Health 5.4

Immigration: The need for foreign nurses

Summary

1. The number of nurses entering the UK has risen from less than 5,000 a year in the 1990s to around 15,000 in each of the last three years. Even this number amounts to only 6% of net foreign immigration. It is not a justification for large scale immigration.

2. Overseas recruitment of nurses was designed as a short-term measure but, without it, the numbers on the UK register would scarcely have been maintained since 1998/99 (although the proportion trained overseas was still only 9% by 2002/03).

3. The NHS Code for International Recruitment is supposed to ensure that poor countries do not suffer as a result of UK overseas nursing recruitment. The Code is not mandatory, however, is limited in scope and does not apply to private agencies.

4. The three countries supplying the largest number of overseas nurses to the UK are the Philippines, India and South Africa. There is evidence that poorer countries, such as Malawi, are being denuded of their nursing workforce by UK and other Western recruitment.

5. The Government claims that most overseas nurses return to their country of origin within a short time frame, but there is little evidence to support this contention, which would in any event imply high staff turnover in NHS trusts if correct.

6. There is, however, an outflow mainly to other English-speaking countries of about 8,000 nurses per year; up from 3-4,000 per year in the mid-1990s.

7. As the NHS recruitment drive continues overseas, applications for diploma-based nursing courses in the UK have fallen.

8. In the longer term, improving domestic recruitment and retention is essential to ethical and sustainable growth in the UK nursing workforce.

Main Paper

1. The present requirement for foreign nurses is clear, but needs to be placed in context. There are 645,000 nurses on the UK register. About 300,000 work for the NHS, some 200,000 are in the private sector and the remainder are not practising. In 2003 there were nearly 59,000 overseas-trained nurses on the UK register, or about 9%.

2. The proportion of new nurses from overseas has risen sharply since the mid 1990s as the number of UK initial registrations has declined:

3. The absolute numbers of nurses recruited from overseas have increased from about 2,000 to some 15,000 a year (see Figure 2 [1]). In the three years to 2003/4 they totalled 40,000:

4. The Main non-EU source countries in 2002/3, as in recent years, were the Philippines (5,593), India (1,830), and South Africa (1,368).

5. Work permit data is not strictly comparable but shows a similar pattern:

6. The NHS Plan of 2000 described the recruitment of NHS staff from abroad as a short term measure [2]. The Department of Healths website now suggests a degree of permanence, stating that; international recruitment is a small but significant part of the drive to expand the NHS workforce. A recent study of the nursing labour market for the Royal College of Nursing by Buchan & Seccombe shows that, far from being a small aspect of the recent expansion of the NHS workforce, international recruitment has been by far the most significant factor. As the graph below illustrates, without it; all the resources being allocated to returners, to improving retention and to increasing the numbers of student nurses, would have done little more than maintain the number of nurses on the register [3] .

7. The NHS Code for International Recruitment is supposed to ensure that less developed countries do not suffer as a result of international recruitment to the UK. The Code is, however, not mandatory, and only advises against targeted recruitment from a list of countries designated as vulnerable. Furthermore, it does not apply to private recruitment agencies, which are an increasingly significant factor in the international recruitment of nurses to the UK.

8. A recent piece of research for the Kings Fund[4] showed that active NHS recruitment drives overseas had become a critical part of overall recruitment strategy for NHS trusts in London, but warned; one countrys policy solution may become anothers problem. The House of Commons International Development Select Committee has said; Rich countries must not exacerbate the problems of the brain drain for poor countries. International recruitment including that of nurses - must be better regulated [5]. The Chairman of the British Medical Association said in a speech on 28th June 2004; Throughout the history of the NHS, we have relied on other countries to fill our NHS manpower gaps both for nurses and doctors. As the fourth largest economy in the world we are still doing so still taking doctors away from countries like South Africa and nurses from the Philippines, who need them more than we do. It's a shameful record of exploitation.

