Brexit and the NHS
Prior to the UK's European Union referendum on 23rd June 2016, a number of Remain campaigners warned that "a vote to Leave is a vote to put our NHS in jeopardy" because "the NHS has become increasingly reliant on EU nationals to keep it on its feet".
After the UK voted to Leave despite these warnings, there have continued to be a number of dire warnings about the NHS's reliance on EU nationals. A typical response was this twitter campaign: "Brits tweet with #LoveOurEUStaff hashtag to thank European NHS workers after Brexit vote". The situation is so serious that "experts say" that without EU nationals, the NHS would "collapse", because the "workforce [is] heavily and increasingly reliant" on them and if EU nationals "left" it would be a "crisis" for the NHS, resulting in a potential "public health emergency".
In a recent statement of the obvious from Pro-EU campaigner Nick Clegg: "The NHS would collapse if we told all the doctors, nurses and other valued staff from other EU countries that they were no longer welcome here". Of course, what is less obvious is why anyone would tell "all" EU doctors and nurses this when:
- The official Vote Leave campaign said that all EU nationals should stay in the UK - everyone, not just NHS workers
- 84% of the British public (including 77% of Leave voters) want all existing EU nationals to stay - roughly the same level of political support as the Conservatives, Labour and Lib Dem parties combined
- Within weeks of the vote, the UK government made clear that "there has been no change to the rights and status of EU nationals in the UK as a result of the referendum"
Regardless, because of this implied unusual reliance on EU nationals*, "experts want Theresa May to make all EU NHS workers British citizens" to "save the NHS" - and not just that, to ensure that "they don’t leave the country after Brexit", EU NHS workers should have an "automatic right to citizenship", a waiver of the £1,200 residence fee, no English language test, and even the ability to skip citizenship tests on British traditions and customs (the 'Life in the UK Test') every other foreign national has to pass.
Why an "unusual reliance"? The discussion is almost always specifically about EU foreign nationals - NOT all immigrants working in the NHS (a notable exception is this article from The Guardian, in 2014 before the EU referendum campaign heated up). This can be demonstrated by the fact there are almost no articles warning about the UK's reliance on Commonwealth or Rest of World foreign nationals, and no #LoveOurCommonwealthStaff hashtags, not even on March 13 2017 (Commonwealth Day). This is curiously myopic when the number of EU nationals in the NHS is put in its proper context.
So, what is the real story? How reliant is the NHS on EU nationals, in fact foreign nationals in general?
In this post I'll use the latest figures available from the NHS and the House of Commons to answer these questions in detail.
NHS staff by Nationality
According to the NHS, as of March 2016, there are 1,102,096 NHS staff who have a recorded nationality & role.
The top 3 nationalities are British, Indian and Filipino. These account for ~91% of all NHS staff.
These figures can be summarised as follows:
- British or Irish - 984,061 - 89.29% (of this 88.07% is British, 1.21% Irish)
- EU/EEA/EFTA - 45,543 - 4.13% (excluding Irish)
- Commonwealth - 44,821 - 4.07%
- Rest of World - 27,671 - 2.51%
Total NHS Staff by Nationality
Top 10 non-British nationalities
Sources & Caveats
- NHS Digital, "NHS Staff by Nationality, March 2016". This includes all NHS Trusts and Care Commissioning Groups (CCGs) as well as Support Organisations. The data has to be manually manipulated to get EU/Commonwealth/Rest of World figures and to combine both Trusts/CCGs and Support Organisations. This is the same data the House of Commons Library used for their most up to date report into NHS nationality figures
- Whilst data is for NHS England only, this is likely to be a higher figure than for Wales, Northern Ireland and Scotland, who don't publish similar figures. For example, Scotland's overall population is ~3.6% EU nationals, whilst the UK as a whole is ~5.9%. So NHS Scotland is very likely to have less EU nationals than NHS England
- Total staff excludes 98K with "unknown" nationality or where a nationality is known but not a role. Nationality is optional and does not have to be declared in the NHS
- "British" includes U.K. overseas territories and Crown Dependencies, these figures are extremely small but avoids counting them as Commonwealth or Rest of World
- EU/EEA/EFTA are combined as all have some aspect of "freedom of movement" for workers within EU member states. For the sake of simplicity throughout this article when I refer to "EU" I mean EU/EEA/EFTA unless stated otherwise
- Commonwealth figures excludes Malta and Cyprus as they are members of both the Commonwealth and the EU
The "Irish Effect" on EU nationality numbers
- As the Republic of Ireland (ROI) is a member of the EU, in any story/article the number of “EU workers in the NHS" invariably includes citizens from the ROI. Nothing wrong with that per se - the ROI is in the EU.
