GUJHS. 2004 April; Vol. 1, No. 3
Kathryn LaRusso, NHS ’03
The demand for nurses globally has increased. Unfortunately, the nursing supply has not been able to keep up with this increasing demand. Many developed countries have had to recruit large numbers of nurses from abroad to fill severe shortages. The United Kingdom is one such country that has initiated large-scale, targeted recruitment campaigns to bring nurses to the UK from overseas. Severe nursing shortages in the National Health Service (NHS) and private sector have resulted in a significant increase in the number of nurses and midwives recruited from outside the European Union (EU) (Royal College of Nursing [RCN], 2002a). Extensive research has been conducted on the UK labor market, but there has been little emphasis on the nursing shortage and the effects of international recruitment on the NHS in Wales. This report is a closer analysis of Wales’ nursing labor market and how NHS Trusts have responded, and what steps the Welsh Assembly Government are taking to recruit and retain more nurses. A series of interviews were conducted with all the major stakeholders in the system. Government officials, policy experts, overseas nurses, hospital managers, workforce planners and nursing agencies were all interviewed. As research was conducted it became clear that the more significant issue surrounding the nursing situation in Wales was not necessarily recruiting nurses from abroad because of vacancies, but inadequate workforce planning.
THE DYNAMICS OF THE UK NURSING LABOUR MARKET
There has been considerable growth in the number of nurses from other countries registering in the UK. As of March 2002, there were 644,025 qualified nurses, midwives, and heath visitors registered to practice in the UK. Registration data shows that there have been more than 30,000 new non-UK nurses registered in the UK since 1999. The main source countries were the Philippines (7,235), South Africa (2,114), and Australia (1,342) (Buchan, 2002b). In just one year, from 2000 to 2001, the number of nurses and midwives from outside the EU who registered with the Nursing and Midwifery Council (NMC)  increased 41% or over 8,000 nurses (RCN, 2002a).
This increase in the number of nurses from overseas has been driven by a number of factors. Since the 1970s, the globalization of markets and the development of free trade agreements have facilitated international migration and reduced barriers to trade. A pattern has emerged where doctors and nurses are continually moving to countries with a perceived higher standard of living, creating what has been referred to as a “carousel” of movement (Martineau, Decker, & Bundred, 2002). The recognition of medical qualifications throughout the EU facilitates this movement.
The international migration of nurses has also increased due to changes in demographics in many developing countries (Martineau, Decker, & Bundred, 2002). The populations of the United States, the UK, Australia, and Canada, as well as other developed countries are growing older. Concurrently, the nursing workforce is also aging in these countries. In the UK for example, more than 73,000 nurses are aged between 50 and 55 and can expect to retire from the nursing workforce in the next five to ten years (Buchan, 2002b). Thus, as the demand for more skilled nursing care increases, more nurses are expected to be leaving the profession in the next ten years, creating more vacancies.
Another factor driving international recruitment has been new NHS staffing targets set by the Secretary of State for Health. England has called for an extra 35,000 nurses, midwives, and health visitors by 2008 to meet the needs of the NHS modernization process in Delivering the Plan: Next steps on investment, next steps on reform. The previous target of 20,000 nurses by 2004 has already been met (Buchan, 2002; Secretary of State for Health, 2002). In Wales, the National Assembly issued its own document Improving Health in Wales: a plan for the NHS with its partners in January 2001. This document also calls for an increase in nursing staffing levels within Wales. It estimates that 6,000 more registered nurses will be needed by to carry out the needs of the health system in the next seven years (RCN, 2002b). There is an explicit recognition by the Department of Health (DH) and Welsh Assembly Government that in order to meet these targets international recruitment will have to be part of this process.
GUIDELINES ON INTERNATIONAL RECRUITMENT
Many international and regional policies have been written pertaining to ethical guidelines for the recruitment of health professionals. There are three important sources of ethical guidelines that have been published of relevance to international recruitment in Wales. These come from the Commonwealth, the DH in England, and the Royal College of Nurses (RCN). The Commonwealth Secretariat has released guidelines that try to be sensitive to the both needs of recipient countries and the migratory rights of individual health professionals (Commonwealth Secretariat, 2002)  . The Commonwealth states that governments should not limit or hinder the freedom of individuals to choose where they wish to live and work. However, “the Code is intended to discourage the targeted recruitment of health workers from countries which are themselves experiencing shortages” (Commonwealth Secretariat, 2002, p.1).
