In a week where the long-promised NHS workforce plan is due to be launched, Neil Stewart, Editorial Director for the Maternity and Midwifery Forum, reflects on the recent conference looking at the International Recruitment of nurses and midwives across UK and Ireland.
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In the week we are promised an NHS workforce plan to tackle staff shortages there were some sobering insights at a major conference programme into the challenges facing the UK and Ireland nursing and midwifery planners.
A UK/ Ireland programme for the Irish Nurses and Midwives Organization (INMO) and the Maternity and Midwifery Forum examined our joint dependency on international nurses and midwives revealing the mountain the NHS and HSE Ireland needs to climb.
The first jolt was that Australia, which recruits from the UK, already educates three times as many nurses and midwives per 100,000 of population and the USA twice as many as the UK. Another league table we are nowhere near the top.
In the UK and Ireland the health service are currently employing 20%, 1 in 5, of their nursing and midwifery staff from overseas.
In the past two years almost 50% of the new entrants to the UK Nurses and Midwives Council register had an overseas qualification.
In Ireland the proportion was even higher, but more selective with theirs coming overwhelmingly from India and the Philippines
The UK Prime Minister Rishi Sunak has indicated that the NHS workforce plan will take 10 to 15 years to reduce our dependency on overseas staff while at the same time indicating he might not implement this year’s review body pay awards.
You do not need to be a mathematics genius to work out that a run rate of 50% new international recruits to the NMC register each year is “unsustainable”, as Prof James Buchan said in opening the event.
Training new UK nurses and midwives could turn into running up a down escalator and never reaching the top unless the workforce plan changes are very large. So, watch out for announcements of big and very big training numbers which, in reality, turn out not to be big enough.
The figures also show that in the UK just over 6085 new international recruits last year came from WHO “Red Flag” countries which desperately need all the nurses and midwives they can keep and from which we are not supposed to actively recruit (in 2017 it was only 190).
The government insist they do not actively recruit from these countries, but that does not stop commercial intermediaries and agents ramping up the offers and making unfulfilled promises as the recent expose of care home nursing recruitment in the Observer demonstrated.
Ireland is in no better a position. It is currently recruiting 2600 nurses from India, which proportionally for a country of 5 million is higher than the UK (60 million population) rate of international recruitment.
On training new nurses and midwives Ireland do, however, have a workforce plan to go from producing around 1800 graduates currently up to 7000 per year – a 388% increase. Many will have seen the news story that along the way to increased capacity 250 of these nurses are to be trained in Northern Ireland as expansion outstrips local provision in the Republic.
How will NHS Trusts cope with the demand for placements when the current increase in new nurse and midwifery courses is already having trouble finding placements? The fear is that in the absence of supervised placements the students will just be dropped back into the workforce as pairs of hands as they were in the 1980’s and 1990’s
One interesting revelation in the programme was the extent that even now student nurses are still used as part of the workforce. They are required in the UK to have 2300 hours in clinical settings, which is a nice way of saying working on the wards, whether they are being actively trained and supervised or not. In Australia the figure is 800 hours, and no one doubts the qualifications or skills of Australian nurses. It is anticipated that the new NHS workforce plan will see the massive expansion of Nurse, Midwife and even Medical Apprenticeship models. Look closely to see how much is on the job training and how much is just old-style free labour.
All this is against a precipitative drop in the numbers coming from the rest of the EU since Brexit.
But why should we worry about International recruitment? They come freely to the UK. They often enhance their skills and go back. Plus remittances of pay are important for families especially in countries like the Philippines.
On the 75th anniversary of the Empire Windrush we can look back on all the African and Caribbean nurses who came to join the NHS with a large degree of pride. Except that many of them, fully qualified nurses, were put in dead-end enrolled nurse roles, never able to be promoted with broken promises that they would get their full registration.
It would be nice to think that this is not happening today, except that Steve Barclay the Secretary of State has recently admitted in a session with the nursing press that highly qualified new recruits are systematically put on the lowest band and get stuck there. Officials have been “examining” this since it was pointed out in 2021 but keep insisting it is a local matter.
Most trust managements and communications directors today will recognise that unconscious bias, systemic racism, racial disparities do not stay local for long.
Marsha Jones from the African and Caribbean Nurses and Midwives association made a shocking presentation of the reports from their panel of international recruits that should send a shameful shudder down the spine of every trust management on who is going to be exposed first. This is not how the NHS needs to welcome international nurses and midwives if they want them to stay.
Here again there may be some complacency. Traditionally international recruits form the EU stayed for an average of 6 years and international recruits from the rest of the world stayed for an average of 12. The EU recruitment has dropped but if we could count on the non EU recruits staying for 12 years the transition to training our own might work.
But as one speaker said, they don’t come on boats anymore; they fly in and they can fly out if they are not made to feel welcome.
Previously many will have aimed to bring family and children to join them but that door is increasing closed by the UK Home Office “hostile environment”, just as they have hit universities by limiting the ability of mature and masters students bringing their family for the few years of study in the UK even when the overwhelming evidence is that they go back this can influence health staff.
Yet another door may be about to open. We know about Australia as an attractive destination for nurses, midwives and doctors but the USA has not traditionally been a big international recruiter. Its nurses are well paid, the numbers trained are higher, but the demographic challenges of an aging population and more chronic diseases applies just as much in the USA as they do here, and that market is beginning to open up – and it is a very big market with attractive salaries.
It has long been known that the majority of Filipino nurses would prefer to work in the USA. After all they are trained in the US naval nursing model as a legacy of the post war occupation, a model that was generally recognised as being better than the UK model when we were reforming nurse and midwifery training in the 1990’s after Project 2000 was accepted.
If you are a follower of international summits, you will have seen the major meeting in Washington between India and the USA opening up co-operation between the two in huge areas previously closed (it used to be India that did not want to be dependent on US) and Canada is again active in international recruitment.
Dr Ray Healy, the Director of Registration at the Nurses and Midwives Board of Ireland confirmed that they are already seeing particularly Filipino staff moving on to the USA as it opens up. Dr James Buchan one of the leading experts in the world on nursing and midwifery numbers confirmed that the opening up of the US and Canada markets would be a huge challenge for UK and Ireland recruitment given their relatively better salaries.
On the evidence of the programme the UK welcome for international nurses and midwives needs to step up, be warm, professional, give them career options, recognise their previous skills and qualifications and support them not just with their registration and clinical transition but in getting settled culturally and domestically. Evidence of casual discrimination in banding plus other countries offering better packages is a real challenge to UK international recruitment and retention.
We are just at the start of a big period of change in training and international recruitment.
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Neil Stewart
Editorial Director, Maternity and Midwifery Forum
June 2023