Published: 15/07/2004, Volume II4, No. 5914 Page 30 31

Is London overly reliant on overseas health professionals - and how would it cope if they dry up? King's Fund researchers outline the problem

The NHS in London has more staff vacancies and shortages than the rest of the country: employers have become increasingly reliant on overseas health workers to make good the staffing shortfall.

The capital has a significantly higher proportion of internationally qualified nurses than the rest of the UK. The annual survey of Royal College of Nursing members in 2003 found that 14 per cent of nurses based in London had qualified outside the UK - compared with just 4 per cent in the UK as a whole.

It is not hard to see why London is such a popular destination for international recruits and migrant workers. It has a diverse population and unparalleled healthcare career opportunities.

And without these overseas workers healthcare services in London would collapse.

But how can NHS employers in London support and develop an increasingly culturally and ethnically diverse workforce to work effectively? And how can they retain hard-won international staff in the face of growing international competition? Finally, how ethical is it for the NHS to continue to recruit health workers from countries experiencing their own shortages?

The King's Fund will explore these questions further in a report due out early next year.

Our initial findings, published today, present data and case studies of three London trusts.

The case studies highlighted that the internationally qualified nurses comprise between 12 per cent and 25 per cent of the total nursing workforce in the three trusts. The majority of these overseas trained nurses were from the Philippines, Australasia, India, Ghana and Nigeria, although most trusts were employing nurses from many other countries as well. One trust employed 39 nationalities.

This practice raises questions about how the NHS and other employers can effectively manage such workforce diversity.

Interviews with managers in the three-case study trusts highlighted that 'successful' recruitment, although usually measured by retention rates, also involved the effective integration of internationally recruited staff into the culture of the organisation.

One trust reported that nurses who had recently arrived from the Philippines required a lot of additional support - for example, managers reported that the Filipino nurses were initially regarded as being less assertive than UK-trained nurses.

Trust managers also highlighted the need to tackle hostility among staff from the host organisation who became resentful of overseas staff being promoted above themselves.

The finding that nurses have arrived from a broad range of countries also raises the question of how to retain staff with a high level of geographical mobility.

Findings from the three trusts showed that retention of overseas recruited staff has, so far, been very good. One case study trust reported that, of those nurses who have been actively recruited, only about 10 per cent have left and the other two trusts both reported that that they no longer had vacancies in previously hardto-fill posts because of success recruiting abroad.

But retention of both overseas and home-trained nurses may become a bigger challenge as other countries seek qualified healthcare staff to boost their own workforces. The big competitor in the Englishspeaking world is the US where more than 3 million extra jobs will be needed in the health sector by 2010, including over 1 million nursing posts. Other English-speaking countries such as Canada and Australia are also becoming more active recruiting in global markets.

There is also the fundamental question of the ethics of international recruitment. The results show that NHS trusts are employing nurses from countries which are suffering from shortages of trained health staff themselves, such as South Africa, Zimbabwe and Nigeria. These countries have requested that the UK government does not pursue active recruitment in their country, and the Department of Health's code of conduct includes these countries on its recruitment 'banned list'.

However, some nurses arriving in the UK find work first in the private sector (which is not covered by the code) and then move quickly on to NHS employment. Others make their own way to the UK.

Individual freedom is a basic human right, and poor pay and conditions are powerful motivators for doctors, nurses and others to move to the West.

London is more reliant than the rest of the UK on international health workers and, as such, is more vulnerable to outflows of these workers.Alongside the challenge to develop effective human resources strategies to support and integrate these staff in the NHS will come the challenge to retain these staff as other countries seek qualified staff to boost their own workforces.

Sustained use of good employment practice that encourages staff to stay in, and return to, the NHS, and the local recruitment of new workers as part of a 'grow your own' strategy, will reduce the need for international recruitment.

Harnessing the professional skills of refugees already in London but sometimes overlooked would also provide another partial answer to meeting London's need for health workers. As well as this, the ethical dimension of migration of health professionals will continue to be a significant feature of health policy debate in the UK as pressure increases on the UK to comply with international codes of practice on international recruitment.

The UK has not signed the code introduced by the Commonwealth, but it will have to take account of the recent World Health Assembly resolution requiring a more managed approach.

One thing is certain: if London is to remain a major destination for internationally recruited health workers, it will have to ensure that it strives to achieve an ethical balance between supporting the rights of individual health workers to move to better their careers, and the potential negative impact on source countries in the developing world.

Professor James Buchan is professor at the Faculty of Social Science and Healthcare, Queen Margaret University College, Edinburgh. Renu Jobanputrar is a researcher, Pippa Gough is a fellow in health policy, King's Fund Further information World Health Assembly resolution: www. King's Fund: www. kingsfund. org. uk