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The foreign backbone of the NHS

The foreign backbone of the NHS

Parts of the NHS are now “wholly reliant” on doctors and nurses trained outside the UK

What are the numbers?

The vast majority (some 90%) of the 1.4 million NHS employees are British, but foreign-trained doctors and nurses make up 15-25% of its clinical staff. In fact, of the 267,150 doctors in the NHS and private sector combined, nearly 100,000 (37%) were trained abroad. For nurses, the proportion is lower: 20% of those newly registered in the UK last year were foreign. Still, there’s no doubt where hospital and ambulance trusts are now recruiting: a Guardian investigation found 32 NHS trusts urgently seeking staff everywhere from Poland to the Philippines, China to Sudan. “There’s a fairly major shortage of homegrown nurses,” says Dr Keith McNeil, chief executive of Cambridge’s Addenbrooke’s Hospital. “Every week we are right down to the wire in terms of finding nurses to fill the rotas.”

Hasn’t there always been such a shortfall?

Yes. Since the founding of the NHS in 1948, Britain has had to recruit from abroad to make up for the shortage of native doctors and nurses. In the NHS’s first decade, England’s healthcare workforce increased by 30%, Scotland’s by 50%; as early as 1949 there were adverts in the Barbados Beacon for hospital auxiliary staff, nurses and trainees. In 1963, Tory health minister Enoch Powell, later a fierce opponent of immigration, led a recruitment drive to hire 18,000 doctors from India and Pakistan alone. By 1971, 31% of NHS doctors in England were qualified overseas, a proportion which – unlike that for nurses – has stayed more or less stable. (In 2004, 44% of new nurses registered in the UK were foreign, last year just 22%.) But for several reasons, the need to recruit yet more foreign nurses and doctors is likely to grow.

What are those reasons?

One is that, despite all the anxiety and political rows over NHS funding, the health service is actually in the middle of a vast recruitment drive. That’s partly because, in the aftermath of the Mid-Staffordshire hospital scandal, new minimum staffing levels have been introduced requiring 8,000 new nurses to be hired. But it’s mainly because of the need to cater for an ageing population with increasingly complex health conditions: the clinically trained NHS workforce has grown by 16% since 2003. Yet with funding for British trainee nurses drying up in the recession – student places dipped by about 13% between 2010 and 2012 – hospitals have had no choice but to look abroad. This year, NHS trusts in England are expected to spend around £1bn on temporary and agency staff (up from £327m in 2012-13), much of this in areas that are increasingly hard to fill with British-trained staff.

Why are they so hard to fill?

A 2014 survey of NHS staff shortages found “desirability of area” a key problem in finding nurses for the elderly. Caring for the old, the mentally ill and those with chronic, complex conditions has always been a low-paid, highly stressful job, but the difference now is that the demand for such jobs is so much greater. The Royal College of Nursing forecasts a fall of 100,000 nurses by 2022; the King’s Fund warns that Britain will need hundreds of thousands of new social care workers to care for its ageing population.

Is the same true of British doctors?

Yes. They, too, tend to shun the less glamorous ranks of the profession, with the result that geriatricians, psychiatrists, radiologists and, crucially, GPs, now face overwhelming workloads. A BBC survey has found that 56% of GPs plan to retire before they reach 60, leaving parts of the UK, notably poor urban and isolated rural areas, dangerously short of local doctors. Others are leaving the country altogether. Since 2012, about 4,700 doctors a year have applied to the General Medical Council (GMC) for a Certificate of Good Standing, allowing them to practise abroad – far more than the intake (about 2,957 last year) of foreign doctors being registered in the UK. Popular destinations are the US, Canada, Australia and the Gulf states. They go for the same reason that East European and Indian doctors come here (see box): better pay and quality of life. Within a few months, a British GP in Australia can expect to earn around £150,000 a year compared to £82,000 in the UK.

Isn’t there anyway a risk of relying on foreign doctors?

Academics have identified a “performance gap” between them and doctors trained here and have urged the GMC to raise the pass rate for the Plab test (which determines if foreign doctors are sufficiently skilled to work in the UK). Foreign doctors are also over-represented in patient complaints, and medical malpractice suits. But it’s a vexed area. Making the Plab test harder would have severe knock-on effects on NHS recruitment, and also re-open debates about discrimination in the medical profession. Medical staff from minority backgrounds are still badly under-represented in the top echelons of the NHS. In London, some 41% of NHS staff are from minority backgrounds, yet all chief executives, and 97.5% of chairs, are white. NHS patients have a quite different set of preferences. A 2005 survey found that most prefer their doctor to be young, Asian and female.

The care drain

The ageing populations of rich countries like Britain and the US have turned their health services into a magnet for doctors and nurses educated and trained in poorer parts of the world. “Every day, for six years, three doctors and two nurses have left Hungary,” János Belteczki, head of the Hungarian Doctors’ Association told The Guardian recently. “The salaries are ten times higher in Sweden, Norway, Germany, the UK, wherever.” Hungarian doctors are paid around €500 a month. Two out of three of Hungary’s medical students left to work in western Europe in 2011.

But it is not all bad news for the poorer nations. In India, which has supplied about 25,000 of Britain’s foreign doctors, many return, bringing new experience and training with new medical technologies. The emigration of Filipino nurses – estimated at 150,000, or 85% of the country’s nursing workforce – sends back billions of dollars every year to the economy (they are its single-largest source of remittances), while studies of Tongan and Samoan nurses in Australia show that the money they send home more than pays for the education and training they received before they left.

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