Are "record numbers" of foreign staff quitting the NHS due to Brexit "xenophobia"?

New NHS data disproves the scaremongering. Again.

On Tuesday April 4 2017, NHS Digital published raw data showing the number of UK, European Union (EU) and Rest of World (RoW) nationalities who are working in the NHS (as of Dec 2016).

This provides an ideal opportunity to correct some of the recent misleading reporting about EU nationals & other foreign staff in the NHS.

In summary, despite what you may have heard:

The number of total NHS staff is going up steadily, twice as fast as the UK population

The number of European Union (EU) staff in the NHS is still increasing

The rate of growth of EU staff is slowing (for EU nurses especially)

“Rest of World” foreign NHS staff are increasing rapidly, to historic highs

The percentage of British nationals continues to fall, but may be poised to turnaround

The NHS is 24% less reliant on EU nationals than the wider economy

Needless to say, you might find these claims surprising if you’ve read any of the recent reporting claiming a “staffing crisis” due to Brexit and EU NHS staff leaving in "droves".

I’ll explain all of these fully and provide the NHS data to back them up.


Disclaimer: Note that none of the above means I'm claiming the NHS doesn't have any problems or other issues. I voted to Leave the EU, and I’m one of the 84% of the British public that think that all EU nationals currently living in the UK should be able to stay (as long as they are here lawfully). New UK immigration controls should apply to new arrivals. In my view these should be the same for everyone wanting to make the UK their home, wherever they are from, without any discrimination or bias towards EU nationals. You can also see my previous analysis of the entire NHS workforce by nationality - How reliant is the NHS on EU Nationals? (based on NHS data up until March 2016)


A case study in scaremongering from The Guardian

On 18 March, Daniel Boffey of the Observer/Guardian revealed  “shock figures”, that show "record numbers" of "EU nurses" quitting the NHS:

The number of EU nationals registering as nurses in England has dropped by 92% since the Brexit referendum in June [2016]”

“A record number [of EU nationals] are quitting the NHS”

There is a “haemorrhaging” of “foreign staff”

“Only 96 nurses joined the NHS from other European nations in December 2016 – a drop from 1,304 in July, the month after the referendum

Former Liberal Democrat Health Minister Norman Lamb is quoted calling the figures “shocking” and claims running the NHS is “incompatible” with “hard Brexit”. Janet Davies, Chief Executive of the Royal College of Nursing (RCN) says the UK government risks “turning off the supply of qualified nurses from around the world". For good measure and a twist of the emotional knife, a Spanish EU nurse (Joan Pons Laplana) is quoted as saying his children are worried he will be kicked out of the country even though he’s lived here for 17 years.

The Observer story was shared at least by at least 30K+ people on social media and likely read by several million. Various others weighed in afterwards, e.g. Polly Toynbee: “a threat to throw out people we absolutely cannot do without” (a reader comment on her piece: “Brexit means slinging out all foreigners”). Or Suzanne Moore: ‘EU nurses no longer want to work in Britain. Brexit is poisoning the NHS”.

But is any of this supported by the NHS's own data? 

Not really, no. There is some grain of truth to these claims, but most of them are extremely misleading, if not verging on outright hysteria.

This is swimming upstream versus a lot of mainstream coverage, so let me try and back up this view with the raw data from the NHS itself and a look at The Guardian's story in more detail.


Two Big Problems with The Guardian EU Nurses story

1. The Key claims are misleading.

2,700 EU nurses left the health service in 2016, compared to 1,600 EU nurses in 2014 – a 68% increase

Strictly speaking this is accurate, but it really shows the problem of cherrypicking statistics. It says nothing about how many EU nurses there are in total in the NHS, and without further context, implies the number of EU Nurses is falling

Using exactly the same years chosen for comparison by The Guardian, NHS data shows that the number of EU Nurses actually increased by 41% from 15,591 (Dec 2014) to 21,981 (Dec 2016).

