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EUC Report: Healthcare Professionals

Volume 736: debated on Thursday 22 March 2012

Motion to Take Note

Moved by

That this House takes note of the report of the European Union Committee, Safety First: Mobility of Healthcare Professionals in the EU (22nd Report, HL Paper 201).

My Lords, domestic healthcare has been high on the agenda of this House for the last six months or so. As with most other policies, there is a European dimension. This afternoon I would like to draw the House’s attention to the mobility of healthcare professionals within the EU.

I am sure that noble Lords will be aware of the debate that took place in the House on 8 September 2011 concerning the disparities between EEA and non-EEA healthcare professionals, as moved by the noble Viscount, Lord Bridgeman—who subsequently joined my committee, I am very pleased to say. On 11 January 2012, a Question for Short Debate asked by the noble Lord, Lord Kakkar, touched on the mobility issues but also considered other EU measures such as the working time and clinical trials directives.

Since its inception in 1948, the NHS has relied heavily on overseas-trained nurses and doctors to bolster its workforce. Their contribution has been significant and, since our accession to the European Union, what began with legal migration under the Commonwealth has been superseded by legal migration from other European countries.

We launched our inquiry into the mobility of healthcare professionals in May, shortly before the Commission published its Green Paper on revising the professional qualifications directive. Our report was published last October and considered the operation of the directive as it relates to the healthcare professions that are covered by its system of automatic recognition. The report not only made a number of recommendations to the Government but acted as our response to the Commission’s Green Paper consultation.

From the outset, we supported the principle that the mobility of healthcare professionals can bring significant benefits to patients, professionals and the EU in general. None of our witnesses challenged this assumption. However, we also recognised that the current directive failed to command the confidence of patients and professionals. Major UK regulators including the General Medical Council and the Nursing and Midwifery Council expressed strong concerns in their evidence to us that discrepancies in the current system forced them to admit individuals who did not meet the standards otherwise required of UK or non-EEA professionals, thereby putting patients at potentially serious risk. Incidents related to the failures of the directive have been statistically low. However, high-profile examples have had fatal results. This has undermined confidence in the directive and led to fears in some quarters that mobility has been prioritised over patient safety.

We examined the minimum training requirements contained in the current directive and concluded that they were out of date and badly in need of updating in order to reflect modern practice. We also considered whether there should be more stringent requirements for professionals to undertake continuing professional development, and whether a more competency- based approach to training and professional development should be adopted. We examined how fitness-to- practise information was shared between competent authorities in each member state, and we were alarmed to hear that competent authorities often fail to share information and that in some member states there are a plethora of different competent authorities, causing added confusion.

We concluded that the use of existing mechanisms such as the internal market information system needed to be enhanced and become more routine, representing a simpler and more cost-effective way of improving information-sharing than the Commission’s favoured option of introducing a European professional card.

Communication between patients and healthcare professionals is vital, and everybody agreed that professionals must be able to communicate effectively in the language of the host member state. We believe that the directive fails to ensure this and needs to be clarified so that language testing is permitted at the point of registration if deemed necessary for patient safety by the relevant regulator.

In the report’s conclusion we reached the view that encouraging mobility should never be at the expense of patient safety and that this must be the overriding concern in all circumstances. We believe that the current directive strikes the wrong balance and therefore welcome the Commission’s review, and we call on all parties, including the Government, to act quickly to ensure that serious failings in the current regime, which places patients at unacceptable risk, are remedied. Such changes would not represent a barrier to free movement but would instead strengthen it by rebuilding confidence.

The Government’s response was published on 19 December 2011, the same day as the Commission’s proposal for a revised directive. There is clearly a lot of common ground between our views and the Government’s views on the issues that we dealt with in our report. The Commission’s proposal to revise the directive goes some way to remedying the shortcomings in the original directive that we identified in our report. An alert mechanism will be introduced so that regulatory bodies must warn each other if, for example, a doctor or nurse has been struck off or suspended from a register and attempts to register in another member state.

