Green Paper On the European Workforce for Health
Date: 2008-12-10
Institutions: European Commission
Subjects: health care, health care profession, new technology, occupational migration, vocational training

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COMMISSION OF THE EUROPEAN COMMUNITIES 

Brussels, 10.12.2008 
COM(2008) 725 final 

GREEN PAPER 

On the European Workforce for Health 

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TABLE OF CONTENTS 

1. 

2. 

3. 

4. 

4.1. 

4.2. 

4.3. 

4.4. 

4.5. 

4.6. 

5. 

6. 

7. 

8. 

Introduction.................................................................................................................. 3 

Rationale for the Green Paper ...................................................................................... 4 

Legal Framework and basis for action at EU Level..................................................... 5 

Factors influencing the workforce for health in the EU and the main issues to be 
addressed...................................................................................................................... 5 

Demography and the promotion of a sustainable health workforce ............................ 5 

Public Health Capacity................................................................................................. 7 

Training........................................................................................................................ 8 

Managing mobility of health workers within the EU .................................................. 9 

Global Migration of Health Workers ......................................................................... 10 

Data to support decision-making ............................................................................... 11 

The impact of new technology: improving the efficiency of the health workforce... 13 

The role of health professional entrepreneurs in the workforce ................................ 13 

Cohesion policy.......................................................................................................... 14 

Consultation ............................................................................................................... 14 

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Promoting a Sustainable Workforce for Health in Europe 

1. 

INTRODUCTION 

EU  health  systems  have  to  perform  a  difficult  balancing  act,  firstly  between  increasing 
demands  on  health  services  and  restricted  supply;  secondly  between  the  need  to  respond  to 
people's health needs locally but also to be prepared for major public health crises. 

There are a number of challenges facing health systems in Europe. 

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Policy  makers  and  health  authorities  have  to  face  the  challenge  of  adapting 
their healthcare systems to an ageing population. Between 2008 and 2060 the 
population  of  the  EU-27  aged  65  and  over  is  projected  to  increase  by 
66.9 million  and  the  "very  old"  (80+)  will  be  the  fastest  growing  segment  of 
the population1.  

The introduction of new technology is making it possible to increase the range 
and quality of healthcare in terms of diagnosis, prevention and treatment – but 
this has to be paid for and staff need to be trained to use it. 

There  are  new  and  re-emerging  threats  to  health,  for  example  from 
communicable diseases. 

All of this is leading to continually increasing spending on health and indeed is 
posing  major  longer-term  issues  for  the  sustainability  of  health  systems  in 
some countries. 

To  respond  adequately  to  these  challenges  requires  health  systems  to  have  efficient  and 
effective  work  forces  of  the  highest  quality  as  health  services  are  very  labour  intensive. 
Indeed,  healthcare  constitutes  one  of  the  most  significant  sectors  of  the  EU  economy, 
providing  employment  for  one  in  ten  of  the  EU  workforce,  and  approximately  70%  of  the 
healthcare budgets are allocated to salaries and other charges related directly to employment 
of the health workforce2. 

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2008-based national population projections, EUROPOP 2008 convergence scenario. 
Dubois C, Mc Kee M, Nolte E (2006) Human Resources for Health in Europe, Open University Press, 
England. 

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Graph 1: Scope of the Workforce for Health 

HEALTH MANAGEMENT WORKFORCE

CLINICAL 

WORKFORCE

SOCIAL CARE 

WORKFORCE

INFORMAL 
CARERS

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2. 

RATIONALE FOR THE GREEN PAPER 

The  European  Commission's  health  strategy  adopted  in  October  2007  and  published  in  the 
White Paper "Together for Health" put forward a new approach to ensure the EU is doing all 
it  can  to  tackle  challenges  such  as  health  threats,  pandemics,  the  burden  of  lifestyle-related 
diseases, inequalities and climate change in an enlarged Europe of 27 Member States. It aims 
to foster good health in an ageing Europe by promoting good health throughout the lifespan, 
by protecting citizens from health threats and by supporting dynamic health systems and new 
technologies. 