Now, both The Guardian spin (record numbers of EU Nurses are leaving) and the NHS data (more EU Nurses are working in the NHS than ever before) can be true at the same time, but only including one of them in a story is quite misleading. In fact, even including both wouldn't really show what is happening: the rate of increase of NHS EU staff is slowing down, coming off an unusual and probably unsustainable peak. I'll show this in more detail shortly.

Haemorrhaging of foreign staff

This is simply false. Far from “haemorrhaging”, the number of "foreign staff" has increased by 3.98%. Whilst the rate of increase is slower than 2014-2015 (4.79%), it is higher than 2013-2014 (3.49%). Needless to say, nobody at The Guardian was complaining about this "problem" back in 2013, when there was also a genuine crisis in loss of Rest of World NHS staff, that dwarfs the current EU issues (see below for this).

2. Potential biases.

I only point out these potential biases out as a statement of the obvious, not to say that they automatically discredit the claims themselves - the NHS's own data does that anyway. For the sake of argument I’m happy to grant that every one of these possible biases isn't true. This is not something that some ardent Pro-Remainers would do, as many refuse to believe anything printed in “the tabloids” or the “Tory Press” and seem to think Leaver opinions should be automatically invalidated.

Author: Daniel Boffey isn’t a health/NHS correspondent, he is The Guardian's Brussels/EU correspondent, with quite a track record of pro-EU material. Other Guardian journalists, even when trying to put a negative spin on similar data, at least admit that "EU staff numbers rose across the period analysed", but Boffey doesn't.

Selective use of data: The use of the data is quite selective. For example, it compares the number of EU new joiners to the NHS in Dec with the number of new joiners in July. As most people know, very few people start a new job in Dec. The total number of EU NHS Nurses isn't mentioned and misleading percentages are used to paint the worst possible case. Only "Nurses" are referenced even though the NHS holds data on all EU staff - this is almost certainly deliberate given the wider picture of EU staff is quite different.

Sourcing: The source of the data is the intermediary of the Pro-Remain Liberal Democrats, who submitted a series of freedom of information act requests for all NHS Trusts in England. In fact, every named source or quote is someone who very likely voted to Remain in the EU - e.g. Norman Lamb or NHS Nurse Joan Pons Laplana. And on the subject of Mr Laplana - he should know full well that living in the UK for 17 years entitles him to a permanent right to reside, as the government has repeatedly stated this since the referendum result (any EU national living here lawfully for 5+ years has this right). I find it hard to believe Mr Laplana really keeps this information from his scared children, as he repeatedly claims - at least I hope not. And Mr Laplana is explicitly political - as well as being Pro-Remain, he spoke at the #MarchForEurope rally in London, and has claimed that due to Brexit, NHS workers might leave the UK to go work in Saudi Arabia instead.


Note: The Lib Dem FOI request also probably wasted the time and effort of the NHS, since this data on foreign nationals is routinely published in full anyway. The responses received via the FOI were also partial and didn’t cover the whole NHS.


Okay, what is really happening?

Based on the NHS Digital figures:

The Total number of NHS Staff has increased by 5.38% in 3 years.

NHS staff numbers have increased from 1,111,744 (Dec 2013) to 1,171,531 (Dec 2016). This is an increase of +5.38%, on a stable trajectory.

5.38% is more than twice as fast as overall UK population growth (over the same period, according to my analysis of ONS data, the overall UK population increased by 2.37% from 64.11m to 65.62m).

Needless to say this should calm at least a few people’s fears already - do you care if you are treated by an EU national, UK national or Rest of World national, as long as you get treated well? Now, perhaps 5.38% more staff still wasn’t enough of an increase given other rising demand but that’s a separate argument.

The number of EU NHS staff is still increasing...

EU NHS staff numbers have increased from 39,807 (Dec 2013) to 60,058 (Dec 2016). This is a huge +50.87% in just 3 years, which is tapering off after a dramatic rise between ’13-’15.

