health professional mobility in europe and the uk: a scoping study

SDO Project (08/1619/134)

© Queen’s Printer and Controller of HMSO 2010 1

Health Professional Mobility in Europe and the UK: A Scoping Study of Issues and Evidence

Research Report

Produced for the National Institute for Health Research Service Delivery and Organisation programme

January 2010

Ruth Young

School of Nursing and Midwifery, King’s College, London

Heather Weir

School of Nursing and Midwifery, King’s College London

James Buchan

Queen Margaret University, Edinburgh

Address for correspondence

Ruth Young

James Clerk Maxwell Building, 57 Waterloo Road, London, SE1 8WA

E-mail:[email protected]


Contents

Acknowledgements ....................................................5

1 Introduction.......................................................6 1.1 Overall Focus and Definitions.................................................6 1.2 UK Context and Historical Background ....................................7 1.3 Why is Europe Important for the NHS Workforce?...................10 1.4 Why the Importance of Within-UK Migration and Competition

for Health Labour? .............................................................14 1.5 Study Design and Main Questions ........................................15 1.6 Remainder of Report ..........................................................16

2 Assessment of Available Data on Health Professional Mobility ................................................17

2.1 What is known About the European Workforce in the UK? ........17 2.1.1 Overall Workforce Contribution of European versus Other

Sources ...................................................................17 2.1.2 Growth of Migration from Different European Sources ....23 2.1.3 Source Country Trends ..............................................27 2.1.4 Contribution of European Health Professionals within

Different Professional Groups......................................35 2.2 What is Known about UK-Europe and Other Out-Migration from

the UK? ............................................................................37 2.3 What is Known Within-UK Migration and Differential Reliance on

Migrant Health Staff?..........................................................40 2.3.1 Perceptions of Trends in Within-UK Migration ................41 2.3.2 Evidence on Within-UK Distribution of European and

Other Internationally-qualified Staff.............................42 2.4 Key Points and Implications of Lack of Data Availability ...........44

3 Drivers and Constraints to Mobility ..................46 3.1 Overall Understandings of Migration Motivations.....................46 3.2 Motivations for European Health Professional Migration to the

UK 49 3.2.1 Motivations and Source Countries................................49 3.2.2 Motivations and Career/Family Stage and other

Demographic Factors.................................................53 3.2.3 Motivations and Different Professional Groups ...............56

3.3 Motivations for Out-migration from the UK and Within-UK Mobility ............................................................................60 3.3.1 Motivations and Outflows from the UK .........................60 3.3.2 Motivations and Mobility within and between the

Different UK Countries ...............................................62 3.4 Constraints to Mobility Within and Between the UK and Europe 63


3.5 Summing Up: The Complexity and Interlinked Nature of Migration Flows .................................................................68

4 Implications for Organisation and Delivery of UK Healthcare ..........................................................70

4.1 Factors Impacting on the Nature of Clinical Practice ................70 4.1.1 Equivalence of Training and Experience........................70 4.1.2 Different Cultural Perceptions of Professional Roles ........74 4.1.3 Potential Implications for Care/Service Standards in the

UK Context ..............................................................75 4.2 Factors Impacting on Dealings with Patients and Carers ..........76

4.2.1 Language Skills and Standards ...................................76 4.2.2 Styles of Communication and Ways of Relating to

Patients ...................................................................77 4.2.3 Implications of Language and Communication for

Therapeutic Relationships...........................................78 4.3 Human Resource and Organisational Management Challenges ..80

4.3.1 Addressing Individual Adjustment and Development Needs .....................................................................80

4.3.2 New Challenges in Day-to-Day HRM Systems................82 4.3.3 Integrating Health Professional Migrants into the NHS

Workforce ................................................................83 4.3.4 Longer-term HR and Workforce Planning Implications ....84

4.4 “Value Added” from Health Professional Mobility/Migration.......86 4.5 Key Questions in the Context of Service Delivery and

Organisation .....................................................................87

5 Evidence About Impacts on Migrants and Source Countries ......................................................89

5.1 The Lack of Evidence on European Health Professionals’ Migration Experience ..........................................................89

5.2 What is known about the Challenges of European Mobility for Source Countries?..............................................................93 5.2.1 The Challenge of Ethical Recruitment and the NHS

Response.................................................................95 5.2.2 The Question of Returning Human Capital, Additional

Skills and Remittances...............................................96 5.2.3 Going Beyond the Overall Workforce Numbers ..............98 5.2.4 Impacts on Source Country Health Systems and the

Question of Finite Supplies .........................................99

6 Implications and Challenges at Health System Level ......................................................................101

6.1 Professional Regulation and Infrastructures to Ensure “Quality”101 6.2 Workforce Planning: Information Availability and Overall

Approach........................................................................ 104 6.3 Labour Market Policy-making in the Context of European

Mobility .......................................................................... 106 6.4 Relationships between Receiver and Source Countries within

Europe ........................................................................... 109

7 Key Findings and Future Research .................111


7.1 Summary of Issues and Further Questions .......................... 111 7.1.1 Literature and Data .................................................111 7.1.2 Migration/Mobility Trends.........................................112 7.1.3 Motives and Constraints Relating to Mobility ...............112 7.1.4 Impacts on Service Delivery and Organisation in the UK113 7.1.5 Impacts on Individual Migrants and Source Countries...115

7.2 Summing-Up: The Continuing Importance of Mobility/Migration for the NHS Workforce...................................................... 116

References .............................................................119

Appendix 1 Study Methods .....................................137

Appendix 2 Interview Schedule Topics...................140

Appendix 3 Countries Covered by International Recruitment Code of Practice .................................142

Appendix 4 Glossary of Terms ...............................144


Acknowledgements

We are grateful to all of the interviewees who took part in this study; and also to the various professional regulatory bodies that provided data. This included the: General Medical Council; Nursing and Midwifery Council; Health Professions Council; General Dental Council; and Royal Pharmaceutical Society of Great Britain. Also, thanks go to Philip Berman, former Director of the European Health Management Association (EHMA), who provided the original inspiration for the study.

This report presents independent research commissioned by the National Institute for Health Research Service Delivery and Organisation Programme. The views expressed in this publication are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health.


The Report

1 Introduction

1.1 Overall Focus and Definitions

This study set out to scope the main issues and identify gaps in knowledge around two key aspects of health professional mobility/migration – within-UK mobility (i.e. movement between England, Scotland, Wales and Northern Ireland) and mobility to and from the different UK countries and Europe. The UK-European migration picture was a key focus because of the consensus that less concrete research has been undertaken on European health professionals compared with those from countries outside Europe. This may be because Europe has historically been less significant as a health professional migration source for the UK than countries elsewhere overseas.1 Now, however, with more and more countries coming into, or coming within scope of Europe’s mutual recognition and free labour movement regulations, it is, at the very least, prudent to ask questions about the potential increasing impact on the NHS and its workforce. Similarly, mobility and competition for health labour within the UK has taken on more significance in recent years as a result of devolution within the political system (Greer, 2001 and 2005); and the lack of evidence on which to make health workforce-related policy decisions within the devolved administrations is well documented (Buchan 2004a).

By Europe, then, we mean both the current member states of the European Union (EU)2 and European Economic Area (EEA)3 which are already

1 “Overseas” is the label applied (e.g. in professional registration statistics) to staff from non-European Union/European Economic Area (EU/EEA) countries, for example, Australia, New Zealand, India, The Philippines; and countries in Africa, Asia, the Middle East, North and South America, and Central and Eastern Europe beyond current EU/EEA borders. 2 In the context of the EU, we also make the distinction between the pre-2004 EU15 (Austria, Belgium, Denmark, Finland, France, Germany, Greece, Ireland, Italy, Luxembourg, Portugal, Spain, Sweden, The Netherlands, and the United Kingdom), and more recent joiners (i.e. Cyprus, Czech Republic, Estonia, Hungary, Latvia, Lithuania, Malta, Poland, Slovakia, Slovenia which joined the EU in 2004 and are collectively known as the EU10; and Bulgaria, Romania, which joined in 2007) that together consist he EU12. Together the EU15 and EU12 make up the current EU27. 3 The EEA is the wider entity that, in addition to EU countries, includes Iceland, Norway, Liechtenstein and Switzerland. Individuals from EEA countries have similar rights to work in the UK as EU citizens.


covered by the mutual recognition of professional training and qualifications and related free movement arrangements with the UK that are associated with the Single European Market (SEM); and countries in what we have termed Wider Europe beyond the current EU/EEA’s eastern and southern borders (e.g. Ukraine, Belarus, Georgia and other former states of the Soviet Union; Serbia, Croatia and other countries that emerged from the former Yugoslavia; and Turkey). The inclusion of Wider European countries was important for the purposes of this report not least because they already constitute a key part of the overall picture of overseas (i.e. non-EU/EEA) health professional migration to the UK; but also because their significance may well increase in future if, as seems likely, some of them enter the EU/EEA itself. Finally, we endeavour to locate UK-EU/EEA and UK-Wider European migration relationships within the complex and competitive context of global health labour markets in general (Bach, 2003; Baumann et al, 2004; Bloor and Maynard, 2003; Buchan, 2006; Buchan and O’May, 1999; Nicholas, 2002). Specifically, the study covers mobility/migration of all the main groups for which the UK relies partly on international health professionals4 to help meet its workforce needs: hospital doctors, general practitioners (GPs), nurses, midwives, allied health professionals5 (AHPs), pharmacists and dentists.

1.2 UK Context and Historical Background

The UK has a long history of employing internationally-qualified healthcare professionals to help sustain the NHS workforce (Aiken and Buchan, 2004b; Buchan and Rafferty, 2004; DH, 2002a; Goodman, 2005; Kelly et al, 2005; Raguhuranm and Kofman, 2002). For some groups (e.g. nursing and general practice), levels of reliance on international supplies have fluctuated – changing in response to the domestic demand-supply trends and cycles associated with economic, political and social circumstances (Buchan, 2002 and 2003; Hall, 2005; Pontin, 2002; Young et al, 2001). With other groups (e.g. junior/non-career grade doctors), however, the NHS has relied almost entirely on international staff to maintain sufficient supplies on an on-going, long-term basis (Grant et al, 2003; Young et al, 2003). Similarly, certain

4 We use the term International Health Professional as an umbrella term to refer to individuals in all groups of interest to the study - medical, nursing, midwifery and allied health professions - who come from countries outside the UK (i.e. from Europe and elsewhere overseas). Other terms used in the literature, which we have subsumed within international, include, for example, foreign medical graduates (FMGs)/international medical graduates (IMGs) for doctors; and international nursing graduates (INGs) for nurses/midwives.

5 Allied health professionals (AHPs) here refers to the following professions regulated by the Health Professions Council (HPC): physiotherapy, occupational therapy, speech and language therapy, dietetics, psychology, psychotherapy, radiotherapy, chiropody and podiatry, orthoptics, prosthetics and orthoptics, paramedics and arts therapies.


regional labour markets have consistently required international staff to meet key workforce needs – a good example being London and the South East of England in relation to overseas AHPs (e.g. from Australia and New Zealand) (Masters, 2004; Young et al, 2008a).

The first example of active international recruitment – when initiatives were specifically undertaken to bring staff into the NHS from abroad – took place as early as the 1950s and 1960s (Buchan and Rafferty, 2004; Taylor and Esmail, 1999); the most recent commenced in the late 1990s when the new Labour government laid out its policy of increasing NHS staffing levels at a rate that could not be achieved via UK-based routes alone6 (Buchan and Seccombe, 2006a and 2006b). International recruitment activity was subsequently further accelerated with the publication of highly ambitious health workforce expansion targets (7,500 more consultants, 2,000 more GPs, 20,000 extra nurses and 6,500 AHPs by 2004) in the NHS Plan (DH, 2000a) – targets that were increased still further in 2001/2 (Deeming, 2004). Although the NHS has always received certain groups of international health professionals there was, then, a step-jump in the level of emphasis placed upon, and the encouragement given to migration across the board in recent years (Buchan, 2004b; Buchan and Maynard, 2003; Buchan et al, 2003).

Historically, in terms of key sources, recruitment and employment of internationally-qualified health professionals has reflected old colonial ties and/or the sharing of English as a common language, as mother tongue or the medium for health education/training. Doctors (both in hospital and general practice), then, have traditionally been recruited from former British colonies, particularly the Indian Sub-Continent – a trend which continues (Young et al, 2003 – India Case Study; Hann et al, 2008). Similarly within nursing, shortages have traditionally been resolved by active recruitment of Commonwealth citizens (e.g. from the West Indies, Asia and Africa) who wished to come to the UK to undertake professional training (Bach, 2007; Buchan and Rafferty, 2004; Rafferty, 2003) (see also Dobson et al, 2001 on general migration patterns). With the exception, therefore, of the – now much reduced, even reversed – flows of nurses and doctors from Ireland

6 Those “UK routes” included the expansion of professional education and training numbers across all relevant health professional groups (UK domestic recruitment); and better use of existing qualified staff – those working in the NHS and those that had left (retention, return and deployment). The latter was to be achieved through: a) improvements in pay, flexible working and childcare provision arrangements intended to encourage retention both of mid-career staff and potential retirees and attract back returners; and b) role redesign, skill-mix change and competence-based working within and between the different healthcare professionals and non-professional staff such as assistants etc (DH, 2000b and 2002b; NHS Modernisation Agency, 2003) (see also DH, 2002a; 2002b). The role of active international recruitment, then, was to boost numbers until these other measures could feed through such that the system might become self-sufficient in health human resources at the higher demand-side levels that were the legacy of the NHS Plan (Mellor, undated).


(Buchan, 2006), and migration associated with source countries’ own fluctuations in training capacity (e.g. general practice in The Netherlands – Pitts et al, 1998), European countries have not been particularly significant as suppliers of health professionals to the NHS labour market. This has been the case consistently for the pre-2004 EU15 despite the freedoms of labour movement associated with EU/EEA membership.

With the most recent wave of international recruitment, however, Europe has become, relatively, more important (DH, 2000c; DH, 2002a; DH, 2007). More specifically, in addition to negotiating recruitment access to countries (e.g. India and The Philippines) outside Europe, the UK government also signed agreements within the EU (e.g. with Spain, Italy, France, Greece, Germany and Austria) and with certain of the then accession states (e.g. Poland and Czech Republic). These agreements enabled NHS organisations and UK recruitment agencies directly to target groups – for instance GPs, nurses and pharmacists in Spain; consultants and GPs in Italy; GPs in France; dentists and GPs in Poland - that the countries concerned saw as being in surplus within their health systems and therefore were willing to see recruited to the UK (Atherton and Mathie, 2002; Ballard et al, 2004a; Blitz, 2005; Wiskow, 2006; Young et al, 2008b). More generally, outside the context of active recruitment, there has been increased interest also in whether overall migration patterns and the relative significance of European health professionals within the NHS workforce might change in light of the accession to the EU of 10 new member states in 2004 and of Bulgaria and Romania in 2007 (Home Office, 2006). This is mainly because of assumptions that wage differentials – i.e. between the countries of Central and Eastern Europe (CEE) and the “Old” EU/EEA member states including the UK- would act as a significant driver for migration of qualified health professionals East-to-West (Buchan, 2006; Buchan and Rafferty, 2004; Krieger, 2004). Finally, there is growing interest in the extent to which EU/EEA students’ entitlement to apply for undergraduate and post-graduate education/training places in the UK (something which again stems from EU/EEA free movement arrangements) might have implications, for instance for workforce planning and the future capacity of the permanent NHS workforce (BMA, 2006; Goldbart et al, 2005; Winyard, 2007).

In the past, perhaps due to the lesser significance of European sources (Buchan, 2003; Krieger, 2004; Simoens and Hurst, 2006), there has been a lack of clear research focusing specifically on European health professionals within the NHS workforce. Compared with evidence about staff from elsewhere overseas, there has been much more reliance on anecdotal evidence and speculation about likely migration trends and the potential impacts on the organisation, management and delivery UK healthcare services (Carlisle, 2005). Such gaps in knowledge have been present for all the UK countries (Buchan and Maynard, 2003). Similarly, most of the evidence about within-UK migration and competition for health human resources has been anecdotal at best - with no clear assessment of overall


workforce availability; or the extent to which different UK countries/regions genuinely out-compete each other for international health professionals (from Europe and elsewhere abroad) and/or actively target areas that cannot afford to lose their health staff within the UK itself. There are, for example, concerns in Scotland about English regions with workforce shortages actively recruiting north of the border (Ashford and St Peter’s Hospitals, 2008; BBC News, 2008); but there has been no appraisal of the full extent and impact of such activity.

1.3 Why is Europe Important for the NHS Workforce?

Although some would undoubtedly claim otherwise, the EU (and its predecessors the European (Economic) Community or EC/EEC) has essentially always been an “economic project” - i.e. its main aim has been to increase the prosperity of Europe and its citizens by enabling greater economic integration, and hence more opportunities for trade, between member countries though the development of an internal or Single European Market (SEM). Another fundamental principal of the EU is subsidiarity – i.e. action is taken and policy is set at EU level only in fields that cannot better be handled at member state or even lower geographical governance levels. This means that in health, the EU itself only has a legal remit to act in relation to public health and ensuring the health protection of citizens within the context of wider EU policies and activities; and even here, “EU action” has “to fully respect the responsibilities of the member states for the actual organisation and delivery of health services and medical care” (Wismar et al, 2002, p.20). On the face of it, therefore, the EU should be having little impact on the workings of the UK health sector because it is the responsibility of individual countries to decide for themselves: how services are delivered (e.g. through what balance of public versus private provision); how treatment or care is paid for (e.g. by a tax-based or a social insurance system); and, most importantly for this report, how or which staff are trained (i.e. in what numbers, to what levels and in what balance between the various different professions). Increasingly, however, it has become obvious that health services and the development of the healthcare workforce within member states cannot be understood without reference to the broader EU-level legislative changes that are being driven by economic considerations (Greer, 2005; Wismar et al, 2002).

More specifically, the SEM or “internal market [is] characterized by the abolition … of obstacles to the free movement [across Europe] of goods, persons, services and capital” (EHPF, 2003: p1). This is pertinent to the


NHS workforce in two key ways.7 The principle of free movement of persons or workers is relevant per se; but it also follows from the free movement of services principle that appropriately qualified individuals have the right to establish themselves (i.e. register to practice) in other countries within the Union. Since its inception, then, the EU (and formerly the EC/EEC) has promoted the mobility/migration of health professionals – primarily through the on-going development of a system of mutual recognition of professional education, training and qualifications based on EU-level Directives (Box 1.1). Two types of Directive have been in place with reference to health professionals. Doctors (hospital and GPs); dentists; general nurses; midwives and pharmacists have been covered by what are termed Sectoral Directives. Harmonization of education/training and skills means these professionals are entitled to automatic registration by their appropriate UK regulatory body (and equivalents in other EU/EEA member states). The other main health professions – including specialist nurses and the various AHPs - have been covered together with a whole range of other occupational groups by the General Directive. Under this, recognition has been decided on a case by case basis – i.e. those with qualifications and experience equivalent to UK qualifiers can be registered but for others a period of adaptation may be deemed necessary. Unlike health professionals from elsewhere overseas, however, no EU/EEA-qualified individual, whether covered by the Sectoral or General Directive, has to prove language proficiency in order to register.

7 N.B. We focus here on the factors most directly relevant to health professional mobility per se. Clearly, however, other aspects of EU policy are also relevant to the NHS and its workforce – e.g. a) measures such as the European Working Time Directive, which stemmed from the EU remit to protect the health of workers/citizens and impacted most notably through the requirement to reduce junior doctors’ hours of work and find workforce (e.g. role/service redesign) solutions that could compensate for that (Mahon and Harris, 2003) (Interviewees A2; B3; C1; D1); and b) the moves to clarify arrangements for patient mobility, made necessary by on-going decisions of the European Court of Justice (ECJ) on patients’ rights to travel to access healthcare in EU member states other than their country of residence (EHMA, 2008) (Interviewee C2). The key point is that ECJ rulings are explicitly based on argument that: “Cross border care does not pose a threat to human health because a similar standard of health care can be expected in all member states”; and legal opinion, in turn, is based on the Court making the assumption that mutual recognition of diplomas and established minimum training requirements for health professionals will guarantee this standard.


BOX 1.1 MUTUAL RECOGNITION DIRECTIVES FOR HEALTH PROFESSIONS

Sectoral Professions (With year Directives introduced shown in brackets)

Medicine – (1975 – modified further to simplify arrangements 1986 and 1993) Nursing - General Care – (1977) Midwifery – (1983) Pharmacy – (1985) Dentistry – (1978)

Directives have provided for: harmonisation of education and training; agreement on minimum educational and training requirements and a listing of qualifications that meet these; and automatic professional recognition of an individual holding a listed qualification.

General System

Allied Health professions – e.g. physiotherapists, occupational therapists, speech and language therapists, radiographers, dieticians and others regulated in the UK by the HPC

Nursing – specialisms such as mental health and learning disability

For General System professions, there has been no harmonisation of education and training – i.e. recognition of qualifications has been on a case-by-case basis and EU member states have retained the right to require compensatory measures (a test of aptitude or period of adaptation up to 3 years).

Compiled from: EC (undated a) Professional Qualifications. Available on website: http://ec.europa.eu/internal_market/qualifications/index_en.htm (Accessed 01/07/2008)

Despite the various mechanisms introduced to facilitate the internal market, the EU has continued to fall behind its main global competitors (e.g. USA and China) in terms of overall economic competitiveness (EC, 2002). At EU level, this is seen as being due primarily to: a) Europe continuing not fully to utilize the resources, in particular the human resources, available to it; and b) the fact that the increased free movement and overall trade achieved for goods and capital has not been matched in the service sector (including health). As just one example in the context of health, the Sectoral Directives have required considerable adjustments on the part of individual countries’ health systems – one instance from the UK being the reductions in the lengths of training necessary for medical specialist recognition. However, the adjustments have not led to the levels of true harmonization and related worker (i.e. individual health professional) mobility – i.e. labour market adaptability - across Europe that were hoped for. Nor have they, therefore, contributed as much as anticipated to growth of trade in services; and hence the contribution of that sector of the economy to overall EU levels of employment and economic competitiveness.

http://ec.europa.eu/internal_market/qualifications/index_en.htm�


Since these continuing economic challenges were identified at the Lisbon European Council in 2000, the resultant EU-level strategy (EC, 2002) has been twofold:

Boosting the production of skilled/knowledgeable workers through the Bologna Accord, which aims to establish a European Higher Education Area by 2010 (EC, undated b); and

Making it easier for those trained/educated people and their knowledge and skills to move through the development of increasingly flexible and accessible labour markets via a new EU Directive 2005/36/EC (EC undated a)

Both measures will impact on mutual recognition of health professionals in the short and longer-term. First, the Bologna Process (which will be particularly relevant in the view of several of our interviewees: B3; C2; C4; E1 – the main exception being dentistry where the profession was still reportedly undecided on how to go forward – C3) is intended to remove obstacles to student mobility and bring higher education systems together in a common framework. That potentially means that different countries could be contracted to train health staff to work elsewhere (e.g. the UK). At the very least, the need to develop mechanisms for greater transferability of qualifications might have implications later on in terms of real equivalence of education/training and in terms of qualified professionals (especially those covered by the General Directive) being recognized. Second, EU Directive 2005/36/EC is intended immediately to reduce regulatory barriers and increase the automatic recognition of qualifications in order to aid free movement of already qualified professionals/workers (Box 1.2). Significantly, in health this free movement of actual professionals/workers is even more important than in other services because so much of service delivery itself is embodied in the people themselves and is only as good as their knowledge and skills.

BOX 1.2 KEY CHANGES INTRODUCED BY EU DIRECTIVE 2005/36/EC

More specifically, under EU Directive 2005/36/EC any professional registered (for at least two years) in one EU/EEA member state now has automatic entitlement to provide, for a limited period each year, services in another member state without registering with the appropriate regulatory body. Thus a health professional from the EU/EEA wishing to work temporarily in the UK need only give a declaration, in advance, of an intention to work to the relevant competent UK authority (DfES, 2008).

In addition, and particularly relevant to the AHPs which have not previously had sectoral

mutual recognition, the Directive permits the formation of profession specific ‘common platforms’ – i.e. where previously agreement on mutual recognition would have been needed between all 27 EU member states, voluntary agreements are now possible between fewer states (two-thirds of states where a particular professional is recognised), which predefine the necessary qualification criteria for registration. If such criteria are complied with there is no need for further compensatory measures (ER-WCPT, 2006). As Petchey and Needle (2007) notes the overall purpose of common platforms is to enhance professional mobility through increased transparency and decreased bureaucracy.


Overall, it is clear that such measures will continue to have implications for the NHS and its workforce; for relevant bodies such as the regulatory authorities and professional organisations; and for policy makers at UK national and constituent country level. There are, for example, potential (some fear negative) implications from the point of view of patient safety and standards (Coombes, 2002; Griffiths, 2002; Scott, 2002). However, there also many potential positive benefits from the viewpoint of overall health human resources that we will return to later in the report. Importantly, what is most clear is that the EU itself will continue to see the health workforce as an increasingly important topic of its attention (Kidd, 2007). At the very least, the NHS itself and other key players at all levels in the UK need to understand such issues surrounding health professional mobility and take a realistic, evidenced view of how to go forward.

1.4 Why the Importance of Within-UK Migration and Competition for Health Labour?

The four UK countries have always had a significant amount of autonomy in determining how many health professionals they train, but with full political devolution since 1998, there is now clear evidence of significant health policy divergence across the four UK countries, with different policy priorities, different underpinning philosophies, and different health systems structures. Regulation of health professionals and pay of NHS staff have however remained mainly a UK wide foundation. This means that NHS staff trained in any one UK country can move freely across all four countries of the UK countries where health policy may be diverging, but where health labour markets are connected freely and with a common currency of a UK wide pay system. Within the UK, then, funding, planning and educating the NHS health workforce are all devolved matters, and those responsible in any one UK country need to be clear about the extent their country is a net gainer or loser in terms of UK cross border flows. A significant net outflow of staff - particularly if recently qualified - represents a funding outflow, and may undermine workforce plans. The extent to which there have been cross border flows has been, however, extremely difficult to ascertain.

As with overseas migration, internal migration and competition (e.g. between the various regions and constituent countries of the UK) of health human resources also has consequences for health care delivery. As Diallo (2004), for instance, highlights, imbalances and inequities in accessing care can arise in those geographical areas within a country which lose health professionals to other regions. A report on the healthcare workforce in Europe by the Hospitals of the European Union organisation in 2004 also commented that recruitment difficulties tend to occur in some specialisms and in certain types of geographical area. The latter would include inner cities and areas of social deprivation, rural areas and areas where living


costs, and particularly accommodation costs, were high (HOPE, 2004). Such issues – and the potential positive and negative impacts - are equally as relevant within and between the different UK countries as they are to Europe as a whole.

1.5 Study Design and Main Questions

Against this background and in accordance with the brief, the main aims of the study were:

To assess what data is available on the mobile health professional workforce (European and other internationally-qualified, and UK) - with a view, for instance, to mapping health professional migration within the four UK countries and between the UK countries and Europe;

To explore drivers and constraints to the different types of health professional mobility of interest to the study. This involved exploring: a) policy and regulatory factors at EU/EEA, UK national and within-UK devolved administrative levels; and b) evidence about the motivations, experiences and on-going migration of individual migrants. It also meant attempting to distinguish: a) what is known specifically about European as opposed to other internationally-qualified individuals working in the NHS; and b) any key commonalities/differences in the factors considered relevant to EU/EEA, non-EEA and UK staff.

To assess the main implications specifically of European health professional mobility in the context of the delivery and organisation of health services. This includes looking at the challenges and opportunities, for instance, for human resources management (HRM) within organisations, and the quality/safety of services and patient experiences of care. A significant feature of this involved examining learning from the NHS’s recent experience of active international recruitment (both in Europe and elsewhere overseas);

To document what is known about the impact and outcomes of European health professional mobility to the UK on: a) individual migrants in different professional groups; and b) source countries in different parts of the EU/EEA and Wider Europe.

To identify the main implications at health system level in the UK and/or its constituent countries – in relation both to the issue of health professional mobility within Europe, and within-UK migration and competition for health labour. This includes the challenges and necessary responses, for instance, the contexts of overall policy-making, regulatory arrangements, national workforce planning, and dealing with source countries.

In all of this (1-5 above), to identify gaps in knowledge and note potential topics for future research relevant to the SDO programme and Scottish Executive (the organisations which funded the study).


The main methodological approaches adopted were: a) a literature review and analysis of information on relevant UK, EU/EEA and international organisational websites; b) collation of workforce data including professional registration and application for registration statistics, employment data from the NHS Information Authority for England and information from relevant bodies (e.g. Scottish Executive) in Scotland, Wales and Northern Ireland; and c) semi-structured interviews with key informants including policy-makers and workforce planners and individuals with responsibility for EU/international affairs and/or registration issues within UK professional regulatory and representative bodies for doctors, nurses/midwives, dentists, pharmacists and AHPs (n=18). (Full details of the study methods and interviewees are provided in Appendix 1). In other words, we were not commissioned to undertake detailed primary research. The objective was to engage with key informants and to look at the nature and quality of existing published evidence, with a view to identifying the main issues for future research agendas.

1.6 Remainder of Report

In Section 2 we outline what is known about the main trends around mobility of the health professional workforce – to and from Europe and within the UK; and in so far as is possible locate this within the broader picture of the migration of health staff from elsewhere overseas. The section also provides a brief assessment of the quality of available data relating to the European and wider international health professional workforce in the UK and its constituent countries – i.e. the devolved administrations of Scotland, Wales and Northern Ireland. In Section 3 we discuss the evidence regarding drivers and constraints (push and pull factors) to health professional mobility/migration as they relate to within-Europe and within-UK movements. We next discuss what, if anything is known about the implications of health professional mobility - i.e. the key challenges and necessary responses – at the following levels: the delivery and organisation of UK health services (Section 4); the individual migrants themselves and source countries (Section 5); and the level of the overall health system in the UK, the devolved administrations and Europe (Section 6). Finally, Section 7 presents our conclusions, including a summary of key issues for potential future research.


2 Assessment of Available Data on Health Professional Mobility

The first task for the study was to assess what is known about the mobility of the health professional workforce – to and from Europe and within the UK - from available information and statistics. To do this we draw primarily on registration data provided by professional and regulatory bodies; but supplement that with intelligence provided by our interviewees and information located by the literature review. In this context it is important to note that a theme that runs through the literature on both migration in general, and health professional mobility in particular, is the inadequacy of existing data (Bach, 2003; Krieger, 2004; Buchan and Perfilieva 2006). There are, for instance, considerable differences between the various professions in terms of data availability and quality. Care must also be taken in terms of drawing firm conclusions given the types of data that are and are not available. For example, information gathered from the professional registers denotes how many internationally-qualified professionals are registered to practice but gives no indication as to whether they are active within the workforce.

2.1 What is known About the European Workforce in the UK?

2.1.1 Overall Workforce Contribution of European versus Other Sources

As Figures 2.1 to 2.4 illustrate, the overall contribution of EU/EEA staff to the migrant doctor and nursing workforces in the NHS is less significant than that of the Rest of the World (N.B. Proportions of the actual NHS workforce and whole professional register were only locatable for doctors – Figures 2.1 and 2.2; for nurses it has been necessary to infer workforce contributions from numbers of new registrations only). It follows that the vast majority of the increase in doctor and nurse migration from abroad of recent years (as might be inferred from numbers newly admitted to the relevant professional registers and/or newly entering the NHS workforce – Figures 2.3 to 2.4) was also accounted for by non-EU/EEA staff. By way of example the increase in numbers from India alone for doctors (from 15,759 on the GMC register in 2000 to 29,215 in 2007 - a total of 13456 in seven years); and the Philippines and India alone for nurses (a total of approximately 22000 and 12000 new registrants to the NMC register respectively between 2001 to 2006) was more than all EU/EEA countries put together. Within the Rest of the World category (where in has been


possible to differentiate), it is also evident that Wider European countries are, overall, relatively, less significant than the UK’s traditional migration sources of South Asia, Australia, Africa etc (see for example Figure 2.1 re. doctors).

Figure 2.1: Percentage of Doctors on GMC Register Accounted for by Different Qualification Sources – 2000-07

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2000 2001 2002 2003 2004 2005 2006 2007

Rest of World

Wider Europe

EU/EEA

UK

Source: General Medical Council Registration Data Note: EU/EEA here covers the combined EU15, EU12 and Remaining EEA (i.e. Iceland, Switzerland, Norway and Lichtenstein) – and is consistent in terms of covering all 31 current EU/EEA members (including 2004 and 2007 joiners) across all years shown.

Wider Europe as used in this Table is defined as including: Albania, Belarus, Bosnia & Herzegovina, Serbia & Montenegro, Croatia, Russian Federation, Ukraine, Macedonia, Georgia, Uzbekistan and Turkey.


Figure 2.2 a) and b): Percentage of Doctors in NHS Workforce in England Accounted for by Different Qualification Sources – 2000-07

Source: NHS Workforce Census (Hospital and Community Health Services and General Practice – excluding registrars and retainers) – available from NHS Information Centre.

b) General Practice

0%10%20%30%40%50%60%70%80%90%

100%

2000 2001 2002 2003 2004 2005 2006 2007

Rest of World

EU/EEA

UK

a) Hospital - All Grades

0%10%20%30%40%50%60%70%80%90%

100%

2000 2001 2002 2003 2004 2005 2006 2007

Rest of World

EU/EEA

UK


Figure 2.3: Numbers of New Entrants on NHS Workforce Census in England - All Doctors, 1998-2003

Source: Young et al, 2008 p.6 - Analysis of NHS Workforce Census (Hospital and Community Health Services and General Practice) – based on the latest year for which figures were available. Note: EU/EEA covers the combined EU15, EU12 and Remaining EEA (i.e. Iceland, Switzerland, Norway and Lichtenstein). Rest of World here includes countries we have classified elsewhere as Wider Europe, plus all others sources such as Australasia, Africa, South Asia, USA etc.

0

2000

4000

6000

8000

10000

12000

1998 1999 2000 2001 2002 2003

Rest of World

EU/EEA

UK


Figure 2.4: Numbers of New NMC Registrations – All Nurses, 1998-9 to 2006-7

Source: Nursing and Midwifery Council Registration Data Note: EU/EEA here covers the combined EU15, EU12 and Remaining EEA (i.e. Iceland, Switzerland, Norway and Lichtenstein). Rest of World here includes countries we have classified elsewhere as Wider Europe, plus all others sources such as Australasia, Africa, South Asia, USA etc.

