RCN position statement on international recruitment

RCN position statement on international recruitment Contents Introduction 3 Workforce planning and sustainable health systems

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Fair treatment for individual migrant nursing staff

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Managing migration – international mobility and recruitment policies

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Summary 9

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RCN Policy and International Department

RCN position statement on international recruitment Introduction Nursing is a global profession and since its founding in 1948 the NHS has benefited enormously from foreign trained health professionals, particularly from Commonwealth countries. Nurse migration can be beneficial with nurses from outside the UK broadening their professional and social experience, enriching professional nursing practice in the UK and bringing great scope to enhance the quality of patient care, particularly in Britain’s multicultural society. Whilst in the UK, international nursing staff may also acquire skills and experiences that boost their employment prospects upon returning to their own country. Similarly, there is also a steady flow of UK nurses travelling overseas to work and expand their experience. Wider international recruitment into the UK has been cyclical, intensifying after periods of insufficient investment in training, recruitment and retention of UK nursing staff as well as a failure to undertake long-term workforce planning, often despite evidence of impending shortages. There was a particularly rapid increase in international recruitment between 1998 and 2004, with new admissions to the Nursing and Midwifery Council (NMC) register in the UK from overseas nurses rising by nearly 400 per cent1. These were mostly non-EU nurses, particularly from Commonwealth countries, but from 2004 onwards numbers dropped rapidly from 15,152 new overseas entrants to 2,519 in 2010 due to a combination of economic factors and changes in regulatory and immigration policies2. Within Europe, where free movement and equal treatment are fundamental principles of the EU, there have been mutual recognition arrangements for nursing qualifications for many years, making the process of registration easier for many nurses. However, language and cultural barriers remain an issue for EU nursing staff and limit effective integration into the UK health workforce. Since 2010 international recruitment into the UK has been largely from these countries and in particular from Spain, Portugal and Ireland. By 2013/14, nurses from the European Economic Area (EEA) made up 87 per cent of new overseas registrants in the UK3. However, research has also shown that some overseas nurses coming to the UK have experienced significant challenges with discrimination, little or no induction, and lack of appreciation for the skills they bring with them4 5 6. These factors are largely cumulative in impact and systemic in nature. Additionally, recruiters have often paid little attention to the wider impact on health services and workforce development both here and in resource poor, source countries.

1 RCN (2013) The Labour Market Review www.rcn.org.uk/__data/assets/pdf_file/0018/541224/004504.pdf 2 RCN(2014) The Labour Market Review www.rcn.org.uk/__data/assets/pdf_file/0005/597713/004_740.pdf 3 Ibid 4 University of Surrey report commissioned by the RCN (2003) We need respect – success with internationally recruited nurses www.rcn.org.uk/__data/assets/pdf_file/0008/78587/002061.pdf 5 Allen H (2010) Mentoring overseas nurses: barriers to effective and non-discriminatory mentorship practices, Nursing Ethics17(5) 603-613 www.coventry.ac.uk/Global/06%20Life%20on%20Campus%20section%20assets/Placement%20Connect/overseas_barriers%20to%20 effective%20and%20non-discriminatory%20mentoring.pdf 6 Alonso-Garbayo, Alvaro (2007) Expectations, experiences and plans of internationally recruited nurses in the UK: a case study in a NHS Acute Trust in London, London School of Hygiene and Tropical Medicine Research Online http://researchonline.lshtm.ac.uk/682369/

RCN Policy and International Department

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RCN position statement on international recruitment There is also concern about the long term impact that the migration of qualified nurses to the UK will have on EU countries that have much weaker health systems or are struggling economically in the aftermath of the global financial crisis. The nature of the nursing workforce in health and social care has also changed over the last 15 years as there is an increasing reliance on a nursing support workforce and a rise in the number of frail, older patients. Within Europe, despite current unemployment in some Eurozone countries, severe long-term health worker shortages are predicted. In a 2012 report, the European Commission estimated that there would be of a shortfall of nearly 600,000 nurses in the EU by 20207. This shows that any large scale recruitment from other European countries will not be sustainable. The RCN has stated clearly that the UK will continue to rely on recruitment of nurses from within and outside the EU to make up for a shortfall in UK nurses until and unless it is able to address long-term systemic issues such as cuts to and insufficient investment in education places, an ageing nursing workforce and effective retention of those already working in the UK health sector, including internationally recruited nurses. The RCN therefore argued strongly in its submission to the Migration Advisory Committee in 2014, for general (adult) nurses to be included on the Shortage Occupation List (SOL) not only to address recruitment but also retention issues. Changes to the immigration rules will make it more difficult for those overseas nurses already in the UK to gain indefinite leave to remain if they are earning less than £35,000 and if nursing is not included on the SOL. This means experienced overseas nurses currently working in the health service in the UK may have to leave8. For these reasons and given the increasing focus in political debates on UK immigration policy and our wider relationship with the EU, it is timely for the RCN to revisit and restate its fundamental position on EU and international nurse recruitment and mobility.

