There is a shortage of doctors and nurses in the UK’s health system. Is the answer importing more who were trained abroad?
For such a rich country, England has a very low proportion of doctors relative to its population. The average number of doctors per 1,000 people in OECD EU nations is 3.7, but England has just 2.9. Germany, by comparison, has 4.3. England needs nearly 50,000 additional FTE doctors simply to put us on an equivalent standard with today’s OECD EU average.
The NHS has long carried a stubbornly high number of unfilled vacancies, a problem that far predates the pandemic. According to the British Medical Association, as of June 2023 there were 125,572 vacancies in secondary care in England. Of these, 10,855 vacancies were medical, amounting to 7.2% of all medical posts. The greatest proportion of all secondary care vacancies remains in nursing, with 43,339 unfilled posts (10.6% of all nursing posts). The training of nurses in the UK numbers decreased after the nursing bursary was removed in 2017, now partially only restored.
As care is delivered by multi-disciplinary teams, these nursing shortages directly impact on the entire medical workforce. High vacancy rates create a vicious cycle: shortages produce environments of chronic stress, which increases pressure on existing staff, and this in turn encourages higher turnover and absence. Ironically, many British health care workers are now seeking better pay and conditions in other countries.
One answer is to recruit foreign health workers but then one doctor friend told me:
‘Some patients were always complaining about going to the hospital and it being full of foreigners and it was true in a way… one took them for an x-ray, another was the nurse and the other was a doctor.’
Overseas health care workers have played an important role in the successful running of the NHS since its inception in 1948. Now around one-third of the total number of UK doctors are either from the European Economic Area or from further afield. The same is true for nurses. Data from the Nursing and Midwifery Council, released in May 2023, show that over 24,000 of new registrants in 2022/23 were trained outside the UK, nearly half the overall total of all new registrants. In the years since 2016, which saw the Brexit vote and new English language test requirements being introduced for nurses, international nurse recruitment from EEA countries dropped markedly. At the same time, there was a substantial increase in new nurse registrants from non-EEA countries. As of March 2023, 3.5% of nurses on the UK register first qualified in EU27 countries, while 17% did so outside Europe.
A recent report from the Nuffield Trust is quoted as showing that without Brexit, had trends continued, there might be 4,000 more EU trained doctors and perhaps 50,000 EU trained nurses than there are.
OECD data show that the proportion of UK-based nurses who are foreign trained (nearly 18% in 2021) is well above that in many comparable OECD countries. The health and care sectors in the UK simply could not function without these internationally trained staff.
The long-term and growing reliance on international recruitment results in reduced incentives to invest in domestic education, and there are also ethical concerns around recruiting staff from lower income countries also facing damaging health workforce shortfalls.
In 2022/23, more than 40% of all new nurses registered with the Nursing and Midwifery Council (domestic and international) came from low and lower middle income countries (using World Bank classification), up from 10% in 2018. Last year, more than 6,000 new nurses registered in the UK came from so-called ‘red list’ countries – highlighted by the World Health Organization as being most at risk of not achieving universal health coverage because of health workforce shortfalls.
Can these ‘red list’ countries and other poorer countries be expected to continue to use their resources to train doctors and nurses they can ill afford to lose, to fill the gaps in the UK’s and other rich countries’ health systems? A study carried out in June 2018 found that of the top 15 countries where NHS staff are most commonly recruited, seven were low and middle-income countries, countries such as Tanzania, where there are around four nurses and midwives for every 10,000 people, compared with a ratio of 84 per 1,000 in the UK.
While the UK may claim to have led the world in becoming the first nation to adopt a Code of Practice for international recruitment of health and social care personnel, there is evidence this code is being breached by some international recruitment agencies who use sub-contractors to recruit nurses and doctors from poorer countries. The need for a coordinated approach that seeks to benefit both these poorer countries and the UK is vital for recruitment to be ethical and to work effectively. The UK government code of practice specifies that there should be no active recruitment from these so-called ‘red list’ countries – though direct applications by individual health and social care personnel are permissible. Since 2019/20, there has been a tenfold increase in the number of new NMC registrants from red list countries.
This is not a new problem. The World Health Organization’s 2006 World Health Report found that while Africa is responsible for 24% of the global burden of disease it has only 3% of the world’s healthcare workforce to manage it. When health workers leave Africa, often for better-paid jobs in wealthier countries, the impact can be devastating. For example, the World health Organization totalled the number of Ghanaian nurses and midwives working in Ghana at 17,322, and the total number working in OECD countries at 2,267, meaning that 13% of the home country workforce is working in OECD nations.
Overseas doctors themselves face challenges entering a new culture, as does the service when taking on those who are unfamiliar with medical traditions in Britain. This continuing complex interaction has become more urgent in the face of Brexit when many health care workers left the UK. Lack of information about the UK health system; language and communication challenges; clinical, educational and work-culture challenges; and discrimination challenges are some of the difficulties that overseas doctors and health care workers might experience. Effective medical communication is a two-way process and is also affected by the patient’s understanding, which in turn is influenced by their social and educational background and local dialect – subtleties, which the overseas doctor may not be in a position to fully understand.
While the UK has cut its foreign aid budget, it continues to recruit health workers from abroad to fill gaps caused by underfunding and mismanaged training in the UK. However, simply importing healthcare workers from around the world to fill the UK’s medical workforce cannot be a long term, effective, ethical solution. At the same time, UK trained health workers are also leaving to take up better working conditions abroad.
It is vital that the government’s promised long-term workforce strategy for the NHS is backed by full funding and with alignment between effective domestic training and effective and ethical international recruitment. Alongside this, a long-term plan to reform pay, training, and working conditions in health and social care, which also supports ethical international recruitment, is long overdue. If the UK wants an effective, safe, valued NHS then it really needs to invest in it!
What’s up Doc?
Well, maybe ask, ‘is there a doctor in the hospital?’ If you live in the UK the answer is probably ‘Yes.’ But realistrically, they are very likely to have been trained abroad.
Ed note: See also ‘Will the doctor see you now?‘
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