This  Paper  aims  to  increase  the  visibility  of  the  issues  facing  the  EU  health  workforce,  to 
generate a clearer picture of the extent to which local and/or national health managers face the 
same challenges and to provide a better basis for considering what could be done at EU level 
to address these problems effectively, and in a manner which does not have a negative impact 
on health systems outside the EU. 

The  Green  Paper  aims  to  describe  as  precisely  as  possible  the  challenges  faced  by  the  EU 
health  workforce  which  are  common  to  all  Member  States:  the  demography  issue  (ageing 
global  population  and  ageing  health  workforce),  which  means  that  there  are  insufficient 
numbers  of  younger  people  coming  through  the  system  to  replace  those  who  leave;  the 
diversity  of  the  health  workforce;  the  weak  attractiveness  of  the  wide  variety  of  healthcare 
and public health related jobs to new generations; the migration of health professionals in and 
out of the EU; the unequal mobility within the EU – and in particular the movement of some 
health professionals from poorer to richer countries within the EU, as well as the health brain 
drain from Third countries. 

The second objective of this Green Paper is to help identify where the Commission believes 
that further action can be undertaken and to launch a debate on it. 

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3. 

LEGAL FRAMEWORK AND BASIS FOR ACTION AT EU LEVEL  

Article 152 of the EC Treaty states that "Community action in the field of public health shall 
fully  respect  the  responsibilities  of  the  Member  States  for  the  organization  and  delivery  of 
health  services  and  medical  care".  However  the  Article  also  stresses  that  the  Community 
should encourage cooperation between the Member States and promote coordination of their 
policies and programmes. 

Community  action  is  therefore  intended  to  complement  national  policies.  The  principal 
responsibility for organising and delivering health services lies with the Member States, but 
the EU has an important role to play in supporting Member States and adding value such as 
through networking and the sharing of good practice. 

Moreover,  the  EC  Treaty  and  secondary  legislation  provide  for  rules  which  have  to  be 
respected by Member States when organising their health sector. 

As regards secondary legislation, relevant examples include European Community labour law 
directives such as the Working Time Directive, which sets maximum limits to working time, 
and imposes minimum daily and weekly rest periods in order to protect workers' health and 
safety.  The  Directive  provides  common  minimum  requirements  for  all  Member  States  but 
each Member State remains free to apply rules which are more favourable to the protection of 
workers, if it so wishes. 

The Court's decisions about on-call time and compensatory rest raise important questions for 
health  and  care  services3.  The  Commission  has  already  put  forward  legislative  proposals4 
which are currently being discussed by the Council and the European Parliament5. 

4. 

FACTORS  INFLUENCING  THE  WORKFORCE  FOR  HEALTH  IN  THE EU  AND  THE  MAIN 
ISSUES TO BE ADDRESSED 

4.1. 

Demography and the promotion of a sustainable health workforce 

Citizens  are  living  longer  and  in  better  health.  Life  expectancy  has  increased  consistently 
since the 1950s by around 2.5 years per decade and is expected to continue to increase. 

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By stating that the time that health professionals spent on call had to be counted as working time, even 
if they are resting and provided that they need to remain at their work place, the Court acknowledged 
that  doctors,  for  instance,  work  more  than  48  hours  a  week  in  most  Member  States.  To  conform 
themselves  to  this  ruling,  some  Member  States  would  need  major  recruitment  efforts,  which  is  not 
always possible. 
COM(2004)  607  (proposal  to  amend  Directive  2003/88/EC);  COM(2005)  246  (amended  proposal, 
taking account of the views of the European Parliament). 
Common Position of the Council, 15th September 2008; Communication from the Commission to the 
European Parliament on the Common Position - COM(2008) 568. 

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100

Men

Women

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Women (2008) Men (2008) Men (2060) Women (2060)

Graph 2: Population projection 2008 - 2060 

With  an  ageing  population  it  is  crucial  that  people  grow  older  in  good  health.  Healthy  Life 
Years must be maximised. Nevertheless, as people live longer, it is expected that there will be 
increasing  numbers  of  older  people  with  a  severe  disability  and  in  need  of  long-term  care6. 
As multiple chronic conditions are more prevalent in old age, this will have implications for 
care  provision.  Moreover,  demand  for  formal  care  is  likely  to  increase  given  the  likely 
reduction  of  availability  of  informal  carers  for  example  as  a  result  of  changing  family 
structures. 

