Research by the Nuffield Trust evaluating the impact of Brexit on the UK workforce previously focused on decreases in the numbers of EU workers in nursing and in social care. In these professional groups, large workforce shortages are a long-standing issue, driven by an ongoing lack of planning or strategy. They have been exacerbated by the Brexit vote.
The picture for doctors has been more complex. Overall, EU numbers have remained relatively stable. However, the Guardian asked us to look at whether this still marked a change from trends before the 2016 EU referendum, and whether certain specialties faced particular problems – a real risk in a workforce where a surgeon is of little help for a shortage of anaesthetists.
We selected four specialties with known ongoing recruitment and retention issues, where staffing data also show a proportionately high number of staff from the EU and from the European Free Trade Association (EFTA) countries also subject to the free movement of labour before Brexit (Norway, Iceland, Switzerland and Liechtenstein). These were anaesthetics, paediatrics, cardio-thoracic surgery and psychiatry.
Using UK-wide registration data provided by the General Medical Council (GMC), we looked at how fast the number of specialists in these fields who first qualified in the EU and EFTA increased in the five years before the EU referendum, from 2010 to 2015. These registered specialists are senior doctors, qualified to be full consultants and registered anywhere in the UK. Forthcoming work from our Health and International Relations Monitor project, funded by the Health Foundation, will look at doctors working at all levels in the English NHS.
We then projected the pre-referendum rate of change forwards and compared it to actual EU/EFTA staffing trends in each of these specialties in the five years after the referendum between 2016 and 2021. Essentially, this tells us whether there was a gap between pre-Brexit rates and growth and what happened later.
Interpreting these numbers
Our simple approach has a number of limitations. GMC figures are a trend for all of the UK, and may mask outliers. For example, large teaching trusts and small rural trusts might have very different experiences of relying on EU staff, and different capabilities still to attract them.
The linear increase in the counterfactual scenario is a simplification. For some specialties and staffing groups, continuing at the same pace may not have been possible or desirable given the limited number of posts the NHS and private health services would actually need or be able to train for.
Nursing saw a far more dramatic collapse in EU and European Free Trade Association (EFTA) migration around the time of the referendum, as mass recruitment ended and a new language test came in. A projection with continued growth at 2010-2015 rates would imply 87,000 EEA nurses registered in the UK in 2021, rather than the true, decreasing figure of 29,000. This would be unrealistic as limits exist to the number of nurses to be recruited, although it does illustrate the scale of the change.
We looked at extending the counterfactual period back to 2007, and this greatly reduces the predicted gaps by taking in a period of much lower EU and EFTA staffing growth. It was specifically the years leading up to 2016 where reliance on EU and EFTA doctors coming to the UK, ironically, reached its peak.
In all four specialties, the increase in EU and EFTA staff slowed down, falling below the projected increase.
Anaesthetics is one of the largest single hospital specialties in the UK. It supports and is indispensable to a range of interventions and surgical procedures – ranging from A&E to obstetrics or psychiatric treatment, for instance through pain relief, intensive medicine and patient rescuscitation. As a result, trained anaesthetists tend to specialise in one or several of these areas.
The specialty faces significant shortages. The overall number of EU or EFTA doctors is consistently far higher than in other specialties, increasing from 1,457 in 2007 to 1,957 in 2021 for the UK. Unlike the other selected specialties, this last number shows a very slight actual decrease from 2020 by around 1.7% or 33. If the number of anaesthetists had kept rising at the pre-referendum rate, there would have been around 400 more in 2021.
Cardio-thoracic surgery broadly covers surgical interventions on the heart, lung, oesophagus and chest, such as transplants, heart failure treatment and congenital disease. It is highly reliant on European staff. Over 15 years, EU and EFTA numbers roughly tripled, from 118 in 2006 to 348 in 2021. Surprisingly, the number of EU and EFTA cardio-thoracic surgeons (291) overtook that of UK-trained surgeons (268) in 2014. It has remained higher since, but has stagnated.
If the meteoric increase before the EU referendum had continued, we would see over 700 EU and EFTA cardio-thoracic surgical specialists. This is likely more than is realistic or needed: a simple linear counterfactual always risks being projected beyond what underlying causes could really deliver. However, some continued growth would have been welcome in a specialty that has struggled seriously in recruiting domestically.
Psychiatry is split into subspecialties providing care for adult, old age and child and adolescent populations, as well as forensics, learning disabilities and medical psychotherapy. It is a well-known area of chronic shortage in the medical workforce. Paediatrics cover age groups from birth to adulthood and subspecialties from neonatal medicine to oncology. It has seen issues with staffing and retention, both generally and in subspecialties such as paediatric intensive care (doctors and nurses) and geographical areas, notably in the north of England and Scotland. Both have again seen a slowdown in EU and EFTA recruitment after 2016. If previous rates of registration had continued, we would see 288 more paediatric specialists and 165 more psychiatrist specialists across the UK.
While these trends are specific to certain specialties, a slowdown in registration of specialists qualified in the EU and EFTA is visible more generally. Had it continued at the rate before the EU referendum, we would have expected over 41,000 in total in 2021 – more than 4,000 greater than the actual figure.
Is Brexit the reason for the slowdown in EU recruitment?
While the effect is subtle, it is inarguable that registration of doctors from the EU and EFTA was slower in the years after 2016 than the years before. So is this because of the EU referendum itself?
Alternative explanations might include changes in demand: the Covid-19 pandemic, and any workforce planning to shift the balance of training, recruitment and retention towards UK doctors. However, previous research findings suggest that such planning has failed to materialise at a national level. This has been especially reported for England.
Covid-19 mostly does not appear to have driven this slowdown, even though it seems to have been associated with some emigration of EU citizens overall. As the charts above show, the change in trend occurs for most specialties in 2015 or 2016, although anaesthetists do drop slightly more in 2020 and 2021. At the level of all specialists, there is actually some acceleration in EU and EFTA numbers during the years in which the pandemic peaked.
It is not clear that demand for doctors in the UK rose less after 2016 than before. Trends in spending were similar in both periods. GMC data show that the number of UK-trained doctors continued to increase at a similar rate, while the number of registered doctors from the rest of the world accelerated towards the end of this period.
While not definitive, the campaign and result of the EU referendum is the obvious reason for a change in trend around 2015 and 2016. So why might Brexit make EU and EFTA doctors less likely to register in the UK?
From the perspective of EU and EFTA doctors, UK-wide changes in immigration rules announced in 2020 meant an increase in periodic costs and bureaucracy for visas. During the referendum campaign and after it until 2018, although the free movement of labour still existed, EU and EFTA doctors faced reduced certainty about whether they would have the right to remain in the UK.
As mentioned, each medical specialty relies on facilities and equipment, and crucially on support teams that have varying degrees of specialisation. Shortages in any of these areas, partially affected by Brexit (particularly in the years immediately after 2016), deteriorating work conditions, and poorer overall living standards in the UK will affect the ability of doctors to work.
Our previous report also highlighted a rise in all non-British NHS staff (in England) citing ethnicity or race as a ground for discrimination. This could suggest a more hostile environment both for EU and non-White staff, as has been found in some studies for migrants in the UK in general.
The findings suggest that stagnation in the number of EU doctors in these specialties has exacerbated existing shortages in areas where the NHS has not been able to find enough qualified staff elsewhere. While deeper research into drivers of migration is needed, it appears likely that the decision to leave the EU in 2016 plays a role.