The Pharmaceutical Journal
Vol 272 No 7297 p537-538
1 May 2004

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As the European Union expands, what are the implications for pharmacy?

On May 1, the EU will expand from its current membership of 15 countries to 25 countries. Pamela Mason examines the diversity in health, health systems and pharmacy practice in the enlarged union

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Most of the 10 new member states that will join the EU on 1 May — Cyprus, the Czech Republic, Estonia, Hungary, Latvia, Lithuania, Malta, Poland, Slovakia and Slovenia — are former communist countries in Eastern Europe.

Prerequisites for accession were the achievement of stable institutions guaranteeing democracy, rule of law, human rights and protection of minorities and the existence of a functioning market economy. Each country was also required to create the conditions for integration through adoption of European Community legislation (known as the acquis communautaire, the accumulated body of European legislation since the creation of the European Community).

From 1 May, the population of the EU will increase by from 375 million to 450 million, bringing together a population one and a half times the size of that of the US within a new political and trading zone. Within this new region, the diversity in health, health systems and pharmacy practice is large.

In relation to health, the gap in mortality patterns between Eastern and Western Europe is well known. Overall life expectancy in the current 15 member countries of the EU is around 78 years while that of the new members (excluding Cyprus) averages 72 years. This is due not only to high levels of smoking and alcohol consumption and poor nutrition but also because health expenditure has not kept up with the challenges to be faced. This is due largely to the competing priorities of transition to market economies during the past decade. However, opening up of markets, with increased access to year-round fresh fruit and vegetables and modern pharmaceuticals is contributing to the improvements in health and life expectancy that are becoming evident now, particularly in the Czech Republic and Poland.

Pharmacy privatised

During the early 1990s, pharmacy was privatised and emerged from the old state-controlled system rapidly. In some countries, this process was chaotic, and although pharmacy legislation was established early on, there was not the infrastructure to enforce it. Today, however, pharmacy in Eastern Europe is increasingly well regulated with most community pharmacies having a bright, modern, professional appearance. Chains or groups of pharmacies are allowed and exist in some form in the new entrants, with the exception of Cyprus, Hungary and Slovakia.

Key pharmacy statistics (2003) for each of the new member countries and, for comparison, the UK are shown in the Table below (p538). Eastern European countries have witnessed an increase in the number of pharmacies since 1990 because of privatisation. However, Slovenian pharmacies still serve large populations in comparison with the UK, although even larger populations per pharmacy are the norm in the Netherlands and the Scandinavian countries. The numbers of pharmacies per head of population are similar to the UK in the Czech Republic, Estonia, Hungary and Slovakia, while the other five new member countries have a relatively large number of pharmacies.

Additional services

Pharmacists are increasingly offering additional services. In the Czech Republic and Hungary there are “ask about your medicines” projects, and in Estonia, Latvia and Lithuania, a “hypertension” service has been in place since 2000. In Latvia a “diabetes care” programme is due to begin shortly. Almost all pharmacies are computerised with the exception of a few in rural areas.

Pharmacists are not without difficulties. In some countries, waits of up to four months for drug reimbursement are not unusual. Many pharmacists in the accession countries say that the political climate at home has not been helpful to pharmacy. Jerzy Lazowski, secretary of the chamber of Polish pharmacists, says: “The politicians see us primarily as business owners contributing to the economy and not as health professionals who want to provide good patient care.”

So what will accession mean for pharmacy and pharmacists, not only in those countries about to join the EU but also in those, including the UK, that have been members for years?

Shortages in the UK pharmacy workforce would suggest that pharmacy employers here might look to the new member countries to solve their difficulties. The current EU has already proved to be a fertile ground for recruitment for some of the larger companies, with Lloydspharmacy employing pharmacists from Spain and, according to Mr Lazowski, planning to recruit in Poland. Adam Holden, of Moss Pharmacy, said that Moss would certainly be looking to some of the new member countries, such as the Czech Republic, to help fill vacancies.

But how easy will it be for pharmacists from the new member countries to work in the UK? Legislation guarantees an automatic equalisation procedure for pharmacists from other EU member states, provided that their qualifications comply with EU directives (85/432/EEC and 85/433/EEC) on the education and training of pharmacists. Scientifically, the education of pharmacists throughout Eastern Europe has always been sound, although training in pharmacy practice lagged behind some of the countries of Western Europe. However, all the new member countries now have training courses for pharmacists in place that comply with the directives.

Conditions or accession

Rebecca Taylor, information officer, Pharmaceutical Group of the European Union, Brussels, says that compliance with the directives was one of the conditions for accession (ie, part of the acquis communautaire) of the 10 new member countries. Evidence for compliance was gathered by the Internal Market and Enlargement Directorates General, together with the Office for Technical Assistance and Information Exchange (TAIEX), which sent teams of experts to examine the pharmacy faculties and the practice of the profession in the 10 candidate countries. The TAIEX missions reported on progress in implementing the relevant acquis communautaire, with any action that needs to be taken to bring pharmacy training in to line with EU standards.

