the nhs: where have all the health workers gone?

WORKERS, JULY 2004 ISSUE

The NHS has a long and dishonourable tradition of poaching overseas trained staff and of enticing young people from developing countries to come to Britain to train.

Alternatively you could say that health professionals around the globe give up the struggle of fighting for better conditions in their own land and seek to find an easier way elsewhere. Every overseas worker makes a conscious decision to come here, although often on the basis of poor information.

Recently the exploits of some of the private agencies, who have asked overseas nurses to part with large sums of cash, confiscated their legal documents, paid them a pittance and have expected them to cook and clean, have hit the headlines. These agencies, people traffickers in effect, represent one end of the spectrum of a huge market in labour.

This movement of labour has its origins in one phenomenon only: poor pay and conditions in the country of origin being used to depress wages and conditions in the country of destination. To put it bluntly, here is a concerted effort by states in the developed world to use low pay abroad to lower pay rates at home.

A long tradition
Although the scale of the movement of labour has grown in recent years, almost since its inception the NHS has had an unhealthy dependence on overseas labour.

Many people remember the huge influx of nurses and student nurses from the Caribbean in the 1950s and 1960s. That influx was associated with a range of injustices — in particular the fact that many of the student nurses with a good education were placed on the enrolled nurse programmes in order to qualify and join the workforce within two years rather than the three-year registered nurse programme and then found themselves unable to progress up the career ladder.

Much less prominence has been given to the NHS dependence on overseas doctors. Non-EU overseas doctors currently account for 33 per cent of senior house officer posts and 14 per cent of pre-registration house officer posts. In many district general hospitals more than two thirds of junior doctors have trained overseas.

Recently Peter Trewby, a consultant at Darlington hospital, along with a junior colleague, Anand Lokare, reported in the Health Services Journal on a study they conducted on the applicants for three junior posts at their hospital. In October 2003 they received a staggering 806 applicants for the three posts, of which all but three were overseas applicants.

The researchers asked all the overseas applicants about their motivation for applying. Overwhelmingly the applicants said that they hoped to gain more experience and a postgraduate diploma.

But only one applicant was positive about training they had received in Britain. Many more described financial stress, housing expenses, and registration and visa costs. Many had believed (erroneously) that having taken the Professional and Linguistic Assessment Board Test (PLAB) that they would quickly find work.

Trewby and Lokare analysed the CVs of the 806 doctors in the sample and calculated the total time in unemployment to be 753 wasted doctor years. A quarter of the candidates had spent more than one year unemployed, 10 per cent had been unemployed more than two years.

Another practical consequence of overseas recruitment waves is that it creates peaks and troughs in workforce development. This is seen in general practice in London where currently a significant group of doctors originally from the Indian subcontinent are all now retiring at the same time. The problems which led to the high vacancy rate 40 years ago remain unresolved: the sickness levels of the patients, the poor practice premises and high insurance costs. Sadly in some areas the TB rate is little changed.

As reported in last month's Workers there has at last been some expansion in medical school places in Britain, but most of that expansion will be taken up by the need to cover the career breaks of an increasing number of female doctors and an increasing trend to part-time working.

Britain's unethical policy
Since October 2001 the NHS has had an ethical recruitment policy which is intended to protect developing countries from targeting by recruitment agencies, to protect the nurses who come here from exploitation and to ensure that those who do come here are properly qualified.

The code has exceptions where there are specific agreements between governments. This currently includes South Africa, the Philippines, Indonesia and parts of India. Given the acute need of some of those countries — South Africa has already lost nearly 14 % of its healthcare workforce to HIV/AIDS — the code is profoundly unethical.

The agreement in South Africa is constantly overridden by the actions of private agencies and anyway cannot prevent individuals applying to the NHS directly. In 2002 Ephraim Mafalo, president of the Democratic Nursing Organisation of South Africa, put it bluntly: "If Britain keeps taking on nurses from this country, it will drain us of all the expertise we need to serve the community."

Average life expectancy in South Africa is currently 60 and is set to fall to 40 by the year 2008 if the Aids epidemic continues at its present rate. Even without the unethical brain drain, it is already a workforce that is quite literally wasting away.

