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Achieving workforce growth in UK nursing: Policy options and implications
Collegian (2009) 16, 3—9
available at www.sciencedirect.com
Achieving workforce growth in UK nursing: Policy options and implications James Buchan, MA(Hons) PhD ∗ Faculty of Health Sciences, Queen Margaret University, Edinburgh EH21 6UU, Scotland, United Kingdom Accepted 22 December 2008
Summary Objective: This paper examines how the National Health Service (NHS) in the UK achieved significant nursing workforce growth during the period between 2000 and 2006 and discusses the policy implications of the methods used to achieve this staffing growth. Methodology: Data analysis, literature review and policy analysis. Results: NHS nurse staffing growth was approximately 25% over the period 1997—2007, with most growth occurring in the years between 1999 and 2005. Whilst increases in intakes to home-based pre-registration education was a factor in achieving growth, the pace and level of growth which occurred was only possible by using active international recruitment, which was adopted as a deliberate national policy. The numbers of nurses and midwives entering the UK from other countries increased rapidly from 1999 onwards, to a peak in 2002, and then reduced markedly in the period from 2005 onwards. The policy of supporting international recruitment shifted rapidly in late 2005/2006 when financial difficulties hit the NHS and staffing growth was curtailed. Discussion: Active international recruitment can contribute to health sector staffing growth, assuming the recruiting country has the resources to recruit and can tap into international markets, but it may not be effective in addressing all types of skills shortages. If it is not well linked to other components of workforce planning it may cause difficulties of over expansion, as well as raising broader issues of the ethics and impact. © 2009 Royal College of Nursing, Australia. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.
Introduction This paper examines the policy interventions used to achieve a rapid growth in the size of the nursing and midwifery
∗
Tel.: +44 131 474 0000. E-mail address: [email protected].
workforce in the National Health Service in the United Kingdom over the period from 2000 to 2006, and the subsequent impact and policy implications of this growth. The paper will have some resonance for policy makers in Australia. Firstly, the UK and Australian labour markets are well connected—–thousands of nurses move between the two countries every year. Policies in one country can have a knock on in the other. Secondly, the policy focus on staffing growth in the UK NHS earlier this decade bears some
1322-7696/$ — see front matter © 2009 Royal College of Nursing, Australia. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.
doi:10.1016/j.colegn.2008.12.005
4 similarities to current policy debate in Australia, about how best to deal with nursing shortages in order to enable changes and expansion in health service delivery. Thirdly, the political may have become personal. Alan Millburn who was the ‘‘Blairite’’ Secretary of State for Health in the UK during part of this period of staffing growth, was more recently involved as an adviser to the Australian Labor Party in the run up to Labor’s success in the November 2007 election; Millburn is reportedly a ‘‘best mate’’ of Prime Minister Rudd (Jackman, 2008, p. 240). The paper is in three sections: • The UK nursing and midwifery labour market section outlines the overall nursing labour market dynamics in the UK, • Growing the workforce: policy options section identifies the key policy interventions which were aimed at achieving nursing and midwifery growth and analyses their impact; in particular it reports on a massive increase in the size and scale of the international recruitment of nurses and midwives to the UK, and • Policy issues and implications section discusses policy implications and lessons to be learned.
The UK nursing and midwifery labour market The UK has devolved government, but a single overarching regulatory model for health professionals. This means that there are health policy variations and policy divergence across the four UK countries of England, Northern Ireland, Scotland and Wales, but nurses and midwives are registered at a UK level. As such, it has a single regulation system of the type that Australia is currently moving towards. The UK has a population of 56 million, and most healthcare is organised and delivered through the National Health Service (NHS). The UK NHS is funded from taxation and free at the point of delivery. As with any health care system, the NHS is a labour-intensive service industry. There is some private sector health provision, mainly in care homes and nursing homes, with a small independent acute sector that provides elective care. Currently, there are approximately 670,000 nurses and midwives on the UK Nursing and Midwifery Council (NMC) register. Of these, about 400,000 are employed in the NHS throughout the UK (of which the vast majority are in the NHS in England, the largest of the four UK countries), and perhaps 100,000 in other jobs and sectors (Buchan & Seccombe, 2008). There has been rapid growth in the numbers of nurses and midwives employed by the NHS over the last ten years, as a direct result of government policies aimed at achieving staffing growth. A Labour government under Tony Blair was elected in 1997, coming into power after a long period of conservative rule—–creating expectations for change which mirrored those in Australia, ten years later in November 2007. One of the key planks of the Labour agenda was to ‘‘modernise’’ the National Health Service, with the aim of reform and expansion of health services—–the so-called ‘‘NHS Plan’’ (Department of Health, 2000a). Shortages of skilled staff were highlighted as one of the main obstacles
J. Buchan Table 1 Whole time equivalent and per cent change in the NHS qualified nursing and midwifery workforce, 1997—2007, four UK countries (September) (data for Scotland is 2006).
England Scotland Wales Northern Ireland
1997
2007
% Change 1997—2007
246,011 35,245 17,228 11,508
307,628 41,004 21,443 13,345
25 17 (2006) 24 16
Sources: England: non-medical staff census, The Information Centre, NHS. Northern Ireland: DHSSPSNI; data is for March. Scotland data: ISD Workforce Statistics. Wales: SDR 43/2008. Note: per cent figures are rounded. Scotland data is for 2006; in 2007 data collection was re-calibrated and it is not possible to conduct a like-for-like comparison.
to achieving this planned reform and growth (see Wanless, 2001). The response by UK government was an explicit commitment to ‘‘grow’’ the NHS workforce, made highly visible by establishing national level ‘‘top down’’ targets for NHS nurse staffing growth, such as the first target set in the year 2000 for ‘‘20,000 more qualified nurses by 2004’’, which was followed by a later commitment to further growth of 35,000. The workforce related elements of the NHS Plan were set out in a national NHS HR strategy (Department of Health, 2002). NHS workforce data from the four UK countries highlights that significant levels of overall nurse staffing growth have been achieved over the period 1997—2007 (Table 1, below; some caution is required in interpreting data as definitions vary in the four countries and across time). England, the largest of the four UK countries, has seen staffing growth of about 25% across the ten-year period. However the growth has not been consistent across the period. Fig. 1 shows the staffing growth in England for registered nurses and midwives since 1997. The lack of growth in more recent years contrasts markedly with the rapid pace of growth in the earlier period, between 2000 and 2004. Generally speaking the last two to three years have seen flat-lining in overall NHS qualified nurse staffing numbers, after rapid growth in the late 1990s and the earlier part of this decade.