The Department of Health in England issued more specific guidance on ethical international recruitment practices in 1999 requiring NHS employers to avoid direct recruitment from designated countries such as South Africa and the West Indies. The DH revamped these guidelines in 2001 publishing The Code of Practice which seeks to promote the best possible standards and discourage any inappropriate practices which could harm other country’s healthcare systems or the interests of healthcare professionals who apply for posts (DH, 2003). The DH has also produced a list of agencies that are operating in line with The Code of Practice, and they advise NHS organizations to refer to the list when making contracts with agencies. The site also provides contact information for local international recruitment coordinators that can be contacted for advice when considering international recruitment.
The DH has also worked together with the Department for International Development (DFID) to produce a definitive list of developing countries from which nurses should not be recruited. This list is based upon the OECD/Development Assistance Committee list of Aid recipients. In addition, it includes a number of countries from which the UK has agreed not to actively recruit from (DH, 2003). Currently, the DH has established bilateral agreements with Spain, India, and the Philippines to recruit nurses even though India and the Philippines are listed as aid recipients. The DH stipulates that recruitment only occur via government agreement with India and only from those states that do not receive DFID aid (Andhra Pradesh, Madhya Pradesh, Orissa, and West Bengal). The National Assembly for Wales has not issued its own policy guidance because it is following the guidelines set by the DH.
The guidelines issued by England are only partially about ethics, but much more about efficiency. It states that NHS employers should “actively seek to collaborate, particularly with neighboring organizations in the same geographical area, to tender for the services of a commercial recruitment agency” (DH, 2001, p.8). One interviewee noted,
“One of the things that has changed significantly in the last four years is the extent to which international recruitment has become systematized. The process has become more efficient and Trusts have learned from earlier mistakes. I think that this has happened because it is top-down. It is national target driven. It is a National Health Service and they have established a national approach. There are regional recruitment co-coordinators and they have encouraged Trusts to bind together. If you look at the detail it is about how to ensure that recruitment approach is effective and what needs to be done operationally to achieve that.”
Research has shown that Trusts in both England and Wales have done exactly this. They have collaborated to reduce costs and use the same agencies that have had extensive experience recruiting from abroad.
The final document that has influenced policy in the UK has been published by the Royal College of Nursing (RCN). The RCN is the UK’s largest professional association and trade union for nurses, and hence is involved in lobbing and advocacy work for nurses throughout the UK. Internationally Recruited Nurses: Good practice guidelines for healthcare employers and RCN negotiators supports individual nurses’ rights to travel and work overseas to develop their practice like the Commonwealth; however, the RCN also states that all employers should refer to the DH’s guidelines, but also encourages all employers to contact the professional nursing association in the source country to obtain their views on whether or not large scale targeted recruitment can be supported without undermining local health care delivery (RCN, 2002a).
THE NURSING WORKFORCE SITUATION IN WALES
The nursing labor market in Wales is similar to that of England. Although England has more internationally recruited nurses due to a higher number of vacancies, particularly in London, the two countries show similar demand patterns and workforce fluctuations. In Wales, there are roughly 24,000 nurses employed by the NHS in 2000/01. Of these there was a total of 17, 670 qualified nurses and 6,560 nursing assistants and auxiliaries (Buchan, 2002b). The NHS Wales currently has a shortage of nurses because of a mixture of market forces, demographic changes, and nurses’ own attitudes about their career structures.
It was in the late 1980s that the shortage of nurses in Wales was first recognized. As a result of a e “demographic time bomb” , or the end of the baby boomer generation, there simply were not enough 18 year olds entering the workforce to keep the number of nurses in pre-registration growing. However, the NHS was saved from a workforce disaster after an economic recession hit and slowed nurse turnover in the early 1990s. It was also during these years that the education and training system for nursing in Britain was changed underProject 2000 with a push from nursing professional associations. With this change there was a view that Project 2000 nurses would be more highly trained and qualified than the previous type of nurse, so that the system would ultimately require less nurses. In fact, the nursing professional bodies created an artificially low number of nurses because they restricted the number of individuals who could pursue other lower grades of nursing. As a result the number of entrants to pre-registration nursing programs fell by 5,400 (26%) between 1989 and 1995 (Buchan & Seccombe, 2002). In Wales, the number in pre-registration, or training programs decreased from about 1000 nurses a year to 600. Workforce planning by Trusts that year did not consider an increase in demand for nurses or take into account the needs of the private sector if the economy picked up again.
