Is the overseas nursing market recession proof?

There have been warnings that the recession has made the UK less attractive to overseas workers.

By Graham Clews | Nursing Times

There have been warnings that the recession has made the UK less attractive to overseas workers. With the UK having long relied on nurses from abroad, Graham Clews examines the challenges facing overseas nurses and those who employ them

If you believe the stories in the national press, one of the effects of the recession is that temporary workers, such as the oft-mentioned Polish builders, are leaving the UK.

The pound has sunk sharply against many other currencies, not least the euro, and this month has seen the biggest rise in unemployment for nearly 30 years, making the UK a less attractive place to come to work.

Could this pose a fresh challenge for the country’s health care providers?

Each year, several thousand overseas nurses still join the NMC register, adding to a pool that has been helping support the NHS and the independent health sectors for many years.

But, even before the recession, this influx had started to slow dramatically, with concerns raised about the potential impact on nursing and care homes in particular.

In 2001 the Department of Health published a code of conduct on recruiting overseas staff. This instructed NHs organisations not to actively recruit from developing countriesdue to concerns about the negative impact this could have on their healthcare systems. This code was revised in 2004 to allow independent sector organisations to sign up to its principles.

Since then, although there has been a slight increase in newly qualified nurses from countries within the European Economic Area joining the NMC’s register over the past five years, the number of nurses joining from outside the EEA has fallen year on year.

From 2004 to 2008, for example, while the number of EEA nurses joining the UK register rose from 1,033 to 1,872, for countries outside the EEA numbers fell from 14,122 to 2,309.

The further fall in non-European nurses may well be explained by changes in Home Office rulings and the introduction of the Overseas Nurses Programme.

The Home Office’s ‘shortage occupation’ list sets out members of which professions are eligible for work permits if they are nationals of countries outside Europe.

In 2006, general nursing was removed from the occupation shortage list, leaving a range of specialist and senior positions on it. Last year, there were further restrictions to the list, with only nurses employed at band 7 or band 8 of Agenda for Change or their independent sector equivalents, operating theatre nurses and critical care nurses remaining on the list.

In response to the restrictions, the RCN said it wanted all categories of nursing put back on the list. RCN general secretary Peter Carter said the government had ‘failed to take into account the disproportionate impact the recommended changes to the shortage occupation list will have on the care home sector, which has become heavily reliant on overseas nurses and care workers’.

Additionally, the NMC’s Overseas Nurses Programme, launched in September 2005 as a response to quality concerns, has added another potential barrier to registration for overseas nurses. It must be completed by all non-EEA nurses and comprises two parts ; 20 days’ protected learning time and, if deemed necessary, a period of supervised practice in a clinical setting.

While the consequences of both these are already well established, the effects of the recession could only just be starting to hit home in the independent sector. And the public sector may well lag some way behind that, because of its relative protection from market forces, the independent sector will be first in line for fallout.

The evidence from independent sector employers is that, so far, economic conditions have not been extreme enough to result in jobs being lost or in the number of shifts being reduced.

Frank Ursell, chief executive of the Registered Nursing Home Association, said that, while nursing homes were feeling the squeeze like everyone else, nurse numbers was not an area where cuts were likely to be made.

‘Nursing homes have to have nurses on 24 hours a day, so I can’t see the numbers need dropping,’ he told Nursing Times.

Mr Ursell said he had heard no reports from his members of nurses being laid off. Indeed, nursing homes were still keen to recruit from abroad, with the occupational shortage list being the biggest barrier to doing so.

One factor that could be protecting overseas nurses from any potential recession-related drop-off is the almost insatiable demand for nurses - on a both national and global scale, according to Barry Proctor, international director of HCL, the UK’s largest health and social care recruiter.

His firm handles recruitment for both NHS and independent sector bodies seeking to recruit permanent healthcare staff, and HCL often recruits from overseas.

The only reason he sees for a reluctance to recruit overseas is the Overseas Nurses Programme, which can dissuade organisations to recruit from outside Europe, because of the costs and time involved.

Another recent trend Mr Proctor has noticed - which may or may not be related to the recession - is a greater demand for work abroad from UK-based nurses. This is from both UK nationals and overseas nurses who have come to the UK and now want to move to the Middle East, the US or Australia.

The trend represents both an increase in the opportunities available in those countries and the chance for overseas nurses who have improved their skills in the UK to progress their careers elsewhere, he said.

Nicola Hooper, national recruitment manager for BUPA Care Homes, told Nursing Times that her company was not actively recruiting nurses from outside Europe but employed significant numbers of overseas nurses who were already working in the UK.

Despite the recession, she said, rather than looking to reduce the number of nurses they employed, BUPA Care Homes intended to provide at least the same level of employment as in recent years.

‘We’re still recruiting at the same levels that we have been for a while, our training and development budget has not been cut, and we are on course to open three new care homes in the UK this year,’ said Ms Hooper.

