Examination of Witnesses (Questions 300
- 314)
TUESDAY 27 NOVEMBER 2007
Dr Edwin Borman, Ms Josie Irwin, Ms Lesley Rimmer
and Mr Colin Angel
Q300 Chairman:
I just wonder whether the BMA and Home Care could both give us
their view on these issues.
Dr Borman: There are some differences which
are significant between our nursing colleagues and ourselves in
the medical profession. With regard to question one, it is important
to lay out one fundamental difference which is that the vast majority
of doctors working in the National Health Service are employed
on national terms and conditions of service, which means that
the direct financial incentive of recruitment and the economic
argument in terms of salaries do not apply. What does apply, however,
in terms of NHS or UK PLC is that these migrants are carrying
their primary qualifications and their expertise to the United
Kingdom effectively for free. It costs in the order of—these
are BMA figures—a quarter of a million pounds to qualify
a doctor within the United Kingdom medical school system and,
clearly, having a doctor who has qualified abroad, bringing those
qualifications means a net gain to the United Kingdom. Another
significant difference is with regard to question two where the
history of the National Health Service effectively describes a
model of reliance on migration. It is very readily arguable that
the United Kingdom never has qualified sufficient doctors from
its own medical schools to fulfill domestic need and has relied
for at least 50 years on migrants coming from abroad and bringing
those skills with them. I would argue that the fact we now have
38% of registered doctors in the United Kingdom who have a primary
qualification from abroad is a clear indication of an implicit
policy of reliance on doctors who have migrated. In terms of the
long-term issue and question two, I would suggest that there is
a very ready answer that yes, it is possible to rely on that.
Of course, the question that would then follow is: is that the
correct thing to be doing?
Ms Rimmer: I should like to start by saying
that there is totally inadequate evidence on the use of migrant
workers in social care. The UKHCA represents independent sector
providers of domiciliary care services, providing care to people
in their own homes. The National Minimum DataSet (NMDS), produced
by Skills for Care, does not cover the area of migrant workers
and, as far as we understand it, has no plans to do so. Therefore,
to assist the Committee, we undertook a very—if you will
excuse the phrase—quick and dirty survey of our members
to try to glean some evidence. We had 127 responses, which was
a 10% response rate, and found out that overall 20% of the workforce
is made up of migrant workers with significant variations: 40%
in London, 15.6% outside London. To the question about whether
it is a reflection of pressures on labour costs, the answer is
frankly yes. The main pressure is to meet the demand for care
services which exceeds supply. But there are huge downward pressures
on prices from the main purchasers, the local authorities, seeking
efficiency savings to meet their own budgetary targets and to
maximise the care they provide from their budgets. This is reflected
in the low level of pay for care staff. Our survey shows that
79% of providers report a shortage of willing workers from the
local population and 61% a shortage of skilled workers with the
appropriate skills. Two thirds of employers say it is difficult
or impossible to recruit locally at current pay rates and these
pay rates are primarily a reflection of what councils are willing
to pay since they make up 80% of the purchasers of care services.
You asked us about whether this is a long-term or short-term issue.
We would say that the long-term solution lies in better pay and
conditions for social care workers, resulting from a rise in the
status of social care as an occupation and recognition of the
skills that it involves in caring for increasingly frail, highly
dependent people in their own homes. Given the demographic pressures
of which we are all aware, the existing unmet need, along with
increasing private purchase, we believe there will be a long-term
need for migrant workers in this sector if capacity is to keep
pace with demand.
Q301 Lord Paul:
A significant number of UK-trained nurses go abroad to work. What
is the reason for that and how does it relate to the migrant nurses
who come to work here?
Ms Irwin: I said in one of my earlier comments
that we are beginning to see a shift in the balance between the
number of nurses coming into the UK from other countries and the
number of nurses leaving the country. Unfortunately, there is
not a huge amount of data around which actually assesses the reasons
for nurses wanting to work in countries other than the UK. Nurses
migrate for a variety of reasons. What we do have in the form
of the RCN's own employment survey, which is something which is
referenced in our written evidence, a survey that we have been
carrying out for some 21 years, is a vast amount of data on how
nurses feel about their employment currently. What we know from
that is that a lot of nurses want to have a better work/life balance,
better prospects, pay and promotions, and all those are drivers
for them to seek employment in, particularly now, the United States
or Australia, which are popular destinations for both UK-trained
nurses and nurses who had come to work in the UK from India and
from the Philippines. One of the statistics which was quite interesting
from the survey that we carried out this year, 2007, was that
55% of the people that we surveyed felt that they were too busy;
their workload had increased to such an extent that they no longer
felt they were able to deliver the standard of care that they
felt professionally they would wish to. That is another driver.
