n°L 267,  19.09.1986, p.26. 

According  to the sixth  recital  of that  last  mentioned  directive,  Ihc  first  step required  the 
Member  States  to  establish,  in  respect  of  general  medicine,  specific  training,  training 
which  at  that  stage  was optional  for  doctors.  The second  stage  was  the  requirement  for 
specific  training  in  general  medicine  for  all  doctors  practising  general  medicine  within 
national  social  security  schemes.  The  third  step  is  the  presentation  of  a  report  to  the 
Council  on  the  developing  situation  and  new  proposals  with  a view  to  achieving  these 
objectives. In describing these three steps the Commission, in its preparatory documents, 
(travaux  préparatoires),  stated,  concerning  the  third  step  "regarding  the difference from 
the two first  steps, it does not envisage legislative,  or regulatory,  reform, but provides for 
reflection before the finalisation  of  the objectives envisaged,  to consider the putting  in 
place  of the second step in all the Member States and to determine what role to bestow, 
within  the  national  medical  treatment  systems,  on  doctors  with  no  complimentary 
training whether as a generalisl or specialist". 

The work of the working group of the ACMT resulted  in the preparation  of a report and 
recommendations. These  recommendations, which  arc annexed  to this document,  reveal 
the numerous aspects examined by the working group. 

In  the  circumstances,  the  Commission  docs  not  consider  it  appropriate  to  alter  the 
conclusions of the ACMT but rather  to present  all  the questions  already  considered  in a 
single report corresponding to the requirements of both Articles 33 and 40 of the Doctors 
Directive. 

This  report  is  above  all  a  consultative  document  designed  to  provide  input  for  the 
dialogue which the Commission wishes to initiate with the institutions, bodies and parties 
concerned by specific training in general medical practice. 

It therefore does not contain any legislative proposal. 

- 3-

SECTION 1 

Introduction 

1.1. 

This  report  contains  the Commission's  submissions  in accordance  with  Article 
33 and Article 40 of the Doctors'  Directive on: 

(a) the  implementation  of  Title  IV and  in  particular  Articles  31 and  32 thereof 
(minimum requirements for specific training for general medical practice); 

(b) analyses  with  a  view  to  achieving  further  harmonization  of  the  training  of 

general medical practitioners and completing the reform; and 

(c) the conclusions to be drawn from experience. 

1.2. 

The  report  is  in  five  sections.  Section  1  contains  the  introduction  and 
background,  Section  2  describes  the  impact  of  introducing  specific  training  in 
general  medical  practice  in all  national  training  systems,  Section  3 presents an 
analysis of possible revision of the Directive, Section 4 outlines the conclusions 
to be drawn from  experience and summarizes the analysis, and Section 5 sets out 
the final conclusions. 

1.3. 

This  report  incorporates  in  particular  the  recommendations  of  the  Advisory 
Committee  on  Medical  Training  and  the  recommendations  of  the  European 
Union of General  Practitioners  (UEMO) (see section 3). 

Background 

1.4. 

Directive 86/457/EEC  (now  Title  IV  of  the  Doctors  Directive)  provided  for 
specific  training  in  general  medical  practice  and  set  a  clear  timetable  for  its 
introduction.  In  1975 specific  training  for  general  medical  practitioners  existed 
in  some  Member States,  e.g.  the  Netherlands  and  Denmark.  However,  it  was 
then  considered  premature 
the 
European Community.  Title IV  was  based  on  the  Report  and  Opinion  of  the 
ACMT adopted in March  1979.3 

introduce  such 

throughout 

training 

to 

1.5. 

The  1986 provisions were introduced step by step. Member States were required 
to  set  up  specific  training  in  general  medical  practice  such  that  the  first 
qualifications  on  completion  of  training  could  be  issued  by  1  January  1990 
(Article 30). It was only on  1  January  1995 that all general medical practitioners 

3  ACMT  Doc.  III/D/697/3/77. 

- 4-

working  in  the  social  security  systems  of  Member  States  were  obliged  to  have 
Article  30  qualifications  (Article  36(1)).  Article 40  of  the  Doctors'  Directive 
envisages  that  specific  training  for  every  general  medical  practitioner  could  be 
introduced  as a final step after  1997. 

