Dental Council of Ireland response to Green Paper re Professional Qualifications Directive Introduction



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Dental Council of Ireland response to Green Paper re Professional Qualifications Directive
Introduction

The Dental Council generally supports initiatives to facilitate the free movement of dental professionals throughout Europe. In any scheme which liberalises movement among health care workers it is vital that the appropriate controls are in place to ensure that standards of education are appropriate and verified and that the directive allows competent authorities take appropriate action where, after a country recognises a qualification/registration from another member state, restrictions are subsequently placed on a practitioner in that member state.


Validation that minimum training standards are met

In this context it is imperative that the revised directive puts structures in place to validate the quality of the education leading to the award of the qualification, and that it meets the standards provided for in the directive. This validation is important because the proposals contained in the Green Paper have the effect of moving responsibility for ensuring compliance with the minimum training standards to the country of departure and away from the receiving country. In order for the receiving country to have trust in this process it is necessary to trust the procedures for validating that the minimum standards are being met and for this reason it is essential that the provisions suggested in section 4.2.3 of the Green Paper are provided for in the revised Directive.


Restrictions on the practitioner (subsequent to registration / recognition)

The Dental Council of Ireland strongly advocates that the revised directive allow competent authorities / registration boards deal with the issue of rogue practitioners.  The Dental Council has had a number of instances in recent times where practitioners have used multiple EU registrations in other jurisdictions to try to avoid the impact of restrictions on practice.  In one case the practitioner was subsequently found guilty of professional misconduct for a clinical matter and in another there were allegations that the practitioner engaged in fraudulent activity.  There is a very serious concern that the failure of the EU systems to deal effectively with this matter could result in serious patient safety and/or probity issues arising.  


The main difficulty is that while Directive 2005/36/EC facilitates the free movement of a professional, it doesn’t address how issues of misconduct should be dealt with.  This means that issues of misconduct becomes a national issue and the legislative frameworks vary from country to country.  In general, the recognition process at EU level is fast and the sanctions process at national level varies from country to country and can be slow. This can leave rogue practitioners relatively free to move from country to country and practice in an unrestricted capacity, while restricted in another member state.  
The revised Directive must provide for a member state to automatically reconsider an application for registration / recognition where any sanction or restrictions are placed on a professionals practice in their originating member state AFTER their qualification has been recognised in another member state. This must be an administrative process facilitated under the Directive to ensure all member states can act in a similar way. 
Responses to specific questions
Question 1: Do you have any comments on the respective roles of the competent authorities in the Member State of departure and the receiving Member State?
The current system for the automatic recognition of qualifications in the “sectoral professions” is currently working reasonably well. Under these provisions the destination member state ultimately has responsible for determining if a practitioner meets the standards necessary for automatic recognition. The proposals in the Green Paper change this dynamic and have the effect of moving responsibility for certifying compliance with the Directive to the competent authority in the departing member state and away from the competent authority in the destination member state. The proposals in the Green Paper predicate this on the introduction of a professional card and an enhanced IMI system. In principle there is merit to the proposals but there may be significant logistical and technological impediments to rolling out these changes.
However this system can only have the confidence of the competent authorities in the destination member state if they are satisfied with the validation processes in place in each member state to ensure that the qualifications that lead to registration meet the minimum training standards provided for in the revised Directive.

Question 2: Do you agree that a professional card could have the following effects, depending on the card holder's objectives?

a) The card holder moves on a temporary basis (temporary mobility):
- Option 1: the card would make any declaration which Member States can currently require under Article 7 of the Directive redundant.
- Option 2: the declaration regime is maintained but the card could be presented in place of any accompanying documents.
The Dental Council agree with Option 2. This still allows for the presentation of credentials to the competent authority in the destination member state and is consistent with the process for permanent establishment.

b) The card holder seeks automatic recognition of his qualifications: presentation of the card would accelerate the recognition procedure (receiving Member State should take a decision within two weeks instead of three months).
In principle the introduction of a professional card in conjunction with the changes providing for the competent authority in the originating member state to confirm compliance with the Directive should significantly reduce the time taken to process applications for the professions where automatic recognition is provided for. This is on the strict proviso that there is confidence in the system which validates compliance with the standards of education provided for in the Directive in each member state. However, there may be technological and logistical issues with the introduction of a “smart card” type solution. A “low tech” solution whereby a passport type document is issued to the professional in the home member state which is endorsed in a manner similar to a Travel Visa by the relevant competent authority may have potential. The two week timeframe is unrealistic as it places significant pressure on smaller competent authorities.

c) The card holder seeks recognition of his qualifications which are not subject to automatic recognition (the general system): presentation of the card would accelerate the recognition procedure (receiving Member State would have to take a decision within one month instead of four months).
This is not feasible as each qualification needs to be individually assessed and the introduction of a card will not make this process any more efficient.

