The NHS will remain dependent on overseas nurses for many years and hospitals must ensure effective recruitment and retention. James Buchan explains

The importance of recruiting nurses from overseas to the NHS has been highlighted by the Department of Health s guidance on international nursing recruitment published in November .

But why has the level of international recruitment grown so dramatically in recent years, and what are the key messages for trust managers who are considering active recruitment in international nursing labour markets?

The growth is a legacy of the downturn in the number of home-based student nurses in the early 1990s.

1 As a result, the UK is currently dealing with its biggest nurse recruitment challenge for a decade or more. The DoH has embarked on an advertising campaign to attract new recruits and returners.

The latest DoH data suggests that this campaign is having a positive effect in increasing numbers of applicants to nursing, but it will take some time for the full effect of the increase in student nurses to become apparent in the nursing workforce.

2,3 It is against this background that more trusts have become active in recruiting nurses from abroad.

The number of internationally recruited nurses entering the UK has increased markedly in recent years. All nurses working in the UK have to be registered with the UK Central Council for Nursing, Midwifery and Health Visiting. UKCC data gives some indication of trends in international activity.

In 1998-99 there were 4,981 initial entrants to the UKCC register from outside the UK, representing 28 per cent of the total intake. Non-UK admissions to the UK register as a proportion of total new admissions is shown in the box, right. There has been a year-on-year rise in the significance of non-UK sources, with the main source countries in recent years being Australia, South Africa, New Zealand and Finland.

But many of these internationally recruited nurses remain in the UK for only a relatively short period of time - often for a planned contract of one or two years. Data from the UKCC register shows that in total, in February 1999 there were about 20,000 overseas nurses resident in the UK. This represents only about 3 per cent of the total number of practitioners on the UKCC register who reported a UK postcode.

The significance of international recruitment becomes more apparent when the geographical distribution of internationally recruited nurses is examined, as indicated by their reported postcode (see table below).

For nurses reporting a central London postcode area, one in three registrants (31 per cent) was from overseas, and in other London areas one in 10 (11 per cent) was from overseas, compared with the average figure for England of 3.5 per cent.

As the DoH guidance makes clear , trusts planning to recruit in international labour markets have three options. They can recruit from the EU and from the European Economic Area, they can use working holiday visas to recruit younger nurses from Commonwealth countries, or they can recruit from non EU countries and obtain work permits.

In the past, much recruitment activity has focused on the countries of the old Commonwealth and on Ireland.

The DoH is advising trusts to give prime consideration to countries in the EU, and should adopt a much more cautious approach with some other countries, such as South Africa and the Caribbean nations, where the potential source countries are reportedly experiencing a brain drain of qualified nursing staff Taking account of these guidelines, NHS managers have to decide which country or countries to target. Many trusts will need a specialist recruitment agency to take the lead. The overall costs to trusts of overseas recruitment activity can vary markedly (see box, above right), depending on the number of nurses recruited, agency fee structures, transport and accommodation. The DoH guidance is explicit that trusts need to ensure they get value for money from overseas recruitment. Trusts can contain these costs by: ensuring that the volume of recruitment justifies the fixed costs relating to recruiters time and travel; negotiating realistic rates with the agency, if used; ensuring that the overseas nurses recruited are effective in their work; ensuring that overseas nurses are retained in employment for the duration of their contracts.

The third point highlights the need for any trust recruiting abroad to ensure that overseas nurses receive proper training and induction on arrival. The induction process should cover the nurse s role and aspects of clinical care, multidisciplinary team-working, clinical governance, standards of practice, the UKCC code of conduct and self-regulation, and employee relations.

Overseas nurses may come from countries with different cultures and health systems, and different approaches to teams and hierarchies in healthcare, and to employment relations.

Induction to nursing employment in the NHS also has to cover broader cultural issues and aspects of living in the UK, such as banking facilities, finding accommodation and educational opportunities. Some contracts with recruitment agencies cover these aspects of the induction process.

Overseas recruitment can offer a trust the opportunity for batch recruitment of a cadre of nurses, with 20-100 being recruited at once. Economies of scale can be achieved with this approach, but it is equally important that the trust maintains a longer-term view of cost effectiveness. If the nurses have been recruited on a short contract basis, they are a short-term solution, and the trust will have to plan what to do at the end of their specified contract of one or two years.

When making a decision on whether or not to recruit actively from other countries, managers should draw on the shared experience of other trusts. They can then weigh up the costs and benefits of overseas recruitment in relation to other viable options.

Variations in labour markets, in trust requirements for nursing staff and in the cost structure of recruitment options mean that the most effective mix of options will be different for different trusts, at different times. Developing an effective integrated recruitment and retention strategy requires that this mix of options is kept under review.

If not properly managed, international recruitment can be a costly short-term solution to skill shortages. If properly integrated and planned, it does give trusts another option when looking to fill vacancies for skilled nursing staff.

Given the current challenges of home-based recruitment, particularly in the south-east, international recruitment is likely to continue at its current relatively high level, at least in the short term.

The tradition of the working holiday means that Australia and New Zealand are likely to remain significant sources, and if the DoH guidance is followed, the EU is likely to grow in importance.

For some other countries, such as South Africa, the DoH's message is very clear . Trusts should not export their skill shortage problems by importing scarce nursing skills from these countries.