Introduction
The United Kingdom is a large net importer of health professionals in the EU. As such, conditions in the British labour market have a disproportionate effect on rates of migration from other countries. It is also the Member State in which migration of health professionals has been studied in most detail.
This chapter examines the connections between the United Kingdom and other EU nursing labour markets, and places these in the broader context of international recruitment of nurses. Specific attention is given to the implica-tions of the accession states becoming part of a pan-Europe labour market for registered nurses.
The chapter has three main objectives:
•
to examine trends in inward recruitment of nurses to the United Kingdom;•
to assess, from a United Kingdom perspective, the impact of free mobility of registered nurses within the EU;•
to explore the implications of the accession states entering a single labour market for nurses.The United Kingdom nursing labour market
The key current feature of the United Kingdom nursing labour market is skill shortages. The United Kingdom Health Department in 2001 acknowledged that
“the biggest constraint on the NHS’s capacity to deliver was the need to increase the number of staff” (Department of Health 2001a). An official survey in 2001 (Office of Manpower Economics Annual Survey 2001) reported that 78% of NHS employers in England and Wales reported that they had “quite a problem” or a “major problem” in recruiting nurses and midwives, up from 69% in the previous year.
These shortages have occurred as a result of a combination of factors. Some are demographically driven, with increased demand for health care related to an ageing population. More patients are being treated, and patient care has become more “intense”, with higher dependency patients requiring more care in a shorter time period. Various supply-side factors, including increased competi-tion from the private sector for skilled nurses, and the ageing of the nursing profession, are also further exacerbating short- and mid-term recruitment difficulties (Buchan and Seccombe 2002).
Most nurses in paid employment in the United Kingdom work in the National Health Service (NHS). In total, there were about 400 000 registered nurses, mid-wives and health visitors employed by the NHS in the four countries of the United Kingdom in September 2000. Nurses are also employed in primary care, as practice nurses working with general practitioners; in private sector nursing and residential homes, independent hospitals and clinics; in independent hos-pices; with nursing agencies; and in other public sector services (prison service, defence medical service, higher education, police service, local authorities).
Table 10.1 shows the best estimates of the overall number of registered nurses in all types of nursing employment in the United Kingdom, which total approximately 518 670.
Since 1998 the implementation of NHS strategies for nursing and human resources, and NHS modernization plans (“The NHS Plan” (NHS Executive 2000)), have symbolized a fundamental policy shift in the NHS. It is recognized that achieving health gain targets depends, in part, on achieving plans to increase NHS nurse numbers throughout the United Kingdom.
Table 10.1 United Kingdom employment of registered nurses, midwives and health visitors, 2000
NHS nursing GP practice nursing
Nursing homes, independent hospitals and clinics
Other Total
England 256 280 10 710 54 830 n/a 321 280
Scotland 35 600 1 123 4 728 n/a 41 451
Wales 16 920 698 2 410 n/a 20 028
NI 11 500 100 1 425 n/a 13 025
Total (wte) 320 300 12 631 63 393 n/a 395 784
TOTAL (heads) 395 430 21 410 82 330 19 500* 518 670
* estimate
Note: non-NHS data for Northern Ireland is from 1999 Source: Buchan and Seccombe 2002
The NHS Plan targets for nurse staffing growth are based on four areas of intervention:
•
attracting more applicants to nurse education;•
encouraging “returners” to nursing employment;•
improving retention through improved career structures and flexible working practices;•
recruiting nurses from other countries.Government action is underway in the first three areas. All pre-registration nurse education in the United Kingdom is funded and provided in the public sector and the number of nursing and midwifery students has increased signifi-cantly in the last three years. Funding has also been allocated to attracting back
“returners” – qualified practitioners returning to paid nursing employment after a career break. There has been an increased emphasis on the provision of flexible working hours, action to reduce violence against staff, a commitment to increased funding for lifelong learning (Department of Health 1999b), and plans to introduce a new pay and career structure for nurses and other NHS staff.
The fourth area for intervention, the active recruitment of nurses from other countries, has become a significant element of British policy in recent years. The English Department of Health has been explicit that international recruitment will be part of the solution to meeting its staffing targets: “we shall build on our successes in recruiting staff, particularly nursing staff, from abroad to help us, in the short term at least to deliver the extra staff we need to deliver the NHS Plan”
(Department of Health 2001b).
