Comment / The nursing target and the case for international recruitment

In the two years since the election, the number of nurses working in hospital and community services or general practice has increased by 22,129 or just over 7%. Or if you start counting from September 2019, two months before the election (as the government is doing) then the increase is 27,003.  A rise of this scale is admittedly impressive and historically high without being totally unprecedented: in the two years to September 2002, the numbers of qualified nursing staff increased by around 24,300.

While increases are welcome and it is important to recognise the endeavour that has gone in to delivering them, those working in general practice or learning disability services will not be feeling so positive given numbers in these areas have actually fallen. Similarly, there are also regional variations with the North East and Yorkshire seeing the lowest growth and South East leading the pack.

The government’s programme for delivering against this target is split into three broad areas: domestic recruitment, retention of existing staff and international recruitment.  On the former – our homegrown supply – the numbers are, to a certain degree, now baked in. While efforts can be made to increase the proportion of students completing their nursing course and joining the NHS, current first-year undergraduates will not qualify in time to count towards the 2024 target.

Improving retention – that is trying to keep existing nurses in the NHS who would otherwise have left – is undoubtedly important. Leaver rates for nurses – as with most healthcare professions – were low during the pandemic, but appear to have returned to pre-pandemic levels. In the year to September 2021, one in 10 nurses left active service, which includes those going on maternity leave or a career break. Predicting future retention is difficult and indeed the government itself has recognised that this element of its programme has greatest ‘uncertainty’ and ‘complexity’, so we cannot bank on this being the golden bullet.

Typically, the balancing figure for the nursing equation is international recruitment. The registered nurses currently living in England were trained in 141 different countries and nearly one in five (and rising) nurses in NHS hospital and community services are overseas nationals. Given its importance, the Nuffield Trust has looked at the return on investment of this supply route.

We found that compared with nurses of UK nationality, those from outside the UK or EU (with the largest numbers coming from India and the Philippines) are more likely to remain in the NHS as a whole and in the same organisation. They are also contracted, on average, to work more hours. This analysis underlines overseas nurses’ contribution, but needs to be interpreted carefully. For example, higher levels of participation could potentially be due to overseas staff not being offered, or feeling as confident in requesting, more flexible arrangements.

There can be considerable upfront costs in recruiting a nurse from overseas – likely to be around £10,000 to £12,000. However, this only equates to around £1,000 per year or 3% of the mean annual nurse salary, if considered over the typical average NHS career of a nurse from outside the EU. These upfront costs also need to be considered in the context of costs of domestic training. This training is expensive for the public purse if not directly for the trusts that eventually employ them.

These upfront costs and administrative burdens mean general practice and smaller, non-acute services will likely need support if they are to benefit from such inwards migration; perhaps this is an early litmus test on the effectiveness of integrated care systems.

It is also expensive to use temporary staff to fill vacancies. The cost premium varies significantly depending on agency and bank rates. However, we estimated it would take six months to two-and-a-half years for the agency and bank option to prove more expensive, with breakeven likely to fall at the later end of the range.

Of course, the UK is not the only country looking to recruit from overseas. And there are a number of areas that the NHS needs to focus on to ensure it is an attractive option. These include the ability to act fast – with many accepting their first job offer – and ensuring the NHS is perceived in a positive light given the feedback loops between current and potential future overseas nurses.

Indeed, there is certainly much to consider in delivering this goal. And is 50,000 enough? Well that’s a debate for another time.