Why foreign nurses hold the nation's health in their hands

Jeremy Laurance

THE INDEPENDENT

By Jeremy Laurance, Health Editor
26 November 2002

Health service trusts are recruiting growing numbers from overseas to ease staff shortages while home-grown hospital workers emigrate



They are of all colours, all backgrounds and from all points of the globe. Some come for love, some for money, some for a better life but they are all here for one purpose – to keep our hospitals, surgeries and care homes going.
They are the overseas nurses on whom the National Health Service now depends and, though they might not realise it, they hold the future of the Labour Government and the Prime Minister in their hands.
Tony Blair has staked his political future on the survival of the NHS. He has invested huge sums to maintain and improve it, sums so large that they are close to the limit of what can be spent. His biggest problem in keeping promises to cut waiting lists, increase the number of patients treated and improve the quality of care is not, any longer, money. It is people.
The NHS does not have enough pairs of hands to deliver the care that the nation needs. There are too few home-grown nurses willing to do the job. So hospitals are turning abroad to find staff.
At the Manchester Royal Infirmary they have recruited more than 250 nurses from India in the past two years, placing advertisements in local newspapers, hiring recruitment agencies and holding interviews by video link. Jinto Joseph, from Bangalore, arrived 18 months ago with 20 of his compatriots and is now working on an orthopaedic ward in Manchester. "I got my work permit and my flight was arranged in four weeks. It was very quick. Everything here is so different," he said.
Those 250 Indian nurses mean the difference between triumph and disaster for the infirmary. Without them almost 20 wards would have to close, according to head of nursing, Cheryl Shuttleworth.
"We anticipate there will be 4,000 vacancies for nurses across Greater Manchester by 2005 unless we do something to boost recruitment. That is a huge number. Our own trust is growing massively and services are expanding but the available workforce has shrunk. There is huge competition for staff."
Indian nurses now account for one in ten of the infirmary's nursing workforce. The infirmary selected India because, Ms Shuttleworth said, it had a surplus of nurses. They also had very good training and a good work ethic. "They are conscientious and caring. Their English is good and we found them highly skilled. We just want to train them to be a bit more assertive," she said.
In addition, a dozen other countries supply staff, including the Philippines, Australia, Spain, Ghana, Germany, Iceland and the Yemen. The infirmary runs an adaptation course – for which it has won a training award – to bring its overseas nurses up to the standards expected in Britain. There has been little racism, few communication difficulties and only minor problems caused by different cultural expectations. Some of the Indian nurses have complained that patients do not show them enough respect, demanding second opinions. But, says Ms Shuttleworth, that is a matter of adjusting to the lower levels of deference shown to professionals in Britain. Overall, the international recruitment programme has been a "huge success", she says.
There is a global shortage of nurses, and a global market that governments, commercial agencies and enterprising individuals are learning to exploit. Countries in the developing world are discovering a valuable export in skilled medical labour. The Philippines is the world's most productive nurse factory – turning out thousands of young nurses to meet the burgeoning demand in the developed world.
Filipino nurses send regular sums of money to support their families at home. So do Filipino technicians and other skilled professionals. By earning much-needed foreign currency, they have become the engine that keeps the home country's economy ticking over.
Last year, 7,235 nurses travelled to the UK from the Philippines, bringing the total to more than 11,000 in three years. In 1998- 99, only 52 Filipino nurses set foot on these shores.
In total, 15,064 nurses from overseas countries outside the European Union arrived in Britain last year. It represented a four-fold increase on the number entering in 1998-99. A further 1,091 nurses from the EU took the total to 16,000 foreign nurses admitted last year.
They are still a tiny proportion of the 400,000 nurses working in the UK, but they are essential to keeping the health service functioning. Beverley Malone, general secretary of the Royal College of Nursing, said: "Overseas recruitment is not a short-term measure, it is a long-term solution. We must work with our overseas colleagues and embrace them. There just are not enough home-grown nurses."
The Government target of an extra 20,000 nurses by 2005, set in the NHS plan published in July 2000, has already been achieved, more than two years ahead of schedule, thanks to overseas recruitment. Now ministers have set a new target, of recruiting an extra 35,000 nurses by 2008.
But the global market is getting tougher as countries vie for position in the increasingly desperate struggle for extra pairs of skilled hands. Tom Sandford, London regional director of the RCN said: "Increasingly, people are fishing in the same pool. The US said it needs to recruit one million nurses over the next 10 years.
"If you go to a recruitment fair in the Philippines, out of 10 interview suites, nine will be occupied by Americans and one by the British. The Americans are offering $5,000 (£3,200) to a nurse who brings a friend to work in the US plus another $5,000 for the friend. The pool of nurses we have been totally reliant on is not going to be there in the future."
The global shortage raises an ethical issue. Should we be poaching nurses from countries that can ill-afford to lose them? The charge is that the NHS is stripping the developing world of its most vital resource, skilled medical staff.
The RCN supports overseas recruitment but says it must be done ethically and that proper support must be given to nurses once they are here.
Three years ago, after an appeal from Nelson Mandela, British ministers issued a directive banning all NHS trusts from recruiting in the developing world, except from named countries (including the Philippines) where there was known to be a surplus.
The abject failure of that directive was revealed this month in figures published by the Nursing and Midwifery Council showing recruitment doubled from South Africa last year. We took 2,114 of its nurses, more than three times as many as in 1998-99 when Mr Mandela made his plea. A further 1,500 came from other African countries, including Zambia, Malawi and Botswana.
