The term "spillover" which appears from time to time in politically oriented literature means that if integration takes place in one area, the economic, technical, social, and political pressures for them to integrate in other areas will increase. Just as no physiological system within the body functions entirely autonomously from the others, no political state has ever been truly independent because none has ever been wholly self-sufficient.

  Spillover also leads to the development of international organisations to address the needs of the regions of the world, which has been mainly a twentieth century phenomenon. In 1914, the world had just 220 international organisations; today, there are about 38,000[1]: one of which is the European Board of Cardiovascular Perfusion.

To gain a full perspective of the events leading up to the founding of the Board, one would need to return to 1981 when Prof. D. Melrose, then Chairman of the UK Board of Perfusion, called a meeting of the UK Board of Perfusion and the American Society of Extracorporeal Technology (AmSect) to discuss the idea of an International Board of Perfusion which would concern itself with the training standards of perfusionists and perfusion training programmes. Although it was agreed upon to have future meetings, none were held because, although there were many national societies, there were no other existing regional Boards that could form an international body.

  Then in 1990, the Board of Clinical Perfusion Sciences and the Society of Perfusionists of Great Britain and Ireland received from the Department of Employment in the United Kingdom a letter which sought their views on a proposal for a new European Community Directive Consultative Document entitled: "European Commission's draft on a second general system for the recognition of professional education and training". 

A group of European Perfusionists held an informal meeting on the 15th of June 1991 at Noordwijk, The Netherlands at the time of the 4th European Congress of Extracorporeal Circulation Technology, to discuss the setting up of a European Board of Perfusion. There were 20 representatives from Belgium, Denmark, France, Germany, Holland, Norway, Spain, the United Kingdom, and the US.

 Mr. Mark Braimbridge was asked to chair the meeting. Mark Kurusz and Richard Chan were invited because of their experience in setting up similar Boards in the US. In addition to the EU directive, the topic of the International Board of Perfusion resurfaced and the need for regional chapters from Europe, North America, South America, Australasia, Asia, and Africa was discussed. It was then unanimously approved that the European Board of Perfusion should be constituted, beginning with western Europe (EU and EFTA countries), and that help would be sought from the cardiac surgeons and anaesthetists in helping to set it up. A Steering Group was formed consisting of Dr. R. Barthelemy (France), Mr. John Bell (UK), Mr. Fred van den Berg (Holland),, Mr. Reg Hobbs (UK), Mr. E. Janssenswillen (Belgium), and Mr. Thore Pedersen (Norway). The Steering Group met in Brussels on the 27th of September 1991.

This group carefully reviewed the EU directive, which stipulated: 

1. "The proposal would complete a system giving every Community national the right to have qualifications and experience gained in one Member State recognised or taken into account in other Member States. It aims to remove restrictions on access to certain jobs, where entry is regulated on the basis of particular national qualifications." 
2. "The removal of barriers to free movement of labour is essential if the concept of a single market is to apply to people as well as to goods and services."
3. "Discriminating on the grounds of national qualifications is just such a barrier. It hampers the best use of the Community's human resources."
4. "The current proposals do not go far enough in removing barriers. Individuals from Member States with little regulation would continue to be placed at a disadvantage to those from more regulated Member States." (2)

Emerging from this directive was the clear message that directives from Brussels could or would be imposed on perfusionists who would have no say in the matter, and even if we were consulted little or no notice would be taken because we would not be responding with one voice.

A general outline of the make up of the Board was decided upon and the date of the first Board Meeting was set for the following month.

For those of you who have heard this before and wonder whether the conclusions of the steering group were premature or maybe even exaggerated, let me jump for a moment again to the present. I can recommend the home-page for the European Union (http://europe.eu.int) for anyone who feels the EU and its directives have little or no effect upon national policy and that General System for the recognition of professional education and training will not take hold. Not only does the General System exist and function, there also exists official procedures defining how any individual within the EU can demand and obtain recognition of his or her professional diploma in any other member country where the profession is regulated. There is also an official step by step procedure outlining how that individual can force, through appeal procedure, any member country where the profession is regulated not wishing to do so. As a particular eye-opener, I recommend you read the infringement listings.

