Plans to bring more nurses from overseas to work in the NHS must not come at the expense of poorer countries in desperate need of nursing staff, according to a new report calling for a more ethical approach to international recruitment.
The report by healthcare charity the Tropical Health and Education Trust – published on the NHS’s 71st birthday – warns the current approach risks stripping nurses from less well-off countries in Africa and Asia that can ill-afford to lose their skills.
“The NHS owes a great deal to countries who can ill afford to lose such a precious resource”
It calls on the government to clamp down on dodgy recruitment practices, do more to work with and support developing countries, and ensure “train and return” schemes really do benefit nations that send nurses to work in the NHS.
The report (see PDF attached below) comes after the UK government outlined plans to ramp up international recruitment in an attempt to tackle widespread staffing shortages with health and social care secretary Matt Hancock suggesting the country needed a new “Windrush generation”.
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The NHS Long Term Plan for England, published earlier this year, signalled a “step change” in the recruitment of international nurses aimed at bringing several thousand into the health service each year over the next five years.
More recently the Interim NHS People Plan confirmed the need to “increase international recruitment significantly” to boost the supply of nurses.
However, the Tropical Health and Education Trust’s analysis warns “there are no winners” in the escalation of international recruitment and the UK’s plans risk undermining its own long-standing commitment to supporting health services in developing countries.
The UK is “increasingly open to criticism for the impact its recruitment is having on low and middle income countries”, said the report.
It highlighted the fact many staff recruited to work in the NHS “come from countries facing grave shortages of health workers themselves”, especially poorer countries in Africa and Asia.
A study carried out in June 2018 found that of the top 15 countries NHS staff are most commonly recruited from, seven were low and middle-income countries
“Indeed, we can say that the NHS owes a great deal to countries who can ill afford to lose such a precious resource,” said the report.
The report found there were a wide range of factors “both positive and negative” explaining why talented and ambitious healthcare staff came to the UK.
This included unemployment or underemployment in their home nations with many low and middle income countries unable – or choosing not to – invest enough money in health services.
The impact of under-investment in some countries is “stark”, said the report, which also put an onus on developing countries to adequately fund healthcare to prevent staff seeking jobs elsewhere.
For example in Tanzania, there are just four nurses and midwives for every 10,000 people, compared with a ratio of 84 per 1,000 in the UK.
“We can readily imagine a world where health inequalities accelerate out of control”
While researching the report the authors visited Uganda, which is struggling to find jobs for thousands of nurses “despite a desperate need”.
“Uganda has a staggering 29,000 nurses unemployed out of a total of 64,000 registered nurses. And the effects of these chronic shortages are felt most acutely in rural areas where ratios of health workers to patients are particularly poor,” said the report.
Countries losing much-needed healthcare workers to the UK include India – which is on a World Health Organisation list of countries where active recruitment is discouraged.
“An ever-growing number of highly qualified doctors and nurses are deciding to leave, facilitated by bilateral agreements with countries including the UK,” said the report.
Meanwhile, The Philippines, which actively trains nurses “for export” to Europe and has a long association with the NHS, is struggling with “serious difficulties in providing health coverage in remoter regions of the country”.
In exploring the need for international recruitment, the report highlights the UK’s “poor track record” in growing its own nursing workforce, which has contributed to the fact more than one in 10 nursing posts in England are currently vacant.
The report goes on to highlight dodgy recruitment practices that have seen nurses and doctors brought to the UK from countries where overseas recruitment is “banned”.
While the UK led the world in becoming the first nation to adopt a Code of Practice for International Recruitment, there is evidence these rules are being breached by some international recruitment agencies who use sub-contractors to recruit nurses and doctors from poorer countries.
According to the report, the number of doctors coming from banned countries to work in the UK has doubled in the past five years.
“It would appear, therefore, that parts of the NHS are colluding with recruitment agencies to, at the very least, contravene the spirit of the UK Code of Practice for International Recruitment and the World Health Organisation’s Global Code of Practice on the International Recruitment of Health Personnel,” said the report.
“If this kind of practice goes unchallenged then we can readily imagine a world where health inequalities accelerate out of control and where a form of ‘health apartheid’, far worse than already exists, prevails within and between nations,” the report added.
