International RescueBMJ 2018; 361 doi: https://doi.org/10.1136/bmj.k2543 (Published 13 June 2018) Cite this as: BMJ 2018;361:k2543
- James Buchan, senior visiting fellow,
- Anita Charlesworth, director of research and economics
The rapid agreement by the UK government to a review of the visa regime for international doctors is a rare glimmer of common sense in a matter that has been more usually characterised by national policy incoherence. What remains of concern is that it required a media campaign (bmj.com/scrap-the-cap) to achieve a response from government, and that the underlying problems of the UK approach to international recruitment of health professionals remain to be acknowledged and tackled.
These problems owe much to a debilitating mix of conflicting policy goals and inadequate national health workforce planning and funding. This has led to a long term “stop-go” approach to international recruitment of doctors and other health professionals, which has often been misaligned with domestic health workforce and immigration policies.
Ten years ago, the UK Parliament Health Committee report on NHS workforce planning concluded that there had been a “disastrous failure” of planning, in part because of a “clear lack of alignment” between domestic training and active international recruitment. It recommended that the Department of Health “needs to work more effectively with other departments, notably the Home Office, to ensure that international recruitment is fair and consistent.”1
Since 2007, little appears to have changed—except NHS funding is tighter, and staff shortages are now more pronounced. While there have been glib statements about the UK achieving “self sufficiency” in doctors and nurses, if this means ending reliance on international recruits then it is unlikely happen in the foreseeable future, given current high vacancy rates, the ageing of the NHS domestic workforce, and retention indicators showing no substantial improvement.2 For example, despite government announcements on expanding primary care and staffing growth targets, the numbers of GPs working for the NHS in England has fallen from 34 025 in September 2015 to 32 748 in March 2018. An international recruitment drive is struggling to fill the gap.
The backdrop to policy is that the UK continues to be heavily reliant on international doctors. Data published by the Organisation for Economic Cooperation and Development3 (OECD) show that 28% of UK based doctors were trained internationally, which sits comfortably in the cluster of high income, English speaking countries of Australia, Canada, Ireland, New Zealand, and the USA, all of which are in the 24-41% range of dependency on internationally trained doctors. Data on annual inflow, also provided by the OECD, show the UK, with 5649 doctors reported inbound in 2016, is the second highest OECD destination country for international doctors, beaten only by the much larger USA.
A more detailed consideration of data related only to the NHS in England exposes the vulnerability of the NHS to changes in flows of international doctors and the extent to which this reliance has switched in recent years to doctors moving from the EU.
NHS England data show that only two thirds of hospital doctors gained their primary medical qualification in the UK (64%), while 20% of doctors qualified in Asia, 6% in Africa, and 9% in another EU country.4
Compared with 2009, however, there is now less reliance on Indian doctors and reductions in doctors from other non-EU countries such as Iran, South Africa, Syria, Zambia, and Zimbabwe. By contrast, the number of doctors from EU countries such as Greece, Ireland, and Romania has increased significantly.4
In short, when compared with other Anglophone OECD countries, the UK is not unusual in its level of reliance on international doctors. Where it does stand out is in its current high level of numerical inflow of doctors, notably from EU countries, combined with its hardening stance on immigration. This makes it vulnerable to Brexit related volatility in health labour markets, while not having the option to easily “switch” back to non-EU immigration pathways because of the tough visa regime.
It is too early to be certain how Brexit will influence flows of health professionals to and from the UK, but it is likely to amplify the focus on international recruitment from non-EU countries. An unintended consequence of the pro Brexit vote is that it may force the NHS to try to replace German doctors with Indian doctors, and Spanish nurses with those from the Philippines.
The simple truth is that there is no overall government policy, published plan, or immediate likelihood of UK self sufficiency in doctors or nurses. What we need is a joined up and strategic approach to the international recruitment of health professionals, involving government health departments, the Home Office, regulators, and employers, which is embedded in overall national health workforce planning.
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