In terms of overall numbers, the contribution of EU/EEA and wider European staff in other health professional groups (i.e. AHP groups, dentistry and pharmacy) is also relatively small compared with other sources. Amongst the AHP groups, for instance, the vast majority of HPC applications and subsequent new registrations in the years for which we have complete data were accounted for by UK-qualified individuals (Figure 2.4). In turn, within the International category, the majority of applications/registrations related to individuals from what we have termed Rest of the World – i.e. outside Europe (especially Africa, Asia and Oceania). Overall, during 2000-07 (for which we have non-UK data only) almost 9000 individuals applied for HPC registration from the Rest of the World, of which approximately 2300, 1900, 1500 came respectively from the countries of Australia, India and South Africa alone. That compared with only around 1020 from all 31 countries of the current EU27/EEA combined in the same period (Figure 2.6). Similarly in dentistry, most dentists on the GDC register are UK-qualified (Table 2.1) and in pharmacy the main flows into the UK from abroad are also from countries outside Europe. Specifically, a census carried out by the pharmacy registration body, the RPSGB, in 2003 demonstrated that non-UK registrants made up just 5.5 percent of the register. Of that, 40.4 percent were from a country with a reciprocal arrangement such as Australia and New Zealand; 39.7 percent were from other overseas countries and only 20% were from the EEA.

0

5000

10000

15000

20000

25000

30000

35000

40000

1998

-9

1999

-0

2000

-1

2001

-2

2002

-3

2003

-4

2004

-5

2005

-6

2006

-7

Rest of World

EU/EEA

UK


Figure 2.5: Percentage of Applications and New Registrations with the HPC Accounted for by Different Qualification Sources – All AHPs, 2003/4 and 2004/5

Source: Health Professions Council Data Note: Grandparenting covers individuals already qualified in the UK coming under the auspices of the newly established HPC. International here covers individuals from all non-UK sources i.e. EU27/EEA, wider Europe and Rest of the World combined. Data for 2004/5 are for 10 months only

Figure 2.6: Numbers of International Route HPC Applications Accounted for by Different Sources – All AHP Groups, 2000-07

Source: Health Professions Council Applications Data Note: The Figure summarises applications statistics not actual registrations. EU/EEA here covers the combined EU15, EU12 and Remaining EEA (i.e. Iceland, Switzerland, Norway and Lichtenstein) – and is consistent in terms of covering all 31 current EU/EEA members (including 2004 and 2007 joiners) across all years shown. Wider Europe as used in this Table includes specifically: Albania, Croatia, Russian Federation, Macedonia and Turkey (combined total 17 applications 2000-7).

0

500

1000

1500

2000

2500

2000 2001 2002 2003 2004 2005 2006 2007

Rest of World

Wider Europe

EU/EEA

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Appications2003/4

Registrations2003/4

Applications2004/5

Registrations2004/5

International

Grandparenting

UK


Table 2.1: Proportion of Dentists on GDC Register Accounted for by Different Qualification Sources – 2005 and 2007

QUALIFICATION SOURCE

NUMBER IN YEAR 2005

NUMBER IN YEAR 2007

% OF TOTAL REGISTER IN 2005 (N=33698)

UK 26201 26422 78%

EU/EEA 3966 7344 12%

Rest of World 2501 nd 7%

IQE 1030 nd 3% Source: General Dental Council Registration Data IQE: The International Qualifying Exam (IQE) tests the knowledge and clinical skills of dentist from overseas (outside the EU/EEA) whose qualifications are not recognised for full registration with the GDC. Dentists who pass can apply for full registration. A record number of candidates passed the examination becoming eligible to join the Dentist Register in 2005.

2.1.2 Growth of Migration from Different European Sources

Nevertheless, despite the relatively fewer numbers than from elsewhere abroad, the figures still equate to more than six thousand additional EU27/EEA doctors and almost a thousand more doctors from wider Europe on the GMC register in 2007 compared with just seven years earlier in 2000 (Table 2.2). Similarly, over the same period within nursing there were over 8000 new entrants to the register from the EU15 countries alone. Within the AHPs, as already noted, over 1000 EU27/EEA-qualifed individuals applied for HPC registration (over 10 percent of all non-UK applications) between 2000 and 2007. Within dentistry, far more new entrants to the register in recent years have been from Europe than the UK itself (Table 2.3). Finally in pharmacy, approximately 500 EU/EEA qualified individuals were on the professional register in 2005/6 (RSPGB, 2006). Given the sheer variety of counties represented within that, 31 in the EU27/EEA alone (and it follows the variety of different professional cultures and experiences that needed integrating in to the NHS workforce over a short timescale) it may be European migration has been equally challenging to the NHS as ostensibly more significant movement from single sources (e.g. India, Philippines, Australia etc) elsewhere abroad (see Section 4 below for more discussion of the implications of this cultural variety).


Table 2.2: Total Numbers of Doctors on GMC Register – Numerical and Relative Percentage Increases between Years 2000-07

QUALIFICATION SOURCE

TOTAL IN YEAR 2000

TOTAL IN YEAR 2007

NUMERICAL (%) INCREASE

UK 133824 150073 16249 (12)

EU/EEA (Combined) 16612 22797 6185 (37) EU15 15437 17311 1874 (12) EU12 1064 5256 4192 (394) Remaining EEA 111 230 119 (107)

Wider Europe 477 1472 995 (209)

Rest of World 46222 68201 21979 (48)

OVERALL TOTAL 197135 242543 45408 (23) Source: General Medical Council Registration Data Note: For the sake of consistency of analysis in the above Table we have counted all current members of the EU15, EU12 and Remaining EEA in the relevant categories – i.e. in both 2000 and 2007.

Table 2.3: New Entrants to GDC Register Accounted for by Different Qualification Sources – 2005 and 2007

QUALIFICATION SOURCE NUMBER IN YEAR

2005 NUMBER IN YEAR 2007

UK 776 751

EU/EEA 1136 937

Rest of World 94 298

IQE 251 nd Source: General Dental Council Registration Data IQE: The International Qualifying Exam (IQE) tests the knowledge and clinical skills of

dentist from overseas (outside the EU/EEA) whose qualifications are not recognised for full registration with the GDC. Dentists who pass can apply for full registration.

Within the overall European numbers, there are also some interesting trends. For example, for doctors the relative increase in numbers from the “Old” EU15 is – at around 12 percent – virtually the same as for UK-qualified staff. However, the relative increase of doctors from sources that in terms of professional cultures are very different to the UK - the EU12 (new joiners in 2004 and 2007) and wider Europe - is around 500 and 200 percent respectively (Table 2.2 above). Also, as Figures 2.7 and 2.8 and illustrate, although migration appears to be on a downturn from the EU15 for doctors and nurses at least it is continuing to rise from the EU12 – with


movements clearly accelerating as a result of the biggest wave of EU expansion in 2004. Amongst AHP groups, numbers of applications for UK registration appear to have risen from both the EU15 and EU12 (Figure 2.9). Even though it is from a low base (especially in some groups such as the AHPs), such trends may be quite significant for the future given wider policy changes (e.g. re. work permits and training regulations – NHS Employers, 2006) that have potential to limit movements to the UK of health professionals (including doctors, nurses, midwives and AHPs) from outside Europe. (N.B. The data available for dentists and pharmacists did not permit this form of analysis for those groups).

Figure 2.7: Total Numbers of Doctors on GMC Register from Different European Sources – 2000-07

Source: General Medical Council Registration Data Note: The EU15, EU12 and Remaining EEA (i.e. Iceland, Switzerland, Norway and Lichtenstein) categories as used in the Figure are consistent in terms of covering all 31 current EU/EEA members (including 2004 and 2007 joiners) across all years shown. Wider Europe as used in this Table is defined as including: Albania, Belarus, Bosnia & Herzegovina, Serbia & Montenegro, Croatia, Russian Federation, Ukraine, Macedonia, Georgia, Uzbekistan and Turkey.

0

2000

4000

6000

8000

10000

12000

14000

16000

18000

20000

2000 2001 2002 2003 2004 2005 2006 2007

EU15

EU12

Remaining EEA

Wider Europe


Figure 2.8: Numbers of New Entrants to NMC Register from Different European Sources – 2000/1-2006/7

Source: Nursing and Midwifery Council Registration Data

Figure 2.9: Numbers of International Route HPC Applications from Different European Sources - All AHP Groups, 2000-07

Source: Health Professions Council Application Data Note: The EU15, EU12 and Remaining EEA (i.e. Iceland, Switzerland, Norway and Lichtenstein) categories as used in the Figure are consistent in terms of covering all 31 current EU/EEA members (including 2004 and 2007 joiners) across all years shown. Wider Europe as used in this Table includes specifically: Albania, Croatia, Russian Federation, Macedonia and Turkey (combined total 17 applications 2000-7).

0

200

400

600

800

1000

1200

1400

1600

1800

2000

2000/1 2001/2 2002/3 2003/4 2004/5 2005/6 2006/7

EU15/EEA

EU12

0

20

40

60

80

100

120

140

160

2000 2001 2002 2003 2004 2005 2006 2007

EU15

EU12

Remaining EEA

Wider Europe


2.1.3 Source Country Trends

In terms of the growing (and likewise the declining) significance of particular individual country sources within Europe, there are also some clear trends. Although still the non-UK country-of-qualification most represented on the GMC register for doctors, Ireland, for example, showed a steep decline in numbers in the period 2000-07 – as did if on smaller scales the Netherlands and Iceland (Table 2.4). By contrast, several countries – most notably Germany from the “Old” EU15 and Poland, Hungary and the Czech republic from the “New” EU12 – showed significant increases in terms of overall numbers of doctors registered, partly reflecting their having been targeted under the UK’s active recruitment policy over the same period (Interviewees: D3 – GPs; C4 - Doctors). This means that Poland, for instance, has gone from being a relatively small-scale supplier of doctors to the UK (with 304 on the GMC register in 2000) to the third biggest EU/EEA source of doctors overall, with a total of 1670 registered in 2007. The trends are similar for nurses – with Germany and Ireland the biggest suppliers of new entrants to the NMC register from the EU15 (Table 2.5). Unfortunately for nurses data was not published for individual countries in the years from 2000 onwards when the UK was most active in terms of recruitment from EU15 countries such as Spain, Italy, Greece and Germany. Nevertheless we can surmise from the limited figures that are available that movement from those countries is now declining; and migration from the EU15 is being rapidly dwarfed by numbers from Poland in particular, but also other CEE countries in the EU12 (e.g. Romania; Czech Republic; Slovakia; Hungary) (Interviewees: B2/C2 – Nurses) (NMC, 2007).


Table 2.4: Numbers of Doctors on GMC Register – EU/EEA Countries of Origin - 2000-07

COUNTRY OF QUALIFICATION

2000 2001 2002 2003 2004 2005 2006 2007 NUMERICAL (%)

INCREASE 2000-07

EU15 Ireland 6829 6826 6756 6549 6457 6177 5962 5553 -1276 (-19) Germany 2860 2895 2766 2725 2862 3515 4234 4364 1504 (53) Greece 1533 1428 1429 1368 1571 1858 1969 1891 358 (23) Italy 1222 1198 1222 1142 1231 1396 1537 1594 372 (30) Spain 1072 1007 1001 998 1056 1092 1131 1148 76 (7) Netherlands 724 714 667 611 607 636 663 677 -47 (-7) France 305 315 335 383 462 562 604 580 275 (90) Sweden 214 236 256 266 293 406 447 437 223 (104) Belgium 338 332 338 328 388 448 444 417 79 (23) Austria 108 135 155 215 241 285 332 320 212 (196) Denmark 110 116 119 132 154 164 191 184 74 (67) Portugal 67 72 67 51 57 71 69 76 9 (13) Finland 55 72 72 66 74 74 72 70 15 (27) Luxembourg - - - - - - - - - EU12 Poland 304 324 331 346 352 837 1570 1974 1670 (549) Hungary 130 154 171 176 211 389 709 872 742 (571) Czech Republic 128 139 174 204 226 465 722 799 671 (524) Romania 116 143 177 201 237 289 345 411 295 (254) Malta 257 281 281 294 298 321 342 374 117 (46) Lithuania 3 4 5 6 8 46 176 224 221 (7367) Bulgaria 67 84 96 102 119 152 203 208 141 (210) Slovakia 4 6 13 17 21 69 151 206 202 (5050) Latvia 6 6 10 15 17 39 89 107 101 (1683) Estonia 4 4 5 5 6 19 43 52 48 (1200) Slovenia 5 5 6 5 8 11 14 19 14 (280) Cyprus - - - - - - - - - Remaining EEA Switzerland 40 37 38 59 86 109 137 142 102 (255) Norway 24 31 36 36 40 45 57 52 28 (117) Iceland 47 47 43 32 36 46 42 36 -11 (-23) Lichtenstein - - - - - - - - -

Source: General Medical Council Registration Data


Table 2.5: Numbers of New Entrants to the NMC Register – EU/EEA Countries of Origin – 2004/5-07

COUNTRY 2004/

5 2005/6 2006/7 April-Dec

2007 TOTAL

2006/7 (EU15) 2004/07 (EU12)

EU15 Germany nd nd 159 79 238 Ireland nd nd 89 33 122 Italy nd nd 54 36 90 Spain nd nd 41 21 62 Sweden nd nd 36 13 49 Portugal nd nd 20 22 42 France nd nd 21 18 39 Denmark nd nd 24 14 38 Netherlands nd nd 23 12 35 Finland nd nd 24 10 34 Greece nd nd 27 3 30 Austria nd nd 20 7 27 Belgium nd nd 18 3 21 Luxembourg nd nd - - - EU12 Poland 133 442 578 241 1394 Romania nd nd 9 204 213 Slovakia 22 64 84 23 193 Czech Republic 23 65 66 23 177 Lithuania 17 74 47 16 154 Hungary 22 63 29 14 128 Bulgaria nd nd 6 77 83 Malta 7 16 16 14 53 Latvia - 17 15 5 37 Estonia 5 13 7 5 30 Cyprus 2 7 6 3 18 Slovenia - 3 - - 3 Remaining EEA Switzerland nd nd 16 2 18 Norway nd nd 12 5 17 Iceland nd nd 2 1 3 Lichtenstein nd nd - - - Source: Nursing and Midwifery Council Data nd indicates no data collected N.B. Data was only separately published for individual EU12 countries from 2004 and 2007 (for Romania and Bulgaria) as they joined the EU. Data for the “Old” EUEU15 countries was not separately collected until 2006.

There are similar trends – for instance the continued significance of Germany and Ireland as suppliers from the “Old” EU15 and increasing numbers from Poland in particular from the EU12 – amongst AHPs (see Tables 2.6 and Table 2.7 for more detailed figures in the context of physiotherapy only), dentists (Table 2.8) and pharmacists (Tables 2.9 and 2.10). However, in the context of dentistry in particular Scandinavian countries such as Sweden also stand out as significant suppliers. Again, as with doctors and nurses, these trends would appear to reflect the active recruitment country targeting of recent years - including, for instance Spain for pharmacists and Poland for dentists and pharmacists (Wang, 2007;


Wiskow, 2006; Young et al, 2008) (Interviewees: B4 – Pharmacists; C3 - Dentists).

Table 2.6: Numbers of International Route HPC Applications – EU/EEA Countries of Origin – All AHP Groups, 2000-07


2000

2001

2002

2003

2004

2005

2006

2007

TOTAL 2000-07

EU15 Germany 6 17 5 13 26 30 20 22 139 Ireland 7 12 17 19 25 18 14 22 134 Spain 3 7 4 7 18 16 13 8 76 Netherlands 3 6 8 4 15 11 14 9 70 Greece 3 5 7 1 13 14 11 10 64 Sweden 7 1 2 2 7 11 10 8 48 France - 2 3 2 7 5 9 9 37 Italy 2 3 3 5 4 4 5 8 34 Portugal 1 2 1 4 5 2 3 11 29 Denmark 1 1 - 2 5 5 3 4 21 Austria 1 - - 5 4 2 1 5 18 Finland 1 1 1 3 5 3 2 1 17 Belgium - 1 1 2 1 2 3 1 11 Luxembourg - - - - - - - - - EU12 Poland 4 3 4 4 16 38 35 47 151 Malta - 6 3 6 8 12 9 7 51 Hungary - 1 1 2 4 3 7 4 22 Czech Republic - 1 - 1 2 7 3 6 20 Bulgaria - - - 2 2 3 1 12 20 Lithuania - - - - 3 3 1 3 10 Romania 1 1 - 1 1 - - 3 7 Cyprus - - - - 1 1 - 2 4 Slovenia - 1 - - - 1 1 - 3 Slovakia - - - - - - - - - Latvia - - - - - - - - - Estonia - - - - - - - - - Remaining EEA Switzerland - - 1 1 2 6 1 4 15 Norway - - 1 5 1 3 3 2 15 Iceland - - - - 1 - 1 1 3 Lichtenstein - - - - - - - - - Source: Health Professions Council Applications Data


Table 2.7: HPC Application to Registration Conversion Rates for Physiotherapists from the EU/EEA – Year ending 9/7/2004

COUNTRY OF QUALIFICATION NUMBER OF APPLICATIONS % REGISTERED

EU15 Spain 34 9% Germany 27 19% Ireland 25 56% Greece 19 26% Sweden 11 18% Netherlands 11 9% Austria 10 50% Finland 9 22% Italy 8 25% Denmark 5 60% EU12 Poland 17 6% Malta 6 50% Hungary 5 20% Remaining EEA Norway 5 0%

OVERALL TOTAL 192 Nd Source: Masters (2004) from Health Professions Council Data

nd: indicates no data


Table 2.8: Numbers of New Entrant Dentists to GDC Register – EU/EEA Countries of Origin – 2000-07


2000

2001

2002

2003

2004

2005

2006

2007

TOTAL 2000-07

EU15 Sweden 163 135 78 130 94 108 77 45 830 Germany 31 37 33 63 73 133 145 119 634 Greece 28 34 46 55 82 123 82 86 536 Ireland 71 50 59 84 68 68 55 46 501 Spain 2 3 10 51 59 116 93 70 404 Portugal 5 - 2 13 44 62 51 76 253 Italy 12 12 16 13 25 27 23 28 156 Denmark 25 27 12 21 18 11 11 6 131 France 10 10 10 11 7 10 21 23 102 Finland 19 15 9 13 6 4 3 3 72 Belgium 11 1 6 6 4 11 8 11 58 Netherlands 4 3 1 7 2 6 8 11 42 Austria - - - - - 1 1 2 4 Luxembourg - - - - - - - - - EU12* Poland - - - - 152 417 235 124 928 Hungary - - - - 33 31 46 59 169 Romania - - - - - - - 155 155 Lithuania - - - - 22 42 31 26 121 Czech R - - - - 8 19 17 13 57 Slovakia - - - - 11 19 13 10 53 Malta 2 - - - 11 7 6 5 31 Latvia - - - - 3 11 4 6 24 Estonia - - - - 6 5 5 1 17 Remaining EEA Norway 10 7 3 6 6 7 3 2 44 Switzerland - - 1 - - 1 3 9 14 Iceland 1 - - 2 2 1 2 1 9 Lichtenstein - - - - - - - - - Source: General Dental Council Registration Data * No dentists were registered from Bulgaria, Slovenia and Cyprus within the EU12. Note: The GDC annual report for 2006 states that 39% of those added to the register in

this year qualified in Europe outside the UK. This percentage was 40% in 2004 and 50% in 2005. In particular, there were a large number of registrations from Poland the year after European enlargement. In addition, the NHS Dental Activity and Workforce Report for England states that in the year ending 31 March 2006 46% of new NHS dentists qualified outside the NHS, the highest recorded number in the last 10 years - 17% of these new entrants qualified in Poland.


Table 2.9: Main EU/EEA Countries of Origin – Pharmacists, 2001-05


2001 2002 2003 2004 2005 TOTAL 2001-05

EU15 Spain 159 291 323 158 76 1007 Germany 19 30 36 27 14 126 Ireland 20 13 22 17 16 88 Source: Royal Pharmaceutical Society of Great Britain Data

Table 2.10: Numbers of EU/EEA Pharmacists on the RPSGB Register by Country of Origin – July 2005 to August 2006

COUNTRY OF QUALIFICATION NUMBER ON REGISTER EU15 Spain 127 Italy 34 Sweden 29 Germany 17 Portugal 15 France 9 Greece 8 Denmark 5 Belgium 4 Austria 3 Finland 2 Ireland 1 Netherlands 1 Luxembourg - EU12 Poland 179 Hungary 12 Malta 11 Slovakia 10 Czech Republic 8 Lithuania 4 Estonia 1 Remaining EEA Switzerland 1 Source: Royal Pharmaceutical Society of Great Britain Data Note: Within the EU12 the following countries were not represented in the data: Bulgaria,

Romania, Cyprus, Slovenia and Latvia. From the Remaining EEA, Norway, Iceland and Lichtenstein were also not represented.

Finally, there appears to be a small but significant rise in numbers of health professionals moving, or looking to move, to the UK from wider European countries – for example, from Russia, Ukraine, Turkey and the various countries of the former Yugoslavia (with the latter all looking to join the EU


at some point in the future). The main example available from the data relates to doctors registering with the GMC and/or taking/passing the PLAB – the clinical exam that non-EEA doctors are required to pass to be allowed UK entry (Table 2.11 and Figure 2.10). Another example is applications for AHP registration with the HPC – though here only very small numbers are involved (Table 2.12). From the viewpoint of “ethical” policy, it is also important to note just how many of the wider European countries shown (as indicated by * in Tables/Figure below) were covered by the DH (2004) Code of Practice restricting active recruitment – yet even though not actively targeted they have clearly still continued to be sources of wider migration to the UK.

Table 2.11: Numbers of Doctors on GMC Register – Wider Europe Countries of Origin - 2000-07


2000 2001 2002 2003 2004 2005 2006 2007 NUMERICAL (%)

INCREASE 2000-07

Wider Europe Russian Federation 187 213 262 329 362 450 569 633 446 (239) Ukraine 71 78 103 124 142 185 238 259 188 (265) Turkey* 75 78 103 109 115 133 168 187 112 (149) Serbia & Montenegro*

60 68 83 95 110 130 161 174 114 (190)

Bosnia & Herzegovina*

41 46 46 46 51 55 59 58 17 (42)

Croatia* 26 26 31 34 37 39 45 49 23 (89) Belarus 1 3 5 8 6 12 19 30 29 (2900) Uzbekistan* 4 6 7 12 14 15 22 25 21 (525) Albania* 2 7 9 10 13 12 20 23 21 (1050) Macedonia* 6 7 8 8 11 15 15 18 12 (200) Georgia* 4 4 4 4 4 4 7 10 6 (150) Moldova* - - 1 1 3 5 4 6 6 (600)

Source: General Medical Council registration data * Indicates countries covered by the DH (2004) Code of Practice on international recruitment.


Figure 2.10: Numbers of Doctors Taking and Passing PLAB Exams – Wider Europe Countries of Origin - 2000-05

Source: General Medical Council * Indicates countries covered by the DH (2004) Code of Practice on international recruitment.

Table 2.12: Numbers of International Route HPC Applications – Wider Europe Countries of Origin - All AHP Groups, 2000-07


2000

2001

2002

2003

2004

2005

2006

2007

TOTAL 2000-07

Wider Europe Turkey* - 2 4 - 1 - - 1 8 Russian Federation - - 1 - - - 2 - 3 Croatia* 1 1 - - - - 1 - 3 Macedonia* - 1 - - 1 - - - 2 Albania* - - - 1 - - - - 1

Source: Health Professions Council applications data * Indicates countries covered by the DH (2004) Code of Practice on international recruitment.

2.1.4 Contribution of European Health Professionals within Different Professional Groups

Finally, it is important to note the different levels of migration (and where relevant migration growth) – and it might be inferred the different levels of potential reliance on European-qualified individuals across the different health professions. An example here would be the relative growth in numbers of GPs from EU/EEA sources between 2000 and 2007 compared with many groups of hospital doctors (Table 2.13) - which partly reflects the fact that registration requirements mean non-EU/EEA countries were less realistic targets for the active GP recruitment of recent years. (N.B. There

0200

400600800

1000

12001400

Russian

Fed

erat

ion

Ukrain

e

Turke

y*

Serbia &

Mont

eneg

ro*

Belaru

s

Albania

*

Uzbek

istan

*

Croat

ia*

Mold

ova*

Georg

ia*

Mac

edon

ia*

Bosnia

& Her

zegov

ina*

PLAB 1 Entry

PLAB 1 Pass

PLAB 2 Entry

PLAB 2 Pass


are similar ease of entry reasons to assume that the EU/EEA will now be the main source of international midwives recruited to the UK (Young et al 2008c), but unfortunately the NMC does not provide midwifery-specific data). As another example, within the AHPs, physiotherapists are by far the most significant group coming to the UK, followed by Occupational Therapy and Speech and Language Therapy – i.e. the other groups that are most consistently recognised across Europe (Table 2.14).

Table 2.13: Changing Contribution of EU/EEA Migrants in Different Doctor Groups - 2000-07

PROFESSIONAL GROUP INDIVIDUALS IN NHS WORKFORCE IN ENGLAND

ORIGINALLY QUALIFIED EU/EEA

TOTAL IN

YEAR 2000 TOTAL IN

YEAR 2007 NUMERICAL (%)

INCREASE

Hospital Doctors – All Grades 4016 5627 1611 (40) Consultant 1269 2360 1091 (86) Staff Grade 309 529 220 (71) Registrar 931 1662 731 (79) SHO and Foundation 2 886 551 -335 (-38) HO and Foundation 281 185 -96 (-34)

General Practitioners 999 1657 658 (66) Source: NHS Workforce Census (Hospital and Community Health Services and General

Practice – excluding registrars and retainers) – available from NHS Information centre.

Table 2.14: Flows of various AHP groups from Europe to the UK 1997-2006


Physio OT S&LT Radiography Dieticians Opticians TOTAL

Netherlands 185 20 9 - - - 214 Ireland 85 34 26 26 16 1 188 Germany 59 17 7 15 - - 98 Belgium 31 - - - - - 31 Sweden - 16 - - - - 16 France - - - - - 12 12

TOTAL 360 87 42 41 16 13 559

Source: Petchey and Needle, 2007 – compiled from: http://ec.europa.eu/internal_market/qualifications/regprof/index.cfm

http://ec.europa.eu/internal_market/qualifications/regprof/index.cfm�


2.2 What is Known about UK-Europe and Other Out-Migration from the UK?

There appears to be little concrete information (and certainly nothing comprehensive across different professional groups) about out-migration of health professionals from the UK - be it UK-qualified staff moving abroad or EU/EEA and/or other internationally-qualified staff returning to countries of origin or moving to alternative destinations altogether. In fact the only relevant UK registration data routinely available relates to nurses (the relevant bodies for doctors, AHPs, dentists and pharmacists could not provide equivalent information) and there is some collated registration data available from the European Commission for AHPs. A further complication is that any data that is available on movement abroad does not differentiate between individuals originally qualified in the UK and those qualified abroad that were simply registered in the UK. Overall, therefore, it is important to remember that most evidence on this topic is impressionistic and anecdotal (see for example, Telegraph 26/02/08) (see Box 2.1).

BOX 2.1 PERCEPTIONS OF DATA QUALITY ON OUT-MIGRATION: INTERVIEWEE VIEWS

“Difficult to know whether doctors stay and for what length as registration data doesn’t say what people are doing” (B3 - Doctors). “The number of outgoing nurses leaving the register and going overseas has increased. We may have reached a point where more are going than coming [but we don’t know]” (C2 - Nurses). “You can’t identify whether it’s a Filipino nurses that is leaving for the US or a UK nurse” (C2 - Nurses). “I don’t know about pharmacists going abroad. We probably provide around 20 certificates of practice each month” (B4 - Pharmacists). “It is not a big issue for dentistry. Obviously some go abroad but I’ve no idea how many” (C3 - Dentists).

Despite the difficulties, we have attempted to piece together a picture of key trends from our interviews, the literature review and what limited professional registration data does exist. This suggests that the majority of out-migration of health professionals from the UK is to other English-speaking countries such as Australia, Canada, New Zealand, the USA etc (Interviewees: A2 – All professional groups; C1- Midwives; B1 – AHPs; C5- Physios) (see Tables 2.15 and 2.16 for nurse registration data; Table 2.17 for AHP data) (see also Hassell et al, 2008 and Hassell, 2007 re.


pharmacists). It follows that within Europe the main destination for UK staff appears to be Ireland. However, it is not possible to tell whether such migration is UK nationals going abroad or Irish nationals that originally trained in the UK returning home. Similarly, in the context of countries such as Australia or the USA, it is likely that a certain proportion of movement is accounted for by UK-qualified staff going to those countries. Equally, however, it could be internationally-qualified staff that have worked in the UK for a few years, who are now moving again to a third country. With reference to nursing, for instance, Buchan and Seccombe (2006) noted that the UK might be viewed by some non-EEA nurses as a stepping stone to moving on to other destinations, primarily the US and Australia. They cite the fact that in 2005, more than 85% of nurses who sat the American CGFNS exam in London, had qualified outside of the UK, mostly in the Philippines or India. Similar trends and questions have also been noted in the context of Indian, Filipino, Australian and New Zealand physiotherapists and OTs (Young et al 2008g and 2008h); and UK-qualified pharmacists living abroad (who are not necessarily UK nationals) (Hassell, 2007).

Table 2.15: Numbers of Registration Verifications for Nurses/Midwives Going Abroad – Main European and Other International Destinations, 2002/03 to 2006/07

DESTINATION COUNTRY

2002/03 2003/04 2004/05 2005/06 2006/07

Australia 2602 2708 3296 3047 4,764 USA 2204 2082 1729 1338 1,613 NZ 958 980 847 1423 1,336 Canada 452 376 461 404 739 Saudi 74 38 28 18 nd Ireland 1177 916 1097 1009 999 Spain 73 103 124 132 142 France 50 74 87 60 56 Other 469 333 375 341 384 Total 8059 7610 8044 7772 10,033Source: Nursing and Midwifery Council Data Note: The table denotes the number of verification checks made by regulators from

outside the UK for nurses and midwives on the NMC register. It should be noted that these denote intention to practice and do not mean that an individual is actual employed as a nurse/midwife (nd indicates no data for that year).


Table 2.16: Longer-term Trends in Registration Verifications for Nurses/Midwives Going Abroad – 1994/95 to 2004/05

DESTINATION 94/5 95/6 96/7 97/8 98/9 99/00 00/1 01/02 02/3 03/4 04/5 EU/EEA 451 510 1232 544 719 827 600 1057 1622 1294 1284 Australia 1118 1215 1102 1329 1504 1661 1859 1973 2602 2708 3296 USA 197 197 281 320 288 319 472 1089 2224 2082 1729 NZ 332 693 720 549 478 630 655 753 958 980 1097 Canada 206 150 143 143 189 262 474 490 452 376 461 Africa 120 127 93 39 30 92 50 40 29 32 46 Others 632 715 473 476 622 1292 546 854 192 138 131 TOTAL 3056 3607 4044 3400 3830 5083 4656 6256 8079 7610 8044

Source: NMC Registration Data

Table 2.17: Flows of various AHP groups from UK to Europe 1997-2006

DESTINATION COUNTRY

Physio OT S&LT Radiography Dieticians Opticians TOTAL

Norway 266 - - 12 - 13 291 Ireland 343 135 60 215 35 28 816 Netherlands 2 - 1 - - - 3 Greece - - - - - 8 8

TOTAL 611 135 61 227 35 49 1118

Source: Petchey and Needle, 2007 – compiled from: http://ec.europa.eu/internal_market/qualifications/regprof/index.cfm

Specifically in the context of return-migration (or from an NHS viewpoint the retention in the UK) of EU/EEA health professionals – particularly those that came as part of the active international recruitment campaigns of recent years - the data is very limited and our interviewees also had little concrete information (see Box 2.2). Amongst our interviewees, for example, there were varying perceptions about whether or not individuals tend to go back depending on the region of the UK about which they had most experience (e.g. D1; D2; D3 - GPs) and their professional group. There were, for instance, mixed views in the context of nurses and AHPs (C2; E1), though with references to dentists there was more of a firm feeling that several had returned to countries of origin due to practice in the UK not living up to their expectations (C3). In terms of quantifiable data, for example on net gains and losses to the UK from Europe as a whole, it is also not possible to say anything with any conviction. The only information we could locate relates to AHPs where the indication from European Commission data is that the UK experienced a net loss of 559 individuals – across all AHP groups - in the period from 1997 onwards (Petchey and Needle, 2008 – based on calculations made from figures provided in Tables 2.14 and 2.17 above). However, this data collated at European level is not considered to be wholly reliable (Interviewee: E1 – AHPs). Other complications, as already noted in the context of movements of nurses to Ireland, relate to the question of who actually the data is revealing as


leaving the UK. So for example in relation to destination countries such as Norway for physiotherapists (Table 2.17) and France and Spain for nurses (Table 2.15), is it European-qualified staff returning to countries of origin or UK-qualified staff moving abroad? France and Spain do seem likely destinations for UK-qualified staff (see Section 3 below on migration drivers). However, with other destinations it does seem more likely that it is individuals recruited to the UK from those countries that are returning home. Another view is that much of the UK-Europe movement can be accounted for by individuals from other European countries coming to the UK as students, but returning home once their professional education/a few years’ work experience is completed (Interviewee E1 – AHPs).

BOX 2.2 RETURN MIGRATION OF EUROPEAN STAFF FROM THE UK: INTERVIEWEE VIEWS

“I don’t have any information but I suspect that probably quite a number recruited from the EU would have gone back. Ease of movement enables this” (A2 – All professional groups). “Anecdotally we know some dentists have gone back. They have just not been happy here, for different reasons: expectations of more sophisticated treatments rather than ‘bread and butter’ dentistry. Cannot give a percentage” (C3) “Most EEA GPs recruited have gone back” (D1); “The GPs from EEA actively recruited by the DH all went back home” (D2). By contrast another view was that “Most GPs that come from EU at least around [this region] stay” (D3 - GPs). “There is a high return rate of IMGs from Commonwealth countries….the DH quotes something like 40% will stay. I think those from EEA may stay longer” (C4 - Doctors).

