the big story

Published: 15/07/2004, Volume II4, No. 5914 Page 8 9

While poaching healthcare staff from developing countries has become something of a taboo, consensus has yet to form around grittier issues such as compensation and the rights of the individual to work in a global market, as Daloni Carlisle explains

'It was really quite bizarre. At one end of the embassy was the Department of Health team recruiting nurses and doctors. At the other was the Department for International Development team advising the host country's government on how to retain health staff. Ultimately we were all working for the same boss - the British government.'

The person making this observation prefers not to be named in print ('International recruitment of doctors and nurses is a very sensitive issue, ' she says), but she sums up the unease that accompanies the UK's attempts to ratchet up staff numbers by recruiting from overseas.

'We are seen internationally as the bad guy draining healthcare workers from developing countries, ' says James Buchan, professor of health employment research at Queen Margaret University College in Edinburgh. Professor Buchan recently published research commissioned by DfID looking at the scale and nature of international recruitment.

Despite a code of conduct governing ethical recruitment in the NHS in England (see box), the UK remains the world's biggest importer of healthcare professionals from the developing world.

The DoH code of conduct says the NHS may recruit only from countries where there is a government-to-government agreement, and sets out a list of 152 countries from which active recruitment is banned. Yet in 2003 one in four new nurse registrations was from countries on that list.

Professor Buchan is at pains to point out that there is no evidence that the NHS is actually breaking the code, but the code only prohibits 'active recruitment' - meaning trusts can employ migrants who are seeking work or poach staff from overseas who register with private agencies.

He also points out that the code only applies in England.

The number of overseas doctors registering with the General Medical Council has risen steadily since 1993, with the major suppliers being India, South Africa, Pakistan, Egypt and Nigeria. Out of 50,898 new full GMC registrations in 2003, 32,118 were doctors from developing nations.

Officially, international recruitment makes only a small contribution to overall NHS recruitment.

But Professor Buchan has been able to demonstrate that the increase in nurse numbers by 10,000 since 1998 is the same as the number of arrivals from overseas. He says: 'The impact of international recruitment should not be underestimated.'

The arguments against recruiting from developing countries are fairly straightforward. UK staffing problems are as nothing to those of, say, Malawi, where there are entire districts with no doctors at all because of migration and the effects of HIV/AIDS.

Most medical training is publicly funded. 'There is an argument that says It is reverse aid when health professionals whose training was paid for by the public purse in developing countries come here to work, ' says executive director of charity Medact, Mike Rowson.

Professor Buchan talks about qualified nurses from Ghana who end up as healthcare assistants here. 'Ghana has lost a nurse and we have not gained one. That is the worst lose-lose situation.'

The opposition to international recruitment from developing nations is growing. In May, the World Health Assembly (the annual meeting of the World Health Organisation member states) passed a resolution condemning recruitment from developing countries and calling for strategies to minimise its harmful effects.

The Royal College of Nursing and British Medical Association joined in the chorus at their summer annual conferences.

The RCN pointed out that since the government keeps no figures on the number of overseas nurses working in the NHS there is no way to audit compliance with its own code.

Meanwhile, BMA chair James Johnson called it 'a shameful record of exploitation'.

The DoH is also uneasy - at the very least. In May it called a seminar jointly with the Foreign and Commonwealth Office to discuss Professor Buchan's findings.

Event chair and DoH head of international affairs Nick Boyd defended international employment as a 'legitimate aim' for the health service seeking to increase capacity. But the mood very clearly was one of concern, with several calls for a strengthening of the code.

Few in the health service are willing to talk openly about international recruitment. Like the British embassy worker they say It is 'very sensitive'. Two trusts approached by HSJ said they had stopped it because of the ethical problems. Another claimed never to have had an active overseas recruitment programme - and all were in London with markedly multiethnic workforces. Four others plus three workforce development confederations said they worked strictly within the DoH code of conduct but they did not want to be quoted.

The independent sector - which most often stands accused of unethical international recruitment - is quicker to defend itself.