Figure 1 England: NHS qualified nursing workforce-% growth, 1997 = 100. Source: Department of Health, Information Centre, Leeds, UK.
Achieving workforce growth in UK nursing: Policy options and implications
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Figure 2 Number of new entrants to the UK nursing register from UK education sources, 1990/1991—2006/2007. Source: NMC annual reports; Nursing and Midwifery Council, London.
How was this rapid growth achieved, over the period up to 2005/2006? Essentially policy makers had four options when they want to increase the supply of NHS nurses and midwives: • ‘‘grow their own’’, by increasing the numbers in preregistration education; • improve retention of the current workforce; • attract back ‘‘returners’’, who have the qualifications but are not currently working; • recruit internationally; A fifth policy option is to act on demand rather than supply, by improving productivity of the current workforce so as to reduce the need for staffing growth. This was also identified as an intervention, but is not the focus of this paper. Nurse education in the UK is delivered by the public sector and funded by the public sector. Given the government funds education, and is the main employer, it has significant policy leverage. It also determines policy on immigration which gives it additional influence on international recruitment; this latter point proved to be of significance as these options for growth were reviewed. The next section examines the impact of these options, focusing mainly on data on growth and change in the NHS in England.
Growing the workforce: policy options Increasing the numbers in pre-registration education The Labour government, when elected in 1997, began to increase funding for pre-registration nurse education, reversing a downward trend earlier in the decade. Data on the number of new entrants to the UK nursing and midwifery register from training in the UK shows an upward trend since the late 1990s (Fig. 2), with the number of new nurses and midwives entering the UK register from UK training in 2006/2007 being the highest it had been at any recent time.
Retention The NHS policy emphasis on improving nurse retention included introducing a new accreditation system for NHS organisations which focused on the provision of flexible hours, improved access to education, and staff involvement (‘‘Improving Working Lives’’) (Department of Health, 2000b); and a new pay system and career structure called ‘‘Agenda for Change’’ (Department of Health, 2004a) (in practice, the latter was not fully implemented until 2006). Measuring the impact of new initiatives on retention is constrained both by the difficult of demonstrating causality, and because data on NHS nurse retention has been limited and incomplete. Until recently, the main published source of data has been an annual survey conducted by the Office of Manpower Economics on behalf of the pay Review Body (OME, annual). This survey examines the number of nurse ‘‘joiners’’ and ‘‘leavers’’ and estimates both a turnover rate (the number and % of nurses and midwives changing jobs and locations, including those moving between NHS organsiations), and a wastage rate (the number and % of leavers, excluding transfers to other NHS employment, but including those retiring). However the survey has had varying, and diminishing, response rates in recent years. Headline wastage data from the OME suggests that the annual wastage rate has been around 8—9% in recent years. Analysis of the annual data gives no indication of any significant improvements in the annual wastage rate of NHS nurses and midwives across the time period of the early/mid decade. Given the limitations in the data it is not possible to be certain that the policies designed to improve retention have had an effect; what can be stated is that the available national data from the relevant period gives no indication of any marked or consistent improvement in retention of NHS nurses and midwives or reduction in wastage.
Returners Encouraging nurses and midwives to return to NHS employment was another key element in NHS policy. A ‘‘returner package’’ providing free refresher training and financial
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J. Buchan
support of £1000 (£1500 for midwives) during training was introduced in 2001 to encourage more returners. However there was little data collated on returners and it is difficult to make an accurate assessment of their actual contribution to achieving staffing growth. Analysis of available data (Buchan & Seccombe, 2005; O’Dowd, 2004) suggests that in the earlier part of this decade on average about 3800 nurses, midwives and health visitors were returning annually to the NHS in England via return to practice schemes, but there was no indication of any upward trend across the period from 2000 to 2004.
International recruitment The data examined above highlights growth in the numbers of nurses and midwives entering the UK register from UK training. This reflected the increased funding for training places—–but with a three to four year time lag before any funding increase began to have a payback with these new trained nurses and midwives entering the workforce. The limited data available on retention and return does not suggest a step change in improvement in the impact of policies in this area—–at an aggregate national level at least. This leaves the fourth option—–active international recruitment. There was a determined and co-ordinated effort to increase the numbers of nurses and midwives being recruited from other countries to work in the UK. Commenting on the rapid policy focus on international recruitment, he HR Director of the NHS noted ‘‘. . . we knew that we did not have enough input of nurses and doctors [from domestic sources] to deliver the capacity that was required to achieve the main objectives of improving access. Thus we set up the international recruitment programme. . .’ (Health Committee, 2007, p. 27). International recruitment activity was conducted by both the NHS and employers in the private sector. Any nurse who wishes to practice in the UK must be registered with the Nursing and Midwifery Council (NMC). As noted earlier, the registration process is via a single authority for the whole of the UK. Data from the NMC professional register can be used to assess trends in the numbers of non-UK trained nurses and midwives who are registering to practice in the UK for the first time. There are two main categories of applications—–nurses and midwives from other European Union (EU) countries, and nurses and midwives from other, non-EU countries. The first group is applications from individuals with first level nursing or midwifery qualifications from the other countries of the European Union (EU)/European Economic Area (EEA). These nurses and midwives have the right to practice in the UK because of mutual recognition of qualifications across the countries of the EU/EEA. As such, they can register in the UK via the European Community Directives. The second group is nurses and midwives from all countries outside the EU wishing to practice in the UK, who have to apply to the NMC for verification of their qualifications in order to be admitted to the Register. Most nurses and midwives from outside the EU, including Australia, will also have to apply for, and be granted a work permit to take up paid employment in the UK (some younger nurses from the Australia and some other Commonwealth countries qualified for access on working holidaymaker schemes).
Figure 3 Admissions to the UK nursing register from EU countries and other (non-EU) countries 1993/1994—2007/2008. Source: Nursing and Midwifery Council, UK. Note: 2007—2008 data are provisional.
