George Gillett: The NHS and immigration

Last February, the UK Home Office announced changes to immigration rules that would mean non-EU nurses would not have their visa applications prioritised. The decision not to add nursing to the list of “shortage occupations” reflects the government’s belief that nursing posts can be filled without international recruitment, but has received criticism from the Royal College of Nursing and a number of NHS managers. Clinical directors went as far as branding the move a “complete disaster,” while NHS Employers wrote to the Home Office to protest their decision earlier this month.

The NHS has long benefitted from immigration to maintain its 1.6 million strong workforce. Indeed, politicians and media commentators often use the UK’s healthcare system to exemplify the merits of international migration. May’s General Election debates saw Natalie Bennett, leader of the Green Party, praise immigration for the fact that “one in four [NHS] doctors is foreign born,” while Guardian commentators laud an “NHS built with the help of foreign workers.” Others suggest the latest immigration reforms will “starve the NHS” of staff.

The unequivocal contribution foreign migrants have made to the NHS is one which patients continue to benefit from. But while showing gratitude to healthcare staff trained overseas, policy-makers should also be mindful of the ethical questions that such wide-ranging migration poses.

It costs the NHS over £485,000 to train a GP, £726,000 to train a consultant and £79,000 to train a nurse. When non-EU healthcare workers are recruited by the UK these costs are outsourced, making significant savings for the UK health service. Yet these cost-effective recruitment decisions rest on a worrying power dynamic; many of these professionals come from some of the world’s least economically developed countries.

The flux of healthcare workers from poorer to wealthier countries is nothing new. A World Health Organisation (WHO) study found that over 53% of medical graduates from Indian universities had emigrated from the country, while thousands of nurses have left Zimbabwe and the Philippines to work in more economically developed countries. Unsurprisingly, this leads to substantial financial loss for these countries, with estimates suggesting that African nations spend over $4 billion each year replacing professionals lost through migration. A case study from Ghana concluded that the country loses more in health worker emigration than it receives in medical aid.

Most concerning is the UK’s role in this global inequity. Statistics from a 2014 General Medical Council report revealed that the main suppliers of the UK’s non-EU doctors were Pakistan, India, Egypt, Nigeria, Sudan and South Sudan. All of these countries are deemed by the WHO to have a “critical” shortage of doctors, nurses, and midwives, with the exception of India which fell into that category as recently as 2009. Today, India lies above the WHO’s boundary by a margin of only two healthcare workers per 10,000 people.

Healthcare professionals have become a globally-circulated commodity, with the NHS relying on an international market to outsource the training of its staff to some of the world’s poorest countries. No formal compensation is provided for lost healthcare workers, nor are UK medical students actively encouraged to consider careers abroad.

Many of these concerns have been raised previously. In 2002, The BMJ published an editorial describing a global “brain drain” of medical professionals. Two years later, the issue was discussed at the World Health Assembly and the UK Department of Health followed by publishing a Code of Practice for the international recruitment of health professionals in 2004. It stated that the NHS should not target developing countries for the recruitment of healthcare workers. The advice however, was not legally binding and has received criticism for being “ineffective” in confronting the inequities of health worker migration. Currently the UK is the second largest destination country for foreign-trained doctors, behind the United States.

Although the profile of immigration as a political issue has grown, interest in the ethical consequences of health worker migration has waned. The debate has shifted away from the acknowledgement that the UK is a beneficiary to the idea that the UK is being “swamped” by migrants. Indeed, the fabricated threat of “health tourism” earlier this year attracted far more attention than the thousands of workers arriving in the UK to treat patients.

While the Home Office’s changes to immigration rules might be characterised as a misplaced attempt to placate public concerns about immigration, the policy can also be framed as a serious challenge to a long-overlooked global inequity. The government’s rationale of “taking the long term decision to train the workforce at home” is in many ways the approach that the WHO has been advocating for the past ten years.

Of course, there are aspects of these new rules that are less forgivable. The decision to deport non-EU nurses earning less than £35,000 a year seems unnecessarily malicious and is perhaps indefensible. The changes will also require sufficient investment to train adequate numbers of nurses, midwives, and doctors in UK institutions. There are doubts as to whether this is happening – a review by the Royal College of Nursing revealed that the proportion of international nurses joining the UK register had doubled in the last six years.

Despite these challenges, recent predictions that the global health worker shortage is to reach 12.9 million by 2035 add to an urgent need for action on the issue. However uncomfortable NHS managers may feel about the financial constraints they face, the Home Office’s decision to take responsibility for the training of healthcare workers is far from the “disaster” it has been labelled. Rather, the real challenge is to ensure that the government adequately invests in a more ethical approach to the training of its healthcare staff.