The Covid-19 pandemic has highlighted shortages in the number of workers needed for key roles in health and social care. With nursing being a major shortfall area, analysis of how effectively domestic training and international recruitment can plug the gap is crucial.
Nurses and other health and social care workers have rightly been applauded for their vital contribution to the fight against Covid-19. But even before the pandemic took hold, the NHS was plagued by workforce shortages, with nursing being the most glaring gap. There are two main routes to addressing this shortfall: increased international recruitment; and enhanced ‘self-sufficiency’ by way of more investment in domestic training.
Increased hiring of nurses from other countries remains attractive as a ‘quick fix’ solution. But the impact of Covid-19 has exposed short-term vulnerability to external shocks, notably the collapse in international travel, and changes in source and destination countries’ policies regarding mobility of nurses and other healthcare staff.
While this may focus more policy attention on increasing investment in domestic nurse training, effective implementation calls for time, resource allocation and political will. Given the cost of domestic training and the wider economic pressures being generated by the crisis, nursing self-sufficiency is unlikely to be feasible in the medium term.
How is Covid-19 affecting nurse numbers in the short term?
Covid-19 is putting unprecedented pressure on the UK health and social care workforce, and it has exacerbated existing shortages of nurses. The NHS in England alone went into the pandemic with vacancies in about one in ten registered nursing posts – about 40,000 full-time equivalents.
The NHS Long term plan and the Interim NHS people plan both recognised the need to fill these vacant NHS posts. The pre-Covid-19 strategy was essentially to ‘buy time’ by ramping up international recruitment. At an estimated cost of £12,000 per nurse recruited from outside the European Economic Area, EEA (National Audit Office, NAO, 2020), it can be quicker and significantly cheaper than investment in domestic training, which entails an investment of around £66,500 per nurse (PSSRU, 2020).
The travel disruption caused by Covid-19 and the consequent decline in nurse arrivals from other countries has called into question the likely effectiveness of the international nurse supply route. In June, the chief executive of the Nursing and Midwifery Council (NMC) noted that the NHS must think ‘long and carefully’ about its reliance on international recruitment, as it will be ‘difficult’ following the Covid-19 pandemic. More recently, however, the Chief Nursing Officer in England reported to the House of Commons public accounts committee that several thousand international nurses were waiting to travel to work in England when Covid-19 related travel restrictions were eased.
Does the impact of Covid-19 mean that the UK needs to focus more clearly on being ‘self-sufficient’ for its future nurse supply – or should it continue to rely on international recruitment? This article explores these questions. We focus primarily on domestic training and international nurse inflows. For want of data, we abstract from delving more deeply into the equally relevant issue of nurse outflows (or emigration).
Questions relating to nurse labour productivity are also important: previous work has highlighted that the number of full-time equivalent nurses rose by less than a tenth of the rate of activity growth in the NHS in the period from 2010/11 to 2016/17. But an in-depth discussion of productivity is outside the scope of this analysis: data on outcomes and outputs that can be attributed to nursing inputs are extremely limited in a UK context; and with available datasets, it is not feasible to examine the relative contribution of domestically trained and internationally recruited nurses.
What do we mean by nursing self-sufficiency?
There is no commonly agreed definition of what health workforce or nursing ‘self-sufficiency’ or ‘sustainability’ means (Buchan et al, 2011). One working definition of self-sufficiency would be ‘a sustainable stock of domestic nurses to meet service requirements’ (Little and Buchan, 2007), where a ‘stock’ is a function of inflow, outflow and existing supply (OECD, 2005).
This lends itself to a broad range of policy options for attaining domestic self-sufficiency. Perhaps most obviously, this might involve increasing domestic nursing student enrolment, but it could also include other policy options, including reducing student attrition and increasing retention and return to employment. The antithesis of domestic self-sufficiency in this working definition is a reliance on international inflows of nurses.
How reliant is the UK on international nurse inflows?
For any country, the degree of vulnerability to disruption in the international supply of nurses will be correlated with the level of reliance on international nurses. The UK is one of the most dependent countries in this regard, with about 15% of registered nurses being foreign-trained (see Figure 1) – more than double the average for high-income OECD countries.