Question 3: Do you agree that there would be important advantages to inserting the principle of partial access and specific criteria for its application into the Directive? (Please provide specific reasons for any derogation from the principle.)
Partial access not relevant in dentistry as in practice it is really only applicable at specialist level expertise and is not applicable at general dental practitioner level. The Directive states that a dentist undergraduate qualification must equip them to ”to gain access to and pursue the activities of prevention, diagnosis and treatment of anomalies and diseases affecting the teeth, mouth, jaws and adjoining tissue,”(article 36(3)). This would seem to preclude any level of partial access to the profession.

Question 4: Do you support lowering the current threshold of two-thirds of the Member States to one-third (i.e. nine out of twenty seven Member States) as a condition for the creation of a common platform? Do you agree on the need for an Internal Market test (based on the proportionality principle) to ensure a common platform does not constitute a barrier for service providers from non-participating Member States? (Please give specific arguments for or against this approach.)Professional qualifications in regulated professions
In principle yes, as it may allow for member states to ensure / validate that the standards of the qualifications awarded in other countries meet the standards set out in the Directive. In practice most of the applications received by Ireland under the Directive come from a proportionately small number of countries. It may also facilitate the easier movement of auxiliary dental workers.

Question 5: Do you know any regulated professions where EU citizens might effectively face such situations? Please explain the profession, the qualifications and for which reasons these situations would not be justifiable.
No

Question 6: Would you support an obligation for Member States to ensure that information on the competent authorities and the required documents for the recognition of professional qualifications is available through a central on line access point in each Member State?
It is a good idea in principle to set up a central portal in each country regarding local requirements for each profession. However there may be technologically and logistically difficulties in setting this up.
Would you support an obligation to enable online completion of recognition procedures for all professionals? (Please give specific arguments for or against this approach).
No, as procedures need to be put in place to independently verify the identity of applicants and the validity of their qualifications at the point when a decision is being made with regard to registration. The suggestion put forward by the Dental Council in response to Question 2(b) regarding the issuing of a “passport” type of document may reduce the burden on practitioners moving to other countries. It is difficult to envisage how an online system can have sufficient controls to mitigate the possible risk to public safety and confidence from a systems failure that allows a rogue health professional practice in a member state.

Question 7: Do you agree that the requirement of two years' professional experience in the case of a professional coming from a non-regulating Member State should be lifted in case of consumers crossing borders and not choosing a local professional in the host Member State?
Not applicable - health care workers are to be excluded from this provision

Should the host Member State still be entitled to require a prior declaration in this case?

(Please give specific arguments for or against this approach.)
The Dental Council welcomes that prior declarations will be required where public health or consumer safety risks justify a prior check of qualifications. If the professional card system is properly functioning then presenting this to the competent authority relevant would be sufficient for the purposes of temporary and occasional access to the profession.

Question 8: Do you agree that the notion of "regulated education and training" could encompass all training recognised by a Member State which is relevant to a profession and not only the training which is explicitly geared towards a specific profession? (Please give specific arguments for or against this approach.)
The Dental Council is unsure of the intent of this proposed provision. If this provision is to allow for the assessment of a candidates continued professional development then it should be provided for in the Directive.

Question 9: Would you support the deletion of the classification outlined in Article 11 (including Annex II)? (Please give specific arguments for or against this approach).
This provision should be replaced by the European Qualifications Framework (EQF). The EQF is focused on outcomes and not time based measures and this is compatible with the Dental Council proposal that the minimum training standards should be replaced with a competence framework.

Question 10: If Article 11 of the Directive is deleted, should the four steps outlined in 3.2.2 be implemented in a modernised Directive? If you do not support the implementation of all four steps, would any of them be acceptable to you? (Please give specific arguments for or against all or each of the steps.)
Step 1: Not relevant if the minimum standards of education move to a competence based criteria.