In the mid 90s when the recession ended, turnover increased and the private sector began to grow again. There were also reductions in the length of stays in hospitals, which meant that the patients were sicker, thus requiring more highly skilled nursing care. Demand rapidly increased for nurses. The private sector, which previously recruited nurses working in the NHS, had to start recruiting newly qualified nurses. These numbers that were once accounted for in the workforce plans of Trusts as nurses who left the Trust, had never been accounted for in nursing pre-registration numbers. It was not until 1997 when the Labor government came into power that the nursing shortage was appropriately addressed and the number of nursing slots for pre-registration increased.
Today in Wales, there are 1,372 nurses in training, which is more then double the low in 1993. However, it takes three to four years for the students to train and become qualified. The philosophy of the Assembly at the moment is to try to train more nurses than needed,,or to offer more nursing placements to students. However, the Assembly is reluctant to increase trainees in fear that the economy will slow again and nurses will be made redundant. Workforce planning tries to appropriately measure the number of newly qualified nurses needed each year to fill the needs of the NHS and the private sector. But as one source commented it is difficult to get workforce planning just right. There is a tendency to either over-shoot or under-shoot nursing projections.
The other issue is that the higher education institutions are at capacity. The issues are space related, but more importantly there are not enough lecturers and enough clinical placements to train all the nurses they might want to. Historically, big hospitals used to have little nursing schools inside the hospital, so if a hospital was running short of nurses they would just recruit more students. But when the system changed in the mid 90s, the universities took over training nurses, so the actual decision making was taken out of the individual hospital. The system has now shown that it has not been flexible enough to increase and decrease the numbers when necessary leading to inappropriate planning and nursing shortages.
The National Assembly in Wales, like the DH, has explicitly declared international recruitment a necessary part of meeting the needs of the expanding NHS. The National Assembly hopes that international recruitment initiatives will not only help to fill domestic vacancies, but also deliver valuable contributions in the exchange of ideas, sharing of best practice, and the fostering of career opportunities for many nurses (NHS Wales, 2003). The National Assembly for Wales now employs an international recruitment coordinator whose job it is to find out which countries have surpluses of nurses and try to arrange government to government agreements to recruit nurses.
Currently in Wales, international recruitment is occurring at the Trust level. Trusts are collaborating together, as well as with Trusts from England, helping to reduce costs. Trusts in Wales have mainly recruited nurses from the Philippines, accounting for over 1,000 employees today in the NHS. In 2001, NHS Wales experienced around 600 whole-time equivalent (WTE) vacancies for all nursing qualifications. In the same year, according to workforce planning numbers from the Assembly, a total of 417 overseas workers joined both the NHS Wales and the private sector (Welsh Assembly Government, 2002). My research has concluded that all Trusts in Wales have expressed problems filling nursing posts since September 2000. The highest vacancies have been reported in intensive care units where there is high pressure, internal rotation of nurses, and full-time work schedules.
Out of a total fourteen Trusts in Wales, three have not gone abroad to recruit nurses from the Philippines. These are Powys, Velindre, and Ceredigion/Mid Wales NHS Trust. Although a source from Powys commented that they struggle with recruitment because it is a rural area with no district general hospital, they simply do not have high vacancies like other Trusts. Velindre is a specialist oncology center located in Cardiff, and Ceredigion/Mid Wales operates an exchange program with Spain from which it recruits Spanish nurses. The remaining eleven Trusts have all been to the Philippines at least once. The four larger Trusts have all been there three times since the fall of 2000. Cardiff/Vale NHS Trust is the first Welsh Trust to go to India in November of 2002. The estimated number of internationally recruited nurses (IRN) working in NHS Wales is 1019.  The source countries are the Philippines (974), India (25), and Spain (20).
Although most nurses in Wales are employed in the NHS, other sectors in which nurses work include general practitioner practices, private sector nursing and residential homes, independent hospitals and clinics, independent hospices, nursing agencies, other public sector services such as higher education, police service, and local authorities (Buchan, 2002b). An accurate and detailed identification of how many nurses are employed in these sectors is not currently possible (Buchan & Seccombe, 2002). Although the Assembly distributes a private sector and social services survey every year, the response rate is only 35-40%. One source noted that vacancy rates for the private sector, nursing homes, and acute sector in England were about 10-15%, but it is not specifically representative of the entire UK.