2.3 What is Known Within-UK Migration and Differential Reliance on Migrant Health Staff?

Migration occurs not only to and from the UK but also within and between the four countries of the UK and, like immigration from overseas, it is a complex phenomenon. There are also differences between the different UK countries and regions within them in terms of levels of self-sufficiency in UK-qualified health professional labour and conversely levels of reliance on migrant health staff from abroad. Once again, however, there appears to be very little concrete data from registration bodies and few if any relevant research studies on either of these topics. We have therefore attempted to infer some key points from our interviews and the limited published information that is available.


2.3.1 Perceptions of Trends in Within-UK Migration

In terms of trends in within-UK migration, a few pointers can be discerned. There is, for example, some indication from Scottish medical workforce data that doctors from other parts of the UK have moved north of the border. More specifically, a total of 15 percent of Scotland’s medical staff originally qualified elsewhere in the UK (ISD data: Table 2.18 below). From a Scottish perspective, however, this inflow has to be compared to any outflow elsewhere within the UK. The majority of evidence points to a view that, within the UK, it is England and in particular London and the South East that benefits from internal migration and circulation of health professionals. This is for example, the opinion of the majority of our interviewees (Box 2.3); and there is also some literature/workforce data backing their view. For instance, registration data for pharmacists indicates that small numbers move annually from Northern Ireland to the rest of the UK – most probably England (e.g. a total of 22 pharmacists with Northern Irish qualifications were registered to practice elsewhere in the UK between July 2005 and August 2006 (RPSGB data). A survey of 22,000 nurses trained in Scotland in the period 1955-1985 reported that Scotland was a net exporter of nurses, with approximately one in five of these nurses having moved to England or abroad - mainly the former (Waite, Buchan and Thomas, 1990). There are also recent reports of active recruitment of Scottish nurses and midwives by NHS Trusts in London and the South East (Ashford and St Peters Hospitals, 2008; BBC News, 2008; Young et al, 2008c) – though some evidence in those same studies that the individuals concerned do not stay as long as Trusts might have hoped, choosing instead to return to Scotland within only one or two years. To make things even more complicated, one of our interviewees also pointed to the view that: “Northern Ireland is employing Scottish midwives who come over and work a week at a time” (C1 - Midwives); and a study of the employment location of nurses three years post-qualification indicated that London and the South East of England tend to lose nurses to the North and North West (NNRU, 2007; Northern Ireland, 2005). Clearly, the key point in the context of within-UK migration is that the evidence is incomplete and often anecdotal – i.e. it is entirely inadequate to allow key workforce analyses (such as answering the question of net gains and net losses across different professional groups) to take place within and between the different UK countries.


BOX 2.3 PERCEPTIONS OF WITHIN-UK MIGRATION: INTERVIEWEE VIEWS

“England probably benefits from the devolved countries. Movement is more likely to be to England than out of England. There’s more opportunity. It’s the same sort of thing as people migrating from rural area to urban areas” (A2 – All professional groups). “There is some mobility in UK due to what could be perceived as overtraining … [for example There is movement from Scotland to London” (C1 - Midwives). “Historically movement from Ireland and Northern Ireland [to England]. [And] There's a lot of movement between North and South in Ireland. I don’t know about Scotland and England” (C3 - Dentists) “People have spoken of doctor migration from NI and Scotland [i.e. to England] but I don’t know” (C4 - Doctors).

2.3.2 Evidence on Within-UK Distribution of European and Other Internationally-qualified Staff

Information on within-UK differences in the distribution, and main sources of migrant health professionals both from Europe and elsewhere abroad appears to be even patchier. Specifically, although some studies have explored distributions/vacancy rates of health professionals in the context of whole workforces (see for example, Wagner et al re, community pharmacists; Leese et al, 2002 re. GPs; and NHS Information Centre, 2007 re. doctors, dentists, nurses, midwives and AHPs) and internationally-qualified staff as a whole (see for instance Young et al, 2008 re. hospital doctors, GPs and nurses/midwives in England; and Stewart, 2005 re. refugee doctors in Scotland), we could locate very little information specifically on the distribution/levels of reliance on EU/EEA and other European staff. In fact the only information we were able to locate in this context was from Scotland regarding doctors (Table 2.18 and Figure 2.11). This shows that overall Scotland may be slightly less reliant even than England on EU/EEA staff (Figure 2.11); and perhaps not surprisingly the most significant European source is Ireland. Nevertheless, the data do (tentatively) indicate that, as with the UK generally (see earlier in Section 2), there may be a small increase in other European sources (Table 2.18). Unfortunately even for Scotland there is no comparable data for other health professional groups and no detailed country-by-country breakdown of key sources within Europe other than Ireland.


Table 2.18: Percentage of Doctors in NHS Scotland by Qualification Source – 2000 and 2007

QUALIFICATION SOURCE % IN 2000 % IN 2007 Scotland 68 61 Other UK 15 15 Ireland 2 1 Other EU/EEA 2 3 Other Europe <1 <1 South Asia (India, Sri Lanka, Pakistan, Bangladesh)

7 11

Australia and New Zealand 1 <1 Other Commonwealth (e.g. in Asia and Africa) <1 <1 Other (including unknown) 4 7

TOTAL 8714 11127 Source: ISD Note: The data in the Table do not indicate when the individual doctors first moved to

Scotland. Also within the 2007 data, the percentage of non-UK qualified doctors varied in

different staff categories. 85% of consultants, 74% of specialty training and 58% of senior house officers/ foundation year 2 staff were UK-qualified. (N.B. No comparable data is available for other occupations).

Figure 2.11: Percentage Distribution of Qualification Source - Medical staff in the NHS (headcount): Scotland and England, 2007

0

10

20

30

40

50

60

70

80

UK EEA Other

Scotland

England


2.4 Key Points and Implications of Lack of Data Availability

The information presented highlights the variable quality of the data available in regard to health professional flows – to the UK from Europe; to Europe and elsewhere in the world from the UK; and to/from the UK’s constituent countries of England, Scotland, Wales and Northern Ireland. Similarly there appears to be a lack of information on the distribution of migrant health professionals from Europe and other sources within the NHS; and it is even more difficult to ascertain the extent to which there have been cross border flows between the four UK countries than it is to monitor flows into and out of the UK as a whole from abroad. Such issues are much commented on within the literature and the lack of concrete information was therefore not unexpected. On a positive note there does appear to be an increased awareness of the need to keep accurate data in relation to migration in order to better inform workforce planning.

Amongst the different health professions it would appear that doctors are most well-served in terms of the comprehensiveness and usefulness of migration-related information. However, even for doctors where for example overall proportions of UK, EU/EEA and other internationally-qualified staff actually active in the NHS workforce are obtainable, data is not broken down by individual source country. It is therefore necessary to rely on professional registration data, which does not necessarily cover individuals that are actually employed. The information about other professions (nursing, midwifery, dentistry, the various AHPs and in particular pharmacy) is even less complete than it is for doctors. It is, therefore, necessary to rely almost entirely on registration data rather than information about actual participation in the NHS workforce (as opposed, for example, to other employers such as private sector nursing homes in the context of nursing) – and within that the registration data there are significant gaps. For example, for nurses the NMC has only published country-level data sources of new registrants for the EU12 since 2004 (and 2007 for Romania and Bulgaria) and for the “Old” EU15 from 2006/07. It is, therefore, very difficult to gauge longer-term migration trends from this data. In addition there is no separate data available from the NMC for midwives, and also little collected/disaggregated registration data for groups such as pharmacists and several of the AHPs.

Overall levels of migration from Europe to the UK remain small, especially when compared to health professional migration from non-EEA countries. However, it is not possible to dismiss European migration to the UK as insignificant. Certain professions (e.g. dentistry; and potentially midwifery and general practice) are, relatively, more reliant on European-qualified migrants than others. In addition, although it appears that migration to the UK from the “Old” EU15 (and single key sources such as Ireland) may be declining overall (again with exceptions e.g. Germany), migration from the “New’ EU12 (2004 and 2007 joiners) is


continuing/increasing. Migration is also evident from countries in what we have termed Wider Europe that are looking to join the EU the future. The fact that the data indicates the continued higher levels of migration from the EU12 and Wider Europe is interesting considering our interviewees mostly perceived that source also to have peaked or to be in decline (B1 – AHPs; B2- Nurses; D2/D3 - GPs). This only serves to emphasise the need for improved data on which to base more accurate workforce analyses and planning projections.

Of all the EU12 countries, it is Poland that is the most significant UK migration source across all the professional groups covered by this study. However, other countries such as Hungary, Czech Republic and Lithuania amongst the 2004 EU joiners and Romania which joined in 2007 have also seen large numerical and percentage rises in their contribution to the UK health professional workforces (as indicated by registration statistics). As Wiskow (2006) notes there was concern in the period prior to the 2004 EU regarding the impact of migration on these countries. Again, however, there is a lack of robust data on which to make concrete judgments. From the source country perspective, for example, fears expressed on the potential impact of migration have been founded on data pertaining to intention to migrate only. The lack of robust migration data on the UK (and its constituent country) side of the equation only makes it more difficult accurately assess the magnitude of any impact on source countries (Buchan, 2006; Wiskow, 2006).

Although Europe itself does not appear to be a significant destination for UK qualified health professionals (who are much more likely to move to other English speaking countries, in particular Australia), it is not possible to dismiss Europe as an issue altogether. In particular there is a lack of data regarding: a) the return migration of European-qualified health professionals (from EU/EEA nationals who come as students to the UK to already qualified professionals that came, for instance, within the auspices of the various active international recruitment schemes of recent years); and b) movement of other internationally-qualified health using the UK as a stepping stone to other European destinations or elsewhere abroad. In addition, it is important to note how difficult it appears to be to elicit information on: a) movement within the four countries of the UK; and b) the distribution/differential reliance of the UK’s constituent countries on UK- (and indeed more locally-) qualified staff as opposed to migrant health professionals – either from Europe or elsewhere abroad. Again these are all potential issues in the context of accurate workforce planning.


3 Drivers and Constraints to Mobility

This Section summarises what, if anything, is known about the drivers or motivations behind mobility/migration in the two contexts of most interest to the study - Europe-UK and within-UK movements of health professionals. It covers: a) the factors underlying European health professionals’ decisions to migrate from their country of origin to the UK in the first place; b) what motivates them to come to the UK as opposed to another potential destination country; and c) what motivates mobile health professionals in general (whether European migrants, or UK and other overseas-qualified individuals) to move within the UK, or leave the UK altogether – either to return to countries of origin or to move to an alternative destination altogether. In addition, the Section provides a brief overview of the factors our interviewees in particular saw as the main constraints to European mobility/migration. This is by way of introduction to issues that will be taken up further in later sections of the report that deal with the impacts and challenges for UK organisations and the system in general stemming from mobility/migration.

3.1 Overall Understandings of Migration Motivations

When considering the motives behind migration it is important to recognise two facts. First that migration from an individual’s country of birth is not the norm (Kingma, 2007) and second, that only a proportion of those declaring an intention to migrate do so in practice. This gap between intention and action is highlighted in a report by Krieger (2004) on migration trends within an enlarged Europe, suggesting a complex interplay of internal and external factors in relation to migratory behaviour. Demographic factors such as gender and ethnicity are also pertinent, which only serves to add to the complexity – of both European and wider global migration patterns (Bach, 2003 and 2007; Buchan and Perfilieva, 2006; Buchan, 2008; Dustmann and Weiss, 2007; Larsen et al, 2005; Stilwell et al, 2003).

It follows that for health professionals, just as other groups, a useful way to view migration drivers is through the lens of the macro-level comparative characteristics – i.e. of particular source countries versus potential migration destinations (e.g. UK) – that influence individual migration decision-making. This includes: a) the comparative national economic, political and social circumstances that exert influence across all international labour markets (OECD, 2002); and b) the comparative profession- and labour market-level factors (education/training and job conditions etc) that frame relevant employment and career opportunities in a given occupational sector (see, for example, Young et al, 2003). However, macro influences need also to be viewed through the lens of the micro-level drivers associated with, for instance, personal and spiritual motivations, language skills development, straightforward opportunism and travel opportunities, the workings of social networks and, above all else, lifecycle (family/career)


stage and circumstances. In other words, there are certain times of life, in particular, when movement is easier or more difficult; and certain factors are more/less of a migration-trigger (Van Lerberghe et al, 2002). This, in turn, may be the context most influenced by demographic factors such as gender. One way of seeing migration, then, is as a mover-stayer process (Goetz, 1999) in which individuals: a) periodically observe their present circumstances; b) compare them with imagined futures elsewhere; and c) on that basis, chose the option offering best opportunities in the context of their own professional/personal position. There will rarely be one single reason why an individual chooses to migrate. The overall complexity already referred is a reflection of the multifaceted nature of this personal level decision-making (see also Bach, 2007; Blitz, 2005; Kingma, 2007; Ross et al, 2005).

Viewed through the model just described (with the addition of the opportunity window provided by the UK’s recent policy of active international recruitment), the migration drivers that have emerged as key within the context of international health professional migration in general can be summarised as in Table 3.1. The question for this report is to what extent these factors can be said to be more or less relevant specifically to European health professionals moving to the UK; and/or health professionals moving within the UK and away from the UK to Europe and elsewhere overseas.


Table 3.1 Motivations for International Health Professionals Seeking Employment in the UK

National Drivers

Examples

Economic Better pay and standard of living for self and family Provide means to send money/remittance income back home Established economic trend of migration from country of origin

Political Desire to leave country associated with clear comparison of political instability versus stability in UK

Health system

Un/Underemployment amongst health professionals generally Shortage of posts in particular specialty/profession in home country Shortage of post-graduate opportunities in chosen specialty/profession Poor salaries and working conditions in health sector

Professional drivers

Examples

Additional skills/ experience

Experience working in different system rather than learning from theory Learn to use state of the art equipment and generally broaden

knowledge Career development

Professional challenge associated, for instance with different ways of working

Reputation and status of the UK system, specific organisation or particular clinical field

Opportunity for career progression and promotion; and training opportunities

Opportunity to get involved in cross cultural research and/or general networking

Individual drivers

Examples

Family/social network

Quality of children’s education and/or quality of life Influenced by decision of partner to work in the UK Choices possible within context of social/migrant networks in UK

Personal Desire for a life change; excitement; a break from predictable pathway Stage in career life cycle – taking opportunities at particular point Experience different culture (e.g. opportunity to live in London)

Spiritual Destiny and/or fulfilling a childhood dream Language skills

Improve own English language proficiency Opportunity for children to practice English English first language so easier to work in UK/Anglophone country

Opportunism Not actively looking but opportunity arose through friendships, holiday, word of mouth

Travel UK provides gateway to Europe Add UK to other overseas experience Actively looking for opportunities to travel; Itchy feet

Opportunity Window

Examples

UK Policy Response to positive recruitment strategy from UK government and DH Recruitment Incentives

UK face presented to international marketplace – market position relative to other countries, barriers or ease of entry, nature of support at recruitment and settling-in stages

Migration stepping stone

Opportunity to work in UK provided by policy window was attractive as potential stage in migration, primarily to the USA

Source: Young et al, 2008a, p.95 (see also Bach, 2007 and Buchan and Rafferty, 2004 for similar categorisations).


3.2 Motivations for European Health Professional Migration to the UK

The literature around European health professional mobility is no different from the wider international migration literature in suggesting that mobile individuals are influenced by a variety of migration drivers. Similarly, our interviewees had observed the “huge variation” (C4) and “mixture of reasons” (D1) underlying individuals’ decisions to move to the UK from Europe. Despite this variety, it is possible to discern some of the migration patterns that might be expected (e.g. on the basis of national-level source country characteristics). In the main, however, what the literature and our interviews reveal is the lack of widespread empirical evidence on migration drivers within Europe in general; and, in particular, the interactions between source country-related and other influences (e.g. professional group, age/family/career stage, gender, ethnicity etc) on migration decision-making.

3.2.1 Motivations and Source Countries

Across all the groups covered by the study what can broadly be defined as economic motivations are seen (both in the literature and our interviews) as the most significant underlying drivers for European-qualified health professionals moving to the UK. As one of our interviewees argued:

“I guess people move for a number of different reasons. [But] Economic migration is a significant proportion of that. So you go where you believe you can, where you're more secure financially” (A2 – All professional groups).

Detailed motivations include, for instance, the prospect of higher wages and a better standard of living for those already in employment (Ast, 2004; Galan, 2006; Mareckova, 2004; Smigelskas et al, 2007; Vork et al, 2004), and/or the straightforward prospect of having a job for those based in source countries with significant un(der)employment in particular professions and health specialties (Pitts et al, 1998; Simmgen, 2004; midwifery case study in Young et al, 2008b) (see Box 3.1 for typical views from interviews).


BOX 3.1

ECONOMIC MIGRATION DRIVERS: INTERVIEWEE VIEWS

Comparative Income Levels and Standard of Living

“If you were to look at how much a Physio earns in Poland, it’s probably, what, £100 a month, or something like that. I've heard that figure bandied about … I mean given the option, and if you had friends that were here, you'd come wouldn’t you?” (B1 - AHPs)

“Poland and Romania are the 2 biggest EU groups of nurses and there are obvious salary differentials” (C2 - Nurses)

“I expect the motivations of EU and accession country doctors are more a mix of economic and others” (D1 - GPs)

“From the new accessions states it’s [migration to the UK] for predominantly economic reasons. [It] Will [however] be interesting to see whether this actually continues from Poland. The exchange rate has dropped significantly so I think that may actually be a, be one factor that might influence mobility in the future” (B4 - Pharmacists)

“I think there are other drivers around coming from Poland. People have felt that the standard of living would be very much higher here” (C3 - Dentists)

Perceived Greater Job Availability in the UK

“It seems a lot of applicants from the EU think there’s a good job market in the UK. A lot also think that if they register, they will have more chance of employment” (B2 - Nurses)

“There has been a shortage of doctors and others in UK and so vacancies to be filled” (C4 – Hospital Doctors)

“Unemployment of GPs in some EU countries acted as a push” (D3 - GPs)

“Situations in home countries. I mean in a number of countries in the past, and this goes in waves, have been overproducing dentists. You would have the sort of Northern English-speaking countries (EU) coming to the UK. So I think the main driver was for employment” (C3 - Dentists)

This comparison between the UK and other European countries in the context of perceived job prospects has been particularly significant in recent years, given the UK’s explicit policy of NHS workforce expansion and active international recruitment following the publication of the NHS Plan (DH, 2000a) (see Box 3.2). The UK situation of perceived shortage in several key health professional groups (hospital consultants, GPs, nurses, midwives, and AHPs) was, then, set against other countries’ overproduction of health professionals in the education system (e.g. Spain, Germany and Italy) and/or their lack of investment resources to create sufficient jobs and pay attractive wages in the health sector (e.g. Poland) (Buchan, 2006; Hassell, 2003; Young et al, 2008a). In this context, it should be reiterated that migration from the EU/EEA to the UK has been consistently less significant for almost all health professional groups than recruitment from outside the EEA. It seems unlikely that without DH led initiatives employer organisations would have prioritised Europe as a source of staff. Clearly, the post-2006 change of UK policy in relation to international recruitment has had a reversing impact on numbers of EU/EEA staff coming to the UK,


just as it has for other internationally-qualified health professionals (quite simply because countries are no longer being actively targeted in large-scale recruitment campaigns). However, this is not the case across all professional groups. Related changes in work permit regulations and the shortage professions list (DH, 2006, 2007 and 2008; NHS Employers 2006) are significant only for staff from outside the EU/EEA. This means that where there is still demand to be filled (e.g. in midwifery):

“We know anecdotally that - [due to] changes to work permits, the introduction of the Overseas Nurses Programme and the dampening of demand - the levels of recruitment from outside the EU have dropped dramatically and the levels of recruitment with the EU are going up. Romania and Poland are the largest …” (C2 - Midwives).

BOX 3.2

THE ROLE OF UK RECRUITMENT POLICY: INTERVIEWEE VIEWS

Impact of Active International Recruitment Policy

“[There was an] … expectation that there were jobs available in the UK following the DH international recruitment campaign. People have thought, `Ah, jobs available.’ Until recently this has been true for EEA graduates” (C4 – Hospital Doctors)

“International applications increased to a peak 2 or 3 years ago. Jobs were available….NHS spending had increased and it was a case of supply and demand … everyone wanted to come here … It went up a lot in 2004 with accession states [joining the EU]. It had a massive impact. [Now] International applications have dropped … jobs are no longer there” (B1 - AHPs)

“As a result of a shortage of UK dentists there was recruitment in Eastern Europe, and India. This was, say, 3 years ago, maybe 4. Poland was particularly targeted” (C3 - Dentists)

“Europe was targeted for active recruitment There were agreements to bring in Spanish Nurses and also work around both Polish GPs and Polish Dentists specifically” (A2 – All professional groups).

“The way we [now] restrict or enhance the opportunities for those groups of nurses [i.e. non-EEA] has an impact then on recruitment from the EU” (C2 - Nurses).

“Huge increase in NHS spending over past 10 years. The situation with migration has been pure supply and demand. There were jobs but not now…physios and OTs” (E1 - AHPs)

Not surprisingly, comparative economic factors are seen as being most significant for individuals coming to the UK from the CEE countries make up the majority of the EU12 that joined the EU in 2004 and 2007. They are also seen as the key driver for migration from East European countries currently outside the EU (Krieger, 2004; see also above - Box 3.1 interview comments). As just one example, Wiskow (2006) notes that Czech doctors are paid four to eight times less than they would be in the “Old” EU15 but even that is around three times more than those in Slovakia. Conversely, the lack of any real discrepancies in pay, conditions and levels of


employment was felt to be a major reason why mobility was less significant prior to 2004 in the EU15. At that time, most movement within Europe tended to occur at regional level – i.e. it was more of a reflection of linguistic and cultural ties, and shared educational curricula and professional practice, than economics (Buchan, 2003; Simoens and Hurst, 2006). An obvious example would be the traditional levels of mobility (especially nurses) between the UK and Ireland (Buchan, 2006). Significantly, however, when concerns over employment stability and un(der)employment within the health system are brought into the equation, as opposed to wages/income per se, other countries in the EU15 have become more relevant as key UK migration sources (see, for instance, the GP and midwife case studies of recruitment from Spain, Germany and Greece in Young et al, 2008b). Interestingly, new regional markets are also reportedly emerging within the EU12 and EU27 (e.g. between the Balkan countries; and between Germany and the west of Poland where German is a widely-spoken language), made possible as more and more countries come into the Union (E1).

Importantly, several authors have also argued against over-focusing on economic motivations per se (see, for instance, Bach, 2007; Grant et al, 2003; Kingma, 2007; Ross et al, 2005; Wiskow, 2006; Young et al, 2003/Poland Case Study; Young et al, 2008a). At one level, Krieger (2004) for instance demonstrates that motives vary significantly between the different CEE and Wider European countries (both new and potential EU joiners) – with financial motives most dominant in Bulgaria and Romania and important in Turkey and the Baltic States, but less of an issue in richer states such as Cyprus, Malta and Slovenia. Conditions within home labour markets appeared particularly important in Poland and Turkey whilst within the more affluent states family and personal motives grew in importance. Elsewhere, studies have similarly shown that even for individual migrants for whom economic gain is a major incentive, career and/or professional skills development and the general challenge of moving to another country are also important (Young et al, 2008a). As in the EU15 countries, professional and personal development are likely to be important motivating factors for individuals from both the EU12 and Wider Europe (just as they also are for other internationally-qualified health professionals). Indeed, such factors may be more important in these countries quite simply because the health systems are so significantly under-funded and challenged organizationally (Burgermeister, 2004; Mareckova, 2004; Pawlak, 2004, Szczudliñski, 2004). Though less relevant than in some countries (e.g. Zimbabwe; Iraq), the other factor felt to be playing a role in driving migration from Wider Europe (e.g. Ukraine, Georgia; and various states of the former Yugoslavia) is the general political situation. One article also suggests that Polish women, including nurses, may be increasingly migrating as a reaction to conservative policies and social values in relation to gender roles (Coyle, 2007).


3.2.2 Motivations and Career/Family Stage and other Demographic Factors

Although the level of significance placed upon them differs depending on the status of a given profession and the economic position of an individual’s source country, career and family circumstances do appear to be important influences in their own right for all professional groups. Once again, much more is known about the individual motivations of non-EEA health professionals, but some literature evidence does exist specifically about European migrants (and the factors noted in the literature were also backed by our interviewees). It is also possible to make some tentative observations about the influence of demographic factors such as gender, age etc – though clearly the key point here is that no studies have systematically compared these influences across the different health professional groups – whether in the context of migration from Europe or elsewhere overseas.

What literature evidence there is indicates that migrating hospital consultants (e.g. Polish doctors recruited as part of the DH’s international recruitment drives) have often reached a stage of seniority in their careers such that motives relating to broadening and consolidating experience and knowledge are often cited. They (especially the men) typically travel with their families and see working in the UK as an opportunity to expose children to a new culture and greater educational opportunities (Young et al, 2003/Poland Case Study; see also hospital doctor case study in Young et al, 2008b). GPs recruited from Europe are also typically seen as responding to better career opportunities in the UK. For those in the younger age groups this usually means post-graduate training opportunities; for older established GPs it might the perceived quality and different nature of practice (Averginos, 2004; Blitz, 2005; Ballard et al, 2004a) (see also Box 3.3 below). Older GPs too have often brought their families with them, and the opportunity to do so is often what tipped the balance for them in choosing to take up UK opportunities rather than remaining in countries of origin (e.g. Spain) (Atherton and Mathie, 2003; GP case study in Young et al, 2008b). By contrast, nurses, midwives and AHPs (who are more likely to be women) frequently travel to the UK alone and those from Europe, though not exclusively, are typically single. This does not mean that family is unimportant in these groups’ motivational decision-making - as is evidenced by the fact that nurses from non-EEA countries are often the sole earners in their families and regularly send remittances to support children or elderly relatives (Daniel et al, 2001; Winkelmann-Gleed and Seeley, 2005; Winkelmann-Gleed, 2006). It is simply a product of the age of individuals that constitute the majority of European migrants within these groups that career development per se is the higher priority – i.e. individuals tend to be at similar stages in their careers when they are ready for additional challenge but are not tied to staying with family in source countries (see nursing and midwifery case studies in Young et al, 2008b). (N.B. We could locate no literature on European AHPs in this context, but interviewees were of the view that they were similar to nurses and


midwives in terms of the relationship between age and career-related motivations). Overall, the perception is that the most significant career-related migration motivation for European health professionals outside medicine is the greater opportunities for professional development and job satisfaction that stems from the particular nature of practice in the UK – in particular the more challenging role content and levels of autonomy in relation to doctors compared with what is the norm in many EU/EEA and Wider European countries (see Box 3.3) (Young et al, 2008a). The only exception here is in dentistry where the view from our interviews was that:

“Dentists don’t particularly move for professional reasons. There wasn’t a perception that dentistry in the UK was better at all. The view of dentistry in the UK, not necessarily clinical is not particularly strong” (C3 - Dentists)

BOX 3.3

PROFESSIONAL MIGRATION DRIVERS: INTERVIEWEE VIEWS

Post-graduate Training and Continuing Development Opportunities

“The overall trend from the EEA is a progressive, but small increase. They tend to be more junior doctors, who may come for post graduate training which is difficult to get in some EU countries such as Germany, Italy and to an extent Spain is a problem” (C4 - Doctors).

“Quality of professional training is a major driver …” (D3 - GPs)

General Career Development

“I think also the career development and opportunities, the way you perceive that your career will be enhanced by moving somewhere, then you'll do that.” (A1 - AHPs)

“I think that the UK PLC, and certainly the NHS PLC, does carry with it credentials that people think will be useful for their CV. So even if they don’t decide to, even if the plan is not necessarily to stay a very long time, having that …. is an additional enhancement to your CV… that I'd worked and practiced in the UK. I think is another reason why people will choose to come here”. (A2 – All professional groups)

Job Challenge and Opportunity to Work Differently

“I think it’s recognised that many AHPs in this country enjoy a level of autonomy, and ability to practice that isn’t the same everywhere. So it’s seen as a really nice opportunity to come here” (A1 - AHPs)

“Career opportunities. Many UK AHPs work with a higher level of autonomy. I think that professionally it must be frustrating for a German Physio who’s always been instructed by a doctor” (B1 - AHPs)

“[The] UK has well developed hospital pharmacy system that doesn’t occur in many EU countries” (B4 - Pharmacists)

“Individual midwives find the UK attractive in terms of the way midwifery is practiced” (C1 - Midwives).

“Also historically GPs in UK have fared well compared to counterparts in Europe, in the main: income and also facilities, working hours, lifestyle. For example in Belgium most GPs still single handed and people don’t have practice nurse” (D2 - GPs)

“Professional satisfaction is more important than money for EU GPs. For example Spanish and Italian GPs [actively recruited as part of an international campaign] felt having 10 minutes to spend with a patient was an improvement” (D3 - GPs)


The literature and our interviewees (see Box 3.4 below) also confirmed that the range of more personal migration drivers identified in wider international studies (Table 3.1 above) are relevant to European health professionals. This includes factors such as experiencing a new culture, developing English language skills, and general quality of life considerations. Once again, however, there is a suggestion that the “luxury” of wanting to experience a new culture is more relevant to individuals from the richer countries of the “Old” EU15 (Averginos, 2004; Ballard et al, 2004a; Blitz, 2005) than the new EU joiners. Here “life opportunity” rather than “experience” per se is most important (Smirgelskas et al, 2007; Vork et al, 2004) (N.B. This reflects similar contrasts outside Europe between countries such as Australia, New Zealand and the USA and others in the “developing” world). Also as might be expected studies hint to the fact that cultural drivers are most significant for those in younger age-groups, whereas for older migrants other considerations such as family are more relevant (Young et al, 2008a; see also Box 3.4 for interviewee views). Overall, the most significant finding is the lack of consistent research data on personal migration drivers in the European context. As a specific example, we located just two studies (Krieger, 2004; Wiskow, 2006) that found that having family and friends abroad had influenced migration decisions within Europe (e.g. in this case from CEE countries). This is important given the evidence from elsewhere (e.g. Filipino nurses) that migration decision-making can belong to a collective social process involving not only immediate households and family but also migrant networks that exist in destination countries (Bach, 2007). As in other areas, however, it would need more in-depth research to establish whether such factors are relevant in the European context.


BOX 3.4

PERSONAL MIGRATION DRIVERS: INTERVIEWEE VIEWS

Life and Cultural Experience

“The people who tend to move, tend to be young its a growing trend…… people want to move and to try new experiences, and practice another country” (B4 - GPs)

“Young midwives want to experience a new country, to travel” (C1 - Midwives)

“There's also a perception that the UK’s great place to come and work: and London [for example] is a great city” (B1 - AHPs)

“For some people [working in the UK is] part of the life experience.” (A1 - AHPs)

Social and Community Networks

“There are well established Polish communities in the UK. This is different from Romania. It is supposition but might be relevant” (C2 - Nurses)

“There is a long standing relationship in nursing between the UK and Ireland so there is movement between the two” (C2 - Nurses)

Domestic and Family Considerations

“Language issues in the EU means physios tend to move more for personal and family than for career reasons … Physiotherapy [for instance] is a female dominated profession and people often move with spouses and not necessarily for career reasons” (C5 - Physios)

3.2.3 Motivations and Different Professional Groups

As we have illustrated, on the basis of the limited evidence available, profession per se does not appear to be a significant influence on migration motivations. Studies show, for example, that GPs and midwives from the EU12 have mainly migrated to the UK in response to a lack of posts in their countries of origin (Averginos, 2004; Ballard et al, 2004a; Blitz, 2005; Young et al, 2008a and 2008b). Both groups, therefore, have been similarly motivated by the same source country health system characteristic. As another example, the few hospital consultants actively recruited from Europe in recent years have tended to emphasise personal and professional migration motivations above financial or economic aspects. However, this appears to be because, compared to the other professional groups, they were older and had already progressed up their professional hierarchies so were relatively well remunerated (see hospital doctor case study in Young et al, 2008b). Similarly, although money appears prominent in the decision-making of European nurses and midwives working in the UK (particularly but not exclusively for those nurses from poorer countries in Eastern Europe – see Galan, 2006; Vork et al, 2004), professional development and career opportunities appear just as important as they are for doctors.


Overall, therefore, just as for international migration in general, the most important factors sitting behind individuals’ migration motivations within the EU/EEA and Wider Europe appear to be: a) type/characteristics (economic and health system) of source countries; and b) age and/or career/family stage - although the level of status afforded to a given professional group (e.g. consultants versus nurses) does appear to influence the degree of choice individuals are able to exercise as part of the process (Young et al, 2008a). It also appears that demographic factors such as gender are less important per se than career/family and source country circumstances – though again it is difficult to separate out any gender influence (given that nurses, midwives and AHPs are more likely women and consultants, and to a lesser extent GPs, are more likely to be men) in the relatively small-scale studies undertaken to date. Once again, the key point to note in the context of profession-specific migration drivers and the balance with other influences is the paucity of clear comparative and empirical (as opposed to anecdotal) information within the European context. Most of the literature that does exist around individual motivations for migrating - both from the “Old” EU15 and the expanding EU27 and Wider Europe - relates to doctors. The literature on nurses’ motives for migrating is very largely focussed on individuals from outside the EU/EEA who make up the majority of non-UK qualified nurses. There is a minimal amount of literature on AHPs and other professional groups.

N.B. The above discussion gives a snapshot of the broad trends that influence individual migratory behaviour. The following Table 3.2 seeks to summarise information gathered from the literature on a country by country and professional group basis – where it is available.


Table 3.2 Literature Review: Summary of Professional Group Findings by Source Country

MOTIVES PROFESSIONAL GROUP

EU15 COUNTRIES

Spain

(Blitz, 2005 Averginos,2004)

Economic/Financial motives

Over supply of doctors, especially GPs, and nurses with consequent unemployment

Active recruitment of doctors, nurses and pharmacists by the UK

Professional motives

Spanish GPs cited professional development GPs liked the way the UK system allowed more

patient contact and continuity of care

Personal

Developing language skills Experiencing a new culture

The literature relates to GPs and nurses

France

(Ballard et al, 2004a)


French GPs cited being able to work as part of a salaried service


Big motivation for GPs. Liked the shorter hours and more flexible ways of working in the UK

‘Fee for service’ nature of the French system was frustrating

UK system allowed for better teamwork and collaboration

Personal

Experiencing a new culture Living in London

Literature relates to GPs

Germany

(Simmgen, 2004)


Medical unemployment


Perception that medical training is of a high standard, especially postgraduate training

Training and working for doctors more flexible Less hierarchy and competitiveness than in

German medical system

Literature relates to doctors

Netherlands

(Pitts et al,1998)


Not stated as being of importance


More availability of training places than in home country

Better teamwork and collaboration

Literature relates to GPs


Table 3.2 Continued

EU12 COUNTRIES

Poland

(Coyle, 2007; Burgermeister, 2004; Pawlak, 2004, Szczudliñski W, 2004; Wang, 2007)


High unemployment affecting all sectors of the Polish economy

Falling living standards Active recruitment of Polish doctors dentists

and pharmacists


Professional development Pharmacists wished to learn to work in a

different system Gaining new skills More and better training opportunities Chronic under funding of Polish health system

Personal

Coyle (2007) suggested that Polish women are increasingly migrating as a reaction to conservative policies and social values in relation to gender roles

Pharmacists mentioned a new culture and way of life

All sectors of healthcare. Poland is the largest supplier from the new accession countries.

