This blog post examines the differences in intensive care transport between the three countries of Euregio Meuse-Rhine (EMR): the Netherlands, Germany, and Belgium. Although cross-border cooperation in this region presents opportunities, as shown by the COVID-19 crisis, the blog post shows that the differences in the education and training of intensive care specialists complicate the provision of these cross-border services. Nevertheless, several solutions may be identified at both the regional as well as the European level able to contribute to enhancing cross-border cooperation and mobility in intensive care transport.
The COVID-19 crisis put a strain on the intensive care capacity in the Netherlands, Belgium, and Germany. Initially, the discoordination of crisis management policies on the national level challenged the existing cross-border collaboration structures in border regions such as the Euregio Meuse-Rhine (EMR). Indeed, COVID-19 patients were frequently transported within national territories over longer distances via ambulances or helicopters, whereas possibilities in neighbouring countries or regions received less attention – if any at all.
The PANDEMRIC-project examined the effects of the COVID-19 crisis on euregional cooperation in the EMR. In the context of this project, a study was carried out on the legal consequences of cross-border ambulance and intensive care transport. While the report found that most of the current cooperation is focused on ambulance services, it identified opportunities to structure cooperation also in (planned) intensive care transport.
Although cross-border cooperation in intensive care (IC) transport presents opportunities, improving the resilience of healthcare systems, the differences between the national systems of the three EMR countries complicate the provision of these cross-border services. On the EU level, however, the difficulties of deploying IC specialists across borders are receiving increased attention due to the vital role of IC services in potential future health crises. Against this background, this blog post examines the differences in IC transport between the three countries of the EMR, as well as the ongoing developments and potential solutions.
A Three-Country Comparison of IC Specialists
This contribution focuses on the primary staff involved in IC transport, namely medical specialists and nurses. Unsurprisingly, differences between national healthcare systems are still considerable. Indeed, there are differences between the three national systems for IC transport regarding not only the professional qualifications of the staff but also how such transport is organised. The Netherlands and Germany consider IC transport as a separate category from ambulance care. By contrast, an overlap may be perceived in Belgium in terms of ambulance and IC transport.
In the Netherlands, IC transport takes place via Mobile IC Units (MICUs). Furthermore, depending on the circumstances, a highly specialised team may be deployed in the form of Paediatric IC Units (PICU), or Neonatal IC Units (NICUs). The team consists of a specialised doctor (arts spoedeisende geneeskunde), as well as an IC nurse (IC-verpleegkundige). Furthermore, Mobile Medical Teams (MMT) may be used. These teams are comprised of a doctor and a medical specialist from the IC department.
In Germany, IC transport takes place via the use of ambulances or special IC vehicles (intensivtransportwagen). The team consists of an emergency doctor (Notarzt) and an emergency nurse (Notfallsänitäter/in). However, regular ambulances may also transport patients if they are appropriately equipped and staffed; unlike in Belgium and the Netherlands, regular emergency ambulances are staffed with a doctor (Notarzt).
In IC transport in Belgium, ambulance teams may make use of Paramedic Invention Teams (PITs) or Mobile Urgency Groups (MUGs). The teams consist of a specialised doctor (gespecialiseerde arts), and an emergency nurse (spoedeisendehulpverpleegkundige).
The following table presents these core IC specialists in the three EMR countries:
|The Netherlands||Belgium||Germany (NRW)|
|Emergency doctor||Arts spoedeisende geneeskunde||Gespecialiseerde arts||Notarzt|
When comparing the profession of emergency doctor between the three legal systems, we find that there are differences in the duration of the specialist training: in the Netherlands, the specialist training as arts spoedeisende geneeskunde takes three years; in Belgium, training as geneesheer-specialist in de urgentiegeneeskunde takes six years; in Germany, the duration of training as Notartz is two years. The differences in duration can be attributed to the fact that, despite all being specialised training, the organisation of this training differs per country. In Germany, emergency medicine is an additional course to an existing medical specialty. The doctor will already have completed basic and specialist training, e.g., in internal medicine or cardiology, before specialising further in emergency medicine. Emergency medicine in Belgium is an independent medical specialty (to be pursued after basic medical training). In the Netherlands, the profession of emergency doctor is not considered a medical speciality under public law. After completing their basic training, the prospective emergency doctor must pursue training supervised by the Royal Dutch Medical Association (KNMG), which protects the title of Arts spoedeisende geneedskunde title under private law. This means that formal recognition procedures as foreseen by EU law are not applicable. Mobile professionals must instead rely on procedures maintained by the KNMG. Differences such as these complicate the recognition of qualifications of IC specialists across borders.
When we shift the focus to comparing the profession of emergency nurses or paramedics, we may see that in the Netherlands (IC-verpleegkundige) and Belgium (verpleegkundige gespecialiseerd in de intensieve zorg en spoedgevallenzorg) the candidates follow two steps in training. First, the candidate obtains a degree as a general care nurse, after which they follow specialised training in IC and emergency care. Similar to the profession of emergency doctor in the Netherlands, the profession of IC-verpleegkundige is not considered a regulated profession. By contrast, in Germany, not a specialised nurse, but an ambulance paramedic (Notfallsanitäter/in) may be involved in situations of IC transport. In this case, training takes three years and is a combination of practical, theoretical and hospital training.
Challenges with cross-border deployment of IC professionals
The previous section showed which professionals are mainly involved in IC transport in the EMR countries and highlighted the differences in training for those roles. One of the main obstacles identified in the Pandemric study on ambulance and IC transport was considered to be the differences in training as well as the structure of professions.
