Published: 05/05/2005, Volume II5, No. 5954 Page 12 13

The NHS relies on thousands of immigrant workers who staff it at all levels. But, asks Daloni Carlisle, where were their supporters during the election campaign?

West Middlesex University Hospital in south-west London is a fairly typical district general hospital. And a fairly typical scene greets any visitor - a workforce so multi-ethnic they could stage a mini UN meeting.

There are nurses, doctors and midwives from Africa, Nepal, India, the Philippines, Hungary, China, Macedonia and Poland. The domestic workers and cleaners come in all shapes, sizes and shades of skin.

'We are totally dependent on immigration for nurses and to some extent for doctors, ' says accident and emergency consultant Mike Beckett.

Sybil Corbin, senior nurse for practice development and in charge of making sure newly arrived overseas nurses are looked after, agrees. 'It is not just the nurses, ' she says. 'It is the domestics, the cleaners, the healthcare assistants too.' None of which sits easily with the election debate on race and immigration. In public all the talk was of quotas and keeping our borders secure; of immigrants putting intolerable strains on public services; of employers who take on overseas staff paying a bond, returnable when the worker goes home.

State of collapse

In practice, say the Royal College of Nursing, Unison and the British Medical Association, the NHS would collapse without its immigrant workers.

In 2003, over half of new registrations with the General Medical Council were by doctors who trained overseas.

Since 1998 the number of nurses registered in the UK has risen steadily, matching the growth in the overall workforce - in other words, without immigration there would have been no increase in the number of practising nurses.

These days, four in 10 nurses registered in the UK were trained overseas. 'International recruitment is very significant and will remain so, ' says Professor James Buchan of Queen Margaret University College in Edinburgh, a long-term commentator on nurse recruitment issues.

Last month's labour market review - an annual exercise he carries out for the RCN - showed a slight slowing, with a drop in international recruitment.

Pressure to recruit

Professor Buchan explains: 'The Department of Health has exceeded its own targets for staff growth so the pressure to recruit abroad is off.' But with an ageing population and an ageing workforce, even the increased home-grown workforce now working its way through college will not fill the gap.

The NHS in London may have the highest number of immigrants in its workforce - up to 50 per cent of nurses in some London trusts were qualified overseas, says Professor Buchan, while the RCN cites hospitals employing people of 60 nationalities. But the capital's use of immigrant works is by no means unique to the NHS.

The election debate left many in the NHS scratching their heads. They point out that most of the overseas nurses and doctors were actively recruited under DoH initiatives set up to help meet staffing targets.

The debate was also in direct conflict with other policy initiatives in the NHS. Equality and diversity, for example, is an Improving Working Lives project requiring trusts to make sure their staff's ethnic profile reflects that of their local population.

Not to mention NHS chief executive Sir Nigel Crisp's 10-point race equality plan.

Yet not one of the major political parties chose to pay fullsome tribute to the immigrants in the health service as they thrashed out their various positions.

Prime minister Tony Blair managed a one-line tribute to the efforts of migrant workers in supporting the NHS in his keynote campaign speeech on immigration.

But by and large, inconvenient facts have been removed from the political debate.

Meanwhile, opinion polls from Mori showed that immigration was high on the electorate's list of concerns while YOUGOV found wide agreement that 'new arrivals' put pressure on public services.

It has all left rather an unpleasant taste in the mouth of many in the NHS.

Huge reservoir of skills

Dr Beckett is all in favour of making better use of the immigrant doctors now looking for work in the UK and unable to find a way into the health service. 'There is a huge reservoir of people and skills being wasted. Used properly they could solve our medical staffing shortages, ' he says.

'I think immigration reinvigorates a society.' 'It is difficult to say 'close the doors, '' adds Ms Corbin. 'Who is going to do the work?' For policy observers like British Medical Association international committee chair Dr Ed Borman, the current debate is disappointing and lacking in sophistication.

Profoundly disappointed

'I am profoundly disappointed that the rhetoric from all the parties is so anti-refugee when we have got experience of the very positive contribution that they can make, ' he says, referring to the BMA's refugee doctor programme, funded by the last Labour government.

The crucial missing element for him is the complete lack of discussion over the affect of the UK's import of thousands of nurses from overseas. Many countries in subSaharan Africa face an overwhelming crisis in their health services, partly because their doctors, nurses and midwives are migrating.

He points out: 'The NHS has depended on nurses and doctors coming from abroad ever since its inception, but in recent years it has become more political as people have begun to realise the potential damage that migration of skilled professionals can do to the country of origin.' For example, Ghana has lost half its qualified medical and nursing staff to developed countries since 1998. In Malawi, some districts are without a doctor or midwife at all.

Despite the DoH having strengthened its code on ethical recruitment from developing countries, last year 4,000 nurses arrived from 'proscribed' nations - those with such a shortage of staff that the DoH has banned active recruitment.

'We do not believe that represents 4,000 individuals making their own way here, ' says Howard Catton, head of policy for the RCN. 'We believe it is evidence of recruitment by agencies.' Jane Gilbert, a clinical psychologist specialising in international mental health issues, describes her visit to a psychiatric hospital in Accra, Ghana, just after a London trust had recruited 40 of its most senior nurses.

Over 220 had applied for the jobs.

'They were very ambivalent, ' she says, 'On the one hand they saw the gaps in the service left by the staff. On the other, they felt left behind.'

Quantifying the impact

Earlier this year, the charity Medact tried to quantify the impact on Ghana where the health service is in a state of near collapse as its nurses and doctors migrate en masse.

Working on the basis that there are 293 Ghanaian-trained doctors in the UK and 1,021 nurses, Medact estimated that Ghana has lost£35m of training investment since 1998 while the UK has saved£65m. The nurses and doctors here deliver services valued at£39m a year.

'There is a huge perverse subsidy going on, ' says Medact's policy adviser, Mike Rowson.

Medact and its partner in the research, Save the Children, would like to see the UK government pay compensation to Ghana.

He realises that the argument is fraught with difficulties but says: 'As health systems become more integrated we have to take account of our ethical responsibilities.' .


Your country's borders protected Labour Party Manifesto.

Labour proposed to control immigration, admitting only skilled workers who can speak English. Accused the Tories of 'scurrilous, right wing, ugly tactics' in their use of immigration in the election debate.

Controlled immigration Conservative Party Manifesto.

Tory leader Michael Howard declared that immigration was 'out of control' and accused prime minister Tony Blair of 'pussy-footing around'. He warned of riots if immigration continues at current rates, and proposed quotas, health checks on immigrants and out-ofcountry processing of visas.

Create confidence in the immigration system Liberal Democrat Manifesto.

The Lib Dems said Britain benefits from being a multi-ethnic, multi-racial society. The party's manifesto proposed setting quotas for immigration based on our economic needs.

Commission for Racial Equality chair Trevor Philips called for calmer words: ' I am concerned that the current debate is actually leading to increased tensions across and between communities. Political leaders and political parties have a responsibility to ensure that loose words in the campaign fray do not ignite tensions and conflicts.' Unison secretary general Dave Prentis paid tribute to NHS workers from overseas.

He told the Scottish Trade Union Congress of his pride at the immigrant workers, 'who have played a massive part in providing services in our hospitals and home help services; services would collapse without their help'.