7 European Commission (2012) Action plan for the EU health workforce, European Commission staff working paper April 2012 http://ec.europa.eu/dgs/health_consumer/docs/swd_ap_eu_healthcare_workforce_en.pdf 8 RCN (2014) Response to Migration Advisory Committee call for evidence: Partial review of the shortage occupation lists for the UK and Scotland.

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RCN Policy and International Department

RCN position statement on international recruitment Workforce planning and sustainable health systems The RCN has argued for many years that the UK should work towards self sufficiency as part of a long-term strategy, rather than relying on waves of international recruitment as a quick fix when long predicted shortages emerge. Key to this is engaging in effective, sustainable and long-term workforce planning; investing in nurse education and training and creating healthy and supportive work environments so as to attract and retain nursing staff, committed to meeting the current and future needs of the populations they serve. For the UK’s health services this means: • commissioning sufficient education places to meet the predicted future need for registered nurses in a range of settings, including in the community and non-NHS services across the UK • investing in the health care support workforce • greater employer support for continuing education/CPD to ensure that nursing staff are able to adapt to changing health challenges and work to their full potential • effective recruitment and retention strategies, particularly given the ageing health workforce. Workforce planning and horizon scanning for future health workforce needs requires accurate data on the existing workforce. This has been difficult to achieve within and across the four UK countries as well as at EU level and beyond. In relation to international recruitment, as a minimum, the RCN calls on the NMC to reinstate regular publication of statistics on non-UK trained nurses entering the NMC register and those UK registered nurses seeking to practice outside the UK (based on verification checks requested by other regulators). In order to avoid or at least ameliorate the predicted European and global nursing shortage, all countries need to look at the workforce planning policies and initiatives, otherwise we risk fishing from the same limited pool. The RCN supports initiatives by the Global Health Workforce Alliance and the World Health Organization to develop a global strategy investing in nursing and midwifery9. Equally, UK workforce considerations need to be informed by global workforce trends and challenges, and particularly within Europe with greater opportunities to agree collective policies that impact on recruitment and retention and where health professionals have the right to free movement. UK Governments need to ensure that domestic and international development policies in relation to human resources for health are mutually supportive. The UK, particularly through the Department for International Development, can play a key role in assisting developing countries to expand their capacity to train and retain health professionals and build sustainable health systems. Some organisations have supported a more direct link between recruiting and source countries in terms of financial

9 RCN (2015) Submission to WHO-Europe technical briefing on strengthening nursing and midwifery www.rcn.org.uk/support/consultations/ responses/strengthening_nursing_and_midwifery._european_strategic_directions_towards_2020_goals

RCN Policy and International Department

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RCN position statement on international recruitment compensation10. This direct compensation approach raises a number of practical challenges but the RCN calls on the UK government to: • champion the implementation of the WHO code and lead in demonstrating how it can improve practice at home as well as supporting countries with the most acute human resources crises • champion scaling up the health workforce as central to achieving the United Nations Millennium Development Goals (MDGs) and the next global development framework • ensure that at least 25 per cent of new UK government development funding for health is directed to support human resources for health in line with the WHO’s 50:50 principle • provide technical and other support to ensure countries can develop and implement robust and funded health workforce plans11.