The minimum training requirements for healthcare professionals will also be updated to reflect modern practices, and regulatory bodies will be able to check the language skills of health professionals. However, there is some confusion here. On the one hand, the GMC says that it is not currently allowed to systematically test language skills. On the other hand, the Commission says that it is. The situation is clearly ambiguous and we call on the Government and the Commission to work together to achieve what seems to be a common goal: to achieve clarity on this crucial issue. The Government’s proposed amendments to the Medical Act should happen in accord with any changes agreed to the EU directive in this area.

We also welcome the proposed exemption of healthcare professionals from the partial access provisions, in the interests of patient safety. We note that with the support of the relevant professional bodies, the Government are intending to push for veterinary surgeons and architects to be exempted. However, we also note that the Commission’s proposal contains no reference to the importance of continuing professional development. We reiterate our report’s recommendation that it should include an obligation on member states to require healthcare professionals to undertake CPD, but without being too prescriptive, and leaving the detail to each member state’s competent authorities. Although we remain to be convinced of the merits of the professional card, we note that the proposal seems to suggest that the introduction of professional cards for different professions will not be mandatory.

Although UK regulators have welcomed the introduction of an alert mechanism, they have questioned why it should apply only to the automatically recognised professions and not to the general professions. They also stress that the mechanism should flag up any conditions, restrictions or limitations placed on an individual’s right to practise, rather than just removals from registers. We share their concerns in this regard.

Data protection concerns have been raised in regard to the proposed alert mechanism, including by the European data protection supervisor. We touched on that in our report and note that the Government are already alive to this issue. We hope that they can successfully address these concerns during the negotiations, particularly in the context of the separate proposals for a revised data protection directive.

We have not yet received the Commission’s response. However, since the publication of our report I have participated in two conferences in Brussels which have included health regulators from across Europe who are working closely together on the proposals for a revised directive. During each event, interest in and awareness of our report was high. It therefore provided an excellent opportunity to reinforce the EU Committee’s views on this matter. I would also say that there was a good deal of consensus around the table among healthcare professionals from across the EU.

I also had the pleasure of hosting a roundtable meeting with senior representatives of all the automatically recognised professionals in the UK—that is, doctors, nurses, midwives, dentists, pharmacists, vets and architects. I hosted this event on 26 January and their views have helped to inform the committee’s ongoing scrutiny of the Commission’s proposal. We know that the Government have already worked closely with UK regulators in an effort to reflect their concerns during the negotiations on the proposal, which we commend.

In conclusion, I hope that my remarks demonstrate that the impact of the committee’s work in this area, as well as its proactive stakeholder engagement, has been successful and resulted in an ongoing scrutiny rather than, as it were, writing a report and leaving it on the shelf. The committee hopes that all parties to the negotiations on the revised directive, which are likely to continue until the end of this year, will strive to achieve real and practical improvements to the draft provisions. I look forward to hearing from other noble Lords, and of course from the noble Earl, Lord Howe, on behalf of the Government regarding this important matter. I beg to move.

My Lords, I thank the noble Baroness, Lady Young of Hornsey, for initiating this debate and I congratulate her on the excellence of the report. I am in a position to say that as I only joined the committee after it had been published. The noble Baroness has set out the timetable for the various consultation papers which have appeared, possibly inconveniently, at the same time as the report. It has to be said that the Commission’s draft on the amendments to the 2006 directive, on which many had pinned high hopes, at first glance is disappointing on the matter of language testing. However I am assured by a number of competent authorities—regulators—I have spoken to that, in reality, slow but sure progress is being made. Again, the noble Baroness has confirmed this.

Let me take one or two specific points relating to language testing. Proportionality, a basic concept of the European Union, has been replaced in the amending document with “when strictly necessary”. I am assured that either of these expressions, each of them as long as a piece of string, is fundamental to the EU principles and that this concept has been upheld in several cases before the European Court. I simply ask the Minister whether, in his negotiations with the Commission together with BIS, the Commission has fully taken on board that healthcare is the most prominent among a small group of professions where patient safety is a vital consideration, in addition to but quite discrete from other factors such as a mutual recognition of qualifications that goes right across the group. In talking to some of the UK bodies, I wonder if the Commission has fully taken this on board. I remain suspicious that patient safety remains as it has been to date; that is, sidelined in favour of single market dogma. Is there not a fundamental complacency about this?