As  the  population  ages,  so  does  the  workforce.  Between  1995  and  2000,  the  number  of 
physicians under the age of 45 across Europe dropped by 20%, whilst the number aged over 
45 went up by over 50%. For nurses as well, average ages are rising; in five Member States 
nearly half the nurses are aged over 457. As these staff approach retirement age there need to 
be sufficient younger recruits to replace them. 

The  participation  of  women  in  the  health  workforce  has  historically  been  significant  and  is 
increasing. Overall, women make up about three quarters of the health workforce in the EU 
and  in  some  Member  States  intake  of  women  to  medical  schools  is  now  over  50%.8  The 
promotion of gender equality measures in human resource strategies is therefore particularly 
important  
The Roadmap for equality between women and men 2006-20109 sets out a number of actions 
with  a  view  to  achieve  equal  economic  independence  and  equal  participation  in  decision-
making  of  women  and  men  and  proposes  measures  to  improve  the  reconciliation  of  work, 
family and private life. 

The key to maintaining a sufficient workforce, in the face of the impending retirement of the 
"baby boom" generation, is to educate, recruit and retain young practitioners while reinvesting 
in mature workforce. 

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OECD: Trends in Severe Disability among Elderly People DELSA/HEA/WD/HWP (2007). 
WHO Observatory Policy series 2006. 
WHO Observatory Policies series 2006. 
COM(2006) 92. 

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Influencing factors and possible areas for action:  

•  Assessing levels of expenditure on the health workforce 

•  Ensuring better working conditions for health workers, Increasing staff motivation 

and morale  

•  Considering recruitment and training campaigns, in particular to take advantage of 
the  growth  in  the  proportion  of  over-55s  in  the  workplace  and  those  who  no 
longer have family commitments 

•  Organising  chronic  disease  management  practices  and  long-term  care  provision 

closer to home or in a community setting 

•  Providing for a more effective deployment of the available health workforce  

•  Considering "return to practice" campaigns to attract back those who have left the 

health workforce 

•  Promoting more social and ethnic diversity in recruitment  

•  Raising awareness in schools large range of careers in the health and care sectors 

4.2. 

Public Health Capacity 

The public health function consists of a range of diverse activities to protect and improve the 
health  of  the  general  population,  tackle  health  inequalities,  and  address  the  needs  of 
disadvantaged  and  vulnerable  groups.  Tasks  include  carrying  out  health  needs  and  health 
impact  assessments  for  service  planning,  prevention  of  diseases,  for  example  through 
vaccination  and  screening  programmes,  health  promotion  and  education,  securing  the  blood 
supply,  epidemiological  surveillance,  and  planning  and  response  to  health  threats  from 
outbreaks  of  infectious  diseases,  pandemics,  and  man-made  and  natural  disasters,  including 
those arising from climate change. 

Health  promotion  and  disease  prevention  are  not  only  important  in  their  own  right,  but  can 
significantly  reduce  future  demand  for  treatment  and  care  services.  The  public  health 
workforce throughout the EU must be properly skilled and have sufficient capacity to be able 
to carry out these activities effectively, and this needs to be built into training and recruitment 
plans. 

Workplace-related  health  will  require  a  special  focus  since  safety  and  health  at  work  issues 
are important determinants of overall public health. Problems such as accidents at work will 
continue to be addressed, but new considerations such as changes in working rhythms, new 
technologies  at  work,  achieving  a  work-life  balance,  job  mobility  and  workplace  related 
stress, call for a special focus on health at work as an important determinant of overall public 
health. The recently adopted safety and health at work strategy 2007–2012 (COM (2007)62) 
sets  out  a  series  of  ambitious  objectives  which  EU  Member  States  agreed  to  embrace  and 
support. However, achieving these objectives is strongly dependent on the availability of the 
necessary specialised health workers, such as occupational health physicians and nurses and 
health and safety inspectors. 

