To overcome the shortage of physiotherapists, the UK is increasingly reliant on recruiting from overseas. But can it be done ethically? James Buchan reports

International recruitment has been highlighted in the NHS plan as a way of expanding the number of NHS health professionals. One profession targeted for growth is physiotherapy, but what part can international recruitment best play in helping meet the employment growth targets?

1 The NHS in Great Britain employs about 14,000 whole-time equivalent physiotherapists and physiotherapy managers.

While there has been significant increase in supply, in terms of the numbers of physiotherapists employed in the NHS in recent years, there have been continued reports of staff shortages, pointing to an even more rapid growth in demand for physiotherapy services. The NHS staff vacancy survey conducted by the Department of Health in 1999 reported that vacancies in physiotherapy were higher than for any other group covered in the survey, other than operating department personnel.

2 More than half of the trusts participating in the survey reported difficulties in recruiting physiotherapists.

While the physiotherapy workforce is small compared with some other NHS professions, such as nursing and medicine, it plays a crucial role in many aspects of NHS delivery. Its very smallness can make it particularly sensitive to staff shortages, as many physiotherapy specialists work alone or as part of small teams.

The NHS plan has reinforced the need to increase staffing levels in therapy services. There are four policy options for meeting the plan's staffing targets: improving staff retention, increasing new entrants from physiotherapy education in the UK, increasing re-entry into physiotherapy employment of returners, and recruiting from other countries.

The number of UK physiotherapy students has been on the increase in recent years. In the period from 1995 to 1999 the Chartered Society of Physiotherapy recorded growth of 39 per cent in the annual number of qualifying students, up from 1,024 to 1,420. The NHS plan projects further growth, but this may depend on increasing the availability of funded clinical placements.

The second source of inflow is returners. Greater emphasis is now being placed on active support and flexibility in supporting managed career breaks for NHS staff. Surveys of potential returners to physiotherapy and to other health professions have highlighted the importance of providing more part-time work, refresher courses, better pay and more patient contact.

The third source of new recruits is physiotherapists from non-UK sources. The plan explicitly states that international recruitment of health professionals will be part of the solution, in the short term at least. How many physiotherapists currently are being recruited internationally and how important are they to the UK in overall terms?

Most physiotherapists entering the UK (including all those working in the NHS) will be required to join the register of the professional body, the Council for the Professions Supplementary to Medicine. Data from the CPSM register therefore gives some indication of inflow of physiotherapists to the UK. Physiotherapists moving to the UK and registering will not necessarily take up employment in physiotherapy, but the data gives a best guess of the numbers coming to the UK to work.

The CPSM data (figure 1) indicates that in recent years, on average, approximately one in three new UK registrants has been non-UK trained. In 1999, 29 per cent of new registrants on the CPSM register had trained abroad. This is similar to the proportion of non-UK nurses (28 per cent) entering the UK nurses' professional register in 1998-99. In 1999 the DoH published guidance on good practice in international recruitment of nurses.

Where have these physiotherapists come from?

Figure 2 shows the main countries of training of non-UK trained registrants entering the CPSM register in 1999. Australia, South Africa and New Zealand were the three main source countries.

Australia alone accounted for 44 per cent of all nonUK educated new registrants. Countries of the EU do not currently represent a major source of non-UK educated physiotherapists.

Where do internationally recruited physiotherapists work in the UK? There is little hard data, but many non-UK physiotherapists appear to be working as locum staff. This was reportedly the case with many physiotherapists working in the UK on a working holiday, particularly from Australia and New Zealand. A survey of UK locum physiotherapists conducted by the CSP revealed that nearly half had previously been working outside the UK. One in three were visitors to the UK on a working visa, and a further 13 per cent were non-UK citizens. Three-quarters of those who were not from the UK reported that they planned to stay in the UK for two years or less.

The survey also found that many non-UK physiotherapists prefer to work as locums because they have more control over their hours of work, and can earn higher pay.

The use of locum physiotherapists in the NHS has policy implications extending beyond the employment of international physiotherapists. The research found that while some locum physiotherapists were used as part of a planned approach to flexibility in trusts, others were being employed on what amounted to a long-term, quasipermanent basis because staff could not be recruited to fill permanent posts.

Something that attracted non-UK physiotherapists was the relative ease with which they could find comparatively well-paid temporary work in the UK, which gave them choice over location and duration of employment, and enabled them to combine periods of work with periods of travel.

How can trusts be effective in international recruitment activity? Four key issues that trusts and other employers have to consider in ensuring cost-effectiveness of international recruitment are: ensuring that the volume of recruitment justifies the fixed costs of recruiters' time and travel, by recruiting in batches of more than one profession, and perhaps in association with other trusts; contracting at realistic rates with the recruitment agency (if one is used); ensuring that the physiotherapists recruited are effective in their work; ensuring that the physiotherapists are retained to the end of their contract.

The third point highlights the need for any employer who is recruiting abroad, to ensure that physiotherapists receive proper induction and training on arrival. A well-planned induction programme is required both to ensure that the trust maximises the contribution made by international physiotherapists, and that they remain committed to the organisation.

In this respect, it is important that internationally recruited physiotherapists receive the same career opportunities and access to training as UK-trained staff.

Where should trusts focus their recruitment efforts? The NHS plan says that the DoH will work with the NHS professions to recruit more staff from abroad, where this meets service standards, but 'will not actively recruit from abroad from developing countries'. As noted above, it has already published guidelines warning trusts against recruiting nurses from some developing countries.

This points to Australasia, the US or Europe as the main 'ethical' recruitment targets. The EU has not been a major source in the past, partly because of variations in training content, partly because of language differences. The Netherlands and Scandinavia may offer some scope for recruitment, but from a small base. Australia and New Zealand probably offer the best short-term targets.

NHS policy changes could also impact on international labour market dynamics. If the NHS tries to reduce its reliance on locum physiotherapists, this could reduce the inflow of physiotherapists from some countries, such as Australia. Maintaining the inflow of 'backpacker' physiotherapists from Australasia would require the NHS to look at how it can improve the flexibility it offers its permanently employed staff.

A move to seven-day working for physiotherapy services, which is highlighted as part of NHS 'modernisation' plans, could increase the demand for physiotherapists by the NHS, and could alter working patterns in ways that would have an impact on the requirement for flexibility in hours worked by permanent and temporary staff.

Future levels of international recruitment activity of physiotherapists to the UK will be dependent partially on the degree of success in improving recruitment, retention and return of home-based physiotherapists.

But this is unlikely to be sufficient to meet short-term physiotherapy staffing growth targets. In the short term at least, the NHS will have to think globally - and hopefully act ethically - in trying to fill vacant posts.