There are limitations in using registration data to monitor inflows to the UK. It only records the fact that the nurse has been registered, it does not show when she or he actually entered the UK, nor does it indicate what the nurse is actually doing. As such, it is a measure of serious intent to practice in the UK, rather than necessarily an indicator that the nurse is actually working in the UK. Even so, trends in this registration data over time gives an insight into the level of interest in working in the UK and highlights any relative shift in the balance of ‘‘source’’ countries from which applications for registration have come. Fig. 3 presents the registration data over the period from 1993 to 2008; data for the most recent year are provisional. It is clear that the inflow of nurses and midwives to the UK, as measured by registration data, rose rapidly in the period 1999—2002 but has since declined year on year. The significance of international inflow is highlighted in the year 2001/2002. In that year more nurses and midwives joined the UK register from non-UK sources than from UK training—– in other words, in that year, the UK had become more reliant on international sources for new registrants than it was on recruits from its own education system. How was the NHS able to ramp up international recruitment activity so quickly and significantly? It had some competitive advantages—–NHS pay rates for nurses and midwives were relatively attractive; it could connect in with, and exploit, a large English speaking network of countries; it had a health system that was being funded for growth up to 2006. It was also able to develop some economies of scale in recruitment activity, as well as fine-tune policies so that its recruitment practices were increasingly effective—– and could be presented as having an ethical dimension. The methods used by the NHS to recruit nurses tended to be based on recruiting ‘batches’ of ten, twenty, fifty or more at a time from a specific country, often using recruitment agencies (Buchan & Seccombe, 2005). The recruitment activity of individual NHS hospital employers was supported by a regional network of international recruitment co-ordinators. There was support for co-ordinated large-scale recruitment, rather than for each NHS employer to recruit independently.
Achieving workforce growth in UK nursing: Policy options and implications Active recruitment was also supported by bilateral country-to-country agreements on nurse recruitment. At various times, government-to-government agreements to support UK recruitment of health professionals existed between the UK and India, the Philippines, Spain, China and Indonesia (the latter apparently was never operationalised). The growth in the UK international recruitment activity led in turn to a growth in recruitment agency activity, and in the number of agencies. The Department of Health established a list of ‘‘preferred’’ recruitment agencies (Department of Health, 2004b) focused NHS recruitment efforts through a group of agencies that have been approved as having an ‘‘ethical’’ and effective approach. The Internet was also used as a source of information on NHS employment opportunities, and as a portal for international recruitment. At the height of the recruitment activity there were dedicated websites for Spanish nurses, for Indian nurses, and for Filipino nurses. At its peak in 2002, more than 16,000 non-UK nurses and midwives were registering to practice in the UK for the first time, up from less than 4000 only five years earlier. The rapid growth was followed by three years of relatively high levels of registration, and then by an equally rapid decline. By 2007/2008 the number of international registrants was back below the 5000 mark. The four most important source countries for nurses and midwives across the peak years were the Philippines, India, South Africa, and Australia. In the last few years however there has been some increase in inflow from EU countries. This reflects eastward expansion in the EU, with ten new states joining in 2004, and a further two in 2007. The new states which have joined the EU have also entered a free market—–appropriately trained nurses and midwives from these new EU states have the right to move west, to longer established EU countries that pay more for their services, and provide better career opportunities. Poland in particular has now become a more prominent source of new registered nurses in the UK. In 2007 more Polish nurses joined the UK register than did Australian nurses. Inflow of new registrants in the peak years earlier this decade reflected active recruitment efforts by the NHS and other UK employers; the more recent decline in numbers has been an outcome of tighter fiscal situation in the NHS. Financial problems hit parts of the NHS in 2005/2006, leading to recruitment freezes, and overall NHS funding has not grown at the same levels as earlier this decade (Buchan, 2007; Buchan & Seccombe, 2006). One policy response was to end active international recruitment. The Department of Health announced in 2006 that the main categories of nursing employment were to be removed from the ‘‘shortage’’ occupations list which facilitated obtaining a work permit. As such, entry to the UK as a nurse then became much more difficult for applicants from outside the European Union. A second factor has also impacted on inflow, which reflected changes in regulatory policy rather than government policy. Whilst the recent reduction in the number of international nurses and midwives entering on the UK register is mainly a result of declining demand in the UK, it is also partly due to the effect of new NMC requirements. The NMC has increased its English language test requirements for all non-EU nurses and midwives (including those
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Figure 4 UK registered nurses applying for verification to move to practice in Australia; Nurses from Australia who registered in the UK, 2000—2007. Source: Nursing and Midwifery Council, UK, annual reports.
from English speaking countries) and has also introduced a new Overseas Nurses Programme (ONP) for non-EU nurses, which has added to the time and expense of obtaining UK registration. (EU nurses and midwives are not required to have passed the IELTS test, and do not have to take the ONP). The impact of these changes in policy can be illustrated by looking at the number of Australia-based nurses and midwives registering to practice in the UK; compared to the number of UK-registered nurses and midwives asking for their registration to be verified to practice in Australian states (Fig. 4). There has been a marked shift in the balance of this ‘‘inflow/outflow’’ across the period since 2002. There has been a significant decline in the number of Australianbased nurses and midwives registering in the UK, from an annual figure in excess of 1000 down to less than 300; whilst there has been an doubling in the number of UK-based nurses and midwives applying to move to Australia—–from about 2000 per year to 4000 per year. The decline in potential moves from Australia to the UK is likely to reflect both the reduction in active recruitment to the UK, and a drop in interest in moving to the UK—–because it is more difficult and costly to enter, and because job opportunities have declined. In summary, when assessing the combined effects of the four policy interventions to increase the supply of NHS nurses and midwives, the following can be concluded. Firstly, the increase in the intakes to UK-based pre-registration education, whilst making a major contribution, has only succeeded in bringing intakes back to the levels of the early 1990s, and inevitably had a time lag between funding and effect; secondly that the allocation of resources to support returners has apparently maintained a relatively consistent annual officially measured ‘‘return’’ (in England at least), and thirdly that any assessment of improvement in retention of NHS nurses and midwives is impossible to make at national level (but one national survey suggests at best that there has been no reduction in wastage of registered nurses and midwives). This pinpoints that the fourth intervention, the policy led approach to international recruitment is where there has been the clearest and least ambiguous growth in recent years—–a fivefold annual increase in the inflow of nurses and midwives to the UK, to an average of 14,000 per annum in the last few years. International recruitment made a major and critical contribution to NHS nurse staffing growth.