The crisis in nurse recruitment

Last year alone more than 13,500 overseas nurses registered with the Nursing and Midwifery Council (NMC). Much less publicity was given to the fact that the number of British nurses going abroad was 8,000.

The number of British-trained nurses registering in the USA has grown from 211 in 1993 to 2,200 in 2002. The International Council of Nurses (ICN) in a recent report entitled International Nurse Mobility, highlighted that it expects the US to be the biggest player as it predicts a shortfall of one million nurses in the US in the next decade.

The true scale of the international merry-go-round is hard to quantify as figures only exist for qualified nurses. But it is clear from ethnicity figures that up to 80% of student nurses at some London universities are African. The rules state that they must have lived in Britain for three years before starting their programme but nevertheless they represent thousands of young people who could have been nurses in their country of origin.

The International Nurse Mobility report was hard hitting, and the solutions it proposes should exercise thought across the globe. The analysis stated that a brain drain of young, highly skilled labour can leave a donor country with a depleted workforce and severely affect the quantity and quality of health services. The report criticises developed countries for the trade in qualified staff and states that they should grow their own. It goes on to suggest three solutions:

Improve pay, working conditions and the prestige of nursing in donor countries Encourage bilateral agreements Recruiting countries should pay compensation to the poorer, supplying countries

While the first solution clearly flows from the analysis the latter two do not.

Around the world
Not all workers have the clarity of Ephraim Mafalo. Despite their own problems with HIV/AIDS and other major health problems, the General Secretary of the Nigerian Nursing Association says there are 30,000 nurses without jobs in Nigeria, and the association encourages nurses to go out of the country since the government cannot give them jobs or pay them properly.

Likewise in Uganda there is significant nurse unemployment, and their health minister, Brigadier Muwhezi, is going for option three in the ICN report and looking for compensation for exporting his people, saying the country is not against those who want to move abroad but that exporting countries should all benefit from it.

But the Uganda Nurses and Midwives Association is taking on the health minister. Its vice president Jemimah Mutabaazi recently said, "How can we talk about training nurses to export, when in our own hospitals we do not have nurses and have a problem with malnutrition?" She went on to say there are substantial problems with nurses being abused and exploited.

In the Philippines the situation is unique in scale. The country has been the largest provider of overseas nurses to Britain for the past four years, and accounted for 5,500 of those who joined the NMC register from overseas last year. There are now nearly 20,000 Filipino nurses registered with our NMC.

The USA now has a commission for Graduate Foreign Nursing Schools, and Barbara Nichols of the US commission recently reported that the Philippines will be opening up to 40 new schools of nursing to keep up with world demand. Where once there were banana republics, will there now be nursing republics?

The US commission also noted that many Filipino physicians are now undertaking two-year programmes to become nurses as well. Retrain your doctors as nurses to meet the export market? Where will this global merry-go-round end?

These are the words of Mireille Kingma, nurse consultant at the International Council of Nurses: "The idea of building a workforce for export is becoming more popular. The United Nations encourages it, and the reason is that those nurses send money home. So instead of male workers migrating to townships and living in shacks, workers of the 21st century both male and female are to migrate thousands of miles leaving families behind."

British workers
Both UNISON and the Royal College of Nurses have voiced their opposition to overseas recruitment and have stated that it is not a solution to the recruitment and retention crisis in the NHS. Yet much of the opposition has focused on the maltreatment and injustices faced by overseas nurses rather than on questioning the whole process of overseas recruitment.

Demands have also been made on government to extend to the private sector the recruitment regulations that apply to the NHS. But as both UNISON and the RCN havealready pointed to the fact that regulation is not working in the NHS, what is the use of extending an unworkable code to the private sector? And if British workers listen to workers' organisations abroad they will see that they do not have any faith in the efficacy of our government's codes or regulations.

Note carefully the words of the General Secretary of the RCN, Beverly Malone (an American), quoted in the Nursing Standard on 19 May this year: "I would never describe the use of Filipino nurses as unethical. It is a strategic decision to export nurses. The weak point is the independent sector. Nurses are brought here under false pretences and something needs to be done."

