Positive Health Online

Despite years of anti-immigration policy and rhetoric from the government, foreign workers continue to play a critical and highly-valued role in the provision of UK healthcare services, as Anne Morris explains. While the UK economy as a whole continues to face critical skills shortages, the consequences of staffing problems are no more perilous than within healthcare, where patient safety and care standards are heavily influenced by the quality and availability of skilled professionals.

But recent workforce data makes for alarming reading. There were a record 132,139 vacancies in the NHS at the end of June 2022, equating to 10% of its planned workforce.

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The Workforce: recruitment, training, and retention in health and social care report published in July 2022 by MPs from the cross-party health and social care committee highlighted the “greatest workforce crisis in the history” of the NHS. The committee noted shortfalls of 12,000 hospital doctors and of more than 50,000 nurses and midwives, as well as a fall in GP numbers of 700. The report projects a further 475,000 jobs will be needed in health and an extra 490,000 jobs in social care by the early 2030s.

In its damning conclusion, the committee states persistent understaffing in the NHS is creating a serious risk to patient safety and the government has no credible strategy to make the situation better.

To address the issues, the committee puts forward specific recommendations aimed at improving the recruitment and retention of healthcare professionals. These include increasing medical school places by 5,000 from 9,500 to 14,500 a year; publishing full workforce projections for the next 5, 10 and 15 years by the end of this year; offering international medical graduates indefinite leave to remain on completion of GP specialty training; and taking into account the flexible working trend in workforce planning and reviewing affordable and flexible childcare, among others.

A Department of Health and Social Care spokesperson responded to the report, saying: “We’re boosting our home-grown recruitment – including by opening five new medical schools and providing a 25 per cent increase in funding for medical school places over three years to 2020, with the first graduates from this cohort entering foundation training this year.

“Internationally trained staff have been part of the NHS ever since its inception and they continue to play a vital role in helping us tackle the Covid backlogs. We have recently signed bilateral agreements with countries like India, Philippines, Kenya, Malaysia and Sri Lanka to support the recruitment and training of nurses.”

Hostile Environment or Warm Welcome?

Overseas recruitment is nothing new within UK health; internationally recruited professionals have worked within the NHS since it was established in 1948.

Figures from NHS Digital show the share of healthcare staff recruited from overseas almost doubled between 2014 and 2021, according to an analysis by the BBC, with 34% of doctors joining the health service in 2021 coming from overseas – a rise from 18 per cent in 2014.

However, Theresa May’s tenures as Home Secretary and as Prime Minister were in good part characterized by policies aimed at creating a 'hostile environment' for foreign nationals. This, together with the Brexit vote that ended EU free movement, effectively saw a period when government policy was used to quash the appeal of the UK among foreign nationals and to make it harder to secure a visa through stringent process and eligibility requirements.

But the post-Brexit and post-Covid landscape has brought extensive and worsening labour shortages. And regardless of its stated position or stance on immigration, it seems the government has recognised the scale of the crisis facing the healthcare sector and has moved to implement measures to provide some relief by making it easier for foreign healthcare workers to come to the UK.

In August, Steve Barclay, the then-Health Minister, instructed an international taskforce to help bring in foreign workers on a “mass scale”, as the health service struggles to fill vacancies and in advance of the winter season when services come under even greater pressure.

This drive is in addition to existing recruitment activity which is already helping to support staffing in the sector.

NMC data published in the summer showed a significant rise in the number of professionals joining the register for the first time last year. And almost half – 23,444 – had trained outside the UK, which is 135% more than the previous year’s 9,962 international joiners.

Health & Care Worker Visa

As part of the UK’s post-Brexit immigration reforms, at the end of 2020, the Tier 2 (General) visa was closed and replaced by the Skilled Worker visa and, specifically for healthcare workers, the Health and Care Worker visa.

The Health and Care Worker visa is a points-based route for healthcare professionals from across the world to work in the UK. It allows visa holders to stay here for up to 5 years and to be joined by their immediate family, such as their spouse or partner, and any dependent children.

To attract foreign healthcare workers, the visa provides fast-tracked processing, a dedicated UKVI application support team, reduced application fees and exemption from the Immigration Health Surcharge. It can also lead to UK Indefinite Leave to Remain.

The visa is open to qualified doctors, nurses, health professionals and adult social care professionals within certain qualifying occupations using the corresponding Standard Occupation Code. The list of eligible professions is subject to change. Examples of current eligible roles include psychologists, pharmacists, ophthalmic opticians, podiatrists, therapy professionals that are ‘not elsewhere classified’, such as osteopaths and psychotherapists and health professionals that are ‘not elsewhere classified’, such as audiologists and occupational health advisers. This is a broad range, reflecting the extent of the recruitment need within the sector..

