Intended for healthcare professionals

Analysis Health Systems Perspectives

Maintaining the competence of Europe’s workforce

BMJ 2010; 341 doi: (Published 03 September 2010) Cite this as: BMJ 2010;341:c4687
  1. T Horsley, educational research scientist1,
  2. J Grimshaw, director23,
  3. C Campbell, director14
  1. 1Centre for Learning in Practice, Royal College of Physicians and Surgeons of Canada, Ottawa, Ontario, Canada
  2. 2Centre for Best Practices, Institute of Population Health, University of Ottawa, Canada
  3. 3Canadian Cochrane Network and Centre, Ottawa
  4. 4Office of Professional Affairs, Royal College of Physicians and Surgeons of Canada
  1. Correspondence to: T Horsley thorsley{at}
  • Accepted 21 August 2010

With increased professional and patient mobility across EU borders, T Horsley and colleagues argue that we need a common set of principles for continuing professional development and a more harmonised approach to accreditation

A cocktail of catastrophic events has politicised the movement of both patients and doctors within the European Union and put unprecedented scrutiny on the competence of doctors and the privilege of self regulation.1 2 3 4 5 European legislation dictates that national licensing authorities such as the General Medical Council must accept qualifications from within the EU, placing onus on the employer to ensure doctors are fit to practise. With striking heterogeneity between EU countries in how continuing professional development systems are currently regulated and delivered and the lack of mandatory requirements for periodic validation or participation in continuing professional development in some countries,3 regulation of continuous learning within the EU is gaining increased attention.6

This article, which is based on a longer report written for the European Union,7 describes the variation between continuing professional development systems across EU countries and argues for harmonisation of accreditation systems.

Variation across the EU

Despite the longstanding recognition in several countries (including the United Kingdom) that continuing professional development is a professional commitment to sustain the quality of medical practice, regulations across EU member states remains diverse. In 2008, Merkur and colleagues reported on seven key features of continuing professional development systems across 26 European countries (table 1).3 Although there have been some changes since then—for example, in France, the system is no longer run by professional bodies—the data provide a good picture of the variation.

Table 1

 Requirements for revalidation of medical professionals in selected countries in WHO European region*3

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Most countries require doctors to report a certain number of credits over a defined period, ranging from one (Belgium) to seven (Slovenia) years. Six countries (Denmark, Luxembourg, Portugal, Spain, Sweden, and Switzerland) with voluntary participation have not established a defined timeframe for reporting activities or credits. All countries include participation in formal continuing professional development but only 10 require some form of formal peer review.

Although 17 of the 26 countries describe continuing professional development as compulsory, the approach to documentation is oriented towards process (participation) rather than outcome (was learning achieved?). Non-compliance has formal consequences in only eight countries: Croatia (examination to continue practice), Germany (reduced reimbursement; after two years licensure is withdrawn), Hungary (special examination before a commission), Netherlands (removal from the medical registry), Romania (practice rights revoked), Slovenia (re-examination), Switzerland (loss of membership of the Swiss Medical Association), and the UK (practice supervision). Only Norway and Belgium have incentive schemes.

The regulation of continuing professional development is equally heterogeneous, being governed by professional bodies in 13 countries, independent authorities in five countries, and government in a further five. Belgium is the only country where an insurance fund and government regulate the system.

All countries except Norway allow industry sponsorship of events so long as conflicts of interest are declared, although advertising during events is strictly prohibited.

Need for EU-wide core principles, values, and measures

Online learning has removed geographical restrictions to continuing professional development. In 2008 Harris and colleagues reported that online continuing medical education accounted for 6.9-8.8% of reported activity in the United States and speculated that it could account for 50% within 7-10 years.8 Unpublished data from Canada suggest a similar pattern of use, with 25% of members of the Royal College of Physicians and Surgeons reporting participation in web based continuing professional development. Although equivalent data for EU member states is not available, participation seems to be lower because e-learning initiatives remain underdeveloped.

Credits for attending group learning events held outside a doctor’s home country are restricted within some EU countries (for example, Italy). These countries also restrict the number of credits obtained by online self learning (such as individual learning or e-self assessment).