A strategic decision to export nurses? RCN members will have to deal with Beverly Malone, as they have clearly stated that exporting nurses is not a solution and is unethical.

Campaign
The most effective campaign to tackle overseas recruitment in the NHS would be one that never mentions the words overseas recruitment; it would mention retention instead. The Department of Health's Director of Human Resources Andrew Foster reported at the beginning of May that staff turnover costs the NHS at least £1.5 billion a year. He warned NHS managers that this figure was probably an underestimate as it ignored the additional costs of losing the productivity of experienced staff, the learning curve of new staff, and the staff time spent in teaching new staff.

The alternative to ever-rising overseas recruitment lies in retaining existing staff and recruiting sufficient new staff to match retirements. Retention means addressing the pay and conditions of existing staff, not importing staff happy to work on low pay and thereby exacerbating the very problem the NHS needs to address. Rather than spending £1.5 billion paying for staff turnover, why not transfer those funds into salaries? You know it makes sense!

Whether NHS staff succeed in dealing with overseas recruitment is intimately tied up with whether they are successful in implementing the new pay framework, Agenda for Change, so that skill is properly rewarded. Equally important is whether they succeed in fighting for pay increases which allow them to meet the cost of living.

The greatest staff turnover is in London and the South East, which as a result rely more on overseas recruitment than other areas. The only solution is a wage which allows staff to live and travel in that area and currently public sector wage rates do not match housing costs.

And now the European Union makes things worse...

Until recently there has not been major movement of labour within the European Union healthcare sector. Why move from the Netherlands, Germany and France for worse pay and conditions in the NHS? Enlargement on 1 May could significantly change trends.

The President of the Latvian Nurses Association, Jolante Zalite, has already sounded the alarm. The Latvians, with a national vacancy rate among nurses, have already experienced an aggressive recruitment campaign by Norwegian agencies — this was largely unsuccessful because of language difficulties — but they fear British recruitment agencies.

Poland is also worried about the consequences. Luycina Plszewska-Zywko of the Jagiellonian University in Krakow said that Polish nurses earn around £280 per month and there are already nurse shortages in her country.

Nurses who trained in these countries before 1 May 2004 have to prove to the NMC that they meet British standards. Practitioners whose training began after 1 May will automatically be eligible for British registration, so there could be a greater impact after 2007.

The EU directives do not require competence in English, but employers are entitled to check that a practitioner can communicate effectively with patients.

At the same time, the EU parliament has been trying to force through a directive which would allow health practitioners to work for six months in other EU countries without registration in the host country. This move has been vigorously opposed by professional bodies but keeps resurfacing in different committees within the EU commission.

Outside the EU the next donor country under consideration is China. This has come as news to most NHS organisations, in the form of a House of Commons announcement from Lord Hutton in mid May.

Hutton suddenly announced that nurse recruitment from China is a key government target. He reported that talks have begun between the Department of Health and the Chinese Embassy.

And what about the patients?
This article has focused on the impact of moving labour across the globe with the consequence on pay and conditions of health professionals. But what about the impact on patients?

Professional bodies with a variety of imperfect mechanisms seek to ensure parity of standards between those trained at home and abroad. Those entering Britain from non-EU countries currently have to undertake a three-month adaptation programme in a NMC approved placement. Those entering from EU countries are exempt from that programme as EU directives ensure harmonisation of practices.

On the one hand, many healthcare skills are international: so does it matter who manages the intravenous infusion so long as they do so safely? But if health care staff are not attuned to the communication needs of those they care for — particularly in intimate procedures or dealing with taboo subjects — then what happens to the quality of the interaction?

Others will point out that as patients come from different countries, then isn't it a good thing that staff are culturally diverse? But when all the staff in a unit are Filipino then where is this diversity? When up to 80% of student nurses in some London institutions are African, where is the diversity?

In time, staff who study and live in London will become Londoners but if overseas recruitment is about staff living abroad and then rotating home every few years (a rotational crop for export?) and a new group arriving, when will that integration ever occur? Even to raise these questions may lead to an accusation of racism, but isn't it time to do so when a section of the nursing curriculum has to be devoted to the cultural needs of the indigenous population?

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