'There is been economic migration for thousands of years, ' says Westminster Healthcare Group human resources director Peter Buckle.Without overseas workers, and this includes non-professionals such as housekeeping staff, Westminster Healthcare would have to close 1,000 of its 6,000 beds. 'And where would NHS waiting lists be then?' he asks.

The Independent Healthcare Association (now Forum) drew up a code in 2001 which says members will be 'sensitive' to the human resources situation in countries where they recruit. Observers say this is not good enough and the sector as a whole has been under intense pressure from ministers to sign up to the DoH code of conduct. It has so far resisted doing so.

'For one thing I jut do not see how it could be audited in the independent sector, ' says Mr Buckle. 'I also think the NHS operates double standards. They are not allowed to recruit from South Africa, but that doesn't stop them poaching my South African staff.

There really is not a high degree of audit and compliance.'

He sees the employment of healthcare workers as a global market. 'If I am a citizen of the Philippines, do I have a right to practise my profession wherever on the globe I choose to go?'

Professor David Sallah, a Ghanaian-born, British-trained nurse who is now director of research at Wolverhampton University's school of health, agrees wholeheartedly: 'If you decide people from developing countries should not have a chance to go to other countries to further their career, then you are developing a kind of apartheid system where one part of the world can move freely and another cannot.'

Mr Rowson, however, feels that it is time the developed world paid for the staff it is taking out of developing countries. He would like to see financial compensation for health systems losing their workers as well as firmer partnerships to make sure there is some sort of exchange and return of staff.

The DoH is against the idea of financial compensation. 'It is not a simple issue, ' says a spokeswoman. 'Most people view it as a developed country compensating a developing country.

'This is not always the case. It could be developing country to developing country - for example, South Africa to Botswana - or it could be developed country to developed country.

'Arguments against mandatory 'compensation' include the difficulty of distinguishing between active recruitment and the workers' own choice to move; questions of parity with practice in respect of other workers; and the extent to which 'push factors' in the country of origin may have contributed to the decision to move.'

Mr Rowson acknowledges all these points: 'We are currently working out what compensation could look like, ' he says.

Professor Buchan also believes the code needs strengthening. The DoH must start recording the number of overseas nurses in the NHS in order to carry out an effective audit, he says. It also needs to examine the 'nuances' whereby healthcare staff recruited by the private sector end up in the NHS.

He would like to see more managed interventions - for example, partnerships between hospitals and universities, where staff can be exchanged or seconded back and forth.

So would Vikram Patel, an Indian who trained as a psychiatrist in the UK. He works in Goa now, but has found the only way to take his skills back home is by using charity money.

He calls international recruitment from developing countries the great brain robbery. 'India has fewer than 3,000 psychiatrists for its 1 billion population compared with one psychiatrist for every 9,000 people in the UK, ' he claims.

'Despite this inequality, the NHS has launched an International Fellowship Scheme that will worsen the brain drain and inequalities in global health unless it is explicitly linked with measures to enable the flow of doctors back to developing countries.' l The NHS has always recruited from overseas.Even Enoch Powell, as a health minister in the 1960s, oversaw international recruitment campaigns.

The latest drive began with the July 2000 NHS plan, which pledged 20,000 extra nurses by 2004.An immediate recruitment drive overseas led to international outcry, with the World Health Organisation accusing the UK government of 'fuelling an international nursing shortage'.

The Department of Health responded in 2001 with its code of conduct, designed to prevent active recruitment in countries with their own shortages. In 2003 this was backed with a list of countries where active recruitment was banned.

In addition to locally organised recruitment efforts, the DoH has a number of projects:

The Global Scheme has recruited 87 consultants to full-time posts;

International GP Recruitment has recruited 199 family doctors.

The International Fellowship Scheme has recruited 232 candidates to take up two-year consultant posts, with more coming on-stream in August 2004.

Casting the net wide: how the DoH recruits

Proscribed countries list: www. dh. gov. uk/assetRoot/04/03/46/ 79/04034679. pdf

Code of practice: www. dh. gov. uk/assetRoot/04/03/46/ 51/04034651. pdf