That is different from the driver on nurses, the push factor for
nurses to seek employment in the UK from the Philippines, from
India and from South Africa. I cite those countries in particular
because they are the biggest contributors to the nursing workforce
in the UK.
Q302 Lord Turner of Ecchinswell:
My question is probably for Dr Borman. There was a lot of reporting
earlier this year about British medical students, on whom we had
spent a quarter of a million pounds each presumably by your figures,
having difficulty getting training posts in the UK. Is there any
relationship between this and the issue of migrant doctors coming
in or should we see this as a separate issue? How would you think
about the inter-relationship with this? If it is the case that
we are expensively training these people but they are not getting
jobs while we are filling jobs with migrant doctors, why is that
disconnect occurring?
Dr Borman: I personally believe that what occurred
in the last 18 months is pretty much without precedent in terms
of catastrophes for the medical career and staffing structure.
I would suggest that there are three key factors that are involved.
The first one is an utter failure of an effective medical planning
structure. The second is the rules on immigration that applied
prior to April 2006, the implementation of the new rules in April
2006 and how those rules were implemented. The third is the decision,
at the same time as these events were occurring, to introduce
a wholly new and virtually untested computer-based appointment
system. The combination of these three factors has generated a
catastrophe that literally has unfolded in slow motion despite
repeated warnings from the British Medical Association. It has
damaged the morale of doctors in training; it has destroyed, at
a very early stage, career development. It has caused staffing
problems that have been enormous and has damaged the UK's reputation
with regard to being a preferred destination for migrants. The
reasons for this, if I could explore each of those three generating
factors, are that there has not been an effective staffing planning
system for approximately ten years. I served on a national manpower
panel when I was the leader of the junior doctors in this country
and the Government at the time decided soon after that to scrap
that and devolve this to a regional level. It has not been effective
since then. What that has meant is that we have been progressively
increasing the number of UK graduates, for good reason, but at
the same time finding that graduates coming from within the EU
and EEA have also increased and there has been an unchecked immigration
of doctors from outside the EU and EEA which has led to an excess,
in terms of the training posts available—and figures vary
quite considerably—of between 11,000 and 18,000. The problems
that we experienced this year have been profound. It is likely
that they will be replicated with even greater consequence next
year because those medical staffing problems have not yet adequately
been addressed. On top of that, add the problems of the manner
in which the new immigration rules for doctors in training were
introduced without adequate consultation, without adequate notification
and without clear guidance once they had been introduced, meaning
that there was a generation of doctors who had come from abroad,
who had no idea what their career prospects were going to be in
the United Kingdom. A legal challenge and an appeal have been
required in order to develop some degree of clarity on that matter.
On top of that, add an untested computer system which, by many
of my senior colleagues' accounts, did not adequately provide
a mechanism for choosing the best person for the job in terms
of their clinical abilities but rather the person who could fill
the form in to the specifications required and you truly have
a catastrophe that I believe is without precedent in the medical
staffing structure of this country.
Q303 Lord Turner of Ecchinswell:
If I could just declare an interest as someone whose daughter
has just gone to medical school, I very much hope these problems
are sorted out within the next five years. May I also just ask
one ancillary question to that? If we had had a better system,
if we had not made these mistakes, would we now have more UK-trained
doctors in staff and fewer migrant doctors? Would that be the
net effect, if we had not made these errors?