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Policy issues and implications International recruitment has attractions for policy makers; it also has potential limitations as well as policy repercussions. In this section the main policy related challenges of the approach used in the NHS are discussed, and lessons for other countries are identified. The lessons learned are of some relevance to Australia, which has in the recent past been debating the notion of national ‘‘self-sufficiency’’ in health workforce terms (COAG, 2006), and which currently in some States is examining an increase in active international recruitment of nurses and midwives. The first point to highlight is that one of the reasons that active international recruitment was so attractive to policy makers in the UK was that it offered a ‘‘quick fix’’— –the nurses and midwives had been trained elsewhere, at someone else’s expense and can be recruited and working in the UK within a few months, not the four years it would take to commission and train a UK educated nurse. The NHS exploited its market position as a relatively well paid location for English speaking nurses and midwives, to stimulate high levels of international inflow of nurses and midwives in the period from 1999 to 2004. Australia is in a similar position. International recruitment also offered some flexibility to UK policy makers. If and when funded demand for nurses and midwives in the UK faltered or reduced, the numbers of international recruits could also be reduced, virtually overnight. Speaking in 2006, the then Secretary of State for Health noted ‘‘The advantage of the managed migration policy is that where shortages arise — and there are shortages in specialist jobs in the NHS — they can be included in the shortage category so that employers can obtain work permits for nurses from abroad. This is a flexible system that can respond to our own labour market.’’ (Secretary of State for Health, Hansard, July 18, 2006). Rapidity and flexibility in response to the need to ‘‘scale up’’ the workforce makes international recruitment an attractive proposition for policy makers, as does the potential to avoid some of the financial risk of funding the basic training of the staff you subsequently recruit. It does however have several limitations. Firstly, the NHS approach, which relied on top down staffing growth targets did not have sufficient fine tuning to necessarily recruit the international nurses and midwives with the skills that were most in demand, or allocate them to the geographical/organisational locations where their skills were most needed. The vast majority of internationally recruited nurses and midwives were recruited to worked in basic grade clinical posts in hospital-based care in large urban areas. Relatively few midwives were recruited internationally; the vast majority of recruits were registered as nurses. International recruitment did very little to solve shortages in some specialities, such as intensive care, where there were international shortages, or others in community nursing and midwifery, where few other countries produced staff who met UK regulatory requirements (Buchan & Seccombe, 2005). Secondly, as well as being a relatively blunt instrument, international recruitment was also not well connected to other nurse workforce planning activity, and contributed to staffing over-expansion, and subsequent NHS financial diffi-
J. Buchan culties. In 2007, the Health Committee of the UK Parliament published an inquiry on NHS workforce planning (Health Committee, 2007). It characterised overall NHS workforce planning in the NHS as a ‘disastrous failure’ and pointed to a lack of strategic planning by the Department of Health as a factor in NHS employers recruiting ‘‘far more staff than they could afford to pay’’ (Health Committee, 2007, p. 289). They also argued that ‘‘Many new staff were recruited from overseas because of limited availability of UK staff. Eventually, many organisations recruited more staff than they could afford to pay. This was a major cause of the widespread deficits which emerged across the NHS from 2004 to 2005 onwards’’ (Health Committee, 2007, p. 72). Thirdly, there is an important ‘‘ethical’’ dimension to international recruitment activity, both in terms of how international recruits are treated, and how recruitment activity is managed in relation to impact on developing countries. As noted earlier, the UK largely ‘‘shut the door’’ to nonEU international nurses and midwives in 2006 when planning failures and financial over—–expansion led to a significant loosening in the UK nursing labour market. The rapid swing away from active international recruitment after 2005/2006 created difficulties for some nurses and midwives who had either recently arrived in the UK or were at that time in the process of recruitment—–they could find that their work permit would not be renewed, or they may have applied for registration in the belief that jobs were still plentiful and have found they had entered into the registration process but could not then obtain employment. Their difficulties were highlighted in the recent House of Commons Health Committee report on NHS Workforce Planning (Health Committee, 2007, pp. 39—40). The broader ‘‘ethical’’ issue related to international recruitment is its impact on under-resourced developing countries. Recruitment of scarce nurses and midwives and other health professionals from the developing world has been controversial, as it can contribute to brain drain (World Health Organisation, 2006). After concerns being raised by Nelson Mandela and others, the Department of Health in England attempted to limit the potential negative impact of its international recruitment activity. It first established guidelines in 1999 (Department of Health, 1999), which required NHS employers not to target South Africa and the West Indies. It then introduced a Code of Practice for international recruitment for NHS employers (Department of Health, 2001). This Code was strengthened in 2004 and now covers the NHS, and recruitment agencies, temporary staff working in the NHS, and private sector organisations providing services to the NHS (Department of Health, 2004b). The Code requires NHS employers and recruitment agencies not to actively recruit from named countries on a list of developing nations. Evaluation of the impact of the Code (Buchan, McPake, Rae, & Mensah, 2007) has highlighted that it has had an effect in focusing recruitment efforts on ‘‘approved’’ countries, but that an absence of systematic monitoring of NHS international recruitment activity has meant that it is not possible to conduct a detailed assessment of its impact. This paper has highlighted that active international recruitment can be a quick fix policy if a country has market advantages to exploit, but that if the international recruit-
Achieving workforce growth in UK nursing: Policy options and implications ment activity is not well integrated with other aspects of workforce planning it can be a factor in uneven distribution of new staff, and can potentially contribute to over expansion in staffing growth. It also has to be managed within a wider policy context of global health and global politics, and is at odds with any notions of national ‘‘self-sufficiency’’ in health workforce terms.
References Buchan, J. (2007). International recruitment of nurses: Policy and practice in the United Kingdom. Health Services Research, 42(3), 1321—1335. Buchan, J., McPake, B., Rae, G., & Mensah, K. (2007). The Impact of the Department of Health, England Code of Practice on International Recruitment. Edinburgh: Queen Margaret University. Buchan, J., & Seccombe, I. (2005). Past trends future imperfect?: A review of the UK nursing Labour Market in 2004/5. London: Royal College of Nursing. Buchan, J., & Seccombe, I. (2006). From boom to bust. London: Royal College of Nursing. Buchan, J., & Seccombe, I. (2008). An incomplete plan. London: Royal College of Nursing. Council of Australian Governments. (2006). COAG Response to the Productivity Commission Report on Australia’s Health Workforce. COAG communiqué, 14 July. Department of Health. (1999). Guidance on international recruitment. London: Department of Health.