The poor have to seek their fortune where they can and few countries are keen to restrict the free flow of labour. But the loophole in the Government's ban on NHS trusts was that it did not extend to commercial recruitment agencies, which are now doing the NHS's dirty work.
Some nurses have alleged exploitation by recruitment agencies, who have charged fees of more than £2,000 to bring them to Britain.
The Government has set up an international helpline for overseas nurses where they can report problems or seek assistance to prevent exploitation.
But even as the NHS pulls in nurses from overseas, British-trained staff are leaving. For every two nurses recruited overseas, a home-grown one moves abroad. Last year 6,256 British nurses emigrated, the highest number for 10 years. There was a strong recruitment drive from America, which took 1,089, more than twice as many as the previous year.
One of them is Alison Webster, from Derby, who is on her way to Seattle on the west coast where she will work as an HIV nurse for twice the salary she can earn at home.
But it is not just the money, she says. "When I went out to the US the staff made me feel important and appreciated. When you go to an interview in the NHS it is about, 'What are you going to bring us'. In Seattle it was more a case of, 'What can we offer you to come?'."
Nurses who speak English are finding they are at a premium – in demand all around the world. America, Australia, New Zealand, the Republic of Ireland and Britain are trying to solve their problems by recruiting from each other and from the developing world.
Work permits for nurses are being fast-tracked by governments desperate to solve their staff shortages, and employers are sponsoring applications for immigration.
British nurses can now pick and choose where they work and more of them are spotting the advantages of becoming internationally mobile.
Nurses are discovering they have economic power and it is a discovery that will cause increasing discomfort to the NHS and, ultimately, to Tony Blair.
CYNTHIA ANKRAH-BOI SENIOR STAFF NURSE, 39, FROM ACCRA
Love was what brought Cynthia Ankrah-Boi, 39, to Britain. She met her future husband – an engineer working in England – while he was on a trip to Ghana. They were old family friends and when the relationship blossomed, she agreed to give up her job at Accra's main hospital and move to Manchester.
She arrived three years ago and initially stayed at home to look after their baby son. Since completing an adaptation course at the infirmary last year she has been working in the endoscopy unit. She was recently promoted to senior staff nurse. She said: "In Ghana you struggle every day to get the equipment and the resources. Here it is up to date and available. I find it very easy to work here."
Her current salary of £16,000 is incomparable with the £40 a month she received in Ghana.Though she admits she struggled at first to cope with her new environment, she now plans to stay.
"Even though I had been trained, the culture was different. I had to get used to the equipment and the way of communicating. But the staff were absolutely lovely and I have had no problems from the patients."
JINTO JOSEPH STAFF NURSE, 26, FROM BANGALORE
Jinto Joseph was working in Hosmat orthopaedic hospital 18 months ago when he saw a newspaper advertisement offering him the chance to work in Britain. He contacted an agency acting for the Manchester Royal Infirmary in India and went to Delhi for an interview by video link with his prospective employers. A few weeks later he was on a flight with 20 others, all bound for jobs at the infirmary.
"There was some fear among us but as soon as we got here we had really good support from the international recruitment department at the hospital. There were no problems except homesickness and after a very few weeks I was becoming like an Englishman. Most of us are really happy." The group took a six-month adaptation course, laid on by the infirmary, to ensure their skills were up to scratch and to help them to adjust to British ways of doing things.
Mr Joseph, 26, earns £16,000 a year basic plus overtime, some £18,000 a year in total. Although the pay is better than in India he does not feel rich because the cost of living is so much higher.
"In India people pay for care and they are more demanding," he says. "Here the patients are more considerate."
MONA FARRER SENIOR STAFF NURSE, 33, FROM YEMEN
Mona Farrer is ambitious. She arrived here three years ago with a degree in nursing from Yemen, her home, and a diploma from Kuwait.
In Manchester she is working towards a masters degree and plans to go on to do a PhD. Eventually she wants to return to Yemen. As a career woman, aged 33 and single, she is a rarity in her home country. "It is not very common to find someone like me," she admits.
She is an E-grade nurse on an acute medical ward at the Manchester Royal Infirmary. She earns £17,000. Her previous post, in Kuwait, was as director of nursing in a maternity unit where her salary was "quite high" although the cost of living was also high. "Nurses never have good salaries. This is true all over the world, even though we work hard," she said.
The work in Britain was satisfying but it was a long way from her family, she said. "I do miss them – although I have lots of wonderful friends."
She does not want to stay single for ever and hopes to have a family. But for now her career takes precedence. She said: "I do want to do something for Yemen. We do not have a [regulatory] council for nurses. I would really like to take that idea back to Yemen."
ROSARIO FERNANDEZ STAFF NURSE, 25, FROM BARCELONA
Spain has a surfeit of nurses. Rosario Fernandez, 25, from Barcelona, wanted a career that offered a broad range of experience ­ and that was hard to find at home. "I was a community nurse and I didn't like the conditions of work in Spain. It is difficult to get a good job. For myself, I found it more satisfying in Manchester," she said.
Ms Fernandez initially came for 18 months, returned to Spain for six months and arrived back here for a second time three weeks ago. "I came the first time for the experience. Then I realised I enjoyed it more so I stayed longer than I expected," she said.
It was the social life that kept her here, as much as the work. Manchester is a multicultural community ­ a melting pot of cultures from around the world.
"England is not only for the English ­ there are people from many countries here. It is not difficult when you respect each other. It is good fun rather than a problem. I am quite happy here."
She did not come here for the pay. Nurses are as poorly paid in Britain as they are the world over, she says. She is a D-grade nurse working on a surgical ward on a salary of £16,000. Although that is slightly more than she was getting in Spain, the cost of living here is higher so it works out about the same.
"I wouldn't come here for the money. I have not met a nurse who is rich," Ms Fernandez said.

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