I note that at paragraph 73 of the report, Emma McClarkin MEP is reported as saying in evidence that there have only been “occasional problems” with competent authorities over the issue of language testing. One death that is attributable to language misunderstanding is one death too many. As I have read somewhere, the difference between a milligram and a microgram in dosage can be a coffin—a smart bit of journalism, but surely that says it all. So there is almost universal agreement that the draft amending regulations as they apply to language testing are not sufficiently specific. I hope that both departments will take on board the message from this debate that they should aim towards unequivocal drafting which ensures that, in this matter, patient safety transcends any other consideration.

The committee’s report makes the point with elegant moderation:

“We consider that the Directive currently strikes the wrong balance between facilitating mobility and ensuring patient safety, which must be the overriding concern. Furthermore the current system undermines public and professional confidence in the mobility of healthcare professionals within the EU”.

I would take this point further. The regulations as they stand inhibit the status of the regulators within their own respective disciplines. After all, what is the raison d’être of a regulating body if it cannot adequately monitor its membership?

Perhaps I may make my own position quite clear. In my view, our aim must be that Article 53 is amended so that healthcare authorities in each member state have the power to impose whatever language testing they think fit. In some cases this may amount to blanket language testing, something the Commission has set its heart against. In other cases, the regulators may consider that some lower level of testing is adequate.

The sub-committee’s report covers the matter of language testing with clarity and common sense, and its proposals are admirably set out in paragraphs 82 to 85. These include provisions for monitoring the language skills of self-employed professionals, an area which in the Commission’s own admission is inadequately covered. There is also the very practical suggestion that, in view of the length of time required to effect legislative change, a code of conduct is an effective and relatively speedy route for clarifying with competent authorities what the directive currently permits with regard to language testing. Finally, the committee is not in favour of restricting language testing to those professionals who come into contact with patients.

In talks with various regulators, I am reassured that slow but steady progress is being made by the Department of Health and BIS in their negotiations with the Commission. I feel that we are all talking to the same purpose and this is very welcome. But perhaps I may ask the Minister whether he will continue to make the point that, whereas proportionality is a fundamental principle going back to the treaty of Rome, the matter of patient safety is quite frankly even more fundamental than that, and that it is patient safety which must in the end prevail.

My Lords, from these Benches, I thank most warmly the noble Baroness, Lady Young of Hornsey, and her sub-committee’s members for this excellent report in what is an incredibly complicated area. A good deal of thought has gone into its construction. I think that the evidence taken from a large number of very impressive people helped the sub-committee’s deliberations. It is good also to see, as usual, the chairman of the European Union Select Committee in his place listening to this debate.

As noble Lords have said, what is striking about the report is that it is not just to be put on a shelf and then forgotten; this is a matter of crucial importance where the report has breathed life into the Government’s own deliberations and conclusions, some of which I am sure we will hear from the Minister today. We will then await the European directive.

I also thank from these Benches the noble Viscount, Lord Bridgeman, for his comments, partly because of his very close connections with and experience of the medical profession and well known hospitals. He has acquired great knowledge over many years. I hope that we can perhaps use instead of “single market dogma” the more congenial “single market objective”, because that is a legitimate objective of the European Union—indeed, it is set down in European Union law and applies to us as well because we obey European Union law, I hope, in all respects. When all the complexities have been ironed out, the mobility of healthcare professionals will be an important part of the growing single market not only in the European Union but in the EEA as well. Therefore, we await the terms and contents of the directive.

I commend the way in which the Commission has very patiently and carefully conducted its hearings and produced its Green Paper. It has consulted and listened to all sorts of advice in a way that happens more often in Brussels than in member states, where Governments sometimes legislate too quickly depending on the individual characteristics of the parliamentary system that they enjoy or suffer from, as the case may be.

This process will lead to a directive and member states will then bring in their own national legislation. That will be the crucial moment for HMG to implant into it those important requirements that we have heard about at the beginning of this debate and the primary considerations of the committee as described by the noble Baroness, Lady Young of Hornsey.