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Department of Health. (2000). The NHS plan: A plan for investment, a plan for reform. London: Department of Health. Department of Health. (2000). Improving working lives standards. London: Department of Health. Department of Health. (2001). Code of practice for NHS employers involved in International recruitment of healthcare professionals. London: Department of Health. Department of Health. (2002). More staff working differently. London: Department of Health. Department of Health. (2004). Agenda for change, final agreements. London: Department of Health. Department of Health. (2004). Code of practice for the international recruitment of healthcare professionals. London: Department of Health. Health Committee, House of Commons. (2007). Fourth report: Workforce planning, 22 March 2007 HC 171-1. London: The Stationary Office. Jackman, C. (2008). Inside Kevin O7. Melbourne: Melbourne University Press. O’Dowd, A. (2004). Return to practice ad sparks 2000 calls. Nursing Times, 100(33), 7. OME (Annual 2000—2006). Workforce survey results for nursing staff, midwives and health visitors. London: Office of Manpower Economics. Wanless D. (2001). Securing our future health: Taking a long term view (p. 183). Interim Report, November. London: Public Enquiry Unit, HM Treasury. World Health Organisation. (2006). Working together for health: World Health Report 2006. Geneva: World Health Organization.
available at www.sciencedirect.com
Achieving workforce growth in UK nursing: Policy options and implications James Buchan, MA(Hons) PhD ∗ Faculty of Health Sciences, Queen Margaret University, Edinburgh EH21 6UU, Scotland, United Kingdom Accepted 22 December 2008
Summary Objective: This paper examines how the National Health Service (NHS) in the UK achieved significant nursing workforce growth during the period between 2000 and 2006 and discusses the policy implications of the methods used to achieve this staffing growth. Methodology: Data analysis, literature review and policy analysis. Results: NHS nurse staffing growth was approximately 25% over the period 1997—2007, with most growth occurring in the years between 1999 and 2005. Whilst increases in intakes to home-based pre-registration education was a factor in achieving growth, the pace and level of growth which occurred was only possible by using active international recruitment, which was adopted as a deliberate national policy. The numbers of nurses and midwives entering the UK from other countries increased rapidly from 1999 onwards, to a peak in 2002, and then reduced markedly in the period from 2005 onwards. The policy of supporting international recruitment shifted rapidly in late 2005/2006 when financial difficulties hit the NHS and staffing growth was curtailed. Discussion: Active international recruitment can contribute to health sector staffing growth, assuming the recruiting country has the resources to recruit and can tap into international markets, but it may not be effective in addressing all types of skills shortages. If it is not well linked to other components of workforce planning it may cause difficulties of over expansion, as well as raising broader issues of the ethics and impact. © 2009 Royal College of Nursing, Australia. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.
Introduction This paper examines the policy interventions used to achieve a rapid growth in the size of the nursing and midwifery
∗
Tel.: +44 131 474 0000. E-mail address: [email protected].
workforce in the National Health Service in the United Kingdom over the period from 2000 to 2006, and the subsequent impact and policy implications of this growth. The paper will have some resonance for policy makers in Australia. Firstly, the UK and Australian labour markets are well connected—–thousands of nurses move between the two countries every year. Policies in one country can have a knock on in the other. Secondly, the policy focus on staffing growth in the UK NHS earlier this decade bears some
1322-7696/$ — see front matter © 2009 Royal College of Nursing, Australia. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.
doi:10.1016/j.colegn.2008.12.005
4 similarities to current policy debate in Australia, about how best to deal with nursing shortages in order to enable changes and expansion in health service delivery. Thirdly, the political may have become personal. Alan Millburn who was the ‘‘Blairite’’ Secretary of State for Health in the UK during part of this period of staffing growth, was more recently involved as an adviser to the Australian Labor Party in the run up to Labor’s success in the November 2007 election; Millburn is reportedly a ‘‘best mate’’ of Prime Minister Rudd (Jackman, 2008, p. 240). The paper is in three sections: • The UK nursing and midwifery labour market section outlines the overall nursing labour market dynamics in the UK, • Growing the workforce: policy options section identifies the key policy interventions which were aimed at achieving nursing and midwifery growth and analyses their impact; in particular it reports on a massive increase in the size and scale of the international recruitment of nurses and midwives to the UK, and • Policy issues and implications section discusses policy implications and lessons to be learned.
The UK nursing and midwifery labour market The UK has devolved government, but a single overarching regulatory model for health professionals. This means that there are health policy variations and policy divergence across the four UK countries of England, Northern Ireland, Scotland and Wales, but nurses and midwives are registered at a UK level. As such, it has a single regulation system of the type that Australia is currently moving towards. The UK has a population of 56 million, and most healthcare is organised and delivered through the National Health Service (NHS). The UK NHS is funded from taxation and free at the point of delivery. As with any health care system, the NHS is a labour-intensive service industry. There is some private sector health provision, mainly in care homes and nursing homes, with a small independent acute sector that provides elective care. Currently, there are approximately 670,000 nurses and midwives on the UK Nursing and Midwifery Council (NMC) register. Of these, about 400,000 are employed in the NHS throughout the UK (of which the vast majority are in the NHS in England, the largest of the four UK countries), and perhaps 100,000 in other jobs and sectors (Buchan & Seccombe, 2008). There has been rapid growth in the numbers of nurses and midwives employed by the NHS over the last ten years, as a direct result of government policies aimed at achieving staffing growth. A Labour government under Tony Blair was elected in 1997, coming into power after a long period of conservative rule—–creating expectations for change which mirrored those in Australia, ten years later in November 2007. One of the key planks of the Labour agenda was to ‘‘modernise’’ the National Health Service, with the aim of reform and expansion of health services—–the so-called ‘‘NHS Plan’’ (Department of Health, 2000a). Shortages of skilled staff were highlighted as one of the main obstacles
J. Buchan Table 1 Whole time equivalent and per cent change in the NHS qualified nursing and midwifery workforce, 1997—2007, four UK countries (September) (data for Scotland is 2006).
