Nurses sans frontiers
How ethical is it to stop healthcare workers from the developing world from living and working in the UK?
‘Kids in Africa are dying because their local doctors and nurses are being looted by Britain to work in the NHS’, reported the UK Sun, in response to a briefing by the charity Save the Children (1). Save the Children suggested that the UK’s health services are benefiting from the collapse of health services in some of the world’s poorest countries, and called on the UK government to address this basic inequality through financial restitution as well as other means.
This briefing taps into an issue about which many people, healthcare workers in particular, feel strongly as well as guilty – the perceived ‘unethical’ international recruitment of healthcare professionals from the developing world. NHS employers are expected to abide by a Department of Health voluntary Code of Practice that prohibits recruitment from the developing world except where the host country invites it, because of the negative impact this might have on the health systems of those countries (2).
In practice, however, this means that healthcare workers from some developing countries not only have tough immigration controls to contend with should they want to travel to the developed world, but are increasingly coming under moral pressure not to attempt what many of us take for granted – searching out better employment opportunities. How ethical is that?
Back in 1997, Nelson Mandela appealed to Britain not to poach nurses from South Africa. The World Health Assembly adopted a resolution that called for countries to mitigate the adverse effects of migration of health personnel (3). The foreword to the UK government’s 2001 Code of Practice, by health minister John Hutton, boasts that Britain was the first nation to produce international recruitment guidance based on ethical principles and the first nation to develop a robust code of practice for international recruitment.
The Code applies to 178 agencies and restricts recruitment of doctors, nurses and other healthcare professionals from over 150 developing countries, including South Africa, Ghana, Uganda, Malawi and some Asian countries. The Department of Health has worked with the Department for International Development to produce a list of countries from which there should be no active recruitment, based on the OECD Development Assistance Committee’s list of aid recipients. Exceptional agreements have been reached with the Philippines and with India, which are content for the UK to recruit from them.
The Code was revised and strengthened in December 2004 ‘to prevent unregulated, proactive recruitment of healthcare professionals from developing countries’. It will be extended to cover the independent sector (200 more recruitment agencies) from 2005. This sector has been criticised for stripping developing nations of vital health professionals, and the NHS is asked to use recruitment agencies that comply with the Code from 2005 onwards. People from overseas will still be able to apply for jobs independently in the UK, and will be considered for employment by NHS Trusts in accordance with NHS employment policies.
The Department of Health is at pains in the revised Code of Practice to demonstrate ‘that the UK is concerned with protecting the healthcare systems of developing countries’. This sounds like a laudable aspiration. But the restrictions in this Code will not solve the immense problems facing healthcare systems in the developing world, which are fundamentally due to lack of economic development, not personnel shortages. And is it fair to deny healthcare workers the opportunity to make a better life elsewhere in the world, by placing them under obligation to work in the place of their birth, with the low wages and lack of professional development entailed?
There is a shortage of qualified nurses in the UK, USA, Australia, Canada, France and Germany, and Britain’s reliance on overseas nurses has increased enormously of late. Britain needs 20,000 temporary or agency nurses daily to fill positions. This is compounded by the fact that nursing has become an increasingly unattractive option in the UK because of its low status and poor pay. Better job opportunities and terms and conditions are available to qualified nurses elsewhere, particularly in Australia and the USA; 7,600 nurses left the UK in 2003/4. The nursing workforce is also ageing, with 50,000 due to retire within the next five years. All of this has led to an increasing demand for and reliance on overseas-trained nurses.
This does not detract from the fact that Britain is an attractive option for some overseas-qualified nurses. They may have had to work for little or no pay, with shortages of supplies, in demanding and dangerous conditions, coping with stifling bureaucracies and hierarchies. In comparison, Britain offers better pay and working conditions, more learning and professional development opportunities and higher standards of living than are available at home. Most are recruited through approved agencies that have signed up to the Code of Practice.
According to the Royal College of Nursing there were at least 42,000 overseas nurses working in the UK in 2003, more than double the figure in 2000. In 2004 the Philippines supplied 4,338 and India 3,073 nurses (4). Despite the Code of Practice, one in three work permits issued to nurses in 2003 were to applicants who come from proscribed developing countries, mainly from sub-Saharan Africa (5). Many are recruited through agencies that take advantage of their vulnerability and desperation.
Individuals can pay agencies enormous amounts of money, between £2,000 and £10,000, for the privilege of helping them get here. Some do not find the promised employment as registered nurses, however, so are forced through economic necessity to work while they try to gain the necessary registration. Many never get registered because they do not find suitable adaptation programmes (supervised practice placements) to enable conversion training and end up working as care assistants and cleaners in hospitals. The Nursing and Midwifery Council reported that only one third of the 41,406 overseas-trained nurses and midwives – mainly from developing countries – who applied for registration were accepted during 2003-04 (6).
The situation is similar for doctors. In 2002, nearly half of the 10,000 new full registrants on the General Medical Council register were from overseas; in 2003 this had risen to more than two thirds of a total of 15,000. Most of the growth has been in entrants from outside the European Economic Area (7). Save the Children estimates that over half the doctors trained in Ghana have migrated – between 1999 and 2004 the total number of doctors registered in the UK and trained in Ghana doubled from 143 to 293 (8).
All this seems to lead to the inexorable conclusion that recruitment from the developing world should be further curtailed, because it leads to an unethical ‘brain drain’. Yet this view is based on the questionable premise that the developing world will develop only if its best and brightest remain there to plug away at the problems that the lack of development presents. Does this really help the developing world – or does it merely guilt-trip people, putting an enormous burden of responsibility on those who want to migrate to gain a better quality of life elsewhere?
Successive UK government hostility towards immigrants from the developing world and tough immigration controls allows for their exploitation before and when they get here. And it is worth noting that, although the call for ‘ethical’ recruitment practices comes from the left, similar language is used by the other side of the political spectrum. So the British National Party (BNP) suggests that ‘Encouraging the immigration of professional workers is leaving developing nations without doctors, nurses and teachers. We must stop this poaching and train and recruit our own professionals’ (9).
We should welcome healthcare workers from the developing world, consider them as assets and not put restrictions on their length of stay or expect that they return home after a period of employment. Professional bodies should ensure that the support they need, including supervised training, is made available. While some organisations have begun to do useful work in this area it is scandalous that the expertise of the 27,000 or so nurses, who applied for but didn’t manage to register during 2003/4, is wasted.
There is much more to be done to make the most of healthcare workers’ expertise in the health arena. The broader problems of development, however, need to be tackled in the political arena.
Brid Hehir is a nurse and a lead for patient and public involvement.
(1) Whose charity? Africa’s aid to the NHS
(2) Code of Practice for the international recruitment of healthcare professionals
(3) World Health Assembly, 2004. Resolution 57.18. Fifty-seventh World Health Assembly, May 2004
(4) Is this the way to treat nurses who want a job?, Guardian, 5 February 2005
(5) International recruitment of health professionals, BMJ (2005), James Buchan
(6) Is this the way to treat nurses who want a job?, Guardian, 5 February 2005
(7) International recruitment of health professionals, BMJ (2005), James Buchan
(8) Whose charity? Africa’s aid to the NHS
(9) See the BNP website
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