It has set up “a network of international recruitment co-ordinators . . . to speed up the recruitment process” (Department of Health 2001c). This network connects with “NHS Professionals”, the nationwide temporary staffing organ-ization recently set up by the NHS in England. The United Kingdom Govern-ment has also initiated governGovern-ment to governGovern-ment “concordats” on nurse recruitment with other governments, such as those in Spain and the Philip-pines. The overall effect of these initiatives has been a significant growth in the numbers of nurses recruited from other countries to work in the United Kingdom. The next section will examine this trend in detail.
International recruitment of nurses to the United Kingdom A historical perspective
There has been a long tradition of United Kingdom recruitment of nurses from other countries. In the earlier part of the twentieth century this owed much to colonial policies and the attitude towards “empire” as a supplier of goods and services to the imperial centre.
During the inter-war period the Aliens Act of 1920 allowed United Kingdom hospitals to employ foreigners under certain restricted conditions. These included where:
•
the foreigner came from a country in which the hospital provision was poor and there was no opportunity for proper training;•
there was definite evidence that the hospital in Britain could not obtain Brit-ish applicants;•
such trainees returned to their native countries after completing training.Matrons had to submit applications to employ foreign nurses to the Ministry of Health, which would then decide whether or not to issue a permit. There was an entry quota of foreign nationals into nursing of 3% (Ministry of Health 1935).
There are few data on numbers of non-United Kingdom nurses working in the United Kingdom in the inter-war period. Census returns correlating occupation with nationality were only made erratically. In 1921, for example, there were 718 foreign-born nurses from 28 different countries, the majority coming from the USA (82 female nurses) and France (206 female nurses). The largest single category of male nurses was Italian.
By 1935 the Ministry of Labour in England was advocating a more restrictive policy on recruitment of foreigners as the shortage of British applicants for training began to wane. Permits for foreign probationers were to be limited to approximately 3% of total probationer posts and furthermore the foreigner was expected to return to her own country after completion of training (Ministry of Health 1935). The situation was to change with the war and the introduction of the NHS.
There was an upsurge in recruitment of nurses during and after the Second World War. One major source of recruits was Ireland. In 1947, the Wood Com-mittee, set up to consider the nursing needs of the new NHS estimated that some 15 000 (12%) of the total hospital nursing workforce had been born in Ireland; their distribution throughout various specialities was uneven. The recruitment of Irish nurses had intensified throughout the war: the Ministry of Labour had a recruitment liaison office staffed by technical nursing officers in Dublin. The numbers peaked in 1946 at 2561 female recruits, and fell to 80 in 1954 (Ministry of Health et al. 1947).
In contrast, recruitment of European foreign nationals for training steadily increased from 584 in 1946 to 2234 in 1957. Surprisingly perhaps, given the prevailing anti-German sentiment after the war, it was German nurses who constituted the largest single group of overseas workers during this period (Min-istry of Health et al. 1947). Volunteers were subject to conditions not imposed on home nationals. Those accepted could enter on a permit valid for only three years, register with the police and enter employment specified by the Ministry of Labour and National Service. They were not allowed to leave their employ-ment without the consent of the Ministry of Labour. This was the de facto direction of labour, which had operated during the war and was feared by some nurse leaders as the price of the introduction of the NHS (Dingwall et al. 1988).
Small numbers of nurses from former British colonies were also recruited after the war but their numbers only became significant in the 1960s. The origins of recruitment from former colonies is complex but derives in part from the early export of British-born nurses to far-flung corners of the empire from the late nineteenth century to provide care and subsequently training for so-called
“native” patients and nurses in government hospitals. Momentum in this pol-icy only began to develop with changes during the inter-war period in colonial development policy itself, with a noticeable shift towards enlightened
self-interest and reciprocal registration schemes for nurses throughout the British Commonwealth.
