The governments' doctors: The roles and responsibilities of chief medical officers in the European Union
Abstract
The regular meetings of the chief medical officers (CMOs) from the European Union's (EU's) 27 Member States provide an important forum to address issues of common interest affecting Europe's populations. Yet there is no universally agreed role for a CMO. This article describes the findings of a study, based on interviews with key informants and documentary analysis that sought to describe their diverse roles. For the purpose of this article, CMOs are defined as those sent by their governments to the regular EU meetings of CMOs. Four broad categories of countries were identified: those whose CMO is the most senior doctor in the health ministry, in some cases with responsibility spanning all of government; where they are head of a division within the health ministry; head of a separate body such as a national board of health; and countries where no single individual can be identified. Although the diversity of health systems means that these roles cannot be harmonised, there is scope to explore what can be learnt from the different approaches.
Introduction
England is about to have a new chief medical officer (CMO), now that Sir Liam Donaldson has stepped down after 12 years in post. One of the many responsibilities that his successor will take over will be attendance at the twice yearly meetings of CMOs of the European Union (EU). This provides senior health professionals within governments with an opportunity to discuss the many shared challenges they face and, in recent years, it has proven a valuable forum for exchange of information on issues such as pandemic preparedness, patient safety and anti-microbial resistance. English CMOs have been able to speak with considerable authority at these meetings, addressing a wide range of issues, from classical public health to healthcare, professional regulation, and ethics. There is, however, no agreed European job description for a CMO, and although the EU Member States designate who should attend the EU CMO meetings, there is considerable heterogeneity in their positions within their own countries. The new CMO for England will be meeting with individuals who have widely varying roles and responsibilities, complicating dialogue and cooperation on matters of vital interest to European citizens. In this paper the diversity of roles among those identifiable as CMOs in the EU will be described.
Methods
A survey of the roles and responsibilities of Europe's CMOs, defined pragmatically as those attending the EU CMO meetings, was undertaken. Specifically, information on their formal titles and positions and the organisational structure within which they worked, their professional background, and their responsibilities in relation to various aspects of public health and healthcare were sought. Most of the information was obtained from a combination of interviews with key informants (current and past CMOs, their assistants, and World Health Organization country officers) supplemented with an iterative internet search using Google and PubMed, with follow-up of citations.
Results
At the outset, it is necessary to recognise that those attending the EU's CMO meetings do so as delegates from the 27 Member States. However, responsibility for many aspects of health and healthcare are devolved to sub-national authorities. This means that those representing federal (or highly decentralised) countries, such as Austria, Belgium, Germany, Italy and Spain, must be acquainted with a range of issues that they have no responsibility for on a day-to-day basis. The UK has adopted a convention whereby the English CMO speaks on behalf of the three devolved administrations (each with their own CMO) and the dependent territories in international fora. This is possible because of the range of issues for which the English CMO is responsible, as well as the constitutional ambiguities that persist in the UK (summarised succinctly by the former MP Tam Dayell in the ‘West Lothian question’).1 However, this can bring its own problems, as seen in discussions over bovine spongiform encephalopathy (BSE) when England and Northern Ireland (which was free of BSE) had directly opposing views about lifting the ban of export of British beef,2 and in the recurring problems of combining data from all of the UK for international comparisons.3
Although no two CMO posts are identical, it is possible to allocate Member States to broad categories according to the roles and responsibilities of their CMOs. First are those where the CMO is the most senior doctor in the health ministry, with responsibilities encompassing many aspects of public health and healthcare. Within this category the English CMO is unique. First, they act as the principal medical advisor across government and not only to the secretary of state for health, whereas their counterparts only advise health ministers. Second, the CMO is the professional head of all medical staff in England, a role not found elsewhere.4 However, CMOs with wide-ranging responsibilities within health ministries can also be identified in six other countries. The Irish CMO is the senior advisor on public health to the health ministry while also leading on issues such as emergency preparedness and patient safety. The French Director General for Health heads a team of several hundred people covering areas such as public health, health technology, forecasting and policy development, and patients' rights. Finland's Director General in the Department for Social and Health Services also has responsibilities for healthcare (with a focus on quality) and broader public health. Similar roles can be found in Belgium, Latvia, Luxembourg and Portugal.
