Memorandum by the Royal College of Nursing
1.0 Background
1.1 The Royal College of Nursing (RCN) welcomes
the opportunity to provide written evidence to the Committee.
The impact of immigration with respect to the provision of healthcare
services in the UK is very important. The RCN is well placed to
comment on the workforce implications and significant contribution
of internationally recruited nurses specifically questions 1,
2 and 12. The RCN is not well equipped to determine with a high
degree of accuracy the impact of immigration on the use of health
care services.
2.0 About the RCN
2.1 With a membership of almost 400,000
registered nurses, midwives, health visitors, nursing students,
health care assistants and nurse cadets, the RCN is the voice
of nursing across the UK and the largest professional union of
nursing staff in the world. RCN members work in a variety of hospital
and community settings in the NHS and the independent sector.
The RCN promotes patient and nursing interests on a wide range
of issues by working closely with the Government, the UK parliaments
and other national and European political institutions, trade
unions, professional bodies and voluntary organisations.
3.0 What are the numbers and characteristics
of recent immigrants? What are the expected future trends?
3.1 Looking specifically at immigration
in relation to the nursing workforce in the UK. Between 1997 and
2005, the NHS registered nurse workforce expanded by 23% across
the UK. This was achieved through a combination of increased nurse
training, international recruits and more temporary staff. International
recruitment has made a significant contribution to meeting nurse
staffing growth targets in the UK—since 1997 more than 90,000
international nurses have registered in the UK (around 45% of
all new entrants to the UK register).[4]
3.2 The Nursing and Midwifery Council (NMC)
UK register shows that in terms of admissions in the year to 31
March 2006 there were 1,753 new registrants from the European
Economic Area (including 764 admissions from EU accession countries).
The major source of non-UK trained nurses, however, is from outside
of the European Economic Area with the majority of admissions
coming from the Philippines, Australia, India and South Africa.
The total admission for these "Overseas" trained nurses
(IRNs) for the year ending 31 March 2006 was 8,709.[5]
3.3 The particular challenge for nurses
trained in European accession countries is that their training
is not always deemed to be sufficient to meet registration requirements
within the UK. This does not necessarily stop these nurses working
in the UK, as many may take on Senior Carer (non-registered) roles
such as in care homes. As this workforce is not required to register
with a professional body, there is no comprehensive data on the
impact that migration may have on this element of the labour market.
3.4 In terms of the migrant labour market,
the "Holding On" survey found that IRN respondents are
more likely than UK qualified nurses to hold degrees (36%) and
are less likely to have no academic qualification.[6]
Research also indicates that nurses who qualified and first registered
overseas are younger than their colleagues who first registered
in the UK, with an average age of 37 compared to 42 years.[7]
3.5 The "Holding On" survey also
indicates that larger proportions of IRNs consider their pay to
be inappropriate to their role and responsibilities. Though there
is a higher proportion of IRNs (21%) who say they do not know
whether or not their grade is appropriate or not, compared to
just 6% of white UK qualified nurses.
3.6 IRN respondents are also more likely
to work full-time (97%). In contrast 59% of UK qualified white
respondents work full-time and 80% of UK qualified BME. The total
average hours worked by IRNs is 47.7 hours, while UK BME nurses
work on average 46.6 hours and UK trained white nurses work 42.9
hours on average.
3.7 The removal of Band 5 and 6 from the UK
work permits shortage list
3.7.1 In terms of future trends the majority
of IRNs especially those who are black and ethnic minorities are
found in jobs equivalent to Bands 5 (covers newly qualified nurses
and staff nurses) and 6 (covers Clinical nurse specialists and
team leaders) on the NHS pay scales.[8]
Given the removal of Bands 5 and 6 from the UK work permits shortage
list 2006, we would now expect the 3.7.2 pattern of NMC registrations
to change, with a drop in "overseas" nurse admissions.