In assessing inflow of nurses into Wales, there are two main sources of official information, which would account for all nurses in the NHS and private sectors – information from the NMC register and information on the provision of work permits. Any nurse who wishes to practice in the UK must be registered with the NMC. Applicants from countries of the European Union and the European Economic Area have the right to practice in Wales because of mutual recognition of qualifications across countries and can apply with the NMC via the European Community Directives. Nurses from all countries outside the EU must apply to the NMC for verification of their qualifications in order to practice. Most nurses from outside the EU will have to also apply for a work permit.
There are limitations in using the data to monitor inflow of nurse to the UK. Registration data only records the fact that a nurse has been registered. It therefore is a measure of intent to practice in the UK, rather than necessarily an indicator that the nurse is actually working in the UK. Overseas recruitment has become an important source of new entrants – since 1997 more entrants to the register have come from outside the UK, than from Northern Ireland, Scotland, and Wales combined (Buchan & Seccombe, 2002). In 2001/02 a total of 13,721 non-EU entrants were recorded. Admissions from India and Zimbabwe have also increased significantly over the last three years (Buchan, 2002b). Whereas nurses from the EU were once a main source of entrants to the UK, they are declining today. This decline in EU entrants has mainly been due to new directives requiring English language exams. Table 2 in the Appendix from Buchan (2003) shows the percentages of UK, EU, and overseas nurses for each UK country. Wales has the second highest portion of overseas nurses with 3.1% of total registrants with a Wales postcode.
WELSH RECRUITMENT AND RETENTION STRATEGY
Besides recruiting nurses from abroad, other government initiatives are underway in Wales. The government is focusing on attracting more applicants to nursing education programs and increasing enrollment, encouraging nurses who have previously left to return, and improving retention through improved career structures and flexible working practices.
Since all pre-registration nurse education is funded in Wales, there has been an increase in funding, and the number of nursing and midwifery students has increased significantly. In Wales, there are six applicants for every training post. This reported ratio may be skewed by students applying to more than one University.The Assembly has put into place a new educational strategy called Creating Potential which instead of a diploma in nursing after 3 years, they are awarding a degree. One source noted that they are just beginning to see the effects of increases in training now.
Although the simple solution to a nursing shortage would be to train more nurses, the Assembly is bound by numbers of clinical places. A nursing student must complete 2,300 hours of clinical practice under the supervision of a qualified nurse. One source commented that it is about finding a balance between taking qualified nurses out of practice to supervise students, while t trying to increase numbers of students in training. The Welsh Assembly Government has appropriately increased funding for lecturer practitioners under Fitness for Practice to train more qualified nurses that are then able supervise students.
The RCN Wales is currently running a policy campaign calling for “Bridging the Gap” by making nurses’ salaries equal with other professions, hoping to boost recruitment and retention, increasing nurse morale during a period of government reforms, and helping nurses deliver the care that patients deserve. According to the RCN, nurses’ pay lags behind other public sector workers – newly registered nurses start on £15,445 compared to £17,055 for a police constable and £17,001 for a teacher (RCN, 2001a).
Another government initiative, Agenda for Change is a plan to overhaul the remuneration of all healthcare staff. Instead of being paid by ‘grade’ of nursing, in which one would need to get a further qualification to have a salary increase, the pay structure will be based on knowledge and skills. This new salary structure is not due out until October 2004, and the Assembly is hoping that it will make nursing a more attractive profession in Wales.
Funding has also been allocated to attracting qualified practitioners to “Return to Practice” (RTP) through a series of RTP campaigns. In Wales, 8,000 nurses have let their registration lapse in the last fifteen years, half of whom are under 55 years of age. However, North Glamorgan stated that they have held RTP courses for the last four years, and only 20 have completed it, and now they only have three of those nurses working for them. In many instances, drastic changes in the way nursing is practiced makes it difficult for RTP nurses to adjust.
Many people have left the nursing profession in Wales because of family commitments and the lack of flexibility in the profession. The RCN in Wales asked members through local newspapers to describe the reasons for leaving, or contemplating doing so. Many people replied that they have left the profession in Wales because of inadequate childcare facilities within the NHS, inadequate pay, and high stress levels (RCN, 2001b, p.22). The Welsh Assembly Government and the RCN have been advocating for more flexible working hours and a commitment to lifelong learning.