Dr Borman: A decision was made six years ago,
if memory serves me, to increase the number of graduates from
UK medical schools and correctly so. The first paper that I recall
reading on this was in 1991 when, at a pan-European level, it
was recognised that Europe was moving from a relative surplus
of doctors to a relative deficit. The BMA started to lobby the
Government to increase the number of UK graduates. There are other
reasons. Ethically, it is appropriate that the UK becomes more
self-sufficient in graduates and, to the Government's credit,
albeit rather late, five or six years ago, medical school places
were increased and these were funded. The difficulty is that we
did not have concurrent with this a review of the projected manpower
needs for the United Kingdom and we did not address the immigration
issue at that point, which has meant that five or six years down
the line, that is now, we have a major problem.
Q304 Lord Griffiths of Fforestfach:
May I just come back to the second point you mentioned, that from
now on it is going to be more difficult for employers in the Health
Service to recruit from outside the European Union? If that is
so, what is your opinion as to the likelihood of meeting demand
from within the EU?
Ms Irwin: The difficulty that presents itself
for the nursing profession is that band five, newly registered
nurses, and band six, specialist nurses, have been removed from
the skills shortage register. Just as my colleague from the BMA
has said, the decision was taken somewhat in the absence of a
UK-wide approach to workforce planning. So the whole of the focus
is on the needs of the NHS and the independent sector, which employs
a significant number of nurses and is likely to employ more if
the Government's current approach to plurality continues, was
ignored, which means that it is more difficult to recruit from
outside the EU. What the figures tell us, in terms of the attractiveness
of the UK to EU nurses, is that there is a significant difference
between the attractiveness of the UK to internationally recruited
nurses, for example from India or the Philippines, and those from
the EU. Between 2005 and 2006, 1,700 and something nurses were
recruited from the EU compared with over 8,000 from countries
outside of the EU. There is substantial ground to make up, particularly
if the tendency for UK-trained and nurses who have trained outside
of the UK and have come to the UK to work, if that trend to work
outside the UK continues. So we have significant concerns that
that supply need is not going to be anything near made up by nurses
from within the EU.
Dr Borman: In the medical profession the British
Medical Association anticipates from our modelling that there
will be a relative shortage of doctors up until approximately
2030. Of course, manpower modelling becomes much less predictable
the further away you are from our index point, but there is reasonable
cause on which to judge these figures. There is a global shortage
of healthcare workers of approximately 4.3 million currently and
we are expecting that with further developments in healthcare,
that shortage, if anything, is likely to be extended. Within the
UK we have seen a small step increase of graduates from within
the EEA coming to the United Kingdom. Medicine is fortunate in
that English is effectively the international language of our
profession, which means that graduates more readily are able to
come to the United Kingdom. Other than for Bulgaria and Romania,
EC Directive 2005/36 will apply, meaning that mutual recognition
of qualifications is readily available to the professional and
registration is easy. It is difficult to see that reliance on
EEA migration will be the sole means of ensuring that we achieve
the figures that we need in the United Kingdom. I would suggest
that there are many good reasons why we in addition should not
rely on the EEA as the sole means. There are very definite advantages
to migration by our colleagues from outside the EEA. The development
of links with developing countries, the recognition that in a
globalised world illness is globalised and healthcare needs to
be and the recognition that developed countries have the potential
to give back to developing countries are other reasons why we
need to look at migration and manpower numbers in more ways than
simply the figures and the economic benefits.
Mr Angel: We have already commented on the lack
of evidence available in the social care sector. From the survey
that we conducted for today's evidence, it is quite clear that
home care providers are recruiting from an international population,
rather than favouring any one country. There is a slight preference
towards the accessions countries of the European Union, closely
followed by Africa. What we do see probably reflects the fact
that the majority of the recruitment being done at the moment
is recruiting people who are already in this country. That means
that, unless the number of migrant workers entering from the European
Union were to increase, we would have difficulty maintaining the
capacity that we do at present, if other areas were to reduce.
We have no data on how the widening of the EU will act long term.
We can be fairly sure that in the home care sector people will
consider more active forms of recruitment, going out of the UK
to find candidates and bring them back to the UK will increase
and providers will get more skilled at doing this; it is very
much in its infancy in home care. In its favour, the European
Union is probably the most economically effective location to
recruit from, both in terms of the travel time and cost of bringing
candidates into the country. We also know that when international
recruitment has happened previously, recruits tend to come to
areas where other people from their home country have come first
and they know that they have been treated well.
