The spring 2004 annual conferences of public service trade unions voiced criticism of the UK government's reliance on expanding the international recruitment of National Health Service staff to combat staff shortages. This article reviews the background to and consequences of this policy.
A central element of the Labour Party government’s modernisation of the National Health Service (NHS) has been an expansion of the workforce to achieve high-profile commitments to improve the quality of public services. The achievement of these staffing targets has involved attracting more applicants to enter nurse training, encouraging returners, improving retention by adopting more flexible pay and grading structures, and reforms of working practices (UK0208103F). The most important and controversial element of the government’s workforce policy, however, has centred on the expansion of international recruitment.
Union criticisms
International NHS recruitment has been a prominent issue during the 2004 public service trade union conference season, particularly its consequences for the terms and conditions of overseas nursing staff, the countries from which they were recruited, and the extent to which it is a sustainable staffing strategy.
The Royal College of Nursing (RCN), meeting in Harrogate during May 2004, highlighted the degree to which the NHS was increasingly reliant on internationally recruited nurses. Since 2001, some 40,000 international nurses have registered in the UK - almost half of new registrations - with the Philippines, South Africa and India being the main source countries. The RCN’s general secretary, Beverly Malone, commented: 'Without nurses from overseas in terms of nursing numbers we would have been running fast just to stand still. We can’t guarantee that these nurses will continue to want to come and to live and work in the UK, nor should we encourage the targeting of nurses from developing countries.' Concerns were raised about independent recruitment agencies that are aggressively recruiting in many developing countries. For the government, health secretary John Reid emphasised the importance of ethical recruitment but rejected the RCN’s call for a total ban on 'unethical' recruitment by the private sector.
The consequences of these recruitment practices were also highlighted the following month at Unison’s annual conference. David Prentis, the union’s general secretary, introduced eight Filipino nurses who, despite being fully qualified and experienced nurses, were given no more than student visas by the agency that brought them to the UK. Once in the country they were made to work in private sector care homes rather than the NHS and their job comprised washing and cleaning. They often worked more than 60 hours a week for GBP 4.74 per hour and subsequently lost their jobs. Unison suggested that their experiences were indicative of the plight of overseas health workers lured to the UK under false pretences.
Government policy
The government has set ambitious targets to recruit an additional 35,000 nurses, midwives and health visitors, an additional 15,000 consultants and general practitioners and 30,000 more therapists and scientists in England by 2008, compared with the position at September 2001. Overseas recruitment has become an integral component of government policy to achieve these targets and to combat existing staff shortages. There have been two main elements of the Department of Health’s approach in England to international recruitment:
- coordinating the activities of NHS trusts, which includes encouraging them to recruit within an ethical framework; and
- establishing inter-governmental agreements to enable the UK to recruit directly from the country concerned.
The international recruitment of health workers has generated controversy since 1997 when Nelson Mandela criticised the UK for recruiting nurses from South Africa. In 1999, the Department of Health produced Guidance on international nursing recruitment that stated: 'It is essential that all NHS employers ensure that they do not actively recruit from developing countries who are experiencing nursing shortages of their own.' In September 2001, a Code of practice for NHS employers involved in the international recruitment of healthcare professionals was issued. This included guidance on working with recruitment agencies and reiterated that NHS trusts should not target recruitment at developing countries unless the Department of Health had a formal agreement with a particular country. In 2003 the Department of Health published its list of 'proscribed' countries.
The impact of the code of practice can be gauged by examining the number of nurses registered to work in the UK. Overseas-trained nurses have accounted for an increasing proportion of the 655,854 nurses on the Nursing and Midwifery Council (NMC) register at March 2003. In 2002-3 there were almost 13,000 overseas-trained nurses entering the NMC register compared with approximately 18,000 UK-trained registrants. The Philippines was the primary source country (5,594 or 43% of overseas-trained registrants), followed by India (1,830), South Africa (1,368) and Australia (920). The sharpest increase had been amongst nurses from India. Interestingly, in view of the debate about the extent to which EU enlargement will foster increased labour mobility, the numbers of annual entrants from EU countries has declined since the late 1990s, although this trend may not be sustained in future years. Registrations from several 'proscribed' countries increased in the year to April 2003 (Ghana, Nigeria and Zimbabwe) or remained stable (Kenya and Mauritius), raising questions about the effectiveness of the code of practice.
A limitation of the code of practice is that it does not apply to private recruitment agencies, although NHS trusts are instructed not to use agencies that do not adhere to the code, and recruitment agencies have been encouraged to adhere to it. There is strong anecdotal evidence that many nurses and midwives recruited to the private sector later move to the NHS for better pay and working conditions, a situation that allows NHS employers to argue that they are complying with government guidelines.
The second main strand of international recruitment concerns the development of bilateral agreements with particular countries. Four agreements exist and in a recent parliamentary answer it was reported that 1,513 nurses working in the NHS had been recruited in this manner, comprising 431 from India, four from Indonesia, 186 from the Philippines and 892 from Spain. This represents a relatively small proportion of the new nurse registrations from these countries.
Commentary
Employers are making increased use of international recruitment and directing more attention to how overseas health workers can be fully integrated into the workforce. Other hard-to-recruit groups including doctors, pharmacists, radiographers and physiotherapists are being recruited by NHS and independent sector employers. Health service managers have suggested that international recruitment is a relatively straightforward method to address their staffing requirements, compared with other recruitment and retention methods. There has also been a concerted effort by the Department of Health to ensure adherence to the code of practice and NHS managers have been encouraged to report agencies that operate outside of the code. Because the Department of Health views international recruitment as so pivotal to its human resources policies for the NHS, it has a strong incentive to ensure that international recruitment is carried out in an ethical manner to deflect criticism of its international recruitment polices which have drawn widespread condemnation from around the world.
Trade unions have focused on ensuring that overseas workers obtain the same terms and conditions of employment as other health workers and have publicised abuses. Unison has 'rescued' nurses from private nursing homes that were being paid less than the agreed wages and required to undertake ancillary tasks such as cleaning.
Unison and the RCN respect the right of individuals to migrate, value the role of overseas health workers in augmenting the workforce, and seek to increase their membership by recruiting overseas health workers, often using low subscription rates to entice overseas nurses into membership. However, they remain critical of poor working conditions in the NHS that have resulted in retention difficulties, and remain wary of supporting overseas recruitment. In particular, they view targeted, large-scale recruitment from countries that have their own shortages of health workers as unethical and have called for an increase in the number of nurses trained in the UK. (Stephen Bach, King’s College London)