The international regulation of healthcare workers?

By Priyasha Saksena

Our AHRC project examines the experiences of overseas-trained healthcare workers in navigating the system of professional regulation in the United Kingdom. The focus is deliberately national rather than international given that the historical development of statutory regulators such as the General Medical Council (GMC) was a consequence of nineteenth-century political struggles over the type of individuals who were entitled to call themselves medical practitioners.[1] This is not to say, however, that proposals for professional regulation exist only in the realm of the national; I examine one suggestion for internationalization in this post.

In October 1945, Dr Leopold Neumann, the chair of the Association of Refugee Doctors and Dentists Without Registration in South Africa, wrote to the British Foreign Office, enclosing a memorandum on the plight of refugee medical professionals.[2] There is little information available about Dr Neumann but it is likely that he was one of the many European refugees who had fled the rise of the Nazi regime and found their way to Johannesburg. Once in South Africa, he realized that he was unable to practise medicine given his continental European education and training, which remained unrecognized.[3] He argued that these restrictions were “illogical” given the “scarcity of qualified doctors” and the fact that “in America, England, France, Germany, Russia and in various other countries, medical training is more or less standard.”[4] The main problem, in his view, was that most countries had not entered into reciprocity agreements to mutually recognize educational qualifications and training, requiring refugee doctors to requalify, something that many of them were unable to do on account of “advanced age as well as for financial and other reasons.”[5] Dr Neumann, therefore, proposed “an international agreement … whereby reciprocity of registration is granted to medical doctors who have obtained a degree at a recognised training centre.”[6] This proposal was timely, given the reinvigorated efforts for the establishment of international institutions at the time: for instance, the United Nations was officially founded on 24 October 1945 and there was a simultaneous push for the creation of the World Health Organization, which ultimately came into existence on 7 April 1948. British Foreign Office officials, therefore, considered Dr Neumann’s proposal to be “a good one fundamentally” but were only willing to flag it to the Ministry of Health as being “of possible interest in connexion with the forthcoming Health Organization.”[7]

Although Dr Neumann’s proposal for reciprocal recognition of qualifications (and thereby the ability to practise medicine) at an international level was soon forgotten, there have been such efforts at a regional level. Perhaps the most successful has been the attempt by the European Union (EU) to require member states to implement means to mutually recognize education and training arrangements in order to facilitate the free movement of professional (not only healthcare) workers.[8] Specifically for doctors, nurses, midwives, and dentists, there is an EU-wide system of automatic recognition of professional qualifications.[9] Some regulators continue to extend such recognition even after the United Kingdom’s exit from the EU; the GMC, for instance, has a list of “relevant European qualifications” that are recognized for full registration although there may be practical constraints on the ease of such recognition.[10] Other regional blocs (such as Mercosur and ASEAN) have also made attempts to pursue automatic recognition of qualifications, with varying degrees of success.[11] The efforts have been met with both praise and pushback. As Julia Evetts notes, “[t]he professions are not passive in these internationalization processes” since they “are themselves internationalizing” with the establishment of “international professional federations” that are “made up of representatives from national professional bodies” and “are meeting to negotiate the profession’s response both to EU directives and to wider global processes of internationalization, such as regional and global trade agreements.”[12] Examples of international professional associations in the healthcare space include the World Medical Association, the International Council of Nurses, and the FDI World Dental Federation. The idea of professional regulation remaining intricately linked with the nation-state has, therefore, been challenged in recent years, with the boundaries between national, regional, and international regulation being a matter of political struggle (involving a range of actors including professional associations and regulators) rather than of legal necessity.

[1] For more details on the context in which the General Medical Council was established, see M. J. D. Roberts, “The Politics of Professionalization: MPs, Medical Men, and the 1858 Medical Act,” Medical History 53, no. 1 (2009): 37–56; and Douglas Haynes, Fit to Practice: Empire, Race, Gender, and the Making of British Medicine, 1850-1980 (Rochester, NY: University of Rochester Press, 2017), 9­–35

[2] Letter from Leopold Neumann to the Foreign Office, 1 October 1945, TNA/FO/371/51250.

[3] For the limitations imposed on refugee doctors from practising in dominions such as South Africa and Australia, see Haynes, Fit to Practice, 88.

[4] Memorandum enclosed in Letter from Leopold Neumann to the Foreign Office, 1 October 1945, TNA/FO/371/51250.

[5] Ibid.

[6] Ibid.

[7] Note by [?], 15 November 1945, TNA/FO/371/51250.

[8] For details of the move from national to regional regulation and the reaction of professional associations, see Julia Evetts, “Professionalism Beyond the Nation-State: International Systems of Professional Regulation in Europe,” International Journal of Sociology and Social Policy 18, no. 11/12 (1998): 47–64.

[9] Directive 2005/36/EC of the European Parliament and of the Council of 7 September 2005 on the recognition of professional qualifications.

[10] “European Economic Area country qualifications,” General Medical Council, https://www.gmc-uk.org/registration-and-licensing/join-the-register/eea-countries.

[11] Rupa Chanda, Regional Harmonization Processes of Health Professional Regulation: Status, Challenges, and Policy Directions (Draft Evidence Brief No. 7 Prepared for the Second Review of Relevance and Effectiveness of the WHO Global Code of Practice on the International Recruitment of Health Personnel), https://www.who.int/docs/default-source/health-workforce/eag2/2nd-review-of-code-relevance-and-effectiveness-evidence-brief-7-regional-harmonization-processes.pdf?sfvrsn=c5e18644_2.

[12] Julia Evetts, “New Directions in State and International Professional Occupations: Discretionary Decision-Making and Acquired Regulation,” Work, Employment and Society 16, no. 2 (2002): 341–353, 348.