Although her firm has not suffered in the recession, one trend she has noticed is a new reticence among nurses to change their current jobs. Whether or not this is because there is less work available for nurses, or whether it is a reaction to the welter of bad news stories about the economy is unclear.

‘There is definitely less movement in the industry and, consequently, fewer job-seekers,’ she said. ‘People are playing it safe.’

This is perhaps unsurprising. The number of nurses seeking advice from the RCN’s welfare rights and guidance service rose by 33% in the year to the end of February 2009 compared with the previous 12 months.

The service provides expert advice and guidance to members across a range of issues from state benefits and debt counselling, to interview techniques and CV production.

Claire Cannings, welfare rights adviser at the RCN, said the likelihood of overseas nurses losing their jobs as a result of the UK’s financial situation was not really any different from that of home-based nurses.

The big difference between them will be the effect if they are made redundant or their level of work reduces, because overseas nurses have no recourse to public funds, which restricts their access to welfare benefits, she said.

‘Overseas nurses do not have the safety net that is available to home-based nurses,’ she added. ‘Childcare is not available, they cannot get housing benefit or help with their mortgage, or jobseeker’s allowance, and they cannot work on the bank.’

The RCN benevolent fund, which provides for nurses in financial difficulty, has always had a significant number of applications from overseas nurses for precisely this reason, Ms Cannings said.

Another factor likely to worsen the effects of a recession on overseas nurses is the fact that a large number work in nursing homes, rather than the NHS, and consequently their terms and conditions mean any redundancy arrangements are likely to be less generous.

Ms Cannings added that, while the job situation appeared stable at the moment across the health sector, things could certainly get worse for overseas nurses. ‘The perception is that nursing is recession proof, but lots of nurses and particularly overseas nurses work in the private and charity sectors, which are feeling the pinch at the moment,’ she said.

‘Perhaps they will be working extra hours to increase income, but that is likely to go if the recession bites.’

Additionally, there are restrictions on work permits for additional work outside nursing that overseas nurses can carry out if they want to take on extra jobs to make ends meet.

Ann Marie Barnard, director of charity Nurse Aid, the UK’s biggest benevolent fund for nurses, said that exact figures were not yet available for the number of nurses that had turned to her charity for assistance since the economic downturn began.

However, she added: ‘We have seen a slight increase in the numbers of nurses in difficulty who don’t have recourse to public funds, and it is something that is becoming of increasing concern to us.

‘It’s something we’re starting to look at in terms of exactly how we can help, but it’s too early in the process to say what we can do,’ she said.

Although the indpendent sector will be the more obvious barometer for recession trends, record NHS investment in recent years is already coming to an end. This financial year’s PCT allocations have increased by less than in recent years, and predictions following announcements in this year’s budget suggest the healthservice will be facing cuts in real terms by 2011- 2012.

Chris Day, director of marketing and communications at NHS Professionals, the health service’s in-house staff agency, said that around 20% of the nurses on its books had qualified overseas.

These nurses came from abroad to the UK to work for NHS organisations then joined NHS Professionals, and are treated identically to UK-qualified staff, he said.

Looking forward, Mr Day said that, within the NHS, the position for overseas nurses would depend on the financial situation that hospital trusts found themselves in over the next couple of years.

‘We are quite early in the cycle at the moment, and there is always a time lag, but demand is beginning to show signs of reducing,’ he said. ‘It will affect acute trusts particularly, as they renegotiate deals with commissioning PCTs.’

He said that the NHS might see a change in the situation during this calendar year, but that would depend on where PCTs wanted to carry out the activities they commissioned. If they moved them to primary care, then there would be further pressure on acute hospital budgets, he said.

If acute trusts find their budgets squeezed by commissioning PCTs, the traditional way of saving money would be to implement a recruitment freeze.

In the short term, this could actually benefit overseas nurses, particularly those who work for agencies, who will be needed to fill in the gaps that will inevitably appear if full-time recruitment tails off.

This will not necessarily benefit all nurses wanting to work in the UK, Mr Day believed. However, for those with more specialist skills there may be more promising news.

NHS Professionals is about to start recruiting from overseas for the first time, with ICU, acute cardiac unit, and maternity nurses all needed from abroad because of the shortage of domestic nurses trained in these fields, Mr Day said.

It will begin its first recruitment activities abroad with targeted campaigns in Ireland. Mr Day said the organisation had not previously recruited abroad, partly because it needed to obtain a licence, and also because it wanted to do this only once it had identified solid demand.

‘It would not be right for nurses from overseas to bring them over if we did not know that there would be demand for their services,’ he said.

Therefore, it would appear that for now the demand for nurses - in both public and independent sectors - is still offering an incentive to overseas nurses to come to the UK. Whether problems are to come further down the line is hard to predict.

Mr Proctor said: ‘Nursing is a hugely sought-after profession globally, and the UK is no different from anywhere else. We’re fairly confident that nursing is going to be in demand in the short and the medium term.’

May 2010