The NHS is continuing to add EU staff, though the number of new joiners is falling in the last year (14,467 compared to 15,440) and the number of leavers is increasing faster (9,023 compared to 7,477). That said, the NHS is still recruiting more new joiners from the EU throughout 2016 than it was in 2014.

...though the net increase has slowed, especially for EU nurses.

The net increase of EU NHS staff is slowing, and this is more pronounced by role, with Nurses slowing faster than Doctors and others. The overall trend in "other" EU staff refutes any claim of a generic "backlash" against EU nationals, which isn’t detectable in these figures. Why would nurses “not feel welcome” but support staff, technicians, ambulance workers and doctors still do? Nurse-specific racism?

The NHS is less reliant on EU nationals than the wider economy, but more reliant on RoW nationals

The percentage of British nationals in the NHS continues to fall, though more slowly than in previous years - it is now 87.75%. This is despite a net increase of +67,532 British nationals in just 3 years.

Despite stories that seem to imply that the NHS is uniquely reliant on foreign workers, the NHS has only 1.3% fewer British nationals than the wider UK economy (according to the ONS, 89.09% of workers are UK Nationals as of Dec 2016). This phenomenon is also relatively new - the NHS had more UK nationals compared to the economy as whole as recently as Dec 2013.

EU nationals as a percentage are starting to plateau out at 5.51%, after 3 years of very fast growth.

The percentage of Rest of World (of which a majority is from the Commonwealth) is starting to increase again after 3 consecutive years of decline, to 6.74%

This means that the NHS is 24% less reliant on EU workers than the wider economy, where 7.02% are EU nationals (ONS figures for Dec 2016). The NHS is however much more dependent on RoW nationals than the wider economy (6.74% versus 3.88%), which makes sense when you consider the number of Indian doctors, Filipino nurses and others.

Note that over 1/5 (22%) of EU NHS staff are from the Republic of Ireland, who have and will retain free movement rights after Brexit, whatever happens with the EU/UK relationship (due to the UK/ROI Common Travel Area). This causes an “Irish Effect” in discussions about EU nationals, especially when talking about possible restrictions on free movement. I discuss this at length in How reliant is the NHS on EU Nationals?

The share of EEA workers in health and social care is lower than the national average, so this is not actually a sector which is hugely exposed
— Professor lan Manning, Chair of the independent Migration Advisory Committee, Evidence given to House of Lords, 1 Nov 2016

The NHS is hiring a LOT more staff from the Rest of World, and more EU staff are leaving than before.

This is the part where the scaremongering has a few grains of truth - when we look at the number of joiners and leavers by nationality.

Yes, "record numbers" of EU staff are leaving the NHS - 9,023 in 2016, but one of the reasons for that is the huge, unsustainable numbers hired in 2014 and 2015. In the period between Dec 2013 and Dec 2015, the NHS had a net increase of EU staff 25 times larger than the rest of the world combined (14,807 versus 583).

Yes, less EU staff are joining the NHS - 14,467 in 2016 compared to 15,440 in 2015. But 1,528 more EU staff still joined the NHS in 2016 than in 2014.

Of particular note is that as recently as 2014, the NHS had a net loss of -549 Rest of World staff, this has been dramatically turned around and now there is a net increase per year of +3,274


Okay - Why is this happening?

It’s not racism or xenophobia. It’s just not.

Despite the British Medical Association publishing a blog in July 2016 about "the scourge of post-Brexit xenophobia", you can easily rule out “racism” or "xenophobia" as an explanation for these changes to the NHS workforce pretty much immediately. By far the largest increase in new joiners to the NHS is from Rest of World foreign nationals - its not even close. They are also by far the largest percentage change in net staff. The NHS is hiring 46% more RoW nationals per year than just a couple of years ago (11,499 in 2016 compared to 7,868 in 2013).

Try and reconcile such a large increase in RoW staff - e.g. from Pakistan, India, Nigeria, The Philippines - with racism. Or with "turning off the supply of qualified nurses from around the world", as claimed by the Royal College of Nursing Chief Exec.

