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Abstract
Background/aim Following large-scale surveys suggesting that large proportions of European doctors are considering leaving the National Health Service (NHS) following the Brexit referendum, this was the first qualitative study assessing if, and how, Brexit has affected European Union (EU) doctors’ views of working in the NHS and their future intentions.
Methods Data were collected from 17 semistructured, qualitative interviews with doctors working at two NHS England trusts, who either had citizenship or had received their primary medical qualification from a member state of the European Economic Area. Transcripts from the interviews were then subjected to thematic content analysis.
Results Despite the majority of EU doctors believing that Brexit would not affect their jobs or rights in the UK, for many the referendum itself and its political handling had made them feel unwanted, undervalued and uncertain about their futures in the NHS. Most doctors intended to remain working in the UK; however, for several interviewees, this, along with fears regarding their future working conditions, had led to them considering leaving the NHS.
Conclusions Some European doctors are now considering leaving the NHS following the Brexit referendum, and their retention will be partly dependent on whether the government and the NHS can persuade them that they are both wanted and valued in the UK, and that their future working conditions will not be significantly affected.
- politics
- health policy
- management
- recruitment
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Introduction
On 23 June 2016, the UK voted to leave the European Union (EU). It is undeniable that the National Health Service (NHS) now faces significant challenges post Brexit, and one such challenge will be Brexit’s impact on staffing in the NHS.1 2 At present, the Directive 2005/36/EC enables the free movement of doctors between member states of the EU, and currently 11% of registered doctors in the UK have received their primary medical qualification from another European Economic Area (EEA) member state.3 With staffing shortages already an issue in the service,4 and plans to expand medical schools not set to yield consultants until at least 2030, it is clear that the loss of even a proportion of these EU doctors could have serious consequences for the NHS.
Following the referendum, there has already been a reduction in the number of EU students applying to UK universities,5 and while admittedly coinciding with changes to their language requirements, a reduction in the number of EU nurses applying to work in the NHS.6 Moreover, along with reports of anxiety among EEA doctors regarding their futures in the NHS,7 surveys earlier this year by the General Medical Council and the British Medical Association have found that 60.8% and 42% of these doctors, respectively, are considering leaving the NHS.8 9 The fear of losing these doctors had led to calls for the government to grant the right to remain to the EU staff currently working in the NHS,10 but despite the government making ‘securing the rights for EU nationals in the UK’ one of their 12 priorities,11 they have, as of yet, been reluctant to unilaterally grant these rights in the fear of losing ‘negotiating capital’.12
Previous studies assessing the views and future intentions of EU doctors working in the NHS are limited, and have all taken place before the Brexit referendum.13–15 This study aims to build on recent large-scale surveys and investigate if, and how, Brexit has affected both EU doctors’ views of working in the NHS and their future career intentions.
Methods
Sample
One specialist (Trust A) and one non-specialist (Trust B) NHS England trust were selected for recruitment. Doctors were eligible for the study if they either had citizenship or had received their primary medical qualification from an EEA member state and were employed as a doctor by either Trust A or Trust B in February 2017. Potential participants were excluded if they were born in the UK.
Due to information governance and data protection, the trusts were unable to disclose contact details for eligible doctors and instead the lead author liaised with the Medical Director of Trust A and the Human Resources department of Trust B, who circulated the study participant information sheet by email to eligible doctors at their respective trust. As well as outlining the purposes and aims of the research, the participant information sheets also contained the researcher’s contact details, thereby allowing doctors to contact them directly if they were interested in participating. Data collection continued until theoretical saturation was reached, at which point 17 doctors had been interviewed. The characteristics of these doctors are included in table 1.
Participant characteristics
Data collection
Seventeen one-to-one, face-to-face, semistructured interviews were carried out between February and March 2017. An interview topic guide was used to maintain consistency and ensure similar types of data were collected from all interviewees. This interview design ensured that the key topics were discussed, while also allowing the researcher to probe and further explore emerging themes that arose during the interview. The topic guide included questions on the motivations of EEA doctors for migrating to the UK, their experience of working in the NHS, how Brexit had affected them personally and professionally and their future career intentions. Doctors were allowed to choose the date, time and location of their interviews in order to fit around their clinical hours. Informed written consent was taken in person before the start of the interview, thereby giving doctors the opportunity to raise any questions or concerns they had before signing the consent form.