However, healthcare professionals can only be employed in the UK under this route by a licenced sponsor. This means the employer has been granted a sponsor licence by the Home Office to hire Health and Care Workers. The employer must also either be an NHS body or trust, a medical services provider to the NHS, an organisation providing adult social care, or one of several other medical and social care organisations listed in the official guidance such as the General Chiropractic Council, General Osteopathic Council or Nursing and Midwifery Council (NMC).

In practice, some of the more challenging requirements for applicants to meet relate to English language and financial maintenance. The worker must be able to demonstrate English language ability in all four components (reading, writing, speaking and listening) to at least level B1 (intermediate), unless they are exempt, for example, because they are a national of a majority English-speaking country.

They must also have funds of at least £1,270 available to show they can support themselves in the UK. Applicants are exempt from the financial requirement if they have been in the UK lawfully for at least 12 months prior to applying. 

They will also have to provide a criminal record certificate from any country where they have lived for 12 months or more within the last 10 years, if working with vulnerable people as a healthcare professional.

Professionals who do not meet the requirements for the Health and Care Worker visa may opt to apply under the Skilled Worker route, as there are fewer stipulations as to the type of organisation that can sponsor workers.

Applicants must also be paid at least £20,480 a year unless the relevant ‘going rate’ for the job is higher. The ‘going rate’ is set by the applicable occupation code and NHS pay bands where relevant. Applicants can only be paid less than the ‘going rate’ if the job is on the shortage occupation list.

Shortage Occupation List

The UK Shortage Occupation List (SOL) specifies the skilled jobs deemed by the government to be in short supply within the UK labour market. Applicants for roles on the SOL benefit from relaxed visa rules and lower visa costs to make it easier and more attractive for those with the required skills and experience to come to the UK.

In practical terms, if a job is on the list, the worker can be paid 80% of the job’s usual going rate to qualify for a Skilled Worker visa or Health and Care Worker visa.

Interestingly, there is a specific, separate list for healthcare and education roles, which in itself is indicative of the extent of the sector’s skills shortages. Currently, the list includes healthcare jobs in a broad range of roles, from ‘medical practitioners’ to ‘health professionals not elsewhere classified’.

The SOL is subject to review, as the Home Office responds to changes in the labour market. Most recently, carers were added to the list in February 2022. Previously, carers had not been deemed to meet the skills threshold, but critical shortages of carers post-Brexit and post-pandemic saw the role added. As it stands, this will be the case until February 2023, meaning carers can only be sponsored until then. However, clarification is awaited from the Home Office on whether this will be extended or any other changes will happen, such as removing carers from the list altogether. If the Home Office does remove carers from the list, this should not affect extensions of existing migrants already in the route.

One area of focus could be to ensure overseas recruitment is open to and effective for the full breadth of roles. According to NMC analysis, the majority of foreign workers are registering with the organization as adult nurses, meaning few professionals are joining the register as children’s, mental health or learning disabilities nurses. This suggests a need to broaden the impact and take up of overseas recruitment across the full skills need.

Ethical Recruitment and Retention

While reliance on overseas recruitment in healthcare looks set to continue, related issues arise about the ethics of bringing talent to the UK, and in doing so taking it away from other countries, and about how foreign workers are treated once they are working in Britain. 

In August 2022, the Department of Health and Social Care amended its Code of practice for international recruitment of health and social care personnel. The Code provides the guidelines that health and social care employers and recruiting firms must adhere to in order to promote efficient, ethical international hiring. The latest version is intended to strengthen best practice including establishing of principles on the use of repayment clauses in employment contracts and outlines the routes of escalation for concerns about exploitative recruitment or employment practices and breaches of the code.

In practice, the code prohibits “active international recruitment from countries on the red list” in the absence of any explicit government-to-government agreement. However, NMC data analysis published in August 2022 shows “Of the top 20 countries of training, four – Nigeria, Ghana, Nepal and Pakistan – were on the World Health Organisation’s ‘red list’ in 2021–2022. This means active recruitment wasn’t permitted from these countries in line with the Department of Health and Social Care (DHSC) Code of practice for the international recruitment of health and social care personnel in England. The Code doesn’t stop individual professionals from seeking employment independently.”

A further consideration for employers is support and retention of their migrant workforce, through effective inclusion and diversity practices that help avoid cultural divisions within organisations, while also maintaining high standards of patient care through adequate support and training. On this point, the NMC is currently developing a new workshop for professionals and employers called, ‘Welcome to the UK Workforce’.

Looking Ahead

While medium to long-term solutions to resolve recruitment and retention issues in the domestic labour market take time to embed and have impact, overseas recruitment continues to provide the lifeline for UK healthcare in addressing the ongoing labour crisis. Indeed, according to recent reports, Liz Truss is planning to open up immigration further to address ongoing shortages and fill vacancies. In which case, we may see relaxations of work visa routes relevant to healthcare roles.