Staffing is the issue keeping NHS leaders awake at night – and which consumes two-thirds of trusts’ spending. The fortnightly The Ward Round newsletter, by HSJ workforce correspondent Annabelle Collins, ensures you are tuned in to the daily pressures on staff, and the wider trends and policies shaping the workforce.
Five years ago, just over 3,500 international nurses and midwives joined the Nursing and Midwifery Council’s register during the course of a year. The latest NMC data revealed that, between March 2022 and March 2023, more than 25,000 internationally educated nurses and midwives joined.
The new high reflects a renewed drive for incoming clinical staff, after the peak of the covid-19 pandemic all-but halted the flow for much of 2020.
In 2021, NHS England told trusts to speed up processing new overseas recruits, with 800 new arrivals joining the NMC register in one week alone, and this has only picked up pace.
The NMC data also shines a light on the changing profile of those joining. There was a further fall in nurses coming from the European Economic Area (a 2.7 per cent year-on-year decrease), in the wake of Brexit; and a huge 20 per cent increase from outside the EEA. Within this, for the first time, most international new joiners were from India. Those from Spain and Italy fell to just a few hundred.
The same trend can be seen for doctors, with the General Medical Council’s latest workforce reporting finding registrants from overseas and from outside the EEA outstripped those within the UK.
International recruitment programmes for nurses and doctors are well established, but there are also plans to beef up those for allied health professions. Trusts are now able to recruit more types of AHPs from abroad, selected because they’re in shortage in the NHS and recruited from countries where there is – apparently – a surplus.
Health and Care Professions Council data (it registers a wide range of health and care professions, including AHPs) has also revealed a fairly sharp increase in international registrants through 2022, rising from around 21,000 in January to almost 30,000 in December. In social care too, the government has changed migration rules and has a concerted push for many more overseas recruits.
For nursing and midwifery, overseas recruitment made a big contribution in 2022-23 to what on the one hand is a positive picture: The highest number of new joiners to the register in a single year since records began in 2001, including a small increase in domestic numbers. There was a slight fall in the number of people leaving the permanent register – but a note of further concern about retention, with 52 per cent of leavers saying they did so “earlier than planned”.
The figures also underline how dependent the NHS now is on the overseas supply – a precarious position, vulnerable to future changes in migration patterns and global events.
And there are, of course, the ethical concerns I’ve discussed several times in this newsletter. Last summer, The Ward Round discussed in detail plans to recruit 100 nurses from Nepal – a red list country.
And analysis by the Nuffield Trust, which monitored Brexit’s impact on health and social care six years on, raised further concerns about “significant” NHS recruitment from ‘red list’ countries. It found sharp increases in staff joining specific trusts from ‘red list’ countries over a short period of time, which suggested they were being targeted rather than ‘passively’ recruited.
Integration into the NHS
Concerns have also been raised about the experience of international staff once they are working in the NHS. Rob Yeldham, Chartered Society of Physiotherapy director of strategy, told HSJ last week there needs to be better induction and support to help international arrivals adapt.
Nuffield Trust senior fellow Billy Palmer described the NHS’s ability to integrate international recruits as “variable”, pointing to data which showed a high turnover of doctors and allied professionals from abroad. However, the reverse is thought to be true for overseas nurses, with NT research finding they are likely to stay longer in the NHS than their UK counterparts.
There are well-known disparities between staff who qualified abroad and those who are UK-trained. They typically have worse exam results and are more likely to be referred for fitness-to-practise.
There’s a need for wider support for and engagement with overseas arrivals, too.
NHSE-commissioned research from Huddersfield University into the experience of international nurses in England found the biggest problem faced by international recruits was housing, with 200 out of 655 respondents finding it difficult to find somewhere appropriate and affordable to live.
The researchers set out a series of recommendations, covering recruitment, accommodation, mental health and wellbeing, communication, and career progression.
Their suggestions included ongoing local support for settling into long-term accommodation, providing more language awareness programmes and exploring the recognition of academic qualifications gained abroad, with many respondents describing how their “role and payment does not reflect my years of experience, my qualifications and my skills”.
With the domestic supply continuing to fall short (and still no workforce plan seeking to increase it), gaps will be plugged by yet more international recruitment – although there is a compelling argument that more people doesn’t equal more productive, as discussed before in the Ward Round and everywhere else too.
The NHS needs to respond to the rapidly changing demographic of its workforce; not only because it has an ethical responsibility to support overseas recruits, but also to try to get the best out of what remains an expensive and time-consuming solution.