It called on the Department of Health and Social Care to strengthen implementation of the code of practice and ensure any agencies using sub-contractors to get round it were barred from a list of approved recruiters.
However, it went to on suggest that changes in UK legislation that make it easier for international nurses to come and work here may mean an upsurge in workers from low and middle income countries seeking work in the NHS without the need for recruitment drives.
“The concern of this report is that, as the UK further relaxes migration policies, with no restrictions on visas for doctors and all nurses, and with further sweeping changes proposed with the UK’s departure from the EU, the UK won’t need to actively recruit from LMICs,” said the report.
“Health workers from LMICs will be increasingly attracted to apply to work in the UK of their own volition, or with the support of private agencies, and they will be welcomed by an NHS that is increasingly fraught in its efforts to attract staff.”
The report calls for the government and NHS to work much more closely with low and middle income countries, claiming the NHS’s engagement with such nations is “currently haphazard”.
“The NHS is very aware of the need for an ethical approach”
More must be done to ensure existing recruitment schemes such as Health Education England’s Global Learners Programme, are indeed mutually beneficial, the report said.
The programme, which has been running for more than two years, includes agreements between the UK and several low and middle income countries including India, Pakistan and Jamaica, with The Philippines set to become an official partner in the near future.
According to the report, 500 nurses are currently enrolled on the Earn, Learn, Return scheme with 100 now in the UK and 400 preparing in their home countries.
The plan is to expand the programme to recruit 1,500 nurses next year with “many more” expected to come to the UK via the scheme in the future.
Under the scheme people are enabled to work in the UK for three years and can extend this for two years before considering applying for British citizenship.
It up to them if they stay or return to their home countries. Those who do consider going back will get help to find jobs that reflect skills and competencies gained in the UK.
Given the programme is in its infancy, the report said it was hard to judge what the impact might be but “it was unclear how many nurses will return to their country of heritage”.
There was a risk the approach may end up being a “win-lose” model, it warned.
An example of a scheme that was more clearly a “win-win” set-up was a partnership between Leeds Teaching Hospital and the Jamaican Ministry of Health, said the report.
The programme – which is due to be evaluated by Health Education England with a view to rolling it out more widely - has seen 15 nurses spend seven months studying and preparing in Jamaica before coming to work at the trust.
The idea was the nurses, who were due to arrive last month, would spend five months rotating around three intensive care units to develop their critical care competencies.
They will get mentoring and a “structured educational experience” and will then be expected to undertake a quality improvement project and demonstrate what they have learned when they return to practice in Jamaica.
The report called on the Department for Health and Social Care to carry out a thorough evaluation of “train and return” schemes to better understand their impact on both domestic and international workforces, including following-up nurses and others once they have returned to their countries of origin.
Other recommendations included the development of a best practice toolkit for NHS employers to ensure international health workers coming to work in the UK were properly supported with good induction and ongoing pastoral care.
The report also said further work was needed to develop schemes where UK nurses and other professionals went to work in developing countries to ensure these were devised in conjunction with the countries in question and targeted where they were most needed.
Overall it said there was a need for a more co-ordinated approach by government with the DHSC and Department for International Development coming together to ensure overseas recruitment strategies and aid packages worked in tandem.
Commenting on the report’s findings Tropical Health Education Trust chief executive Ben Simms said ensuring a more joined up approach was key.
“The universal health provision embodied by the NHS and the UK’s commitment to spend 0.7% of our national wealth on international aid are two things which define the UK in the eyes of the world as a generous, compassionate and innovative nation,” he said.
“It is vital that as we move towards leaving the EU, these two pillar of our national policy pull in the same direction,” he added.
Danny Mortimer, chief executive of NHS Employers, who sat on the steering group for the report, said: “The interaction between global healthcare and migration is highly complex and the report THET have published today rightly highlights the many intricacies in this area.
“The NHS is very aware of the need for an ethical approach and has developed interventions that seek to benefit both the UK and low and middle-income countries, helping to improve the resilience of their health systems.
“The report and its recommendations will be a key reference to inform the work already underway to look at how we better co-ordinate efforts and policy in this area across government and within the NHS.”