Going places

Published: 01/08/2002, Volume II2, No. 5816 Page 22 23 24

The UK's recruitment of overseas nurses is more than a sticking-plaster solution and looks set to become an established part of health policy.But it will face increasing competition from other countries, says James Buchan

There has never been a better time to be a nurse with wanderlust.

The UK, like many other developed countries which are experiencing nursing shortages, is using international recruitment as one of the solutions to staffing difficulties.

1Just how important is this to the UK, and can it be sustained?

I have investigated trends in the movement of nurses to the UK from other countries to assess the overall contribution of international recruitment and to identify the main countries from which the UK is recruiting.

2Nurse staffing is one of the critical issues that the government will have to get right if it is to deliver on the NHS plan. In England, the Department of Health met this staffing challenge head on.Having already met an initial target of 20,000 additional nurses by 2004, it has now announced a further long-term target of 35,000 additional nurses by 2008. The DoH is achieving growth by concentrating on four areas:

attracting (and funding) more entrants to nurse education;

encouraging returners to nursing employment;

improving retention through improved career structures and flexible working practices;

recruiting from abroad.

International recruitment has offered a relatively quick fix, with scope for rapid increases in staff, without the need to wait the three years for increased numbers of home-grown student nurses to enter the workforce. It may not always be the most cost-effective solution, but at a time of shortages it is sometimes the only one.

When the DoH announced the new 2008 staffing target, it acknowledged that 'international recruitment will continue to play a significant part in boosting nursing numbers'.

3Historically, the UK has often played a significant role in international nursing labour markets, recruiting nurses from places such as Ireland and the Caribbean. In recent years this activity has become more systematic and co-ordinated, stimulated by skill shortages and government policy.

The DoH has a network of international recruitment co-ordinators linked into NHS Professionals, the nationwide staffing organisation. The DoH has also initiated inter-government nurse recruitment agreements with the governments of Spain and the Philippines and indicated that more will follow.

One key indicator of the impact of international recruitment activity is the growth in overseas nurses registering to practise in the UK. Any nurse who wishes to do so must be registered with the professional regulatory authority, the Nursing and Midwifery Council, which succeeded the UK Central Council for Nursing, Midwifery and Health Visiting in April.

The NMC makes individual judgements on applications from overseas nurses, on the basis of the applicant's length and type of training, and previous work experience. Applications are handled in two different categories: those from the EU, and those from outside it.

Applicants with general nursing qualifications from the other countries of the EU/European economic area have the right to practise in the UK because of mutual recognition of qualifications across the countries of the EU/European economic area. EC directives enable them to register with the NMC. Nurses from all countries outside the EU have to apply to the NMC for verification of their qualifications to be admitted to the register.Most nurses from outside the EU will also have to obtain a work permit for paid employment in the UK.

Registration information only records the fact that a nurse has been registered, not when a nurse enters the UK; nor does it indicate what the nurse is doing. Even so, it is a strong indicator of trends in applications to practise in the UK.

Figure 1 highlights the strong growth in the numbers of new overseas nurse registrants. In the past three years more than 30,000 new registrants from overseas have been admitted to the UK register.

In 2001-02, 13,721 new non-EU entrants were recorded, suggesting that overseas admissions will have been around 15,000. The main nonEU source countries in 2001-02 were the Philippines (7,235), South Africa (2,114) and Australia (1,342), but admissions from other countries such as India and Zimbabwe have also increased significantly over the past three years. In the previous year (200001), 9,694 entrants were recorded.Of these, 8,403 (87 per cent) were from non-EU/European economic area countries.Again, the three most important source countries had been the Philippines (3,396), South Africa (1,086) and Australia (1,046).

In some cases, UK employers have facilitated this marked increase in recruitment activity, both in the NHS and in the independent healthcare sector, making use of international recruitment agencies.

Concern about the activities of some agencies led the DoH to introduce a code of practice, and some employers now use NHS Professionals to assist in supporting international recruitment activity, rather than a private sector agency.

While there has been a significant and sustained increase in the number of overseas nurse registrants in recent years, admissions from EU countries have levelled off. In the mid-1990s, admissions from EU sources accounted for between a quarter and a third of annual total overseas admissions, but by 2000-01 this had dropped to only 13 per cent, with a further drop forecast for 2001-02. EU nationals have free mobility, but most newly recruited non-EU nurses require work permits. The UK has therefore become increasingly reliant on recruiting nurses who are initially permitted to work in the UK, rather than having free access.

This changing profile may also impact on the future pattern of how many of these nurses stay or leave.

The significant upward trends in admissions to the register from non-UK sources is obvious in figure 1, but how important has this overseas contribution been to the total number of annual admissions to the UK nursing register?

Figure 2 shows the comparative importance of non-UK source countries, in relation to the annual total number of all 'new' nurses on the UK register, including those from UK sources. In the early to mid-1990s about one in 10 new entrants was from non UK sources; by 2000-01 this had risen to almost four in 10 of total initial registrations, with this upward trend likely to continue. In 2001-02 it is estimated that nearly one in every two new registrants in this year will have been from overseas.

The upward trend in the numbers of overseas nurses is confirmed by data on the number of work permits issued to nurses. In the UK, nursing is one of the professions designated as a shortage occupation. These occupations have been acknowledged to be particularly difficult to fill. The designation means that there is a simplified procedure for overseas applicants, in order to fasttrack the application process. In 2001 about 12,700 new work permits were issued to individuals who had not previously been working as nurses in the UK. The main sources of application were the Philippines, India and South Africa.