“In most of the new countries, pharmacy education was already longer than the five years (including preregistration training) required by the directives,” Ms Taylor said. “But one of the changes that a number of countries did have to implement was in relation to practical, on-the-job training. In some countries this was not a prerequisite for qualification as a pharmacist, but rather an additional step to be taken in order to be able to work in a community pharmacy or to be responsible for or own a pharmacy. But in general there were no problems with the length of studies, rather the opposite,” she added.

Pharmacist mobility

This means that pharmacists from the accession countries will have the “right” to work anywhere in the expanded EU. However, the issue of pharmacist mobility is not quite as clear cut as first appears.

Language is a significant issue, but there is currently no requirement in the EU directives for pharmacists to be fluent in the language of the country in which they wish to work. According to Ms Taylor, this means in theory that a Spanish-speaking pharmacist with no French has the automatic right to work in a French pharmacy. “Of course, it is doubtful whether any French pharmacy would employ a pharmacist unable to speak French,” she said.

However, the PGEU has successfully lobbied the European Parliament for an amendment to the directive on the mutual recognition of professional qualifications that will give member states the possibility to assess the language skills of EU pharmacists coming to work in their country. “How language fluency is assessed will be up to the member states,” says Ms Taylor. Applicant pharmacists could be required to pass a language test or undertake language classes. The amendment to the directive has been accepted by the European Parliament and its report has now gone to the council, but it is not yet known whether the council will accept it.

The UK is likely to be more accessible to pharmacists from the new countries. English is now widely taught in Eastern Europe, particularly in health and scientific disciplines, and has to a large extent replaced Russian as the preferred second language, so some younger pharmacists from the new countries may well have the language skills to enable them to work in a British pharmacy.

Another issue is that the movement of workers from the new countries will not — during the early years after accession — be as free as it might appear. Transitional measures will operate in which current member states can restrict the immigration of workers, and complete freedom of movement across the EU is not guaranteed until 2011. This is because many of the “old” EU countries fear an influx of people from the “new” countries. Pharmacists from the new member states wanting to work in most of the old member states will therefore need a work permit. The only exceptions are the UK and Ireland, where no work permit will be needed. However, pharmacists from the new countries will have to live in Britain for two years before they can claim state benefits.

These measures apply to employees but not to self-employed people. However, self-employed pharmacists (ie, those wanting to run their own pharmacies) will be subject to the rules on the opening of pharmacies applicable to all pharmacists in that member state.

Foppe van Mil, pharmacist owner in the Netherlands, has no concerns about an influx of pharmacists to his country. “Language will be a definite barrier,” he says. “In any case, we have no shortage of pharmacists here and the rules for opening up a pharmacy are pretty stringent. The main implications for pharmacy in the Netherlands could be an increase in parallel imports from the new member countries.”

“Brain drain” concern

Concern has been widely expressed about a potential “brain drain” of health professionals from the new EU countries. Given the higher salaries in the old EU countries, this is not surprising. However, at a round-table meeting of the Pharmaceutical Group of the European Union last week, none of the accession country members believed that they would face a mass exodus of pharmacists to the West, although some did expect that a small number of predominantly young pharmacists might be interested in working abroad.

Stefan Krchoak, president of the pharmacy association in Slovakia, confirmed this. “Certainly there will not be a strong flood of Slovak pharmacists heading west. Historically there has always been exchange of pharmacists between Slovakia and the Czech Republic but this is due to the language similarity.”

Sandra Berzina, vice-president of the Latvian pharmacy association, thinks that Western pharmacy chains may want to open in Latvia, but she adds that regulations will be a barrier. The UK’s Alliance Unichem Retail International already owns pharmacies in some European countries, including Norway, Switzerland and Italy, and it has a wholesaling venture in the Czech Rrepublic. It is therefore possible that it might consider opening community pharmacies in the new member countries.

Benefits for pharmacy?

So what will be the benefits of EU enlargement for pharmacy? The new countries have already gained from the impetus to reform pharmacy education and practice. Changes made in pharmacy training will not only assure equal status for pharmacists in the labour market of the enlarged EU, but will also be beneficial for patient care. Given the shortages of pharmacists in some EU countries, a wider pool of pharmacists who do not incur education costs will be an advantage.

What is also important is that the new countries bring with them new ideas that will add to the wealth of expertise available. In the past few years they have progressed up a steep learning curve on how to change and improve pharmacy practice — in short, to find out which approaches work and which do not. Moreover, many of the issues pharmacists face, such as obtaining payment for providing new pharmaceutical services, are the same throughout Europe and lessons can be learnt from each other, leading to improvements in the quality of patient care.

Mr Lazowski is optimistic. “We hope that joining the EU will help our profession [in Poland] to defend the most important interests of pharmacy and enable us to collaborate more effectively with our colleagues from other EU countries.”