This  long  lead-in  period  for  spccilic training  in general  medical  practice  was  felt 
to  be  necessary  at  the  time  to  prepare  the  European  Community  for  what  was 
The  idea  was  to  recognize  the  general  medical 
then  a  new  discipline. 
practitioner's  specific  role  and  function  within  the  health  care  system  of 
Member  States.  In  many  Member  States  general  medicine  has  now  become  a 
medical  speciality,  like  other  medical  specialities  listed  in  Article  5 or  Article  7 
of the  Doctors  Directive. 

It  should  be  noted  in  this  connection  that  the  ACMT  recommended  that  the 
Member  States recognize  general  medicine  as a specific  discipline, on a par  with 
the  recognized  specialist  disciplines  (recommendation  of  March  1979  already 
mentioned  at  point  1.4.).  It  should  be  remembered  that  the  third  step  was  to 
make  specific  training  in  general  medical  practice  compulsory  for  all  those  who 
practice  general  medicine.  In  other  words,  the  basic  training  envisaged  by  the 
Doctors  Directive  would  lead  only  to  a qualification  granting  entry  to  specialist 
training,  including  specific  training  in general  medicine. 

The  staged  process  was  also  necessary  to  allow  Member  States  to  adjust  their 
training  schemes  so  as  to  make  provision  for  the  adequate  placement  of  young 
doctors.  In  some  Member  States  the  concept  of  general  medical  practice  was 
not  as  developed.  It  is  for  this  reason,  that  it  has  been  judged  necessary  to 
proceed  by  successive  steps.  It  is  considered  that  the  adaptation,  notably  of  an 
educational  nature,  will  require  considerable  time. 

Article  31  (3)  makes  the  possession  of  a  formal  qualification  referred  to  in 
Article  3,  a  condition  for  the  issue  of  an  Article  30  qualification.  Article  31 
also  contains  the  minimum  content,  duration  and  other  general  criteria  for  the 
specific  education  and  training  of  general  medical  practitioners. 

In  Article  32  a  derogation  on  a  temporary  basis  was  provided  for  those 
Member  States  in  which  training  for  general  medical  practice  takes  place  in 
the  context  of  the  provision  of  services  from  the  surgery  of  the  trainee  general 
practitioner.  It  was  quite  clearly  envisaged  in  1986  that  the  introduction  of  the 
obligations  in  Articles  31  and  32  would  require  time,  resources  and  careful 
preparation  of  the  profession,  recipients  of  health  care  and  the  authorities.  It 
was  also  foreseen  that  Article  31  would  have  repercussions  for  Articles  23  and 
24  (minimum  criteria  for  the undergraduate  medical  education  and  training  and 
for  specialised  courses).  Thus  Article  33  set  the  review  date  of  1  January 
1996. 

1.6. 

1.7. 

1.8. 

SECTION  2 

Impact  of  the  introduction  of  specific  training  for  general  medical  practice  to  all 
national training systems. 

2.1. 

2.2. 

2.3. 

2.4. 

In  1975  the  Community  scheme  for  the  mutual  recognition  of  medical 
diplomas  included  the  co-ordination  of  undergraduate  education  and  training 
and  certain  specialist  education  and  training.  Other  post  graduate  training 
courses,  which  lead  to  the  award  of  qualifications  not  specified  in  either 
Articles  5 or  7  are  not  co-ordinated.  The  rights  of  free  movement  of  doctors 
with  qualifications  in  a  speciality  not  specified  in  the  Directive  is  based  on 
mutual acceptance as set out in Article 8. 