The European Accreditation Council for Continuing Medical Education has successfully connected existing and emerging accreditation systems in Europe by acting as a clearing house for accreditation.9 EACCME devised a system of European continuing medical education credits (ECMEC) that harmonises the number of credits awarded across countries by using a gradient for hours of engagement (hour, half day, full day). This work has been complemented by agreements between some specialty accreditation boards and the European Union of Medical Specialists.

Although these are important developments, the EU has an opportunity to create a system of mutual recognition of regional or national systems for accrediting continuing professional development by adopting a core set of principles, values, and measures—a process defined as substantive equivalency.

The Rome group—which comprises leaders of accreditation systems in several EU countries, the United States, and Canada —proposed several enduring values that any system should reflect and articulated the expected responsibilities of the accrediting bodies, learners, and provider organisations (box 1).10 The Royal College of Physicians and Surgeons of Canada and the Accreditation Council for Continuing Medical Education in the US are using these principles to establish a substantive equivalency agreement.

Box 1: Rome Group summary recommendations for continuing professional development systems

Systems should be based on values that:
  • Enhance physician performance and thereby improve the health of people

  • Are based on information concerning the educational needs of doctors with the ultimate aim of helping them improve health

Responsibilities of the system (accrediting bodies)
  • Fairness, validity, innovation, honesty, and consistency in accreditation practices

  • Reasonable standards and criteria for providers or organisers

  • Accountability, responsiveness, and leadership

  • Accreditation process should include verification that providers carry out their required responsibilities

  • Promotion of continuous quality improvement of the accreditation process as well as the education systems it supports

  • Collaboration and partnership between and among accreditation bodies, and between accreditation bodies and providers

Responsibilities of the learner (to be fulfilled in order to claim credit)
  • Participate in continuing professional development that meets their educational needs

  • Ensure that the needs are relevant to their professional practice and development aimed at improving patient care and health

  • Evaluate the extent to which their needs have been met, in the context of a change in knowledge, competence, or performance

  • Verify that mechanisms are in place to keep educational activities free of commercial bias

Responsibilities of provider or organiser
  • Any commercial sponsorship or interests of the activity planner, presenters, or facilitators must be disclosed to the provider, the learners and the accrediting bodies

  • Any support, sponsorship, or funding by commercial healthcare organisations must not influence the structure or content of the educational activity and should be made clear to the participants and the accrediting bodies

  • Ensure there are outcome measures of education effectiveness expressed in terms of meeting the knowledge, competence or performance objectives of the activity.

  • Be able to confirm participation, at a frequency and nature appropriate to regulatory requirements.

  • Ensure that the learning objectives are specifically defined in terms of knowledge, competence, or performance, and are appropriate for the target audience

  • Ensure that the teaching methods used are appropriate to the stated learning objectives

  • Be able to show that they have evaluated the quality of any previous education activities and have made improvements, where necessary

Continuing professional development systems should also ensure that the activities achieve meaningful outcomes. Drawing from multiple conceptual frameworks, Moore et al described seven levels of outcomes (both subjective and objective) ranging from measuring participation and satisfaction to objective improvements in competence, performance, and the health of patients or populations (box 2). This conceptual model scan be used to explore the characteristics of continuing professional development activities that contribute to achieving specific metrics and the learning techniques that enable and reinforce specific outcomes.11

Box 2: Seven levels of outcomes for assessing continuing professional development11

  • Level 1: Participation (eg, attendance records)

  • Level 2: Satisfaction (eg, questionnaires completed by attendees after the activity)

  • Level 3A: Declarative learning: objective (before and after tests of knowledge) or subjective (self reported knowledge gain)

  • Level 3B: Procedural learning: objective (before and after tests of knowledge) or subjective (self reported knowledge gain)

  • Level 4: Competence: objective (observation in educational setting) or subjective (self reported competence; intention to change)

  • Level 5: Performance: objective (observation of performance in patient care setting; patient charts; administrative databases) or subjective (self reported performance)

  • Level 6: Patient health: objective (health status measures recorded in patient charts or administrative databases) or subjective (patient report of health status)

  • Level 7: Community health: objective (epidemiological data and reports) or subjective (community self report)

Mandatory participation

One of the commonest arguments against mandatory continuing professional development is the lack of evidence that it improves practice. There is growing and consistent evidence that participation in group learning is effective in improving knowledge but has a lower effect on behaviours and clinical outcomes.12 13 In 2009, a review of continuing education meetings and workshops showed a median adjusted absolute improvement in compliance with desired behaviours of 6% and improvement in patient outcomes of 3%.14 However, the median improvements increased to 13.6% when the group event included both didactic and interactive educational methods and when the complexity of the behaviour change was moderate (10.5%) or low (4.7%). These findings show that group learning can be as effective as many other interventions to change clinical behaviours.

