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NHS staffing shortages and the Brexit effect

Louise Dalingwater
p. 67-86

Résumés

L’un des défis les plus importants de l’après-Brexit est celui de la capacité du système britannique de santé publique (National Health Service) à retenir du personnel de santé qualifié. Le NHS a recours à des travailleurs étrangers pour combler le déficit chronique en personnel. Cet article montre pourquoi le NHS connaît actuellement une crise de recrutement et souligne comment la sortie du Royaume-Uni de l’UE pourrait aggraver le problème. Il examine ensuite l’impact potentiel du Brexit sur la présence de personnel européen dans le NHS. L’article examine pourquoi une évaluation de l’effet du Brexit sur cette crise de recrutement est difficile à effectuer. Enfin, il analyse les politiques mises en place par le Gouvernement britannique pour tenter de limiter les départs du personnel et pour remédier à la crise de recrutement.

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Texte intégral

Introduction

  • 1 NHS Digital data reported in a House of Commons Library report: Carl Baker ‘NHS Staff from Oversea: (...)

1 One of the most significant post-Brexit challenges for the UK is the one raised by the ability of the British National Health Service (NHS) to retain qualified health care staff. This is of course not just an issue for the public health sector since many other key sectors of the British economy actually rely more on EU workers than the NHS. Indeed, 14% of workers in the accommodation and food services sector are EU migrants, compared with 5.6% of NHS workers.1

2 However, the NHS could lose a significant number of EU workers post-Brexit or, at the very least, find it difficult to recruit from the EU in the future. The key problem in the public health sector, which is not necessarily an issue for many other sectors with high numbers of EU workers, is that the NHS was already finding it difficult to retain staff before the 2016 referendum. The NHS relies quite heavily on foreign workers to make up for the shortfall in staff. This article will begin by explaining why this public health institution is currently suffering from a staffing crisis and to understand why the UK withdrawal from the EU could accentuate the problem. It will then consider not only the potential loss of EU citizens after the UK leaves the European Union, but also explain why this loss is so difficult to calculate and attribute to the Brexit effect. Finally, it will consider the policies which have been put in place by the government to attempt to compress the loss of EU staff and address staff shortages in the NHS.

The NHS staffing crisis

  • 2 NHS Digital, ‘NHS Hospital & Community Health Service (HCHS) workforce statistics’, 2018, https://d (...)

3 Official NHS figures illustrate the fall in retention levels of NHS staff for UK in the year following the EU referendum, for EU and other non-EU nationals. There have been significant difficulties in retaining UK workers with almost 110,000 British citizens choosing to leave this institution (both on a temporary and permanent basis) between June 2016 and June 2017. The retention rate still remains higher for British citizens (88.4%) compared to EU nationals 83.2%2 (see Table below). Such high levels of departure for both categories of workers are a cause for concern because it will no longer be as simple to recruit from other countries in the European Union post Brexit to make up for the shortfall.

Table 1. NHS Staff Departures and Retention Levels

Between June 2016 and June 2017

headcount & percentage

 

Leavers

Stability index

All staff

136 474

88,3%

United Kingdom

109 662

88,4 %

European Union

9 854

83,2 %

European Economic Area

73

81,1 %

Rest of World

8 156

88,7 %

Unknown

8 729

90,3 %

Source: NHS Digital, NHS Hospital & Community Health Service (HCHS) workforce statistics, 2018, op.cit.

  • 3 NHS Digital data reported in a House of Commons Library report: Carl Baker, op.cit. 2018.
  • 4 NHS Improvement, ‘Evidence from NHS Improvement on clinical staff shortages: A workforce analysis’, (...)

4 But why are workers increasingly deserting an institution which was once described by Nigel Lawson, former Chancellor of the Exchequer, as the closest thing that English people have to a religion? The reason why so many workers are leaving the NHS is because the professional environment has been reported to be deteriorating in recent years. The chronic shortage of staff means that conditions for those remaining have worsened, thus prompting ever more staff to leave. While the number of NHS staff, totaling 1.2 million in 2018 (including 110 000 doctors and 315 000 nurses), has increased significantly since its inception in 1948, it has not been able to keep up with requirements.3 Greater health demands and an ageing population have resulted in the need for more medical interventions and greater medical expertise. While productivity improvements have reduced the lengths of stay and the need for ever more staff, vacancies rose from 98,475 in March 2018 to 107,743 in June 2018, meaning one post in eleven is now vacant in the NHS.4 The shortfall varies according to the different staff groups as is evident from Table 2.