9. A BBC television news report of 17th August 2004 concerned a hospital in Ilongwe, Malawi; one of the worlds poorest countries, where the average life expectancy is just 38. The number of nurses at the hospital had fallen from over 500 to just 2, resulting in women giving birth unassisted and regular patient deaths from quite curable diseases. Like many of her former colleagues, one of the two remaining nurses was planning to go and work in the UK, where she could earn in a morning what she currently earned in a month. A spokesman for the Government of Malawi said that they would have to train more nurses, and train them so that they would not be marketable in the UK, but unacceptable to the west. When asked if this meant that standards would be reduced, he replied that standards would remain at levels adequate for our needs.

10. The Government emphasises that most employment of nurses from abroad is for a specified period, so their country of origin will benefit from their training and experience in the UK on their return, within a relatively short time-frame. Due to the abolition of exit controls, however, the Government has no way of knowing whether any individual has left the UK. One of the Trusts examined in the Kings Fund research reported that, of the nurses it had recruited from overseas, only about 10% had left [6]. Given that many have paid thousands of pounds to undertake a student programme as part of a period of adaptation to the UK profession, as required by the Nursing and Midwifery Council, and many more have paid a placement fee to a recruitment agency, they would be failing to make the most of a big personal investment by leaving the UK after only a short period.

11. Even if the Governments assertion that nurses return to their country of origin relatively quickly was correct, this would mean that the increasingly large, internationally recruited element of the NHS nursing workforce would be subject to sustained high staff turnover and that NHS patients would benefit little from the UK training and experience provided to internationally recruited nurses. Whilst there could be mutual benefit from controlled internship or training programmes, current overseas recruitment trends, whilst target-driven, are not controlled and are not recorded in aggregate.

12. An important consideration is the outflow of nurses from the UK; mainly to Australia, North America and the European Economic Area (EEA); this last being mainly accounted for by a reversal in the direction of the traditional flow of nurses from the Republic of Ireland to the UK in recent years [7]. The outflow is thus mainly to other developed, English-speaking countries.

TABLE 1:
Number of verifications issued to destination countries, 2002-3

Africa	29
Australia	2602
Canada	452
European Economic Area	1622
New Zealand	958
USA	1622
Others	192
Total	8079

Source: NMC.
13. The overall outflow has risen steadily from 3-4,000 a year in the mid 1990s to about 8,000 in recent years, set against the inflow of about 15,000. The recent Wanless Review of NHS funding suggested that, over the period up to 2020, the NHS in England would have to increase its workforce by 108,500 whole time equivalents. This could be equivalent to about 134,000 nurses, to allow for those who work part-time. Yet the expansion in the domestic nursing workforce appears to be faltering at grass-roots level: the number of applications for diploma-based nursing courses in England fell by over 18% in the most recent year for which data are available (2001/02) to 37,314 below the level for 1999/00 [8].

14. The NHS Plan of 2000 committed the NHS to recruiting 20,000 extra nurses between 2000 and 2004, projecting that 45,000 would come out of training in the UK over that period: more than twice the total needed. On the figures currently available, 45,000 does not look unrealistic [9]. The trouble is that, if the pattern for recent years is followed, many of those who complete their training will not join the nursing workforce in the UK, either going to work abroad or not entering the nursing labour market at all; whilst there are indications that the numbers of people wanting to train as a nurse in the UK are starting to fall. As the Kings Fund research found in one London NHS trust; Managers reported that for long-term sustainability the trust will need to look to grow its own" [10]. At present, the signs are not encouraging.

Conclusion
Given the ageing of the nursing profession, the competition from other developed, English-speaking countries and the demands arising from the present substantial injection of public funds into the NHS, several points are clear:

a) In the longer term, the main thrust of expanding the NHS nursing workforce will have to be on the training, recruitment and retention of UK nurses, for which international recruitment is not a sustainable substitute;

b) The recruitment of overseas nurses should be limited by the needs of those developing countries from which they come this requires better regulation;

c) Even at the present unprecedented rate of 15,000 a year, the number of overseas nurses is only 6% of net foreign immigration of 245,000 (in 2002) and cannot, in itself, justify large-scale immigration.

1 November, 2004