England Scotland Wales Northern Ireland
1997
2007
% Change 1997—2007
246,011 35,245 17,228 11,508
307,628 41,004 21,443 13,345
25 17 (2006) 24 16
Sources: England: non-medical staff census, The Information Centre, NHS. Northern Ireland: DHSSPSNI; data is for March. Scotland data: ISD Workforce Statistics. Wales: SDR 43/2008. Note: per cent figures are rounded. Scotland data is for 2006; in 2007 data collection was re-calibrated and it is not possible to conduct a like-for-like comparison.
to achieving this planned reform and growth (see Wanless, 2001). The response by UK government was an explicit commitment to ‘‘grow’’ the NHS workforce, made highly visible by establishing national level ‘‘top down’’ targets for NHS nurse staffing growth, such as the first target set in the year 2000 for ‘‘20,000 more qualified nurses by 2004’’, which was followed by a later commitment to further growth of 35,000. The workforce related elements of the NHS Plan were set out in a national NHS HR strategy (Department of Health, 2002). NHS workforce data from the four UK countries highlights that significant levels of overall nurse staffing growth have been achieved over the period 1997—2007 (Table 1, below; some caution is required in interpreting data as definitions vary in the four countries and across time). England, the largest of the four UK countries, has seen staffing growth of about 25% across the ten-year period. However the growth has not been consistent across the period. Fig. 1 shows the staffing growth in England for registered nurses and midwives since 1997. The lack of growth in more recent years contrasts markedly with the rapid pace of growth in the earlier period, between 2000 and 2004. Generally speaking the last two to three years have seen flat-lining in overall NHS qualified nurse staffing numbers, after rapid growth in the late 1990s and the earlier part of this decade.
Figure 1 England: NHS qualified nursing workforce-% growth, 1997 = 100. Source: Department of Health, Information Centre, Leeds, UK.
Achieving workforce growth in UK nursing: Policy options and implications
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Figure 2 Number of new entrants to the UK nursing register from UK education sources, 1990/1991—2006/2007. Source: NMC annual reports; Nursing and Midwifery Council, London.
How was this rapid growth achieved, over the period up to 2005/2006? Essentially policy makers had four options when they want to increase the supply of NHS nurses and midwives: • ‘‘grow their own’’, by increasing the numbers in preregistration education; • improve retention of the current workforce; • attract back ‘‘returners’’, who have the qualifications but are not currently working; • recruit internationally; A fifth policy option is to act on demand rather than supply, by improving productivity of the current workforce so as to reduce the need for staffing growth. This was also identified as an intervention, but is not the focus of this paper. Nurse education in the UK is delivered by the public sector and funded by the public sector. Given the government funds education, and is the main employer, it has significant policy leverage. It also determines policy on immigration which gives it additional influence on international recruitment; this latter point proved to be of significance as these options for growth were reviewed. The next section examines the impact of these options, focusing mainly on data on growth and change in the NHS in England.
Growing the workforce: policy options Increasing the numbers in pre-registration education The Labour government, when elected in 1997, began to increase funding for pre-registration nurse education, reversing a downward trend earlier in the decade. Data on the number of new entrants to the UK nursing and midwifery register from training in the UK shows an upward trend since the late 1990s (Fig. 2), with the number of new nurses and midwives entering the UK register from UK training in 2006/2007 being the highest it had been at any recent time.
Retention The NHS policy emphasis on improving nurse retention included introducing a new accreditation system for NHS organisations which focused on the provision of flexible hours, improved access to education, and staff involvement (‘‘Improving Working Lives’’) (Department of Health, 2000b); and a new pay system and career structure called ‘‘Agenda for Change’’ (Department of Health, 2004a) (in practice, the latter was not fully implemented until 2006). Measuring the impact of new initiatives on retention is constrained both by the difficult of demonstrating causality, and because data on NHS nurse retention has been limited and incomplete. Until recently, the main published source of data has been an annual survey conducted by the Office of Manpower Economics on behalf of the pay Review Body (OME, annual). This survey examines the number of nurse ‘‘joiners’’ and ‘‘leavers’’ and estimates both a turnover rate (the number and % of nurses and midwives changing jobs and locations, including those moving between NHS organsiations), and a wastage rate (the number and % of leavers, excluding transfers to other NHS employment, but including those retiring). However the survey has had varying, and diminishing, response rates in recent years. Headline wastage data from the OME suggests that the annual wastage rate has been around 8—9% in recent years. Analysis of the annual data gives no indication of any significant improvements in the annual wastage rate of NHS nurses and midwives across the time period of the early/mid decade. Given the limitations in the data it is not possible to be certain that the policies designed to improve retention have had an effect; what can be stated is that the available national data from the relevant period gives no indication of any marked or consistent improvement in retention of NHS nurses and midwives or reduction in wastage.
Returners Encouraging nurses and midwives to return to NHS employment was another key element in NHS policy. A ‘‘returner package’’ providing free refresher training and financial
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support of £1000 (£1500 for midwives) during training was introduced in 2001 to encourage more returners. However there was little data collated on returners and it is difficult to make an accurate assessment of their actual contribution to achieving staffing growth. Analysis of available data (Buchan & Seccombe, 2005; O’Dowd, 2004) suggests that in the earlier part of this decade on average about 3800 nurses, midwives and health visitors were returning annually to the NHS in England via return to practice schemes, but there was no indication of any upward trend across the period from 2000 to 2004.
International recruitment The data examined above highlights growth in the numbers of nurses and midwives entering the UK register from UK training. This reflected the increased funding for training places—–but with a three to four year time lag before any funding increase began to have a payback with these new trained nurses and midwives entering the workforce. The limited data available on retention and return does not suggest a step change in improvement in the impact of policies in this area—–at an aggregate national level at least. This leaves the fourth option—–active international recruitment. There was a determined and co-ordinated effort to increase the numbers of nurses and midwives being recruited from other countries to work in the UK. Commenting on the rapid policy focus on international recruitment, he HR Director of the NHS noted ‘‘. . . we knew that we did not have enough input of nurses and doctors [from domestic sources] to deliver the capacity that was required to achieve the main objectives of improving access. Thus we set up the international recruitment programme. . .’ (Health Committee, 2007, p. 27). International recruitment activity was conducted by both the NHS and employers in the private sector. Any nurse who wishes to practice in the UK must be registered with the Nursing and Midwifery Council (NMC). As noted earlier, the registration process is via a single authority for the whole of the UK. Data from the NMC professional register can be used to assess trends in the numbers of non-UK trained nurses and midwives who are registering to practice in the UK for the first time. There are two main categories of applications—–nurses and midwives from other European Union (EU) countries, and nurses and midwives from other, non-EU countries. The first group is applications from individuals with first level nursing or midwifery qualifications from the other countries of the European Union (EU)/European Economic Area (EEA). These nurses and midwives have the right to practice in the UK because of mutual recognition of qualifications across the countries of the EU/EEA. As such, they can register in the UK via the European Community Directives. The second group is nurses and midwives from all countries outside the EU wishing to practice in the UK, who have to apply to the NMC for verification of their qualifications in order to be admitted to the Register. Most nurses and midwives from outside the EU, including Australia, will also have to apply for, and be granted a work permit to take up paid employment in the UK (some younger nurses from the Australia and some other Commonwealth countries qualified for access on working holidaymaker schemes).