Step 2: Agree, if automatic recognition is not allowed for then the provisions of the general systems should be followed, regardless of the level of practical experience obtained by the professional


Step 3: Agree, competent authorities should provide clear reasons for / explanation of negative decisions
Step 4: Disagree as twice yearly testing is disproportionate and expensive for smaller competent authorities

Question 11: Would you support extending the benefits of the Directive to graduates from academic training who wish to complete a period of remunerated supervised practical experience in the profession abroad? (Please give specific arguments for or against this approach.)
Not relevant in dentistry in Ireland

Question 12: Which of the two options for the introduction of an alert mechanism for health professionals within the IMI system do you prefer?
Option 1: Extending the alert mechanism as foreseen under the Services Directive to all professionals, including health professionals? The initiating Member State would decide to which other Member States the alert should be addressed.)
Option 2: Introducing the wider and more rigorous alert obligation for Member States to immediately alert all other Member States if a health professional is no longer allowed to practise due to a disciplinary sanction? The initiating Member State would be obliged to address each alert to all other Member States.)
Option 2 is the preferred option and in this context the revised Directive must provide for a member state to automatically reconsider an application for registration / recognition where sanctions or restrictions are placed on a professionals practice in their originating member state AFTER their qualification has been recognised in another member state. This must be an administrative process facilitated under the Directive to ensure all member states can act in a similar way. 

Question 13: Which of the two options outlines above do you prefer?

Option 1: Clarifying the existing rules in the Code of Conduct;

Option 2: Amending the Directive itself with regard to health professionals having direct contact with patients and benefiting from automatic recognition.

Option 2: The Dental Council supports the option to amend the directive with regard to the language skills of health care workers before the health professional first comes into contact patients. With the way the dental profession in configured in Ireland this will be a responsibility of the The Dental Council. The Council would advocate making this a test of communications skills (i.e. in a context broader than just purely language). This is necessary because the practitioner will be interacting with patients, other health and social care professionals and health administrators. For example, explaining complex diagnosis in an understandable manner, the referral of patients for specialist care or to hospital, writing prescriptions, understanding ethical obligations etc.


The Directive should provide that the competent authority could automatically reconsider an application for registration / recognition where there are allegations concerning the practitioners capacity to communicate local language AFTER the practitioner has been registered (a similar provision to the one sought in relation to restrictions placed in other member states). This provision should be provided for in the Directive and could provide for a competent authority to suspend registration pending the attainment of the necessary language / communications skills.

Question 14: Would you support a three-phase approach to modernisation of the minimum training requirements under the Directive consisting of the following phases:
- the first phase to review the foundations, notably the minimum training periods, and preparing the institutional framework for further adaptations, as part of the modernisation of the Directive in 2011-2012;
The Dental Council agrees with this proposal. Any changes to the minimum training periods must allow for graduate entry dentistry programmes of shorter duration to the undergraduate entry programmes but which similarly equip the practitioner to meet with the minimum training standards provided for in the Directive. The Dental Council strongly feels that making graduates with a health or bio-science qualification undertake a further five year programme is unfair as it does take account of common or relevant subject matter.
- the second phase (2013-2014) to build on the reviewed foundations, including, where necessary, the revision of training subjects and initial work on adding competences using the new institutional framework; and
The Dental Council recommends amending the provisions of the Directive to focus on minimum standards / minimum skill sets for all dental graduates in Europe. A member of the public visiting the dentist should have the same expectation of the expertise of the practitioner regardless of the origin of the qualification. The Dental Council is of the view that this can only be achieved by setting a minimum competency standard which all dental students must achieve in order to graduate with a qualification that allows access to the dental profession. The Dental Council agrees with the proposed timeframe for considering this matter.
- the third phase (post-2014) to address the issue of ECTS credits using the new institutional framework?
Dental Council agrees with this proposal

Question 15: Once professionals seek establishment in a Member State other than that in which they acquired their qualifications, they should demonstrate to the host Member State that they have the right to exercise their profession in the home Member State. This principle applies in the case of temporary mobility. Should it be extended to cases where a professional wishes to establish himself? (Please give specific arguments for or against this approach.)Is there a need for the Directive to address the question of continuing professional development more extensively?
The revised Directive must provide for a member state to automatically reconsider an application for registration / recognition where restrictions are placed on a professionals practice in their originating member state AFTER their qualification has been recognised in another member state. This should apply either in circumstances whereby a practitioner does not maintain their competence or where sanctions have been applied after a disciplinary process. This must be an administrative process facilitated under the Directive to ensure all member states can act in a similar way. 

