Saturday, 5 December 2015

Kick out overseas nurses...

...seems to be the message coming from two recent publications.

Both publications - one a report and the other a scientific paper - were published at the end of 2015.  The report is Supplying the demand for nurses by Edmund Stubbs and published by Civitas, in November, which claims to be the Insitute for the Study of Civil Society.  The second, published by Germack et al. in BMJ Open titled: 'Patient satisfaction and non-UK educated nurses' was published in December.  Both publications report the employment of overseas nurses in the UK National Health Service (NHS) in a poor light; one (Stubbs) from what appears to be a position of sheer prejudice and the other (Germack et al.) on the basis of scientific inquiry.  The Stubbs report goes much further than recommend a reduction in overseas nurses, as I will explain below.  The Germack et al. paper is concerned solely with overseas nurses.  The timing could not be better...if you think overseas nurses are at the heart of the problem in the UK NHS.

The Stubbs report
Edmund Stubbs is eminently qualified to comment on the nursing workforce, in addition to a biosciences degree he worked for four years as a healthcare assistant, no further relevant qualifications.  His report was commissioned to address the current shortage of nurses - on the face of it - but, in fact, is about the shortage of UK 'trained' nurses (he refers to training as opposed to education consistently throughout).  The recommendations of the Stubbs report include an end to nursing student bursaries, something with which I agree as explained in The case against bursaries and fee payments for nursing students.  He also recommends removing the cap on the training places at universities for nursing students (mainly referred to by Subbs as 'student nurses'), as has already been done for other student places.  This could be problematic for the NHS as it has to provide clinical placements for nurses, an issue that Stubbs does not address directly but does seem to address indirectly in his claim that the extra students will be cheap pairs of hands for the NHS as they will work, essentially, as healthcare assistants.  There is no mention of the supernumerary status of nursing students and I can only assume that, from his perspective as a former healthcare assistant, that this is something he did not realise or - worse - he means that the supernumerary status of nursing students should end.  The UK Council of Deans of Health should clarify that point as a matter of urgency.  If the intention of the report is to end supernumerary status for nursing students then the cause of nursing education in the UK will be set back by nearly 20 years.  The end of bursaries and the lifting of the cap are already UK government policy, influenced by Stubbs, and I expect we will see the cheap labour recommendation implemented before too long.  This is all shaping up nicely for the enemies of university education for nurses.

Overseas nurses
Stubbs and Germack et al., I predict, will become a combined force for an end to the employment of overseas nurses in the UK.  Thus, seemingly reasonable people will become a voice for the British National Party and its anti-immigration clones.  Stubbs provides the facts and figures regarding overseas nurses and his message is that we employ vast numbers of them, costing vast amounts of money when nursing programmes are oversubscribed.  Now, that does seem anomalous and, clearly, if we had more 'home grown' nurses, we would need fewer overseas nurses - logical; but we don't have enough and we have gone and actively sought overseas nurses to meet the demands of our health service; it's our fault they are here, we offered them the jobs.  The information is not new but Stubbs does not cite one of the most valuable sources of information on the nursing workforce - Jim Buchan.  Stubbs cites the most recent Royal College of Nursing review of the nursing workforce (An uncertain future), which they now  produce by themselves but which, until 2012, was the work of Jim Buchan and Ian Seccombe.  Buchan and Seccombe's final report Overstretched. Under-resourced addressed the issue of the number of overseas nurses in the workforce but also produced a very interesting chart (Figure 6, page 15) which showed that the percentage of overseas nurses entering the nursing register (presumably to work in the UK) increased until 2001/02 when the number of overseas registrants exceeded the number of UK registrants (I don't recall a hue and cry at the time) but has since been steadily declining with a slight increase since 2009/10.  Of course, these are registrants and only a proxy indicator of employment in the NHS which will be cumulative as many of those registering until the decline will still be employed in the NHS.  Nevertheless, the registration trend of overseas nurses is declining and the problem which Stubbs purports to be fixing has already, largely, been addressed.