Figure 3 Admissions to the UK nursing register from EU countries and other (non-EU) countries 1993/1994—2007/2008. Source: Nursing and Midwifery Council, UK. Note: 2007—2008 data are provisional.
There are limitations in using registration data to monitor inflows to the UK. It only records the fact that the nurse has been registered, it does not show when she or he actually entered the UK, nor does it indicate what the nurse is actually doing. As such, it is a measure of serious intent to practice in the UK, rather than necessarily an indicator that the nurse is actually working in the UK. Even so, trends in this registration data over time gives an insight into the level of interest in working in the UK and highlights any relative shift in the balance of ‘‘source’’ countries from which applications for registration have come. Fig. 3 presents the registration data over the period from 1993 to 2008; data for the most recent year are provisional. It is clear that the inflow of nurses and midwives to the UK, as measured by registration data, rose rapidly in the period 1999—2002 but has since declined year on year. The significance of international inflow is highlighted in the year 2001/2002. In that year more nurses and midwives joined the UK register from non-UK sources than from UK training—– in other words, in that year, the UK had become more reliant on international sources for new registrants than it was on recruits from its own education system. How was the NHS able to ramp up international recruitment activity so quickly and significantly? It had some competitive advantages—–NHS pay rates for nurses and midwives were relatively attractive; it could connect in with, and exploit, a large English speaking network of countries; it had a health system that was being funded for growth up to 2006. It was also able to develop some economies of scale in recruitment activity, as well as fine-tune policies so that its recruitment practices were increasingly effective—– and could be presented as having an ethical dimension. The methods used by the NHS to recruit nurses tended to be based on recruiting ‘batches’ of ten, twenty, fifty or more at a time from a specific country, often using recruitment agencies (Buchan & Seccombe, 2005). The recruitment activity of individual NHS hospital employers was supported by a regional network of international recruitment co-ordinators. There was support for co-ordinated large-scale recruitment, rather than for each NHS employer to recruit independently.
Achieving workforce growth in UK nursing: Policy options and implications Active recruitment was also supported by bilateral country-to-country agreements on nurse recruitment. At various times, government-to-government agreements to support UK recruitment of health professionals existed between the UK and India, the Philippines, Spain, China and Indonesia (the latter apparently was never operationalised). The growth in the UK international recruitment activity led in turn to a growth in recruitment agency activity, and in the number of agencies. The Department of Health established a list of ‘‘preferred’’ recruitment agencies (Department of Health, 2004b) focused NHS recruitment efforts through a group of agencies that have been approved as having an ‘‘ethical’’ and effective approach. The Internet was also used as a source of information on NHS employment opportunities, and as a portal for international recruitment. At the height of the recruitment activity there were dedicated websites for Spanish nurses, for Indian nurses, and for Filipino nurses. At its peak in 2002, more than 16,000 non-UK nurses and midwives were registering to practice in the UK for the first time, up from less than 4000 only five years earlier. The rapid growth was followed by three years of relatively high levels of registration, and then by an equally rapid decline. By 2007/2008 the number of international registrants was back below the 5000 mark. The four most important source countries for nurses and midwives across the peak years were the Philippines, India, South Africa, and Australia. In the last few years however there has been some increase in inflow from EU countries. This reflects eastward expansion in the EU, with ten new states joining in 2004, and a further two in 2007. The new states which have joined the EU have also entered a free market—–appropriately trained nurses and midwives from these new EU states have the right to move west, to longer established EU countries that pay more for their services, and provide better career opportunities. Poland in particular has now become a more prominent source of new registered nurses in the UK. In 2007 more Polish nurses joined the UK register than did Australian nurses. Inflow of new registrants in the peak years earlier this decade reflected active recruitment efforts by the NHS and other UK employers; the more recent decline in numbers has been an outcome of tighter fiscal situation in the NHS. Financial problems hit parts of the NHS in 2005/2006, leading to recruitment freezes, and overall NHS funding has not grown at the same levels as earlier this decade (Buchan, 2007; Buchan & Seccombe, 2006). One policy response was to end active international recruitment. The Department of Health announced in 2006 that the main categories of nursing employment were to be removed from the ‘‘shortage’’ occupations list which facilitated obtaining a work permit. As such, entry to the UK as a nurse then became much more difficult for applicants from outside the European Union. A second factor has also impacted on inflow, which reflected changes in regulatory policy rather than government policy. Whilst the recent reduction in the number of international nurses and midwives entering on the UK register is mainly a result of declining demand in the UK, it is also partly due to the effect of new NMC requirements. The NMC has increased its English language test requirements for all non-EU nurses and midwives (including those
7
Figure 4 UK registered nurses applying for verification to move to practice in Australia; Nurses from Australia who registered in the UK, 2000—2007. Source: Nursing and Midwifery Council, UK, annual reports.
from English speaking countries) and has also introduced a new Overseas Nurses Programme (ONP) for non-EU nurses, which has added to the time and expense of obtaining UK registration. (EU nurses and midwives are not required to have passed the IELTS test, and do not have to take the ONP). The impact of these changes in policy can be illustrated by looking at the number of Australia-based nurses and midwives registering to practice in the UK; compared to the number of UK-registered nurses and midwives asking for their registration to be verified to practice in Australian states (Fig. 4). There has been a marked shift in the balance of this ‘‘inflow/outflow’’ across the period since 2002. There has been a significant decline in the number of Australianbased nurses and midwives registering in the UK, from an annual figure in excess of 1000 down to less than 300; whilst there has been an doubling in the number of UK-based nurses and midwives applying to move to Australia—–from about 2000 per year to 4000 per year. The decline in potential moves from Australia to the UK is likely to reflect both the reduction in active recruitment to the UK, and a drop in interest in moving to the UK—–because it is more difficult and costly to enter, and because job opportunities have declined. In summary, when assessing the combined effects of the four policy interventions to increase the supply of NHS nurses and midwives, the following can be concluded. Firstly, the increase in the intakes to UK-based pre-registration education, whilst making a major contribution, has only succeeded in bringing intakes back to the levels of the early 1990s, and inevitably had a time lag between funding and effect; secondly that the allocation of resources to support returners has apparently maintained a relatively consistent annual officially measured ‘‘return’’ (in England at least), and thirdly that any assessment of improvement in retention of NHS nurses and midwives is impossible to make at national level (but one national survey suggests at best that there has been no reduction in wastage of registered nurses and midwives). This pinpoints that the fourth intervention, the policy led approach to international recruitment is where there has been the clearest and least ambiguous growth in recent years—–a fivefold annual increase in the inflow of nurses and midwives to the UK, to an average of 14,000 per annum in the last few years. International recruitment made a major and critical contribution to NHS nurse staffing growth.