Some Trusts have been looking at how flexible they can be in their staffing procedures without creating problems with continuity of care. Term-time, or only working when the schools are in, is a new staffing pattern that is being advocated for by the RCN, as well as by members of the Assembly. The RCN has also been lobbying for workforce initiatives that adapt to the needs of the nurse, such as Family Friendly Initiatives. The difficultly is moving ideas from a central idea into practice has been a problem in Wales, one interviewee stated. “People can’t get jobs because they want to work less than 22 hours a week.” The system is going to have to become more flexible in order to address the nursing shortage.
Another source stated that flexible working policies do not seem to get through to the middle management. A new system called ‘self-rostering’ in which staff pick what shifts they work has had noteworthy results in Gwent. One particular ward in Gwent has seen increases in applications of nurses wanting to transfer to it, but middle managers are still afraid of giving staff too much freedom to choose, the source noted. But it is these types of changes that will determine the future of nursing in Wales and the UK.
THE PROCESS OF INTERNATIONAL RECRUITMENT
In Wales and England, the process for recruiting nurses overseas begins when the Trust identifies a need for batch recruitment. An agency will then facilitate the in-country screening and recruitment of 20, 50, 100 or more nurses. One interviewee from one of the Trusts said they first contacted the DH and the National Assembly to find out which countries they could recruit from. The countries that were identified at the time were the Philippines and Spain. The Trust made the decision to go to the Philippines because they knew they had available nurses, and England had been there previously. It seemed to the Trust as having been “tried and tested.” The Trust then contacted, Jenrick, a British nursing agency used by most Welsh Trusts, to act as their liaison. Jenrick then agrees on a price with the Trust per nurse. This number usually varies from Trust to Trust, but has been estimated to range between 8-10% of the first-year salary to between £1000-1200 per nurse recruited (Buchan, 2003).
Jenrick will then organize the trip with a partner agency in the Philippines that is registered with the Filipino government. Trusts give Jenrick a “skill set” for the nurses they are seeking and how many they hope to recruit. Many of the Trusts are recruiting nurses for general surgeries, according to a Jenrick employee. Each applicant in the Philippines must complete a math and English test, and those that pass are short-listed for interviews, which last approximately 20 minutes. After decisions have been made, Jenrick then sponsors an employment ceremony where all the nurses come and receive their job offers. They watch videos and instructions are given on how to register with the NMC. A deployment date is then set for all the nurses to come over in a group. Jenrick has an arrangement with British Airways to fly them all over en masse and help them through immigration. Jenrick also secures transportation from the airport to tjheir living accommodations and provides ongoing support for the recruited nurses throughout their stay in he UK. There is a 24-hour phone line available, and the agency personally evgaluates each nurse after 6-8 weeks to see how adaptation process went. The source from Jenrick stated that they do not recruit from any of the countries on the Department of Health’s prohibited countries list, or those countries receiving DFID aid.
The process of adaptation varies in length from Trust to Trust. Adaptation programs last between 4 weeks to 6 months in which the nurse is supervised by a mentor and clinical skills are assessed. In Carmarthenshire, nurses must complete two weeks of theory and three months of supervised practice on a particular ward or department where they have to meet specific competencies. After the adaptation period, the nurse is then eligible to register with the NMC. Some Trusts that were interviewed also had induction programs about living in the UK and connected nurses with the Filipino Workers Association in Wales.
Once registered the nurses are offered a two-year work permit with the option of renewing for a third. All the interviewees stated that most of the nurses they have recruited have opted to stay. Only a couple of people from each Trust have not stayed, but Trusts usually find that they may lose one or two nurses, but will then gain partners or relatives of other employees.
Most Trusts that were consulted stated that recruiting from the Philippines was been a positive experience. It could be implied that if the process was not seen as efficient or affordable, Trusts would not continue to go back as data illustrates. Out of the eleven Trusts that have gone to the Philippines, eight have gone more than once.
Although international recruitment has not worked for some Trusts, most Trusts in Wales will continue to recruit nurses from overseas. Although data shows that the Welsh Assembly Government is training more nurses, recruiting nurses from abroad has become an efficient and easy process. Since the nurses are already qualified, they do not require as much supervised training as recent graduates from nursing schools.
|Box 1: The Philippines – A case for concern or not?
