No country is an island UK and international health workforce mobility

How does the UK compare with competitor countries in international health workers labour markets?

We recently collaborated with colleagues at the World Health Organization (WHO) to develop an international policy brief examining the migration and mobility of health workers. The brief, now published as a Health Foundation working paper, has a global perspective. But it provides a backdrop against which the UK can be assessed, and how its policies on migration and the mobility of health workers compare with those of other countries – notably those in Europe and North America, which the UK is competing against for the pool of internationally mobile recruits.

Recently, there has been an increase in the level of international mobility of health workers, particularly to Organisation for Economic Co-operation and Development (OECD) countries, with more high-income countries looking at international recruitment as a solution to domestic shortages. There has also been greater interconnectedness, with all countries being to some extent both source and destination for international health workers. 

There are a range of different types of mobility emerging, some of which are based on daily or periodic cross border flows, rather than the traditional one-way, long-term migration. Policy responses to make international recruitment more effective at the national and global levels are becoming more focused and nuanced, with more prominence being given to the rights of mobile workers and their effective induction, and increasing emphasis on bilateral agreements between recruiting and source countries.

Ethical recruitment

There is an increasing recognition that active international recruitment of scarce health workers can damage the health system of low-income countries, if that recruitment exacerbates skills shortages. This is tempered by the acknowledgement that mobility and migration, if effectively managed and ethical, can improve the situation of individual workers, and enable mutuality of benefits.

This approach, shaped by the WHO's Global Code of Practice on International Recruitment, is being fostered through the recently developed International Platform on Health Worker Mobility, which is co-sponsored by the WHO, OECD and the International Labour Organization (ILO).

The UK’s reliance on international recruitment

The UK is a major player in international health care labour markets. In comparison with many, but not all, OECD countries, the UK is heavily reliant on international recruits to make its health system function. OECD data show that 28% of UK-based doctors were trained internationally, while about 14% of UK nurses are foreign trained. Our assessment of the NHS labour market in England highlighted the relative dependency on international inflows of nurses registering in the UK, in comparison with flows of 'new’ nurses from UK training.

International inflow has ebbed and flowed over the years, but has always been important. This is illustrated in Figure 1. Every year since 1990, at least one in ten new nurses eligible to practice in the UK has come from another country. In most years, this international inflow has been much higher. The long-term trend shows a growing reliance on international inflows, stimulated by active international recruitment, reaching a high of just over 50% in 2001/2, then a rapid decline in subsequent years, followed by a second period of growing reliance between 2011 and 2016, followed by a second, recent period of decline.

Registered nurses from other EU countries currently have the right to move and practise within the EU, while nurses from non-EU countries have to gain approval to enter the UK to work, and have to be approved for registration. Figure 2 shows the number of nurses from the EU and from other international sources who have registered in the UK since 1990. 

Additional analysis of the data shows that the recent surge in EU registrants was from Portugal, Spain and Italy, which then dramatically tailed off in the last two years. Non-EU inflow has increased in recent years, but not at a pace to compensate for the drop in EU nurses. This picture is mirrored in the overall migration data from ONS, which show an increase in non-EU migrants and a reduction in EU migrants.

A precarious position

The recent drop in overall international inflow of nurses does not reflect a lack of recruitment interest from UK employers. Rather, it is the result of three factors: a restrictive general immigration policy, which may have prevented non-EU nurses and doctors entering the UK to practise (which, after a campaign led by the British Medical Journal, was partly, and 'temporarily' alleviated by removal of restrictions on the number of tier 2 visas available to doctors and nurses); tougher regulatory requirements for English-language testing of nurses (now largely reversed ); and the Brexit vote in mid-2016, after which there was a significant net decline in the number of EU nurses registering to practise in the UK.

The NHS in England reports approximately 40,000 registered nurse vacancies. Despite rhetoric about workforce ’self-sufficiency’, the UK cannot ignore the potential of the international inflow of health workers, or the risk of outflow. The NHS Long Term Plan has acknowledged as much, stressing the need for continued international recruitment to fill vacancies.

The UK has traditionally been heavily reliant on international recruitment, but is at risk of losing out to competitor countries. It will have to get smarter in how it uses international recruitment to develop a sustainable health workforce. A more strategic and aligned approach is needed, involving government health departments, the Home Office, regulators and employers – one that is embedded in overall national health workforce policy and planning, and that fully respects the rights and potential of mobile health workers.

Professor James Buchan is a Senior Visiting Fellow at the Health Foundation and an international expert on health care workforce policy.

Anita Charlesworth is the Director of Research and Economics at the Health Foundation.

Ben Gershlick is an Economics Analyst at the Health Foundation.