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Figures released this week by the Nursing and Midwifery Council show a 96% drop in the number of EU nurses applying for jobs in the UK after the Brexit vote in June 2016.  In July 2016, 1304 nurses joined the NHS from the EU.  This fell to 96 applications by December 2016 and a new low of 46 applications were received in April 2017.  Figures obtained by the Health Foundation from the Nursing and Midwifery Council suggest that 30,000 nursing positions in the NHS in England remain unfilled, representing almost 10% of the nursing workforce.  This comes on top of figures released in March 2017 which showed that over 17000 EU nationals left the NHS last year including both doctors and nurses.

The anti-immigration rhetoric that underpinned much of the Brexit campaign, along with the failure of the current government to assure the status of current EU migrants living in the UK and working in the NHS, is simply the most recent event amongst many that act to devalue this substantial portion of the workforce.

Prior to Brexit the 2010 Conservative/Liberal Democrat Coalition Government outlined plans to cap the number of non-EU migrants and apply transition controls for migrants from new EU countries.  Whilst only 5.5% of nurses in the NHS come from the EU, there is little doubt that this current exodus exacerbates the nursing shortage across the NHS which has built up through years of underfunding, pay freezes and the most recent removal of bursaries for students training as nurses.  This is encapsulated in the fact that 96% of registered trusts in the UK are not currently able to meet the numbers of registered nurses required for government assigned safe staffing levels within their services.  The RCN has called for a ‘summer of protest activity’ over the 1% pay cap and the Health Secretary Jeremy Hunt has hinted that the cap will be removed in the near future.    In March 2017 Janet Davies, Chief Executive of the RCN, said:

“The Government risks turning off the supply of qualified nurses from around the world at the very moment the health service is in a staffing crisis like never before. As she pulls the trigger to begin negotiations, Theresa May must tell EU nurses and other occupations that they are needed and welcome in the NHS. It would not survive without their contribution “.

The UK is far from the only country experiencing nursing shortages, however, and figures suggest a global shortage of health workers, estimated at a shortfall of 53,000 in UK, 40,000 in Australia and 275,000 in US in 2011. Indeed this is not just an issue in the UK, shortages in nurses in the US affects the supply of nurses in the developing nations targeted for international recruitment including Philippines and India.

Debates about the position of migrant workers within the NHS are not new.  Historians have repeatedly called for a recognition of the role that this, often devalued, sector of the health workforce, has played in the development of healthcare in the UK and of the NHS in particular.  The recruitment of doctors, nurses and other healthcare workers from overseas to work in our healthcare system predates the NHS.  From 1930s onwards governments have systematically and actively recruited doctors and nurses from overseas at times of staffing crisis.  Irish nurses had long been working in the UK and increasing numbers came post-1948 with the promise of better pay and working conditions in the newly formed NHS.

The unexpected success of the NHS and the rise in demand in the first years after its launch led to recruitment campaigns in 1949 which saw thousands more migrant nurses arriving in Britain predominantly from the Caribbean.  And it was not just nurses being welcomed in to the NHS, by 1957 12% of NHS doctors were mainly overseas trained, with the majority being Jewish or central European refugees from WW2.  In the 1960’s-70’s immigration controls were tightened but active recruitment of migrant workers for the NHS continued with a focus on skilled workers from the Indian subcontinent.

Similarly, in the early 2000’s there was another period with a recognised shortage of nurses and campaigns were designed to actively recruit nurses from Africa, India and the Philippines.  Between 2002 and 2006 over 14000 Philippino nurses were registered with the UK Nursing and Midwifery Council allowing them to work in the UK.  Putting aside the moral issues inherent in stripping developing countries of their desperately needed skilled health workforce, skilled migrant labour has been at the heart of the NHS from its inception.  In 2010, research evidence showed that ‘43.5% of nurses recruited to the NHS after 1999 were born outside the UK’.   Not all nurses are from developing countries however and large numbers of nurses from Australia, New Zealand and South Africa also work in the NHS.  By 2007 the single biggest supplier of nurses to the UK from the EU was Poland.

“Putting history to the forefront would help policymakers realize the significance of the NHS’s continuous dependence on overseas health workers and the need therefore both to improve equity and opportunity for such health workers and to integrate this fact of health manpower planning into national immigration policy.

It is argued that migration has not just underpinned the NHS but has shaped the ways in which services have developed.  Indeed, the NHS “could not have existed in the form that it took without overseas employees“.

British healthcare as we know it today is at least in part a product of international population movements and the National Health Service needs to be studied in its international context – skilled migration affects welfare provision, not just wealth creation”.

Clearly recent government initiatives on immigration, culminating in the Brexit referendum, have failed to address this, so where does this leave us?  Acknowledging the sociohistorical context of the migrant workforce within the NHS and the integral part they played in the development of the health service in the UK does not change the fact that the NHS is facing a crisis exacerbated by underfunding and a shift in the politics of immigration after the Brexit vote.  But failing to acknowledge this context risks further denigration of an already devalued and underappreciated group, and further escalation of the current crisis.