Several pieces of literature relating to doctors and one to pharmacists.

Academic article on migration and women

Czech Republic

(Wiskow,2006; Mareckova, 2004)


Low salaries for doctors Wage differentials between countries and

between doctors and other professionals


Better working conditions

Personal

Family and friends abroad Better quality of life

Several pieces of literature relating to doctors: one a report for ILO and one a news report for a medical journal

Lithuania

(Smigelskas et al, 2007)


Pharmacists cited desire for higher salaries and..

Better living conditions


Professional development

Personal

Quality of life

One piece of literature relating to pharmacists

Estonia

(Vork et al, 2004)


Higher salaries cited by doctors, dentists, nurses and midwives

Better working conditions cited by the above

Personal

All cited improved quality of life

One piece of literature: a report relating to doctors, dentists, nurses and midwives

Romania

(Galan,2006)


Wage differentials Pull factors more important than push

Report on health professional migration, with nurses being largest percentage.


3.3 Motivations for Out-migration from the UK and Within-UK Mobility

3.3.1 Motivations and Outflows from the UK

As illustrated in Section 2, most outflows of UK-qualified health professionals are to other English speaking countries outside the EU/EEA though there is some migration to areas within Europe with large ex- pat communities, such as southern Spain and parts of Italy. It would appear, therefore, that there are more constraints than drivers around movement from the UK to the EU, with language and the nature of professional practice being the most significant (see below). If individuals do decide to migrate to the EU/EEA our interviewees felt anecdotally that it was most likely to be for personal motives, for example to join a partner, or to gain an improved quality of life – “They might not benefit overall financially but I think they feel the quality of life will be better for them” (A2 – All professional groups). Movement to countries outside Europe (e.g. Australia, New Zealand and USA) tended, by contrast, to be the type of migration perceived as likely to stem from career development aspirations as well as general lifestyle gains (A1) (see Box 3.5). They were also most likely to be seen as attractive destinations in the context of general life experience motivations. As two of our interviewees put it: “Again, it’s a life experience thing, it’s a different way of living [e.g. in Australia] – and attractions will come with that” (A1); and “The world is a smaller place. So I think people’s minds are more geared to moving [again to Australia for instance]” (A2). Broadly speaking, then, the main drivers for migration are perceived as being common between UK-qualified health professionals and mobile individuals in general. The balance of emphasis on personal and professional drivers, followed by economic (rather than the other way round), also places UK migrants, unsurprisingly, as being most like their counterparts from other affluent countries (e.g. EU15) rather than poorer developing and CEE economies. Overall, however, there appears to be very little concrete research exploring out-migration of UK-qualified staff or the reasons behind it, if and when it does happen. The majority of evidence and opinion was anecdotal. (N.B. We found nothing in the literature review regarding the migration of UK-qualified health professionals specifically to Europe).


BOX 3.5

DRIVERS FOR OUT-MIGRATION FROM THE UK: INTERVIEWEE PERCEPTIONS

Out-migration of UK-qualified Health Professionals

“Some midwives go to EEA but often with a partner” (C1 - Midwives)

“Some dentists do go to Spain where there is an ex pat community” (C3 - Dentists)

“Very few doctors go to Europe….they go to the Anglophone countries, North America and Australasia” (C4 - Doctors) – “GPs tend to go to Australia and New Zealand” (D1; D2; D3 – Doctors)

“There are young doctors who will do some training abroad again the English speaking commonwealth countries” (D2 - GPs).

“UK physios go to Australia and New Zealand because it is the most similar to here so they feel comfortable, particularly as juniors” (C5 - Physios) - “AHPs do move but not to EU….they go to Australia and New Zealand” (A1; B1 - AHPs)

“Professional reasons for some groups, and it varies. Currently Australia is the place to be, for muscular skeletal Physiotherapy….. So a lot of people will go there to try and get experience. I’m sure there are similar issues for other groups”. (A1 - AHPs)

Return-migration of EU/EEA-qualified Migrants

“I don’t have any information but I suspect that probably quite a number recruited from the EU would have gone back. Ease of movement enables this.” (A2 – All professional groups).

“Anecdotally we know some dentists have gone back. They have just not been happy here, for different reasons: expectations of more sophisticated treatments rather than ‘bread and butter’ dentistry …” (C3 - Dentists)

Outflows of Other Internationally-qualified Staff

“New Zealand, Australia, Canada and the US are all recruiting heavily at the moment with lots of adverts in the nursing press. Intentions of non-EEA nurses will be influenced partly by how easy it is for them to stay in the UK, what their experience is but also who is actively recruiting them to go and work elsewhere” (C2 - Nurses)

Interviewees also had little concrete information (and we located minimal published literature – see only Hann et al, 2008) regarding retention of European (or indeed other internationally-qualified individuals working in the UK - either from the active recruitment initiatives of recent years or more general migration. As reported in Section 2, however, there is a general perception that a significant proportion of EU/EEA-qualified individuals return to their countries of origin. Reasons given by our interviewees ranged from individuals not being able to settle in the UK (e.g. due to gaps between expectations and reality), and the fact that many only ever intend to migrate for a limited time period (see Box 3.5). With references to dentists in particular there was a feeling some EU-qualified individuals had return-migrated due to practice in the UK not living up to their expectations (C3 - Dentists). The other key facilitator of return migration within the EU/EEA was, quite simply, the ease of movement enabled by the mutual recognition arrangements that brought them to the UK in the first place (A2 – All professional groups). By contrast, non-EEA


professionals are generally perceived as staying in the UK for longer than EU/EEA migrants (N.B. This perception has been confirmed from workforce data, but only for doctors – Hann et al, 2008). Just as UK policy was a key driver for in-migration in recent years, the most significant perceived reason for overseas-qualified professionals now leaving the UK is competition from other countries (e.g. Australia, USA) themselves actively recruiting from the ranks of staff previously recruited by the UK NHS (see Box 3.5).

3.3.2 Motivations and Mobility within and between the Different UK Countries

We were able to locate little, if any, published research on within-UK migration of health professionals and, in particular, mobility to and from the different UK countries. Anecdotal evidence and the small-scale studies that do exist suggest, however, that motivations to move within the UK are essentially very similar to those for EU/EEA and overseas-qualified staff already described. They include, for instance, economic/financial, life experience and qualify of life, and career development aspirations (see Box 3.6 for our interviewee views). As for EU/EEA and other internationally-qualified staff the draw of NHS organisations actively recruiting is also seen as significant. The key example we have is of midwife recruitment from Scotland to London and the South East of England (see midwifery case study in Young et al, 2008b; also Ashford and St Peter’s Hospitals, 2008). Overall, however, the majority of questions in this area remain unanswered and there is clear scope for additional research to fill the knowledge gaps.


BOX 3.6

DRIVERS FOR WITHIN-UK MIGRATION: INTERVIEWEE PERCEPTIONS

Comparative Income Levels and Standard of Living

“It’s a good question. I guess most of the jobs/wealth are in the bottom half of the country as has always been, so that’s where people move to” (B1 – Nurses/Midwives)

“Movement is more likely to be to England than out of England. There’s more opportunity. It’s the same sort of thing as people migrating from rural area to urban areas” (A2 – All professional groups)

Perceived Greater Job Availability in England

“There is some mobility in UK due to what could be perceived as overtraining. Scotland has always over trained so there are problems getting a first job. Often jobs advertised were for midwives who had been qualified 6 months or a year and had done the consolidation. The problem was if you couldn’t get a job to consolidate you had to move” (C1 - Midwives).

General Career Development and Ways of Working

“I don’t know really [about motivations for moving within the UK] but I’m very tempted! The situation is certainly better for general practice in Scotland…the Government is more supportive. People are demoralized in England so movement is possible, though it’s difficult” (D1 - GPs).

Life and Cultural Experience

“The younger ones gravitate towards London and tend to be young or old and often if younger after 2 or 3 years they are at maximum use to the NHS and then they leave” (C1 - Midwives).

“People migrate from the provinces, or the counties, to London. To where they think it’s all happening” (A2 – All professional groups)

3.4 Constraints to Mobility Within and Between the UK and Europe

As noted above, active promotion of labour mobility is a key policy instrument for developing a competitive European labour market as well as a fundamental right of all EU citizens. This means that the height of the usual main barriers to international cross-border mobility – a) restrictions on access to labour markets imposed by individual states through immigration policy; and b) in the case of regulated professions such as those in health, the need to meet regulatory requirements controlling the right to practice – is greatly reduced for EU/EEA-qualified individuals moving within the Union.8 Despite such facilitative arrangements, overall mobility

8 By contrast, those who qualify outside the EU/EEA (including in what we have termed “wider Europe”) must individually prove their competence to practice (e.g. through passing additional UK-specific clinical exams, for example the Professional and Linguistic Assessment Board (PLAB) for doctors, and undertaking specified periods of adaptation)


in the EU/EEA remains low however - with only 1.5 percent of EU citizens currently living and working in a member state other than their country of origin, a figure that has not changed for 30 years (Eurostat, 2006). The health professions are reflective of this wider situation. Apart from the obvious personal factors (e.g. family responsibilities) that might tie an individual to a particular location - which are equally as applicable to other sectors as well as healthcare and also to within-UK movement in addition to migration across Europe (C1), there are some restrictions particular to the health sector, which are seen as adding to general mobility barriers.

For example, despite the long-standing arrangements for Sectoral mutual recognition of training and qualifications for doctors, general care nurses, midwives, dentists and pharmacists within the “Old” EU15 and the “harmonisation” incentives that those provide, there remain significant differences between these countries in terms of prevailing professional cultures, ways of working and the task content of jobs amongst these groups (A2 – All groups; B2 – Nurses/Midwives; C4 – Doctors; C3 - Dentists) (see also Simon et al, 2005; Bola et al, 2003; Buth et al, 2000; Cashman and Slovak, 2005; Grisold et al, 2007; McKendrick, 2005; Wang, 2007; Woolf, 2002). Even greater differences (e.g. around scope of practice, levels of professional autonomy, experience of multi-disciplinary team-working, roles in relation to dealing with patients etc) exist amongst the various AHPs, exacerbated by the fact that they have, until very recently, only been mutual recognised under the General System on an individualised case-by-case basis (Petchey and Needle, 2008). The expansion of the EU/EEA in 2004 and 2007 has simply added further complications in terms of the very different histories (e.g. around levels of medical specialisation, and the relationship to medicine of nursing, midwifery and other relevant health professions) added into the mutual recognition mix. Not surprisingly, such differences in customs and methods of practice (which need entirely separate consideration from straightforward qualifications etc) are reported as key barriers to significant movement of health professionals within the EU/EEA and also Wider Europe – both in our interviews (A1; A2; B2; B3; C4) and the literature (see, for example, Young et al, 2008a). This applies equally to the movement of European-qualified health professionals to the UK; and the potential movement of UK-qualified health professionals to Europe (see Box 3.7). Overall, within Europe, the UK is perceived as having most in common with certain of the former EU15 countries, and then only in relation to some professional groups (e.g. Netherlands for GPs) (Pitts et al, 1998).

and may also be required to undergo language testing (International English Language Testing System - IELTS) in order to obtain professional registration. In addition, they must fulfil government determined immigration criteria, and successfully obtain a work permit etc, before they can be employed.


BOX 3.7

CONSTRAINTS TO MOBILITY IN EUROPE: INTERVIEWEE VIEWS

Inflows to the UK from Europe

“Language and scope of practice are problematic in relation to EU healthcare professionals. EU regulations dictate mutual recognition of qualifications, but in reality customs in practice varies significantly within Europe” (A2 – All professional groups).

“In Europe there are differences in ways of working and autonomy of practice for AHPs. In France and Germany people often work to doctors instructions. Netherlands is more similar to UK” (A1 - AHPs)

“… [With staff] from Eastern Europe. There are qualification and very often languages problems” (B2 – Nurses/Midwives)

“The reason why we’ve had much more international as opposed to EU recruitment, even though it’s easier for an EU nurses to get on the register/don’t need a work permit, has been the cultural ties with overseas countries and the language issues” (C2 - Nurses).

“[There have been] Progressive attempts to try to align the [post-graduate] training policies. That hasn’t formally been recognised at EU level. The profession's been calling for greater alignment for ages …” (B3 – Doctors).

Movement of UK-qualified Staff to Europe

“[Mostly] They find the models of working too difficult. Fine in Scandinavia or Germany if you like labour ward [but] In the Latin countries things are more medically led. [Mainly] Midwives go to Canada, New Zealand and Australia …[because there are] no language barriers” (C1 - Midwives)

“There is also the opportunity, if you think you might be going for a while for a career more like the one you anticipated in the UK, you can see yourself having a more similar career in somewhere like Australia, New Zealand, or the States. If you went to France, you would surmise you wouldn’t have such opportunities in your career, plus the language” (A1 - AHPs)

“The EU is obsessed with free movement and have done everything possible to maximise it. Of course then English Doctors are let down by the English education system, which doesn’t give them any language skills” (D1 - GPs)

A further complication in the context of the AHPs is that not all professions are recognized in all the EU/EEA member states. Table 3.3 shows just the AHPs that are regulated in the UK against the other EU countries where they are also recognized. Across Europe as a whole, however, more than 250 AHP groups are recognized. Moreover, although professional titles may be ostensibly the same, it does not follow that staff with those particular titles in different countries are “doing the same jobs”. One example is a Physiotherapist, whose practice places much greater emphasis on spa therapies in CEE countries and Germany than in most West European countries including the UK. Another example would be a Dental Technician. This title allows individuals to work inside the mouth of a patient in the Netherlands, but they cannot do so, for instance, in France. By contrast, the same job may be given an entirely different title from country to country (Petchey and Needle, 2007 and 2008). As the European Commission states: “The only authentic title of a [AHP] profession is that of the language of the country in which the profession is regulated”.


Therefore, if AHPs are to move within Europe separate assessment is needed “of the areas of activity covered by each profession” (see http://ec.europa.eu/internal_market/qualifications/regprof/professions). As two of our interviewees explained, these differences are likely to continue to have profound implications for ease of AHP mobility – even given the changes introduced by the Bologna Process and EU Directive 2005/36/EC (described in Section 1):

“I think there are some real tensions because within the European Commission this is run by Politicians and Civil Servants, they don’t really understand the world of education at all. And at our very first meeting we said the whole idea of a common platform is based on a quantitative analysis of circular content - that is not where education is going and it’s very much a qualitative approach and an outcomes based learning approach, competencies approach, that’s where we all want to be, that is what the Bologna process is about. The common platform, doesn’t seem to me, to sit easily with that, I think that’s a real tension, however, the answer from the EU Commission was we go for a quantitative approach because that’s legally neat and tidy well if might be but if it’s not helpful then there’s no point doing it really” (C5 - Physiotherapists).

“Common platforms are extremely unlikely to develop for the AHPs, given the size of the AHPs, the diversity and variability across Europe, and the small numbers involved. Difficult to see any of the professions, or many of the professions putting in the time and effort to develop them” (E1 - AHPs)

http://ec.europa.eu/internal_market/qualifications/regprof/professions�

http://ec.europa.eu/internal_market/qualifications/regprof/professions�


Table 3.3 Selected UK Registered Allied Health Professions by European Member State Recognition

Art

s Th

era

pis

t

Ch

iro

po

dis

t

Die

tici

an

OT

Op

tom

etr

ist

Ort

ho

pti

st

Para

med

ic

Ph

ysi

oth

era

pis

t

Ort

ho

pti

st/

P

rost

heti

cist

Rad

iog

rap

her

S&

LT

EU15 Austria 2 2 Belgium Denmark Finland France Germany Greece 3 Ireland 2 Italy 2 Luxembourg Netherlands 3 Portugal 2 Spain 2 Sweden EU12 Bulgaria* Cyprus Czech Republic 2 2 Estonia* Hungary* Latvia* Lithuania Malta Poland Romania Slovakia Slovenia Remaining EEA Switzerland Norway Iceland Lichtenstein 2 Source: Reproduced from Petchey and Needle (2007) – collated from:

http://ec.europa.eu/internal_market/qualifications/regrof/index.cfm (Accessed May 2007)

Notes: * No data for Bulgaria, Estonia, Latvia and Romania. 2 Two professions registered under this title. 3 Three professions registered under this title.

http://ec.europa.eu/internal_market/qualifications/regrof/index.cfm�


The other main barrier to health professional mobility from Europe to the UK and vice versa is, not surprisingly,9 the challenge around language and communication. Specifically, this means the extent to which potential migrants speak good English (in the case of individuals moving to the UK) and other European languages (in the case of individuals thinking of leaving the UK). In other words, despite the fact that (unlike individuals from elsewhere overseas) under mutual recognition arrangements health professionals moving within the EU/EEA cannot be tested for English language competency as part of the professional recognition process, these factors were still seen as potential discouragements to individuals themselves in terms of what levels of mobility are realistic in practice. The key point here is that the requirements of speaking a language in the sorts of everyday contexts taught in schools are very different from those in a working situation in health care (e.g. when staff are required to have medical as well as conversational language skills; need to have quick reactions; and be confident to work in potential crisis situations in certain roles). Again such issues were picked up both in our interviews (Box 3.7 above) and by the literature review (Allen and Carter, 2007; Ballard et al, 2004b; Bola et al, 2003; Coombes, 2002; Cowan, 2006; Grant et al, 2004; Magnussdottir, 2005; Mathie, 2002; O’Dowd, 2003; Palese et al, 2007; Porter and Powell, 2005; Sales, 2003; Whalley, 2001; Young et al, 2008). However, as with other aspects of the European mobility debate, the extent to which these, and indeed the equivalence of practice factors noted above, actually discourage mobility (rather than simply presenting challenges to employers and the individuals that do choose to migrate – see below) has not been fully researched or equated.

3.5 Summing Up: The Complexity and Interlinked Nature of Migration Flows

Although it is possible to distinguish various drivers and constraints to health professional mobility (to and from, and within the UK), the overwhelming observation from both the literature and our interviews is the sheer complexity of underlying factors involved. No single driver/constraint can be singled out as key either for individual migrants or source/receiver countries as a whole. As one of our interviewees perceptively observed in the context of the UK:

“Inflows and outflows [of EU/EEA and other internationally-qualified health professionals] are completely interlinked. They’re not separate labour markets operating in a separate way. The intentions of overseas nurses to

9 Such findings simply reflect the challenges associated with international health professional migration in general (Daniel et al, 2001; Grant et al, 2004; Magnusdottir, 2005; Moore, 2002; Stanley, 2001; Taylor 2005; Winkelmann-Gleed and Seeley, 2005; Young, 2008a).


stay in the UK in the presence of active recruitment from Australia etc will be influenced partly by how easy it is for them to stay, what their experience and also who is actively recruiting them to go and work elsewhere. The way we restrict or enhance the opportunities for those groups of nurses has an impact then on recruitment from the EU” (C2 - Nurses)


4 Implications for Organisation and Delivery of UK Healthcare

This section deals with the implications (real and potential) of European health professional migration for NHS organisations in their role of overall responsibility for service provision. This includes both the negative and positive challenges around service delivery itself, for example, the nature of clinical care, the point of contact experience between patients/carers and different types of health professional, and the team context in which that takes place. It also covers the immediate and longer-term organisational and management challenges (e.g. around HRM and local workforce planning) associated with integrating European health professionals into the NHS workforce. As with other aspects of this report, the themes discussed essentially emerge from the wider literature on international health professional migration in general; however, it is common sense that they also apply to migrants from the EU/EEA and “Wider Europe. What we attempt to do, then, is illustrate where there is actual, documented evidence about European-qualified health professionals working in the NHS as opposed to anecdotal concerns about the possible implications of mobility/migration. Again, what it is clear from the ensuing discussion is just how much scope there is for comprehensive, comparative (cross-professional and multi-source country) research to unpack the complexities of the issues in relation to Europe.

4.1 Factors Impacting on the Nature of Clinical Practice

4.1.1 Equivalence of Training and Experience

Despite mutual recognition of formal training and qualifications, the literature and our interviewees highlight several concerns around the real equivalence of European healthcare professionals’ knowledge and experience compared with that needed to deliver services in the UK system. The issue is generally not clinical skills and competencies per se, but gaps in knowledge due to lack of prior learning opportunity or differences in the responsibilities of the posts migrants are coming from and going to (Interviews A2 – All professional groups; C4/D2 – Doctors; C5/E1 - AHPs) (De Raeve, 2003). In the context of prior learning, several authors and our interviewees note what, from a UK viewpoint, appear as continuing gaps in post-graduate training coverage – particularly in medical specialties (Birt, 2002; Jinks, 2000) (Table 4.1) and general practice (Atherton and Mathie, 2002; Interviewees C4; D2; D3). Other professional groups such as dentistry reportedly have no equivalent at all, of the UK’s requirement for


post-graduate vocational training and/or are not allowed to deal with patients (something which would be a key part of the training experience of all health professionals in training in the UK) before they are fully qualified to practice (Interviewees A2; C3). The other main differences between the UK and other European countries are around nature and pace of workload; and the structural system of healthcare, in particular the divide of responsibilities between health and social care, which is relevant, for example, in the context of hospital discharge. In other words, training itself cannot be seen in isolation from other factors, for example, national differences in how services are delivered, how clinical conditions are managed and the expected roles of individuals within that context (see Tables 4.2 and 4.3).

Table 4.1 Issues of Equivalence in Training: The Example of Medical Specialties

Buth et al (2000); Cashman and Slovak (2005); Grisold et al (2007); McKendrick, (2005); Scherpereel and Sondore (202); Woolfe (2002) have examined specialist medical training in the EEA within the fields of vascular surgery, occupational medicine, neurology, infectious diseases, occupational medicine, anaesthesia, and rheumatology respectively. All note the potential benefits of free migration of doctors within Europe and the moves towards harmonisation of education and training. They also note the complexities of this in view of the variations that exist with regards to individual member states, as follows:

Variations Examples Reference

Non or limited recognition of a speciality

Infectious disease not recognised in Spain and Belgium

Vascular surgery is an independent surgical speciality in some countries but not others

McKendrick (2005)

Buth et al (2000)

Different specialities deal with different conditions

In some countries dementia is dealt with by neurologists and in others by geriatricians

Grisold et al (2007)

Differences in entry to and length of specialist training

Neurology training in the EEA is a minimum of 4 years but in some countries is between 4 and 8 years

Training to be a vascular surgeon can be as short as 5 years in Greece and Spain and as long as 11 in the UK

Training in Occupational Medicine varies from 1 year in Portugal to 4 in Ireland

Grisold et al (2007)

Buth et al (2000)

Cashman and Slovak (2005)

Differences in how care is delivered in the wider system influences training content

Rheumatology training, for example, has been influenced in some countries by greater emphasis on rehabilitation and balneotherapy

Woolfe (2002)

Differences in standard combinations of sub-specialty knowledge

Anaesthesia is an example of a specialty where the duties differ from country to country across Europe – i.e. duties may include everything from intensive care to emergency medicine and pain therapy.

Scherpereel and Sondore (2002)

Young et al (2003) – Spain case study


Table 4.2 Nature and Pace of Clinical Workload: Differences in Types of Experience


Differences in how care is delivered influences job content and experience profile

General Practice - Spanish GPs, for instance, have less gynaecology and family planning; paediatrics and child protection, and dermatology experience. Polish GPs have less gynaecology and family planning, and less experience dealing with children. Partly this reflects the greater emphasis in some countries on community-based specialists (e.g. paediatricians; gynaecologists) - hence GPs do not have to cover such a wide range of tasks as in the UK**

Physiotherapy – A key difference here is between, for example, Germany and various CEE countries where there is greater emphasis on spa-based therapy than in the UK and other countries in Western Europe**

Atherton and Mathie (2002)

Mathie (2002)

Young et al (2008a and 2008b)

Petchey and Needle (2007 and 2008)

Differences in the pace of work and experience of organisational capacity/throughput

Midwifery – The number of deliveries per year that German midwives are used to is far less than in UK units; and actually far less than what UK midwives are required to do individually to maintain their registration. They are also more used to consultant-led care so have less experience of high risk patients and “managing the abnormal”, having mainly focused on antenatal care and straightforward deliveries**

Nurses – Romanian and Russian nurses working respectively in Italy and the USA have commented on the major differences they encounter in terms of nurse/patient ratios and size of hospital/levels of care. As another example, Spanish nurses sometimes do not have experience in big teaching hospitals. In surgical units in smaller hospitals they potentially see ‘a bit of everything’; but may not become acquainted with the specialist technology used in equivalent UK clinical areas** Doctors – Radiologists recruited to the UK from other countries, for example, report seeing many more patients than they were used to.


Palese et al (2007)

Bola et al (2003)



Different models of care, hence levels of responsibility individuals are use to

Nurses - Spanish nurses’ basic nursing care competences include procedures considered to be advanced skills/part of extended nursing roles in the UK (e.g. urinary catheterisation; insertion of venflons and central venous catheters etc). Midwifery - Managers report that Greek midwives are more used to an obstetric nursing approach, caring for women during labour but calling in the obstetrician for the actual delivery. Due to lack of resources in their training hospitals, midwives from some Eastern European countries are felt to lack experience of key procedures such as epidurals because they are not routinely available.



Differences in prevalence of different health problems and/or resource availability influences type of experience

Doctors/Nurses – Levels of experience of different conditions (e.g. HIV) that migrants bring with them to the UK depends on prevalence in the general population in source countries.

Doctors/Nurses – High dependency or specialist settings in one country do not necessarily equate to such settings in the UK - which, relatively, care for sicker patients and are faster paced than in countries where units are less well resourced in equipment and technology terms

Bola (2003)



Table 4.2 Continued

Differences in professional practices in general influence on-the-job experience

Pharmacy - Wang (2007) notes differences in professional practices amongst Lithuanian and Polish pharmacists as compared to those from the UK.

Dentistry – In some countries dentists are not taught to deal with children; and do not undertake certain tasks (e.g. using radiographs as diagnostic tools) that are regarded as a key part of practice in the UK

Wang (2007)

Mentioned by interviewee C3 – no references located in the literature review

** Note: As with medical specialties (see Table 4.1) differences in models of care and the workings of the health system are reflected in the detailed content and lengths of training for other professional groups – e.g. general practice, midwifery, nursing, physiotherapy, dentistry etc (D2 – GPs; C1 – Midwifery; A2/C3 - Dentistry) (Bola et al, 2003; Simon et al, 2005). In the context of the AHPs, the wide variation in the professions that fall under this umbrella term within Europe makes discussion of equivalence even more problematic. At present there is no equivalence of qualifications and cases are decided on an individual basis. As noted by interviewees professions with the same title in individual EU countries can often have very different roles and are trained to different levels (C5; E1) (Petchey and Needle, 2008).

Table 4.3 Health System Differences: Types of Knowledge Required for Role Effectiveness


Procedural knowledge needed for effective hospital discharge

Medical Specialties and General Practice - Studies illustrate the need for additional training regarding the hospital discharge (e.g. needs assessment procedures; role of social services; general organisational mechanisms involved etc). These need be understood from both sides of the equation – hospital doctor and GP

Santana (1999)


Mechanisms for making referrals so that patients receive specialist care

General Practice - Studies of Spanish GPs working in the UK have reported their lack of understanding of referral processes

Santana (1999)


Technical and procedural knowledge around doctors’ wider legal responsibilities

Medical Specialties and General Practice – All migrant doctors need additional input regarding issues such as death certification, coroner’s referral and the law as it relates to medical practice in the UK

DH (2002a)

Additional management knowledge needed to operate in UK general practice

General Practice – All migrant GPs need input regarding systems for delivery of primary care – including practice organisation and team-working in general practice

DH (2002a)


Knowledge of general organisational systems necessary to work effectively in the UK and local system

All Professional Groups – Regardless of the transferability of clinical skills and experience, all groups need training in the specific organisational systems, procedures and documentation etc relevant to the UK organisation in which they work. As just one example, Scandinavian nurses’ clinical skills and knowledge were reported as highly transferable in Young et al’s (2008) study, but they often had “a bit of a problem getting up to speed on the standard of documentation required”.



4.1.2 Different Cultural Perceptions of Professional Roles

There is wide variety in the ways that health professionals perform their work both outside of and within the EU/EEA and such differences should not be underestimated. The UK, in theory if not always in practice, takes a holistic approach to the delivery of healthcare with importance given to psychological and social, as well as physical factors. This overall ethos impacts on many interrelated aspects of clinical and professional practice, such as autonomy, responsibility and accountability and assumptions around procedures and practice (Interviewees: A1; A2; B3; B4; C1; C2; C4; E1).

Roles and status with teams - Autonomous practice is a key area where there are significant differences between internationally-qualified health professionals and those from the UK. The issue of autonomy is particularly relevant to nurses, midwives and AHPs who have a complex relationship with the medical profession. More specifically, many in these groups are used to a medically-led system of care – i.e. a strong hierarchy and clearly defined relationship between doctors and the other professions - in their countries of origin. This is not necessarily problematic if the system is designed to work effectively on that basis and everyone concerned understands “the rules of the game” (O’Brien, 2007). In the UK, however, migrants have to adapt to the more equal relationship between doctors and other health professionals on which the workings of NHS services relies; and the implications that has for appropriate roles, status and responsibilities (e.g. to question the medical profession where that is appropriate) within multi-disciplinary teams (Young et al, 2008a).

Content of healthcare jobs - In the context of cultural differences around expectations about the content of job roles, UK nurses, for example, generally plan and deliver care to a group of patients and liaise with other professionals in and out of the hospital setting. This contrasts with the more task-orientated methods of delivering care prevalent in other countries – e.g. where nurses’ roles are closely focussed on carrying out particular clinical activities (e.g. drug administration, taking bloods, IV cannulation, ECGs, stoma care, tissue viability, doctors’ rounds etc) rather than doing the wider aspects of care as well. Linked to this is the fact that in many countries it is not the role of the qualified nurse, but that of healthcare assistants and patients’ families, to carry out basic care (e.g. washing; dressing; feeding assistance; making patients comfortable etc). Such activities are, however, is essential to the UK concept of nursing. Another aspect of the equation is the differences in terms of what is considered normal clinical practice/competencies for a given professional group and what is considered an extended or specialist role – with migrants sometimes frustrated and deskilled when they cannot perform such tasks in the UK (Interviewee C2 - Nurses).


All of these issues are mainly highlighted in the literature in the context of non-EEA staff - especially overseas nurses (e.g. from Africa, India, The Philippines and China – Daniel et al, 2001; Gerrish and Griffiths, 2004; Taylor, 2005; O’Brien, 2007) and AHPs (e.g. from countries other than Australia/New Zealand – Masters, 2005; Petchey and Needle, 2007). However, there is some evidence of their being relevant also to European health professionals (e.g. midwives, nurses, physiotherapists and other AHPs) – and again there are differences depending on country/region (Petchey and Needle, 2008; Young et al, 2008a). As a particular example, Spanish nurses were reported in Young et al’s study of international recruitment as used to healthcare assistants providing day-to-day care while their own role was to monitor the patient’s condition and do all the technical tasks, which included some (e.g. urinary catheterisation; insertion of venflons and central venous catheters) that would be classed as extended roles in the UK. They were, however, reported as being less confident in terms of autonomous practice and challenging doctors where appropriate than, for instance Finnish nurses recruited to the same hospital. As another example from the same study, Scandinavian and Dutch midwives were reported as being used to practicing autonomously, while those from Greece, Germany, Italy and Spain were used to working more closely with doctors. Some were, therefore, initially fearful of being left to manage labour completely, and needed intense induction in order to build confidence. Polish midwives and those from other CEE countries had even greater adaptation needs due to their lack of exposure to advanced midwifery practice, which in turn stemmed from the lack of equipment and resources in countries of origin.

4.1.3 Potential Implications for Care/Service Standards in the UK Context

The literature provides various examples of where the nature of care might be directly affected by the existence of different cultural norms and training/on-the-job experience profiles. Decision-making about how long to continue seriously ill patients’ treatment is a key example in hospital settings; as is level of initial competence in highly technical, high dependency service settings such as ICU. In both of these instances, variation reportedly exists due to equipment and other resource availability differences between the UK and other countries (Young et al, 2008a). Patient safety and service standards concerns have also been expressed at a more general level, for example, related to the initial unwillingness or lack of confidence of some nurse, midwife and AHP migrants to take responsibility and/or be assertive and challenge medics where necessary (Interviewees C2 and A1). As one of our interviewees argued: “There are huge transitions around moving from carrying out other peoples wishes to working independently” (A1). As another broader example, there are different perceptions about who’s job it is to break bad news (e.g. about


bereavement), which can mean that patients/carers do not receive relevant information in a timely manner. Again this can relate to straightforward gaps in training and experience, but it can also be to do with different perceptions about appropriate doctor/nurse divisions of labour (see for example Bola (2003) on the lack of education/training in the death and dying process of Russian nurses working in the USA). Once again, although there is some UK-based research relating to EU/EEA and Wider European health professionals in this area (e.g. Young et al, 2008b re. midwives; and Ballard et al, 2004b re. GPs), most research on this topic has been about non-EEA groups (especially nurses) – and even then it is more likely to note potential problems than make any attempt to document actual reports of minor or serious failure.