Until  1  January  1995  a  doctor  who  had  successfully  completed  his 
undergraduate  medical  education  and  possessed  a  qualification  set  out  in 
Article  3  had  access  to  general  medical  practice  in  a  host  Member  State. 
Member  States were allowed  to maintain  national  requirements  for  specific,  or 
vocational,  training  in  addition  to  undergraduate  training  for  the  purposes  of 
general  medical  practice  within their  own territory,  but were obliged  to accept 
migrant  doctors  from  other  Member  States  who did  not  have  specific  training 
in  general  medical  practice  who  wished  to  practise  as  general  medical 
practitioners. 

As  from  1  January  1995  all  doctors  practising  within  the  national  social 
security  schemes  have  to  be  in  possession  of  an  Article  30  qualifications  in 
general  medical  practice  (Article  36(1)).  Member  States  were,  of  course, 
entitled  to confer  acquired  rights on practitioners  who were regarded  as having 
acquired  national  rights  in the practice  of general  medical practice.  In addition 
those  doctors  who  were  already  established  in  the  national  security  scheme 
system  of  a  host  Member  State  as  general  medical  practitioners  by  31 
December  1994  were  given  the  acquired  right  by  virtue  of  Article  36 (2), 
second  sentence.  In  certain  circumstances  Member  States  may  issue  a 
qualification 
in  general  medical  practice  to  those  who  possess  another 
specialist qualification  and fulfil  Article 35. 

The  introduction  of  specific  training  for  general  medical  practice  had  different 
effects  in  the  various  national  training  schemes.  In  some  Member  States 
the  same  footing  as  other 
general  medical  practice  was  placed  on 
specialisations  or was treated  as a discipline  in its own right.  In other  Member 
States  the  transition  from  treating  general  medical  practice  as  an  area  of 
practice open to a doctor  with  nothing  more than an Article  3 qualification,  to 
the  present  situation  of  it  having  to  be  treated  as  a  distinct  postgraduate 
discipline  in  its  own  right,  has  not  yet  taken  place.  The  requirement  in  Title 
IV  for  a  minimum  period  of  2  years  of  specific  training  is  regarded  as  a 
prolongation  of undergraduate  medical education and training. 

2.5. 

2.6. 

2.7. 

Although  an  Article  3 diploma  is  issued  at  the  end  of  undergraduate  medical 
education  and training,  as from  1  January  1995 such a diploma does not entitle 
the holder to access to the medical  profession  in some Member  States.  In these 
States  general  medical  practice  is  exclusively  within  the  national  social 
security  schemes  and entry  conditions  operate  to  limit  the  numbers  of  entrants 
to  further  or  specialist  training  places.  The  combination  of  the  two  factors 
meant  that  doctors  holding  an  Article  3 diploma  who  failed  to  secure  training 
•  posts  either  in  general  medical  practice  or  in  other  speciality  training,  found 
themselves  unable  to  work  at  all,  whereas  previously  they  were  able  to  work 
in general  medical practice until they qualified  for  entry  to a specialist  training 
place. 

Article  36  (1)  requires  that  Member  States  ensure  that  every  general  medical 
practitioner  in  the  national  social  security  scheme  is  specifically  trained, 
subject,  of  course  to,  acquired  rights.  The  impact  of  this  provision  is  that 
Member  States  must  ensure  that  third  country  nationals  and  EU  nationals 
alike,  who  hold  third  country  qualifications,  are  specifically 
trained  in 
accordance  with  national  standards  if  they  are  to  be  authorised  for  practice 
under  national  security  schemes. 

Article  36  (5)  makes  it  clear  that  the  requirements  in  the  Directive  do  not 
prevent  Member  States  from  authorising  for  general  medical  practice  in 
accordance  with  their  own  rules  within  the  national  social  security  scheme, 
those  with  either  medical  training,  or  specific  training,  or  both,  obtained 
outside the EU. 

2.8.  Member  States  are  obliged  by  Article  37  (2)  to  recognise  an  acquired  rights 
certificate  (Article  36  (4))  issued  by  other  Member  States.  If  a  Member  State 
issues  an  acquired  rights  certificate  to  an  EU  national  practising  within  its 
social  security  scheme,  a host  Member  State  is obliged,  per  se,  to recognise  it 
and consider  it equivalent  within  its own territory. 