- But - the ROI/UK relationship is unique, pre-dates the EU and is not reliant on EU membership. The UK has had a Common Travel Area (CTA) with Ireland since 1923, 50 years before both the ROI & UK joined the EU, and the CTA has also been repeatedly reaffirmed since then. The CTA and other visa waiver arrangements entitles ROI citizens to move and settle in the UK, and of course work in the NHS. As an indication of their special status, unlike other foreign nationals, ROI citizens can vote in UK general elections, have enhanced permanent settlement rights and are often exempt from deportation even if they commit crimes with prison sentences. No other foreign nationals enjoy similar benefits. As long as the UK maintains its bilateral relationships with the ROI (e.g. the CTA), the UK leaving the EU is virtually irrelevant when it comes to Irish NHS workers. They will likely retain their current enhanced status whatever happens in any future UK/EU relationship, unlike other EU nationals.
- Given that the NHS has 13,307 Irish Nationals (1.21% of all staff; 22% of all EU nationals) - more than all Romanians, Greeks, Germans, Dutch, and French combined - implying Irish workers are equivalent to, say, those from Luxembourg can be misleading when considering the impact of Brexit on NHS workers. As a result, it is reasonable to count "British & Irish" together and other EU/EEA/EFTA nationals separately.
NHS roles by Nationality - who is the NHS most reliant on, and where?
The reliance the NHS has on non British nationalities varies considerably by role. For example:
- Only 76.35% of Doctors are British/Irish whilst 97.20% of Managers are
- There are a larger % of EU staff working in Property (5.76%) than as Nurses or Health Visitors (5.53%)
- Only 0.74% of Ambulance staff are from the entire EU combined, vastly outnumbered by 2.81% from the Commonwealth (and 91% of these are Australians).
Overall, nearly 96% of all NHS staff are either British/Irish, or from the Commonwealth/Rest of World
Nurses & Health Visitors
All other roles
So, what do these numbers mean?
The NHS isn't a special case when it comes to reliance on EU or foreign nationals. The NHS has almost the same reliance on non-British workers/immigrants as the wider economy.
According to the House of Commons Library - the economy as a whole is 88.6% British workers as of Nov 2016. British workers are 88.07% of NHS staff. Accordingly, the NHS as a whole appears only very slightly more at risk of disruption through leaving the EU than average due to reliance on EU nationals in its workforce. In addition, the NHS has considerably more nationals from pre-2004 EU members (3.8%) than the wider economy (3.2%), making it highly likely that such staff have been resident in the UK for a considerable period of time - and anyone resident for 5 years or more is entitled to stay permanently.
There is no special NHS dependency on EU workers, so talking as if there is a threat to them because of Brexit is irresponsible.
Despite all the focus being on EU nationals:
- Commonwealth and Rest of World nationals combined are nearly 60% larger than EU/EEA/EFTA. Virtually no-one is talking about how the NHS might collapse without Commonwealth or Rest of World nationals - and I doubt this would be a widely covered topic even if the UK voted to leave the Commonwealth, leaving aside that it obviously can't vote to leave the world
- Commonwealth nationals alone are nearly identical to those from the EU/EEA/EFTA. Once you correct for the ‘Irish effect’, the NHS has almost the same number of Commonwealth staff as EU staff. This shows how unfair it is to make statements that we need to “immediately” give citizenship to NHS workers from EU states to prevent the “collapse” of the NHS. What is the moral basis for the 10 (yes, ten) Luxembourg citizens working in the NHS getting UK citizenship no questions asked, but the 1,849 Australians don't? Why should 164 Estonians, but not 17,823 Indians? Why 5,299 Italians but not 5,040 Nigerians?