Influencing factors and possible areas for action:  

•  Strengthening capacity for screening, health promotion and disease prevention  

•  Collecting better information about actual and potential population health needs in 

order to plan the future development of the public health workforce  

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•  Promoting scientific vocations in schools by highlighting career options in lesser 

known public health jobs (biologists, epidemiologists, etc.) 

•  Giving the Agency for Safety and Health at Work (OSHA) more visibility in the 

Member States by publicising its existence directly at workplaces 

•  Promoting  the  work  of  occupational  health  physicians  and  giving  incentives  to 

doctors to join this area 

4.3. 

Training 

Training  capacity  is  also  an  issue  to  be  considered  as  part  of  workforce  planning.  If  more 
doctors and nurses and other staff are needed, more university places or training schools will 
need to be created and more teaching staff to train them. This will require both planning and 
investment. 

Member States will have to assess what types of specialist skills will be needed, taking into 
account that healthcare treatments change with the introduction of new technology, the effects 
of  the  ageing  population  on  the  pattern  of  disease,  the  increase  of  elderly  patients  with 
multiple chronic conditions. A specific problem is that increased travel and mobility have also 
increased the risk of spread of diseases hitherto more prevalent in tropical countries. This is 
creating  a  new  training  requirement  for  clinicians  and  for  those  engaged  in  communicable 
disease surveillance. 

Influencing factors and possible areas for action:  

•  Ensuring that training courses are designed to take into account the special needs 
of people with disabilities (they should receive the same quality of care as non-
disabled patients and be provided with the specific health services they need10).  

•  Focusing  on  health  professionals'  continuous  professional  development  (CPD). 
Updating professional skills improves the quality of health outcomes and ensures 
patient safety. 

•  Developing training courses to encourage the return to the workforce of mature 

workers.  

•  Providing management training for health professionals 

•  Fostering  the  cooperation  between  Member  States  in  the  management  of 

numerus clausus for health workers and enabling them to be more flexible. 

•  Developing  possibilities  for  providing  language  training  to  assist  in  potential 

mobility 

•  Creating an EU mechanism e.g. an Observatory on the health workforce which 
would  assist  Member  States  in  planning  future  workforce  capacity,  training 
needs and the implementation of technological developments. 

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As stated by Article 35 of the UN Convention on the rights of persons with disabilities signed by all 
Member States and the European Community. 

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4.4.  Managing mobility of health workers within the EU 

Free  movement  of  persons  is  one  of  the  fundamental  freedoms  guaranteed  by  Community 
law.  Free  movement  of  workers  is  laid  down  in  Article  39  EC  and  further  developed  in 
Regulation  1612/6811:  it  provides  for  the  right  of  EU  citizens  to  work  in  another  Member 
State  as  an  employee  or  civil  servant.  The  right  of  establishment  is  laid  down  in  Article  43 
which  provides  for  the  right  to  work  as  a  self-employed  person  in  another  Member  State. 
Article  49  enshrines  the  right  of  free  provision  of  services.  Regulation  1408/71  and 
implementing Regulation 574/7212 coordinate the various social security schemes in order to 
facilitate this fundamental right of free movement. EU citizens also have the right to study in 
other Member States under the same conditions as nationals. 

Directive  2005/36/EC  provides  for  the  recognition  of  professional  qualifications  in  view  of 
establishment  in  another  Member  State  and  in  view  of  facilitating  the  provision  of  cross-
border services in a Member State other than the one of establishment. The Directive has also 
introduced a requirement for the competent authorities of the host and home Member States to 
exchange  information  regarding  disciplinary  action  or  criminal  sanctions  taken  or  any  other 
serious, specific circumstances. Outside the regulatory framework, some initiatives linked to 
the mobility of health professionals have been taken by professional organisations such as the 
Health  Professionals  Crossing  Borders  initiative  and  the  professional  card  pilot  initiative 
which  both  aim  at  improving  access  to  information  where  conduct  has  been  brought  into 
question. The progress of these initiatives will need to be kept under review.  