Q305 Lord MacGregor of Pulham Market:
I should like to turn away from employment of migrants in the
Health Service to a different aspect in relation to immigration
and that is how recent immigration has affected the use of health
services in your sectors. Are there any health service sectors
that have experienced particularly large increases in case load
because of recent immigration? Are there regional differences
and if so, what?
Ms Irwin: Unfortunately, we are not able to
comment on this question. We do not have any evidence that we
are able to provide.
Q306 Lord Griffiths of Fforestfach:
I used to live in North London and one certainly reads in the
press that there are individual hospitals which would seem to
be inundated. This may be very localised, but to say you cannot
comment at all surprises me.
Ms Irwin: The reason for saying that we cannot
comment is that we can provide generalisations or anecdotal evidence
based on individual experience, just as you have, but what we
do not have is any full, researched evidence to offer and obviously
that is something that we would prefer to do.
Q307 Lord MacGregor of Pulham Market:
Do you anecdotally get any feeling that there are differences
between regions, for example, areas like London and other big
cities?
Ms Irwin: Our members would tell us that there
are particular difficulties in inner cities, which is to be expected.
Dr Borman: I regret that the British Medical
Association does not have a dataset which would allow me authoritatively
to answer that question. However, anticipating that you may, as
Lord Griffiths of Fforestfach has just done, try to push me on
that, I would perhaps give an analogy of an editorial that I have
had published on the issue of health tourism. There I was very
concerned by media reports about migrants coming to the UK specifically
for health care. When I looked to see what evidence there was
for that phenomenon I was horrified to find that there was no-one
collecting that evidence, that it was based on anecdote and, with
quite some furore at the time, given that this was picked up on
by the media during, I suppose, a relatively quiet period, I did
challenge the Government to collect the necessary information.
I would suggest that this is information that should be collected
but I regret the BMA is not able to help with that.
Q308 Chairman:
I suppose you could ask the question two ways: why do you not
collect it? Do you not think it is something you should collect?
Ms Irwin: I do think it is something that is
of clear interest to both the clients and patients and our own
members in terms of the skill sets that are required. However,
the recent large increase in migrant workers coming to the UK
is something which is so recent that it is a piece of research
that we have not yet embarked upon. It is obviously an area of
clear interest to the Royal College of Nursing.
Q309 Chairman:
Do you give the same answer from the BMA?
Dr Borman: If I could smilingly challenge my
own suggestion that the Government should collect these figures,
I have to be fair and recognise that it would pose considerable
difficulty. One would need to look at registrations with general
practitioners based on nationality and there are very good reasons
why people will not allow that information to be provided. One
may need to look at provision within the hospital sector but,
to my knowledge, no-one will be specifically collecting that information
for patients who are clearly entitled to healthcare—they
are EU/EEA citizens—and where that information would not
accurately be able to be analysed. We are having some difficulties
with information technology systems within the NHS and I suspect
it will require some time before we would be able to have this
degree of sophisticated information.
Q310 Chairman:
I wonder whether the Home Care people would like to go back to
Lord McGregor of Pulham Market's original question and comment
on it.
Mr Angel: Like our colleagues in other sectors
we have begun to draw attention to the lack of information available.
David Behan, Director General of Social Care, described the social
care sector recently as being a "data desert". In relation
to whether we should be collecting the information, the last information
funded within the independent home care sector was in 2004; there
has been nothing that we have been able to tap into since then.
In terms of the effect of migrant populations on home care services,
we are in a slightly different position. The majority of people
who use home-based services are older people and the migrant populations
that are currently in the country have not reached that age (that
is 65 plus) where the effect is felt.
Chairman: That is a very convincing answer.
Q311 Lord MacGregor of Pulham Market:
I understand that. Does that mean, therefore, that actually you
suspect, in terms of the general reactions that you get from your
own members, this is not a big issue among your members?
Ms Rimmer: Not in terms of provision of care
services or the utilisation of care services. In terms of capacity,
clearly that is the issue we have been stressing, the importance
of the workers.
Q312 Lord Best:
I should like to stay with UK Home Care, the social care side.