It would certainly be a funny kind of racism or xenophobia that is against Lithuanians but has no problem with Nigerians, or is intolerant to Polish but not Filipinos. This is also supported by multiple independent data sources - 84% of the British public say they want all EU workers to stay in the UK, opinion polls ran by the European Union(!) say favourable British attitudes to immigrants increased after the referendum (the study of these polls in the LSE is titled 'Talk of a nonexistent ‘tide of hate’ against EU migrants does nothing to help their cause’) and Pew Research says that UK attitudes towards immigrants are "more uniformly positive" than many EU states.

Even if all of this is wrong, and die-hard Remainers are right that the UK has turned hostile to foreigners overnight, what is the explanation for that virulent xenophobia affecting EU NHS nationals - but nobody else from the rest of the world, who are flocking to the NHS? I don't think there is one. 

So, if it isn’t racism/xenophobia, what is it? Probably several reasons combined, in order of probable importance:

The IELTS English language test being introduced for EU/EEA nationals. 

The legal requirement for EU nurses and some other staff to be able to pass a comprehensive English language test was introduced on Jan 19 2016, well before Brexit and unrelated to it (following the vote to Leave, the requirements were slightly relaxed). Needless to say, for patient safety and inter-staff communication, NHS staff being able to speak/read/write English to a good standard is quite sensible, and supported by the British public, all UK political parties, charities like the Patients Association and the Head of the General Medical Council. The score required is also similar to entrance requirements to study at UK Universities (though some do claim that the pass rate is set too high, including English language NHS training providers).

The quality of medical professionals from some European countries left much to be desired…automatic entry to the GMC register, without assessment of competence in their specialty and in colloquial and medical English was a travesty
— British Association of Plastic Reconstructive and Aesthetic Surgeons (BAPRAS) – Written evidence (NHS0015) to House of Lords NHS Sustainability Committee

The IELTS requirements, according to NHS Trusts themselves, “pretty much rules out” most EEA recruitment. Trusts now say that there is little cost/effort difference between EU/EEA recruitment and Rest of World, with the bonus that Rest of World staff tends to have better retention rates (See How reliant is the NHS on EU Nationals? for more on this; RoW staff have had the IELTS requirements for longer).

This theory is backed up in the data showing that RoW recruitment also accelerated around the same time as the test was introduced, and the number of net new UK staff also started to stabilise and increase once again. It also shows how shocking it was for the NHS to hire 42K EU/EEA staff in a 3 year period. If as soon as the IELTS requirement is introduced, this same group of workers is then "ruled out" of future recruitment, what does it say about the quality of some of those recruits in the first place?

Over-reliance on EU nationals to fill NHS roles in previous years, particularly Nurses.

The House of Lords NHS Sustainability Committee recently carried out a 9 month investigation into the future of the NHS between July 2016 and April 2017. It heard testimony from dozens of NHS witnesses, and received thousands of pages of written evidence. The HoL report comes to the unequivocal conclusion that the NHS had too much reliance on overseas recruitment, due to poor workforce strategy:

Workforce strategy has been poor with too much reliance on overseas recruitment. … the Government should go to greater lengths to secure a reliable supply of well-trained professionals and other health and social care workers from within this country
— 'The Long-term Sustainability of the NHS and Adult Social Care', House of Lords Select Committee on Sustainability of the NHS, 5 April 2017

One of the reasons the report came to this conclusion is that the organisation representing all NHS employers, admitted that the NHS was playing a 'get out of jail free card' by over-relying on overseas recruitment over the last few years, which it had also been criticised for by the independent Migration Advisory Board.

What [our recruitment contingency] cannot be, we accept, is the “get out of jail free” card that the Migration Advisory Committee has rightly criticised us for playing in this last few years because we have not planned our services properly or planned our workforce properly
— Danny Mortimer, Chief Executive, NHS Employers, evidence given to House of Lords, 1 Nov 2016

The NHS nationality data is clear that "too much reliance on overseas recruitment" is really shorthand for EU recruitment, since as noted earlier, it went up by 25 times as much as RoW foreign nationals, with the largest spike in EU Nurses.

