Plug and play?

There has been a trend towards mandatory CME across Europe in recognition of the vital role it plays in updating physicians on new developments in their field, as well as in maintaining competence and improving public confidence in the healthcare profession. However, there is considerable disparity in the way that CME programmes are organised and run within Europe.

Currently no central body for CME standards exists in Europe and, hence, no common framework for the development and running of CME programmes. As a result, countries each have separate systems, with different methods of assessment and different systems of awarding credits to programmes.

To begin with, different countries, and even different regions within countries, have different criteria for what constitutes one CME credit. Some countries operate on the basis of one hour per credit, while in others credits are weighted according to the level of participation required. Of course, the quality of the content will determine the ultimate value of credits to the physician. Furthermore, there are different rules across Europe regarding who can and who can't contribute to and pay for the development of CME activities. This primarily concerns the involvement of pharmaceutical companies. The largest barrier to standardised CME practices in Europe, however, remains the complexity of its accreditation process.

Accreditation
Within each country, the process of CME accreditation is relatively simple. National Accreditation Authorities (NAAs) are responsible for assessing and awarding credits for each activity using their own criteria and their own systems. NAAs can include the national health authority, professional bodies, medical associations, universities, or other eligible organisations. In countries without NAAs, the European Union of Medical Specialists (UEMS) Specialist Sections /European Specialty Accreditation Boards (ESABs) can also fulfill this role.

Applying for European CME accreditation is far more complicated. For international activities, approval must be obtained both from the national board of the country in which the activity is taking place, as well as from the accreditation body of the UEMS; the European Accreditation Council for Continuing Medical Education (EACCME), in addition to quality assessment from an appropriate professional organisation. All CME activities taking place in Europe are eligible to apply for EACCME accreditation, which has the advantage of ensuring that credits are transferable. This removes the need for individual applications to multiple national bodies and does not supersede national authority on accreditation decisions.

However, activities are still assessed according to national, rather than European, criteria. Some national bodies, eg the Royal College of Surgeons (RCS), do not recognise EACCME accreditation, presumably for this very reason. This is a significant barrier to a single process for CME in Europe, and one that is unlikely to be resolved until countries operate to the same set of standards and criteria when assessing CME activities.

Transfer of credits
A significant problem with the organisation of CME in Europe is that currently, credits are not always transferable between countries, or if agreements are in place, credits may lose value when transferred. This is especially relevant to e-learning, the use of which is on the rise. Without harmonisation of accreditation, an e-module accredited in one country could be worth much less to a physician taking part from a different country.

Without portability of CME credits across Europe, the whole point of harmonisation of CME is missed. It is crucial, therefore, that the accreditation process be based on the same set of criteria and regulations across the whole region.

Quality control
Without pan-European standards of quality assurance, there are likely to be huge variances in the quality of CME activities between countries, regions and even individual providers.

Most countries in Europe operate on a model of event accreditation, where an application for a CME credit must be made for every activity. While, in theory, this system has the power to monitor closely the quality of CME activities, in practice, it is often not the case.

The vast majority of CME activities in Europe are live events, but it is particularly difficult to assess their quality based on an agenda. This means that, in practice, most applications for accreditation for these activities are approved. Furthermore, because proof of attendance is all that is required to obtain credits from live events, there is a real concern that current systems act as little more than attendance registers, and fail to assess the quality of educational programmes, or the relevance to clinical practice.

Italy has recently implemented a CME system based on the US model of provider accreditation. In this system the provider is assessed for its capability of providing relevant and high-quality CME, rather than accreditation of individual educational events. However, there are concerns that not all activities can be assured to be of suitable quality or content, and it remains to be seen how successful this system be.

Quality isn't just about the accuracy of the content, it should also consider the relevance of the content to clinical practice and whether the teaching methods utilised are appropriate for, and effective at, delivering the learning. Some form of needs assessment is important in determining whether an activity addresses an identified knowledge gap rather than perceived needs, and this process should be built in to providers' methodologies for developing CME educational activities. But this is not always required for accreditation so may not take place. Moreover, there is no guidance in place on how to carry out a needs assessment.

Pharma involvement
Another aspect of quality control is the perception of bias introduced by organisations, primarily pharmaceutical companies, who contribute to and/or fund CME activities. In the US, CME has changed over the last few years to all but exclude pharma involvement – with the exception of its unrestricted funding. This was in reaction to concerns that pharma has too much influence over physicians through its involvement in developing CME activities. As a result, providers must be independent and pharma can now only be involved in CME through third parties. In fact, it is usually only possible for pharma to be considered independent enough for CME accreditation when events are sponsored by multiple companies.

In Europe, currently about half of all CME is funded by pharma, although the level of pharma involvement varies greatly between countries. While many would suggest that educational content provided by pharma can be at least as valuable as independently provided CME, others believe pharma should have no involvement. It is expected that Europe will fall in line with the US on this matter in the future, however, at present there is limited guidance available on how CME organisations in Europe should engage with pharma, or on how to ensure that appropriate distance and transparency is maintained.

Moving forwards
The Good CME Practice Group, launched at the second European CME Forum in November 2009, was set up to define good practice in CME, with the aim of working towards converging standards and practices across Europe. Its main activity is to focus on improving quality in CME by implementing good CME practice through transparent relationships and appropriate standards.

Impact on the UK
Due to the distinctive way in which the UK healthcare system operates compared with the rest of Europe, decisions on CME made in Europe may be less straightforward to implement.

Most healthcare in the UK is publicly funded through the NHS and, consequently, there are limits placed on CME spending. Decisions relating to the funding of CME, particularly any that result in physicians themselves picking up a greater proportion of the bill, are likely to impact on the type of CME events that will be attractive to UK physicians. Furthermore, predicted budget cuts over the next few years make it likely that funds for educational activities will get smaller, so the healthcare industry may well look towards pharma money.

However, if European standards are set to restrict pharma involvement, this could severely impact on the resources available for the running of CME programmes in the UK. It is accepted that a pragmatic solution to manage conflict of interest issues created by pharma involvement is needed, but many question the need for a complete ban. Full transparency may be adequate to manage these issues, enabling physicians to approach pharma sponsored education with full knowledge of their support.

Another option is to separate budgets, and even personnel and departments, for promotional and non-promotional activities. This may also impact upon the medical communications agencies who traditionally work on both these types of activities, forcing them to form separate CME arms of their businesses. 

While a pan-European approach to CME will ultimately benefit physicians in the UK, the nuances of the UK healthcare system may affect the way in which decisions regarding funding, pharma involvement, conflict of interest and quality control are implemented compared with the rest of Europe.

The Authors
Lindsay Napier is senior science writer and Sandy Agnew is senior client service director at Apothecom, a Huntsworth Health Company, while Sandy Royden is European CEO, Huntsworth Health

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