Data analysis
The audio recordings of the interviews were transcribed verbatim by the lead author within 48 hours of the interviews, before being anonymised and sent back to the individual doctor by email as part of a member check. This gave the opportunity for doctors to assess whether their account had been accurately represented, while also allowing the researcher to clarify parts of the interview that were unclear.
Braun and Clarke’s six-phase thematic analysis was used to systematically analyse the interview transcripts,16 with Nvivo software used during the coding process in order to minimise errors and make the analysis more efficient and manageable. During the coding process, the coauthor coded two randomly selected transcripts, allowing the two researchers to compare their coding and discuss any inconsistencies.
Results
Three topics were dominant in the analysis: the personal impact of Brexit, Brexit’s impact on the NHS and EU doctors’ future intentions.
Personal impact of Brexit
In all, 11 of the doctors were confident that they would not be made to leave the UK following Brexit, nor would their jobs change in the imminent future. These doctors could not foresee the UK government negotiating a deal that would mean EU doctors would have to leave their jobs in the NHS, especially at a time when staffing shortages were already a major issue in the service. However, this relaxed attitude was not shared by all interviewees. For six doctors, Brexit had introduced uncertainty into their lives, resulting in them feeling as though they were in ‘limbo’ and unable to make future plans.
I don’t feel actually threatened that I would lose my job or right to stay. I don’t think that would happen. (German doctor)
I believe my career will not change in any way, I’m confident of that. (Greek doctor)
Well it’s a lot of uncertainty. It’s in the back of your mind and as I mentioned it doesn’t allow me to make any long term plans. (Romanian doctor)
For four of these doctors, this uncertainty did not just surround their right to remain or their job security. Doctors expressed fears over their pensions, university fees for their children and the future of the UK’s research funding; with the latter especially pertinent to two doctors who were considering starting PhDs. Doctors of a range of seniority levels shared an opinion that the referendum results and the subsequent aftermath had made them feel both unwelcome and undervalued in the UK. For many this had been exacerbated by the political handling of Brexit, with five doctors adding that the government had made them feel like a ‘bargaining chip’ in EU negotiations, rather than valued for the job they do. For some this had added to a feeling of being separate and different from the rest of society since the referendum.
I have never actually, wrongly perhaps, considered myself as a migrant, but now I suddenly am. (German doctor)
For several doctors, the campaign and rhetoric of the referendum had made it difficult for them to not see Brexit as a personal attack. Doctors revealed that this had made them feel ‘uncomfortable’, and a couple discussed how they thought they were now viewed negatively by the rest of the UK society.
I know the rhetoric of Brexit involves me because its projected against the allogen and I’m part of that. (Romanian doctor)
Brexit’s impact on the NHS
There was a shared opinion among many of the doctors that Brexit would have a negative impact on the UK economy which would, in turn, adversely affect the NHS. As well as this potentially having financial implications for doctors, through devalued wages, several recognised that underfunding was already a major issue in the NHS and feared for the future of the service if further budget cuts and spending restrictions were put in place.
I really see the NHS going down because of underfunding and because the economy suffers now with Brexit. I think Brexit will be just one more hit (German doctor)
The interviewees spoke of the difficulty in recruiting EU staff to the NHS following Brexit. Many doctors described how they felt the UK was now less appealing for those qualifying elsewhere in the EU. As well as the uncertainty surrounding the rights of EU citizens in the UK, these doctors felt that the referendum vote will have given European doctors the impression that they are no longer wanted in the NHS.
Why would you want to go to a country that is openly closing its borders? Why would you want to do that?- (Croatian doctor)
As well as some interviewees being aware of EU colleagues that were now no longer considering migrating to the UK after Brexit, several senior doctors revealed how they had experienced considerable reductions in the number of EU applicants for recent posts in their departments.
We have seen a massive reduction in the number of European Union doctors wanting to do junior work here. (Greek doctor)
Absolutely, we are not able to recruit any of them [EU doctors]. (Croatian doctor)
Doctors feared that reduced funding for the NHS combined with difficulties in recruiting EU staff would accentuate staffing shortfalls that already exist in the service and ultimately negatively impact on their working hours and the quality of patient care in the NHS. For the doctors who had expressed their pride of working in the NHS system, there was a concern that these issues would make the current system unsustainable and increase the likelihood of it moving towards privatisation. For some, this potential scenario was even cited as a reason for them wanting to leave in the future.