4.2 Factors Impacting on Dealings with Patients and Carers

The ability of the patient/carer and healthcare worker to understanding one another and to communicate effectively is integral to the delivery of safe and effective care. Key to this is the worker’s capacity to speak in the same language as the patient to an appropriate standard – i.e. verbal skills. In addition, written language skills (e.g. regarding medical documentation) and non-verbal communication skills are highly relevant, all of which are culturally influenced. Individual health professionals, whatever their country of origin, possess these skills to varying degrees and it should not be assumed that the skills of non-UK qualified individuals are necessarily inferior to those who trained within the UK. What is clear, however, from both the literature (e.g. Allen and Carter, 2007; Coombes, 2002; O’Dowd, 2003) and our interviews is that concerns do exist about language/communication challenges compromising the ability of some migrant health professionals to “do their job”. Whilst, once again, much of the detailed literature relates to individuals from outside Europe and is predominantly about nurses, the findings are relevant to any discussion of the difficulties that arise from communicating both in a language that is not the mother tongue and in the context of an entirely different culture. In addition, there are particular issues that relate to European health professionals.

4.2.1 Language Skills and Standards

Anxieties about standards of English amongst EU/EEA health professionals are frequently voiced, even more so than for many non-EEA (e.g. from India and The Philippines) who have often received their education and training in English (Grant et al, 2004 re. doctors; Young et al, 2008b re. nurses) (Interviewees: C3; C4; D2; D3). Of particular concern is the fact that – unlike for non-EEA staff, who have to pass the IELTS exam to a


relatively high standard as a pre-requisite for professional registration – under free labour movement regulations the language competence of EU/EEA migrants cannot be tested as part of the registration process (Interviewees A2; B1; B2; D2). This makes it the responsibility of employing organisations to ensure that EU/EEA migrants’ language skills are of a standard fit for purpose through local systems of application and interview. Although managers do report feeling that they can judge everyday language skills adequately at interview, a good deal of additional support can still be required – whatever their origin country/world region - to “get internationally-qualified health professionals up to speed” both with technical/medical English and the language required to communicate in the context of patient care (Bola et al, 2003; Sales, 2002; Whalley, 2001; Young et al, 2008a). Partly this is about general exposure and building confidence, but added challenges include: local accents and dialects; the variety of accents in English that need to be understood when working in the context of multi-ethnic patient populations; and the various colloquialisms and expressions with which migrant health professionals can be unfamiliar, however fluent their standard English. The latter includes both everyday expressions and health-related expressions such as euphemisms for parts of the body and different words for expressing particular types of pain (Daniel et al, 2001; Grant et al, 2004; Moore, 2002; Stanley, 2001). As others have argued: “it is communication skills truly focused on the needs of the patient and the team that need to be measured and taught; and they must be taught in context” (Arakelian, 2003).

Significantly, it appears from the literature that compared with those actively recruiting non-EEA staff, local organisations recruiting from the EU/EEA in recent years initially underestimated language proficiency as an issue (Grant et al, 2004). Increased recruitment levels have, however, made organisations much more aware of its importance and most have developed systems to address the key challenges (see for example, Ballard et al (2004b), Mathie (2002), Porter and Powell (2005) re. French and Spanish GPs) (see also “Organisational Responses” to migration below). There is also increasing awareness of the potential differences between health professionals from different European countries that are dependent on the education systems they have come through. Young et al (2008b), for example, reported mangers’ views that midwives from Scandinavia, Germany and Spain had good spoken and written English, compared to those from Greece who were less confident speaking English because their language education had primarily concentrated on writing skills.

4.2.2 Styles of Communication and Ways of Relating to Patients


Patients’ perceptions of, and satisfaction with, their care are influenced by their expectations. In the UK, patients often expect to engage in conversation with their caregivers. This is both part of how patients generally feel reassured in the strange/crisis situation in which they find themselves, and it is part of information giving and receiving (e.g. around nature of the patient’s condition, medication, prognosis etc). In addition to language skills, therefore, cultural differences in style of communication and perceptions of ostensibly the same interaction can be problematic in patient-caregiver exchanges. Differences noted in relation to international health professionals in general include: a) reticence around verbally engaging with patients (i.e. because of different perceptions about when it is appropriate to talk or be silent); b) manner and tone of speaking; c) how to address patients (i.e. formally or informally); d) body language and other non-verbal communication (e.g. eye contact, turning backs on patients, smiling etc); and e) gender-related cultural norms around inter-personal interaction (e.g. handshakes, touching, seeing patients undress etc) (Daniel et al, 2001; Grant et al, 2004; Magnusdottir, 2005; Winkelmann-Gleed and Seeley, 2005; Young et al, 2008a). Other style-related issues include: a) international recruits talking in their own language instead of English in clinical areas (see also bellow under HRM implications); b) not knowing what are acceptable questions or subjects of conversation in different contexts; and c) not realising what is/is not perceived as rude in a UK context (e.g. taking mobile phone calls during patient treatment sessions; when to/not to say please, thank you, sorry etc), which can lead to misunderstandings in both directions – caregiver to patient and vice versa. In the context of “rudeness”, it is also necessary to learn, for example, how/when to use humour to diffuse problems (Grant et al, 2004).

4.2.3 Implications of Language and Communication for Therapeutic Relationships

In addition to affecting patient/carer perceptions of services, language and communication style can impact in concrete ways on the therapeutic relationship with patients/carers – for example in the context of:

Building a Rapport - As noted already, several studies mention that migrant health professionals can find it difficult to engage in the small-talk that helps put patients and carers at their ease. Rapport based on humour is obviously also easier when staff and patients/carers have a shared heritage, history and remembrances (Winkelmann-Gleed and Seeley, 2005; Young et al, 2008a).

The Balance of Power - Migrants from systems where the doctor and the nurse ‘know best’ have to adapt to the UK system, which sees patients and carers as being in a more equal relationship to healthcare professionals. In


this context, patient compliance is a particular noted aspect of behavioural difference, with migrant health professionals often finding it difficult to understand why patients do not come for appointments, take prescribed medications etc. In some cases this means that individual health professionals can find patients hard to deal with and even intimidating – particularly given what is more generally perceived as the UK’s ‘blame culture’ in the context of healthcare (Young et al, 2008a; Allan and Larsen, 2003a).

Facilitating Patient/Carer Decision-making – Staff (e.g. doctors, nurses and AHPs) used to medically-led healthcare systems need time to get used to it being entirely legitimate that patients and carers (e.g. parents of sick children) have a strong say in their own treatment. The challenges involved include being questioned by patients and their relatives and actively working with them in decision-making, rather than being prescriptive in relation to care delivery (i.e. seeing it as a succession of tasks to be completed rather than an aspect of planning and delivering patient-centred care (Daniel et al, 2001; Taylor, 2005)

Effective Information-giving – Information-giving in general is also a challenge, and some migrants again need help to develop the necessary skills and knowledge to communicate effectively with patients. Particular examples include: a) how to talk to patients and families, both in general and in particular situations such as breaking bad news (Ong, 2003); and b) how to answer and what information to give out over the telephone. Indeed, talking on the telephone is frequently highlighted as being especially difficult given the loss of the non-verbal cues that in a face-to-face situation would complement the linguistic parts of communication (Ballard et al, 2004b; Daniel et al, 2001; Magnusdottir, 2005; Palese et al, 2006). Such practicalities of information giving are relevant to all health professional groups (doctors and others); however a further issue for nurses, AHPs etc. is, once again, the very fact that coming from highly medicalised systems they are not used to the delivery of information to patients being part of their role (Daniel et al, 2001; Young et al, 2008b – midwifery case study).

Overall, cultural differences led one manager in Young et al’s (2008a) study to go so far as to make the observation that: “Since the late 1990’s, when international recruitment stepped up, the communication between patient and [in this case] nurses has actually changed quite dramatically” (p.86). Clearly, given the relative proportions of new workforce entrants form different countries and world regions (see Section 2 above) such comments primarily refer to the changes introduced by non-EEA health professionals. Significantly for this report, however, although most of the literature relates to migrants from elsewhere overseas, authors do point to the need not to underestimate the challenges also experienced by EU/EEA and other European-qualified individuals. As just one example, Grant et al (2004)


report that in addition to 33 percent of the non-EEA doctors they interviewed, 22 percent of EEA interviewees reported problems with culture. They also note that whilst these doctors are in a clear minority such a finding is still significant finding in a profession where effective interpersonal skills are vital. As another example, Cowan (2006) points to the fact that not all nurses from the EU/EEA have experience of working in the sorts of multicultural environments common in London and other urban areas of the UK. Dealing with patient populations who speak many different languages other than English and have a diverse range of beliefs and cultural practices can be overwhelming. As a final concrete example relating to the therapeutic relationship between migrant health staff and UK patients, one study noted the extra encouragement German and Greek midwives needed before they gave women in their care what was considered enough, and the right kind of, information to make an informed choice (e.g. to have or not to have a particular screening test). This was such a challenge because they were used to a medicalised model of midwifery where tests are “carried out almost automatically” and decisions are “made for the woman” by health professionals (Young et al, 2008b).

4.3 Human Resource and Organisational Management Challenges

The existence of equivalence issues arising from professional, language and other cultural differences gives rise to a number of challenges from the employer viewpoint. First and foremost it is necessary to put in place appropriate mechanisms to support both the initial adjustment and on-going development of individual migrants. In addition, managers and management systems need to facilitate the provision of such support; and, more straightforwardly, there are various logistical and team-building considerations associated with the employment of health professionals from abroad. Most relevant information on this topic comes from research on overseas staff in general (which is perhaps not surprising given the quantitative balance of EU/EEA staff versus other groups in the NHS workforce) and in particular the NHS’ recent experience of large-scale international recruitment. Importantly, however, there are a number of generic messages from broader experience; and, embedded within the wider body of research, some examples of how relevant challenges also apply to EU/EEA and other European migrants.

4.3.1 Addressing Individual Adjustment and Development Needs

Whether from the EU/EEA or non-EEA countries, individual migrants cannot simply be expected to slot in to the NHS and immediately perform to their maximum. Induction and ongoing - medium and longer-term - support is vital to managing both the immediate adjustment process, and continuing


progress/development in the NHS workforce (Interviewees: A1; A2; B1; B2; B4; C1; C2; C3; C4) (Close, 2002; Masters, 2005; Whalley, 2001). Even prior to that robust recruitment processes will have been important: to ensure that individual health professionals are adaptable and as “right as possible for the job”; and to begin to identify the adjustment and development needs of those who are recruited. In addition, once the initial adjustment has taken place, access to continuing professional development is vital (Young et al, 2008a; Interviewee: C2). In all of these contexts there is a considerable body of experience, particularly from the NHS’ active international recruitment activities post the NHS Plan (DH, 2000) (e.g. Atherton and Mathie, 2002; Ballard et al, 2004b; Bradford City PCT, 2004; Gerrish and Griffiths, 2004; Martell, 2004; Ong, 2003; Whalley, 2004; Young et al, 2008a). Although most of the documented evidence comes from the large-scale recruitment experience of recent years, however, the messages are just as relevant to the general employment of European and, where still applicable other overseas, health professionals.

Important generic features of the recruitment and induction/on-going support process include, for instance:

In terms of immediate topics to be covered regarding work: NHS and social care functions and structures; cultural challenges in the context of clinical practice, team-working and dealing with patients/carers; and organisational procedures and processes (e.g. Trust/other organisational policy, accountability arrangements, record keeping, methods and protocols for use of particular types of equipment etc); and additional language support where required;

In terms of tools: an insightful interview process in which both sides are able to ask questions and ensure that there are no subsequent “surprises” regarding expected job content, responsibilities etc;10 and, once work has begun in the NHS, clear and comprehensive induction packs; clinical placements and/or reduced workload to give individuals a sufficient learning experience to “get up to speed”; seminars and study leave; peer support, mentoring and/or buddying; and, above all, adequate time and space to adjust.

10 Several interviewees pointed out that migrant health professionals can, without proper information, have “unrealistic expectations” about what it is like practising in the UK (C3; C4; D3). With reference to doctors, for instance, it was felt that DH active recruitment had inadvertently given a message that unlimited job opportunities existed in the UK (C4). Likewise many EU/EEA GPs had reportedly expected their NHS career to progress faster than it did (D2;D3); and dentists (e.g. from Poland) often thought they would be engaging in more sophisticated dentistry than the “bread and butter” practice they were actually asked to carry out (C3).


In terms of types of support: both professional and work-related (as above) and personal, including for instance assistance with the costs of relocation, finding initial accommodation, mechanisms to encourage social integration etc.

In terms of the detail of content and how they actually take place, however, the various topics, tools and types of support just outlined, still need to be tailored both to particular organisations and work settings within the NHS, and to particular professional groups and source countries. Several authors/interviewees point, for example, to the importance of tailoring measures to the needs of EU/EEA-qualified professionals separately from other overseas staff (Ong, 2003); and further to the necessity not to assume that health professional migrants from different EU/EEA countries will have the same information and developmental needs (Interviewees: C2 - Midwives). Although it is possible, therefore, to say something about the aspects of induction/support that different EU/EEA groups have found most helpful (e.g. EU/EEA doctors with their appreciation of information regarding medical English and informed consent, and role play around breaking bad news etc – see Dye and Gajewska, 2002; Ballard et al, 2004b; McFadden, 2993; Ong, 2003), personalising inputs is vital. This is just as much the case for EU/EEA health professionals as it for UK-qualified staff (and indeed those from other overseas countries) (Young et al, 2008a). Another key point made by our interviewees is that, given the change of policy on international recruitment at national level, it is now primarily the responsibility of local NHS organisations and other bodies to provide appropriate induction and support to individual health professionals migrating from abroad. This presents considerable challenges both from a funding and consistency viewpoint; and in terms of the amount of effort needed to maintain local organisational memory about how best to go about the whole induction/support process.

4.3.2 New Challenges in Day-to-Day HRM Systems

Most of the on-going logistical challenges in the context of employment of migrant health professionals stem, quite simply, from the pressures associated with individuals being so many miles from home; and the need for flexibility in HRM systems to accommodate that. This is obviously most significant to those from farthest away (e.g. Australia, Philippines, India), but is still reported as relevant to European migrants (Young et al, 2008a). Homesickness, for example, can be a major issue because staff cannot simply “pop home”; and compassionate leave (e.g. for bereavement) necessarily takes up more time than would be usual for entirely UK-based staff due to the need to add on international travel time. There are also some national/cultural differences in terms of when staff prefer to take annual leave (e.g. Greeks reportedly are used to taking holidays for all of August; and Scandinavians want to save holidays until summer when there were longer daylight hours at home) (Young et al, 2000b). These


challenges tend to have been handled by individuals’ willingness to “do the long shifts”, which frees them up at other times (i.e. giving them time to travel to and from home countries). Overall, and not surprisingly, there are fewer challenges encountered when migrants are able to bring families to the UK as part of their relocation package, and therefore have less need to make long visits home. As noted earlier, however, this is more likely to have been possible for certain professional groups (e.g. GPs), but not others (e.g. nurses) (Winkelmann-Gleed and Seeley, 2005; Young et al, 2008b).

4.3.3 Integrating Health Professional Migrants into the NHS Workforce

As a general rule the more “equivalent” their training and experience and professional/cultural ways of working to the UK system, the easier it is for colleagues to help migrants to integrate successfully into the NHS workforce. By contrast where there are significant cultural differences (professionally and more generally, for instance in terms of communication styles), tensions can arise (Young et al, 2008a). Importantly, however, colleagues’ role in supporting the majority for whom there are significant professional and other cultural differences is no less vital; and managers and employer organisations need to facilitate that support to happen. Just as with patients/carers, misunderstandings need to be addressed – hence there are implications from an organisational and HRM viewpoint. Examples of issues that have arisen in the context of international recruitment in general include: a) professionally: colleagues being frustrated that, from their own NHS viewpoint, migrants did not know as much as anticipated; b) inter-personally: conflicts caused by migrants and existing staff having a different manner of speaking and/or dealing with each other (e.g. being more/less direct, using/not using please and thank you, or being more/less informal with colleagues of different ranks and disciplines than each was used to); and c) in the context of language: migrants (including EU/EEA staff) needing to be informed that speaking English rather than other languages in work settings (clinical areas and staff rooms) was considered key to teams blending and working well together (Young et al, 2008a). Of course, in all of these contexts, it is important from an HR viewpoint to tease out the real concerns from any issues stemming from potential discrimination (Alexis et al, 2006; Buchan, 2003; Larsen, 2007; Narayanasamy and White, 2004; Taylor, 2005).

Ultimately successful integration of any internationally-qualified health professional into the NHS workforce depends on a range of factors – not least the personality and attitudes of the individuals concerned. On the other side of the equation, however, particular organisational characteristics impact directly on how welcomed and valued migrants feel and how effective they, therefore, become in professional/work terms (Hunt, 2007; Taylor, 2005; Young et al, 2008a). Such factors include: the views of


managers and hence the receptive/less receptive climate they set for internationally-qualified staff; and most importantly colleagues’ readiness and ability to support newcomers. Both of these are influenced by the cultural mix and levels of diversity that already exist within the workforce; but there are also additional management measures that research suggests are important to facilitate mutual-understanding. As just one example, experience shows that recruiting smaller numbers (i.e. so as not significantly to alter group dynamics) and spreading newly recruited staff throughout existing teams helps to manage capacity (Young et al, 2008b – midwifery and GP case studies). In addition (though few organisations appear to provide it, partly because of the learning process that managers also go though), it is very helpful if colleagues are given training regarding what to expect in the context of international recruitment/employment of internationally-qualified staff (Young et al, 2008b – Radiographer case study; Interviewees: C2; C5). This not only includes the obvious practical implications (e.g. the amount and nature of support required for different professional groups from different countries); but also pointers to subtler interpersonal considerations – for example the fact that individuals may be extremely knowledgeable professionally, but just not appear so because their language and communication skills are lacking (Bola et al, 2003; Taylor, 2005). As another example, it is clearly important that colleagues be aware that as individuals gain more language skills native speakers can tend to overestimate their levels of fluency, creating further anxiety and insecurity (Magnusdottir, 2005). Finally, at a more general level, “successful” teams appear to be those where managers also take time to think about the role of social activities in helping to integrate colleagues from different backgrounds. Again, however, the evidence suggests that there are cultural differences to be addressed around what constitutes socialising (e.g. regarding the role of alcohol; appropriate types of event etc).

Why is this issue of the potential impact of mobility/migration on team cohesion so important? It is because effective team-working is, in and of itself, an important part of quality service delivery (Xyrichis and Ream, 2008).

4.3.4 Longer-term HR and Workforce Planning Implications

Finally, there is some suggestion in the literature (e.g. Young et al, 2008a) and from our interviews that there may be longer-term HR challenges stemming from the employment of migrant health professionals. Essentially, the view is that internationally-qualified health professionals do not always behave in the way that local organisations and their existing management and planning systems are geared to expect. Examples would be around: a) timescales for staff applying for promotion and climbing the career ladder, and for that career progression in turn freeing up entry grades for new staff; and b) overall lengths of stay in a given NHS job


before moving on. The latter relates, for example, to the question of how far migrant health professionals remain a potentially mobile workforce resource, more reactive than say UK-qualified staff to on-going labour market signals (e.g. in an international context, the attractions of the UK and its constituent countries versus the alternatives of returning to countries of origin or moving to an another destination altogether). In such circumstances workforce supplies would clearly be at risk if something outside the control of an individual organisation (e.g. active recruitment to a third country such as the USA or Australia) triggers its staff to move.

Addressing these sorts of challenges requires time and effort in terms of HRM (from the HR department itself and service managers) – both on a personal level with staff (e.g. building individuals’ confidence to apply for promotion when opportunities arise) and in terms of improving systems. It seems important, for instance, to factor possible behavioural differences into workforce planning models – especially where large cohorts of migrant staff are involved such that the balance of behaviour and risk might even be altered across the workforce as a whole. Equally, all of these issues of promotion and length of stay etc are highly significant concerns from diversity and discrimination perspectives (Alexis et al, 2006 and 2007; Buchan, 2006; Larsen, 2007; Taylor, 2005; Winkelmann-Gleed and Seeley, 2005). Once again (as with initial induction/support – see above) there are few if any ready-made tools or mechanisms for NHS organisations to share knowledge and experience regarding appropriate assumptions and expectations and transparent performance management and HR processes (Hunt, 2007).

Again, most of the evidence on this topic relates to non-EU/EEA staff (e.g. Filipino nurses) (Young et al, 2008a). However, there is some evidence that EU/EEA staff also have different work/progress patterns and behaviours compared with both their UK-qualified counterparts and non-EEA migrants. A good example is the length of time individuals remain in NHS posts before moving on – EU/EEA doctors, for example, turnover much sooner than those from non-EEA countries. As another example, in the first year of participation in the UK workforce, non-EEA qualified doctors appear to have the ‘best’ promotion prospects and EEA qualified doctors the poorest. After the second year of workforce participation, however, promotion prospects are much poorer for non-EEA qualified doctors than both UK and EEA qualified. EEA qualified doctors have the same opportunities for promotion as UK qualified doctors over this period (Hann et al, 2008). (N.B. The question of different lengths of stay etc is also relevant in the context of within-UK migration and that too would merit further exploration)


4.4 “Value Added” from Health Professional Mobility/Migration

Much of what has been discussed so far in this Section could come across as quite negative, but it is important to note that the literature and our interviews also point to the benefits that EU/EEA and other migrant health professionals bring with them into the NHS – particularly in the context of service delivery (see, for instance, Alexis et al, 2007; Lee, 1997) (see also Blachflower et al, 2007 for similar arguments re. general migration). The first benefit highlighted (Interviewees C4 – Doctors; C2 – Nurses; B1 – AHPs) is, not surprisingly the overall workforce and service capacity expansion facilitated by the sheer numbers of internationally mobile health professionals coming to the UK in recent years. Another quantitative bonus is that organisations can also gain access to additional word of mouth recruitment of health professionals (relatives and friends of the original recruits) already in the UK and back in source countries (Young et al, 2008a). Of course, quantitatively EU/EEA mobility has been relatively less important than migration from elsewhere overseas (see Section 2 above; Interviewee A2 – All professional groups). In qualitative terms, however, EU/EEA migrants are perceived as potentially bringing just as much value added to clinical areas and the NHS workforce as other overseas staff (Interviewees A1; B1; B4; C1; C2; C4; D1).

Briefly what is described is (depending on their professional group/countries of origin) migrants adding value in terms of:

Bringing new ideas and offering critical appraisal of existing practices and procedures;

Bringing particular skills, such as specialist skills or those not included in UK training;

Having positive personal qualities, such as being friendly, hard working, having a “can do” attitude, setting a good example etc;

Having a more caring approach to patients, particularly the elderly;

Generally contributing to workforce diversity and cultural understanding/exchange;

Being able to translate for non-English speaking patients;

Having experience caring for patients from a similar cultural background as local populations;

Generally increasing team morale and, in some cases, raising standards.

Again a key example in the context of the EU/EEA is provided by Young et al’s (2008b – Midwifery case study) exploration of international recruitment. In terms, for example, of bringing new ideas and generally questioning practices, the following were highlighted: use of: a) acupuncture and acupressure (Scandinavian midwives), and aromatherapy and water births


to ease mothers’ birth pain/stress (German midwives); and b) possible higher medication doses to stimulate labour (Greek midwives). Some groups were also said to be strong on promoting “normal deliveries”, which was important in departments that had “perhaps become overused” to high risk births (p.92). In the context of bringing particular specialist skills, the use of certain instruments of delivery not generally in use in the UK was also noted (Scandinavian midwives). Significantly, in the same study, interviewees pointed to the fact that organisations had not fully exploited the opportunity to use the skills and experience that many international recruits came with. As just one EU/EEA example, managers were concerned that the advanced skills that Spanish nurses had gained during training would quickly be lost if they were not allowed to use them (Young et al, 2008b – Nursing case study). On a more general level, EU/EEA migrants were said to bring key language skills relevant to undertaking translations for non-English speaking patients (e.g. Polish and other East European nurses and midwives). Importantly, where migrants were willing to use and pass on their particular knowledge and skills (e.g. through acting as mentors, providing tailored training sessions etc) it was seen as “giving something back” in return for the support they had initially received from UK colleagues to help them integrate into the NHS workforce (Young et al, 2008a). Such activities were, therefore, highly relevant to on-going team-building, which links back to the discussion on HRM above. In that context, a key issue for organisations is the development of appropriate systems, organisational cultures and team-working that recognises such value-added (including skills that would not be immediately recognised in the UK system) and brings it to the fore (Larsen, 2007; O’Brien, 2007; Taylor, 2005).

Overall, therefore, whilst there has been little if any research majoring on the qualitative benefits of European mobility (or indeed international migration in general) for NHS service delivery, those studies that are available definitely hint at this being a potentially interesting field of investigation.

4.5 Key Questions in the Context of Service Delivery and Organisation

Overall, in the context of the factors potentially impacting on the nature of clinical practice and the therapeutic relationship, it is important to note that even where an individual has years of relevant experience, simply moving to another country and having to learn a different organisational structure and working systems can lead to loss of confidence and quality of performance. It follows that migrants, whether they are from the EU/EEA or elsewhere, cannot simply be expected to slot in directly to the NHS without substantial support (Interviewees A1; A2; C1; C2; D2). A key question for research is, however, how far and in what ways issues of


education/training and role equivalence really follow through to impact on service delivery from the patient/carer viewpoint – or is it other issues such as language and communication that have a greater impact. In their study of international recruitment in general, Young et al (2008a), for example, note that although migrant health professionals were not always able to give the level of care that managers ideally wanted, any complaints from patients tended to relate to communication issues rather than standards of clinical care per se.

Of course, whether or not professional equivalence impacts directly on patient perceptions of care, it is clear that induction/adaptation is necessary to “head off” the potential for problems from the viewpoint of maintaining clinical standards and safety within UK cultural systems and norms for service delivery. A question not yet fully answered in this context regards whether there are any key differences or commonalities specific to particular professional groups and/or individuals from different source countries across Europe, a better understanding of which would improve induction/adaptation and other measures used to integrate or socialise European migrants into the NHS workforce. Our interviewees pointed, for instance, to the highly contextualised nature of general practice from country to country compared with other professional groups whose knowledge base focused on narrower clinical fields (i.e. specialist doctors, nurses and certain AHPs) (D2; D3). However, they also argued that where differences do exist (e.g. in general practice and midwifery) they are not as great as some would argue (C4 – Doctors; C1 - Midwifery). As another example, though it is possible to make certain geographical generalisations within Europe (e.g. between northern and southern Europe, the so-called “olive line” (Jinks et al, 2000); between the EU15 including the UK and the new EU12 (Grisold et al, 2007; Interviewees: C1 – Midwifery; D2 - GPs); or between the EU/EEA as a whole and Wider Europe where the barriers of cultural difference, and standards of education and training are even greater) no one has documented the comparative differences and actual reality of the challenges in a truly comprehensive way. Similarly, there appears to have been no comprehensive teasing out of either the language and communication issues, or the HR and other organisational management challenges specific to different European professional groups as opposed to those from elsewhere overseas. Nor more positively has there been any real exploration of the potential value added of European health professional migration for NHS services and organisations.


5 Evidence About Impacts on Migrants and Source Countries

This section documents what if anything, is known about the implications and outcomes specifically of European health professional mobility to the UK for: a) individual migrants in different professional groups; and b) source countries in different parts of the EU/EEA and Wider Europe.

5.1 The Lack of Evidence on European Health Professionals’ Migration Experience

Internationally-qualified health professionals that move to the UK, whether from EU/EEA or non-EEA countries, are confronted by an alien healthcare system, a different professional culture, and a new social and domestic environment. All undergo a period of transition both in their work and personal lives. As Allan and Larsen (2003) note, any consideration of migrants’ experiences of working and living in the UK must recognise how an individual’s social and cultural traditions have shaped both their previous experiences and present expectations. Care must also be taken not to see migrants as a homogenous mass. Regional sub-groups often have very different experiences of migration from one another; and individuals within any of these groups can likewise experience and adapt to life in the UK in varying ways and with varying degrees of ease (Buchan, 2003). Overall, then, migration to a new country makes significant demands of individuals on a personal level, and this is especially the case when there is a mismatch between expectations and the realities of working and living conditions (Young et al, 2008a).

We located only a small amount of literature on internationally-qualified doctors’ and AHPs’ experiences of living and working in the UK; and little, if anything, specifically regarding pharmacists or dentists. In addition, few of the doctor (with the exception, for example, of Grant et al, 2004 and Simmgen, 2004 on doctors; and Ballard et al, 2004a or Young et al, 2008b on GPs) and none of the AHP studies include an element exploring the experiences of European migrants. In the main, and perhaps not surprisingly given the relative proportions of EU/EEA and non-EEA- qualified staff (e.g. South Asian doctors) working in the NHS, these studies tend to have focused exclusively on individuals from outside Europe. There is a larger literature, which examines the experience of being an international nurse migrant both in the UK and countries such as the USA, Canada and Australia (e.g. Allen et al, 2005; Allan and Larsen, 2003a and 2003b; Alexis et al, 2006 and 2007; Buchan et al, 2005; Larsen et al, 2006; Omeri and Atkins, 2002; Taylor, 2005; Winkelmann-Gleed and Seeley, 2005). As


Magnusdottir (2005) argues, however, this literature is also predominantly about English speaking nurses that have migrated from developing countries/world regions (e.g. Philippines, India, Africa and The Caribbean) outside Europe.

Nevertheless, the available literature does provide valuable insights into the general experience of being a ‘foreign’ health professional in the UK (and indeed other countries). The following are the themes that emerge:

The significant learning process required regarding service delivery – For example, around a) different professional cultures and working practices, which is relevant for all professional groups covered by this study; b) equivalence of training and experience, which can either be more limited than required or conversely exceed the expectations of individuals’ different roles in the NHS; c) unfamiliarity with different types of equipment, procedures, protocols and documentation, and the UK health and social care system in general; and d) language and communication issues (e.g. understanding UK medical terminology, everyday usage of accents, dialects, colloquialisms etc, and different interaction styles with patients) (see, for example, Young et al, 2008a). The latter, in particular, can impact significantly on professional esteem and self-confidence (Magnusdottir, 2005; Taylor, 2005). Also relevant in this context is that fact that some migrants are reportedly afraid to ask to ask questions and admit mistakes because of concerns that being seen not “to know” or make “mistakes” will result in job loss and loss of the income that is also supporting families back home (Young et al, 2008a).

The challenge of settling-in outside work and adjusting socially – Migrant health professionals often report finding themselves in a strange and unfriendly environment, within which they feel lonely, isolated and uncared for (see, for instance: Allan and Larsen, 2003a; Omeri and Atkins, 2002; Taylor, 2005); Winkelmann-Gleed and Seeley, 2005). Different cultures (e.g. regarding the role of pubs and alcohol) can, for instance, make it difficult for migrants to make friends and become “part of the team”. Homesickness in general is an issue; and such feelings can be especially acute for single recruits without friends and family in the UK (Young et al, 2008a). Material and practical problems – e.g. dissatisfaction with standards of accommodation – also add to the emotional challenges that new migrants need to overcome (Allan and Larsen, 2003a).

The importance of robust recruitment and support structures – A number of measures are perceived as key from the migrant health professional viewpoint including: effective information and communication so that individuals “know what they are letting themselves in for” in the NHS; job-matching so that migrants find themselves in posts where they can use their specific skills and experience confidently and appropriately; tailored


induction and adaptation, and on-going targeted personal development that recognises the existence of different professional cultures and health system norms; language and social support; and where possible assistance from employers with the practicalities and financial costs of relocation from another country. As Hunt (2007) comments there are no ready made tools available for dealing with the such issues but developing strategies for doing so are fundamental to running an effective and high quality organisation. Above all, migrant health professionals point to the need to be given sufficient time to adjust to the new contexts(s) in which they find themselves (Allan and Larsen, 2003a; Ballard et al, 2004b; Grant et al, 2004; Young et al, 2003 and 2008a).

Varying satisfaction with clinical grading, salaries and career progression – Clinical grading and salaries, and access to skills development and additional training, are key areas of potential dissatisfaction for new migrants. Over half of the nurses in Buchan et al’s (2006) survey of overseas nurses who had recently migrated to London, for example, were dissatisfied with the clinical grade at which they were paid, especially given the higher cost of living in the UK. Individuals from Sub-Saharan Africa and the Indian Sub-continent were most likely to be paid at lowest staff nurse grade and those from Sub-Saharan and South Africa were most unhappy with this – often because they were their household’s major or sole breadwinner and also needed to remit as much money as possible to families in source countries. In the context of career progression, views and experiences also differ depending on professional group, age/family stage and, to some extent, source country. Paradoxically, where maximising income (e.g. for remittances) is a key priority it can be that individuals are put off from applying for promotion because the increased salary is insufficient to compensate for lost earnings from extra shifts. This has been noted particularly in relation to Filipino nurses – but it is something that needs to be untangled from the issue of potential discrimination discussed below (Allan and Larsen, 2003a; Alexis et al, 2006; Larsen, 2007; Taylor, 2005; Winkelmann-Gleed, 2006; Young et al, 2008a).

The personal costs of the migration experience – Apart from the general emotional challenges described above, studies and our interviewees note the additional hardships that health professional migrants frequently endure as a result of separation from family and children (Larsen et al, 2005; Winkelmann-Gleed and Seeley, 2005; Interviewee: D1). However, there do appear to be differences between professional groups in this respect with consultants and GPs more likely from the outset to be able to afford to bring their families with them to the UK. With nurses, families and/or children either followed on later, or remained behind indefinitely in countries of origin (Young et al, 2008a). Buchan et al (2006) and Buchan and Seccombe (2006a) report, for example, that two thirds of overseas nurses in their survey had children, 39 percent having left them in their home country. As one of our interviewees summed up: “I don’t think people


move lightly. It’s very traumatic to move. Why would you leave home unless you have to” (D1).

Experience of discrimination - Various authors have commented on the discrimination, prejudice and even potential racism experienced by overseas health professionals (Grant et al, 2004; Allan and Larsen, 2003a; Smith et al, 2006). A piece in the BMJ by Esmail (2005) noted, for instance, that ethnic minority doctors, many of whom qualified overseas, are disadvantaged when applying for jobs; are more likely to be disciplined by the GMC and are paid less. Buchan (2003) and others (Alexis et al, 2006; Larsen, 2007; Narayanasamy and White, 2004; Taylor, 2005) note similar perceptions of the discrimination faced by overseas nurses in the NHS and wider health/social care sector. There is also a perception that complaints in the context of language and communication are more prevalent for non-EEA staff than EEA. As one manager in Young et al’s (2008b – GP case study) study of international recruitment tellingly commented in relation to Spanish GPs: “I think culturally they weren’t so adrift from us, so our patients tended to really warm to them”. This clearly compared with the situation regarding, for instance Philippine radiographers where the relevant manager reported receiving patient complaints where “you can tell that they’ve dismissed the individual [simply] because English was their second language” (p.89). As Larsen (2007) notes, such discrimination, whether blatant or subtle, compromises migrants’ quality of life, and undermines their confidence and professional effectiveness.

