Intended for healthcare professionals

Views And Reviews Acute Perspective

David Oliver: Falling immigration could destroy the NHS

BMJ 2019; 364 doi: (Published 02 January 2019) Cite this as: BMJ 2019;364:k5308
  1. David Oliver, consultant in geriatrics and acute general medicine
  1. Berkshire
  1. davidoliver372{at}
    Follow David on Twitter: @mancunianmedic

Workforce gaps currently pose a major threat to the viability of our health services, as noted in a joint 2018 report by the King’s Fund, Nuffield Trust, and Health Foundation.1

One in 11 NHS clinical posts is currently unfilled, rising to one in eight nursing posts.2 The report estimates that, without concerted action, the current shortage of NHS staff employed by trusts in England—already around 100 000—will grow to an estimated 250 000 by 2030.

Some of the proposed solutions have been put forward before, by organisations including NHS Providers3 and the Royal College of Physicians.4 These centre on training more staff at home and doing more to look after staff so that more of them stay in the workforce. But this will take years, so let’s get real.

Burdensome process

There is no magic workforce tree and, without workers from overseas, the NHS is on a slippery cliff edge. Around 144 000 NHS staff (12.7% of the total) have non-British nationality, and 63 000 (5.7%) have non-UK European Union nationality.5 These numbers are far higher in some specialties, organisations, and regions—often the least glamorous and the most in need.

But clinicians from overseas who want to work here are put off by the burdensome process of dealing with professional registration and regulation and by immigration bureaucracy. Tier 2 visa rules requiring new entrants to be earning or expecting to earn over £30 000 (€33 400; $37 900) a year, even those from the EU, disqualify a range of nursing and allied health professional staff and junior doctors.6

There is no magic workforce tree and, without workers from overseas, the NHS is on a slippery cliff edge

Applying for visas carries costs for applicants and a further cost and administration burden for employers, estimated at £490m a year post-Brexit.7 Although the home secretary announced a relaxation in visa restrictions for doctors and nurses in 2018,8 he then said that this was temporary.9 December’s immigration white paper discussed increasing the number of tier 2 visas—but not lowering the £30 000 salary threshold that will exclude many skilled clinical staff.10 Are we actively trying to confuse or put off potential immigrant NHS workers?

Of course, the UK should not set out to strip poorer countries of clinicians they’ve trained, but schemes such as the Medical Training Initiative offer a win-win solution. This stipulates that non-EU doctors who come to the UK under the scheme must return home after 24 months, with the training and knowledge they’ve gained while working for the NHS.11 The scheme was capped at 1500 places a year but after concerted lobbying is set to increase to 3000, bucking the bad news trend.12

Net exit from the NHS

Even though Brexit has yet to be implemented, the mood music and ongoing uncertainty mean that EU trained clinicians no longer feel welcome or certain of their future here. As a result, the number of EU nurses registering to practice here has fallen dramatically,13 and for the first time in over 20 years we have a net exit from the NHS by EU trained clinicians.14

Barnstorming rhetoric from pro-leave campaigners, newspapers, and MPs have made immigration a signal issue. Opinion polls have shown that immigration curbs and the need to control our own borders were key factors in the leave vote.15 In reality we’ve been able to control non-EU immigration for years and have expediently chosen not to—partly because public services such as the NHS need the staff.

Of course, we need to train more of our own staff and to do a much better job of retaining them. But policies and attitudes that adversely affect our current and potential immigrant workforce will sabotage our own interests and those of patients who might need the NHS.



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