Now lets go back again from the present and review the steps that the initiators of the EBCP decided to take.

It was agreed by the steering group that a Board of Perfusion should be set up to unify training standards in perfusion at both basic and advanced levels in the EU and EFTA countries. The Board was to make every effort to raise and maintain these standards to the highest level of acceptance to all Societies of Perfusion in Europe.

Such a Board was deemed essential for the future development of perfusionists' education and training and as the organisation to speak on these matters with the European Commission in Brussels.

"If formed, such a Board should:

1. Establish separate committees to accredit training programmes and to certify, by examination, competence of perfusionists with or without a Grandperson Clause.
2. Invite representatives of the European Society for Cardiovascular Surgery, the European Association for Cardio-Thoracic Surgery and the European Association of Cardiothoracic Anaesthesiologists to sit on the Board.
3. Establish a liaison committee to negotiate with Brussels after 1992.
4. Represent western European countries initially, but as soon as practicable, all European countries."

1. "Union on international associations," home page, 1998, URL: <www.uia.org/index.html>.
2. European Community Directive Consultative Document:1991

1992-3: During the first years of the EBCP the basic documents needed to function and address new areas of responsibility were discussed and formulated: the Memorandum and Articles of Association, the Essentials and Guidelines, the Programme Syllabus, and initial work on a proposed Logbook. These fundamental publications of the EBCP would enable the Board to function effectively and provide guidance for training programmes.

1994: Initial plans for the Grandperson Clause were agreed upon, as well as the examination process that would follow.

1995: In this year the Grandperson Clause took place, allowing 1021 practicing perfusionists to gain their European Certificate in Cardiovascular Perfusion. With the passing of the deadline, the requirement of Written Examination became effective. Preparations were already well underway in gathering proposed questions and translations so that simultaneous examinations could be held in different member countries while using the identical examination material. 

In 1996, the first Written Examination for the ECCP was staged, from which 290 candidates received their certification. Requirements to qualify for the exam were:

1. 2 years experience in an EU-EFTA country
2. minimum of 100 cases as single-handed
3. Written Examination (new requirement)

Upon completion of this first examination, the numbers of perfusionists holding the certification through the EBCP compared to the estimated number of practicing perfusionists in each member country appeared as in Figure 2.

In 1997 the accreditation of training programmes was initiated and it was hereafter required that candidates graduate from these institutions in order to qualify for future examinations. Requirements to qualify for the 2nd Written exam were:

1. 2 years experience in an EU-EFTA country
2. minimum of 100 cases as single-handed
3. applicants required to graduate from programmes who have successfully applied for accreditation (new requirement)
4. Written Examination

68 candidates successfully completed the examination.

In Figure 3. one sees outlined the areas in training programme structure which will be scrutinised by the EBCP in future re-accreditation and will act as the basis for forthcoming site visits by an EBCP delegation.

Requirements for the 3rd examination were: (62 candidates certified)

1. 2 years experience in an EU-EFTA country
2. minimum of 100 cases as single-handed
3. applicants required to graduate from programmes who have successfully applied for accreditation
4. Logbook (new requirement)
5. Written Examination 

In 1999 the first cycle for the re-certification of ECCP holders was required, resulting in varying results throughout EBCP member countries as seen in Figure 4. Site Visits for re-accreditation of programmes commenced.

1. 2 years experience in an EU-EFTA country
2. minimum of 100 cases as single-handed
3. applicants required to graduate from programmes who have successfully applied for accreditation
4. Logbook
5. Written Examination

  In 2000, practical evaluation was added as a requirement for the ECCP. Requirements for the 5th Examination were: (39 candidates certified)

1. 2 years experience in an EU-EFTA country
2. minimum of 100 cases as single-handed
3. applicants required to graduate from programmes who have successfully applied for accreditation
4. Logbook
5. Written and
6. Practical Examination (new requirement)

This year, in 2001, the final component of Oral examination will be added to the examination process. Requirements for the 6th Examination will be

1. 2 years experience in an EU-EFTA country
2. minimum of 100 cases as single-handed
3. applicants required to graduate from programmes who have successfully applied for accreditation
4. Logbook
5. Written,
6. Practical, and
7. Oral Examination (new requirement)

A total of 525 candidates have been examined since 1996 with a relatively consistent fail rate over the last few years at 10-12%. Most perfusionists, who fail, re-sit the examinations the following year and usually pass.