Importantly, despite all the difficulties, many of the health professionals studied have reported positive outcomes from migration to the UK. Significantly, as Winkelmann-Gleed and Seeley (2005) comment, the very experience of employment, despite difficulties, can help individuals to develop a positive sense of belonging. Other benefits potentially include the general experience of travel and life change, improvement in English language skills, and professional gains such as additional training, job-related experience and career development (Ballard et al, 2004a; Larsen et al, 2005; Young et al, 2008a). How individuals perceive the outcomes and their experience in general varies, however, depending on such factors and personality, original motivations for migrating (see Section 5 above), and expectations of what work and life would be like in the UK (Allan and Larsen, 2003a; Larsen et al, 2005).

On the basis of the few studies that have included them, it can reasonably be assumed that European-qualified health professionals regard many of these factors and experiences as also applying to them. Grant et al (2004) and Young et al (2008a) both touch, for instance, on migrant hospital doctors’, GPs’, nurses’ and midwives’ concerns about issues of professional equivalence within the EU/EEA; and the challenges of adjusting to different professional cultures and ways of working in the service delivery context (see also De Veer, 2004 for equivalent experiences in the Netherlands). As


another example, Larsen (2007) notes that it is not only nurses from developing countries (who are often from ethnic minorities) that experience negative stereotypical attitudes and discrimination. They are also experienced by white nurse migrants (e.g. from Eastern Europe) working in both health and social care - who like overseas staff in general are often perceived by their colleagues as economic migrants who came to the UK to escape poor socio-economic conditions rather than for the complex mix of reasons described above in Section 3. Similarly, Cowan (2006) in an article on cultural competence in nursing notes that EEA nurses employed in London felt that whilst UK staff were respectful towards cultural differences of patients and families, they failed to consider cultural differences between themselves and EU/EEA recruits. It is also important not to assume that all health professional migrants from the EEA are white. As Ballard et al (2004a) note in their study of GPs from France who migrated to work in London, a third were from ethnic minority backgrounds. Finally, both EU/EEA and non-EEA nurses point to the fact that they often have limited opportunities to return to countries of origin, should they want to – either because their UK qualifications and experience would not be recognised and/or because of the limited opportunities that had been their original reason for migrating in the first place (Young et al, 2008a). Clearly, the personal costs of migration (e.g. being away from home and families for longer than hoped; disappointment about levels of income against expenditure in the UK) are also potentially relevant to European migrants. In terms, however, of the detail of how European migrants (in different professional groups; from different countries etc) regard themselves as being affected, in all of these contexts much more specific research is needed.

5.2 What is known about the Challenges of European Mobility for Source Countries?

The question of the impact of health professional mobility/out-migration on source countries is a complex one – i.e. there are no straightforward answers regarding whether, overall, source countries benefit or suffer as a result (Buchan et al, 2006; Bach, 2004; UN, 2004). On the one hand, commentators point to key economic benefits; on the other, they describe negative effects associated particularly with brain drain (see Table 5.1) (Sigler, 2007; Winnett, 2008). In the context of health, there can be little doubt that some countries’ workforce shortages and related service problems are being exacerbated by out-migration - which is, at the very least, indirectly encouraged by others’ openness to that migration (Buchan and Solchalski, 2004; Bundred and Levitt, 2000; Bueno de Mesquita and Gordon, 2005; Fourcier et al, 2004; Martineau et al, 2002; Pond and McPake, 2006; Reid, 2002; Sigler, 2007; Simeons et al, 2005; WHO, 2006). It is also an issue – both for the individuals concerned and from the viewpoint of return-migration to source countries - if, as some argue,


migrants do not gain the skills and experience expected (Allan and Larsen, 2003a).

Table 5.1 Possible Economic Impacts of Out-Migration on Source Countries

Positive effects Negative effects Opportunities for individual

workers that cannot be gained at home

Reduce unemployment at home Inflow of remittances Stimulus to investment in domestic

education Incentives for population to

acquire human capital Increased skills and knowledge as

individuals return

Loss of highly skilled workers and their expertise

Reduction in quality of services at home

Lower return from public funding of education/training

Loss of taxation – whether or not a health professional’s original training is funded by the state or privately

Diminishing of remittances over time

Source: Adapted from the UN World Economic and Social Survey of 2004 (UN, 2004). The Table refers to migration in general rather than health professional migration specifically. For further discussion of the various potential positive and negative economic effects of out-migration see, for example: Blitz 2005; Findlay & Lowell, 2002; Golfarb and Havrylyshyn, 1984; Jalowiecki et al, 2004; Krieger, 2004; Mareckova, 2004; Robinson, 2007; Van Lerberge et al, 2002; and Wiskow, 2006.

As is well known, in the UK such concerns have resulted in attempts to ensure that active international recruitment at least is done ethically (Mellor 2003), based on clear Codes of Practice11 to which NHS organisations are required to adhere (see DH 2001 and 2004 regarding England; and Scottish Executive, 2006 regarding Scotland; see Buchan et al, 2009 for an assessment of the impact of the DoH code). Overall, these Codes have restricted recruitment from over 150 countries that cannot afford to lose health staff (see Appendix 3); and, importantly for this report, a number in what we have defined as Wider Europe are covered.12 Significantly, the

11 The original DH Code in England (DH, 2001) (the main tenets of which have been widely built upon both by professional and other international/governmental bodies– see Commonwealth Secretariat, 2003; ICN, 2001; McIntosh et al, 2007; RCN, 2005; Scottish Executive, 2006) aimed: a) to prevent recruitment from countries that could least afford to lose skilled HRH; and b) to ensure that, once in the UK, international recruits were treated fairly – i.e. experiencing the same salary levels and employment conditions as UK-qualified staff. The Code was further revised in 2004 to include temporary as well as permanent staff and to encourage all healthcare organisations, not just the NHS, to sign up (DH, 2004). Best practice benchmarks were provided, together with a list of commercial agencies that had agreed to abide by the Code. The idea was that the NHS and other recruiters would use only these recommended agencies in any subsequent recruitment activities (NHS Employers, 2005). N.B. The key difference between the English and Scottish Codes was the stated commitment in Scotland to undertake regular monitoring of international recruitment practice by NHS organisations within that country. 12 Including: Albania; Bosnia & Herzogovina; Croatia; Georgia; Macedonia; Moldova; Turkey, Uzbekistan, Yugoslavia (i.e. Serbia, Montenegro etc).


types of government-to-government agreement advocated as the means to control active recruitment from the developing world are also seen as relevant to managing health professional migration within the EU/EEA (see Introduction to this report). In particular, the CEE countries, with their considerable economic and health system challenges, are seen as needing some protection (Blitz, 2005; Den Exter, 2004; Jalowiecki et al, 2004; Wiskow, 2006).

Clearly, we cannot even begin to do justice to the source country benefit/dis-benefit debate in this report – particularly since much of the literature, unsurprisingly, focuses on poorer, developing countries outside Europe (Buchan and Solchalski, 2004). Given the significance of global health professional migration generally, it is also difficult to tease out the specific impact of UK (and its constituent countries’) policies and actions from those of other receiver countries. What we can do, however, is note some key findings from the literature and our interviews in order: a) to look at the extent to which wider arguments might also apply within Europe; and b) to illustrate that, just as in the wider global marketplace, the picture of benefit/dis-benefit for EU/EEA countries is not as straightforward as might be hoped. There are two elements to the analysis:

First, given that from the UK perspective there was the attempt to take an ethical approach to the active international recruitment of recent years, we have attempted to explore how “successful” that approach was.

Second, from the source country viewpoint, there is the question of: a) how far they have been successfully able to engage with UK recruitment agendas in a way advantageous, or at least not damaging, to their own health systems; or b) have been able successfully to disengage with UK agendas if they so wished.

5.2.1 The Challenge of Ethical Recruitment and the NHS Response

From the small amount of evidence available, it does appear that the Codes of Practice and the policy of ethical recruitment in general have influenced the behaviour of NHS organisations (Buchan 2008; Young et al, 2008a and 2008b – Midwifery case study, Buchan et al, 2009). A survey of NHS Trusts and PCTs in England showed, for instance, that in the context of active international recruitment post-2001 there was an emphasis both within and outside Europe on countries with which the DH specifically negotiated agreements and/or utilised British Embassy infrastructures to facilitate recruitment (Young et al, 2008a). Specifically, within Europe, Spain, Poland, Germany, Italy and the Czech Republic were the most frequently targeted countries; though a whole range of other countries were also


recruited from (e.g. Ireland, France, Austria, Greece, the various Scandinavian countries, Belgium, Netherlands, Hungary and Estonia). (Outside Europe India, The Philippines and, to a lesser extent Australia, the USA, and the Middle East were the most targeted countries/world regions).

Despite the influence of ethical recruitment policy on active recruitment, there is, however, still the issue of wider health professional migration to be considered. Such migration – as indicated by UK professional registration statistics - continued from many of the countries covered by the various Codes. As just one example, of the 121 countries from which doctors took PLAB Part 1 or 2, and the 107 countries from which doctors received limited GMC registration between 2001/05, 86 and 83 countries respectively were covered by the DH Code. This includes various countries in what we have termed Wider Europe for the purposes of this report. As others have also suggested (Martineau, 2004), Codes of Practice can only go so far. First, they only apply to direct recruitment (i.e. they hold no sway in the context of groups not actively targeted such as junior doctors entering the UK via PLAB). Second, there are many cases where the push factors out of a country (political, economic and professional) are very significant indeed; and it would be equally unethical to restrict individuals’ freedom to migrate on the grounds of human rights. The simple fact that the UK has had such a strong image or message of workforce shortage and expansion targets in the international marketplace has been, therefore, enough to encourage significant numbers to respond. The question we cannot answer is how many would have migrated anyway without the additional UK image pull. There seems little doubt that many would have, but equally the effect of the message itself should not be underestimated.

5.2.2 The Question of Returning Human Capital, Additional Skills and Remittances

The question of remittances and their contribution to the national income of source countries – both in Europe and elsewhere - is a complex one (Bach, 2003). Although some reports (e.g. Mansoour et al, 2006) on migration from Eastern Europe and the former Soviet Union note the importance of remittances for many countries in the region (and politicians in CEE countries reportedly see the prospect of increased remittances as a potentially positive feature of EU enlargement), others indicate that such benefits are not relevant to all (Sorsca, 2008). Young et al’s (2008a) qualitative interviews with source country stakeholders and individual migrants suggest, for instance, that it may be developing countries outside Europe (e.g. The Philippines and countries in Africa such as Zimbabwe and South Africa) where remittances from health professionals working in the UK are most relevant. Survey evidence from international nurses in London does suggest that some- notably from the Philippines- are remitting a significant proportion of their salary (Buchan, Jobanputra, Gough, 2007). Elsewhere the distinction is made between the poorest countries beyond


current EU/EEA borders (i.e. in what we have termed Wider Europe) and those that already joined (especially the 2004 joiners) where income levels are, relatively, higher and so there is less need for migrants to support household and family consumption by sending remittances from abroad (Mansoor et al, 2006). Another key point is that there is limited remittance-related data relating specifically to health professionals; and there are major difficulties generally in terms of accurately estimating the financial value and scale of remittances that are made (Bach, 2003).

The evidence is also mixed in relation to potential benefits and prospects of return-migration – i.e. the gains that might bring in terms of the additional skills, competencies and experiences embodied in human capital (Angelovski, 2006; Bach, 2003; Blitz, 2004; Goldbart et al, 2005; Krieger, 2004). At a general level, just as the NHS potentially benefits from the challenge of new/different ways of thinking from abroad, so too can source countries - particularly when returning staff go into professional leadership and/or teaching positions. Equally, however, UK experience (e.g. understanding the way the NHS interacts with social services) is not always relevant; and where health professionals develop specialisms in the UK, the experience and additional qualifications are not always properly recognised in their countries of origin. In Young et al’s (2008a) study, for example, such problems were reported as equally applicable to countries in Europe (e.g. Spain; Greece; Czech Republic) as those elsewhere (see Box 5.1) (see also Blitz, 2005 in relation to Spanish doctors). Another issue reported in the same study was the continued un/underemployment of health professionals in some countries (e.g. Greece), which can mean that more experienced – i.e. more expensive – returning staff are less likely to be employed.

BOX 5.1

VIEWS ON THE OPPORTUNITIES FOR RETURN MIGRATION: NURSING EXAMPLE

Spain - “I think it’s a difficult process [return migration] because … if they [nurses] were to have that experience outside Spain it counts less [for getting an equivalent job] than if you have the experience in Spain” (SC4Int1).

Greece - “As European countries, why was I accepted here with this [Greek] qualification which was tiny … and the Bachelor’s degree [gained in UK] means nothing to them? It does mean something but why would I have to go through all this six month process and wait all this time in order to get my registration, I just don’t understand it! … And my friend [who has already gone back to Greece] she can’t even get that bit of paper to have the opportunity to work. Is it not madness? … I mean half of me wants to go back, half of me not. From the professional point of view and the career development I don’t, but from the social and the family.. and I terribly miss my country” (CS3Recruit12).

Czech Republic – “I won’t get a better job. I think I will be punished that I’ve been abroad. This is the way, how, nursing, it is there [Czech Republic]. And from sort of attitude, how they actually talk to you, if you want a job back home. I’ve got a friend who worked here for three years. And she went back home the beginning of this year and she is so disappointed … So I’m not planning to go home … I think it just needs time when they realise that it will be good experience for nursing, for nurses to go abroad, get experience and some back. So far, it’s not


a good idea” (CS3Recruit6).

Source: Young et al (2008a: p.123)

5.2.3 Going Beyond the Overall Workforce Numbers

Other key questions are: a) To what the extent countries that appear to have health professional surpluses really do; and b) Whether perceived overall surpluses are sufficient to make facilitating out-migration and/or signing up to active recruitment (such as that undertaken to the UK in recent years) advisable.

For the first, the literature suggests that unemployment and/or underemployment, which has been taken (e.g. for purposes of the UK negotiating government-to-government recruitment agreements) as a key indictor of a surplus of health professionals, does not make those individuals unneeded within the source country health system. It can simply be that a country cannot afford to employ the available staff to fill its own job gaps or employ them at a salary level for which individuals could afford to work – particularly in the public sector (WHO, 2006; Zajac, 2004) (see also Young et al’s 2003 and 2008a interviews in Spain and Poland). The question is whether international recruitment and/or the message of opportunities available in countries such as the UK has helped or hindered this sort of situation. Some professional commentators argue, for instance, that it simply gives a particular government an “easy way out” thereby enabling it to continue with a lack of will to address key health system issues (Kingma, 2007).

Looking within the overall, to a subtler level of analysis – e.g. different specialties – also complicates matters. As just one example, figures show that between March 2006-March 2008 alone, 280 doctors with a Polish primary medical qualification were entered onto the GP register in the UK (GMC Email communication). Although the view from Young et al’s (2008a) Polish interviewees is that migration is a fact of life – especially given low doctor salaries and restricted job opportunities in Poland – there is an argument that the UK should not have actively encouraged Polish GP migration given the particular professional circumstances in that country. As noted in an earlier study (Young et al, 2003), Poland introduced vocational training in general practice, an entirely new specialty, in 1993 – the intention being to gear the health system more towards a primary care gate-keeper model similar to the UK. By 2003, Poland had trained just 6,000 family doctors/GPs, compared with the 20,000 needed to reorganise the health system as intended, and the estimate was that it would take another 15 years before enough trainees had gone through the system. Factoring in losses to migration partly encouraged by the UK’s (and other


countries’ e.g. Sweden and Norway) active international recruitment drives, it is likely to take even longer.

5.2.4 Impacts on Source Country Health Systems and the Question of Finite Supplies

Although there is little hard evidence being collected in many source countries, the feeling is that some health systems at least are suffering as a result of health professional out-migration (Bach, 2003). For instance in Poland, “anecdotally, from friends and colleagues, everyone knows someone who has gone” (Polish interviewee cited in Young et al, 2008a: p.126). Much of the concern relates to the scale and the speed of the increase in migration rates, the impact of which it is difficult for source country workforces and throughput from education/training systems to absorb. For example: “Last year 498 Polish doctors registered with Britain’s General Medial Council, compared with an average of 17 a year previously. With more than 150,000 doctors, Polish hospitals are not facing an imminent crisis, but the Ministry is [quoted as being] concerned that too many of the present medical students will want to go abroad” (McLaughlin, 2005). So there is greater concern for the future, and increasingly the view, as expressed by the Polish Chamber of Physicians, is that “recruiting our [Polish] doctors is a good solution for western European countries but not for us” (Burgermeister, 2004, p.1280).

Elsewhere in CEE countries there are concerns that the small numbers working in some health professional categories means that even small-scale migration will have a negative impact on ability to deliver care in source health systems. This is reportedly the case, for instance, in Lithuania in the context of pharmacists (Smigelskas et al, 2007) and both Lithuania and Estonia for medical specialties (Buchan and Perfilieva, 2006). Others note similar concerns, for example, regarding doctors in the Czech Republic (Mareckova, 2004) and nurses in Hungary (Bethlem, 2003). Indeed even where migration is short term – as in the case of the temporary migration of dentists and specialist doctors, such as anaesthetists, from Poland – service delivery can be affected (Buchan, 2008). As Wiskow (2006) also notes, one key effect of the westwards movement of health professionals from the CEE countries newly joining the EU in 2004 and 2007 is that vacancies there are being filled by workers from further east. At the very least that raises similar concerns regarding the need to induct/adapt migrants into different service delivery systems as are raised by UK commentators about migration from CEE countries themselves (Interviewees C1; C2; C4).

The seriousness of these issues is clearly illustrated by the fact that some source country governments (e.g. Estonia, Lithuania, Latvia and Poland) have begun to act in an attempt to counteract some of the pressures – e.g.


by improving salaries and working conditions (Buchan and Perfilieva, 2006). Such measures are perhaps not surprising for CEE countries where there is little doubt that they are losing more staff than health systems can necessarily stand. However, it also applies to countries that in recent years have appeared to have ready surpluses to supply to the world market – i.e. countries that were signed up to the UK’s active recruitment agenda and welcomed health professional migration as part of government policy/economic strategy. In Spain, for example, the bottlenecks in medical training that acted as a significant trigger to doctor out-migration have “gradually been corrected, under pressure from the medical profession, and in recent years the offer of training positions has exceeded the number of medical graduates … by about 10%” (Gual et al, 2005). Elsewhere Spanish commentators are reported as arguing that there will in future be greater home demand for nurses given service expansion in the Spanish national health system. Indeed, the feeling is that Spain might become “a country like the UK, that’s going to import nurses to fulfil all positions that’s going to be available” (Spanish interviewee cited in Young et al, 2008a: p.128). Such views are also backed up by evidence that Spain has gone in a relatively few years from being a country which was content to see its doctors being recruited by the UK, to one which is also importing doctors from Poland (another key UK supply source within Europe) (Ciepielak, 2007).

Overall, therefore, even those source countries with an image of health professional surplus and ready migration during the years of the UK’s active recruitment policy, are being shown to have finite supplies and/or are adjusting their perspective in particular areas and in response to changing circumstances. Despite the genuine and laudable intentions of ethical recruitment policies, it also does not seem that it was possible to protect for all possible negative “outcomes”. Clearly, it is not possible to separate out the extent to which the UK’s active recruitment stance of recent years may or may not have contributed to this. However, the speed at which such changes have happened – in just a 6-8 year period - at least raises questions about whether the major source health systems such as Spain and Poland could have continued to absorb migration on the scale the UK amongst others was placing upon them. The indication of finite recruitment supplies (see, for example, Young et al, 2008b – Midwifery case study) also backs the view that overall surplus may be an insufficient means to gauge the suitability of a country as a target for active recruitment and/or a continued source of sustained out-migration. Once again, however, comprehensive research has yet to be undertaken regarding the impact of health professional out-migration on countries in Europe.


6 Implications and Challenges at Health System Level

This section deals with the perceived challenges and implications of European health professional mobility, and within-UK migration and competition both for migrant and UK-qualified labour at health system level – for instance regarding: regulatory arrangements and mechanisms to ensure quality/safety in NHS employment contexts; workforce planning at national and devolved administrative level; dealing with source countries; and overall policy-and decision-making in the context of the UK/within-UK and European health workforce. It draws on the literature but also primarily on the views of our interviewees: regulatory bodies, professional representatives, employer organisations, and DH policy makers.

6.1 Professional Regulation and Infrastructures to Ensure “Quality”

The primary purpose of regulation is to protect the public by ensuring proper standards of practice. To practice in the UK, all doctors; dentists; nurses and midwives; pharmacists and allied health professionals must be registered with the appropriate regulatory body; and are admitted to the professional register only after completion of education and training that satisfies stringent academic and clinical criteria. Developing agreement around educational and training curricula and qualification requirements has been, therefore, a major focus in the drive to encourage mobility within the EU/EEA. As we have illustrated, however, ensuring individuals are truly able to practice effectively requires consideration of the concept of a culture of healthcare. The UK, like other EU/EEA states has its own particular ethos and system of health care delivery that has emerged as a result of cultural and historical factors, which are often intangible and difficult to quantify. Not surprisingly, therefore, in terms of their views about the main challenges of European mobility for the UK health system, many of our interviewees (e.g. B2; C1; C4) reiterated the concerns already described (Section 4) regarding the implications of different professional cultures/clinical practices for quality of NHS service delivery. Some even went so far as to question whether formal competency-based education and assessment systems (of the sort being lobbied for by professional bodies as a means to address the current continuing lack of real equivalence – C4) would truly be able to underpin more rigorous free movement criteria. In addition, a major continuing concern was around language standards and, in particular, the fact that a test of competence in English is not a pre-requisite for professional registration for individuals moving from the EU/EEA (Interviewees: A2; B1; B2; C2; D2) (see Box 6.1).


BOX 6.1 REGULATORY AND ADJUSTMENT CHALLENGES OF MOBILITY: INTERVIEWEE VIEWS

The Question of Real Equivalence

“You don’t employ someone from overseas lightly. There are issues around differences in clinical practice and broader competencies that need managing … Mobility is a big thing for employers. It doesn’t matter were people come from, it is a big investment for employers to ensure they can do the whole job” (A1 - AHPs)

“Challenges around language and scope of practice. There are significant differences within Europe despite mutual recognition. Hence it can be easier for employers to bring people from overseas rather than EU” (A2 – All professional groups)

“We encourage employers to do a thorough induction process for people. It’s like a period of familiarisation. Just because you can practice and are fit to practice in [professional registration] terms of meeting the standards, doesn’t mean you can go straight to work. Need to know about UK system etc” (B1 - AHPs)

“I can’t think of induction programmes particularly focused on EU nurses. There maybe an assumption that because they’re EU nurses it’s ok, but there is a danger in this” (C2 - Nurses)

“We encourage employers to carry out induction programmes using NHS Employers’ guidance to ensure that even our community pharmacies provide induction programmes for their newly qualified European pharmacists” (B4 - Pharmacists)

Language Standards and Testing

“You cannot test EEA migrants. I question the wisdom of this. It is strange it is not part of the regulatory process” (A2 – All professional groups)

“This is a big issue … But the [European] Commission is very definite in its view. [This organisation] … sees language testing as necessary and we’re trying to lobby the EU about” (B2 - Nurses)

“No ones tackling the problem of language testing. It will be interesting and sad to look 5 years down the track to see what’s happening in terms of poor performance and involvement with the [regulatory body]. I think it will highlight problems” (D2 - Doctors)

“That has actually been a problem. We’ve had fitness to practice cases, based on language. It is an issue” (B4 - Pharmacists)

Perceived Variability of Employer Checking Practices

“Language is definitely an issue. [This organisation] … supports the … view that if there isn’t language testing at the point of registration employers need to understand what their responsibilities are” (C2 - Nurses)

“Language can be a problem at employment levels. Some assume the [regulatory body] should test but we can’t. There are language barriers” (B1 – AHPs)

“Employers can test language but it varies as to whether they do. Depends on the person and which role you're appointed to, who the other candidates are, and those sorts of things. There are problems for employers about how to implement language testing” (A2 – All professional groups)

“The PCT in England and also individual practices are responsible for language and it’s anecdotal but we suspect they have no idea about what legal requirements are” (D2 - GPs)

Recognition and management of potential difficulties within these areas is vital for three reasons: first, to ensure the individual patient experience is safe and of high quality; second, to enable NHS organizations to get maximum value from employing EU/EEA migrants; and third, to assist individual health professionals to gain positive benefits from moving to work


in the UK. In this context, the main concern of our interviewees was that – since the 2006 change of policy towards international recruitment and the related loss of support previously ensured at national/regional level – the provision of appropriate induction/adjustment support is (in most cases) the responsibility completely of local organisations (e.g. C3 – Dentists; C4 - Doctors) (see Box 6.1). As one interviewee explained, the anxiety was that:

“Employers haven’t [universally] taken this diversity agenda on as they should [e.g. in relation to support needs]. How does this affect the experience [and successful integration into the NHS] of people who come here, not just from India or from Africa but from Eastern Europe, which is different. This diversity will increase as we [i.e. EU enlargement] move[s] across the Balkans” (C5 - AHPs).

Similarly, given that regulatory bodies have no remit in terms of language, it falls to local organisations to ensure language proficiency – and, as some pointed out, there may be a temptation to take on an individual even if language is poor when there are vacancies to be filled (B4). At least one regulatory body reported that it continues to lobby the EU on the subject of language testing, supported by the relevant professional organisation (B2; C2). For the most part, however, interviewees accepted the EU position as “the way it is”; and felt it was, in any case, an inherent part of an employers’ duty to ensure those they employed were competent in English (C1; C4). What they mostly argued for, therefore, was a better infrastructure (underpinned by high-level funding) for NHS organisations to share experience and intelligence about how best to ensure language competency; and deliver both language training and professional/clinical induction and support (A2; C3). Some also felt there was a continuing role for the publication of guidance, oversight of activities and provision itself at regional/national level – i.e. to stimulate local organisations to act; and to ensure economies of scale and less likelihood of loss of the organisational memory relevant to adaptation/adjustment of European staff. Essentially, the view was that only such wider infrastructures (which could be switch-on/switch-off by organisations as required) could ensure the necessary consistency and effectiveness of induction/support inputs.

Overall, our interviewees felt that there are tensions between the EU’s emphasis on freedom of movement and the responsibility of professional/regulatory bodies to ensure patient safety and competent practice within healthcare (B2; C1) (a point also made strongly in the literature – see for instance, Griffiths, 2002; Mead, 2003). The concern voiced was that the balance is too much about “the individual’s right to move and not the collective right of the public to be protected” (C1). One interviewee pointed, for instance, to the possibility that an individual might have the prerequisite training and qualifications to obtain UK registration,


but may not have practised for several years (B4). In addition, several interviewees spoke of their concerns about the latest EU Directive (EU Directive 2005/36/EC) (see Section 1 above) effectively removing control altogether from UK regulators and the UK service delivery system. The introduction of temporary registration, in particular, raised questions about potential “border hopping” and how continuity of care for patients would be ensured (B3 - Doctors; B4 – Pharmacists; C1 - Midwives). Other concerns included the lack of clarity around the definition of temporary and what it might mean for continuing professional development (C1). In all of this the key concern related to incomplete exchange of regulatory information between countries; and what was perceived as potentially poor regulatory practice in some EU/EEA member states (and indeed Wider European countries) (C2; D2). Although the professional and regulatory bodies across Europe have been working to address these challenges (AURE, 2005; HPCB, 2007), the view was that, UK stakeholders may still have to rely on what for them would be inadequate assurances of quality. Having the infrastructures in place to support NHS organisations in their induction/support activities is likely, therefore, to become all the more important. It will also be important for richer countries such as the UK and Europe as a whole to support all member states to develop the systems and infrastructures to underpin mobility. We will return to this issue of developmental support to what are currently the major health professional migration source countries within Europe in more detail below.

6.2 Workforce Planning: Information Availability and Overall Approach

In addition to professional entry barriers, the mobility of all health professionals (EU/EEA and other overseas to the UK; and UK-qualified either moving within the UK or going abroad) has implications in the context of workforce planning mechanisms. This applies both within individual NHS organisations (and discussed above in Section 4) and multiplied up to the UK/constituent country health system(s) as a whole. Once again, the feeling from our interviews and the literature is that the links to wider workforce planning infrastructures have not been fully thought through. In relation to international recruitment and migrant health staff in general, several issues are raised – but viewed as particularly questionable was the fact that planners appear not to have foreseen the implications of on-going migration for openings available to UK qualifiers when increased training numbers also fed though into the system (in 2006) (Young et al, 2008a) (Interviewees A1; B1; C1; C3; D1) (see also Buchan, 2007 on nursing). Of course the policy stance in relation to active international recruitment and many groups of non-EEA health professionals has now changed (DH, 2007 and 2008; NHS Employers, 2006), and in the context specifically of Europe many would also argue that migrant numbers are too small to need separately accounting for. From others’ viewpoint, however, this stance seems short-sighted. Even though numbers of European health


professionals moving to the UK are small compared with other international sources, they are still in the order of several hundreds per year across the NHS (B1; C4). Moreover, for some professional groups (e.g. dentists) the contribution of European migrants to the workforce is – relatively – quite large (C3). Given that there is evidence the workforce behaviours of European migrants differ from other groups (see, for example, Box 6.2), at the very least it would seem prudent to do more to understand those differences and take them into account in workforce planning. In other words, the view was that just as different behaviours (e.g. in relation to promotion; lengths of stay etc) have implications for organisations (see Section 4), so too do they have implications for the NHS as a whole – and they need to be taken into account at both at the national UK level and at the level of the devolved administrations.

BOX 6.2

NHS WORKFORCE CENSUS: TRENDS AMONGST DIFFERENT DOCTOR GROUPS

EEA qualified doctors were generally around twice as likely as UK qualified doctors to leave the workforce at any given time. In contrast, doctors who qualified elsewhere in the world (RoW) were more likely to leave the workforce than UK qualified doctors only in their first few years after entry; thereafter they were no more likely to leave than UK qualified doctors.

The median length of stay in the workforce (i.e. number of years at which 50 per cent of doctors had left) for a first ‘episode’ of work was longest for UK qualified doctors (4 years), intermediate for RoW qualified doctors (3 years), and shortest for doctors who qualified in the EEA (2 years). Second episodes of work tended to be longer than first episodes for both EEA qualified doctors (3 years) and RoW qualified doctors (5 years), but remained unchanged for UK qualified doctors (4 years).

EEA qualified doctors were less likely than UK qualified doctors to be promoted in their first year in the workforce but thereafter their promotion prospects remained similar to those of UK qualified doctors. In contrast, RoW qualified doctors had better promotion prospects than other doctors in their first year of workforce participation but thereafter their promotion prospects were much worse than all other doctors.

Source: Adapted from Hann et al, 2008

Even at the simplest level, modelling in European health professionals (and internationally-qualified health staff in general) could help reduce the stop-start nature of workforce planning that makes for real difficulties for employers. As our interviewees described in the context of just two of the professions covered in this report:

“We have an interesting situation in terms of workforce numbers … We have now brought in some Dentists from overseas and increased the numbers


graduating … There could [now] be a complete reversal and where we had a shortage, we could have a glut. It needs careful watching” (C3).

“[An] Important factor is the fact the DH no longer does workforce planning at a central level. This is a major component of current crisis around medical students and jobs. We have committed ourselves as a country, to self-sufficiency and appropriately increased medical student numbers in the UK. But we haven’t looked at the way things would be 5 or 7 years down the line, which is where we are now” (C4 - Doctors).

Overall, however, the feeling is that simple is not enough. Workforce planning models need to be much more sophisticated than they currently are in terms of factoring in of the behaviours of EU/EEA (and indeed Wider European and other international) migrants (and also groups from different countries) (C1). Such challenges are all the more relevant in regional/professional labour markets that are heavily reliant on EU/EEA and/or overseas supplies (see Section 2). The key point, however, is - as we have illustrated throughout this report - the lack of concrete information on which to base detailed modelling for the migrant health workforce as a whole – and the European-qualified workforce in particular (see also Buchan and Dovlo, 2004; Dosani et al, 2003; Findlay, 2001; Hutt and Buchan, 2005; Young et al, 2008a). Significantly, workforce planning models for nurses, midwives, AHPs, dentists and pharmacists are even less sophisticated than for doctors so the gaps in knowledge and questions in the context of those groups are even greater.

N.B. All of these arguments are equally as relevant in the context of within-UK migration as they are for European and other internationally-qualified staff.

6.3 Labour Market Policy-making in the Context of European Mobility

It is vital that the EU/EEA as an economic bloc can (as envisaged in the Lisbon Strategy – see Section 2 above) make the best possible use of all of its shared resources – including HRH. Such arguments undoubtedly mean that on-going moves, for instance towards the liberalisation of services, and related attempts at further facilitation of mutual recognition and free movement (see Section 1), will continue. Hence the “EU project” will keep on impacting upon the NHS and the UK health system(s). For the future, therefore, it will be increasingly relevant for UK-based policy-makers (national and devolved administration) and other stakeholders to consider the actual and potential workforce contribution of all mobile health professionals (UK and European); and actively engage in debates about how


best to go forward at European level. There is also an argument that influencing debates in Europe is actually in the positive interests of the NHS and UK/constituent countries’ workforce supply. Although, for example, current policy views are that NHS organisations do not need actively to recruit from abroad, there is no guarantee that it will not need to do so again in future (Young et al, 2008) (see also Box 6.3). Recognising the potential to make more effective use of easily available (due to mutual recognition) HRH from within Europe, it could be argued, is a better overall workforce strategy than having to compete globally for health workers. This is particularly the case given that several of the biggest players in global health labour markets (e.g. USA, Australia) have key attraction advantages over the UK countries – even for migrants coming from the UK’s traditional main international supply sources such as India (Young et al, 2003).