Given these two points it's hard to explain investigations like 'Crisis on the wards' from "Dispatches" which focuses solely on EU nationals, and the articles based on it such as 'NHS could lose 25,000 workers because of EU vote' and 'Record numbers of EU nurses quit NHS'. Imagine being an Australian Ambulance driver and you watch this? By implication you don't count, but Estonians do?
Focusing solely on EU nationals unfairly discriminates against the much larger group of non-EU foreign nationals in the NHS (Commonwealth + Rest of World).
The huge numbers of non-EU nationals barely get mentioned even though they perform the same services in the NHS, and are generally in more highly skilled roles - e.g. Doctors, Nurses and Midwives. EU nationals aren't in the Top 3 largest nationalities for any roles except midwifery (where Italians are 3rd; an area where British/Irish nationals are already high anyway). If the NHS is "over-reliant" on anything, it is Indian doctors, Filipino nurses and Australian ambulance drivers. Yes, without them the NHS would collapse, but they often don't even get mentioned in articles that claim to be about how the NHS is reliant on "immigrants". Only the pro-EU viewpoint gets a look in, suggesting the concern for the NHS may be possibly disingenuous and being used as a political pretext by those who wanted to Remain in the EU.
The NHS's reliance on foreign nationals overall, whilst higher than average, is not especially unusual.
The NHS has a high number of foreign born doctors and nurses compared to other nations, according to the Organisation for Economic Co-operation and Development (OECD) which tracks data for 29 nations. That said, the UK figures have been dropping in the last decade and are quite similar to Canada.
Just because a country has a high number of foreign nationals in their healthcare system does not mean it is required to have membership of a trans-national organisation like the EU to ensure its healthcare system doesn't "collapse".
This should be blatantly obvious but doesn't seem to be. Based on the OECD data for foreign born doctors and nurses:
- Both Australia and New Zealand have higher numbers of foreign born doctors and nurses than the U.K. And survive outside the EU or any equivalent.
- Canada has very similar foreign national numbers to the U.K - and survives outside the EU or any equivalent
- Even within the EU - Poland has the lowest numbers of foreign nationals in its healthcare system. Italy also has very low numbers
Based on the OECD, it seems clear that the number of foreign nationals in healthcare is obviously not correlated with reliance on membership of organisations like the EU. About the best case you could make is that being a long term member of such an organisation and then leaving it might cause some issues if risks weren't mitigated. But even then, only if membership of the transnational organisation demonstrably increased a country's unique reliance on healthcare workers specifically from that organisation
The "problem" with EU nationals is largely invented for political purposes & self-furfilling
Any organisation would have major difficulties if you simply - poof! - "removed" ~5% of its workforce, not just the NHS. But nobody who matters is proposing to "remove" EU NHS workers or even encourage them to leave, nor would it be feasible to do so if anyone was proposing it. Not even those who have invented this problem have explained the mechanism by which these workers would be "removed". Deportation? Encouragement to leave? Voluntary relocation back to the EU?
Did anyone from the Vote Leave campaign ever talk about "removing" NHS workers, or even restricting future NHS workers? Or even UKIP? No - so why are people who presumably voted Remain the only ones bringing it up? Foreign NHS workers here for 5 years or more are generally entitled to permanent residence anyway, and can't legally be removed even if a party to the right of UKIP or the left of Communist somehow swept to power. This likely covers a very large number of NHS staff, or certainly will by 2019. So this "removal" is simply not remotely likely to happen.