It is worth highlighting the situation in the Philippines because it is a unique example. The Philippines currently trains more nurses than it needs according to officials in the country, whereas many other developing countries have significant problems in meeting the needs of their own health system. However, according to WHO (2001) although officials in the Philippines claim that they have an oversupply of nurses and doctors, their ratios do not indicate this. Instead, the problem appears to be an oversupply of graduates from nursing and medical schools, many of whom are unwilling to work in rural areas, and as a result, emigrate to countries where the pay and work conditions are more attractive. A distributional imbalance exists where they have much higher ratios of health professionals to population in urban areas and very low or none in many rural areas (WHO, 2001). The government has decided to focus on redistribution strategies rather than training and education appropriately.
Besides the staff losses, there is also concern about the investment that poorer countries make in human capital being lost. Training nurses is also expensive and can drain scarce resources from developing countries. But in the case of the Philippines, many of the nurses could actually be termed a ‘gain’ for the country. Figures show that the Philippine economy is heavily dependent on Filipino overseas workers sending home an average of US$8 billion a year in remittances (Agence France Presse, 2001). Many sources have indicated that Filipino nurses send most of the money they make back to the Philippines, therefore helping their families, but also the Filipino economy. It would then seem that the money spent by the government in training would not be considered a loss or drain from the economy. It is estimated that nurses in the UK make six times as much money as they would in the Philippines.
According to figures from the International Council of Nurses (ICN), the Philippines in 2002 had 332,000 registered nurses in the country. The number of new graduates from the preceding year totaled 4,430 male and female. The national unemployment rate for nursing is 1%, whereas the turnover rate (nurses terminating employment during 1 year) is as high as 15%. The estimated number of years a nurse works out of the country is five. The main reasons the government gives for why nurses are leaving the country is for salary and benefits given by other countries and professional development (International Council of Nurses [ICN], 2002).
THE IMPLICATIONS OF INTERNATIONAL RECRUITMENT
While the UK is employing various strategies to train and retain more nurses evidence suggests that this targeted, international recruitment can only be a short-term solution to domestic shortages. The global nursing crisis means that more and more countries with nursing shortages are recruiting from abroad. This is leading to an increasingly competitive labor market and, if current trends continue, it is likely that the countries that traditionally supply nurses will reach a limit.
The level at which the migration of health professionals becomes a problem for the destination, or recipient country, is when the level of reliance on international recruitment makes that country vulnerable to future changes in the labor market, or if the level of skills or competencies begin to compromise patient care. From the standpoint of the source country, a problem exists if nurses are leaving, and creating vacancies that then compromise the level of care these countries can provide. One interviewee noted that the broader context must be analyzed as to the resources available for nurses or medical professionals in general. Questions like what is the status of nurses in the country? Are they being fairly paid? How significant is the outflow of nurses into the private sector or out of the country? Are there large numbers of nurses deciding not to practice?
It is important to remember that nurse migration can also be mutually beneficial (RCN, 2002a). The international mobility of nurses offers opportunities for nurses to learn and build expertise. This knowledge can then be transferred to their native country. However, the emigration can also result in the loss of health professionals from the emigrating country if they do not return or send money back. In the UK, although many Filipino nurses are sending remittance monies back to the Philippines, there is an unbalanced flow of nurses with many more nurses immigrating to the UK than are leaving.
Most internationally recruited nurses coming to the UK today conform to the typology of an economic migrant. They are here on a two year work permit with the option of a third year. But they are in the UK because they are attracted by a better standard of living. One source stated that this suggests that many of the nurses are not just temporary migrants, but will wish to stay in the UK for as long as they can unless the situation improves in their own country. Will the UK then send these nurses home after their 3 year work permit expires? One source stated that in Wales, the government is currently extending all contracts for another three years.
There exists a natural level of migration of skilled health professionals for personal reasons. Individuals may be in search of better returns to one’s knowledge, skills, qualifications and competencies. However, large migrations of health personnel can affect many countries and ultimately the provision of health services worldwide (World Health Organization, 2002). Large emigrations of health professionals can leave the poorest countries with inadequate human resources to care for their already deficient health systems.