In 1957 the Ministry of Labour handed its recruitment and “placing” func-tions in nursing over to the Ministry of Health which then became responsible for statistics on nursing services, recruitment campaigns and matters related to publicity. The rise in recruitment from overseas resulted from what Thomas and Morton-Williams refer to as a “marriage of convenience” between the nursing shortage in the NHS and Commonwealth citizens keen to enter the United Kingdom to train as nurses (Beishon et al. 1995). By 1971 there were 15 000 overseas student nurses, of whom 40% were West Indian, 29% Asian and 27%
African (Beishon et al. 1995). Recruitment from non-Commonwealth sources had tended to rely upon nurses from Ireland, where a long tradition had built up of recruitment to mental health hospitals. In the early 1970s it has been suggested that overseas nurses represented some 10% of the NHS workforce (Beishon et al. 1995).
International nurse recruitment: The current situation
The previous section has highlighted how the United Kingdom has placed a heavy reliance on international recruitment of nurses at various times through the last century, primarily as a reaction to skills shortages. In recent years this reliance has been reaffirmed. This section assesses the current level of inflow of nurses to the United Kingdom.
There are two sources of data that can be used to assess trends in the inflow of nurses to the United Kingdom; work permits and the professional register. Nei-ther gives a complete picture, but in combination they enable an overview to be established.
One main source of data is applications for work permits. All non-United Kingdom applicants from countries outside the EU/European Economic Area (EU/EEA) who wish to take up employment in the United Kingdom are required to obtain a work permit. Work permit data can therefore be used as another source of information on trends in inflow of nurses from non-EU/EEA countries.
Work permit data are presented primarily in terms of numbers of new applica-tions and applicaapplica-tions for extension approved in calendar years. Because data on new applications and applications for extension are reported separately, there is some scope to use data to assess the numbers of non-EU nurses already working in the United Kingdom who wish to continue working after their initial permit has expired (usually a two year permit is granted). Some occupations and professions are designated as “shortage occupations”. These occupations have been acknowledged to be particularly difficult to fill, and their designation means that there is a simplified procedure for applicants, in order to “fast track”
the work permit application process. The designation of shortage occupations is under continuous review, but at the current time “all registered nurses and midwives” are listed as facing a shortage in the United Kingdom.
Table 10.2 shows the work permit data for 2001 for the job title “nurse” (see Box 10.1 for details). It shows the overall data, main countries of nationality of applicants and applicants from accession states. There were a total of 23 603
applications recorded, up to 17 December of the year, of which 12 762 (54%) were recorded as “work permit” – in other words over 12 700 new work permits were issued to individuals who had not previously been working as nurses in the United Kingdom.
These work permit data highlight the significant numbers of applications from non-EU countries, particularly the Philippines, South Africa and other British Commonwealth countries, with the Philippines alone accounting for nearly half (44%) of the overall total, the majority of which were new work permits (7422). In contrast, candidate countries accounted for only 289 applica-tions (or just over 1% of applicaapplica-tions), of which 141 were for new work permits.
The five main candidate countries from which applications were processed were Poland, Bulgaria, the Czech Republic, Romania and Slovakia. However, no single accession state accounted for 100 or more applications.
The other main source of data is the professional register of the United King-dom Central Council for Nursing Midwifery and Health Visiting (UKCC). These data can be used to assess trends in the number of applications and admissions from non-United Kingdom nurses. Individual judgements are made by the Table 10.2 Total numbers of work permits approved for nurses, UK, 2001, by category and selected country of nationality, including accession countries
Composition of total applications:
Philippines 10 050 210 1433 952 26 7422 7
India 2 612 105 646 92 9 1759 1
South Africa 2 514 149 669 490 33 1163 10
Zimbabwe 1 801 851 527 146 13 261 1
Nigeria 1 110 217 424 104 11 354 0
Australia 601 149 69 99 4 277 3
Poland 56 13 4 5 0 34 0
Source: Work Permits United Kingdom; provisional, up to 17 December 2001 only.
UKCC on each application, on the basis of the duration and type of training and previous work experience of the applicant. Because the UKCC deals differently with applications from EU and non-EU countries, it is possible to track the relative importance of these two sources.
Individuals with general first level nursing or midwifery qualifications from the other countries of the EU/European Economic Area (EU/EEA), have the right to practise in the United Kingdom because of mutual recognition of qualifica-tions across the countries of the EU/EEA (see Chapter 7). As such, they can register with the UKCC via the European Community Directives. All other nurses from non-EU/EEA countries have to apply to the UKCC for verification of their qualifications in order to be admitted to the Register. Most nurses from outside the EU will also have to apply for, and be granted, a work permit to take up paid employment in the United Kingdom.