BOX 6.3

CONTINUING NEED FOR INTERNATIONAL HEALTH WORKERS: INTERVIEWEE VIEWS

General Migration of International Health Staff

“NHS is currently almost self-sufficient, but bringing another government in, things could just change overnight … It is not an exact science” (A2 – All professional groups)

“There has been a shortage of pharmacists – but [is that] still the case? There are two pressures: new schools of pharmacy opening, which is going to increase the number of new registrants that are UK qualified and an explosion of opening hours of the sort of supermarket-based pharmacies. Therefore you’re never quite sure of the balance” (B4 - Pharmacists)

Role Specifically for European Migration

“Changes in migration policy making it more difficult for nurses from non-EU countries to actually access nursing roles in the UK at the same time as we’ve been expanding membership of the EU. What happens when work permits come to an end?” (C2 - Nurses)

Moreover, there remain circumstances in which employment of additional staff from outside the UK still has a role. In the context of medicine, for instance, it seems likely the UK countries will remain a migration destination for some groups (e.g. GP registrars) – i.e. given that one of the main incentives for EU/EEA doctors to come to the UK is the lack of availability of post-graduate training in their home countries (Pitts et al, 1998; Young et al, 2003). In these circumstances, it may be better use of UK resources to attempt to encourage doctors to stay post-specialist qualification rather than see them re-migrate elsewhere. In addition, there are certain local/regional labour markets (e.g. London and the South East; and Northern Ireland) and individual professions (e.g. midwifery) that continue to have staff shortages – despite the reported overall situation of health workforce self-sufficiency. Recruitment into midwifery, for example, is much more difficult from outside Europe due to the fact that regulatory


changes have raised the entry barriers (i.e. adaptation requirements) for non-EEA-qualified individuals (NHS Employers, 2006; Young et al, 2008b). As another example, in nursing certain specialties (e.g. mental health) continue to report workforce shortages due to numbers growth (increased supply) not keeping pace with service expansion (increased demand). In this context EU/EEA countries – primarily Ireland – are reportedly seen as a key continuing supply source. In all of these cases, both general health professional migration, and European migration specifically, remain significant potential workforce solutions (Young et al, 2008a).

The areas our interviewees felt were most important for policy-makers to consider given the potential continued significance of Europe to the UK are illustrated in Box 6.4. Following on from the challenges already outlined, they primarily focus on the need to lobby: a) for improvements in cross-border information exchange per se; and b) for different countries to be supported to improve the quality/accessibility/usefulness of the information they provide to underpin any exchange mechanisms put in place. The view was that if such mechanisms could be developed that would assist both the UK and Europe as a whole – in the context both of professional regulation and quality safe-guards, plus workforce planning (see also EFPH, 2003; Scepereel and Sondore, 2002).

BOX 6.4

AREAS THAT NEED ADDRESSING AT EUROPEAN LEVEL: INTERVIEWEE VIEWS

Information Sharing re. Professional Registration

“There have been discussions around some sort of qualification passport. If that can be developed and is not bureaucratic it would be a useful tool to consider” (A2 – All professional groups).

“The emphasis on rights to free movement is challenging from the regulatory perspective. [This organisation] would like disciplinary information to follow the professional who’s moving” (B4 - Pharmacists).

“There are challenges around regulation in relation to the exchange of information. Some of the countries that recently acceded [to the EU] didn’t have any national registration system only regional systems” (C2 - Nurses)

Information Sharing re. Workforce Planning

“Getting the numbers right first time round. Being realistic and honest with the numbers, to allow people to get organised. If, I think we could have done better with the, you know when Europe really grew in 2004, I think we could have been better prepared for that had we been better informed of the numbers. We’d have been ready had there been some accurate data” (B1 - AHPs).

“Sharing market intelligence would be useful. Anything that’s not too bureaucratic. There have been conversations about everybody sharing data, and collecting data, but I’m not sure that in the long term, that’s useful. But what might be useful is the intelligence around, `Well actually currently in the UK we have an adequate supply, and therefore we’ll not be looking to recruit from overseas’. Should you want to do an active process of targeting, you can be a bit more constructive in the way that’s done” (A2 – All professional groups).


6.4 Relationships between Receiver and Source Countries within Europe

The final area where the literature and our interviewees suggest more thinking and joined-up-ness may be needed – both within the UK and at European level – is around policy in relation to migration source countries (e.g. in Central and Eastern Europe). What evidence there is (Section 5) suggests, for example, that from a UK viewpoint any future recruitment should be based on a very sophisticated prior-analysis of within-country markets to ensure source health systems are fully protected. This would involve the detail of UK needs (the demand-side market position) being set against a similarly detailed analysis of available supplies – i.e. supplies distinguished below national level in source countries at the level of specialties or service areas (Young et al, 2008a). In doing this, however, it needs to be recognised that not all countries have workforce planning mechanisms in place enabling any prediction of future risk. Support of such developments – and necessary developments to improve the information sharing mechanisms (see Box 6.4 above) - may be something that should be addressed as EU/EEA level.

In addition, there is a straightforward development role for the UK and its constituent countries. As we also noted in Section 5, Codes of Practice and ethical policy stances around migration/recruitment, though essential, can only achieve so much to protect vulnerable countries – including those in Europe - against losing migrant health professionals when they cannot afford to do so. Again this is a complex debate – one that we cannot do justice to here. The key point, however, is that if the UK countries really wish to help influence the balance of “buyer power” (of health professional labour) in favour of weaker countries in the system there are other more proactive measures that need to be taken. The literature provides a number of examples of such a development approach in the context of the health workforce – both in Europe (Young et al, 2008a) and in developing countries (Sloan, 2005). However: “there is clear scope to increase the effectiveness and strategic impact of this work” (Crisp, 2007; DfID, 2007). Activities highlighted in this context include, for instance:

Bilateral arrangements – e.g. around recruiter countries like the UK investing in health education institutions in source countries in return for recruitment;

Institutional collaboration between healthcare systems and universities;

Expansion of exchange programmes for health workers that give assurance that migrants will return to countries of origin after a specified time.

Importantly, being strategic also means allowing for greater “joined-up-ness” at the level of UK policy around the issue of matching UK workforce


needs in a manner that helps benefit source countries. As in other studies (e.g. Young et al, 2008a), our interviewees made a clear argument in this context that developed countries such as the UK need to do more to manage cyclical market fluctuations (stop-start migration needs) that impact negatively on stability for developing country supplies. This is another side of the argument around the need for improvements in UK workforce planning that we dealt with earlier.


7 Key Findings and Future Research

The aims of this study were to look at the nature and quality of existing evidence and scope the main issues around two key aspects of health professional mobility/migration: within-UK mobility and related competition for health professional labour; and mobility to and from the different UK countries and Europe (including EU/EEA and Wider European countries). The overall intention was to identify any key gaps in knowledge and note potential topics for future research relevant to the NCCSDO programme and Scottish Executive (the organisations which funded the study). This section summarises the main findings from this scoping exercise and outlines some possible lines of future enquiry. The key lessons for policy and practice and the main opportunities for future research are also set out Box 7.1 at the end of the section.

7.1 Summary of Issues and Further Questions

7.1.1 Literature and Data

The study clearly shows that literature (especially that reporting research findings rather than anecdotal evidence) regarding health professional mobility/migration from Europe to the UK is much more limited than that focusing on migration/mobility from elsewhere overseas. Available information also mainly relates to doctors and nurses and/or particular international recruitment drives undertaken in recent years (e.g. GP or nurse recruitment from Spain). There is very little research indeed regarding AHPs, pharmacists and dentists – even though the latter two groups at least were the subject of dedicated international recruitment initiatives, for example, in Spain and Poland. Likewise, studies have rarely focussed on out-migration from the UK - including return migration of European-qualified staff to countries of origin - or within-UK migration and competition for health labour (migrant or UK-qualified). Finally, it appears that available/published NHS workforce and professional registration data also leave key questions unanswered. Once again, information is most available and informative for doctors, and to a lesser extent nurses and dentists; but is particularly limited with regard to midwives, AHPs and pharmacists. A key issue here is that registration data itself does not necessarily indicate that the professionals concerned are active in the NHS or other parts of the UK health/social care workforce. In addition published statistics on countries of origin often refer to countries of application rather than actual qualification; and there is considerable inconsistency between the different professional groups regarding collation and/or publication of data that might shed light on out-migration (of migrants or UK-qualified individuals). In the context of data there is, then, a need to establish the minimum dataset requirements to monitor within-UK and Europe-UK-


Europe movements of health professionals in order to inform both mobility-related policy making and workforce planning. Greater consistency of information is also required across the different professional groups.

7.1.2 Migration/Mobility Trends

There is, of course, an argument that UK/constituent country bodies do not need detailed information regarding Europe-UK migration/mobility because in all health professions (with the exception of dentistry), the greater proportion of migrants are from outside Europe. This argument, however, seems short-sighted because European sources have, in recent years started to become much more important - at least in relative terms. More specifically the relatively fewer EU/EEA numbers still equates to thousands of additional NHS staff in 2007 compared with 2000; with the sheer variety of counties (31 in the EU27/EEA alone) and professional cultures represented making workforce integration equally if not more, challenging than for other ostensibly more significant movements from single-country sources such as India and The Philippines. European sources are also likely to remain significant in their own right due to:

The continuing numbers of professional registrations (particularly from CEE countries, especially Poland); and

The on-going need, in the face of greater restrictions on migration from outside Europe, of certain professions (e.g. midwifery and dentistry) and local labour markets (e.g. London and the South East of England) to supplement workforce supplies with non-UK staff.

In other words, the suggestion is that the relative trend towards more EU/EEA migrants will continue as numbers of non-EU NHS recruits fall (due to changes in work permit regulations etc), but EU-resident professionals carry on exercising their rights to free movement. Another point in this context is that the EU itself is significantly raising its profile in respect of Europe’s health workforce, and is continuing to legislate in a variety of areas further to remove the barriers to professional mobility/migration.

7.1.3 Motives and Constraints Relating to Mobility

As with migration generally, motives for movement within and between the different UK countries and Europe are complex. What data there is suggests that:

Unemployment (in relation to jobs generally and/or post-graduate training opportunities) was a push factor in the early 2000s, for example for Spanish, German, Italian, and Greek doctors, nurses and midwives;


Economic factors are more significant per se with reference to CEE countries but are not the only reasons for movement; and

Professional (e.g. career development) and personal (e.g. travel and cultural opportunities; family/social network links) factors are important for all groups (European and UK); and are relevant both in the context of within-UK, and Europe-UK/UK-Europe mobility/migration.

The main mobility constraints tend to be language and professional cultural differences. Language in particular appears to be even more of a constraint for UK-qualified professionals moving abroad than it is for European-qualified staff moving to the UK.

Overall, no one driver or constraint to health professional mobility (to and from, and within the UK) can be singled out as key - either for individual migrants or source/receiver countries as a whole. Inflows and outflows are linked and movements to and from different countries change as the balance of drivers versus constraint alters over time. How to capitalise upon these different drivers and address constraints in ways that are of benefit to all (receiver and source countries; and individual migrants) is a clear topic for Europe-wide, comparative research.

7.1.4 Impacts on Service Delivery and Organisation in the UK

No comprehensive research appears to exist regarding impacts of European mobility on the NHS. However, this scoping study clearly showed that there are several issues which it will be important to investigate. These include:

The real equivalence of training and experience (whatever the mutual recognition arrangements) and the different cultural perceptions of professional roles (e.g. in the context of multi-disciplinary team-working and core tasks to be undertaken) between the UK and different European countries. A key question here is the extent to which such concerns follow through to impact on clinical practice and care standards in different professional contexts and care/service settings.

The question of language skills (oral and written; everyday and medical) and standards – in particular the lack of testing of EU/EEA migrants as part of the professional registration process and the extent to which that impacts on service quality and patient experiences. Teasing out patient perceptions and experiences will be important here given that the few studies there are indicate that complaints from patients about internationally-qualified staff have tended to relate to language issues rather than clinical care/service standards per se.


Related to language, the question of different styles of communication. Those noted in the literature in relation to international health professionals in general include: a) Perceived reticence (from a UK viewpoint) around verbally engaging with patients - i.e. because of different perceptions about when it is appropriate to talk or be silent; b) Different norms regarding what is the appropriate manner and tone of speaking, and way to address patients (i.e. formally or informally); c) Different use of body language and other non-verbal communication (e.g. eye contact, turning backs on patients, smiling etc); and d) Gender-related cultural norms around inter-personal interaction. The question for research here would be whether such differences are also relevant to European-qualified staff and how/whether such differences also impact on patient/carer experiences and quality of therapeutic relationships (e.g. around rapport building, balance of power issues, facilitation of decision-making, effective information giving etc.).

The challenges to NHS organisations stemming from the need to deal with individual migrants’ adjustment and development needs. In terms of types of support, for example, the literature points to the need both for professional and work-related support (e.g. initial induction on the workings of the NHS, peer support, time to settle in, on-going career development etc); and personal support (including for instance assistance with the costs of relocation, finding initial accommodation, mechanisms to encourage social integration etc). Such measures were generally in place during the active international recruitment drives of recent years. Key questions now are the extent to which similar measures need to become standard activities for the NHS in supporting EU/EEA migrants in general; and whether there are additional infrastructures (e.g. regional/national; educational/professional body etc) needed to support that. Another question not yet fully answered in this context regards whether there are any key differences or commonalities specific to particular professional groups and/or individuals from different source countries across Europe, a better understanding of which would improve induction/adaptation and other measures used to integrate or socialise European migrants into the NHS workforce. Our interviewees pointed, for instance, to the highly contextualised nature of certain fields (e.g. general practice) compared with other professional groups (e.g. specialist doctors, nurses and certain AHPs) whose clinical knowledge base is potentially much narrower and, therefore, more transferable from country to country. However, several of our interviewees also felt that where differences do exist they are not as great as some would argue. The view was that no one has yet documented the comparative differences and actual reality of the challenges in a truly comprehensive way.

Other HR challenges around: day-to-day HRM (e.g. necessary arrangements to accommodate annual and compassionate leave); team-working and integration in the context of the increasingly wide variety of professional cultures working in the NHS; and the different behaviours that need factoring into workforce planning at local level. Factors relevant in the


context of workforce planning include for instance: a) timescales for staff applying for promotion and climbing the career ladder, and for that career progression in turn freeing up entry grades for new staff; and b) overall lengths of stay in the NHS before moving on (whether to return to countries of origin or move on to a third country such as the USA, Australia etc). Again there is very little information in this context regarding internationally-qualified health professionals in general, but even less information in relation to migrants from the different EU/EEA and Wider European countries covered by this study.

The need to harness the potential for value-added that European migration brings to the NHS. Again most concrete information here relates to international health professionals in general - with the observation being that migration brings many new ideas, positive attitudes and different approaches to patients, different skills bundles and critical appraisal of existing practices to the NHS. Further work is needed to unpack this value added to be gained – both generally and specifically from migrants with experience from different European countries (and indeed other countries outside Europe) entering the different health professions in the UK.

7.1.5 Impacts on Individual Migrants and Source Countries

Most research relates to professionals and countries outside Europe, however common themes do emerge:

For any individual, moving into the NHS is a significant learning/adjustment process (professional and personal) requiring comprehensive support both at the point of recruitment and on an on-going basis. In addition, there appears to be considerable variation across professional groups and countries/world regions of origin around experience/satisfaction with clinical grading, salaries and career progression; the personal costs (financial and family) of migration; and experience of discrimination. On the basis of the few studies that have included them, it can reasonably be assumed that European-qualified health professionals regard many of these factors and experiences as also applying to them. Discrimination and stereotypical attitudes, for example, have been reported by health professional migrants from Eastern Europe. Again, however, there as yet are more questions than answers in the context of the range of European migrants’ experiences of working in the NHS. There is, therefore, considerable scope for research to establish the extent to which the experiences of health professional migrants from EU/EEA and Wider European countries are like those of overseas staff generally; or whether there are unique experiences that need to be taken into account in integrating European health professionals (from different source countries and/or European regions) into the NHS workforce.


For source countries (even those with apparent workforce surpluses), impacts can be unpredictable and highly challenging from a health system viewpoint. Concerns are being raised, for example, in CEE countries about the scale and pace of health professional out-migration as encouraged by EU mobility opportunities; and governments there are beginning to take action (e.g. improving salaries and working conditions) to attempt to reduce movement levels. Elsewhere, countries such as Spain (which in the early 2000s was a significant source of health professional migrants to the UK) have gone from being major suppliers to the European market, to significant importers (e.g. from Poland). Unpacking these complex relationships between surplus and shortage countries and managing the impacts of migration as a whole is obviously an issue for all European countries. However, there are lines of research enquiry to which the UK might well contribute – for example: around: a) the extent to which a perception of overall surplus of supplies in a given professional group is adequate to make substantial out-migration from certain source countries a sensible prospect; and b) the extent to which source countries in Europe (and indeed elsewhere) are benefiting from returning human capital (i.e. return migrants coming back with additional, relevant skills, competencies and experiences gained in the UK). At the very least collation and publication of appropriate data by UK professional bodies would be a help here.

Overall, it is clear that diversity issues and ethical recruitment considerations are equally as relevant for the UK in its dealings with European migrants and source countries as those from elsewhere.

7.2 Summing-Up: The Continuing Importance of Mobility/Migration for the NHS Workforce

Given that the EU as an economic bloc needs to make better use of all its shared resources – including HRH – moves to encourage free movement are likely to continue. Undoubtedly this will continue to produce tensions in respect of professional regulators’ and employers’ responsibilities to ensure patient safety and service quality. Mobility (UK and European) also has potential implications for workforce planning at health system level (UK/constituent country). Similarly, from source country viewpoints, more joined-up-ness and developmental approaches are needed to link recruitment/migration to the real availability of supplies. In all of the above, appropriate infrastructures, information resources, and collaborative action and decision-making are needed at UK/constituent country and European level; and there are – as indicated throughout this final section of the report - opportunities for research in all areas covered by this study to help underpin informed debate (see Box 7.1).


Overall, as one of the largest importers of health professional labour within Europe – and given the added experience of the large scale recruitment drives of recent years – the UK countries are an ideal crucible in which to research this European mobility perspective. From the viewpoint of the UK countries themselves, recognising the potential to make better use of more easily available HRH from within Europe may also be a better workforce strategy than having to compete with other big players (e.g. USA, Australia) globally. Being part of a Europe of free moving workers is then, as much an opportunity as it is a challenge to UK healthcare and its effective delivery – but the evidence base needs to be strengthened considerable if the NHS is fully to capitalise upon that opportunity.


BOX 7.1

KEY LESSONS FOR POLICY & PRACTICE FUTURE RESEARCH OPPORTUNITIES

1. The argument that UK bodies do not need information on European health professionals because their numbers are relatively fewer than from countries outside Europe is short sighted. This is because European sources are becoming more important and the incentives (economic and professional) for health professionals to move to the UK continue to be significant.

2. Improved data on health professional

mobility/migration is particularly important for human resources management and for workforce planning at national, profession and organisational level. Key issues include the need: To ensure greater information

consistency across professional groups; To establish minimum dataset

requirements to monitor both within-UK and Europe-UK-Europe movements;

To improve information on the lengths of stay, career progression etc of different migrant groups.

3. The main constraints on mobility are

language/communication and professional cultural differences between countries. If migrant health professionals are to integrate effectively into the UK workforce they need to be properly supported to do so. Both work-related (induction and on-going career development) and outside-work (e.g. with relocation) support is often needed.

4. Although discussion of health professional

mobility/migration can often be negative, organisations also need to be open to the potential gains - including opportunities for critical appraisal of existing practices and to learn from different skills bundles, approaches to patients etc.

5. Much emphasis has been placed on the

UK’s responsibilities regarding ethical recruitment and the impact of mobility/migration on source countries. These issues are just as important for countries within Europe as outside.

1. Research has often focussed on doctors and nurses from countries outside Europe and on in-migration to the UK. This leaves knowledge gaps on:

EU/EEA and other European mobility in general and the experiences of European health professional migrants as opposed to those from elsewhere overseas;

Other professions including midwives, dentists, pharmacists and the main AHP groups (e.g. physiotherapy);

Out-migration (whether by UK-qualified or EU/EEA and other internationally-qualified health professionals) and within-UK movements.

In-migration from professionals not moving as “professionals”- e.g. Polish nurses entering UK as care assistants

Linkage to health workforce planning- the issue of UK ’self sufficiency” in health workforce, and the apparently rapid changes in level of outflow of staff

2. Anecdotal evidence often highlights potential

negative impact of mobility/migration on service delivery and quality. There are therefore clear questions for research around:

The extent to which, for example, language and communication and professional cultural issues do or do not follow though to impact on clinical practice and care standards, multi-professional team-working and interactions with patients;

The key differences and commonalities between health professional cultures, scope of practice etc in the UK and other countries’ - a better understanding of which would help UK organisations to improve induction/support measures for European migrants;

What the UK has to learn from the experience brought in by migrant health professionals from Europe and elsewhere overseas.

3. Regarding impacts on source countries, UK

research effort could help answer questions around, for example:

The extent to which countries in Europe (and indeed elsewhere) are benefiting from returning human capital (i.e. return migrants coming back with additional, relevant skills, competencies and experiences gained in the UK);

How Europe as a whole can capitalise upon the different mobility/migration drivers and address the constraints in ways that are of benefit to all (receiver and source countries and individual migrants).


References

Ackers (2004) ‘Managing relationships in peripatetic careers: scientific mobility in the EU ’ Women's Studies Int. Forum 27 189-201

Aiken L and Buchan J (2004) Trends in international nurse migration. Health Affairs 2004 23 (3) 69

Allan H and Larsen J A (2003a) “We need respect”: experiences of internationally recruited nurses in the UK. Report to the Royal College of Nursing, European Institute of Health and Medical Sciences, University of Surrey.

Allan H and Larsen J A (2003b) Learning from Others: Overseas Nurses’ Views of UK Nursing, Nurse Education Today, 23, 393.

Alexis 0, Vydelingum V, Robbins I (2006) ‘Overseas nurses’ experiences of equal opportunities in the NHS in England’. Journal of Health Organisation and Management 20 (2) pp130-139

Alexis O, Vydelingum V, Robbins I (2007) Engaging with a new reality: experiences of overseas minority ethnic nurses in the NHS. Journal of Clinical Nursing 16 pp2221-2228

Allen J, Carter K (2007) Training and assessment for doctors coming from the EU to work in UK general practice. Information for RCGP Postgraduate Training Board

Arekalian, C. (2003) On Speaking Terms. Nursing Standard, 16 July, 17, (44), 23.

Ashford and St Peter’s Hospitals (2008) Surrey Hospitals Seek Scottish Angels. Press Release: 06/02/2008.

Ast J (2004) A first-hand personal account of the thinking of young Polish doctors BMJ Online response 2 June 2004

Atherton, S. & Mathie, T. (2002) GP and consultant planning and quality assurance. Paper presented to the International Recruitment and Co-operation: A Global Perspective Conference, London, May 1st.


AURE (2005) Healthcare Professions Crossing Borders UK Presidency Patient Safety Initiative. London: Alliance of UK Health Regulators on Europe (AURE) and Department of Health.

Avgerinos E, Koupidis S, Filippou D (2004) Impact of the European Union enlargement on health professionals and health care systems. Health Policy 69 403-408

Bach S (2003) International migration of health workers: labour and social issues. Sectoral Activities Programme Working Paper WP. 209. Geneva: International Labour Office

Bach S (2007) Going global? The regulation of nurse migration in the UK. British Journal of Industrial Relations 45 (2) 383-403

Ballard K, Laurence P (2004b) An induction programme for European GPs coming to work in England: development and evaluation. Education for Primary Care 15 pp584-95

Ballard K, Robinson S, Laurence P (2004a) Why do general practitioners from France choose to work in London? a qualitative study. British Journal of General Practice 54 747-752

Baumann A, Blythe J, Kolotylo C and Underwood J (2004) The International Nursing Labour Market Report. Submitted as part of the “Building the Future: An integrated strategy for nursing human resources in Canada. Ottawa: The Nursing Sector Study Corporation. (http://www. buildingthefuture.ca).

BBC News (2008) NHS trust looks north for nurses. http://news.bbc.co.uk/1/hi/england/southern_counties/7230984

Bellingham (2001) Facing the Recruitment and Retention Crisis in Pharmacy: Looking Abroad. Pharmaceutical Journal, 267 (7156), 45-46

Betlehem (2003) Hungary is already seeing an exodus of nursing staff Nursing Times 99 N0 24 14-15

Birt C (2002) The European Union: open to the practising physician? Clinical Medicine 2 224-226

Blanchflower D, Rauner B, Saleheen J, Shadforth C (2007) The impact of the recent migration from Eastern Europe on the UK economy

http://news.bbc.co.uk/1/hi/england/southern_counties/7230984�


Blitz B, (2005) ‘Brain circulation’: the Spanish medical profession and international medical recruitment in the UK. Journal of European Social Policy 15 (4) 363-369

Bloor, K., & Maynard, A. (2003) Planning human resources in health care: Towards an economic approach – An international comparative review. Ottawa: Canadian Health Services Research Foundation (http//:www.chsf.ca).

Bola T, Driggers K, Dunlap C, Ebersole M, (2003) Foreign-educated nurses: Strangers in a strange land? Nursing Management. 34(7):39-42

Bourassa Forcier, Simoens (2004) “Impact, Regulation and Health Policy Implications of Physician Migration in OECD Countries. Human Resources for Health 2;12.

Bradford City PCT (2004) Guide to IR of GPs Based on the West Yorkshire Experience

Buchan J (2002) Global Nursing Shortages, BMJ, 324: 751

Buchan J (2003) Here to stay? International nurses in the UK. London: Royal College of Nursing.

Buchan J (2004a) Commentary: Nurse Workforce Planning in the UK: Policies and Impact. Journal of Nursing Management, 12 (6), 388-392.

Buchan J (2004b) International Rescue? The Dynamics and Policy Implications of International Recruitment, Journal of Health Services Research and Policy, 9 (Supplement 1)

Buchan J (2006) Migration of health workers in Europe: policy problem or policy solution? In Dubois C-A, Nolte E and McKee M (eds), Human Resources for Health I Europe, Chapter 3. London: European Observatory on Healthcare Systems.

Buchan J (2008) ‘How can the migration of health service professionals be managed in ways that reduce any negative effects on supply?’ Report

Buchan, J. and Dovlo, D. (2004) International Recruitment of Health Workers to the UK: A report for the DFID. London, DFID Health Systems Resource Centre.


Buchan J, Jobanputra R, Gough P, Hutt R (2006) Internationally recruited nurses in London: a survey of career paths and plans. Human Resources for Health 4 :14

Buchan J and Maynard A (2003) Human resources for Health Study: UK Case Study. Submitted as part of study leading to: Dubois C-A, Nolte E and McKee M (eds), Human Resources for Health in Europe. London: European Observatory on Healthcare Systems.

Buchan J, McPake B, Mensah K, Rae G (2009) Does a Code Make A Difference? Assessing the English Code of Practice on International Recruitment. Human Resources for Health 7:33

Buchan J and O’May F (1999) Globalisation and healthcare labour markets: A case study from the United Kingdom. Human resources for Health Development Journal, 3 (3).

Buchan J, Perfilieva G (2006b) Health worker migration in the European region: Country case studies and policy implications. WHO www.euro.who.int/e88366.pdf

Buchan, J. and Rafferty, A. M. (2004) ‘Not From Our Backyard? The United Kingdom, Europe and International Recruitment of Nurses’. In McKee, M., MacLehose, L. and Nolte, E.(eds.) Health Policy and European Union Enlargement. Buckingham, Philadelphia: Open University Press, pp.143-56

Buchan J, Seccombe I (2004) Fragile Future? a Review of the UK Nursing Labour Market in 2003 RCN Labour Market Review 2004.

Buchan J, Seccombe I (2006a) Worlds Apart? The UK and International Nurses RCN publication 003049

Buchan J and Seccombe I (2006b): From Boom to Bust? The UK Nursing Labour Market Review 2005/6. RCN

Buchan, J. and Sochalski, J. (2004) The migration of nurses: trends and policies. Bulletin of the World Health Organisation. 82 (8); 587-94.

Bueno de Mesquita1 J, Gordon M (2005) The International Migration of Health Workers: A Human Rights Analysis. London: MEDACT.

Bundred P E and Levitt C (2000) Medical migration: who are the real losers? Lancet, 356, 245-246.


Burgermeister J (2004) Exodus of Polish doctors could threaten health system BMJ 328:1280 (29 May)

Buth J., Harris P.L; Maurer P.C., Nachbur B, van Urk H. (2000) Harmonization of vascular surgical training in Europe. A task for the European Board of Vascular Surgery (EBVS) Cardiovascular Surgery. 8, (2) 98-103

Carlisle (2005) Needed by the NHS but denigrated by the politicians HSJ 115, 5954 12-13

Cashman C, Slovak A (2005) The Occupational Medicine agenda: routes and standards of specialization in Occupational Medicine in Europe Occupational Medicine 55:308–311

Ciepielak M. (2007) Our doctor being talked to Spain. Gazeta.pl. http://www.polishworkers.pl/polishworkers/2029020,60747,4255996.html (Accessed 13/03.08).

Close A (2002) recruits from overseas need better assessment and support British Journal of Nursing 11, 15 994

Commonwealth Secretariat (2003) Commonwealth Code of Practice for the International Recruitment of Health Workers [Online] [Accessed 01/05/2006].

Cowan D (2006) Cultural competence in nursing: new meanings Journal of Transcultural Nursing 17 (1) 82-88

Cowan, D (2005) A project to establish a skills competency matrix for EU nurses. British Journal of Nursing 14 (11) 613-617

Coyle A (2007) resistance, regulation and rights: the changing status of Polish women’s migration and work in the ‘new’ Europe. European Journal of Women’s Studies 14 (1) 37-50

Crisp N. (2007) Global Health Partnerships: The UK Contribution to Health in Developing Countries”. London: DfID. http://dfid.gov.uk/pubs/files/ghp.pdf (Accessed February 2008).

Daniel P, Chamberlain A, Gordon F (2001) Expectations and experiences of newly recruited Filipino nurses. British Journal of Nursing. 10 4 pp254- 265

http://www.polishworkers.pl/polishworkers/2029020,60747,4255996.html�

http://dfid.gov.uk/pubs/files/ghp.pdf�


Deeming C (2004) Policy targets and ethical tensions: UK nurse recruitment Social Policy and Administration 38, 7 775-792

Den Exter A (2004) EU accession and its consequences for Czech professionals. Medicine and Law 23, 753-758

De Raeve, P. (2003) The free movement of nurses: a win-win situation if based on ethical recruitment guidelines. Eurohealth. 9 (3): 24-26.

De Veer (2004) Experiences of Foreign European Nurses in the Netherlands. Health Policy, 68, 55-61

DfES (2008) www.dfes.gov.uk/europeopen/page_5.shtml

DfID (2007) “Stopping the brain drain: £1 million boost for global health workers”. Press release 13 February 2007. http://dfid.giv.uk//news/files/pressreleases/boost-health-workers.asp (Accessed 02/08).

DH (2000a) The NHS Plan - A plan for investment – a plan for reform. London: The Stationery Office.

DH (2000b) A Health Service for all our Talents: Developing the NHS Workforce. London: Department of Health.

DH (2000c) “NHS Aims to Recruit Up to 5,000 Spanish Nurses”. Press release: 7th November 2000.

DH (2001) Code of Practice for NHS Employers involved in the international recruitment of healthcare professionals. London: Department of Health (www.doh.gov.uk/international-recruitment).

DH (2002a) International Recruitment of Consultants and General Practitioners for the NHS in England. Current initiatives and guidance to NHS employers on and infrastructure to support international recruitment. London: Department of Health.

DH (2002b) HR in the NHS plan: more staff working differently. London: Department of Health.

DH (2004) Code of Practice for the International Recruitment of Healthcare Professionals. London, Department of Health (http://www.dh.gov.uk/assetRoot/04/09/77/34/04097734.pdf)

http://www.dfes.gov.uk/europeopen/page_5.shtml�

http://dfid.giv.uk//news/files/pressreleases/boost-health-workers.asp�

http://www.doh.gov.uk/international-recruitment�

http://www.dh.gov.uk/assetRoot/04/09/77/34/04097734.pdf�


DH (2006) Change to the Immigration Rules for Postgraduate Doctors and Dentists. [Accessed 21/02/2008]. Available from: www.dh.gov.uk/en/Managingyourorganisation/Humanresourcesandtraining/Morestaff/International

DH (2007) International Nursing Recruitment. [Accessed 21/02/2008]. Available from: www.dh.gov.uk/en/Managingyourorganisation/Humanresourcesandtraining/Morestaff/International

DH (2008) New immigration rules to restrict International Medical Graduates’ access to UK postgraduate medical training. [Accessed 21/02/2008]. Available from: www.gnn/gov.uk

Diallo K (2004) Data on the migration of health-care workers: sources, uses and challenges. Bulletin of the World Health Organisation 82 (8) 601-607

Dobson J, Koser K, Mclaughlan G and John Salt (2001) International migration and the UK: recent patterns and trends. Final report to the Home Office RDS Occasional Paper No 75 London: Home Office

Dosani, S. et al. (2003) Recruitment of doctors to non-standard grades in the NHS: analysis of job advertisements and survey of advertisers. BMJ, 327 (7421): 961-964.

Dustmann C and Weiss Y (2007) Return migration: theory and empirical evidence from the UK. British Journal of Industrial Relations 45 (2) 236-256

Dye and Gajewska (2002) Meeting the Needs of Non-UK Trained European Physios Seeking Employment in the UK. Physiotherapy, 87 (8), 424-432.

EC (undated a) Professional Qualifications. Information on European Commission (EC) website: http://ec.europa.eu/internal_market/qualifications/index_en.htm (Accessed 01/07/2008)

EC (undated b) Higher Education in Europe. Information on European Commission (EC) website: http://ec.europa.eu/education/policies/educ/higher/higher_en.html (Accessed 30/07/2007)

EHMA (2008) EU Briefing (on the EU Directive on the Application of Patients’ Rights in Cross-Border Healthcare). Brussels: European Health Management Association (EHMA), July. (For full text of the Directive see:

http://www.dh.gov.uk/en/Managingyourorganisation/Humanresourcesandtraining/Morestaff/International�





http://ec.europa.eu/internal_market/qualifications/index_en.htm�

http://ec.europa.eu/education/policies/educ/higher/higher_en.html�


http://ec.europa.eu/health/ph_overview/co_operation/healthcare/docs/COM_en.pdf

EHPF (2003) Recommendations on Mobility of Health Professionals. Brussels: EU Health Policy Forum.

Esmail, A. (2005) Service and betrayal. BMA News. 23 April, 6.

Eurostat (2006) “Introduction- workers mobility” in Migration and Mobility - Report from: www.euractiv.com /en/migration+mobility/introduction-workers-mobility/article-155759).