Different strategies have been proposed to mitigate the negative impact of international migration. Measures have included good practice guidelines and taxes on host countries, but these policies have not yet produced their expected effect (OECD, 2002). Other suggestions include some kind of compulsory community service before leaving the source country, or imposing licensing restrictions by the destination country to curb migration.
Peter Bundred (2000) suggests that if developing countries are bearing the cost of educating the nurses that subsequently emigrate, maybe they should be reimbursed for the loss of that investment, when the graduate leaves to work in another country. The gaining country might have to reimburse the cost of nursing and medical education (Bundred & Levitt, 2000). Such a measure might require new international laws or bilateral agreements between the destination and source country.
More research within countries is needed to evaluate the effects of over training nurses, how cultural differences might be affecting patient care or management changes needed when employing a multicultural staff. There needs to be better evidence on the extent of the problem from both the standpoint of the source and destination country. It is worrisome as to how reliant some of the Welsh Trusts have become on overseas nurses with Cardiff/Vale in particular looking for new solutions in India. Are they setting the tone for other Trusts to then go to India?
Developed countries also need to make every effort to train sufficient medical professionals to meet their projected human resource needs, and to find new ways. Developed countries need to find more innovative ways to provide adequate human resources for their health systems than pulling them from other countries who have borne the cost of training those health professionals.
There needs to be more of an emphasis on the sharing of medical knowledge and expertise. If health professionals want to travel aboard to enhance their skills and training, then they should be able to. But there must be a social responsibility attached to medical ethics that correlates to the distribution of human resources. Professional organizations and educational bodies need to promote partnerships in which both nations can prosper from the transfer of health professionals.
Countries of the Commonwealth, European Union, and European Economic Area
Commonwealth European Union European Economic Area
Antigua and Barbuda Austria All EU countries plus
Australia Belgium Iceland
Bangladesh Denmark Norway
Barbados Finland Liechtenstein
Brunei Darussalam Greece
Fiji Islands Portugal
Guyana United Kingdom
Papua New Guinea
St. Kitts and Nevis
St. Vincent and the Grenadines
Trinidad and Tobago
United Republic of Vanuatu
Trusts in Wales
I. South East Wales
Bro Morgannwg NHS Trust
a. Number of trips: 3 trips to the Philippines
b. Number of nurses recruited: 29, 40, and then 35 with each consecutive trip
c. Losses: The trust has lost a couple of people to other NHS Trusts, but gained also gained 2 nurses that were wives for current employees.
d. Total Number of IRNs Currently with Trust: 104
Cardiff and Vale NHS Trust
a. Number of trip: 3 trips to the Philippines, first trip in Oct ’00 with Bro Morgannwg and an English Trust (Norfolk); 1 trip to India in Nov ’02 with the Department of Health and the Welsh Assembly
b. Number of nurses recruited: 110 in total from the Philippines and 25 from India
They will be recruiting more within the year because they have so many vacancies and are constantly upgrading services requiring more staff.
d. Total Number of IRNs: 135
Gwent Healthcare NHS Trust
a. Number of trips: February 2000 went to the Philippines, and then again in June 2001, and April 2003. The Trust was actually planning on going to Singapore, but due to the SARS Virus, they decided to go back to the Philippines. The decision to go to Singapore initially was planned because of a terrorist bomb in the Philippines during their last recruitment initiative. The Trust then sought different options because it saw the Philippines as being unsafe.
b. Number of nurses: Recruited 59 in first cohort and 60 in June 2001. Hoping to recruit another 40 for this fall. They have gained 10 or so partners from the first 2 cohorts. The Trust noted that it was easier the second time with help from the first group of recruits.
c. Losses: None.
d. Total Number of IRNs: 130
North Glamorgan NHS Trust
a. Number of trips: Prince Charles Hospital took 1 trip to the Philippines in Nov ’02
b. Number of nurses recruited: 37
c. Losses: They have lost 5, but then gained 1
d. Total Number of IRNs Currently with Trust: 33
Pontypridd & Rhondda NHS Trust
a. Number of trips: Just went in Sept 2001 to the Philippines. No other foreign nurses.
b. Number of nurses recruited: Roughly 40 to 43 nurses were recruited, all have stayed on.
d. Total Number of IRNs Currently with Trust: 42
Velindre NHS Trust
b. Number of IRNs: No foreign nurses working with Velindre Trust. Trust is a specialist oncology centre only.
