52012SC0093

COMMISSION STAFF WORKING DOCUMENT

on an Action Plan for the EU Health Workforce

Accompanying the document

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

Towards a job-rich recovery

TABLE OF CONTENTS

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

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

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

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

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

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

1.           Introduction

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

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

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

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

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

2.           Defining and measuring healthcare jobs

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

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

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

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

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

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

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

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

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

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

3.           Key Challenges Facing the EU Health Workforce

Labour demand will increase as the population ages…

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

… with consequences for future skills and competences…

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

… while the number of health professionals decreases…

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

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

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

… and difficulties to recruit and retain healthcare staff

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

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

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

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

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

… resulting in worsening healthcare labour shortages

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

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

Table 1: SHORTAGES IN SELECTED EU MEMBER STATES

Country ||

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

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

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

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

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

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

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

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

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

Table 2: estimated shortage in healthcare sector by 2020

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

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

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

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

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

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

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

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

· Forecasting workforce needs and improving workforce planning methodologies

· Anticipating future skills needs in the health professions;

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

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

4.1.        Forecasting Health Workforce Needs

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

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

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

4.2.        Anticipating skills needs in the health professions

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

4.4.        Addressing the ethical recruitment of health professionals

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

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

5.           Delivering the Actions

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

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

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

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

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

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

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

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

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

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

[6]               Eurostat (2011)

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

[8]               Eurofound (2010)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

[29]             C-73/08; C-417/03

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

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

[32]             Erasmus Programme 2012

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

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

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

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

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

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

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

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

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

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

[43]             Article 8(2) and recital 22

[44]             Article 20

[45]             Common Strategic Framework

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

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

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

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