Free  movement  of  students  and  workers  helps  to  ensure  that  health  professionals  go  where 
they  are  most  needed.  But  health  professionals  move  for  a  variety  of  reasons  -  to  achieve 
improved career and training opportunities or for better pay and working conditions. Mobility 
can affect disparities –positively or negatively- within and between countries. In this context, 
some  Member  States  may  be  unwilling  to  risk  investment  in  training  more  health 
professionals if there is poor retention and return on the investment. 

The response to tackling the effects of increased mobility is not to introduce legal restrictions 
to  the  free  movement  of  students  or  workers,  but  rather  to  address  these  issues  through 
appropriate  policies  and  in  a  coordinated  manner  with  EU  authorities  and  other  Member 
States. The increased mobility of the workforce may therefore require workforce managers at 
local  and/or  national  level  to  review  the  adequacy  of  their  recruitment  and  professional 
development measures. 

Citizens  also  enjoy  rights  to  access  healthcare  in  other  Member  States.  The  proposed 
Directive  for  cross-border  healthcare  aims  to  ensure  application  of  common  principles  for 
cross-border healthcare in the EU. One pillar of the Directive is that of realising the potential 
of  European  cooperation  in  areas  where  this  is  useful,  including  in  border  regions,  through 
European  reference  networks  of  specialised  centres,  through  EU  network  for  Health 
technology assessment or through e-health. 

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Regulation (EEC) No 1612/68 of the Council of 15 October 1968 on freedom of movement for workers 
within the Community. 
Council Regulation (EC) No 1408/71 of 14 June 1971 on the application of social security schemes to 
employed  persons,  to  self-employed  persons  and  to  members  of  their  families  moving  within  the 
Community; Council regulation (EEC) No 574/72 of 21 MARCH 1972 laying down the procedure for 
implementing Regulation (EEC) No 1408/71 on the application of social security schemes to employed 
persons,  to  self-employed  persons,  to  self-employed  persons  and  to  their  families  moving  within  the 
Community. 

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Influencing factors and possible areas for action:  

•  Fostering  bilateral  agreements  between  Member  States  to  take  advantage  of  any 

surpluses of doctors and nurses. 

•  Investing to train and recruit sufficient health personnel to achieve self-sufficiency 

at EU level. 

•  Encouraging cross-border agreements on training and staff exchanges, which may 
help  to  manage  the  outward  flow  of  health  workers  while  respecting  Community 
law. 

•  Promoting  "circular"  movement  of  staff  (i.e.  staff  moving  to  another  country  for 
training and/or to gain experience, and then returning to their home countries with 
additional knowledge and skills).  

•  Creating  an  EU-wide  forum  or  platform  where  managers  could  exchange 

experiences. 

4.5. 

Global Migration of Health Workers 

The  shortage  of  health  workers  is  global,  but  the  problem  is  most  acute  in  Sub-Saharan 
Africa, where the problem has reached crisis level13. The shortage is worsened by increased 
demand and competition for medical and nursing staff across the developed world.  

Action on health within the EU also has important policy implications for the EU's external 
and  development  policy.  Unless  the  EU  takes  appropriate  steps  to  produce  and  retain 
sufficient numbers of its own health workers, the negative impact of migration on the health 
systems of developing countries is not likely to decrease14. 

The  EU  Strategy  for  Action  on  the  Crisis  in  Human  Resources  for  Health  in  Developing 
Countries15  adopted  in  December  2005,  and  the  Programme  for  Action  (PfA)  to  tackle  the 
shortage  of  health  workers  in  developing  countries  (2007  –  2013)16  adopted  a  year  later, 
recognised  that  the  EU  has  a  responsibility  to  take  steps  to  meet  its  own  objective  of 
providing high quality healthcare without having a negative impact on the situation in non-EU 
countries. 
The  EU  is  developing  a  common  immigration  policy17which  includes  approaches  to  avoid 
undermining  development  prospects  of  third  countries  through,  for  example,  exacerbating 
"brain  drain",  by  instead  promoting  circular  migration.  These  are  a  component  part  of  the 
Global Approach to Migration18. Additionally, in 2007, the Commission produced a proposal 
for a Directive to facilitate the admission of highly-qualified migrants into the EU19. Within 
this proposal, a clause is foreseen specifically requiring ethical recruitment in sectors, such as 
the health sector, experiencing a lack of personnel. 