I again thank the chairman of the European Union Select Committee. I think that it is now in order to quote a letter from him to the members of the committee because it is in the public and parliamentary domain. The last but one paragraph of his letter of 16 March, referring to the report from the committee of the noble Baroness, Lady Young, states:

“The Committee considered that to ensure that professionals’ qualifications and skills were adequate and reflected modern practice, the training requirements of the Directive needed updating”.

That will surely be one of the most important components of the directive that we await. The letter continues:

“The Committee proposed that mandatory use of the Internal Market Information System by competent authorities in Member States to exchange information about healthcare professionals would be simpler and more cost-effective than the European professional card”.

From these Benches, I agree with that very much indeed. In the longer-term future there may be a European-wide single market healthcare professional electronic identity card that can be used, but that is further down the track.

Public confidence is important, not only in this country. There are individual medical stories in the dramatic press in other member states too about things that go wrong with a doctor, healthcare professional or nurse practitioner where something tragic happens—or if someone suffers prolonged illness rather than the tragedy of death. Those people have come with inadequate language qualifications, or other details of their training were substandard, and therefore they were not able to perform as the public would want.

But there are very small numbers of those cases. The press with its lurid headlines is bound to highlight them. In this case it does a good service. We often grumble about the press and its dramatic headlines, but in this case it is good to make sure that patients’ safety is the real priority. But it is a small number, so we should not go too far down the other path. That is something to which we are prone in this country, with our excessively nationalistic press: saying that in all respects British standards are higher and better than in other member states, including large member states in the European Union where more and more now the standards are getting very similar. There is a high level of quality and of protection. It is easy and tempting to go down that path, but it is a flawed path and misleading and one that I think the Government would be wise to discourage as much as possible and explain the realities behind these matters.

We wish the report well. We look forward to the final judgment of the Commission, the publication of the proposed new European directive and the Government's conclusions pro tem today. I also thank the noble Earl, Lord Howe, for coming here only three days after the end of his herculean efforts on the Health and Social Care Bill to deal with this important matter. We thank him for that and support the conclusions that he may lead us to this afternoon.

My Lords, it does indeed feel that normal service has been resumed in the Chamber. I thank the noble Baroness, Lady Young, for the report and for the coherent way that she introduced it. I congratulate her and her committee on a brilliant job.

It is true that in September we had a preview of the report. We even saw some of it circulated during the debate initiated by the noble Viscount, Lord Bridgeman. During that debate in September, the Minister said:

“This summer we have been working constructively with other government departments and the health regulators themselves to formulate our response to the European Commission’s Green Paper on reforms to the directive. On that Green Paper there is very little on which the department and our partners disagree regarding areas of the directive that need strengthening. We agree that the harmonised training standards underpinning automatic recognition need updating and that a mechanism for regular updates is required. We would also like to see a focus over time on competencies in training rather than particular length of training”.—[Official Report, 8/9/11; col. 457.]

The Minister then goes on to talk about those negotiations. Those remarks were very important because they showed that we were making progress and moving forward together in the UK. What further progress is being made on that? I ask because it is not completely clear from the Government’s response to the report what the scale of progress is in the different areas that are covered by this report.

It seems to me that government policy, the report and the response are all broadly in the right place and there has been agreement in the House many times, not least because the noble Viscount has championed this issue for some time.

As well as being grateful for the report from the noble Baroness’s committee, we also need a report back on how the Government are progressing with these negotiations, what they expect the outcomes will be and at what times. This is indeed an issue of patient safety but, as the noble Lord, Lord Dykes, said, we also have to recognise that it is an issue from our NHS benefiting from the free movement of health professionals across Europe. Which one of us has not been treated by a nurse, doctor or health professional from some part of the European Union? That will absolutely be the case and is quite right. In the vast majority of cases, we do not even think about the fact that we may be treated by a German doctor, a Scandinavian nurse or whatever because we assume that they will be competent. In the vast majority of cases, they will be.

I hope that the unanimity in this House will help to inform the Government’s position on this review and indeed strengthen the Minister’s arm in these negotiations. However, I have a question about what and how much impact the Government’s position on light-touch regulation will have on these negotiations. That is slightly going back to the Health and Social Care Bill, where we had a discussion about that. I would like to know what impact that might have. It seems clear that the language skills clarity and the continuing professional development are still very important issues that need to be resolved. However, finally, there is no question that the EU Committee has done a great favour for patient safety not only in the UK but also across the whole of the European Union.