I declare an interest in that I chair an organisation that provides
housing and care to 19,000 older people. In terms of the change
in the composition and nationality of the people who are providing
social care today compared with yesteryear—and this is a
qualitative question for you, you do not need to have a survey
to answer it—do you think that there is a difference in
the social care workers of today in terms of their skills, their
qualifications, their attitudes, their understanding of the role
that they are playing that means that we are either better off
or worse off in terms now of the care provision that we are providing
at the social care level? With the medical profession we have
international standards and doctors are the same the world over;
not so with social care. Is there a difference in the quality
of care provided now that we are so dependent, my organisation
is utterly dependent, on people from other countries providing
the social care?
Mr Angel: In the home care sector we are not
today doing the job of the old-fashioned home help which might,
10 years ago, have been the model that people would have thought
of. The expectations on workers are increasingly high. Many of
the roles previously held by community nurses are now being delivered
by domiciliary care workers. It is very difficult therefore to
do a comparison to see whether we are better or worse off. We
are certainly doing something a lot more sophisticated than we
would have been doing a decade ago.
Ms Rimmer: And the level of dependency of the
population being looked after at home, has increased enormously,
and that is something that the general perception has simply failed
to come to terms with. Indeed, if government plans for greater
utilisation of individual budgets and direct payments and promoting
independence go forward, as one expects they will, then that increased
level of dependency is likely to get greater. The utilisation
of telecare services at home is going to get greater. It is going
to be a much more demanding, almost quasi-nursing in many instances,
setup in social care.
Q313 Lord Best:
And has that increase in the requirement for higher skills today
than yesteryear been fulfilled by the immigrant workforce that
now does so much of the social care work?
Ms Rimmer: It is honestly very difficult to
give a judgment on that. Overall, as you know, there has been
enormous effort into trying to upskill the workforce, but there
are real barriers to doing that in terms of the complexity of
the funding systems for training in social care, which we as a
relatively small voluntary organisation try to access. It is extremely
bureaucratic, very time-consuming, very ineffective or inefficient
perhaps, and the needs for these higher grade skills are growing
all the time. Because of the relatively poor terms and conditions
of workers in social care, you get very high levels of turnover.
You are getting reported from the National Minimum DataSet something
like 24 per cent turnover rates, where one of the main criteria—you
asked me about quality—that clients give is that they want
continuity of their care worker. This is a major, major issue
which needs to be addressed very urgently.
Chairman: Thank you very much. I was
going to say to our witnesses first of all that we have got through
most of the prepared parts of the agenda, but is there anything
you have not said that you wanted to say?
Q314 Lord Layard:
Could I just ask about the immigration policy and the points-based
system?
Ms Irwin: To respond on that, one of the difficulties
for the RCN in responding to a question on what we think about
the points-based system is that it is difficult to comment in
the absence of any UK workforce planning system, which we have
all referred to in different ways. Unless you know what levers
you are trying to pull and what outcome you are trying to achieve,
which we do not know because there is not a UK workforce planning
system, making a point about the migration points system is actually
very difficult.
Dr Borman: From the British Medical Association's
perspective, firstly we will provide in our written submission
a more detailed response, including copies as an appendix of our
submission to the Home Office consultation on this particular
matter, so it will provide a more detailed view. In general terms,
what I would say is that we would be looking to have a migration
model that would be based not purely on economic factors; the
points-based system dominantly is based on a UK view and an economic
model only and we would want to see a greater recognition of the
broader social implications of migration and, specifically, the
implications in terms of employee protection within the specific
post that that migrant is likely to be taking up. It has been
of considerable concern to the British Medical Association, and
indeed having had discussions with my colleagues here before the
Committee's hearing, that migrants are much more likely to find
themselves on the wrong side of a glass ceiling and are employed
in posts which are not necessarily of the best calibre, do not
necessarily achieve their best career potential and, regrettably,
we feel that this does need to be considered more carefully when
any points-based system is reviewed.
Ms Rimmer: We do not have any specific views
on the points-based system, but we do have a view that there is
an urgent need for more information about migration and social
care and its significance. That is given even more force by the
complementarity of social care services with health going forward.
Chairman: Thank you very much indeed;
we are most grateful to you and you have given us a lot of information
in the time we had. Thank you very much.
|
