Recent media reports have highlighted the issue of nurses coming to the UK to work for the NHS from poorer countries with their own nursing shortfalls. This is a problem because when nurses leave countries that already have workforce shortages, healthcare in those countries inevitably suffers.
The World Health Organization (WHO) has identified more than 50 countries where exporting nurses is putting their healthcare systems at risk. The WHO advises that in these countries, international recruitment should only take place if very carefully managed.
While we would not criticise any person who is looking for a better life for themselves and their family, nurses are often trained at taxpayers’ expense to meet the pressing healthcare needs in their own countries.
So is there a better way?
Not a new trend
It’s important to see this phenomenon in its historical context. Britain has been recruiting nurses from its former colonies since the 1940s. Some of the original Windrush passengers 75 years ago were nurses and midwives from Jamaica who had been invited to work in the newly-created NHS to meet workforce needs.
According to the Nursing and Midwifery Council, the countries that the UK recruits the most nurses from post-Brexit are India, the Philippines, Nigeria, Zimbabwe, Ghana, Kenya and Nepal.
Some 91% of the overseas nurses registered to practice in the UK in 2021-2022 came from these seven countries. Four of these countries (Nigeria, Zimbabwe, Ghana and Nepal) are on the WHO’s safeguarding list.
Countries such as the Philippines and India – where the majority of internationally trained nurses in the UK come from – have a “surplus” of nurses, insofar as they train more nurses than they can employ with the intention that those nurses will work elsewhere. The Philippines in particular is economically dependent on the remittance of expatriate citizens, including nurses.
Nonetheless, both the Philippines and especially India have very low levels of nurses per capita, according to data from the World Bank. This is even more of an issue in rural areas. Given this, and the underdeveloped state of their healthcare systems, recruiting nurses even from these countries is not a straightforward ethical proposition.
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This is not a uniquely British situation. Of the OECD countries, the UK is similar to New Zealand, Switzerland and Australia where at least 20% of the nursing workforce is trained elsewhere.
Even Japan, a country that has traditionally been wary of immigration, is now recruiting nurses from Indonesia and the Philippines. This means that the UK is in competition with other rich countries for nurses and other healthcare workers.
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What’s the solution?
The obvious long-term solution, featured in the recent NHS workforce plan, is to train more nurses in the UK. However, this is not as simple as funding additional places at university for students to study nursing. Student nurses need supervised practice as part of their education, and the NHS has a limited capacity to absorb students, especially given the pressure the system is under.
It takes at least three years to train a nurse, and longer before they can take on complex roles like advanced nurse practitioner. Around the world, there is also a shortage of nursing lecturers (notably in the US).
While there is not yet firm evidence of such a shortage in the UK, the nursing lecturer workforce, like the wider nursing workforce, is ageing, with many set to retire in the coming years.
In the short term, the policy intervention that will be most effective is for the NHS to retain more of the nurses that it already has. The easiest and quickest way of doing this would be to pay nurses more and give them better working conditions, including improved professional development and training.
Our own research supports this. We ran a development programme for late-career nurses and the participants talked about “feeling energised” by the programme.
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The UK government has reached agreements with Nepal and India that aim to allow the UK to recruit healthcare workers from these countries but without damaging their healthcare systems. They are currently frameworks for the development of more detailed policy but do not contain specific targets for recruitment numbers.
Given global economic inequalities, and ageing populations in the world’s richer countries, some movement of nurses from poorer countries to richer countries is inevitable, at least in the short term.
But there are measures that richer countries can take to manage this process ethically, not least a strong commitment to the existing nursing workforce in terms of pay, working conditions and development.