If anything, talking up the possibility of a problem makes the problem worse - as talk of "deportation" in a "backlash" against EU nationals simply makes people scared and less certain of wanting to stay in the UK. Research based on EU-ran opinion polls even suggests that the "so-called tide of hate against EU migrants is non-existent" with the UK becoming more positive to EU nationals after the Brexit vote. Also:
- Control of UK borders, as opposed to closure of them, would not necessarily affect the NHS as any skills required could be obtained via work permits or visas
- Arguably, sensible control of immigration would even improve the NHS as skills shortages could be better managed with a higher degree of immigration control and by prioritising countries outside the EU (e.g. more Indians or Australians versus those from Luxembourg or Estonia would be a boon for the NHS as it is set up today)
- According to a July 2016 report from the Institute for Employment Studies for the Migration Advisory Board, after the introduction of English language tests for safety reasons in Jan 2016 (unrelated to Brexit), many NHS trusts will prefer to recruit outside of the EU/EEA - citing similar recruitment costs to elsewhere in the world, and better retention rates. Some trusts are even saying recruiting in Europe is becoming "a less viable option" and recruiting in Europe may "diminish altogether"
Inventing this "problem" harms the people that those who invented it claim they are helping.
Implying that EU citizens could be "asked to leave" or actually deported clearly scares EU NHS workers - and worse, unnecessarily just to make a false political point. EU NHS workers may not know about permanent residency laws or that NHS workers post Brexit are likely to get visas or work permits if there is demand for them. As the House of Commons library states: "Following the vote to leave the European Union, the Health Secretary and senior NHS leaders have sought to provide reassurance to NHS employees from the EU that they continue to be welcome in the UK and have praised their huge contribution to the country". The "misleading stories" are why these NHS staff need this reassurance in the first place!
Many figures given for EU nationals working in the NHS are inaccurate at worst, often misleading at best.
- They don't account for the "Irish Effect" - counting Irish nationals as generic EU nationals, when the ROI/UK bilateral relationship is clearly relevant
- They are overstated - as an example London Mayor Sadiq Khan claimed that "10% of NHS workers are from the EU" during the highest profile Brexit debate at Wembley watched by millions (full disclosure: I was there). The real figure, as shown here is 4.13% after correcting for the Irish Effect, even then only 5.35% without this (so Sadiq was wrong by about 50,000, just under double the number of employees of Transport for London). Remember that Vote Leave apparently misled voters on "£350m for the NHS"* but a popular mayor with the biggest personal mandate in Europe misleading voters on national TV about a top priority issue for voters somehow didn't influence people to erroneously vote for Remain
- They don't account for role differences within the NHS - for EU nationals, relatively speaking, there is a higher reliance on doctors, but far less in the Ambulance Service. A very low % of NHS managers are non-British. This means any reliance is specific to certain NHS roles, with good workforce planning it can be managed
- They don't compare to the wider economy's reliance on non-British workers - the NHS is almost identical - i.e. It's not a specific NHS issue.
- They don't compare to other nations for context - e.g. Canada, Australia, New Zealand - all not in the EU and all have similar or higher reliance on foreign healthcare workers, based on OECD data. Others are in the EU yet have far lower foreign nationals (e.g. Italy and Poland). Yet they all somehow avoid "collapse"
*Vote Leave never literally claimed *all* £350m a week saved on EU membership fees would be spent on the NHS. In fact they published a detailed paper signed by Michael Gove and others saying that £200m a week should be spent on the NHS. This is almost never mentioned or even known by Remain supporters as it was barely reported. That said, £350m a week in total *being available to be spent elsewhere* is too high and misleading. The real figure is closer to ~£135m-£150m depending how you count UK foreign aid contributions. Change Britain (the successor to Vote Leave) is now saying £100m a week for the NHS.