II. West Wales
Carmarthenshire NHS Trust
a. Number of Trips: Philippines 2 trips, Sept 2000 and Jan 2001
b. Number of IRNs: 52 and then 56
c. Losses: 4 at Prince Phillip and maybe more at West Wales Hospital
d. Total Number of IRNs Currently with Trust: 108
Ceredigion & Mid Wales NHS Trust – Note: small trust only 1,000 employees
b. Number of IRNs: Only Spanish nurses working for Trust. They have not recruited from the Philippines because of the time scale in getting Filipino nurses registered. The qualifications of Spanish nurses are recognized as a member of the EU. The Trust has had links for several years with Spain through an exchange program.
d. Total Number of IRNs Currently with Trust: 20 approximately
Pembrokeshire and Derwen NHS Trust
a. Number of Trips: They went 2 times to the Philippines, each time with Carmarthenshire and Swansea. The 1st group came in Jan 2001, and the 2nd group came over in Oct 2001.
b. Number of IRNs: 12 in the first recruitment, and then 25 in Jan ‘01
c. Losses: Six losses all moved within the UK. No one went back to the Philippines.
d. Total Number of IRNs Currently with Trust: 31
Notes from Phone Interview: No plans to recruit abroad currently. Stated there have been some communication problems with the Filipino nurses, possibly due to the differences in nursing cultures.
Swansea NHS Trust
a. Number of Trips: Went in Fall 2000, Jan 2001, and June 2002 to the Philippines.
b. Number of IRNs: Recruited 60 in first cohort, 50 in second, and 60 in third. They have also gained partners and relatives of recruited nurses since.
c. Losses: 4
d. Total Number of IRNs Currently with Trust: 250
Notes from Phone Interview: Stated that it has “absolutely worked out.” They have “enhanced nursing” in Swansea and they wouldn’t know what to do without them. The Trust does not need to go back currently, but would go back if needed.
Powys Healthcare NHS Trust
b. Number of IRNs: No overseas nurses working for the Trust, and they have not participated in active recruitment either. They struggle with recruitment though. Powys is much more locally staffed, and it does not have any large district general hospital, so it doesn’t have the vacancies like other areas.
VI. North Wales
Conwy & Denbighshire NHS Trust
a. Number of Trips: The Trust has taken 2 trips to recruit nurses in the Philippines.
b. Number of IRNs: The first trip (December 2000) recruited 17 who arrived March 2001, second trip (May 2001) recruited 46 who arrived as follows: 24 in August 2001 and 22 in January 2002.
c. Losses: March 2001 intake – 3 left, August 2001 – 3 left, January 2002 intake – 1 left
d. Total Number of IRNs Currently with Trust: 56
North East Wales NHS Trust
a. Number of Trips: Went in Dec 2001 to the Philippines. (Three N Wales Trusts went together).
b. Number of IRNs: 48 from Philippines recruitment and an estimated 25 other overseas nurses not actively recruited.
c. Losses: 11
d. Total Number of IRNs Currently with Trust: 48
Note from Phone Interview: No plans to go back currently. Noted that the Trust is starting to see the benefits of increased training flow.
North West Wales NHS Trust
a. Number of Trips: Went to the Philippines in Dec 2000, and again in Sept 2001.
b. Number of IRNs: 70
c. Losses: 8 nurses in total have left. Some have left to be with their partners in other parts of the UK, one did not complete the adaptation course, and one was asked to leave.
d. Total Number of IRNs Currently with Trust: 62
Table 1 Number of Internationally Recruited Nurses per Welsh Trust
|Bro Morgannwg Trust||104|
|Cardiff and Vale||135|
|Ceredigion & Mid Wales||20|
|Conwy & Denbighshire||56|
|North East Wales||48|
|North West Wales||62|
|Pembrokeshire & Derwen||31|
|Pontypridd & Rhondda||42|
*Rural area with no district general hospital.
**Specialist oncology center
Table 2 Percent Distribution of UK, EU, and Overseas Nurses in Each of the Four UK Countries as of October 2002 (UK-based registrants with available postcode data)
|UK (%)||EU (%)||OVERSEAS (%)||N=|
|Northern Ireland||96.7||0.7||2.7||20, 782|
Buchan, J. (2003). Here to stay? International nurses in the UK. London: RCN.