It is no secret that one of the biggest challenges facing NHS trusts is recruiting and retaining sufficient staff to run services safely. Vacancies for nursing and midwifery posts are already hovering around the 40,000 mark and, based on current trends, that shortfall could go beyond 100,000 full-time equivalent nurses within a decade.
In the run-up to December’s election, the Conservatives pledged to boost nursing numbers by 50,000 by 2024/25, and it was widely reported that 12,500 of those extra nurses were to be recruited from abroad.
So what are the challenges of international recruitment for those trusts actually doing the recruiting?
Recruitment strategies and costs
Foreign nurses are recruited in two main ways: directly by the trusts, without any intermediaries, or through a recruitment agency. For the latter, trusts hire an agency to identify, select and facilitate the process for a fee per nurse hired.
As well as that fee, there are additional charges for the employer. They include the costs of accommodation, flights, language lessons, the Objective Structured Clinical Examination (OSCE) tuition programme and fees specific to non-EEA nurses, alongside other expenses of inducting and mentoring nurses from abroad. As the competition for nurse supply gets tougher, some trusts are also offering to pay the health surcharge and even visa fees.
All routes to increase the supply of nurses have financial implications. Although international recruitment remains the overall cheapest (and quickest) option, it can cost an NHS trust between £2,000 and £12,000 per nurse hired, depending on where that nurse is from. In comparison, a nurse degree apprenticeship scheme, for example, can cost an NHS trust around £140,000 per nurse (over and above the annual designated levy of up to £27,000).
And it’s not just money. Recruiting internationally often also brings extra work for other staff at a trust. In some cases, they may need to travel to source countries for several days or provide extra guidance and training, particularly if there are language and cultural barriers to overcome.
Higher competition and higher demand
Vacancies are so widespread in the NHS that organisations have to compete with each other to bring new staff. Some organisations have local shared recruitment initiatives, but in most cases it is every trust for itself.
And identifying foreign nurses who want to (and can) come in is not always straightforward. In a recent blog, we discussed how England has to compete with other EU and non-EU countries for qualified nurses. Countries such as New Zealand, Switzerland and Australia have shares of around or above 20% of foreign-trained nurses (compared to the UK, which has 15%). Highly qualified health professionals are coveted globally, with many destinations to choose from.
Increasing the immigration health surcharge to £625 per person per year could make it particularly difficult to attract foreign nurses in the lowest bands (such as Band 5, where salaries range from £24,000 to £30,000), given those nurses will often migrate with their families (meaning £625 x family of four = £2,500 a year).
On top of that, the pool from where the NHS can recruit foreign nurses is getting smaller in some regions. The numbers coming in from the EU since the 2016 Brexit referendum suggest these countries are no longer a reliable source of nurse supply. And it’s not always possible to recruit from further afield. Even though the UK’s commitment to the WHO Global Code of Practice on the international recruitment of health personnel isn’t getting the attention it deserves, there are a number of countries from where it is simply not ethical to recruit. That commitment stresses the importance of not debilitating the health systems of developing countries.
Keeping staff happy
Even if organisations are able to bring foreign staff in, those staff then need to stay.
During my doctoral research, I found that once in the UK, EU nurses move within and between different trusts and regions. Many non-EU nurses come to England as a stepping stone, and many return to their home countries.
From an individual trust’s perspective, it makes no difference if those professionals leave for the nearest trust, return back home, or go to another country – turnover means loss of investment. And in most cases, it means having to repeat the recruitment process (and its costs) all over again.
What might help?
Opening the doors to a country is not enough. Most of the responsibility to recruit new staff and make migrant workers feel welcomed and integrated falls on trusts. But Brexit, and any more restrictive immigration policy that is implemented, will have a significant impact on the ability of those trusts (particularly the smallest ones) to do just that.
Cohesive and strategic processes for international recruitment – aimed at reducing financial barriers, visa restrictions and other hurdles that affect the willingness of qualified nurses to choose the UK to come and stay – are certainly part of the way forward. But there also needs to be more focus and resources directed at the workplace.
Existing initiatives, such as the one aiming to make the NHS (and every individual trust) the best place to work, are a good start. Sharing intelligence between trusts on where to find nurses, as well as sharing good practice on how to recruit and retain them, would also be a welcome step in the right direction.
Given we are at a point in the NHS where overseas recruitment of nurses is not just an option but an ‘absolute necessity’, having the right support for trusts is a matter of urgency.
Leone C (2020) “Recruiting nurses from overseas: the main challenges facing trusts”, Nuffield Trust comment.