Figure 1: The proportion of foreign-trained nurses in the UK is among the highest in the OECD
Source: OECD Health Statistics 2020 – Health Workforce Migration, stats.oecd.org
The year-on-year trend for international inflows of nurses can be assessed using data from the NMC (previously the UKCC). These highlight considerable recent growth in the level of reliance on international nurses. There was a rapid increase in non-EEA international inflows in the period up to 2001/02, mainly driven by the active recruitment of nurses from India and the Philippines, at a time of NHS-funded staff expansion (see Figure 2). This was followed by a decline in non-EEA inflows in the period up to 2009/10, driven by stricter immigration rules and a more expensive application regime for international nurses.
There was then a second phase of increased international nurse inflows (2010 to 2016) as UK employers struggled to address nursing shortages, mainly switching to recruitment from EEA countries, such as Romania, Spain, Portugal and Italy. Finally, in the most recent period since 2016, which saw the Brexit vote and new English language test requirements for nurses, there has been a rapid decline in inflows from the EEA but a rapid increase in non-EEA international recruitment, mainly resulting from a switch back to India and the Philippines.
Figure 2: Since the Brexit vote, the number of new nurse registrants from outside the EEA has increased significantly
Source: NMC/ UKCC data, authors’ analysis
(EEA: European Economic Area)
Comparing the numbers of new annual registrants from the UK to those from other countries gives an insight into the relative importance of each source, and in doing so provides an indicator of the level of self-sufficiency. The higher the relative importance of domestic training as a source of ‘new’ nurses, the nearer the UK may be inferred to be to self-sufficiency in nursing.
In every year since 1990/91, at least one in every ten new entrants to the NMC register has come from other countries (see Figure 3). In most years, international inflows have accounted for a higher fraction of overall inflows, peaking at over 50% in 2001/02. Most recently, international inflows have again risen in prominence, from 23% of new registrants in 2018/19 to 34% in 2019/20. The recent trend is therefore away from a position of self-sufficiency towards greater reliance on international inflows.
Figure 3: The proportion of new international nurse registrants in the UK has increased substantially in the last two years
Source: NMC/ UKCC data, authors’ analysis
Covid-19 came as a major external shock to international inflows. Monthly data from the NMC suggest that the number of nurses trained outside the EEA joining the NMC’s permanent register plummeted from 1,348 in March to only 35 in April (see Figure 4), with the pandemic imposing a stranglehold on international travel.
Figure 4: As Covid-19 led to a fall in international mobility, the number of non-EEA-trained nurses newly registering fell sharply
Source: NMC data
Should the NHS look to reduce its reliance on international nurse recruitment?
Data from the OECD present an opportunity to assess how many nurses the UK is training compared to other high-income countries. Using the indicator of nurse graduates per 100,000 population (the number of students who have obtained a recognised qualification required to become a licensed or registered nurse) gives us a broad brush ‘league table’ of how many new graduate nurses are potentially entering the labour market in each OECD country.
The UK is in the bottom half of the table, graduating approximately 30 new nurse graduates per 100,000 population every year (see Figure 5). This is much less than a third of the output in Australia (where there are more than 80 graduates per 100,000 population every year), and half the nurse training output in the United States.
Figure 5: The UK trained just 30 nurses per 100,000 population in 2018, while the United States trained twice as many and Australia trained three times as many
Source: OECD (2019) data: Nursing graduates (indicator). doi: 10.1787/c54611e3-en (Accessed on 3 August 2020)
A more detailed trend analysis of nurse graduation rates in the UK and some important comparator countries (see Figure 6) reinforces the point that the UK not only reports a lower nurse graduation rate than many other OECD countries, but has also not exhibited the kind of growth rates in nurse graduations that Germany, Australia and the United States have since 2001.
Figure 6: The UK’s nurse graduation rate has hardly increased since 2001, while the rates in Australia, Germany and the United States have exhibited significant increases
(Trends in nursing graduates per 100,000 inhabitants (2001-2018), selected OECD countries)
Source: OECD (2019) data: Nursing graduates (indicator). doi: 10.1787/c54611e3-en (Accessed on 3 August 2020)
This analysis suggests that the UK has been producing a significantly lower rate of new nurse graduations than a majority of OECD comparator countries, and that it has not shown the increase evident in some other OECD countries in recent years.