My Lords, I echo the comments just made by the noble Baroness, Lady Thornton. I, too, am extremely grateful to the noble Baroness, Lady Young, for her work and the work of her sub-committee in undertaking the inquiry that it did and for producing the report which has proved extremely valuable to us. Like the noble Baroness, Lady Young, I welcome the European Commission’s review of the directive on the mutual recognition of professional qualifications. It is a priority for the Government to ensure an appropriate balance between free movement and patient safety in the new directive. I will come on to say something more about that.

To start with, I broadly agree with the findings of the sub-committee’s report. As the Committee’s report highlighted, there have been significant concerns expressed by partners and stakeholders as to the applicability of aspects of the directive and its provisions to health professionals. The proposal published by the European Commission in December contains some welcome amendments that should, if introduced effectively, contribute significantly to tightening the European regulatory framework and improving patient and public safety. The Government’s negotiating position on the new directive has been informed by the sub-committee’s recommendations as well as the views of the devolved Administrations and our partners within the healthcare sector. There are a number of aspects in the proposals where we will seek clarification. I shall come on to those one by one.

First, the noble Baroness referred to information sharing. A key consideration for the Government is supporting the proposed new alert mechanism. As she mentioned, there is a proposal for a proactive alert mechanism for healthcare professionals falling within the sectoral professions—that is, those subject to automatic recognition of their qualification—in Article 56a(1). This looks positive. A different system will apply to healthcare professionals that fall within the general system under Article 56a(2)—the regime applicable for professionals under the general system that do not fall within the scope of the services directive. While this difference is not ideal, it arises from the different legislative bases across the European Union. However, the system should be workable if there is clear guidance from the Commission as to what can be shared and when, and if competent authorities under the general system comply with and take their responsibilities seriously and notify member states as appropriate. Having said that, I believe that there are points of detail we still need to clarify regarding the practicalities of administering the system. Ensuring proactive sharing of information when concerns arise about a healthcare professional is one of our top priorities, and we welcome the proposals in the new directive for the alert mechanism.

The legislative formulation of the proposals for alert mechanisms is complex, because the provisions differ for the sectoral professions. The Commission needs to ensure that all European competent authorities fully understand their obligations. At this point, we require further clarity on the application of the alert mechanisms for the general system and the implications of data protection overall.

We share some of the concerns of our partners about the proposal for a European professional card, an electronic card that links to the internal market information system, or IMI, and can be used by individual professionals for identification purposes. The new proposal, underpinned by the use of IMI, is a positive development, but the time limits proposed for decision-making when an application is made are potentially problematic and may prove to be counterproductive. In cases where satisfactory information has not been provided to the host member state competent authority within the time limit, it would be likely to have to reject an application. More generally, our view is that the whole concept needs to be properly piloted. While there may be some benefits in a professional card, proposals for it need more work—and I agreed with the remarks of my noble friend Lord Dykes on this issue. We need to ensure that the impact on competent authorities and professionals is properly considered so that patient safety is protected. We await with interest the results of the pilots. Our overriding concern in this area is to protect UK patients from healthcare professionals who may not be properly skilled to do the job.

The proposed move to a minimum duration of medical training from six to five years is also welcomed, as it provides greater flexibility to adapt medical training to meet the UK’s needs. We would eventually like to see a competence-based system of training standards, but we recognise the scale of such an undertaking in the short term. The move to modernise training over time, through a process for updating the core subjects that must be covered by training for the sectoral professions and by providing the Commission with delegated powers in this area, is a move in the right direction.

My noble friend Lord Bridgeman focused on an issue that he has consistently championed—that of language testing. This Government have made it clear that we want to stop foreign healthcare professionals working in the NHS unless they have passed robust language and competence tests. While the proposed new directive would not allow language checks by a competent authority before recognition of the qualification of a professional, it makes it clear that controls on language checks are permissible and can be undertaken before a professional is able to practise. The proposals in respect of language checks do not go as far as the GMC would like, as they do not enable checks at the point of registration, but would permit healthcare competent authorities to undertake language controls following registration when there are serious or concrete doubts about a doctor’s language ability, or following a request by the NHS or patient organisation. There is evidence of the Commission having considered the views of the UK Government in its proposals, and there have been positive developments in the proposals in relation to patient safety overall.