Reliance on foreign nationals in the NHS is not an unqualified good
A number of those in favour of unlimited immigration generally, or at the very least "freedom of movement" within the EU seem to have fetishised the NHS's reliance on foreign workers to the extent that it is seen as having almost no downside. At least in a few examples, this isn't the case:
Healthcare professionals are removed from their home countries, who may desperately need it
- Greece: There are 1,665 Greek doctors working in the NHS in 2016. The number of greek doctors is the same as another 19 EU/EEA/EFTA nationalities combined and has more than doubled from 695 in 2009, i.e. post financial crash. The Greek healthcare system is in crisis due to EU-imposed austerity. Is this a good thing for Greece? Or a positive advertisement for the EU? Is the UK leaving the EU really the deciding factor for whether these Greeks return home, if ever?
- Malawi: Malawi has between 265 and 618 doctors in the entire country (with a population of 17.2 million; UN Population Division; 2015). The English NHS alone has 212 Malawian staff. Though only 22 of these are doctors, should we really be hoovering up Malawi healthcare staff for the NHS or encouraging them to stay home and help their fellow citizens? Note that Malawians outnumber quite a few EU/EEA/EFTA nationalities
- Sudan: Back in 2012 The International Red Cross said that South Sudan had only 120 doctors for a population of 9 million people. 388 Sudanese doctors work in the NHS. Good for us, but is it good for desperate people back home in Sudan?
Without sensible immigration controls, strain on public services is almost inevitable
Whilst EU free movement brings with it doctors and other NHS staff, it also brings with it everyone else, included a large majority of unskilled workers. The UK population is projected to rise by 500,000 a year over the next decade - a city the size of Liverpool every year, roughly 85% of this directly related to migration. This means we might get doctors, but we need to build more hospitals. We might get more GPs, but we need to build their surgeries. There is other strain on transport, technical infrastructure, schools, housing etc. Outside the EU, it is clearly possible to cut unskilled migration, whilst still granting work permits and residency to healthcare workers. One estimate of such a policy is that it would retain nearly all skilled EU immigration whilst reducing overall numbers by 100,000 a year. That would be a win-win, reducing strain on public services, not increasing it, whilst ensuring the NHS could retain & recruit the people they need.
Patient and staff communications can suffer
If English is not a first language it introduces additional risk into the NHS. Almost everyone working there has encountered badly written prescriptions, or staff not understanding instructions or training. This is why all NHS staff as of Jan 2016 have to pass the new English language test. As noted above, many/most trusts have even suggested this means Commonwealth or Rest of World recruitment will now be preferred to that from the EU/EEA (which rather implies a serious problem in recruiting staff without sufficient English language skills previously). Also, NHS figures suggest that non-UK born doctors are twice as likely to be struck off for disiplinary reasons.
A permanent reliance on foreign nationals reduces the incentive for the NHS & government to train UK nationals
It's not "nativist", "old fashioned", "populist" or "racist" to want to have a high % of home grown medical staff. What is wrong with aiming to have a similar level of domestic doctors as say, France? Or Italy? Or Germany? Nothing.
In fact, the NHS being "self-reliant" in UK doctors by 2025 is the official goal of the NHS. Whilst I wouldn't go this far as I think it is 0% non-British doctors is crazy & unrealistic (and this goal has been on the end of criticism from the British Medical Association and others), targeting levels similar to the OECD average, or those in Germany seems more than reasonable, given the other benefits it would have. If anything it is the more liberal and progressive option as it doesn't involve over reliance on medical staff from foreign nations that may have a shortage - e.g. Greece, Malawi and Sudan, or other less fortunate places in the world, whilst also improving patient safety.
Everyone should stop playing politics with the NHS, particularly when it comes to the after-effects of Brexit.
- The vast majority of EU nationals already have a permanent right to remain in the UK
- Irish EU nationals are 1/5 of NHS EU worker numbers and they will very likely be unaffected by Brexit
- Membership of a trans-national organisation is not required to have a successful healthcare service
- Focusing solely on EU nationals does a disservice to all of the other foreign born NHS workers
- Reliance on foreign nationals in the NHS is not an unqualified good
- Any likely future UK immigration policy would obviously prioritise healthcare workers, and may even still prioritise EU nationals
Anyone scaremongering about Brexit without pointing out some of these points is being irresponsible and damaging the NHS - which is exactly what they say they want to avoid.