The UK is reliant on overseas nurses more than ever, andmany arrive from countries which have shortages of their own, contravening DoH advice. James Buchan reports

It is 10 months since the Department of Health in England published its guidance on international recruitment of nurses.Since then, there has been no sign of any slackening in the level of international recruitment activity, and China is just the latest in a series of countries in recruiters' sights.

Earlier this year David Amos, head of NHS recruitment, visited the country with representatives from Barts and the London, Hammersmith Hospitals, University Hospital Birmingham and Walsgrave Hospitals trusts.

The latest statistics from the UK Central Council for Nursing, Midwifery and Health Visiting, published in June, highlighted further growth in the number of overseas nurses joining the UK register.

1Can this trend continue, and is the UK in danger of becoming over-reliant on international recruitment?

Any nurse wishing to work in the UK has to be registered with the UKCC. Its latest data was released with the headline: 'The number of overseas-trained nurses and midwives coming to the UK to work has risen dramatically to record levels.' It reported an increase of 48 per cent on the number registered from abroad in the previous 12 months.

A total of 7,361 nurses and midwives were registered from abroad in the year up to 31 March,2000.

The five major source countries reported by the UKCC were South Africa, Australia, the Philippines, New Zealand and the West Indies. This is a change in pattern from previous years, with South Africa, the Philippines and the West Indies increasing in numerical importance.

Table 1 gives the trend figures for initial registration of overseas nurses and midwives. It is clear from the data in the table that EU countries have not grown in importance as a source of nursing recruits over the last three years. In that time all of the growth in registration activity by international nurses has been accounted for by applicants from non-EU countries.

One key factor in the international mobility of nurses and other health professionals is the capacity to communicate with patients, clients and other health workers in the host country. The trends picked out in the UKCC data reinforce this point. It is the English-speaking countries that have been the growth areas for recruitment.

The UKCC data covers the period up to, and four months beyond, the release of the DoH guidelines, so it is too early for a complete assessment of the effect the guidelines may have on patterns of inward recruitment. But it is evident that the trend is in the opposite direction to that set out by the DoH.

Its guidelines were prompted by concern about overrecruitment of nurses in some countries, such as South Africa and the West Indies. This had been voiced by the South African government, among others, and was noted in the House of Commons health committee report on the NHS workforce, published in 1999.While the department guidelines were not a directive, the message to trusts was to look at Europe as a source for new recruits, and to avoid draining developing countries of their relatively scarce nursing skills. The department stressed in the guidance: 'It is essential that all NHS employers ensure that they do not actively recruit from developing countries who are experiencing nursing shortages of their own.'

This statement was qualified only in regard to temporary recruitment relating to training and development of nurses, or unsolicited applications from non-UK nurses.

This commitment was restated in the NHS plan, published last month, which says: 'The NHS will not actively recruit from developing countries in order not to undermine their efforts to provide local healthcare.'

The latest UKCC data gives no sign that Europe has grown in importance as a source of nursing recruits over the period up to March 2000.Over the last three years there was no growth in recruitment from the countries of the EU, while recruitment of nurses from non-EU sources has doubled.

Furthermore, South Africa and the West Indies were growing in importance compared to 1998-99, just as NHS employers were being warned off recruiting in these countries. It can be argued that the DoH guidelines were prompted by the growth in recruitment from these countries which is captured retrospectively in the UKCC data. Next year's data (covering March 2000-01) will give a better measure of any changes in recruitment behaviour by trust and other employers of nurses.

The other issue which has to be factored into the UKCC analysis is that it records when a nurse is entered on the register, not when (or if) they arrive in the UK, or begin work. This may lead to some distortion. For example, many of the Filipino nurses recorded as having entered the register in 1999-2000 may have entered the UK earlier, and have been working as auxiliaries (paid or unpaid) during a period of adaptation required by the UKCC before being accepted on its register. The UKCC notes that only 35 per cent of non-EU applicants were accepted on their first application; many were rejected or were required to undertake a period of adaptation in the UK, to upgrade their skills.

The reason for the growth in international recruitment of nurses to the UK is our own home-grown shortages. A reduction in the number of nurses being educated in the UK in the 1990s has led to a numerical and skills deficit in the UK nursing workforce.

NHS trusts and other employers have looked abroad to fill vacant posts.

Research published earlier this year in HSJ revealed that some parts of the NHS would be hard-pushed to function without the contribution of internationally recruited nurses.

3While trusts throughout the UK have been active in recruiting nurses and other health workers from abroad, south-east England has been the major destination. Analysis of postcode data of the registered location of non-UK-trained nurses based here suggests that, on average, they comprised 3.5 per cent of nuses in England. In inner London the same figure was 31 per cent - almost one in three of all nurses in the capital.

Should we be concerned about this level of reliance on these overseas recruits? Certainly we should be worried about the impact on their home countries if it leads to a brain drain. We also need to recognise that the level of inflow of internationally recruited nurses may appear high, but many will stay at most for two years in the UK.

They are on Commonwealth working visas, which limits their stay, or they regard the UK only as a temporary base.

To a large extent, this type of international recruitment activity is a short-term solution. It will fill a vacancy for a year or two.But in the absence of other options it can become the only solution.

In purely economic terms it makes little sense in terms of cost-effectiveness for trusts and other employers to recruit nurses on short-term contracts from other countries. Recent growth in the number of UK nursing students, and reported success in improving the number of local nurse 'returners' to the NHS, will ease pressure on UK nursing labour markets, and would suggest that there could be a lessening of international recruitment activity in the next few years.

The pressure on UK nursing labour markets may ease as home-based solutions take effect, but it will not end. The UK nursing workforce is ageing, and there will be an increasing need, particularly from mid-decade onwards, to replace the many UK- based nurses, who will be reaching the age when they could retire.

4Pressure does not just come from labour market dynamics, it derives from political sources.

The same department that issued the guidelines on international recruitment is also committed in the NHS plan to an extra 20,000 nurses over the next four years. The plan acknowledges that this will require targeted international recruitment. The department is well aware that it is quicker, and cheaper, to recruit a trained nurse from abroad than to spend several tens of thousands of pounds and wait three years for the home-grown version to count towards the target.

Short-term recruitment targets have to be met, and longer-term projections suggest a continued need for creativity in nursing recruitment policy and practice to meet the challenges of changing demographics. NHS recruitment managers would be wise to keep their passports up to date.


1 Overseas trained nurses and midwives coming to the UK at record levels. UKCC press release 117/ 2000; 14 June 2000.

2 Guidance on International Nursing Recruitment. Department of Health. London, 1999.

3 Buchan J.'Abroad Minded'.HSJ, 6 January, 2000.

4 Buchan J, Seccombe I, Smith I.Nurses Work.An Analysis of the UK Nursing Labour Market.Aldershot: Ashgate Press, 1998.

Key points The number of overseas nurses coming to the UK has risen 48 per cent in 12 months.

The bulk of the increase has come from non-EU countries such as South Africa, Australia, the Philippines, New Zealand and the West Indies.

This trend flies in the face of Department of Health guidance that urged trusts not to recruit from developing countries which were experiencing shortages of their own.

Overseas nurses now account for almost one third of those working in inner London and 3.5 per cent of the nursing workforce in England.

Professor James Buchan is based at the faculty of social sciences and healthcare, Queen Margaret University College, Edinburgh.