Table 2. Shortfalls for selected staff groups, 31 March 2014

Staff establishment

Staff in post

Shortfalls as at 31 March 2014 (Number) (%)

Nursing, midwifery and health visiting staff

386,200

358,220

-27,980 -7.2%

Support to clinical staff

306,480

291,970

-14,500 -4.7%

Allied health professionals

68,630

65,100

-3,530 -5.1

Junior doctors and equivalents

59,110

56,560

-2,550 -4.3

Health scientists

38,670

36,140

-2,530 -6.5

Consulants

42,970

40,640

-2,330 -5.4

Ambulance staff

18,980

17,650

-1,330 -7.0

NHS Improvement, 2016 (most recent available breakdown)

  • 5 National Audit Office/Department of Health, ‘Managing the Supply of NHS Clinical Staff in England, (...)

5 Indeed, the shortage of nurses is particularly acute, followed by ambulance staff. The extent of the staffing crisis also depends on the region, with London reporting the highest shortfall in both medical and non-medical NHS staff.5

6 Ahead of the June 2018 celebrations to mark 70 years of the NHS, Unison investigated why NHS workers were leaving the NHS, drawing on information relayed by their members but also official government data. They explored the reasons for leaving between the financial year 2011/12 and 2017/18. During this period, they noted a 6% increase in the number of staff leaving the NHS. The data showed that one of the major reasons for leaving the NHS was to achieve a ‘better work-life balance’. Indeed, almost 5,000 staff reported this as a reason for leaving their job. Other reasons cited were lack of opportunities and inadequate pay or benefits.6

  • 7 The Mid Staffordshire failure of care, which led to an enquiry, involved a hospital in Mid Stafford (...)
  • 8 NHS data published in Abi Rimmer, ‘Staff stress levels reflect rising pressures on NHS, says NHS le (...)

7 Overall, the NHS workforce is more fragmented than ever before. There is a high staff turnover and low morale reported among NHS staff related to recent pay freezes, under staffing, ever-increasing targets and top down approaches. The Francis report on the Mid Staffordshire scandal7 underlined how low staff morale could have a disastrous effect on the provision of good patient care. Personnel are said to be working under increasing pressure. According to the NHS staff survey based on 487227 staff and 235 NHS trusts in England, the number of staff reporting that they were unwell because of work related stress stood at 38.4%.8

  • 9 NHS Digital reported by health minister Philip Dunne on the Parliament website: NHS Loss Working Da (...)

8 There were more NHS staff taking time off work for illness than ever before in 2017. According to a House of Commons report, health personnel took a total of 16,866, 471 sick days off work between 2016 and 2017; a steady rise has been noted since 2012.9

Table 3. Number of days lost in the NHS as a result of sickness absence 2012-2016

Year

Sum of Full Time equivalent sick days taken

Sum of Full Time equivalent working days

Sickness absence rate (%)

2012

15,970,492

376,888,359

4.24%

2013

15,424,804

377,092,245

4.09%

2014

16,178,672

384,714,386

4.21%

2015

16,346,443

392,433,945

4.17%

2016

16,866,471

403,377,016

4.18%

Source : NHS Digital

9 Michelle Sanderson, a paramedic for over 20 years in both the NHS and Royal Air Force (RAF), retired prematurely in 2014 after suffering from Post-Traumatic Stress Disorder (PTSD) and told the press:

  • 10 Kirk A., ‘Paramedics take 40,000 days off sick with stress as strain on NHS takes toll’, The Observ (...)

There was just far too much to cope with as a paramedic. Working 24-hour shifts and seeing trauma on a daily basis. You’re on standby waiting for that radio to go off – your hyperarousal state and anxiety levels are unbelievable, and that’s before you even go on a callout.10

  • 11 Kline R., Lewis D., ‘The price of fear: estimating the financial cost of bullying and harassment to (...)
  • 12 Fèvre R., Nichols T., Prior G., Rutherford I., ‘The fair treatment at work report: Findings from th (...)
  • 13 Fèvre R., Lewis D., Robinson A., Jones T., Trouble at Work, London, Bloomsbury, 2012. 
  • 14 NHS England, 2017, see www.nhsstaffsurveys.com/Page/1064/Latest-Results/2017-Results , reported in (...)
  • 15 Robinson, D. and Perryman, S. (Eds), (2004), Healthy Attitudes: Quality of Working Life in the Lond (...)