Fair treatment for individual migrant nursing staff The RCN supports individual nurses’ right to travel and work overseas to develop their practice and further their experiences. It therefore recommends that health care employers should consider individual applications to work in the UK in accordance with relevant equality legislation in operation across the UK which is aimed at eliminating discrimination in the recruitment and selection process. The RCN recognises the impact that non-UK nursing staff make to the UK’s health services and has expressed serious concerns about the introduction of a health surcharge for all non-EEA migrants coming to live in the UK. Overseas nursing staff working here are already contributing to our health system as part of the nursing workforce and by paying tax and national insurance. Therefore, this surcharge is patently unjust. Moreover, it adds a further and unnecessary cost to their recruitment. The RCN raised these concerns during the passage of the Immigration Act 2014, and calls on the Government to reverse these rules12. The RCN has produced practical guidance for nursing staff and employers on ethical international recruitment and employment to support good practice13. International nursing staff should expect to be treated fairly whilst they are being recruited and once they are employed in the UK, this includes: • transparent and fair immigration and registration processes, where any charges made are proportionate • fair pay for the role undertaken • good terms and conditions of employment on equal terms with the rest of the employer’s workforce

10 Health Policy Action (2013) Aid in reverse: the UK’s responsibility to address the health workforce crisis www.healthpovertyaction.org/wp-content/uploads/downloads/2013/11/Aid-in-Reverse-briefing-web.pdf 11 Action for Global Health et al (2010) Putting health workers at the heart of the MDGs. Joint agencies call to the coalition government www.vsointernational.org/Images/putting-health-workers-at-heart-of-mdgs_tcm76-28565.pdf 12 RCN (2013) Response to Department of Health England consultation on migrant access and their financial contribution to the NHS in England www.rcn.org.uk/support/consultations/responses/migrant_access_to_the_nhs 13 RCN (2015) Internationally recruited nurses: RCN guidance for RCN representatives, UK employers, and nursing staff considering work in the UK

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RCN Policy and International Department

RCN position statement on international recruitment • dignity at work free from discrimination and support for whistleblowers uncovering abusive workplace practices • healthy and safe work environments • career development opportunities • access to trade unions. The treatment of staff impacts significantly on the patient experience. It should therefore be incumbent on employers to ensure that they have appropriate policies, structures and behavioural competences to ensure international and EU nursing staff are free to work in environments that are free from unlawful discrimination. Employers also have a responsibility to organise proper induction and support for nursing staff joining their workforce from outside the UK. The RCN believes it is also important to prepare existing staff to support and work with migrant nursing staff by fostering better understanding of different nursing systems and cultures and preparing them to work alongside those who come from different working cultures. Similarly, migrant workers may require help and support in furthering their understanding of the particular system and culture they are working in, within the UK.

Managing migration – international mobility and recruitment policies The RCN supported the development of a Department of Health ethical recruitment code in the UK (2001, revised in 200414), the Code of Practice for the international recruitment of healthcare professionals in Scotland in 200615 , the Code of Practice for the Commonwealth (200316) and most recently the World Health Organization’s global code adopted in 201017. These codes share the common principle that active international recruitment of nurses and other health professionals should not be targeted at low and middle income countries with critical nursing shortages. The RCN recommends that employers not only seek the views of governments but also of the national nursing organisation on the impact of active recruitment in that country. International recruitment policies should not prevent individual nurses from seeking to gain experience and opportunities to practice outside the country where they have trained. Actions to combat the skills drain need to balance a population’s right to health with the individual rights of health practitioners. Whilst the Department of Health Code applies to NHS trusts in England and was extended in 2004 to cover recruitment agencies working for NHS employers and private sector organisations that provide services directly to the English NHS, it does not cover private providers eg care homes and is not

14 Department of Health (2004) Code of practice for the international recruitment of healthcare professionals www.rcn.org.uk/__data/assets/pdf_file/0008/78587/002061.pdf 15 Scottish Executive (2006) Code of Practice for the International Recruitment of Healthcare Professionals in Scotland www.gov.scot/Resource/0041/00412480.pdf 16 Commonwealth Secretariat (2003) Commonwealth code of practice for the international recruitment of health workers http://secretariat.thecommonwealth.org/files/35877/FileName/CommonwealthCodeofPractice.pdf, 17 World Health Organisation (2010) WHO global code of practice on the international recruitment of health workers http://apps.who.int/gb/ebwha/pdf_files/WHA63/A63_R16-en.pdf