Since almost all doctors participate in group learning, creating accreditation systems and standards that ensure adherence to factors that enhance the educational process should enhance outcomes and give doctors more confidence in the quality of these activities.

The effectiveness of continuing professional development systems to engage physicians in learning that is directly linked to improved patient care remains somewhat elusive, and there is no concrete evidence on how systems should be structured, delivered, or regulated to achieve these objectives. Harmonisation would see each member state considering a range of options for documenting participation in learning activities “for credit” that demonstrate achievement of measurable outcomes. Although similar in standards, systems would be developed and regulated within each country’s unique societal, cultural, historical, and financial frameworks.

Lifelong learning competencies

Within the past decade, several alternative approaches to defining the clinical competencies required for practice have been developed. For example in the UK, the General Medical Council’s Good Medical Practice defines a set of general and discipline specific competencies expected of doctors and serves as a framework for developing curriculums and assessment strategies across all phases of medical education.15 In Canada, the CanMEDS framework describes a set of general competency domains that are used to develop educational and assessment strategies for residents16 and are being promoted as the basis for developing and evaluating continuing professional development activities. Recently, the royal college has described a set of learning competencies shown by effective lifelong learners (table 2).17

Table 2

 Domains of competency for lifelong learning*

View this table:

These general statements of competencies can help learners and provider organisations to select or organise continuing professional development activities, but further development of meaningful metrics and assessment strategies is needed to foster credibility, transparency, and accountability.

Can harmonisation ever be a reality?

Although harmonisation of continuing professional development is possible, concerted effort is required to establish a common set of core principles, values, and measures. This will allow mutual recognition of learning activities and provide a rationale for including those completed abroad. Beyond that, if all EU member states accept that continuing professional development is a professional obligation and sufficient evidence exists that it improves performance and health outcomes, then participation should be a mandatory requirement for licensure. This is not an argument for periodic formal revalidation or certification but for engagement in continuous lifelong learning.

Our arguments for harmonisation raise some obvious and complex questions. For example, who should ultimately take responsibility for motivating change and monitoring fitness to practise? A reasonable expectation would be that it would be the joint responsibility of doctors, continuing professional development provider organisations, and the health system. For example responsibilities for healthcare systems include supporting an environment that is both safe (that is, not punitive) and conducive to learning and provides data that enable doctors and health teams to assess their performance against defined practice standards.

There is also the question of who should pay. Few data are available in Europe, but in North America doctors pay only a portion of the costs, with the remainder funded through industry grants and, to a lesser extent, government or practice plans. Industry funding varies substantively between provider organisations18 but is controversial because of concerns about commercial influence on the content.

The creation of systems of lifelong learning will need to consider the changing economic, political, and social landscape but pursue efficient approaches to maintaining and improving the competencies and performance of a diverse and ageing healthcare workforce.

This paper is part of an occasional series prepared in conjunction with the European Observatory on Health Systems and Policies (


Cite this as: BMJ 2010;341:c4687


  • Contributors and sources: TH has been involved with the production, teaching, and peer review of systematic reviews for nearly a decade. She is a board member for the Society of Academic Continuing Medical Education and her research focuses on broader lifelong learning strategies. This article is derived from a larger report commissioned by the European Observatory (on Health Systems and Policies on health workforce issues in the European Union, in response to a request from the European Commission. The main sources of the report were derived from traditional scoping review methods that included searching electronic databases, contacting experts, information available through the world wide web, and discussions with relevant stakeholders to identify relevant literature. TH wrote the draft manuscript. TH, JG, and CC finalised the draft. TH is the guarantor.

  • Competing interests: All authors have completed the unified competing interest form at (available on request from the corresponding author) and declare no support from any organisation for the submitted work; no relationships with companies that might have an interest in the submitted work in the previous three years; CC is a member of the ROME Group and has been supported by Serono Symposia International Foundation to attend an annual meeting of CPD accreditation system leaders from several EU member states, the United States, and Canada.

  • Provenance and peer review: Not commissioned; externally peer reviewed.