I’m not keen to work in a system that will be similar to the US. I really do not agree in principle with the system and how it is designed (Irish doctor)
Future intentions
In total, 10 of the 17 interviewees reported that Brexit had not impacted on their future career intentions, and that they planned to remain working in the NHS. The most frequently cited reason for wanting to stay in the UK post Brexit was that doctors were settled both professionally and personally, with many doctors having accommodation, family and friends within the UK. For all of the doctors with families in the UK, their children had spent nearly all, if not their entire lives living there, and the majority felt it would be unfair to make them move now.
She [daughter] feels probably more British than Italian, so when I joke and say let’s go back home, back to Italy, she says ‘no, this is home for me’. So in a way I’m stuck for another 8, 9 years, at least till she’s grown up. (Italian doctor)
Many doctors also referred to the perceived difficulty of moving to a new country and adjusting to another culture. Furthermore, doctors who had spent a considerable amount of time away from their home country described how it would be difficult for them to now move back home.
There’s probably things that I would find difficult about living in Ireland now that I wouldn’t have noticed when I was there, because I’ve been away for so long. (Irish doctor, 11 years in the NHS)
However, for several doctors Brexit had made them seriously consider their options for the first time since they had moved to the UK. Moreover, for one consultant and one junior doctor, who were both already considering leaving the UK before the referendum, Brexit had accelerated and affirmed their respective decisions to emigrate. For the consultant, family and financial factors had resulted in them considering a move back to Germany, and despite this only being a vague plan before Brexit, they were now almost certain of leaving and were already actively seeking jobs.
We thought maybe over the next 5 years or so we may decide to go back to Germany but that really has changed with the referendum. This [Brexit] was the final straw that broke the camel’s back. (German doctor)
On the other hand, the junior doctor had always planned to move back to her home country and had been working in the UK while she saved the money for her home country’s licensing examination. However, the Brexit vote and the subsequent statements by the government had made her feel undervalued and underappreciated as a foreign doctor working in the NHS, and had ultimately led to her beginning the process of migrating back.
The day I finally bit the bullet and signed up for the exam was back in October when Theresa May made some stupid comments … they were going to train more UK doctors. They didn’t need the immigrants. It made me think why am I sacrificing my life and my time to serve a government that have zero appreciation. (Canadian-Polish doctor)
For a couple of interviewees, Brexit had changed their future intentions from remaining in the NHS for the rest of their careers, to now being almost certain of leaving. As well as being fearful for their future working conditions and subsequent quality of life, these doctors also described how political statements following the referendum had made them feel undervalued working in the NHS.
I don’t think that British politics gives highly qualified professionals like me or my husband, the impression that we are wanted. On the contrary we are being used as a toy in political games with other European countries, which is very frustrating and very humiliating. (Croatian doctor)
Along with the high education fees in the UK, compared with their home countries, several doctors also discussed how they believed it would be beneficial for their children to be brought up within the EU following the referendum. These doctors felt their children would have better future career prospects in the EU, while also being able to live in a more open society.
After Brexit the economy here will struggle for a bit and of course if they went into business, or careers like that, it is probably easier to find choices all over Europe in that sector. (German doctor)
Like those who were now uncertain about their futures following Brexit, the doctors who had changed their intentions to now leave the UK did not plan on leaving imminently. The stages they were at in their careers appeared to have a significant impact on this decision, with several consultants conceding that they would be more likely to leave after retirement rather than straight away. In contrast, one of the registrar doctors now intending to leave was still in a training post and acknowledged that it was likely she would finish her training before emigrating.
I’ve got a run through now till consultancy, because I’ve got my registrar job, so it’s more than likely that I will complete my training here. (Austrian doctor)
As well as remaining in the UK for the immediate future, both of the doctors who now planned to leave as a result of Brexit did concede that they could be persuaded to stay. One had given themselves a year to see how politics develop and to see if the government could persuade them that they, as EU citizens, were both wanted and valued in the UK.