The figures show a marked growth in the level of international recruitment of nurses to the UK in the past four years, to a point where four in every 10 new nurses entering the UK professional register has been trained in another country. This has been driven primarily by nursing shortages in the UK, stimulated by the need to meet the governmentendorsed NHS plan target in England of '20,000 more nurses' by 2004.

The growth in international recruitment by the NHS and other employers has been matched by a broadening of the range of source countries in which UK employers and recruitment agencies have been active. The main areas of growth have been the Philippines and to a lesser extent the African countries and India, with a continued reliance on Australia. The EU in general has not been an area of increased activity. Given that England now has a new set of nurse staffing targets to aim at for 2008, can - and should - this high level of activity be sustained?

International recruitment is increasingly becoming the focus of policy attention, on the basis that it may damage the staffing infrastructure in some developing countries, depriving them of nursing skills that are scarce and relatively expensive to replace. This issue has led the International Council of Nurses to introduce a position statement on the migration of nurses.

4Asecond area of concern has been that some internationally recruited nurses have reportedly been misinformed or mistreated by employers or recruitment agencies.

5The DoH has recently published a strengthened code of practice for NHS employers.

6It is primarily about improving the effectiveness of international recruitment, not ending it.

Inter-government agreements, already in place with Spain and the Philippines, are one model for future recruitment activities with other countries.

It is too early to assess the overall impact of these agreements. They may have the potential to develop a more systematic and 'managed' approach to international recruitment, but the dynamics between different countries will vary, as will the motivations of governments who wish to encourage their nurses to move.

In the past, Europe has been flagged up as an ethical place to recruit. But there has been no recent significant growth in the annual number of nurses entering the UK register from EU countries.What accounts for this relative lack of integration, as indicated by the absence of a growing 'flow' of nurses to and from continental Europe?

Two explanations are likely. Despite a shared European labour market, and mutual recognition of nursing qualifications, there is not a shared language.Most EU-recruited nurses working in the UK in the past have come from Ireland, or from Scandinavian countries where English is a second language. Lack of language skills has hampered easy integration of UK nurses into continental Europe.

Also, while the UK may be interested in recruiting more nurses from EU countries, most of these may not have enough 'push factors' to motivate nurses to move to the UK. Language differences are compounded by the fact that salaries, working conditions and quality of life may not be sufficiently unattractive at home or, relatively, attractive enough in the UK to attract these nurses across the Channel in significant numbers.

The likely continuation of this push-pull balance means that there will not be a large growth in recruitment of EU nurses to the UK, with the possible exception of Spain, at least until some of the Eastern European accession states enter the EU.

In the absence of any increase in EU activity, the large and long-term international flows of nurses have been between the UK and other Englishspeaking countries.These include the two-way flow with Australia, with the countries 'exchanging' some of their nurses, often on a temporary basis, and the one-way flow from the Caribbean, Africa, India and the Philippines, with nurses stimulated to move by factors related to better career opportunities, salaries and stability.

The pull factor of meeting NHS plan staffing targets is likely to mean that the UK, particularly England, will continue to recruit from these international markets.Attempts to increase the number of home-educated nursing students, and to improve retention and return rates, can have a positive effect, but the ageing of UK nurses will lead to a growth in retirement levels, particularly from the middle of the decade onwards.

This is likely to be an increasing challenge on the capacity of the NHS to retain its nurses.

When coupled with the likely liberalisation of global labour markets, it points to a continuing high profile for the UK in international nursing labour markets. Just as there is a challenge to retain home-grown nurses in the NHS, there may be an increasing challenge to retain nurses in the UK.

The big player in English-speaking nursing labour markets has been the US.

In the past it has recruited large numbers of nurses from the Philippines, Canada and elsewhere.

This sleeping giant was dormant in the late 1990s, dealing with temporary oversupply of nurses due to health sector restructuring. It is now projecting overall staffing growth in the healthcare sector of 3.1 million jobs by 2010.This includes the need to recruit over a million registered nurses to fill replacement and new jobs. It is waking up to the need to look internationally to meet this shortfall.

There is increasing pressure from US employers to reduce immigration constraints on foreign nurses.

When the US re-enters English-speaking nursing labour markets in a big way, the UK can expect to have to work harder in its own recruitment efforts in other countries, such as the Philippines.

It can also anticipate more recruiting missions from the US arriving at Heathrow. When this happens, we can have no complaints.We are playing a global game, and we will have to work hard to keep 'our'nurses.

Key points

Overseas nurses account for 40 per cent of all new registrations in the UK and this may be rising to 50 per cent.

This upward trend is likely to continue.

International recruitment is to be part of the NHS's long-term strategy and is becoming the focus of increasing policy attention.

The international labour market will become tighter: the US needs to recruit an extra million nurses of its own.

James Buchan is professor of health employment research, Queen Margaret University College, Edinburgh.

REFERENCES

1.Buchan J. Global nursing shortages. Br Med J 2002; 321: 751-752.

2 Buchan J. International recruitment of nurses: UK case study. Royal College of Nursing, London, 2002.

3Department of Health. HR directors' bulletin, special issue. Budget 2002. DoH, 2002.

4International Council of Nurses. Position statement on ethical nurse recruitment.

ICN, Geneva 2002. Available at www. icn. ch 5War on foreign nurse abuse (editorial). Nursing Times 2002; 98 (18): 11.

6Department of Health.

Code of practice for NHS employers involved in international recruitment of healthcare professionals.

DoH, 2001.