2.9. 

Article  34 provides  for  part-time  training  for  general  medical  practitioners.  It 
was  found  that  part-time  training  is  still  relevant.  Some  Member  States' 
training  schemes  were  experiencing  serious  difficulty 
the 
requirement  that the weekly  duration  of part-time training  may  not be  less that 
60  %  of  weekly  full-time  training  and  that  a  certain  number  of  full-time 
training periods should be  included. 

in  meeting 

- 7-

The  provision  for  part-time  training  in  other  specialities  specifies  that  the 
minimum necessary  to ensure the level of quality  equivalent  to that of  full-time 
training  is 50 %. 

Member  States training  programmes  for  general  medical  practice  often  include 
a component  of certain  speciality  training  and certain  training  programmes  for 
specialisations  include periods of general medical practice training. 

The  different  provision  for  general  medical  practice  training  and  speciality 
training  results  in unnecessary  complications. 

- 8-

SKC.TION 3 

Analysis of possible revision of the Directive 

3.1. 

Developments  within  national  training  and  health  care  systems  and  between 
the recognition  systems of Member  States  necessitated  a review  at EU  level of 
the  quality  of  education  and  training  and  the  national  arrangements  for 
recognition.  In  addition,  the  profession  represented  at  EU  level  in  particular 
the UEMO4, the CP\  the UEMS6 and PWG7 put  forward  initiatives to address 
the assessment  and evaluation of the quality  of education  and training. 

The  Commission  requested  the  advice  of  the  ACMT,  in  order  to  incorporate 
the  profession's  advice  on  matters  affecting  quality  in  medical  education  and 
training  in  the  Commission's  report  under  Article  33.  The  following  items  / 
issues  in Title  IV  in Paragraphs  3.2.  to  3.9.  following  have  been  identified  by 
the  profession. 

Postgraduate training in general medical practice 

3.2. 

The  21st  recital  to  the  Directive  reads  as  follows:  "whereas  it  is  immaterial 
whether  this  training  in  general  medical  practice  is  received  as  part  of,  or 
separately  from,  basic  medical  training  as  laid  down  nationally".  Experience 
appears  to  suggest  that  the  Doctors  Directive  could  be  revised  to  provide  that 
specific  training  in general  medical  practice  may  not  begin  before  the  education 
common  for all doctors is completed  and should  begin at the same point as other 
specialist training begins. 

So  that  the  future  doctor  is  made  aware  of  the  main  forms  in  which  medicine 
may be practised  and can make an informed  choice of career,  thought  should be 
given  to the possibility  of  including  a new provision  specifying  that  appropriate 
exposure  to  general  medical  practice  should  be  mandatory  in  undergraduate 
medical training. 

4 

5 

6 

7 

European  Union  of General  Practitioners 

Standing  Committee  of European  Doctors 

European  Union  of Specialist  Medical  Practitioners 

Permanent  Working Group of Junior  Hospital  Doctors 

Duration  and Design of General  Medical  Practice Training  Programmes 

3.3. 

Article 31(1 )(b)  provides  that  the  training  shall  be  a  full-time  course  lasting  at 
least  two  years and  shall  be  supervised  by  competent  authorities  or  bodies. The 
UEMO  proposal  that  the  course  leading  to  qualifications  in  general  medical 
practice should be a full-time  course lasting at least three years has been endorsed 
by  the  ACMT, though  this  would  be a problem  for  some  Member States  and  is 
probably  not  feasible  in  the  coming  years.  Other  Member States  would  need  a 
longer transitional period to increase the length of the training period because such 
an extension would have significant  budgetary implications. 

The  requirement  that  general  medical  practice  training  must  be  supervised  by 
competent  authorities  could  perhaps  be  strengthened  by  making  provision  for 
these  competent  authorities  or  bodies  to  do  so  with  the  involvement  of  general 
medical practitioners throughout the period of training. 

