As we face Brexit negotiations with curtailed and controlled immigration as a key objective, it is worth reflecting on what capping migration—from the EU or from elsewhere—would mean for the NHS. This means not only thinking about immigration targets, but about the wider systems that govern who works in our NHS—and how we ensure that they are prepared for that work.
Health systems are highly dependent on being able to employ people with knowledge developed through experience and not only through classroom learning, and therefore not subject to the quick fix of more courses. In the past, the NHS had a planning function which oversaw the development pipeline for doctors, nurses and other health professionals which ensured that the supply more or less matched the demand—and that mitigating steps were taken if this was not going to be the case.
Two factors placed this system in jeopardy. First, the 2012 Health and Social Care Act turned a planned public service into a market, with the assumption being that competing providers, rather than central planners, would make sure they had the capability to operate successfully. Secondly, much of Whitehall was hollowed out in the name of austerity and “shrinking the state.” Those concerned with ensuring that there was a continuing flow of people with the right skills and experience were despatched to early retirement.
Gaps began to appear in the pipelines. Only five people were trained as district nurses in London in 2013/14, basic nurse training was reduced between 2010 and 2013. There were even cuts in medical training in 2012, on the grounds that we might have too many doctors.
Nurses from overseas
Meanwhile, new immigration laws introduced in 2011 meant migrants were required to earn a minimum income. This was set higher than the salary for a main grade qualified nurse, choking off migration from outside the European Economic Area (EEA).
This had a drastic effect. In 2001-02, there were just over 15,000 new entries on the Nursing and Midwifery Council (NMC) register by people not from the EEA. This fell to under 700 in 2014-5.
Fortunately for the NHS, the Eurozone crisis created a new supply of qualified doctors and nurses from Portugal, Italy, Greece and Spain—so for a while, the problem was solved. New registrations with the by people from within the EEA rose from the historic pattern of about 1500 per year to 7500 in 2014-15.
However, the latest figures from the NMC for 2016/17—the year of the referendum—shows a 96% drop.
A worrying staff shortage
Following the publication of the Francis Report on the Mid Staffs hospital disaster, it was announced that there would be a stated maximum number of patients per nurse—but in 2015, there were 30,818 full time, or full time equivalent, vacancies (an 8.9% vacancy rate). Health Education England hopes to reverse earlier cuts to nurse training in the coming years but it seems unlikely that without the incentives of nurse bursaries—just abolished—that this will be achievable.
Annual below-inflation pay rises affect all, and the fall in the value of the pound changes the incentives for overseas staff sending money home. The NHS is failing to hang on to the nurses it has and failing to attract others from elsewhere. Overall, a rumbling crisis in the nurse and midwifery workforce is becoming a perfect storm.
Call the doctor
The situation when it comes to doctors is not much more encouraging. It has always been the case that a large number of NHS doctors, especially in hospitals, have come from abroad. In 2014, more than 45,000 doctors working in the NHS—almost 30%—had received their primary medical qualification from a country outside the UK: 10,000 from an EEA country, and 35,000 from a country outside the EEA. The General Medical Council's Specialist Register notes that consultant-level posts in surgery and ophthalmology are particularly reliant on EEA graduates.
Jeremy Hunt has promised 5000 more GPs by 2021, and the role of GPs is pivotal to achieving the spending reductions planned by the government.
Yet recent evidence about the unwillingness of junior hospital doctors who have completed their Foundation training to progress to Senior training—the route normally taken by about 75% of trainees, but this year down to 52%—tells its own story about the morale of junior doctors, but also indicates the plight the NHS will be in if the supply of overseas doctors is turned off.
The challenge ahead
Law firm Baker McKenzie's recent survey of highly skilled workers from the EU demonstrates that large numbers are planning to leave the UK even before the final deal is struck on Brexit—across a wide range of professions. The psychological contract has been broken and these workers now feel unwelcome. The research concludes that employers should reinforce the extent to which these workers are valued, reassuring them of our continued need for them.
We can only hope that senior NHS managers will give at least some of their attention to the important task of finding, and keeping, the workforce that is so crucial to the future of the NHS—and to us all.