Somebody has to tell me, listen I’m really keen that you are staying, I value you, I value what you are contributing, I value your taxes, I value the money you are giving to this country. Please stay. (Croatian doctor)
In contrast, the other considered it more important that the government introduced a plan to address the deterioration in working standards for NHS employees in order to convince them to stay.
If there has been a dramatic improvement or even just a plan in place, for how working in the NHS would improve or at least stay the same, that would probably shift the balance again. (Austrian doctor)
Discussion
As anecdotal evidence had suggested,9 17 Brexit had made many of the doctors in this study feel unwanted, undervalued and uncertain about their futures. However, despite the lack of clarity from the government, many senior doctors did not feel they would be asked to leave the UK following Brexit, nor would their jobs change in the immediate future. For some, the referendum had made them feel different and separated from both their colleagues in the NHS and the rest of society. This is significant because if these feelings were to persist long term it could lead to the loss of these EU doctors as a perception of not belonging to a society has previously been found to be an important instigating factor in their migration.18
The majority of interviewees intended to remain working in the NHS for the foreseeable future, much like the findings of previous studies with EU healthcare professionals.13 15 As researchers have found in the past, family and personal factors were extremely important in the decisions of these doctors to remain in the NHS.13 Personal factors included friendships and relationships, as well as some doctors having English-speaking children raised in the UK. Many doctors described the inconvenience they would experience moving to another country, and as has previously been found, several interviewees felt they could no longer work in their home country after having worked in the UK.14 This was especially the case for doctors who had spent extended periods of time working in the NHS, and along with the personal factors discussed above, may help to explain why the likelihood of EEA doctors leaving the NHS has been shown to decrease with age.19
For some doctors, however, the referendum had led to them either considering their future career options or intending to leave the UK. Recent large-scale surveys have indicated that high proportions of EU doctors are ‘considering’ leaving the NHS;8 9 however, the findings from this study suggest the matter is more complex than these crude figures would suggest. Instead, those doctors ‘considering leaving’ can be divided into three categories; those who are leaving due to Brexit, those who are considering their options due to Brexit and not necessarily intending to leave and those who were already considering leaving before the referendum, and Brexit has either accelerated or affirmed their decision to migrate. As previous studies have found,13 18 the decisions of these doctors to emigrate resulted from a combination of push and pull factors, both professional and personal, rather than Brexit alone. One of the biggest push factors for these doctors was the perceived impact of Brexit on the NHS. Interviewees made particular reference to future issues such as funding and the recruitment of EU staff to the NHS, and believed that these would ultimately negatively impact their working conditions and threaten the sustainability of the service. With regards to the future recruitment of EU doctors, several interviewees discussed how the UK had become a less attractive place for European doctors to come and work following the referendum. This had resulted from a general perception that EU staff were no longer wanted or valued in the UK, as well as the uncertainty surrounding the rights of EU citizens.
Many of the doctors now considering or intending to leave due to Brexit did not have immediate plans to leave. These doctors were waiting to see where they and the future of the NHS stand following Brexit negotiations, and whether the government could persuade them to stay. This therefore suggests that if the government can secure the rights of these doctors, convince them that they are valued and outline plans for how the NHS will function following Brexit, many EU doctors considering leaving the UK could be persuaded to stay.
Acknowledgments
In order to preserve the anonymity of the doctors in this study, the authors are sadly unable to name the two NHS England trusts that were used in the recruitment of these individuals. However, the authors acknowledge their Research and Development departments, as well as the Human Resources department of one trust and the Medical Director of the other, for helping to facilitate this project. Most importantly, the authors wholeheartedly thank the 17 EU doctors who kindly gave the time out of their busy schedules to allow to interview them on what is a very personal, and for some, emotive topic. Without them, this research project would not have been possible.
Footnotes
Competing interests None declared.
Ethics approval Prior to recruitment and data collection, the lead author applied for, and received, ethical approval from the University of Birmingham’s Internal Research and Ethics Committee, as well as the Research and Development departments of the two NHS England trusts used for recruitment. University of Birmingham BMedSc Population Sciences and Humanities Internal Ethics Review Committee reference number Y16_C2_12_SJCH.
Provenance and peer review Not commissioned; externally peer reviewed.