Question 16: Would you support clarifying the minimum training requirements for doctors, nurses and midwives to state that the conditions relating to the minimum years of training and the minimum hours of training apply cumulatively? (Please give specific arguments for or against this approach.)
Even though this question is not specific to dentistry it is possible that changes to the minimum training standards may have an impact on dental education. For the purposes of clarity it is assumed that the use of the word “cumulatively” in the question does not mean, for example, that students must undertake training of 5 years training and then undertake an additional 5000 hours. It is the Dental Councils understanding that such a provision would be a concurrent requirement rather than a cumulative or consecutive requirement.
The Dental Council is of the view that the provisions regarding minimum training must allow for graduate entry dentistry programmes where the student has previously completed a relevant health or bio science degree. The competent authority should have a clear and transparent mechanism to provide assurance that the programmes equip the practitioner to meet with the minimum training standards provided for in the Directive. The Dental Council strongly feels it is inherently unfair to make graduates with a health or bio-science qualification undertake a full, five year programme and not take account of common and/or relevant subject matter from the previous programme.

Question 17: Do you agree that Member States should make notifications as soon as a new program of education and training is approved?
Yes, immediately on approval of any new programme of education and training

Would you support an obligation for Member States to submit a report to the Commission on the compliance of each programme of education and training leading to the acquisition of a title notified to the Commission with the Directive? Should Member States designate a national compliance function for this purpose?

(Please give specific arguments for or against this approach.)
It is essential that there is an open and transparent mechanism to ensure that each programme of training leading to the acquisition of dentistry qualification complies with the minimum training standards set out in revised Directive. This validation is important because the proposals contained in the Green Paper have the effect of moving responsibility for ensuring compliance with the minimum training standards to the country of departure and away from the receiving country. In order for the receiving country to have trust in this process it is necessary to trust the procedures for validating that the minimum standards are being met. Member states should designate a national compliance function for this purpose and the Directive should provide for the reports to be published. The Directive should provide that each programme is revalidated periodically. The Dental Council recommend that a report on each programme be made every a five years.

Question 18: Do you agree that the threshold of the minimum number of Member States where the medical speciality exists should be lowered from two-fifths to one-third? (Please give specific arguments for or against this approach.)
Not relevant to dentistry

Question 19: Do you agree that the modernisation of the Directive could be an opportunity for Member States for granting partial exemptions if part of the training has been already completed in the context of another specialist training programme? If yes, are there any conditions that should be fulfilled in order to benefit from a partial exemption? (Please give specific arguments for or against this approach.)
Not relevant to dentistry

Question 20: Which of the options outlined above do you prefer?

Option 1: Maintaining the requirement of ten years of general school education

Option 2: Increasing the requirement of ten years to twelve years of general school education
Not relevant to dentistry

Question 21: Do you agree that the list of pharmacists’ activities should be expanded? Do you support the suggestion to add the requirement of six months training, as outlined above? Do you support the deletion of Article 21(4) of the Directive? (Please give specific arguments for or against this approach.)
Not relevant to dentistry

Question 22: Which of the two options outlined above do you prefer?

Option 1: Maintaining the current requirement of at least four years academic training?

Option 2: Complementing the current requirement of a minimum four-year academic training by a requirement of two years of professional practice. As an alternative option, architects would also qualify for automatic recognition after completing a five-year academic programme, complemented by at least one year of professional practice.
Not relevant to dentistry

Question 23: Which of the following options do you prefer?

Option 1: Immediate modernisation through replacing the ISIC classification of 1958 by the ISIC classification of 2008?

Option 2: Immediate modernisation through replacing Annex IV by the common vocabulary used in the area of public procurement?

Option 3: Immediate modernisation through replacing Annex IV by the ISCO nomenclature as last revised by 2008?

Option 4: Modernisation in two phases: confirming in a modernised Directive that automatic recognition continues to apply for activities related to crafts, trade and industry activities. The related activities continue to be as set out in Annex IV until 2014, date by which a new list of activities should be established by a delegated act. The list of activities should be based on one of the classifications presented under options 1, 2 or 3.
Not relevant to dentistry

Question 24:

Do you consider it necessary to make adjustments to the treatment of EU citizens holding third country qualifications under the Directive, for example by reducing the three years rule in Article 3 (3)? Would you welcome such adjustment also for third country nationals, including those falling under the European Neighbourhood Policy, who benefit from an equal treatment clause under relevant European legislation? (Please give specific arguments for or against this approach.)
The Dental Council do not support any diminution in the standards applying to third party qualifications. If the Directive is implemented as proposed the provisions set out in 4.2.3 regarding compliance with the minimum training provisions become a critical strand in the revised Directive. Unless qualifications from third party countries are subject to the same validation it is unfair to oblige other member states to recognise such qualifications. It should be a matter for each member state to decide if they wish to recognise qualifications from other third party countries to address their own domestic issues. This should not confer an obligation on other member states to recognise such qualifications.


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