It is, however, unclear as to whether the loss of these nurses
will be replaced by an increase in nurses from the EEA.
3.8 Challenge of outward migration
3.8.1 The NMC register not only shows the
inflow of nurses into the UK, but it also shows the "outflow"
of nurses from the UK to other countries, as measured by NMC verifications,
has risen in recent years. The UK "loses" nurses to
Australia, New Zealand, Canada, the USA and Ireland. In 2005-06
the NMC provided verifications for 7,800 nurses looking to work
outside of the UK. There is an impending global nursing shortage
and the likelihood is that there will be an increased trend towards
outward migration of nurses from the UK.
3.8.2 In addition to this "outflow",
the nurse labour market, also, is being affected by the increase
in nurses taking retirement—180,000 nurses are likely to
retire some time over the next ten years. The Nurse labour market
within the UK is ageing steadily in 1995 the average age of nurses
responding to the survey was 37 in 2007 it is 42. The RCN survey
"Holding On" also shows that there is a higher age profile
in community nursing and nurses working in care homes.
4.0 In what sectors and occupations are immigrants
employed? How do migrant's labour market outcomes compare to those
of local workers?
4.1 In terms of the nursing workforce there
are clear divisions in relation to migrant workers and UK trained
nurses in terms of qualifications and pay. The RCN's "Holding
On" survey shows that IRNs are making a significant contribution
to the Care Homes sector with 25% of Care Home respondents coming
from overseas (a higher proportion than any other employer group).
While the results from the 2007 survey of Independent Sector nurses
indicates that IRNs working in the Independent Sector (especially
in care homes) are more likely to hold a degree or diploma than
UK qualified nurses working in the Independent Sector.[9]
4.2 We also know from RCN surveys that Independent
Care Homes traditionally pay staff on lower grades compared with
all other employers. Data available in the surveys show that there
has been a downward shift in the grades at which care-home staff
are paid, with a larger proportion of respondents in this sector
being paid on lower grades. For example, in the current Report
on Independent Sector Nurses, 50% of care home respondents stated
that they were paid on a clinical grade equivalent to Grade D
(the basic grade for a registered nurse—equivalent to a
Band 5 in the NHS pay system). In 2005 this figure was 38% and
in 2001 it was 25%. This would seem to represent a marked shift
in grading. Among the IRNs who gave a clinical grade, 84% are
employed on Grade D compared with 31% of UK qualified nurses.
4.3 During this same period, in the Independent
Sector, there has also been a significant increase in the proportion
of nurses working full-time; from 55% in 2001, to 64% in 2005,
and 68% in 2007. In Care Homes there has been a more significant
shift with 77% working full-time in 2007 compared with 63% in
2001.
4.4 This increase in numbers of Independent
Sector nurses working full-time has been primarily linked to the
increased number of IRNs working in the sector, the majority of
whom are working full-time. Almost two-thirds (65%) of IRNs in
the Independent Sector worked more than their contracted hours
in their last full working week.
4.5 The report "Black and minority
ethnic and internationally recruited nurses" does indicate
differences between BME IRNs and White IRNs. BME IRNs are much
more concentrated in the lower grades (64% compared with 36%);
are more likely to work full-time (90% compared with 81%), and
are more likely to work internal rotation (61% compared with 48%)
and permanent nights (13% compared with 0%). BME IRNs are also
much less likely than white IRNs to be given continuing professional
development (CPD).
4.6 Despite more IRNs working full-time
and for longer hours, more also have second jobs (26% compared
with 19% of UK qualified nurses). Taking all work into account
full-time IRNs on average work a total of 52 hours per week compared
with 45 hours amongst UK qualified nurses.
5.0 Does immigration fill skills gaps? What
is the relationship between government migration policies and
labour market policies?