It  is  proposed  in  some  quarters  that  the  clinical  nature  of  training  for  general 
medical practice should be emphasized  and that at least  12 months be spent in an 
approved  general  medical  practice  or comparable  setting.  For  financial  reasons, 
such  a  requirement  should  be  phased  in  over  a  period  of  years.  This  does  not 
prevent those countries  who wish to extend  the minimum  12-month period  to an 
18-month period from  doing so. 

Article 32 

3.4. 

The  provision  in Article  32  which  makes  temporary  provision  for  training  by 
experience  in the surgery  of the trainee  has no time limit.  It seems  appropriate 
to examine with the Member  States  if this derogation  should  be maintained. 

Part-time Training 

3.5.  With  regard  to  part-time  training,  consideration  should  be  given  to  the 
possibility  of  requiring  that  the  minimum  time  commitment  for  those  in 
part-time  training  for  general  medical  practice  should  be  50  %  of  full-time 
training  so that the requirements  in general  medical  practice  are  in line with the 
provisions  for  part-time  training  in  other  specialities.  The  third  indent  of 
Article 34(1) (part-time  training  to include a certain  number of full-time  training 
periods)  should  in that  case  be deleted,  so as to make  the  provisions  relating  to 
part-time training the same for  all postgraduate courses. Part-time training  offers 
certain  advantages,  and  in particular  the  possibility  of  increasing  the  number of 
training opportunities since these are dependent on the number of places. 

Assessment  and evaluation of Training  Programmes 

-  10  -

3.6. 

It is  recommended  to  the  Member  States  that  a  statement  of  intent  relating  to 
good  practice  be  introduced 
in  the  assessment  and  quality  control  of 
programmes  for  specific  training  and education  for  general  medical  practice. 

Induction Training 

3.7. 

Thought  could  usefully  be  given  to  the  desirability  of  inserting  a  carefully 
to  ensure  that  there  is  no 
worded  provision,  with  adequate  safeguards 
discrimination,  on  the  organization  of  induction  training  for  migrants  if  this  is 
found  to be necessary  in individual cases. 

Adequate resource for Training  Programmes 

3.8. 

in  Article 31(l)(d),  which  is  currently 

Consideration  should  be  given  to  the  possibility  of  adding  a  provision  on  the 
need  to provide  resources  which  are commensurate  with  the  objectives,  design, 
supervision  and evaluation  of specific  training  for  general  medical  practitioners. 
The  provision 
the  basis  for  the 
remuneration  of  trainees,  should  be  more  explicit.  It  would  probably  be 
appropriate,  for  example,  to  introduce  a  point  (e)  equating  the  position  of  a 
doctor  following  specific  training  in  general  medicine  with  that  of  a  doctor 
following  specialist  medical  training,  at  least  for  a  significant  part  of  the 
training. 

Specific  Training for every general medical  practitioner 

3.9. 

The  profession  are  of  the  view  that  it  is  appropriate  to  introduce  specific 
training  for  every  general  medical  practitioner 
immediately.  It  is  not 
appropriate  to  maintain  the  possibility  of  practising  medicine  without  training 
as  a  specialist  and  without  specific  training  in  general  medicine.  Indeed  there 
is  little  understanding  as  to  what  training  conditions  will  be  maintained 
according  to  whether  or  not  the  practice  takes  place  within  the  context  of  a 
social  security  system.  Apart  from  this  theoretical  incoherence,  one  can 
reasonably  conclude  that  it  does  not  constitute  a  practical  necessity.  Finally, 
the  appropriateness  of  such  an  approach  is certainly  confirmed  if  the  view  of 
patients  is taken into account.  The experience  in Member  States  is that there  is 
no justification  for  a further  delay  as envisaged  in Article 40. 

