NHS trusts are in the midst of a nurse staffing crisis, struggling to fill around 40,000 vacancies. The situation is set to get even more difficult. Our analysis with the King’s Fund and Health Foundation shows that the gap will actually grow even with a range of actions over the next five years – unless, that is, we can bring in around 5,000 more nurses each year from other countries.
The recently published Interim NHS People Plan is realistic and clear in saying England will continue to need foreign nurses. But at the same time, the proposal to replace free movement of labour from most of Europe with a set of tight restrictions, including a £30,000 salary limit, threatens to bring in more barriers.
And beyond those hard barriers to migration, foreign nurses’ decisions to work in the English NHS are also influenced by individual choices. Even now, with free movement still in place, the proportion of nursing joiners who hold an EU nationality has halved, while they account for more of those leaving. I spoke to many EU nursing migrants in the English NHS for my PhD, discussing their choices and perspectives. So what are the problems, and the possible solutions?
England needs to compete
The nurses I spoke to were clear that they make ongoing calculations of the ‘pluses’ and ‘minuses’ of moving country. As highly qualified professionals aware of their value, nurses ask themselves questions such as what kind of career development and further training opportunities are there? Would I be properly remunerated? How is nursing perceived by the society? How far and easy is it to go back home?
The process of Brexit so far has already brought a less valuable pound sterling, and perhaps a sense that the UK is less welcoming of migrant workers. A no deal Brexit actually taking place would immediately add a more onerous migration system and remove the laws that often make training and qualifications here transferable across Europe. All these factors risk bringing more difficulty and lower rewards into the calculations nurses make.
Meanwhile, these nurses are needed and sought after in many other European countries, where they can work without any, or with very little, administrative hassle. The NHS is going to have to work hard to encourage foreign nurses, even those who earn enough to still come under the proposed system, to continue coming and staying in the long term.
Actions the NHS could take to better manage recruitment and retention of EU nurses
The retention programme and the direct support programme as set out in the Interim People Plan are promising in recognising that people on the shop floor best understand how to make the NHS more attractive. Recent analysis by NHS England and NHS Improvement is already showing promising results. But considering the urgency of the workforce crisis, what other specific and quick actions could help?
My research revealed that efforts and resources to shape recruitment and retention strategies to foreign nurses’ needs vary greatly among trusts. Moreover, understanding of the experiences and aspirations of these nurses, and how these may change over time, was often poor.
One way to find out more information more quickly would be for NHS England to add a question on nationality in the annual NHS staff survey, or add to the current questions on ethnicity. This would allow NHS employers to compare the experiences and working preferences of nurses from different nationalities and countries of training, and whether there are differences or similarities that need to be investigated.
The main current categories included in the survey are White, Mixed, Asian/Asian-British, Black/Black-British and Chinese/Other. This means that many EU migrants – and others – are lumped in with British staff of the same race, telling us little about their experiences.
Other ways to get more insight would be to investigate sick leave reports in greater depth and to hold regular meetings, focus groups or short interviews with newly recruited nurses. These could be used to obtain information on nurses’ wellbeing and overall working conditions, as well as to gain a fresh perspective on the weaknesses and areas to improve.
What made all the difference for some of the trusts where I conducted interviews was the allocation of a clinical psychologist or a willing member of staff, both from an EU country, to chair and monitor these meetings with new recruits. This provided a person of contact as well as a welcoming space and additional support to ease their transition into the new organisation.
None of these options require significant investment of time or money. But they not only tell us much more about new and ongoing morale problems across the NHS, they also show up differences between trusts and wards and tell us who have initiatives that work. Even as processes, these measures could help all nurses to feel listened to and valued.
Accountability goes both ways
These measures should help us understand the problems, but it is also important to hold people to account for solving them. The Interim People Plan attaches responsibility for most proposed actions to specific central bodies.
However, because the migration system and local actions play an important role, real accountability for NHS staffing also needs to extend both downwards to trusts and upwards all the way to the Home Office and to government. Without migration policies that recognise the health service needs to be an attractive destination, the full people plan due this autumn will not be able to stop the gaps in the nursing workforce growing ever bigger.
Leone C (2019) “How can the English NHS attract and keep more of the international nurses it needs?” Nuffield Trust comment.