As I said, the Commission’s proposed draft would not appear to allow the GMC to undertake systematic language testing at the point of registration. The GMC would be required, as it is now, to consider the recognition of the qualification and, if accepted, to register the EEA migrant. However, the proposals appear to give greater scope for the GMC to be able to apply language checks after registration where serious concerns are identified, which is a positive development. We believe that what the Commission is proposing would be consistent with the proposed model for a strengthened system of checks, overseen by responsible officers, that we are working up in conjunction with the GMC. I will now come on to that.

In the UK, we have implemented a system of checks at a local level through duties on primary care trusts and guidelines to local NHS employers. We have already taken steps to strengthen the system and, since 2011, all designated bodies have been required to nominate or appoint a responsible officer—for example, a medical director in an NHS trust. In England, the responsible officer’s duties include ensuring that medical practitioners have the qualifications and experience they need for their area of work, and that references are checked, but we think that we can and should do more. We expect to consult shortly on new guidelines for responsible officers, which will build on the existing role of responsible officers in England to explicitly check for language ability.

We are also working with the GMC to develop further proposals and amend the Medical Act. This will mean the GMC is better able to take action where language concerns arise as part of the registration process and when a licence to practise has already been issued. The proposed changes to the directive would appear to facilitate the implementation of our preferred approach to language controls, which I have described.

In common with the sub-committee, the Government are disappointed that the proposals do not include a clearer requirement for all member states to have continuous professional development for their healthcare professionals. We think that all member states should be required to have a system of CPD in place for the healthcare professions within their territories, since out-of-date training presents a much greater risk for healthcare workers than for other non-health professions covered by the directive. We would not be prescriptive on the CPD system used by the member states. However, migrant professionals should be expected to demonstrate that they have kept up with latest developments in practice, and that recognition should be linked to them being able to do so. Overall, the key issue is that health professions should be able to demonstrate relevant recent practice.

The noble Baroness, Lady Thornton, referred to training. Negotiations on the directive commenced in January, with the aim of reaching agreement by the end of 2012. However, training has not yet been discussed in any detail at European level. We will continue to work with stakeholders on that important topic. As regards the use of delegated and implementing acts by the Commission, the Government recognise the need for those acts to facilitate the effective functioning of the European Union and the freedom of movement of professionals. However, we seek further clarity on the appropriateness of some of the proposed changes to the use of delegated and implementing acts and the surrounding processes.

We are pleased that the European Commission has proposed a “transparency” process under Article 59, which is likely to bring significant benefits in terms of increased trade and ease of doing business across Europe. Member states are obliged to check that their regulation of professionals is necessary and proportionate, while allowing member states ultimately to decide whether to regulate professions, which is of particular significance for health and caring sectors, to ensure patient safety. Inherently, in the context of European law, there is a balance to be struck here.

That balance was something to which the noble Baroness, Lady Young, and my noble friend Lord Bridgeman referred. I very much take the points that they made. Naturally, we believe in proportionality in regulation, but the Government have previously made their view absolutely clear that in places there needs to be a stronger focus on patient safety in the directive. Some of what is proposed in the draft new directive will help to achieve a better balance, and that is to be welcomed. Our approach to the negotiations over the coming months will be to ensure an appropriate and improved balance between freedom of movement and patient safety.

I listened with care to my noble friend Lord Dykes and agreed with much of what he said. We should not assume that our standards in this country are necessarily higher than those in other countries. Having said that, I think that there is one issue here of which we should not lose sight. As highlighted in evidence given by the General Pharmaceutical Council and the Nursing and Midwifery Council to the House of Lords inquiry last year, a small but significant risk is posed by professionals who are entitled to automatic recognition and seek establishment in the UK but who have not practised their profession for some years. As a result, in the Government’s Green Paper response to the Commission, we asked for the addition of a requirement of two years’ experience in the last five years, unless the applicant graduated in the last three years. However, this suggestion was not included in the Commission’s recent legislative proposals.