"Euro certificates" 

3.10. 

that  some  Member  States  have  designated  an  Article  30 
It  appears 
qualification,  which  is  evidence  of  the  minimum  requirements  set  out  in 
Article  31  but  which  have  no  currency  within  the  national  social  security 
schemes of these Member States. 

-  11  -

An Article  30 qualification  issued  to an EU  national  will  not give that  national 
access  to  general  medical  practice  within  the  social  security  scheme  of  that 
Member State. 

A higher  national  qualification  (not  identified  by  those  States  for  the  purposes 
of  Title  IV  of  the  Directive)  gives  the  holder  access  to  general  medical 
practice  within those national schemes. 

The  Article  30  qualifications  issued  by  those  States  therefore  serve  only  one 
purpose  - export  - that  is they  provide  access to practice  within  social  security 
schemes of other Member States. 

3.11. 

This  situation  is  incompatible  with  the  scheme  set  out  by  the  Directive  which 
relies  on  completion  of  national  training  programmes  which  are  relevant 
within the national  health care schemes. 

Infraction  proceedings  under  Article  169  of  the  Treaty  against  one  Member 
State resulted  in it changing  its rules. 

Firstly  this  type  of  implementation  contravenes  the  principle  of  reciprocity  on 
which the Community  scheme of mutual  recognition  is  founded. 

Secondly,  nationals  of other  Member  States may  wish  to take advantage  of the 
shorter,  and  less  demanding,  training  programme  in  order  to  achieve  a 
certificate  which  would then give them access to the profession  at home. 

Thirdly,  where  a Member  State  has  already  set  for  its  own  purposes  a  higher 
standard  of  training,  having  designated  a  lower  level  qualification  as  the 
Article  30  qualification  it  has  no "interest  in  raising  the  Community  standards 
above  the  minimum  which  is  set  in the  Directive.  That  State  may  rely  on  the 
technical  provision  in the  Directive  to deny  access  to general  medical  practice 
within  their  territory  to  those  who  hold  Article  30  qualifications  from  other 
Member  States  but  have  the  advantage  of  sending  its  own  practitioners  with 
that lower  national  level qualification  to other Member States. 

3.12.  This  development  has  been  already  been  the  subject  of  discussion  within  the 
ACMT.  Minimum  harmonisation  imposes  a  common  denominator  for  all 
Member  States  but  allows  higher  national  standards  which  encourages  and 
fosters  progress  within  the  context  of  the  EU  system  of  automatic  mutual 
recognition.  The  impetus  for  upward  revision  is  necessary  to  respond  to  the 
training 
dynamic  needs  of  medicine.  The  progress 
programmes  which  have  been  achieved  since  1975  will  be  undermined  if 
individual  Member  States  have  no  self  interest  in  setting  higher  standards  in 
the Doctors'  Directive. 

in  standards  for 

Trainee doctors 

12 

3.13. 

EU  rules  for  the  mutual  recognition  of  medical  qualifications  have  been  in 
place  for  20  years.  Community  programmes  such  as  Socrates  (previously 
Erasmus)  for  the mobility  of university  students, co-operation  and  information 
networks  like  the  European  Credit  Transfer  System  (ECTS),  information  on 
study  programmes  and  national  education  systems  by  the  NARIC  network  and 
improvement  in  language  learning  through  LINGUA  programme  have  all 
contributed  to greater  mobility  of the student and trainee doctor. 

3.14. 

The  natural  evolution  of  these  measures  calls  for  specific  provision  for 
the  movement  of  trainee  doctors.  Council  Recommendation 
facilitating 
75/367/EEC8  urged  Member  States  to  accept  trainees  during  their  clinical 
training periods. 

Since  then  the  jurisprudence  of  the  European  Court  of  Justice9  has  made  it 
clear  that  any  training  (including  university)  which  leads  to  a  professional 
qualification  affects  free  movement  of  persons  and  is  therefore  protected  by 
the  non  discrimination  principle  of  Community  law.  Access  to  training  posts 
therefore  must  be  open  to  EU  nationals  on  the  same  terms  as  to  nationals  of 
the host State. This  is a requirement  which  is not  respected. 