There are limitations in using the data to monitor inflows to the United King-dom. Registration data only record the fact that a nurse has been registered, they do not show when a nurse actually enters the United Kingdom, nor do they indicate what the nurse is doing. As such, it is a measure of intent to practise in the United Kingdom, rather than necessarily an indicator that the nurse is actu-ally working in the United Kingdom. Figure 10.1 shows the trend in annual number of non-United Kingdom trained nurses that were accepted onto the United Kingdom nursing register. Without registration, a nurse cannot practise in the United Kingdom, so the data give a broad indication of trends in inward mobility of nurses to the United Kingdom.
In 2000/2001 a total of 9694 entrants were recorded as entering the Register from abroad (provisional data); of these, 8403 (87%) were from non-EU/EEA countries. The three most important source countries were the Philippines
Box 10.1 Work permit definitions
“First permission.” Records that the applicant has been given permission to work in the United Kingdom, subject to Home Office approval, that is the applicant has not yet entered the United Kingdom.
“In country change of employment.” Records that an applicant already in the United Kingdom has been granted a change in type of employment. One example would be an individual working as an auxiliary during an adaptation period who has now been granted a change of status to nurse on successful registration with the UKCC.
“In country extension.” Records that an applicant already in the United Kingdom has been granted an extension to the time period of their work permit – for example a nurse working on a two year period applying for and being granted a further two year extension.
“In country technical change.” In a small number of cases there will be a technical change to permit details – for example if the employer for whom the nurse is working changes their location or the title of the organization.
“Work Permit.” Records the first time issuing of a work permit to the individual applicant.
“Work permit extension.” Records the issuing of an extension to a work permit, for an applicant currently not located in the United Kingdom.
(3396), South Africa (1086) and Australia (1046). An estimate for 2001/02 sug-gests that admissions will have increased further this year, to almost 15 000 (Buchan 2002).
The number of nurses from EU Member States has flattened off. In the mid-1990s they accounted for between one-quarter and one-third of annual total overseas admissions, but by 2000/01 this had dropped to only 13% of the total.
In 2000/01 the total number of nurses registering from all EU countries was 1291, little more than from either Australia or South Africa, and much less than the numbers registering from the Philippines.
The European Union
First level registered nurses from EU Member States have a right to free mobility within the countries of the EU under Directives that guarantee mutual recogni-tion of nursing qualificarecogni-tions (see Chapter 7). Yet relatively few nurses from elsewhere have been exercising this freedom to move to the United Kingdom, compared to the inflow of nurses from other countries, whose entry is compli-cated by the need to apply for a work permit.
The EU was also highlighted in the 1999 guidance from the Department of Health as being an “acceptable” source of recruits. The Department has reached Figure 10.1 Admissions to the UKCC Register from EU Directive/Non-EU Sources 1993/
94–2000/01 (Initial Registrations)
Source: UKCC/Buchan 2002
agreement with the Government of Spain to undertake systematic and struc-tured recruitment of cohorts of Spanish nurses to designated NHS employers in England. However, as noted above, all the recent growth in the numbers of overseas nurses on the United Kingdom Register has been accounted for by an increase in inflow from non-EU countries. The overall contribution of EU coun-tries reduced from 33% to 13% of total inflow of overseas registrants between 1997/8 and 2000/01 (Table 10.3).
Spain reportedly has a surplus of nurses, so there is an apparent “win-win”
situation, with vacant nursing posts in the United Kingdom being filled by nurses currently unemployed in Spain. The initial projections were to recruit several thousand nurses from Spain. There is as yet little sign of an inflow of this magnitude. Media coverage has suggested that some of the Spanish nurses already recruited to the United Kingdom have had English language difficulties (Akid 2002). Under EU law a language test cannot be applied to EU nationals,
situation, with vacant nursing posts in the United Kingdom being filled by nurses currently unemployed in Spain. The initial projections were to recruit several thousand nurses from Spain. There is as yet little sign of an inflow of this magnitude. Media coverage has suggested that some of the Spanish nurses already recruited to the United Kingdom have had English language difficulties (Akid 2002). Under EU law a language test cannot be applied to EU nationals,