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A critical health workforce shortage is experienced in 57 countries, 36 of which are in Africa. 
It is not just those in developing countries who migrate: there are doctors and nurses who leave the EU 
to take up posts for example in the USA, Canada, Australia and New Zealand. 
COM(2005) 642 
COM(2006) 870.  
See COM(2008) 359 on "A Common immigration policy for Europe: principles, actions and tools". 
See COM(2006) 735 and COM(2007) 247. 
COM(2007)  637.  At  the  same  time,  a  proposal  -  COM(2007)  638  -  for  another  directive  on  a  single 
application  procedure  and  common  rights  to  all  legally-resident  third-country  national  workers  was 
adopted. 

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Over the past decade, Codes of Practice for ethical recruitment have been produced which aim 
to  reduce  the  negative  impact  of  migrant  flows  on  vulnerable  health  care  systems  in 
developing  countries.  The  UK  has  a  Code  of  Practice  for  International  recruitment20  and 
Norway21and  the  Netherlands22  have  both  issued  workforce  strategies  which  include  ethical 
recruitment policies by setting limits for active state recruitment or by promoting recruitment 
via bilateral agreements. At EU level in 2008, the European Social dialogue committee in the 
Hospital  sector,  composed  of  HOSPEEM  and  EPSU  acting  as  European  social  partners, 
adopted  a  common  "Code  of  Conduct  and  follow-up  on  Ethical  Cross-Border  Recruitment 
and  Retention",23  which  aims  to  promote  ethical  behaviours  and  stop  unethical  practices  in 
cross-border recruitment of health workers.  

The EU has made a commitment to develop a Code of Conduct for the ethical recruitment of 
health workers from non-EU countries and to take other steps to minimise the negative and 
maximise  the  positive  impacts  on  developing  countries  resulting  from  the  immigration  of 
health  workers  to  the  EU24.  The  need  to  deliver  on  these  commitments  is  reiterated  in  the 
Progress report on the implementation of the PfA adopted in September 2008.25 

Influencing factors and possible areas for action:  

•  Putting  in  place  a  set  of  principles  to  guide  recruitment  of  health  workers  from 

developing countries and introducing methods for monitoring 

•  Supporting  the  WHO  in  its  work  to  develop  a  global  code  of  conduct  for  ethical 

recruitment 

•  Stimulating  Bilateral  and  Plurilateral  agreements  with  source  countries  and 

developing mechanisms for support of circular migration26 

4.6. 

Data to support decision-making 

All the issues described present challenges to planners, providers and managers of health care 
systems.  The  situation  is  made  more  difficult because of the lack of up-to-date, comparable 
data  and  information,  for  example  on  numbers  of  health  workers,  in  training  and  in 
employment,  their  specialisations,  their  geographical  spread,  age,  gender  and  country  of 
provenance.  Given  the  potential  for  shortages  in  one  part  of  Europe  to  have  an  impact 
elsewhere, Europe-wide information is important for planning and providing health services 
for all health authorities throughout the EU.  

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www.nhsemployers.org 
(Recruitment of Health Workers: towards Global Solidarity) 2007. 
"Working on Care" action plan 2007. 
www.hospeem.eu/content/download/313/1631/version/2/file/EPSU- 
European  Parliament:  EU  Strategy  for  Action  on  the  Crisis  in  Human  Resources  for  Health  in 
Developing Countries, and COM(2006)870, Communication from the Commission to the Council and 
the  European  Parliament:  a  programme  for  action  to  tackle  the  critical  shortage  of  health  workers  in 
developing countries (2007 – 2013). 
SEC(2008) 2476. 
Circular migration refers to staff moving to another country for training and/or to gain experience, and 
then returning to their home countries with additional knowledge and skills. Attractive incentives could 
take  the  form  of  an  agreed  career  pathway,  so  that  the  person  returning  comes  back  to  a  post  and 
receives a salary which recognises the experience gained. 