Findlay, A. (2001) From brain exchange to brain gain: policy implications for the UK of recent trends in skilled migration from developing countries. International migration papers 43. Geneva, International Labour Office.

Findlay, A., & Lowell, L. (2002) Migration of highly skilled persons from developing countries: impact and policy responses. International Migration Papers No. 43. Geneva: International Labour Organisation.

Forcier, MB.; Simeons, S. and Giuffrids, A. (2004) Impact, regulation and health policy implications of physician migration in OECD countries. Human Resources for Health. 2 (1):12.

Galan A (2006)in Wiscow C: Health worker migration flows in Europe: Overview and case studies in selected CEE countries – Romania, Czech Republic, Serbia and Croatia Sectoral Activities programme. International Labour Organization 2006

Gual A., Pales J., Pardell H. and oriole-Bosch A. (2005) Doctors in Spain. An old country, old and new structures, and a new future. The Clinical Teacher, 2 (10), 59-63.

Gerrish and Griffiths (2004) Integration of overseas RNs: evaluation of an adaptation programme. Journal of Advanced Nursing 45 (6) 579-587

Goetz, S. J. (1999) The Mover/Stayer Selectivity Model. In Migration and Local Labor Markets on The Web Book of Regional Science (Section III). Regional Research Institute, West Virginia University. (http://www.rri.wvu.edu/WebBook/Geotz/contents.htm/).

Goldbart J, Marshall J, Evans I (2005) International students of speech and language therapy in the UK: choices about where to study and whether to return. Higher Education (2005) 50 89-109

http://ec.europa.eu/health/ph_overview/co_operation/healthcare/docs/COM_en.pdf�

http://ec.europa.eu/health/ph_overview/co_operation/healthcare/docs/COM_en.pdf�

http://www.who.int/health-services-delivery/imbalances/�


Goldfarb R and Havrylyshyn O (1984) “Can remittances compensate for manpower outflows: the case of Philippine physicians”. Journal of Development Economics, 15 (1-3), 1-17.

Goodman (2005) Overseas recruitment and migration. Nursing Management 12 (8)

Grant, J., Jones, H., Kilminster, S., Macdonald, M., Maxted, M., Nathanson, B., & Owen, H. (2004) Overseas Doctors’ Expectations and Experiences of Training and Practice in the UK. Final Report to the Department of Health. Milton Keynes: Open University Centre for Education in Medicine.

Greer S L (2001) Divergence and Devolution. London: Nuffield Trust (available from www.nuffieldtrust.org.uk)

Greer S L (2005) The New EU Health Policy and the NHS Systems. London: Nuffield Trust (available from www.nuffieldtrust.org.uk)

Griffiths H (2002) EU’s proposed policies are unfair and unsafe 11, 19 1234

Grisold W, Galvin R, Lisnic V et al (2007) ‘One Europe one neurologist’ European Journal of Neurology 14: 241-247

Hall J (2005) Health care workforce planning: can it ever work? Journal of Health Services Research and Policy 10, (2) 55-56

Harding (2003) Foreign Legion HSJ 113, 5875 37-38

Hassell K (2003) National Workforce Census (4): Overseas Pharmacists: does the ‘globalisation of pharmacy affect workforce supply. Pharmaceutical Journal 271 183-5

Hassell K (2007) HSRN Annual Meeting: Power point presentation: A global healthcare workforce: emigration of British trained pharmacists

Hassell K, Nicchols L and Noyce P (2008) ‘Part of a global workforce: migration of British-trained pharmacists. Journal of Health Service Research and Policy 13 (2): 32. (2008)

HPCB (2007) Healthcare Professions Crossing Borders Portugal Agreement. London: Healthcare Professions Crossing Borders.

http://www.nuffieldtrust.org.uk/�

http://www.nuffieldtrust.org.uk/�


Home Office (2006) Accession Monitoring Report May 2004-June 2006

HOPE (2004) The Healthcare Workforce in Europe: Problems and Solutions. Brussels. Standing Committee of the Hospitals of the European Union (HOPE), Study Group on Workforce Issues.

Hunt B (2007): Managing equality and cultural diversity in the health workforce: Journal of Clinical Nursing 16 pp 2252-2259

Hutt R and Buchan J (2005) Trends in London’s NHS Workforce: An Updated Analysis of Key Data London: Kings Fund

ICN (2001) Ethical nurse recruitment: position statement. International Council of Nurses [Accessed 01/05/2006]. Available from: http://www.icn.org

Jalowiecki B, Jerzy Gorzelak, G (2004). Brain drain, brain gain and mobility: theories and prospective methods. Higher Education in Europe, XX1X (3), 299-308

Jinks C, Ong B, Paton C (2000) Mobile Medics? The mobility of doctors in the European Economic Area. Health Policy 2000, 54 (1): 4-5.

Kelly R, Morrell G, Sriskandarajah D (2005) Migration and Health in the UK. IPPR Factfile: IPPR London

Kidd L (2007) Roadmap (re. Green Paper on Health Professionals in Europe). Brussels: European Commission, Directorate General for Health and Consumer Protection.

Kingma M. (2007) “Nurses on the Move: A Global Overview“, Health Services Reseach 42:3 Part II, 1281-1298.

Krieger H (2004) Quality of life in Europe: migration trends in an enlarged Europe. European Foundation for the Improvement of Living and Working Conditions. Luxembourg: European Commission.

Larsen J A (2007) Embodiment of discrimination and overseas’ nurses’ career progression. Journal of Clinical Nursing 16 pp 2187-2195

http://www.icn.org/�


Larsen J, Allan H, Bryan K, Smith P (2005) Overseas nurses’ motivations for working in the UK: globalisation and life politics. Work, Employment and Society 19 (2) 349-368

Lee (1997) Learning from abroad: the benefits for nursing Journal of Nursing Management 5, 359-365

Leese B, Young B, Sibbald B (2002) Recruitment and retention of general practitioners in England: a survey of health authorities and directors of postgraduate GP education. Primary Health Care, Research and Development 3: 43–51

Magnusdottir H (2005) Overcoming strangeness and communication barriers: a phenomenological study of becoming a foreign nurse. International Nursing Review 52 pp263-269.

Mahon A and Harris C (2003) The European Working Time Directive and Doctors in Training: An early Evaluation of 19 Pilot Projects. London: Department of Health.

Mansoor A, Quillin B (2007) Migration and remittances: Eastern Europe and the former Soviet Union. Washington: The World Bank.

Mareckova M (2004) Exodus of Czech doctors leaves gaps in health care. Lancet 363 May 1st 1443-1446

Martell (2004) Adaptation woes. Frontline 1st September

Martineau T (2003) Ethical International Recruitment and Codes of Practice. Paper presented to the European Health Management Association (EHMA) Annual Conference, Caltanissetta, Sicily, June.

Martineau, T., Decker, K. & Bundred, P. (2002) Briefing note on international migration of medical professionals: levelling the playing field for developing country health systems. Liverpool: Liverpool School of Tropical Medicine (www.liv.ac.uk/lstm/hssrhome.html).

Masters P (2005) Working Out: Developing the London Physiotherapy Workforce. Report commissioned by the London Physiotherapy Managers’ Education Steering Group for South East London health Authority (SELHA).

Mathie T (2002) The Spanish acquisitions Health Services Journal December 2002

http://www.liv.ac.uk/lstm/hssrhome.html�


McFadden (2003) Inducting Doctors from EU into the NHS BMJ 327, 99

McIntosh T., Torgerson R. and Klassen N. (2007) The Ethical Recruitment of Internationally Educated Health Professionals: Lessons from Abroad and Options for Canada. CRRN Research Report.

McKendrick M (2005) The European Union of Medical Specialties core training curriculum in infectious diseases: overview of national systems and distribution of Specialists Clinical Microbiology and Infection 11 (Suppl. 1): 28–32

McLaughlin D (2005) “Doctors go west in Polish brain drain”, The Guardia, 15 May. http//www.guardian.co.uk/money/2005/may/15/workandcareers.europeanunion (Accesses 12/03/08).

Mead M (2003) Midwifery and the enlarged European Union Midwifery 19, 82-86

Mellor D (2003) Commentary: Recruitment is ethical. BMJ, 327, 928.

Mellor D (undated) Presentation on: The workforce challenge – managing migration and moving to self-sufficiency. (Provided through personal communication with DH).

Mesner (2004) Guten Tag Pet Health Services Journal 114, 5915 32-33

Moore (2002) First Team of Overseas Surgeons Arrives in England. BMJ, 325: 297

Narayanasamy A, White E (2005) A review of transcultural nursing. Nurse education Today 25, 102-111

NHS Employers (2005) List of Agencies adhering to Department of Health Code of Recruitment Practice for International Recruitment (Downloaded October 2005: http://www.nhsemployers.org/Workforce/list_of_agencies.asp?kh=agencies&smode=or)

NHS Employers (2006) Changes to the immigration rules for postgraduate doctors and dentists. [Accessed 18/07/2006]. Available from URL: http://nhsemployers.org/workforce/workforce-718.cfm

http://www.nhsemployers.org/Workforce/list_of_agencies.asp?kh=agencies&smode=or�

http://www.nhsemployers.org/Workforce/list_of_agencies.asp?kh=agencies&smode=or�

http://nhsemployers.org/workforce/workforce-718.cfm Accessed 18/07/2006�


NHS Modernisation Agency (2003) Changing Workforce Programme Pilot Site Progress Reports. London: NHS Modernisation Agency.

Nicholas S (2002) “Movement of Health Professionals: Trends and enlargement”. Eurohealth (Special Issue: Gateway to the European Union: Health and EU Enlargement), 8 (4), 111-12.

NMC (2005) Statistical analysis of the register: 1 April 1999 to 31 March 2005. London, Nursing and Midwifery Council.

Available at: http://www.nmc-uk.org/(uuy5xs55eafwo32331tzahfh)/aArticle.aspx?ArticleID=1588


Available at: http://www.nmc-uk.org/aFrameDisplay.aspx?DocumentID=3593


Available at: http://www.nmc-uk.org/aFrameDisplay.aspx?DocumentID=3600

NMC (2007) Applications from Nurses from Romania and Bulgaria. London, Nursing and Midwifery Council. Available at: http://www.nmc-uk.org

NNRU (2007). Nurses on the move: implications of internal migration in the UK. Policy Plus 3, Nursing Research Unit, Kings College London.

Northern Ireland (2005) Guidance on International Nurse Recruitment. Policy Guidance.

O' Brien T (2007) Overseas nurses in the NHS: a process of deskilling. Journal of Clinical Nursing 16 pp 2229-2236

O’Dowd A (2003) How will the UK cope with an influx of EU nurses? Nursing Times 99 (21) 10-11

OECD (2002) International mobility of the highly skilled. Paris: Organisation for Economic Co-operation and Development.

Omeri A, Atkins K (2002) Lived experiences of immigrant nurses in New South Wales, Australia: searching for meaning international. Journal of Nursing Studies 39 pp495-505

http://www.nmc-uk.org/(uuy5xs55eafwo32331tzahfh)/aArticle.aspx?ArticleID=1588�


http://www.nmc-uk.org/aFrameDisplay.aspx?DocumentID=3593�






Ong L (2003) Running an Induction course BMJ 326, S5 7379

Palese A, Barba M, Borghi G, Mesaglio M, Brusaferro S (2006) Competence of Romanian nurses after their first six months in Italy: a descriptive study. Journal of Clinical Nursing 16 2260-2271

Pawlak M (2004) Money is not the major factor BMJ Online response 2 June 2004

Petchey R, Needle J (2007) Helping Hands? The Allied Health Professions in Europe: a reconnaissance Seminar presentation for Nuffield Trust. June 2007

Petchey R, Needle J (2008) Helping Hands? The Allied Health Professions in Europe. Paper presented to the Workforce Special Interest Group of the European Health Management Association, EHMA Annual Conference, Athens, Greece, June.

Pitts J, Holloway J, Attwood M, Percy D, Kooij L (1998) Experiences and career intentions of general practice registrars from the Netherlands. Medical Education 32 613-621

Pond B, McPake B (2006):The health migration crisis: the role of 4 OECD countries Lancet 367 1448-1455

Pontin S (2002) Nurses from abroad should be welcomed British Journal of Nursing 11, 8 p530

Porter E, Powell G (2005) Recruitment of European Union general practitioners: developing a process for the analysis of English language training needs. Education for Primary Care 16: 31–5

Raghuram P, Kofman, E (2002) The state skilled labour markets and immigration: the case of doctors in England. Environment and Planning 34 2071-2089

RCN (2003) Internationally recruited nurses: Good practice guidance for healthcare employers and RCN negotiators. London: Royal College of Nursing.

Reid S (2002) Health professional migration: a call to action. Paper presented to the ARRWAG national conference, Adelaide, Australia, 24 April.


Robinson R (2007) The costs and benefits of health worker migration from East and Southern Africa: a literature review. Regional Network for Equity in Health in east and southern Africa (EQUINET). Discussion paper

Ross SJ, Polsky D, Sochalski J (2005) Nursing shortages and international nurse migration International Nursing Review 52: 253-262

Sales (2002) Bad Accent, Good Nurse. Nursing Times, 98 (44), 24-25

Santana, S. (1999) The experience of Spanish trainees in the UK (1986-1996): a tragedy in four acts. Hospital Medicine. 60 (1): 58-61.

Scepereel and Sondore (2002) ‘The evolution of human resource needs in Europe’ Best Practice and Research in Clinical Anaesthesiology 16 No 3 443-457

Scott H (2002) Nurses from EU may not have to register with NMC British Journal of nursing 11, 18 1172

Scottish Executive (2006) Code of Practice for the International Recruitment of Healthcare Professionals in Scotland. Edinburgh: Scottish Executive.

Sigler N (2007) Global health, justice and the brain drain: a trade union perspective. Address to Keele University Conference – September 2007

Simmgen M (2004) Why German doctors enjoy British medicine. Clinical Medicine 4 (1) 57-59)

Simoens S, Hurst J (2006) The supply of physician services in OECD countries. Paris, OECD (Health Working Paper No 21)

Simoens S, Villeneuve M, Hurst J (2005) Tackling nurse shortages in OECD countries OECD Working Paper No 19

Simon M, Hasselhorn H-M, Meuller B H, Tackenberg P, Buescher A and the NEXT Study Group (2005) NEXT – scientific results. www.next-study.net

Sloan J. (2005) “NHS Links: a new approach to international health links”, BMJ Careers. http://careers.bmj.com/careers/advice/view-article.html?id=680 (Accessed 22/02/08).

http://www.next-study.net/�

http://careers.bmj.com/careers/advice/view-article.html?id=680�

http://careers.bmj.com/careers/advice/view-article.html?id=680�


Smigelskas K, Starkiene L, Padaiga Z (2007) Do Lithuanian pharmacists intend to migrate? Journal of Ethnic and Migration Studies. 33 (3) 501-509

Smith P A, Allan H, Henry L W, Larsen J A and Mackintoch M M (2006) Researching Equal Opportunities for Internationally Recruited Nurses and Other Healthcare Professionals: Valuing and Recognising the Talents of a Diverse Healthcare Workforce. Report to the Royal College of Nursing and European Social Fund, University of Surrey and Open University.

Sorska M (2008) Personal communication regarding health professional out-migration from Hungary.

Stewart E (2005) Employment and Integration of Refugee Doctors in Scotland. Global Migration Perspectives No. 49. Geneva: Global Commission on International Migration (GCIM)

Szczudliñski W (2004) Real reasons BMJ Online response 2 June 2004

Taylor B (2005) Experiences of Overseas Nurses Working in the NHS: Results of a Qualitative Study. Diversity in Health/Social Care 2 17-27.

Taylor, DH. And Esmail, A. (1999) Retrospective analysis of census data on general practitioners who qualified in South Asia: who will replace them when they retire? BMJ. 318: 306-310.

UN (2004) UN World Economic and Social Survey of 2004

Van Lerberghe W, Conceicao C, Van Damme W and Ferrinho P (2002) “When staff is underpaid: dealing with the individual coping strategies of health personnel”, Bulletin of the World Health Organisation, 80 (7), 581-84.

Vork, Kallaste, Priniinits (2004) Migration Intentions of Health Care Professionals: the case of Estonia PRAXIS Centre for Policy Studies (Estonia) Online publication 21 June 2004

Wagner A, Seston L, Hassell K (2008) Distribution of the community pharmacist workforce. Bulletin No. 5. Centre for Pharmacy Workforce Studies, University of Manchester.

Waite R Buchan J Thomas J (1990) Career Patterns of Scotland’s Qualified Nurses. Scottish Office, Central Research Unit. Scottish Office, Edinburgh.


Wang L (2007) Eastern European pharmacists in the UK. The Pharmaceutical Journal 278 7-8

WHO (2006) The World Health Report 2006 – Working Together for Health. Geneva: World Health Organisation.

Winkelmann-Gleed A (2006) Migrant Nurses: Motivation, Integration and Contribution. Oxford: Radcliffe Press.

Winkelmann-Gleed A, Seeley J (2005) Strangers in a British world? Integration of international nurses. British Journal of Nursing 14 18 pp954-961

Winnett R (2008) Biggest brain drain from UK in 50 years. Daily Telegraph 26/02/2008

Winyard G (2007) Medical immigration: the elephant in the room. British Medical Journal, 335 593-595

Wiskow C (2006) Health worker migration flows in Europe: Overview and case studies in selected CEE countries – Romania, Czech Republic, Serbia and Croatia Sectoral Activities programme. International Labour Organization 2006

Wismar M, Busse R and Berman P (2002) “The European Union and health services – the context”. In Busse R et al (eds) The European Union and Health Services, Chapter. IOS Press.

Woolf A (2002) Specialist training in rheumatology in Europe Rheumatology 41 1062-1066

Xyrichis A and Ream E (2008) “Teamworking: A Concept Analysis”, Journal of Advanced Nursing. 61 (2), 232-241.

Young R, Leese B , Sibbald B (2001) “Imbalances in the GP labour market in the UK: Evidence from a postal survey and interviews with GP leavers”. Work, Employment & Society, 15 (4), 699-719.

Young, R., Noble, J., Hann, M. & Sibbald, B. (2003) The International Market for Medical Doctors: Perspectives on Positioning of the UK. Report submitted to the Department of Health, June. MCHM and NPCRDC, University of Manchester.


Young R, Noble J, Owen H, Mahon A, Grant G G, Hann, M, Swallow A, Maxted M, Grant J and Sibbald B. (2008a) International Recruitment into the NHS: Evaluation of Initiatives for Hospital Doctors, General Practitioners, Nurses, Midwives and Allied Health Professionals. Report submitted to the Department of Health, April. Florence Nightingale School of Nursing and Midwifery, King’s College, London; Open University Centre for Education in Medicine; Manchester Business School and NPCRDC, University of Manchester.

Young R, Noble J, Owen H, Mahon A, Grant G G, Hann, M, Swallow A, Maxted M, Grant J and Sibbald B. (2008b) Case Study Reports – Volume submitted as part of: International Recruitment into the NHS: Evaluation of Initiatives for Hospital Doctors, General Practitioners, Nurses, Midwives and Allied Health Professionals. Report submitted to the Department of Health, April. Florence Nightingale School of Nursing and Midwifery, King’s College, London; Open University Centre for Education in Medicine; Manchester Business School and NPCRDC, University of Manchester.

Zajac M (2004) Free movement of health professionals: the Polish experience. Health Policy and European Union Enlargement ed McKee M; MacLehose L and Nolte E Open University Press, Maidenhead UK.


Appendix 1 Study Methods

Literature Review

The initial phase of the project was a rapid literature review, specifically aimed at exploring European (including EU/EEA and wider-Europe) migration-related evidence and issues as they affect the UK. First, the literature gathered for a previous large scale project on international recruitment into the NHS (Young et al, 2008) was reviewed. Any literature specifically relating to Europe, EU and EEA was highlighted for use. A fresh literature search of English language publications from 1996 was then carried out to bring above mentioned search up to date.

The following databases were searched: Medline; Embase; British Nursing Index; Web of Knowledge; Health Management Information Consortium’ and SIGLE. The following search terms were used and combined:

Doctor/physician, clinician, nurse, midwife, practitioner, therapist, health professional, healthcare worker, physiotherapist, dentist, pharmacist, radiotherapist/radiographer

Migration, mobility, im(em)migration , recruitment

International, overseas, foreign, EU, EEA, Europe

The resulting hits (1116) and abstracts were examined for relevance.

The websites of a variety of organisations (and their regional/UK constituent country divisions where they exist) were also searched and follow-up telephone enquiries were made where appropriate - for example:

Professional regulatory bodies: General Medical Council (GMC); Nursing and Midwifery Council (NMC); Health Professions Council (HPC); General Dental Council (GDC); Royal Pharmaceutical Society of Great Britain (RPSGB)

Professional associations: British Medical Association (BMA); Royal College of Nurses (RCN); Royal College of Midwives (RCM); Chartered Society of Physiotherapists; Royal College of Occupational Therapy; Royal College of Speech and Language Therapists; British Dietetic Association; The Society and College of Radiographers etc

Government and European websites; Department of Health; European Commission (DG Health and Consumer Protection and DG Internal Market); European Health Management Association (EHMA); Standing Committee of the Hospitals of the European Union (HOPE) etc

Policy and academic websites: IPPR; Kings Fund; NHS Confederation; NHS Employers; European Observatory on Health Systems (WHO Europe); World Health Organisation (WHO) HR Division; International Labour Organisation (ILO).


In total 134 documents were analysed. These ranged from reports, journal articles, book chapters, commentaries, news items and seminar/conference presentations. 52 pieces of data focused specifically to the EEA/EU.

Semi-structured Interviews

In addition to gathering information from the literature, we interviewed key informants with responsibility for EU/international affairs and/or registration issues within the following organisations in early 2008 using the interview schedule outlined in Appendix 2.

Regulatory Bodies

General Medical Council

Nursing and Midwifery Council

Health Professions Council

General Dental Council

Royal Pharmaceutical Society of Great Britain (also acts as relevant professional association)

Professional Associations and Trade Unions

British Medical Association

Royal College of General Practitioners

Royal College of Nursing

Royal College of Midwives

British Dental Association

UNISON

Other

Department of Health (x2 Directorates)

Workforce Reviews Teams

NHS Confederation/NHS Employers

Policy Analysts e.g. on AHP mobility in the EEA

The intention was to get “expert” views in order to identify key migration trends and drivers within the different professions; views on the costs and benefits European mobility to the UK health system; and other key issues, in particular the professional and regulatory implications of European mobility/migration. Lastly, the interviews asked about whether there was any other relevant information or known research not already identified by the literature/websites review. The interviews (n=18) at UK level were primarily carried out face-to-face, with telephone interviews taking place in a small number of cases due to logistical necessity. We also consulted via email and/or telephone other relevant stakeholders (e.g. policy-makers; country level divisions of professional organisations etc) in England,


Scotland, Wales and Northern Ireland as appropriate. All interviews (except one where the participants did not wish to be recorded) were taped with permission, were fully transcribed, and analysed on the basis of key themes.

Review of Available Workforce Statistics

Finally, a desk-based review of available health professional workforce data was conducted. The information was gathered from a variety of sources including regulatory councils, professional bodies and employer organisations. Data reported in government and official reports and articles and presentations was also used. Initially, statistical data were collected whenever available as part of the initial literature and websites review. Subsequently, interview participants were asked for up-to-date information and any data they were willing to provide that was not in the public domain. The sorts of workforce statistics available included: the Hospital and Community Health Services (HCHS) and GP Principal and GP Registrar Censuses collated by the NHS Information Centre in England and ISD in Scotland (covering doctors), and application and/or registration data provided by the relevant registration/professional bodies for doctors, nurses/midwives, AHPs, dentists and pharmacists (e.g. GMC, NMC, HPC, GDC, RPSGB; Royal Colleges etc.).


Appendix 2 Interview Schedule Topics

The following is a summary of the topic guide for the interviews carried out with professional regulatory and representative bodies, employer organisations, policy makers etc:

Respondent’s role and organisation – Questions intended to position the organisation (and within it, the respondent) in terms of its role and level/sphere of influence around health professional migration/mobility (e.g. education/training; post-qualification employment; professional regulation; union/representative body etc). Also to get a general idea, at the outset, of key topics of interest from the respondent’s perspective. We are interested both in the present EU/EEA (potentially differentiating between the pre-2004 EU15 and the new members that joined in 2004 and subsequently 2007*) and what might be seen as the Wider Europe beyond the current EU/EEA borders from where more migrants may come in future.

Mapping health professional migration flows – Questions intended to locate the UK’s health professional labour market or the labour market for a particular professional group within the Wider European and global picture - both generally and over the time period of the UK’s policy of active international recruitment. For this we need a broad-brush picture of the overall significance of migration for particular UK countries and professional groups and the significance of migration to/from Europe versus that to/from other countries overseas. We are looking for a general overview - backed up by harder data if this exists (e.g. surveys/analyses in particular regions, specialties or amongst different health professional groups). N.B. Focus on all health professional groups or a particular group such as doctors or nurses (including individual specialties) as appropriate – e.g. depending on the interviewee.

Drivers and constraints to mobility – Questions intended to identify the main push and pull factors and the main constraints underlying migration to/from the different UK countries and Europe. This is at a number of levels – individual motivations for moving, UK employer organisations’ reasons for undertaking active recruitment and/or employing migrant health professionals, and policy/regulatory level drivers and constraints to migration. N.B. Focus on all professional groups or a particular group e.g. doctors or nurses (including individual specialties) as appropriate – e.g. depending on the interviewee. Examples of push/pull factors might be:

Country-level circumstances – RELATIVE: Economic situation - (un)employment, living standards; Socio-cultural


factors/changes – e.g. changing gender balance, attitudes to employment/family, flexible work availability, increased early retirement etc

Professional/Organisational-level circumstances – RELATIVE: Education/training/employment availability (numbers/competition for places; opportunities in particular specialties/ roles etc; status/portability of UK qualification to return to supply country, existence of oversupply versus shortages amongst different staff groups); Perceived quality of training/employment (e.g. working conditions/environment, resources; experience in the UK re quality of training/employment, discrimination, working with colleagues etc); Professional climate (degree of professional liberalisation/external control, state vs. private insurance fee structures, opportunities for increasing earnings through private practice etc.).

National/EU-EEA policy: - e.g. changing UK national policies regarding active recruitment from Europe and elsewhere; national attitudes/policies towards production/supply of health professionals and out-migration in source countries; EU policies in relation to education harmonisation, mutual recognition of training and qualifications, free movement; working conditions etc (e.g. Bologna Accord, Mutual recognition Directives, Working Time Directive etc)

Impact on the UK – Challenges and responses – Questions intended to explore the perceived impact of migration to and from Europe on for example: individual health professionals, employer organisations e.g. regarding human resource management, the service delivery and patient care context, regulatory bodies, and the UK’s health professional labour market as a whole (or that of the individual UK country). Section 4 is also intended to explore the MAIN responses(e.g. policy and regulatory) to the topics covered and to identify any key gaps in research/knowledge about the challenges and impacts (positive or negative) of health professional mobility within the UK and to from the UK (and individual UK countries) and Europe from the interviewee’s perspective.

Impacts on migrants and source countries and summing up – Questions intended to explore perceptions and evidence for any impacts on the individual migrants themselves and source countries within Europe. Relevant issues might be whether countries: a) benefit e.g. from remittance income coming into the economy; migrants returning with valuable additional skills and experiences which boost health service delivery etc.; or b) suffer because of e.g. the loss of investment in education and training is more than it can afford; the scale of health workforce depletion because numbers migrating are so large; the real risks that migrants do not return;


impact of workforce losses on ability to deliver health services; social problems resulting from children/families not seeing one or both parents for long periods. We also if possible want to ask about views on the efficacy of UK policy in relation to migrants and source countries; and to draw out any key conclusions about health professional mobility within the UK and to from the UK (and individual UK countries) and Europe from the interviewee’s perspective.

Appendix 3 Countries Covered by International Recruitment Code of Practice

Note: Countries highlighted in bold-underline are included in what, for the purposes of this report, we have termed Wider Europe.

Afghanistan Albania Algeria Angola Anguilla Antigua & Barbuda Armenia Aruba Azerbaijan Bahamas Bahrain Bangladesh Barbados Belize Benin Bermuda Bhutan Bolivia Bosnia &Herzegovina Botswana Brazil Burkina Faso Burundi Cambodia Cameroon Cape Verde Central African Republic Chad Chile Chinese Taipei Columbia Comoros Congo, Rep Cook Islands Costa Rica Cote d’Ivoire Croatia Cuba

Congo, Democratic Republic Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Ethiopia Fiji Gabon Gambia Georgia Ghana Grenada Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Iran Iraq Jamaica Jordan Kazakhstan Kenya Kiribati Korea, Democratic Republic Kyrgyz Republic Laos Lebanon Lesotho Liberia Macedonia

Madagascar Malaysia Malawi Maldives Mali Marshall Islands Mauritania Mauritius Mayotte Mexico Micronesia Moldova Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Nicaragua Niger Nigeria Niue Oman Pakistan Palau Islands Palistinian Territories Panama Papua New Guinea Paraguay Peru Rwanda Samoa Sao Tome & Principe Saudi Arabia Senegal

Seychelles Sierra Leone Solomon Islands Somalia South Africa Sri Lanka St Helena St Kitts and Nevis St Lucia St Vincent & Grenadines Sudan Suriname Swaziland Syria Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks & Caicos Islands Tuvalu Uganda Uruguay Uzbekistan Vanuatu Venezuela Vietnam Virgin Islands Wallis and Futuna Yemen Yugoslavia Zambia Zimbabwe


Philippines: A Memorandum of Understanding was signed to enable the UK to recruit registered nurses and AHPs.

China: Asked to be removed from this list but requested that no recruitment should take place in small rural areas.

India: Agencies could recruit all types of healthcare professionals, but not from the States of Andhra Pradesh, Madhya Pradesh, Orissa and West Bengal.

South Africa: Agreement focused on sharing expertise e.g. through time-limited placements of healthcare staff.

Indonesia: Memorandum of Understanding signed. Downloaded October 2005 (plus subsequently annotated) from: http://www.nhsemployers.org/Workforce/list_developing_countries.asp?kh=developing%2Bcountries&smode=or

http://www.nhsemployers.org/Workforce/list_developing_countries.asp?kh=developing%2Bcountries&smode=or�



Appendix 4 Glossary of Terms

AHP(s) Allied Health Professional(s) – including physiotherapy, occupational therapy,

speech and language therapy, dietetics, psychology, psychotherapy, radiotherapy, podiatry, orthoptics, prosthetics and orthoptics, paramedics and arts therapies.

Developing country

Defined for our purposes as those from which the DH stated active recruitment should not take place – The list is reproduced in the report Appendix. See also: http://www.nhsemployers.org/Workforce/list_developing_countries.asp?kh=developing%2Bcountries&smode=or

CEE countries Central and East European countries – in this report CEE is generally used to refer to those CEE countries already in the EU/EEA (i.e. Czech Republic; Estonia; Hungary; Latvia; Lithuania; Poland; Slovakia; Slovenia) and/or others in what we have termed Wider Europe (e.g. Belarus; Ukraine; Georgia, the states of the former Yugoslavia etc).

EU15 European Union – Until 2004, the EU’s 15 members included: Austria, Belgium, Denmark, Finland, France, Germany, Greece, Ireland, Italy, Luxembourg, Portugal, Spain, Sweden, The Netherlands, and the United Kingdom.

EU12 In 2004 a further 10 countries (Cyprus, Czech Republic, Estonia, Hungary, Latvia, Lithuania, Malta, Poland, Slovakia, Slovenia) joined. They have since been followed by Romania and Bulgaria in 2007, though these countries have not yet shared the same labour movement rights as other members. Together these 2004 and 2007 joiners make up the EU12.

EU27 Together the EU15 and EU12 are referred to as the EU27

EEA European Economic Area (a broader grouping of countries including all EU27 member states, plus Iceland, Norway, Liechtenstein and Switzerland that are also covered by mutual recognition and free movement arrangements).

GMC General Medical Council – responsible for general professional registration of doctors; and for administration of the PLAB exams for overseas doctors to come to the UK (there are additional arrangements for subsequent specialist and general practice registration).

GDC General Dental Council - Responsible for professional registration of dentists. HPC Health Professions Council – responsible for professional registration of AHP

groups. HRH Human Resources for Health (umbrella term for all groups of health professional

including doctors, nurses, midwives AHPs, pharmacists, dentists and others). IMG International Medical Graduate (used as umbrella term for migrant doctors; an

alternative used in the literature is FMG or Foreign Medical Graduate). ING International Nursing Graduate (used as umbrella term for migrant nurses; an

alternative used in the literature is FNG or Foreign Nursing Graduate). IHP International Health Professional (used in this report as an umbrella term for

migrant doctors, nurses, AHPs, pharmacists and dentists (i.e. includes IMGs and INGs, plus other individuals originally qualified in EU/EEA and elsewhere overseas).

Overseas Umbrella term used in the UK to refer to health professionals with qualifications from outside the EU or EEA (i.e. from non-EU/EEA countries), not automatically covered by mutual recognition arrangements.

NMC Nursing and Midwifery Council - Responsible for professional registration of nurses (generalist and specialist) and midwives

RPSGB Royal Pharmaceutical Society of Great Britain - Responsible for professional registration of pharmacists.

Wider Europe For the purposes of this report, we have defined Wider Europe as those countries beyond the current EU/EEA’s eastern and southern borders (e.g. Ukraine, Belarus, Georgia and other former states of the Soviet Union; Serbia, Croatia and other states that emerged from the former Yugoslavia; and Turkey) that are increasingly looking to link with the EU/EEA economically.



This document is an output from a research project that was commissioned by the Service Delivery and Organisation (SDO) programme, and managed by the National Coordinating Centre for the Service Delivery and Organisation (NCCSDO), based at the London School of Hygiene & Tropical Medicine.

The management of the SDO programme has now transferred to the National Institute for Health Research Evaluations, Trials and Studies Coordinating Centre (NETSCC) based at the University of Southampton. Although NETSCC, SDO has conducted the editorial review of this document, we had no involvement in the commissioning, and therefore may not be able to comment on the background of this document. Should you have any queries please contact [email protected].

Disclaimer: This report presents independent research commissioned by the National Institute for Health Research (NIHR). The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the NHS, the NIHR, the SDO programme or the Department of Health.

health professional mobility in europe and the uk: a scoping study

Documents