EU Nurse recruitment has also been subject to a number of newspaper exposes - for example, one investigation claimed that during 2013-2015 the NHS was paying recruitment agencies £2,000 per EU nurse, holding open day recruitment centres in lavish European hotels, ignoring nurses ability to speak/read English (e.g. using Google Translate to fill out application forms) and carrying out cursory interviews regarding their capability. It was also offering "joining bonuses" and even outbidding itself in competition between different trusts for the same staff.

None of this means the NHS was doing this out of malice - as well as bad planning, cuts to UK nursing bursaries and a conservative government target of reducing net migration to the tends of thousands (without the ability to control EU numbers) would both have contributed to this preference for recruitment within the EU.

Hysteria and scaring people for political purposes. Die-hard Remainers who will not accept the referendum result.

I sympathise with EU NHS staff who are worried about their future and looking for reassurance. But I have little tolerance for those exploiting their fears for political purposes, or to try and re-run the referendum result with tactics like these:

  • Selective use of data: The Lib Dem’s going on FOI fishing expeditions and The Guardian’s Brussels correspondent hyping up the resulting figures without any context, with this being reinforced by NHS recruitment agencies and bodies like the Royal College of Nursing
  • Vested interests in the status quo: NHS recruitment agencies (and NHS managers) have a vested interest in being able to continue to their existing business model of hiring health workers from low-cost EU states
  • Exaggeration and lies: Guardian columnists talking about virtually non-existent “threats” to “throw people out”. And really, this is an outrageous slur, completely unsubstantiated and contradicted by all public opinion polling, with not a single credible public figure in favour of this from any political party (even UKIP)
  • Misleading innuendo: People like Nick Clegg asking what would happen "if we asked all NHS staff to leave”. Who is asking? Anyone? (Don't say the handful of idiots like Britain First or the BNP with no realistic hope of ever winning more than a few council seats, never mind being in power to implement such policies)
  • People who should know better: NHS nurses themselves (e.g. Joan Pons Laplana) speaking at Pro-Remain rallies and writing Huffington Post op-eds about his unfounded fears about being deported
  • Various opportunist politicians: e.g. Scottish National Party MP Tasmina Ahmed-Sheikh asking if the government is considering "contingency plans" for "deportation” of EU nationals during high profile televised House of Commons sessions (resulting in audible groans of astonishment from everybody else)

And so on. If you keep talking about “hatred”, “deportations”, and “xenophobia” in places where NHS staff are likely to see and hear it (e.g. The Guardian, Independent, HuffPost, Financial Times) and on TV, radio and the internet 24/7, don’t be surprised if - in a self-fulfilling prophecy - some EU nationals start to believe it.

Following the EU referendum, thousands of EEA [European Economic Area] nationals working in the NHS and wider health and social care system have been left feeling uncertain as to whether they and their families will have the right to live and work here. One in four EEA doctors working in the UK have told the BMA that they are considering leaving following the referendum, with many feeling substantially less appreciated by the government
— Dr Mark Porter, British Medical Association Council Chair

The referendum itself and lack of unilateral guarantee for EU nationals.

Of course such a major political event as the EU referendum would cause uncertainty and worry in of itself, even if it wasn’t being exploited. This was compounded by the UK government’s decision not to unilaterally guarantee the status of all 3m+ EU nationals in the UK immediately after the result. 

That said, the UK government preferring to try and secure a deal for all 4m+affected (EU nationals in the UK, and UK nationals in the EU) is not wholly unreasonable, given that the UK’s responsibility is surely to its own citizens first. Plus the failure to secure a quick deal with the EU is down to the EU's refusal to negotiate anything before the triggering of Article 50 (which ironically, many Remainers tried to delay), something which has no basis in the treaties or law of the EU and was invented by the unelected Commission, later supported by states such as Germany and France. The EU is also now saying that a deal on EU/UK nationals is "many months" away, whilst the UK wants to secure it immediately. Needless to say, few Remainers are "demanding" the EU change its unreasonable position.