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A  2006  report  produced  for  the  WHO27,  comprising  5  country  case  studies  –  Estonia, 
Germany, Lithuania, Poland and the United Kingdom - found that none of them could provide 
accurate,  complete  information  on  international  flows  of  health  professionals.  The  most 
common measure of flow is from certificates issued to competent authorities ("verifications"). 
This gives an overall annual measure of the number of professionals, who consider moving to 
another country, but not all of them actually move, and others may apply more than once. For 
example, the Estonia country report notes that only 182 doctors actually emigrated out of the 
344 who took out certificates.  

The  European  Commission  collects  data  on  the  decisions  on  recognition  of  qualifications 
covered by the sectoral systems of recognition. These data are  summarised at the  following 
website: 

http://ec.europa.eu/internal_market/qualifications/regprof/index.cfm.  

They  show  movement  to,  or  the  intention  to  practise,  in  another  Member  State.  However, 
since there is no further information on whether the professional did in fact take up a post in 
another Member State, whether the professional moved on to a third country or returned to the 
home  country,  these  data  can  be  used  only  as  a  proxy  in  the  absence  of  more  detailed 
information.  

Other  data  collected  by  EUROSTAT  on  numbers  of  health  professionals  relies  upon  what 
different Member States collect. These data are available on the following website:  

http://ec.europa.eu/health/ph_information/dissemination/echi/echi_en.htm.  

In  addition  an  EU-supported  OECD  project  on  the  migration  of  doctors  and  nurses  in  the 
OECD/EU-25 countries is underway and will in future look also at other health professionals. 
This project will provide useful information, but can not ensure full comparability of the data 
used because of different registration processes and the differences between Member States in 
the degree of central data collection.  
The  European  Migration  Network  (EMN)28  undertook  a  study  of  managed  migration  in  the 
health sector in November 2006 involving eleven of its National Contact points. It found that 
data,  particularly  on  third  country  national  health  workers  in  the  EU,  was  limited  and  often 
same  Member  State. 
distributed 

even  within 

sources, 

several 

across 

the 

Influencing factors and possible areas for action:  

•  Harmonising or standardising health workforce indicators 

•  Setting up systems to monitor flows of health workers 

•  Ensuring  the  availability  and  comparability  of  data  on  the  health  workforce,  in 
particular with a view to determining the precise movements of particular groups of 
the health workforce 

27 

28 

Health  Worker  Migration  in  the  European  Region:  Country  Case  Studies  and  Policy  Implications 
Buchan J, Perfilieva G. 
http://emn.sarenet.es/ 

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5. 

THE IMPACT OF NEW TECHNOLOGY: IMPROVING THE EFFICIENCY OF THE HEALTH 
WORKFORCE 

Progress in healthcare depends upon scientific and technological advances. New technology 
affects what can be achieved and how healthcare is organised and provided. New technology 
is  now  allowing  health  workers  more  easily  to  share  information  and  to  work  more  closely 
together,  improving  overall  care.  For  certain  diseases  and  patients,  technology  may  allow 
shifting the bulk of care away from hospitals into community and primary care settings and 
even into patients' homes, which can improve the quality of life and contribute to better use of 
resources. 

In the short term, new technology such as telemedicine, can ensure better healthcare coverage 
in remote areas or in areas with shortages of health workers. For example, there are areas in 
the  EU  where  telemedicine  enables  distant  diagnostic  services,  and  the  distant  diagnosis  of 
mammography screening results help to improve access and services to patients. 

The introduction of new technology requires that health workers are properly trained, and if 
necessary re-skilled, to use it. Moreover, it will also be necessary to gain the acceptance of the 
health workforce for its use, which may sometimes disturb established working methods and 
structures.  The  Commission  Communication  on  "Telemedicine  for  the  benefit  of  patients, 
society and the economy" proposes a European framework to tackle some of these challenges.  

Influencing factors and possible areas for action: 

•  Ensuring  suitable  training  to  enable  health  professionals  to  make  the  best  use  of 

new technologies 

•  Taking action to encourage the use of new information technologies 

•  Ensuring inter-operability of new information technology  

•  Ensuring better distribution of new technology throughout the EU. 