It is what Stubbs has to say about overseas nurses that is worrying, for example (page 11): 'Staff recruited from overseas often, through no fault of their own, decide to return to their home countries and some are forced to do so by the application of immigration restraints. With many such staff entering and leaving the clinical workforce, it seems almost inevitable that the quality and safety of patient care must suffer.'  Let's break this one down. Overseas nurses 'often...decide' to return home 'through no fault of their own' - now, there's a surprise and a contradiction. Do we want them or not; if they return home then is that not what we want? What is the issue here? It seems to be turnover - but there are no comparable figures about turnover of UK nurses which is also high and has been of concern and cost to the NHS since at least 1986 as reported in Staff Turnover in the NHS, at a time when the percentage of overseas registrants was less than 10%.  So, turnover is not a problem unique to overseas nurses, it is a also a problem for UK nurses and will not be solved by getting rid of the overseas nurses.  Stubbs claims that: 'it seems almost inevitable that the quality and safety of patient care must suffer' - really TWO qualifiers 'seems' and 'almost' before the 'inevitable'. To me it is certain that Stubbs has no evidence to substantiate his claim - no qualifiers necessary.  Earlier in the report Stubbs raises the old moralistic and spurious spectre about depriving countries of their own nurses; he says (page 4): 'The morality of expensively recruiting nurses trained overseas to the probable detriment of the health services of those countries is also highly questionable.'  Again, he's not sure - ' probable'?  We have no evidence that this is the case.  While it is frustrating for some countries, especially in Europe as revealed in this interview of an Italian nursing leader with the BBC's Jane Dreaper (which I helped to set up), to see their nurses disappear, the fact is that it is the NHS that has actively pursued these nurses and they leave because their own countries are in dire financial straits.  The Philippines deliberately over produces nurses (no cap there!) so that they can seek employment overseas and, along with millions of expatriate Filipinos and Filipinas, make a major contribution to their economy by sending money home.  I can provide concrete evidence that stopping the employment of nurses from the Philippines will have a detrimental, if indirect, effect on the health service there because they will be less able to finance it.  Saint Nelson Mandela - he who must always be listened to and obeyed - did once ask the UK to stop 'poaching' third world nurses which is often used as evidence against us.  The answer, Saint Nelson, is to create freer, democratic and economically strong countries where nurses - black or white - are well paid (something you, singularly, failed to do).  If some countries are hard-pressed for good nurses then we could encourage some of our new registrants to go there for experience,  but Stubbs has a fix for that too - bribe them to remain in the UK by allowing the NHS to repay their student loans...but only if they remain in the UK in the NHS.  This is the most petty-minded and 'little Englander' of suggestions I have ever encountered.  We are a global community and we should be educating nurses to think and to work globally and also value their international experience which they bring back to the NHS.  I am eternally grateful to the NHS which has, literally, saved my life on one occasion but it is not the only nor is it necessarily the best healthcare system in the world.

BMJ Open to the rescue
I said above that Stubbs had no evidence to back his assertions about overseas nurses; none...until now.  The Germack et al. article provides just the evidence he needs and will greatly satisfy the smug neo-Stalinists (whichever party is in power) of the UK Department of Health; another cause to promote, another metric to beat the downtrodden masses of the NHS, another report on the NHS websites and another reason to send more hard-pressed NHS managers to the Gulag Archipelago if they don't comply.  Germack et al. report that there is lower patient satisfaction where there are higher percentages of overseas nurses employed in the NHS.  The results are quite striking and I do not doubt them.  The sample seems representative and the statistics sophisticated taking various factors into account to isolate the effect of overseas nurse employment.  Worrying stuff.  But wait a minute...  I know the authors of this report - personally - and they are not right wing fascists; far from it.  They are scientists, they had an issue to investigate and they report as they find.  They make the excellent point, with which I agree, that the NHS must move to a more centralised system of workforce planning, not to be even more Stalinist, but only because the current system is patently not working.  That employment of overseas nurses varies markedly across the UK indicates a problem.  As good scientists they do not speculate but they cannot be so naive as to think that their data will not be misused, misquoted and - quite possibly - lead to some brutality towards and further bullying of overseas nurses in the NHS.  We academics have terrific problems getting our stuff 'out there' but, believe me, this article 'has legs'.

What is the problem?
I don't know.  If the implication of these reports is that overseas nurses are in some way less competent than UK nurses then people need to think again.  For example, as shown by my Hull colleague Gloria Likupe in her PhD thesis, nurses from Africa coming to work in the NHS think UK nurses are a joke (admittedly, not Gloria's exact words).  They come with prescribing, phlebotomy and intravenous skills and find that the most advanced procedure a UK nurse at the point of registration can do is give an injection.  Why there should be an association - and, as robust as it is, the effect seen by Germack et al. is just that: an association and not a cause and effect relationship - between the percentage of overseas nurses and low patient satisfaction is not clear. But I will speculate.  Is it not possible that those areas of the NHS where there are higher percentages of overseas nurses are the areas where there are most problems - anyway?  By dint of the fact that there are so many overseas nurses are these not the areas most hard-pressed financially, the worst managed and where the UK as well as the non-UK nurses provide the poorest care?

As my email signature says, 'the plural of anecdote is not data' but I must say, having trained as a nurse in London I trained alongside many nationalities and worked alongside them too.  Some of them were shocking, and some of them were brilliant - just like my UK classmates and colleagues.  Overseas registrants are over represented in Nursing and Midwifery Council disciplinary hearings, but so are men.  Is there a call to have fewer men in nursing? No, quite the opposite.  It cannot have escaped anyone's notice that we have increasing numbers of overseas patients; by whom do they prefer to be cared?  I have just returned from the Middle East; where once expatriates stocked their health services, they are talking about 'Saudi-isation', 'Bahraini-isation', 'Qatari-isation' and 'Omani-isation' of their workforces.  It is natural and right to want to educate and employ your own people.  But these are, largely, mono-cultural societies.  We are not.

Some of my best friends and colleagues in nursing are non-UK educated, I wonder how these reports make them feel?  Inevitably, there will be some qualification by UK health ministers about aspects of the Stubbs report on overseas nurses, but I think we will lose a valuable contribution to our NHS workforce if we target overseas nurses.  As for the Germack et al. article, if Jeremy Hunt can make use of one article on weekend working then he can make use and mis-use of this one.

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