Brexit and Covid are contributory factors to current health care workforce challenges. The former, as the recent Nuffield Trust report highlights, shifted the geographic focus of the UK’s pre-Covid international recruitment efforts. The latter has now driven up demand for health care staff, while damaging health care workforce retention, and hence has driven up overall international recruitment activity.
The UK has long tapped into anglophone labour markets – many of them post-colonial and with similar health professional training. The Nuffield report highlights different patterns of international connections for different health professions. In this blog, the focus is on the largest health professional labour market – nurses.
International nurses in the UK
There are about 150,000 foreign-trained nurses on the UK nursing council register. This makes the UK the second largest labour market for international nurses (the US is first). The proportion of foreign-trained nurses in the UK is about 15%, which is more than double the OECD country average of 6%.
The annual number of international nurses registering for the first time with the UK nursing council has ebbed and flowed over the decades, but has always been an important source. In the year to September 2022, the council reported almost 24,000 new international nurse registrants – a record high across the last 30 years. Annual analysis since 1990 shows that, on average, about one in four new nurses becoming eligible to practise in the UK every year has been trained in another country.
There was a growing reliance on international inflows in the period up to 2002, mainly from non-EU source countries such as the Philippines and India. This reflected active international recruitment at the time, driven by the NHS Plan, and peaked at just over 50% of total new registrants in 2001/02. This was then followed by a rapid decline in international recruitment, as NHS funding constraints bit.
The second phase of growing reliance on international nurses began in the mid-2010s and, as the Nuffield report highlights, included a surge in EU nurse registrants from Portugal, Romania, Spain and Italy. However, after 2016 there was a rapid ‘switch’ back to non-EU countries. Recruitment refocused on lower-income anglophone countries, such as India, the Philippines and Nigeria.
Taking this long-term view, it becomes clear that the relative importance of EU source countries identified in the Nuffield report was concentrated in a short time period – growing quickly in the period after the global financial crises of 2008, and then dropping rapidly after 2016, the year of the Brexit vote.
NHS workforce planning and the 50k target
The main current nursing workforce policy driver for the NHS in England is the 2019 electoral commitment to increase the number of nurses by 50,000 (full-time equivalent) by the end of 2023/24. This is a loose, top-down but tightly time-constrained political target. The imperative to meet it is more important than how it is met, or ensuring that the 50,000 nurses are necessarily in the right place with the right skills. Significant nurse shortages are also evident in social care and nursing homes.
Our recent scenario analysis highlighted that the NHS cannot hope to achieve the required sustained nurse numbers without a continued high-level reliance on international recruitment. However, international recruitment will not be effective in filling all the 47,000 NHS England nurse vacancies, or all nurse shortages in other sectors. Some are in specialties such as community nursing and mental health, for which there is no ready-made international market to tap. For example, only one of the 23,444 international registrants in 2021/22 was a learning disabilities qualified nurse.
The risk is that target-driven ‘quick fix’ international recruitment distracts from domestic training. Using the number of nurse graduates per 100,000 population as an indicator, the UK stands out as being at the low end of the output range of OECD countries, with around 31 nurse graduates per 100,000 population. This is well below the OECD average of 46, is only half the size of the figure in the USA, and is less than a third of the level in Australia.
In addition, the latest UCAS data suggests there was a 10% reduction in the number of student acceptances to UK nursing degree programmes in 2022. When the country should be investing in increasing training numbers, these have actually dropped back, from an already low international comparative base.
“Code red”? The impact and ethics of international recruitment
Active international recruitment of scarce health workers can damage low-income countries’ health systems, if it exacerbates skills shortages. But this mobility, if effectively managed and is “ethical”, can improve the situation of individual workers, and enable mutuality of benefits.
Achieving this policy balance is always difficult, but when there is a political imperative to meet a recruitment target, it becomes even more challenging. The approach of any country, including the UK, should be shaped by the WHO’s Global Code of Practice on International Recruitment, which emphasises mutuality, promotes the use of government-to-government bilateral agreements on recruitment, and has set out the so-called “red list” of countries to avoid “active” recruitment.
Of concern, the Nuffield analysis builds on other recent reports which flag a marked increase in inflow of nurses to the UK from red list countries. In the six months to September 2022, more than 2,200 (20%) of new international nurses came from just two red list countries: Nigeria and Ghana.
The UK government is developing the use of bilateral agreements, and some are with red list countries. Last month, it was reported that a new bilateral agreement with Ghana would include a payment of £1,000 per nurse to the Ghanaian government. An earlier bilateral arrangement with also red listed Nepal had already caused controversy. There is a risk that some of these bilaterals could be perceived as not fully meeting the spirit of mutuality, and give the appearance of a workaround to enable employers in the UK to “actively” recruit nurses from red list countries.
Connect and disconnect
The UK has traditionally been heavily reliant on international recruitment. Despite Brexit, it remains internationally connected. However, it must get smarter and safer in how it uses international recruitment. A more strategic and aligned approach is needed, involving government departments, regulators, the NHS and other employers, which is embedded in national health workforce policy and planning, which fully respects the rights of mobile health care workers, and which takes full account of WHO code requirements about the possible negative impact on source countries.
We need effective monitoring to verify that international recruitment codes are being fully respected, and we need to invest more in domestic training of the health care workforce for long-term sustainability.
Jim is a Senior Visiting Fellow at The Health Foundation.
Please note that views expressed in guest articles on our website are the authors' own and do not necessarily reflect the views of the Nuffield Trust.
In a project supported by The Health Foundation, the Nuffield Trust recently published a report, Health and Brexit: six years on, which considers the impact of Brexit on health across three major areas – staffing, medicines and the economy.