In 2002 the EBCP will initiate the 2nd re-certification cycle and create an online public ECCP registry. A continuation of this year's Perfusion Education Conference prior to the EACTS Conference is planned for September 2002.

The examination database has expanded to the point where the Board is now able to set up simultaneous written examinations in 8 different languages. The translations of database questions, as well as the Logbook and basic EBCP publications, is initiated by the national delegates and, in most cases, accomplished through their personal efforts. This voluntary effort and responsibility has made our work possible.

Of the original published goals of the EBCP [Fig. 5], all but one has been successfully addressed within this ten-year period.

The board's decision-making process encourages members with the strongest professional development to encourage, therefore accelerate, the adoption of higher standards by members where professional status and standards are poorest. But the European Board has not yet convinced all national perfusion societies from countries where professional levels have gained highest respect and recognition to re-commit their energies through the European Board towards helping other countries where professional training and development is less developed.

Adjustments will need to be made in light of enlargement including geographic Europe. [Fig. 6]. There are 21 potential new members of the EBCP: three in the Mediterranean (Malta, Cyprus, and Turkey), twelve in Eastern Europe (including the five states of the former Yugoslavia), and six in the former Soviet Union. The next enlargement will focus on Poland, the Czech Republic, Hungary, Slovenia, Estonia, and Cyprus. This will change the professional and geographic balance of the Board and make more urgent the need to establish the efficiency of the adopted activities and decision-making processes of the Board.

Despite some voiced scepticism from EBCP protagonists about the chances of success of the EBCP's mission, the Board has successfully committed itself to the certification and re-certification of perfusionists in Europe; the accreditation, inspection, and maintaining of standards in training programmes; the training of trainers throughout Europe. EU recognition and professional liaison remains illusive, but will be achieved in time. A careful watch of the EU reports and publications reveals that education and employment objectives and policies have moved up in the EU agenda. As more countries establish perfusion as a governmentally regulated profession, the addition of perfusion to the EU General System list of professions will follow.

Occasionally I receive feverishly expressed lists of ailments and grievances from perfusionists complaining that the Board places too many demands upon them rather than devoting itself to making them happy as professionals. The fact is and remains that the EBCP needs to do a limited number of things very well. The Board does not apologise for all the things it cannot do, or will it rush into new areas merely to fill some real or imagined void. 

Seasoned perfusionist know that there is simply no short cut to developing the capability to handle with excellence almost any situation or condition that may occur in the operating theatre. Real excellence does not come cheaply. A certain price must be paid in terms of patience, practice, and persistence through professionally exercised self-regulation, continuing education and clinical experience.

The idea of professionalism is as important now as it ever was and should be reinforced, not devalued. It would be hoped that nationalistic groups within the perfusion profession would not see themselves as needing to jealously preserve ancient privileges. The status of a profession in any given country should not be taken as a badge of exclusivity. Rather, it should be seen as an acceptance of responsibility. For the public interest is the ultimate test of the legitimacy of our practices.

But the motivating force behind professional goals must not primarily be the improvement of salaries. Otherwise, we as professionals are doomed to become a self-centred and over-proud group of specialized medical technicians. Rather, it is essential that we do not lose sight of the fact that the benefit of the re-certification process for cardiovascular perfusionists begins and ends with improved patient care.

In closing, I want to relate how inherently satisfying it is to work in a team of people who trust one another and feel aligned to a sense of common purpose as we have under the members of the Board. As a person note, Mark Braimbridge and Reg Hobbs provided many of us with valued encouragement and professional expertise that helped us through many challenging years. I am extremely pleased that Reg Hobbs is here today, for it is to a great extent through his personal efforts that the Board stands where it is today. I lastly want to express my deepest admiration and gratitude to all past and present Delegates, Chairmen, Committee members and representatives of EACTS and EACTA for their tremendous voluntary contributions to the activities of the Board and the perfusion profession. Their early and continued commitments to the mission of the EBCP, their search for professional standards and opportunities to bring improve patient care throughout Europe needs to be recognised and strongly applauded.