5.1 One of the reasons that active international
recruitment has been so attractive to policy makers in the UK
is that it offers the possibility of a "quick fix"—the
nurses are trained elsewhere at someone else's expense, and can
be recruited and working in the UK within a few months, not the
four years it would take to commission and train a UK educated
nurse. The rapid nature of the policy response can work both ways,
if and when funded demand for nurses in the UK falters or reduces,
the numbers of international recruits can also be reduced, virtually
overnight.
5.2 Indeed, international "inflow"
is now reducing markedly as a result of NHS funding difficulties
and the removal of band 5 and 6 nursing posts from the work permits
national shortage occupation list.
5.3 One of the RCN's concerns in relation
to the removal of Band 5 and Band 6 nursing posts from the Work
Permits UK shortage list, is that employers can only recruit overseas
nurses in to nursing posts at Band 5 and 6 if they can show there
are no suitable UK or EU applicants. Given that most of the UK's
international nurses come from outside the EU this impacts a significant
minority of the workforce and is likely to have a disproportionate
impact on the Care Homes sector.
5.4 The RCN has criticised the decision
to remove Bands 5 and 6 approach from a workforce planning perspective,
as it was not based on detailed evidence of future staffing requirements.
The RCN is concerned that it may become difficult for internationally
recruited nurses already in the country to renew their visas,
although Work Permits UK has assured us that providing there is
no change in the Band, the new arrangements should not restrict
renewal. We would also not want the policy to act as a deterrent
to employers to invest in training and development for these nurses
or to block their career development. Further to this, however,
the RCN is concerned that IRNs already employed, will now be
restricted in movement across employer groups. This restriction
on movement is especially of concern, where IRNs may be exploited
by individual employers.
5.5 When asked about staffing levels and
workloads there are some significant differences between IRNs
working in the independent sector and UK qualified nurses. For
example, 65% of IRNs say that their workload is too heavy compared
with 42% of UK qualified nurses, 59% of IRNs say they feel under
too much pressure at work compared with 41% of UK qualified nurses.
5.6 Given the research findings, which have
been described in this paper, it may not be surprising to find
that twice as many IRNs (40%) are seeking a change of work as
UK qualified nurses (20%) and most are wanting to move to the
NHS (67%) compared with 44% of UK qualified nurses.
6.0 RCN recommendations on migration
— Targeting IRNs can only be a short-term
solution to domestic shortages, but decisions on limiting migration
should only be made with comprehensive workforce information.
— Large scale recruitment requires
agreement on how to manage the process between the UK, the source
country and the professional nursing association of the source
country without prejudice to the health care systems of any countries.
— That employment of IRNs should be
on the same basis as those staff trained in the UK. They should
have access to the same pay, terms and conditions and a decent
and healthy working environment as those trained in the host country.
— That there is fair and transparent
contracting. Workers and employers need to be protected from false
information, misleading claims and exploitation.
— That employers only sign up to recruitment
agencies, which are committed to ethical treatment of workers.
— That systems and resources are put
in place to recruit, induct, and support suitably qualified nurses
with good language skills.
— That they should also have freedom
of association—all workers should have the right to affiliate
to a trade union and/or a professional association in order to
safeguard their rights as workers and professionals.
18 November 2007
4 Buchan J (2006) "From Boom to Bust?" The
UK Labour Market Review 2005-06 RCN London Back
5
The Nursing and Midwifery Council, Statistical analysis of the
register 1 April 2005 to 31 March 2006 Back
6
Ball J & Pike G, Holding On: Nurses' Employment and Morale
in 2007, RCN London. Back
7
Ball J & Pike G, Black and minority ethnic and internationally
recruited nurses-Results from RCN Employment/Working Well Surveys
2005 and 2002, RCN London Back
8
Ball J & Pike G, Black and minority ethnic and internationally
recruited nurses: Results from RCN Employment/Working Well Surveys
2005 and 2002. Back
9
Ball J & Pike G, Independent Sector Nurses in 2007-Results
by sector from the RCN annual Employment Survey 2007, RCN London. Back
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