Can and should there be a focus on increasing self-sufficiency?
Can, and should, the UK move towards greater self-sufficiency by training more nurses at home? The data analysed above suggest that the country has had a relatively high long-term, if variable, dependency on international recruitment, with a rather low level of domestic supply of nurses compared with many OECD countries.
Increasing the supply of domestically trained nurse graduates entails, at best, a time lag of three to four years. It also implies a level of uncertainty, because the scope to increase nurse trainee numbers may be constrained by university capacity and clinical placement bottlenecks. Attrition from training also reduces the final inflow of new graduates: recent analysis suggests that about one in four student nurses does not complete training (Health Foundation, 2019).
In this context, deliberately reducing international recruitment in the short to medium term would exacerbate the problem of high vacancy rates. International recruitment is attractive to policy-makers because it is a relatively cheap and effective ‘quick fix’ to nursing shortfalls. As such, notwithstanding travel restrictions caused by Covid-19 this year, there is likely to be a continuing emphasis on fast-track international recruitment in the near future. Whether this is used to ‘buy time’ for ramping up domestic training remains open to question, as it would require strong policy commitment and funding, combined with increases in current education capacity and resolving clinical placement issues.
From the perspective of nurses based in source countries who are considering emigration, the choice of where to go will depend on which destination countries offer them the best earnings, career opportunities and working conditions. In the near future, the fact that nurses are on the UK’s Shortage Occupation List, coupled with the government’s recent proposals for a post-Brexit ‘Health and Care Visa’, and the recent exemption of key NHS and social care staff (including nurses) from the immigration health surcharge, should further facilitate the ‘fast track’ recruitment of nurses trained abroad. But in a post-Covid-19 world, the UK will have to compete with other OECD countries looking to reduce their own nurse staffing shortfalls, such as Germany.
Two longer-term issues must be kept in mind. First, there is a risk that any further ramping up of active international recruitment by the UK could damage fragile health systems in source countries. These countries are already having to deal with a major pandemic with inadequate nurse numbers. The UK has endorsed the World Health Organization’s WHO global code of practice on the international recruitment of health personnel. This sets out a framework for a managed and ethical approach to international recruitment, and the UK should continue to comply with the code.
Second, the underlying challenge faced by the UK in recruiting nurses from other countries will not be the short-term supply disruption arising from this phase of Covid-19, but rather the longer-term negative economic impacts of the pandemic and related NHS funding pressures, with clear implications for workforce policy and planning in both health and social care. This may mean that the real question is not whether the UK can recruit more international nurses, but whether the NHS has the funding to employ them.
Where can I find out more?
- Thinking local and global: exploring the UK’s reliance on international nurses and the impact of COVID-19: James Buchan and Nihar Shembavnekar from the Health Foundation examine the potential impact of Covid-19 on new international nurse registrations in the UK, against the backdrop of longer-term trends.
- The NHS nursing workforce: This NAO report outlines key facts and statistics bringing out NHS nurse staffing challenges.
- OECD Health Statistics 2020 – Health Workforce Migration: OECD statistics on the number and proportion of foreign-trained nurses by country of origin.
- NMC registration data reports: The NMC’s register reports, published every six months, provide updated data on the number of registered nurses and midwives in the UK, including the number of new registrations by category of origin (UK, EEA and non-EEA).
- Royal College of Nursing (RCN): As the world’s largest nursing union and professional body, the RCN is a major stakeholder and regularly publishes reports and responses to government policy announcements.
- NHS Workforce Statistics: The key source of data on UK nurse numbers and vacancies as well as data on other healthcare workforce categories.
- Office of Manpower Economics (OME): A major stakeholder on pay issues, the OME provides an independent secretariat to eight pay review bodies in the UK.
- Migration Advisory Committee (MAC): An independent stakeholder organisation, which provides expert advice to the government on migration issues.