The NHS’s duty of care with its overseas staff

The NHS faces great challenges in attracting new staff to help fulfil ambitious workforce targets and fill existing shortages. Overseas staff have long offered an invaluable contribution to the NHS, not least in nursing where they make up nearly a fifth of the current workforce.

But many are suffering from exhaustion and burnout from the Covid-19 pandemic. Many of these issues are also experienced by their colleagues, but staff from abroad face some unique challenges. Drawing on our conversations about the pandemic with communities of overseas nurses, this blog emphasises once more how important it is for the NHS to support and retain staff from overseas, while delivering on its duty of care to all employees.

What has been the impact of the pandemic on overseas nurses?  

There is evidence to suggest that Covid-19 has had a disproportionate effect on the working patterns of some staff groups. While there is limited data on nationality, almost half (47%) of NHS staff from ethnic minority background have worked in Covid-19 roles in England, compared to under a third (31%) of all staff. Our conversations with nurses from particular nationalities – including with representatives from Indian and Jamaican diasporas as well as two Filipino associations – would seem to back this up. They told us they have felt less safe than domestic nurses during the pandemic.

We heard from overseas nurses about being placed in riskier posts, without always having as appropriate personal protective equipment (PPE), training or support as their domestic colleagues. Again this tallies with concerns raised elsewhere about some groups receiving less support. Aside from worrying about the consequences for speaking up, the diasporas told us that overseas nurses are often more likely to comply with what they were asked to do, as culturally they may be less likely to complain or ask for another role.

Living conditions have been another problem. One reason why overseas nurses move for work is to send money back to their family, so sharing their living space with others, often other nurses, can save more money for that purpose. But the overseas nurses told us that such arrangements made them prone to recurrent isolation and infection during the worst of the crisis.

While everyone has endured restrictions, overseas nurses have been doing so far away from home, without many of the same support systems. In the absence of more formal support, many diasporas and other associations such as the British Indian Nurse Association (BINA) and the Filipino UK nurse community were therefore formed, enabling nurses to share with someone their concerns and fears about the support or equipment they were or were not getting at work.

Some hospitals did try to introduce support schemes, but we heard that sometimes they did so without really understanding cultural differences, habits and preferences, rendering them less effective.

Long stints of service and longer hours of work

As well as making up such a large part of the NHS’s workforce, overseas nurses also typically offer long stints of service. Based on joining at an average age of 30, we previously estimated that an overseas nurse not from the EU might work in the NHS for an average of 12 years, which is three years longer than an UK national and six years longer than a nurse from the EU.

Overseas nurses from outside the EU are also contracted to work, on average, three more hours a week than those from the EU and UK, but the implications of those differences should be treated with caution. It is not clear whether the longer hours worked by nurses with overseas nationalities is out of choice or lack of opportunity to work more flexibly.

Data quality is poor and is often limited to ethnicity

In the past few years, several events – the pandemic, but also the murder of George Floyd in the USA and the emergence of Black Lives Matter – have increased awareness and interest in issues of equality, diversity and inclusion.

However, as we recently highlighted in our report on diversity in the NHS workforce, poor quality of data means we cannot fully understand what and where these inequalities are in the NHS, meaning that much knowledge is anecdotal. That followed another Nuffield Trust report highlighting problems with ethnicity coding in English health service datasets (which will hopefully change soon).

Much of the research on race relies on comparing proportions of White staff with umbrella Black, Asian and minority ethnicities. In fact, a Filipino diaspora told me that they felt invisible in that umbrella of being “Asian” or “Other Asian”, as it doesn’t represent who they are or their specific circumstances. Work on diversity and inclusion often also overlooks other protected characteristics, and we particularly need to understand the experiences by country of origin to have a fuller picture.

Duty of care with all NHS staff

Perception and feedback from existing nurses are important in driving future overseas recruitment. When nurses are deciding where to go, they will likely know someone in that country to ask about their experiences and what’s available elsewhere. And we must remember that the nursing shortage is global. England is competing with other countries who want the nurses we already have. Some of them – including Germany, Switzerland, the US and Australia – are offering more money and better employment conditions than the NHS.

The NHS has a duty of care to secure the health, safety and wellbeing of all its staff. But despite it being the largest employer of ethnic minority staff in England, it is still falling short on diversity, equality and inclusion. Given the contribution made by staff, including those from overseas who – as outlined above – faced some particular challenges, this duty is more important than ever.

I recently saw privilege described not as the presence of perks and benefits, but as the absence of obstacles and barriers, which are much harder to notice. Failing to understand the range of experiences of different groups of staff, including those from overseas, and to identify better solutions and interventions to support those more disadvantaged will only lead to more turnover, and even more staffing vacancies than already the case.