RCN Policy and International Department

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RCN position statement on international recruitment mandatory for recruitment agencies working with them. This has always been a concern for the RCN and we want the code to be extended to cover the private sector. Some countries have signed memoranda of understanding (MoUs) with governments in countries where there has been a high level of recruitment. Whilst the RCN supports the aim of encouraging greater joint learning and investment in the workforce, such MoUs can only play a limited role in addressing health workforce shortages and struggling health systems. Recognition arrangements for EU trained nurses will differ from those for nurses trained outside the UK, given the common minimum standards for nurse education in Europe. There are automatic recognition arrangements in place for those educated as general care nurses across Europe. EU citizens have the right to move and seek work in other European countries, and these rights are underpinned by policies that actively encourage free movement. Nevertheless, large scale recruitment of health professionals from one EU country to another can be detrimental. As part of the European public sector trade unions’ and hospital employers’ agreed Code of Conduct (2008)18, the RCN supports the position that all member states should be able to maintain an effective health care system which includes “an adequate supply of well-trained and committed health workers”. It is important that international recruitment policies are underpinned by fair, robust and transparent registration processes both for nursing staff coming into the UK from other EU countries and internationally recruited staff. However, there are some fundamental principles that should apply to the regulation of all nurses trained outside the UK: • the UK regulator, the Nursing and Midwifery Council (NMC), should be able to test nurses’ ability to communicate effectively in English with patients and colleagues, whether EU or internationally trained • the NMC should have robust guidance for all employers (NHS and independent sector) on the need for them to effectively induct overseas nurses into the functioning and culture of the UK health system and the specific service they are joining and ensure, as with all recruits, that they have the appropriate knowledge and skills for the role, including communication • as with UK nurses, overseas nurses will be expected to keep their skills up to date to remain on the register and should therefore have similar access to opportunities for continuous professional development (CPD) • any charges to individual nurses seeking recognition and registration with the NMC from within or outside the EU should be proportionate. The cost of such application processes should not be borne by existing registrants. The RCN called for the adoption of a revised European directive on professional qualifications in 201319 which explicitly allows health regulators to control for EU applicants’ language ability. A new system for assessing non-EU trained applicants was introduced in 2014 by the NMC which focuses more strongly on individual competency through a series of assessments and should also make the system more accessible and swifter for applicants. The RCN has welcomed its introduction but given this is such a radical change would like the system to be reviewed once rolled out.

18 EPSU-HOSPEEM (2008) Code of conduct and follow up on ethical cross border recruitment and retention in the health sector European Federation of Public Service Unions (EPSU) and HOSPEE. http://apps.who.int/gb/ebwha/pdf_files/WHA63/A63_R16-en.pdf 19 RCN (2013) Trialogue agreement on professional qualifications directive www.rcn.org.uk/__data/assets/pdf_file/0017/531008/21.13_Trialogue_ Agreement_of_Professional_Qualifications_Directive.pdf

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RCN Policy and International Department

RCN position statement on international recruitment In addition the RCN has a longstanding position that all health care assistants (HCAs) and assistant practitioners (APs) in the UK should be regulated in the interests of public safety. They should be appropriately trained for their roles, and like nurses, have access to lifelong learning. Clearly the RCN would want these arrangements to apply to UK and overseas trained health care support workers.

Summary • The RCN supports ethical EU/international recruitment and retention and recognises the benefis this can bring to UK health economies. • International mobility offers opportunities to individual health professionals crossing borders, including the experience UK nurses can gain in working in other countries. • The RCN believes recruiting employers in the UK must ensure the fair treatment of the staff they recruit and their full and dignified integration into the workforce. • However, the UK also has a responsibility to invest in effective long-term planning and retention of its own nursing workforce and work towards self sufficiency. • The UK has a responsibility to consider the impact of targeted recruitment on health systems in countries from which they recruit. • As a leading player in international development, the government has a key role to play in developing health workforce planning and recruitment and retention in other countries. • This approach offers a triple win for UK health services, for the individual migrant and for countries needing greater investment in their health systems and nursing workforce.

Further information For further information on this statement contact Susan Williams, RCN Senior International Adviser at [email protected]

RCN Policy and International Department 020 7647 3598 [email protected] www.rcn.org.uk/policy

RCN Policy and International Department

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June 2015 Published by the Royal College of Nursing 20 Cavendish Square London W1G 0RN 020 7409 3333 www.rcn.org.uk The RCN represents nurses and nursing, promotes excellence in practice and shapes health policies

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