The NHS strategic objective to be self-reliant by 2025.

You would expect when a strategic target to be self-reliant within 10 years is set, that it would have an effect on the percentage split of NHS staff, with home grown British nationals increasing instead of others. This would explain the stabilisation of net staff increases for UK nationals. It doesn't explain the large increase in Rest of World staff though. It is worth noting that based on this data, the 2025 target is unlikely to be achieved as an extra “fast-tracked” 2,200 UK nursing places a year will not get the job done and the percentage of British nationals in the NHS isn't even rising yet.

We believe that, as the fifth-largest economy in the world, we have a moral duty to produce the healthcare workforce that we require for our National Health Service, and we should not be reliant on recruiting from other countries. That is absolutely not the same as saying that we do not welcome the opportunity for people from other countries to come and learn here and work with us
— Ian Cumming, Chief Executive of Health Education England (evidence given to House of Lords, 1 Nov 2016)

Small improvements in the European Union economies.

Many EU nationals have come to work in the NHS because of the disaster wrought on their countries by the financial crisis in the Eurozone. For example, the number of Greek doctors in the NHS increased by 140% between 2009-2016 (695 > 1,665). But in other places, such as Spain and Portugal, unemployment has been falling. This could explain some choosing to return home, for positive reasons.


Conclusion

The NHS is less reliant than the wider UK economy on EU nationals. Using it as a political football for the sake of undermining Brexit is a bad idea. That doesn't mean it isn't a good idea to give certainty and reassurance to the EU nationals who have already made the UK their home and the NHS their career. But that means the EU playing ball as well as the UK.

It is "morally" right that the UK tries to be as self-reliant as possible for providing its own healthcare workforce. We should not be relying on a 'get out of jail free card' that involves hiring Greek doctors and Spanish nurses because we don't have the ability to plan for and recruit enough home-grown NHS staff.

Foreign nationals are generally welcome in the UK, often more than other countries in Europe. But that means all foreign nationals, not just those from the EU/EEA. Focusing on just EU staff is pretty obviously political, mainly from those with an axe to grind over the referendum result. Personally, I value an Australian ambulance driver just as much as a German doctor.

Racism or xenophobia cannot be an explanation for the slowdown in the net increase of NHS EU staff, unless it is somehow precisely targeted at EU nationals and RoW foreign nationals are immune to it. A more plausible explanation, supported by NHS Trusts and the Migration Advisory Board, is the introduction of stricter English language requirements.

If you supported Remain: ask yourself if you are spending more time scaring EU/foreign nationals in the NHS rather than reassuring them? Nobody is mentioning "deportations" or calling for EU/EEA staff to leave - almost without exception, you are the only ones mentioning it. Your political leaders are constantly talking about it. And you only focus on EU/EEA staff, and not all of the other foreign nationals who make just as much of a contribution. I wonder why that is?

If you work in the NHS: give yourself a pat on the back. It's a hard job, and thank you!* (*unless you are involved in bad workforce planning of course).


*Note regarding NHS Digital data and terminology. In keeping with the terms used by the NHS and the data available, “NHS” in this blog means NHS England and “Nurses” also includes Health Visitors. The NHS data is for NHS Hospitals and Community Health Services for NHS Trusts and Care Commissioning Groups (CCG's). This excludes some support service staff as this data is published on a separate schedule, but it doesn't change the numbers or any of the conclusions in any meaningful way. Also,if you are wondering, EU/EEA numbers for "Social Care" staff are essentially no different than the wider NHS. Though anti-Brexit folks like to throw them about as they are numerically very high, only 5% of social care staff are EU/EEA, with 7 of the top 10 foreign nationalities being non-EU/EEA (the other 3 are Poland, Romania and ROI).