With recruits from the European Union beginning to leave the NHS in greater numbers, the question of how to staff English hospitals and care homes becomes more acute.  More than 40,000 nursing roles are currently unfilled amid a sector-wide crisis.  Experts warn three things need to happen simultaneously to begin to bridge the gap: 

• more recruits from abroad
• training more UK nurses, and
• keeping hold of the current workforce

After visa restrictions were relaxed in 2018, last year saw the number of nurses arriving from outside the European Economic Area double to more than 8,000, but with average nursing wages in the UK lagging behind competitors, and an historic reliance on migrant labour, solving the staffing shortage will be an uphill battle.

Mark Dayan, policy analyst at health think tank the Nuffield Trust, said continued migration into the UK is critical.  “The NHS has a long-term tendency to rely on non-UK migration,” he said. “The NHS is also more dependent on migrants than other sections of the economy are on average.”

But Ben Gershlick, senior economist at the Health Foundation, said international recruitment will not be enough to solve the staffing crisis alone.   “A continued over-reliance on nurses from abroad places the UK in a precarious position for the future,” he said. “It is crucial for the future of the health service that the government secures the long-term supply of new nurses in the UK.”

The NHS staffing crisis is most acute among nurses and midwives, with more than 1 in 10 positions going unfilled. That leaves more than 40,000 vacancies across NHS England.  The worst affected area is London, where more than 15 per cent of nursing roles were being advertised in June last year.  It leaves a shortfall of more than 10,000 nursing posts across the capital – a quarter of all vacancies in England.

In their general election manifesto the Conservatives committed to funding 50,000 more nurses over the next five years – increasing nursing numbers from 280,000 to 330,000 by 2024/25.  31,500 of these new posts will be new, including 14,000 newly-trained nurses, 5,000 nursing apprentices and 12,500 nurses from overseas. The remaining 18,500 will be nurses who have been persuaded not to leave, or to return to, the profession.

Measures to shore up the front line have already seen some success. In 2018 doctors and nurses were exempted from the Tier 2 visa cap which limits the number of skilled migrants entering the UK to 20,000 a year.  The result was a net increase of 4,000 nurses a year from outside the EEA.  “In the short- to medium-term more nurses are required from abroad than are currently being attracted in order to keep the NHS running,” said Mr Gershlick.   “The government must therefore ensure that the migration policy does not put barriers in the way of recruiting nurses from both EU and non-EU countries.”

The fresh influx of nurses from outside the EU is generally benefiting the capital, the East and the Midlands – the areas with some of the highest vacancy rates for doctors and nurses, and reliance on migrant labour.  Those areas have seen the number of nurses from abroad rise by more than 1,000 a year since 2018, while northern England struggles to attract fresh talent from overseas.

Migration alone won’t solve the problem. Many more nurses also need to be trained in the UK – something seen as a key opportunity from Brexit.  In June 2015, nurses from the UK were leaving NHS England at a rate of more than 2,500 a year. At the same time, the number of EU nurses increased by 3,500.  In the four years since, after the EU referendum vote, the trend has reversed.  In the year to June 2019, nurses from outside the EEA increased by more than 4,000, while European nurses begin to leave the NHS.

For the first time in years more UK nationals are joining the NHS after a drive to encourage staff to return and boost retention rates.  Almost 1,500 more UK nurses joined NHS England than left in the 12 months to June, but more are needed.  “The NHS is failing to train and recruit enough new nurses domestically and retain enough of those it has,” said Mr Gershlick.

“While the number of people in England starting nursing degrees was up in 2018, this was still some way short of the additional 4,000 nurses in training by 2023/24 pledged in the long term plan for the NHS.”  Sources of recruitment have always fluctuated, according to Mr Dayan, but “there is a level of dependence we have built up on migrant nurses”.   “There have been cycles of the NHS having workforce shortages, either because they haven’t trained enough people or there haven’t been staff to match vacancies,” he said.   “We then need to recruit from overseas in waves to match it.  “In the 2000s when we had large increases in the NHS budget we used non-EU migrants quite heavily to grow the workforce in every area.  “In the middle of the last decade we had a spike in EEA migration, which got up to nearly 10,000 a year, but dropped off a cliff with Brexit and the language test.”

Difficulties attracting new recruits into training or moving to the UK to work in the NHS have various factors, including pay.  The Government has pledged to reintroduce nursing bursaries, worth up to £8,000, to try to entice more students to train in the UK. This would give every student nurse an annual bursary of £5,000 for living costs, with up to £3,000 more for those in particular areas of need.  But once they are in the profession, average wages for nurses in the UK measure poorly against the health services in other countries.  According to OECD data, nurses in the UK are paid in line with the average UK salary.  It amounts to less compared to average wages in countries including Greece, Ireland, Australia, the United States and Chile, where nurses are paid 1.5 times the national average wage.

Mr Gershlick said: “A global nursing shortage means the UK is competing internationally for scarce nurses and this is likely to become increasingly challenging as other high income countries such as Germany become more active recruiters.”  While staff from the EU dry up, the NHS is falling back on historically reliable sources of recruitment.  Staff from the Philippines and India now make up the bulk of nurses from overseas, with more than 30,000 of those registered with the Nursing and Midwifery Council from the Philippines.  The UK has pledged not to recruit from Indian states which are in receipt of aid from the British Government, but the rest of India is not covered by the agreement.

And Britain has a memorandum of understanding with the Philippine Government allowing it to target healthcare professionals.  In the last two years, the number of Filipino recruits has grown by more than 20 per cent, while those from Spain, Portugal and Romania quit.  And while the Asian labour market can provide a vast recruitment pool, there are concerns around the ethics of sourcing staff from poorer countries.   “In both India and the Philippines the recruitment pool is quite deep,” said Mr Dayan. But he added there is a concern over sourcing recruitment from less-developed countries where they are needed.

Experts warn that poor performance in hospital waiting times are directly impacted by the staffing crisis, and that the only way to deal with this is through a combination of improved training, retention and migration.  “The only chance to deliver the 50,000 nurses the Prime Minister promised is increased training, better retention and higher migration,” said Mr Dayan. “It would need about 5,000 additional migrants a year.”  Stopping nurses leaving the profession is just as important. Since 2011/12, around 30,000 more NHS staff are resigning each year, according to workforce data.

Andrea Sutcliffe CBE, chief executive and registrar for the Nursing and Midwifery Council, said: “More needs to be done to address the pressures nurses and midwives face to successfully attract and retain the workforce we need.  “In our last survey of those leaving the register, one third cited too much pressure leading to stress and poor mental health as a reason for leaving.

“These are system-wide challenges that require a system-wide solution – including effective workforce planning, a joined up approach across health and social care and ongoing support for continuing professional development both to benefit people who use services, and create an attractive career pathway for new recruits and existing staff.  “While recent investment by the Government in establishing a grant for student nurses and midwives is a step in the right direction, there is still much more to be done.” 

An NHS spokesperson said: “It’s no secret that the NHS needs more beds, which means we need more nurses from home and abroad.  “This is why the NHS has funded thousands more clinical placements for those in training, delivered a 6 per cent increase in nursing applications as a result of the largest ever recruitment campaign, and rolled out a successful nurse retention programme which has reduced turnover rates.” 

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