The Government will continue to work with the Commission to ensure that safeguards are in place. However, we come back in the end, I think, to the role of employers and commissioners in this context, because that is clearly vital in ensuring the suitability of the individuals they seek to contract with for the specific role they intend them to undertake, including acceptable relevant experience.

There is no question that overall the UK healthcare system benefits from the free movement of professionals. I think we all agree about that. However, the Government will continue to prioritise and promote satisfactory safeguards for the health professions and to ensure that the principles of free movement are balanced with the need for adequate safeguards for patients.

My Lords, I thank all noble Lords who have taken part in today’s debate. It was heartening to hear so much consensus across the House on the issues that have been raised by the inquiry and in our subsequent report. As I said earlier, I was pleased that the noble Viscount, Lord Bridgeman, joined the committee after having initiated a debate about language. I am very grateful to him for his diligence in pursuing that issue. It has to be said that he also has a very well rounded view of the whole set of issues involved in this report, although his focus has been on language-testing and so on. I think we all want to see something unequivocal and unambiguous in relation to language-testing to which we can subscribe.

I am grateful, too, to the noble Lord, Lord Dykes, for helping to put the report in a wider context. That is important, as is flagging up the fact that we feel that mobility is a good thing. We benefit from it, as we have done for many years and will continue to do. The question is really how we make the balance between the desirability of mobility and patient safety work. Of course, the noble Lord is correct to point out that we are talking about a very low incidence of fatal and serious impacts arising from the mobility of inappropriate practitioners. By the same token, as I think the noble Viscount, Lord Bridgeman, said, one is one too many, and that is what we have to tackle. In fact, somebody brought to my attention another very worrying incident concerning a doctor who has left a trail behind him on mainland Europe. Therefore, we have to be vigilant on those issues.

The noble Baroness, Lady Thornton, again emphasised the issue of benefiting from free movement. It can sometimes be easy to lose sight of that when we discuss and focus on what are, essentially, problems. I am glad that she raised continuing professional development, which the Minister picked up and went into in some depth. Again, many of us would agree that it is an absolutely crucial area.

During our evidence-taking, we heard the example of someone from outside the UK who had trained as a midwife 20 years ago and had no professional development subsequent to that. That is an area in which there have been lots of advances in many different ways. The idea that someone who first trained 20 years ago and has not practised since could come into midwifery here is quite disturbing. Therefore, CPD is very important.

I will not pick up on everything; it has been a long day. I will just deal with the professional card, which is another area on which we agree. It is interesting to note that at the conference called by Healthcare Professionals Crossing Borders in Brussels a couple of weeks ago, that was something of which some people were in favour while others had deep concerns about it.

I should also say that most people at that gathering had deep concerns about language. It is not only us who have these anxieties about how and at what point we test language. Part of the problem is that the complexity is there anyway but there are other layers of complexity to do with all the different systems that are in place in different member states. There are even different ways of thinking about registration. Some member states separate registration from licensing, which we do not. Therefore, if we say that something can come into play at the point of registration, it will mean something different in different places. All that complexity means that it is even more crucial that we have absolute clarity and push forward.

I reiterate how pleased I am that there is so much consensus on the areas in which we need to make progress, and that the Government are taking up those areas and working with organisations such as the GMC to ensure that we maintain and enhance a balance between mobility and patient safety.

In conclusion, it is absolutely right for me to acknowledge the unequivocal pleasure and delight of working with Sub-Committee G and my colleagues on it, who are represented today by the noble Viscount, Lord Bridgeman. We worked very hard on the report, as noble Lords can see. We did a lot of questioning and reflecting, which paid off in producing a report that many people have referred to. When I go to meetings in Brussels and elsewhere, people brandish copies of the report, which is heartening to see. I also thank the staff, particularly Talitha Rowland and Alistair Dillon, for their work on the report.

The debate today has, typically, been very informative and well informed. It points to the ways in which different parts of the House and our society can work together to ensure that we achieve the balance that we all seek. I beg to move.

Motion agreed.

House adjourned at 5.43 pm.