Diversity within diversity: the NHS workforce from overseas

Amid news that hundreds of doctors from overseas have been refused visas to work in the UK due to a migration cap, Fiona Johnson reflects on NHS workforce planning and the changing profile of our foreign staff.

Blog post

Published: 02/05/2018

While the scandal surrounding the treatment of the Windrush communities continues to reverberate through public life, the NHS is currently making new efforts to recruit qualified nurses from Jamaica through an ‘earn, learn and return’ scheme.

So it seems timely to reflect on the contribution people from outside the UK have made and continue to make to our National Health Service.

The House of Commons Library published a briefing in February on the countries our NHS staff come from. British nationals top the table with almost a million staff, followed by India and the Philippines. The list runs down through 102 nations to reach Venezuela with 42 nationals and the Cayman Islands with 40.

But a closer look at NHS Digital figures for trust and CCG staff in 2009–2017 reveals some striking differences between the major health professions, as well as providing a quiet history of recent UK immigration policy and the way in which the NHS has compensated for its failure to plan the NHS workforce by engaging staff from Europe and overseas.

What the numbers show

Back in September 2009, the NHS in England had more than one million staff. In round numbers, this included 100,000 doctors, over 300,000 nurses, 23,000 midwives and just under 40,000 managers and senior managers.

Of those one million staff, more than 80% (817,000) were British nationals. There were 10,000 doctors from India but only 6,000 nurses and 22 midwives. Conversely, nearly 9,000 nurses and midwives came from the Philippines, but only 35 doctors. There were only 12 Indian nationals employed as senior NHS managers in 2009.

At that point there were only 27,000 EU nationals working in England’s NHS, less than 3% of the total workforce. These included nearly 6,000 doctors – the biggest cohorts of whom came from the Republic of Ireland, Germany, Greece and Poland – and 7,000 nurses.

Ireland also contributed the greatest number of EU nurses with close to 4,000. The next highest numbers came from Germany and Poland, with less than 400 apiece. But far more significant in numbers were the nurses from the ‘rest of the world’, led by the Philippines, Zimbabwe, Nigeria, Ghana, Mauritius, South Africa and Jamaica. North American and Australasian nurses contributed only around 1,000 practitioners to the mix.

Still the same?

Fast forward to June 2017 (the latest available data) and the picture appears superficially similar. The NHS in England now employs 1,185,500 staff. The medical and midwifery professions have grown by 10% apiece; nursing by a mere 0.4%. Although we have far fewer doctors who are Indian nationals, we still have roughly the same number of Indian nurses, midwives and senior managers. And we still employ more than 9,000 nurses from the Philippines.

But these headline totals mask some significant differences.

For a start, we now rely far more on EU nationals, who are more than 60,000 in number. This includes 10,000 doctors and 20,000-plus nurses, contributing 9.34% and 6.84% of the medical and nursing workforces respectively.

To take one example, the number of Spanish nationals rose more than four-fold between 2009 and 2016, as workforce shortages in the NHS coincided with high levels of unemployment and economic uncertainty in Spain. Two-thirds of the increase is accounted for by Spanish nurses under the age of 30, with more than 1,000 recruited in both 2014 and 2015 – although 500 have left since the Brexit vote and there is concern over how attractive the UK NHS will be for EU nationals in the future.

Staff from elsewhere

The profile of other nationalities has changed radically too.

The number of doctors from India has fallen sharply, by nearly 40%. Year on year, the proportion of older Indian doctors has grown, and as these people head towards retirement, they are not being replaced – though their British sons and daughters are well represented in the workforce. The numbers of younger Indian nationals, aged between 30 and 40, have fallen sharply, from 6,000-plus in 2009 to 2,300 in 2015, with a small uptick in the last couple of years post-Brexit.

Recruitment of nurses from other non-EU countries such as Nigeria, Zimbabwe, South Africa, Mauritius and Jamaica – all substantial sources of overseas NHS nurses in the past – was already in decline in 2009, and accelerates further from 2010 onwards in line with the coalition and Conservative governments’ immigration policies. The same pattern held true for Filipino nurses until 2016, when we saw a renewed overseas recruitment drive, bringing in 600-plus younger nurses per year.

The people behind the numbers

Some of the numbers in the NHS Digital statistics are so tiny, they produce a curious sense of intimacy. You wonder what happened to the lone Moldovan doctor working in the NHS in 2009. Is he or she still there, as one of the 12 listed for 2017? Or were those dozen doctors in the NHS all along? The reporting of nationalities has greatly improved in recent years.

Most of the 91 Ghanaian midwives working here in 2009 were well into their forties and fifties. Very few younger Ghanaians have joined them since, so overall numbers have dwindled. You can’t help hoping that their reward for a long career in the NHS will not be the eventual disappearance of their national group from the service.

Similarly, in 2009, more than half of the 600-plus Jamaican nurses were over 40.  Now, total numbers have fallen by a third and the proportion older than 40 has risen to 70%.  If the current recruitment drive is successful, the number of Jamaican nurses supporting the NHS is set to rise sharply, albeit on a temporary basis.

Failure to plan

Stepping back to look at the bigger picture, the NHS workforce has become superficially more diverse in the last 10 years because of an increase in staff from the 27 countries of the European Union – although many countries are represented by only handfuls of individuals. But our migration system has become much less welcoming of nationals from the rest of the world, with notable drops in NHS staff numbers from the Caribbean, New Zealand, and Africa as a whole.

The NHS has been widely criticised for its long-standing failure to plan the workforce effectively. In the absence of a coherent strategy, recurrent staffing crises have been alleviated by short-term recruitment drives abroad. Whether deliberately recruited in groups from Spain or the Philippines, or appointed as individuals who have chosen to migrate here, primarily from the EU, it has largely been registered health professionals joining the NHS workforce. Those in support worker roles are still overwhelmingly drawn from the domestic market.

It is rather dubious ethically, but by ruthlessly targeting clinicians who have already qualified, the NHS has largely avoided the costs of medical and nurse training for these groups. You would like to think the NHS compensates for this by giving them a great experience and plenty of opportunities for CPD, promotion and progression. With the exception of the ’earn, learn and return’ schemes currently targeting India, the Philippines and Jamaica, I am not sure there is much evidence of this.

In today’s competitive labour market, with sterling lower and uncertainty greater – but above all as a matter of decency and equity – we must do better.

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