3.15. 

Further,  in many  Member  States training  for  general  medical  practitioners  and 
of  other  specialities  takes  place  by  involvement  of  the  trainee  in  the 
professional  activity.  He  is  remunerated  for  this  service  element  in  his 
training.  Notwithstanding  that  the  service  element  is part  of  training  it  is  also 
employment  and  EU  principles  prohibit  any  discriminatory  practices  either  in 
relation  to  access  to  employment  or  in  relation  to  the  conditions  of 
employment. 

3.16.  Trainee doctors  are still experiencing  barriers  when applying  for  training  posts 
in  other  Member  States.  Even  where  posts  have  been  offered  and  accepted, 
national  authorities  are  reluctant  to  process  applications  for  several  reasons 
including  for  those within  the  national  training  schemes.  This  is an area  which 
should  be studied  with a view to developing  proposals to include the principles 
contained  in Council  Recommendation  75/367/EEC  as binding  measures  in the 
context of the trainee  in general  medical  practice and specialists. 

8  OJn°L  167 30.6.1975. 

9  Gravier Case 83/293 [ 1989] E.C.R. 593 
Kraus Case  19/92 [1993] E.C.R. 1 

Article 5 

-  13-

3.17. 

If  specific  training  in  general  medicine  is  actually  considered  by  all  the 
Member  States  as  a  medical  specialisation,  on  the  same  basis  as  the  others 
listed  in this Article,  then this Article should  be adapted  to reflect  this. 

SECTION 4:  CONSEQUENTIALS AND SYNOPSIS OF PROPOSALS 

-  14-

Amalgamated,  Augmented  and  Strengthened  common  provisions  for  postgraduate 
education and training 

4.1. 

is 

in  the  same  category  as  qualifications 

Paragraphs  1.7.,  2.4.  and  2.5.  above  indicate clearly  that  for  EU  purposes  an 
Article  30  qualification 
in 
specialisations  referred  to  in  Article  5.  Paragraphs  2.9.,  3.2.,  3.13.  -  3.16. 
also  explain  that  trainees,  be  they  general  medical  practitioner  or  specialist, 
are  subject  to  similar  conditions.  The  minimum  conditions  for  training 
specified  in  Articles  24  and  31  should  be  examined  for  the  purposes  of 
reinforcing  the  minimum  conditions.  It  is desirable  to  amalgamate  both  these 
Articles as they  share common aims and contain common provisions. 

4.2.  With the  increased  size of the EU such a guarantee  can only be achieved  if the 
provisions  enable  an  objective  structure  that  is  transparent  and  that  can  be 
enforced  directly  in  the  Member  States.  The  amalgamated  provisions  may 
include  statements  of  good  practice  and  policy  objectives  of  training  but  must 
be underpinned  by provision  for  adequate resources  and  transparency. 

4.3. 

4.4. 

4.5. 

4.6. 

Clearly  defined  bodies  responsible  for  the  supervision,  co-ordination  and 
regulation  of  education  and  training  programmes  should  be  identified  by  each 
Member  State.  The  exact  scope  and  function  of  those  bodies  must  be 
published. 

The  training  programmes  should  be  defined  with  precise  detail  concerning 
duration  and  structure.  They  should  be  assessed  and  accredited  based  on 
training  syllabuses  and  a  range  of  training  methods.  In  order  to  ensure  that 
high  standards  are  achieved  and  maintained,  defined  scientific  evaluation 
methods  of  trainees,  training  posts  and  programmes  should  be  incorporated. 
Trainees  should  be engaged  in accredited  training  programmes  so as to ensure 
a balance between the educational  and service elements  in the posts. 

Trainers  should  be  adequately  prepared  for  their  role  and  should  be  assessed 
and  monitored. 

The  ACMT  should  be  called  upon  to  develop  examples  of  good  practice  for 
successful  postgraduate  training. 

-  15-

4.7. 

