Plugging the gap: How the NHS is “brain-draining” other countries for a quick fix to workforce problems


As the staffing crisis in the NHS continues to worsen, and health organisations routinely look abroad to plug gaps in their recruitment, Laura Sanders investigates the growing problems facing the sector, from a “hostile environment” towards immigrants to the growing concern in other countries about a medical ‘brain drain’ to the UK.

Filipino nurse caring for an elderly patient | Photo by Matthias Zomer on

With A&E waiting times at their worst in a decade, and the axing of NHS bursaries contributing to a drop in UK trainees replenishing the workforce, the NHS is facing a staffing crisis.

One of the largest sections of the NHS workforce is nurses. There are 50,000 vacancies for nurses alone at the moment, and the role has been on the UK’s shortage occupation list for almost four years.

“On current trends,” a joint report by the Nuffield Trust, The Health Foundation and The King’s Fund warns:

“In 10 years’ time the NHS will have a shortfall of 108,000 full-time equivalent nurses. Half this gap could be bridged by increasing the number of nurses joining the NHS from training.”

However, while educating, training and retention of the UK workforce remains a problem, the NHS has been looking overseas for a “quick fix” to plug the gap.

Brain draining the Philippines

Filipino nurses made up the largest proportion of NHS overseas nurses last year, with over 10,000 working here in the UK.

But the knock-on effect of such migration is that medical staff trained in the Philippines rarely stay to practice: one study found that 85 percent of the country’s nurses were working abroad in the UK, US and other countries.

The Filipino government does benefit from the trade — but income generated by expat workers does not necessarily go back into the healthcare system.

Jocelyn Andamo, Secretary General of Filipino Nurses United, says that remittances from overseas workers amount to 17 per cent of the GDP — but the Filipino government only invests 2 per cent of GDP in the health system, well below the World Health Organisation’s (WHO) recommendation of 5 per cent.

Manila, Philippines | Photo by Christian Paul Del Rosario on

3 in 5 patients dying without seeing a health worker

3 in 5 patients in the Philippines will die without seeing any medical personnel according to Jocelyn Andamo.

“The supply of nurses [in the Philippines]is not a problem,” she says — rather, it’s the retention of them.

Listen: From an internet café in Manila, Jocelyn describes what it’s like to be a nurse in the Philippines.

Playing by the rules on international recruitment?

The World Health Organisation (WHO) does have a Global Code of Practice on the International Recruitment of Health Personnel. The code provides guidance to member states for the ethical recruitment and mobility of health workers between source and destination country.

But an analysis of the code, in which the Philippines was one of the countries studied, found that:

“The Code does not have prominence in those countries that need it most, namely those still lacking sufficient health workers and experiencing ongoing out-migration of those they train.”

The same study also found that there was little to no awareness of the code of practice in destination countries, and it was “all but absent in policy documents.”

An interviewee from the study in India says that the code “has no teeth” with its voluntary status, and the analysis of the WHO code of practice concludes by suggesting the code be made more mandatory to member states.

Creating a sustainable health system: the case of South Africa

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Outward migration of health workers from South Africa has been on the decrease since the early 2000’s. One 2015 study says internal reforms were a contributing factor to the country retaining its workforce.

A significant spike in return migration in South Africa is credited to closing the gap between overseas wages and wages in the region in 2007 with Occupational Specific Dispensation (OSD).

“Nurses were the first to benefit from the OSD in 2007… Despite critiques of the program, the OSD has narrowed the gap between salaries at home and abroad and the OSD has been cited as one factor that appears to have slowed out-migration and promoted return, especially for nurses who registered significant improvements in their pay and benefits.”

Under OSD, skilled workers such as nurses are recognised for their professional development and paid accordingly. Work overseas is included

“With the introduction of OSD, we found some people coming back especially with the nurses because they were there in numbers. We found them coming back because… when OSD was introduced, it considered the previous experience [which included]the experience you had overseas so at least it was easy [for nurses]to come back.”

The situation is particularly stark when compared to Portugal where, according to Lucia Leite, nurses who have practised for up to 25 years could be getting paid the same as a newly qualified nurse.

“Spiralling extra charges”

Attracted to the UK by the prospects of better pay and career development, migrant health workers often take a leap of faith, leaving behind homes, families and culture.

But this leap is becoming bigger with the introduction of extra costs to work in the country.

In December 2018, MPs voted in favour of doubling a charge levied on non-European workers and their families to £400 per person.

The Immigration Health Surcharge (IHS) must be paid to have use of the NHS during their time in the UK — for each year of the working visa.

The £400 fee is equivalent to four months’ wages for a nurse in the Philippines. It has to be paid up-front and is charged in addition to tax and National Insurance that also funds health services.

“It’s too much,” says Kemi, a Nigerian nurse working in London.

Kemi migrated to the UK fifteen years ago, before the IHS was implemented. She feels that the charge could put other Nigerian nurses off coming.

The Home Office estimates the higher fee could raise an extra £220ma year for the NHS. But the Nursing and Midwifery Council are campaigning against the government’s decision, saying:

“The very people who deliver healthcare should be the last people to have to pay spiralling extra charges for it.”

When asked about the charge, a spokesperson from the Home Office responded:

“Although some temporary migrants will be paying tax and National Insurance contributions, they will not have made the same financial contribution to the NHS which most UK nationals and permanent residents have made. It is therefore fair to require them to make an up-front and proportionate contribution to the NHS.

“We value the contribution overseas nurses make to the health system; and nurses will benefit from a pay increase as set out in the Agenda for Change framework.”

With the UK government proposing to inject £20.5bn into the NHS by 2023/4 under the Long-Term Plan,experts are calling for a significant amount of this to be allocated to developing the workforce.

Could Brexit change the recruitment of overseas nurses?

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Since the referendum vote in 2017 to leave the EU, the number of EU health workers staying in the UK has dropped significantly.

Home Secretary Sajid Javid has now said he will review plans that require EU migrants to be earning a minimum of £30k to work in the UK.

But Lucia Leite, President of the Portuguese nursing union, Associação Sindical Portuguesa dos Enfermeiros, thinks that Brexit will not be an obstacle. She says:

“We know that the UK has reduced the number of [nursing]schools and nurses, so they will easily come and pick nurses [who are]already trained from Portugal.

“Brexit is happening because the UK wants to stop the levels of immigration which have been high for a long time, but the immigration they want to avoid is not from nurses, so I’m sure they will find a way to salvage the qualified professionals who are needed by the country.”

Translated by Teresa Conceicao.

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