A second category comprises those countries where the CMO heads a department within the national ministry. This is most commonly a department of public health, as in Austria, Germany, Italy and Malta. However, the range of responsibilities of these departments varies considerably. For example, the Austrian CMO covers pharmaceuticals, food and drug safety, and regulation on non-medical health professionals. The Spanish and Italian CMOs cover a range of public health issues as well as international affairs. The German CMO heads a department of prevention, health protection, disease control, and biomedicine, as well as overseeing the work of the Robert Koch Institute, the federal institution responsible for disease control and prevention.
A third comprises countries where the CMO heads an agency that is, to varying degrees, separate from the health ministry. Thus, the Swedish and Danish CMOs are the heads of their countries' National Boards of Health. These bodies have wide-ranging responsibilities including patient safety, oversight of health promotion and disease prevention, and licensing of health professionals. The Polish and Bulgarian CMOs are the chief public health inspectors, responsible for national networks of public health departments. The Hungarian CMO heads the National Public Health and Medical Officer Service, which includes a national institute of public health. The responsibilities of the Slovenian CMO are more closely focused on healthcare, with the post being held by the director general of the Health Care Inspectorate.
A fourth comprises those Member States where no single individual can be identified clearly as fulfilling the role of CMO. This includes Lithuania and Czech Republic, whose representatives attend EU CMO meetings only sporadically, sending different individuals according to the agenda. Also falling within this category is The Netherlands, where the CMO role is divided between the director general for public health and the head of the Health Care Inspectorate, with one or other attending EU CMO meetings according to the agenda.
The CMO roles differ in some other respects. Not all are medical doctors. Exceptions (at the time of writing) include Denmark where the last incumbent was previously the chief executive of the Copenhagen University Hospital and Germany, where the CMO is a lawyer. They vary greatly in the resources available to them and this is not simply a reflection of the size of the country. Thus, the Luxembourg CMO heads a team of more than 200, comparatively bigger than that in several much larger countries. They vary in the extent to which they have advisory or executive functions although, in general, CMOs seem to have more direct responsibility for emergency planning than for other areas of activity. Finally, they differ in their tenure. CMOs in some member states have remained in post for many years and long-serving incumbents from the UK, Ireland and Finland have acted as the repository for the EU's institutional memory. In other cases, an individual may ever attend only one or two meetings.
Discussion
The EU is now a major player in public health policy, as set out in successive European Treaties,5 and although less explicitly, also in many aspects of healthcare.6 Health professionals from across the EU collaborate on a daily basis in many areas, such as the disease surveillance networks working with the European Centre for Disease Prevention and Control and the research networks seeking to solve problems of common interest, as well as a series of activities linked to the EU's increasing number of specialist agencies in areas such as pharmaceutical regulation, illicit drug monitoring, food safety and environmental health. This might suggest that meetings of CMOs are superfluous. However, given the commitment of European governments to Health in all policies,7 there is still considerable value in having a forum that can transcend specific issues, exchanging ideas on how to tackle common problems and delivering consistent messages to governments. The regular meetings of CMOs offer such an opportunity.
Given the diversity of European Member States and their health systems, it is unsurprising that the systems by which governments obtain professional advice on health and health policy will vary. Even if it was deemed desirable to do so, it is difficult to see how the diverse roles of CMOs could be harmonised. However, this does not preclude a substantive discussion about the strengths and weaknesses of the different models that currently exist and whether the means by which they collaborate to address issues of shared concern across Europe might be strengthened.
- Royal College of Physicians
References
- ↵
- Gay O,
- Holden H
- ↵
- Butler K
- ↵
- Connolly S,
- Bevan G,
- Mays N
- ↵
- Sheard S,
- Donaldson LJ
- ↵
- ↵
- McKee M,
- Mossialos E,
- Baeten R
- ↵
- Ståhl T,
- Wismar M,
- Ollila E,
- Lahtinen E,
- Leppo K
Article Tools
Citation Manager Formats
Related Articles
- No related articles found.