6. 

THE ROLE OF HEALTH PROFESSIONAL ENTREPRENEURS IN THE WORKFORCE 

Some  health  professionals,  such  as  physicians,  psychologists,  dentists,  podiatrists, 
physiotherapists  and  occupational  therapists,  work  as  entrepreneurs  running  their  own 
practices  or  medical  centres  and  employing  staff.  Commission  policies  to  improve  the 
business  environment  in  Europe  and  to  support  and  encourage  entrepreneurship  have  an 
impact  on  these  activities.  A  recent  Commission  Communication  was  published  on  "Small 
and medium-sized enterprises (SMEs) - Key for delivering more growth and jobs. A mid-term 
review  of  Modern  SME  Policy"  (4  October  2007)  recognises  the  importance  of  the 
contribution of SMEs to realising the goals of the Lisbon Strategy - to foster economic growth 
and  create  new  and  better  jobs.  Such  entrepreneurs  can  contribute  to  the  strengthening  of 
European growth and acting as a driving force for innovation, local development, training and 
employment, as well as helping to improve access to healthcare.  

The  Small  Business  Act  (SBA)  is  a  key  element  in  the  EU's  Growth  and  Jobs  Strategy 
(Commission  Communication  "Think  Small  First  –A  Small  Business  Act  for  Europe"  – 
COM(2008)394).  It  comprises  a  set  of  common  principles  to  guide  SME  policy  as  well  as 
proposed  actions  to  translate  the  principles  into  practice.  It  focuses  on  promoting 
entrepreneurship, anchoring the Think Small First principle in policy-making and supporting 
SMEs' growth.  

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Influencing factors and possible areas for action:  

•  Encouraging  more  entrepreneurs  to  enter  the  health  sector  in  order  to  improve 

planning of healthcare provision and to create new jobs 

•  Examining the barriers to entrepreneurial activity in the health sector 

7. 

COHESION POLICY 

Development of the EU health workforce is also linked to Cohesion Policy. Under the current 
legal  framework  it  is  possible  to  use  Structural  Funds  to  develop  the  health  workforce.  The 
Community Strategic Guidelines for Cohesion, which defines the priorities for the Structural 
Funds  for  the  2007-13  period,  contains  a  section  describing  the  aim  to  “Help  maintain  a 
healthy  labour  force”.  The  Regulation  on  the  European  Social  Fund  (ESF)  of  July  2006 
(Regulation  1081/2006)  identifies  prolonging  working  lives  and  "better  health"  among  the 
priority areas of the ESF. In this context some Member States (mostly new ones) plan major 
investment in the education and training of health professionals by using the ESF. In addition, 
some  €5.2  billion  will  be  invested  in  hea lth  infrastructure  by  the  European  Regional 
Development  Fund.  The  effective  use  of  the  Structural  Funds  to  improve  skills  and 
competencies  of  the  health  workforce  and  develop  health  infrastructure  can  effectively 
contribute to the improvement of working conditions and increase quality of health services, 
thus reducing the health gaps and strengthening cohesion within and between Member States.  

Influencing factors and possible areas of action:  

•  Making  more  use  of  the  support  offered  by  structural  funds  to  train  and  re-skill 

health professionals 

•  Improving  the  use  of  the  structural  funds  for  the  development  of  the  health 

workforce 

•  Enhancing  the  use  of  structural  funds  for  infrastructures  to  improve  working 

conditions 

8. 

CONSULTATION 

The European Commission calls on all interested organisations to submit responses the issues 
raised  in  this  Green  paper,  no  later  than  31  March  2009,  preferably  to  the  following  e-mail 
box SANCO-health-workforce@ec.europa.eu 

or to the following address: 

European Commission, B-1049, Brussels, Belgium 

Unless respondents make a declaration to the contrary, the Commission services will assume 
that  they  do  not  object  to  having  their  responses,  or  parts  thereof,  published  on  the 
Commission's  website  and/or  quoted  in  reports  analysing  the  outcome  of  the  consultation 
process. 

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