8
Policy issues and implications International recruitment has attractions for policy makers; it also has potential limitations as well as policy repercussions. In this section the main policy related challenges of the approach used in the NHS are discussed, and lessons for other countries are identified. The lessons learned are of some relevance to Australia, which has in the recent past been debating the notion of national ‘‘self-sufficiency’’ in health workforce terms (COAG, 2006), and which currently in some States is examining an increase in active international recruitment of nurses and midwives. The first point to highlight is that one of the reasons that active international recruitment was so attractive to policy makers in the UK was that it offered a ‘‘quick fix’’— –the nurses and midwives had been trained elsewhere, at someone else’s expense and can be recruited and working in the UK within a few months, not the four years it would take to commission and train a UK educated nurse. The NHS exploited its market position as a relatively well paid location for English speaking nurses and midwives, to stimulate high levels of international inflow of nurses and midwives in the period from 1999 to 2004. Australia is in a similar position. International recruitment also offered some flexibility to UK policy makers. If and when funded demand for nurses and midwives in the UK faltered or reduced, the numbers of international recruits could also be reduced, virtually overnight. Speaking in 2006, the then Secretary of State for Health noted ‘‘The advantage of the managed migration policy is that where shortages arise — and there are shortages in specialist jobs in the NHS — they can be included in the shortage category so that employers can obtain work permits for nurses from abroad. This is a flexible system that can respond to our own labour market.’’ (Secretary of State for Health, Hansard, July 18, 2006). Rapidity and flexibility in response to the need to ‘‘scale up’’ the workforce makes international recruitment an attractive proposition for policy makers, as does the potential to avoid some of the financial risk of funding the basic training of the staff you subsequently recruit. It does however have several limitations. Firstly, the NHS approach, which relied on top down staffing growth targets did not have sufficient fine tuning to necessarily recruit the international nurses and midwives with the skills that were most in demand, or allocate them to the geographical/organisational locations where their skills were most needed. The vast majority of internationally recruited nurses and midwives were recruited to worked in basic grade clinical posts in hospital-based care in large urban areas. Relatively few midwives were recruited internationally; the vast majority of recruits were registered as nurses. International recruitment did very little to solve shortages in some specialities, such as intensive care, where there were international shortages, or others in community nursing and midwifery, where few other countries produced staff who met UK regulatory requirements (Buchan & Seccombe, 2005). Secondly, as well as being a relatively blunt instrument, international recruitment was also not well connected to other nurse workforce planning activity, and contributed to staffing over-expansion, and subsequent NHS financial diffi-
J. Buchan culties. In 2007, the Health Committee of the UK Parliament published an inquiry on NHS workforce planning (Health Committee, 2007). It characterised overall NHS workforce planning in the NHS as a ‘disastrous failure’ and pointed to a lack of strategic planning by the Department of Health as a factor in NHS employers recruiting ‘‘far more staff than they could afford to pay’’ (Health Committee, 2007, p. 289). They also argued that ‘‘Many new staff were recruited from overseas because of limited availability of UK staff. Eventually, many organisations recruited more staff than they could afford to pay. This was a major cause of the widespread deficits which emerged across the NHS from 2004 to 2005 onwards’’ (Health Committee, 2007, p. 72). Thirdly, there is an important ‘‘ethical’’ dimension to international recruitment activity, both in terms of how international recruits are treated, and how recruitment activity is managed in relation to impact on developing countries. As noted earlier, the UK largely ‘‘shut the door’’ to nonEU international nurses and midwives in 2006 when planning failures and financial over—–expansion led to a significant loosening in the UK nursing labour market. The rapid swing away from active international recruitment after 2005/2006 created difficulties for some nurses and midwives who had either recently arrived in the UK or were at that time in the process of recruitment—–they could find that their work permit would not be renewed, or they may have applied for registration in the belief that jobs were still plentiful and have found they had entered into the registration process but could not then obtain employment. Their difficulties were highlighted in the recent House of Commons Health Committee report on NHS Workforce Planning (Health Committee, 2007, pp. 39—40). The broader ‘‘ethical’’ issue related to international recruitment is its impact on under-resourced developing countries. Recruitment of scarce nurses and midwives and other health professionals from the developing world has been controversial, as it can contribute to brain drain (World Health Organisation, 2006). After concerns being raised by Nelson Mandela and others, the Department of Health in England attempted to limit the potential negative impact of its international recruitment activity. It first established guidelines in 1999 (Department of Health, 1999), which required NHS employers not to target South Africa and the West Indies. It then introduced a Code of Practice for international recruitment for NHS employers (Department of Health, 2001). This Code was strengthened in 2004 and now covers the NHS, and recruitment agencies, temporary staff working in the NHS, and private sector organisations providing services to the NHS (Department of Health, 2004b). The Code requires NHS employers and recruitment agencies not to actively recruit from named countries on a list of developing nations. Evaluation of the impact of the Code (Buchan, McPake, Rae, & Mensah, 2007) has highlighted that it has had an effect in focusing recruitment efforts on ‘‘approved’’ countries, but that an absence of systematic monitoring of NHS international recruitment activity has meant that it is not possible to conduct a detailed assessment of its impact. This paper has highlighted that active international recruitment can be a quick fix policy if a country has market advantages to exploit, but that if the international recruit-
Achieving workforce growth in UK nursing: Policy options and implications ment activity is not well integrated with other aspects of workforce planning it can be a factor in uneven distribution of new staff, and can potentially contribute to over expansion in staffing growth. It also has to be managed within a wider policy context of global health and global politics, and is at odds with any notions of national ‘‘self-sufficiency’’ in health workforce terms.
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