General  medical  practice  qualifications  are  postgraduate  qualifications  common 
to all  Member States. 

It  follows  that  the  Article  30  qualiflcations  should  be  included  in  Article  5  as 
general  medical  practice  qualifications  are  postgraduate  qualifications  common 
to all  Member States. 

SECTION 5:  CONCLUSION 

5.1. 

The  Doctors  Directive  is  a  Community  measure  which  respects  the  principle 
of  subsidiarity.  It  lays  down  a  framework  to ensure  the automatic  recognition 
of  qualifications. 

It  seeks  to  guarantee  the  host  Member  State  that  the  qualifications  which  it  is 
obliged  to  accept  for  access  to  the  medical  profession  within  its  territory,  is 
evidence of at least a minimum (in most cases it may be of a higher) standard of 
training.  The  form  of  the  guarantee  on  the  other  hand,  provides  scope  for 
national  particularities  and  allows  for  national  training  needs.  That  framework 
has  stood  the test  of time  and  responds  to the  needs of the enlarged  EU  which 
needs the flexibility  to adjust to EU standards and methods. 

5.2.  Moreover  the  complexities  of  medical  education  and  training  require  clearer 
guidelines  for  the  achievement  of  enforceable  guarantees  of  the  quality  of 
training. 

.5.3. 

Objective  rules  which  are  transparent  and  directly  applicable  are  necessary  to 
achieve the goal of quality.  Mutual  trust  is based  on guarantees of the quality of 
training.  The  Doctors  Directive  has  provided  the  foundations  for  quality  and 
trust.  It  is  necessary  to  strengthen  and  develop  these  foundations,  in  particular 
along the lines set out in this report. 

-  17-

ANNEX 

RECOMMENDATIONS OF THE ACMT: 

The ACMT makes the following recommendations: 

1. 

2. 

3. 

4. 

5. 

6. 

7. 

8. 

9. 

A  properly  trained,  well  resourced  cohort  of  General  Practitioners  will  in 
future  play  an  increasingly  important  part  in the organisation  and  development 
of  an  increasingly  scientifically  based,  cost  effective,  health  care  system  and 
that  perception  should  be  reflected  throughout  medical  training  both  at 
undergraduate  and post graduate level. 

It  is important  to establish,  as a priority,  the on-going  involvement  by  General 
Practitioners,  both from  an academic  back ground  and  active  general  practice, 
in  the  organisation/development/administration  and  evaluation  of  General 
Practitioner  training  programmes. 

There  should  be  mandatory  and  adequate  exposure  of  all  medical  students  at 
undergraduate  level to general  practice. 

training  for  general  practice  should  commence  only  after 

Specific 
the 
completion  of  basic  medical  training,  the  end  point  of  which  needs  clearer 
definition. 

As  conditions  permit,  the  minimum  duration  of  specific  training  for  general 
practice  should  be three years. 

The  part  of  training  carried  out  in  general  practice  or  comparable  settings 
should  be  extended  from  six  months  to  one  year  and  as  conditions  permit 
should  be further  extended  to eighteen months. 

The  facility  enabling  practitioners  to  train  in  their  own  surgeries  should  be 
terminated. 

The provisions  in respect of part-time training  should  be amended  and  brought 
into  line with  those of all other  specialities,  i.e.  minimum of 50  % of full  time 
training and the requirement  for  periods of full  time training to be abolished. 

Induction  training  for  doctors  travelling  from  one  EU  country  to  another  be 
introduced  where  necessary  and  efforts  made  to  facilitate  exchange  both 
among  established  General  Practitioners,  trainees,  trainers  and  academic 
departments. 

10. 

Specific  training be made mandatory  for  all general  practitioners. 

ISSN 0254-1475 

COM(96) 434  final 

DOCUMENTS 

EN 

10  04 

Catalogue number  : CB-CO-96-436-EN-C 

ISBN 92-78-08570-7 

Office for Official  Publications of the European Communities 

L-2985 Luxembourg