Challenges arising from differences in education and training are in no way new. The EU has long been working to facilitate the mobility of professionals by building bridges between the different professions. At present, the Professional Qualifications Directive – PQD (2005/36/EC amended by 2013/55/EU) forms the legal framework to facilitate cross-border work of professionals working in regulated professions across the EU. Regulated professions are those for which qualification requirements are laid down by law, thus requiring a formal recognition procedure before a professional may assume work in a host Member State.
The PQD provides for different systems enabling professionals to work across the EU. The system for automatic recognition enables professionals of seven professions (including medical specialists and nurses) to follow expedited procedures due to minimum harmonization of education and training, as well as lists of diplomas enabling recognition to take place automatically (i.e., without additional assessments as to the contents of the degree). However, most professions are subject to the general system. Based on the principle of mutual recognition, this system entails a comparison of the foreign qualification with that of the host Member State. In the event of substantial differences, the professional may be asked to complete an adaptation period (max. 3 years) or aptitude test.
Focusing on IC professionals, we may perceive that these are some of the categories of professionals seemingly benefiting from automatic recognition. Nevertheless, the differences in IC transport challenge this expedited recognition. In the case of emergency doctors, their specialization is not taken up in the relevant table in the Annexes of the PQD (point 5.1.3 specifically) which would enable automatic recognition. This means that these professionals are forced to rely on the general system and therefore face potential adaptation periods or aptitude tests.
In the case of IC nurses, more issues may arise due to the differences in professions between the Netherlands and Belgium (where professionals have basic training in nursing and an IC specialization) and Germany (where Notfallsanitäter/innen constitutes a separate profession, different from that of nurses). Moreover, even if professions might appear similar between the Netherlands and Belgium, obstacles also exist in this border region. Whereas Dutch nurses seeking to work in Belgium must follow the general system described above to obtain recognition, Belgian nurses in the Netherlands may face different challenges, since the profession is not formally regulated there. Prior research has shown that the lack of regulation of the profession does not lead to an absence of obstacles. More specifically, a quality standard set by the medical field in the Netherlands determines that IC nurses must have diploma issued by the College Zorgopleidingen – CZO (College for Healthcare Training) whose role is to safeguard the quality of healthcare training and issue diplomas. Since such diplomas are only issued to those having pursued the CZO training in the Netherlands, this requirement forms an obstacle in the cross-border context since it creates uncertainty with employers as to whether and under which circumstances they may employ IC nurses with foreign qualifications (i.e. not fulfilling the requirement of the diploma being issued by CZO).
Concluding remarks: Potential solutions and current developments
Rather than pursuing harmonisation of the three systems, it may be more feasible to find solutions that enable cross-border cooperation regardless of the differences in the national IC transport systems.
Indeed, a related obstacle identified in the aforementioned Pandemric study concerned a lack of familiarity with each other’s respective systems. The best approach was considered to be the adoption of a mutual recognition approach (rather than harmonisation). Cross-border cooperation in the form of networking, joint training, staff exchanges and internships were considered particularly productive ways of enhancing understanding of the respective systems. Steps such as these may furthermore also facilitate more formal recognition procedures since a better understanding of the respective systems can lead to facilitated identification of potential differences and their subsequent mitigation.
However, activities have recently been initiated in connection with the PQD that facilitate the cross-border mobility of some categories of IC staff. In particular, the COVID-19 pandemic and the resulting pressure on IC across the EU led to the establishment of the European Parliament IC Interest Group (EPIC-IG). EPIC-IG aims to facilitate dialogue between Members of the European Parliament on the significance of IC preparedness for future crises, with a focus on the professional recognition of IC qualifications. It has been discussed whether IC specialists could be included under Annex V of the PQD (facilitating automatic recognition). This issue was also addressed by the European Policy Centre, calling for minimum training conditions for IC specialists at the EU level.
Even though this contribution focused on the obstacles associated with different training conditions for intensive care specialists, it is important to note that other categories of obstacles may also impede the provision of these cross-border services. For instance, EPIC-IG has discussed the involvement of IC units in the recently proposed European Health Data Space[*], which aims to create a data infrastructure under which health data could be more easily shared cross-border. This issue is also known to EMRIC, the network on incident control and crisis management in the EMR. Data on the capacity of IC units and the location and availability of IC ambulances are unavailable, thereby complicating cross-border cooperation and understanding. To overcome these obstacles, the partners of this network are currently discussing opportunities to formalise and structure cross-border cooperation in IC transport in the EMR.
[*] Susanne Sivonen, co-author of this blog post, is currently researching the legal implications of the proposed Regulation on the European Health Data Space on the border regions in the EMR. The results of this research will be published on November 18th 2022 at the ITEM Annual Conference.
Posted by Lavinia Kortese and Susanne Sivonen
Suggested citation: L Kortese and S Sivonen, “Organising intensive care transport in the Euregio Meuse-Rhine: Examining differences and identifying solutions”, available on REALaw.blog, https://realaw.blog/?p=1586
Dr. Lavinia Kortese, Assistant Professor in European Law at Utrecht University. Lavinia’s research interests are related to EU Internal market law (recognition of qualifications), education, migration, and health.
Susanne Sivonen, LL.M., Researcher at ITEM (Institute of Transnational and Euregional Cooperation and Mobility), Maastricht University. With a background in European law, she is specialised in cross-border healthcare in the EU.
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