10 Kline and Lewis also point to the disastrous effects of disproportionate bullying and harassment in the NHS11 compared to the private sector.12 Health and social care workers in particular have been subjected to unreasonable management pressure, incivility between co-workers and violent behaviour from patients or relatives of patients.13 NHS staff surveys showed that 13% of all staff had suffered from bullying or harassment by managers, 18% by co-workers and 28% by patients or relatives of patients.14 This can have a significant effect on staff turnover. According to some studies harassment doubles the levels of turnover.15

  • 16 HM Treasury, ‘Around one million public sector workers to get pay rise’, 24 July 2018, accessed on (...)

11 Recruiting more staff is thus a priority. The NHS needs to recruit more staff, to improve conditions for health workers and to increase pay. Indeed, another reason why fewer people are interested in working for the public sector nowadays is because of public sector pay freezes. Pay was frozen in the public sector for 2011 and 2012 and then capped to rise only 1% until 2018. Public sector pay has thus not risen in line with inflation overall, meaning a fall in real incomes for public sector workers.16

  • 17 General Medical Council, ‘The state of medical education and practice in the UK’, London, General M (...)

12 The future is looking bleak. According to a survey carried out by the General Medical Council in 2018, around a third of the 2,600 doctors interviewed said they were considering reducing hours, a fifth plan to switch to part time work and a further fifth plan to leave to work abroad. The doctors regretted the staff shortages which have made it increasingly difficult to cope with work pressures or ensure the quality care they would wish to provide.17

13 It is not only conditions but also how recruitment is managed has also led to an undersupply. The management of the supply of clinical staff is fragmented involving various departmental bodies, arms-length organisations, healthcare commissioners and providers at both national and local levels, which can lead to uneven supply across the country. The exit of Britain from the EU is likely to further exacerbate the situation.

EU nationals and potential losses post-Brexit

  • 18 NHS Digital data reported in House of Commons Library report, op.cit.

14 The tensions surrounding the recruitment of qualified NHS staff have risen since the 2016 referendum results when a majority (51.8 %) voted in favour of leaving the European Union. Many other sectors, and not just the health sector, are anticipating difficulties because of the high rate of EU workers. However, in the accommodation and food sector (14% of EU workers18) there is a high turnover within the sector rather than a net loss towards another sector. So while other sectors may be set to lose many workers, they do not have the added problem of British workers also leaving the sector altogether, which is the case in the public health domain.

  • 19 Ibid.
  • 20 Department of Health, Managing the supply of NHS clinical staff in England, London, National Audit (...)
  • 21 NHS Digital data reported in House of Commons Library report, op.cit.
  • 22 These figures are estimated for nationalities which are known. For 7% of NHS staff, the nationality (...)

15 Support from qualified personnel from other EU countries has been essential for the smooth functioning of the UK public healthcare system. Thanks to the free movement of people within the EU, among the 1.2 million NHS workers, England has 63,650 migrants of European nationality.19 In addition, 80,000 EU nationals work in Social Care.20 Some regions are set to lose more than others, with 11 % of EU nationals working for the NHS in London, but only 2 % in the North East of England. The percentage is also higher if we consider specific jobs : 10 % of hospital doctors and 7 % of nurses are reported to be nationals of other EU countries.21 Moreover, 21 hospital trusts across the UK report more than a quarter of their staff to be non-British (other EU nationals or non-EU nationals combined).22

  • 23 NHS Digital data reported in House of Commons Library report, op.cit. As the report underlines, the (...)

16 Figures show an increase in the number of EU nationals coming to work in the NHS between 2009 and 2018. Nationals from the EU-15 (pre-2004 countries) increased from 2.2 to 3.8 % and those from the Eastern bloc, who entered the European Union after 2004, from 0.7 to 1.8 % during this period.23

  • 24 NHS Digital data reported in House of Commons Library report, op.cit.
  • 25 Ibid.
  • 26 Ibid.

17 According to such calculations and contrary to a certain number of newspaper articles on this issue, overall there has been very little change to EU staff working for the NHS since June 2016 and, interestingly enough, a slight increase from 5.5 % to 5.6 %. However, there is a category which has recorded a fall : EU nurses and health visitors.24 Using the calculation of the percentage of known nationality, it is estimated that the number of EU nurses has fallen from 7.4 % to 6.8 %. The percentage of doctors working in the NHS from EU countries other than Britain has remained the same at 9.7 % (with a slight initial increase until March 2017) and the percentage of EU clinical support staff has increased from 3.7 to 4.2 %.25 Increases and decreases in the number of EU nationals would seem to depend on the country. NHS staff declaring Spanish nationality have fallen from 7,420 to 6,160 (15 % drop) while the number of Romanians has increased from 3,098 to 4,091 since the 2016 referendum.26 Again, these figures need to be treated with a degree of caution because of the fact that there may be Spanish or Romanian staff who have not reported their nationality. For this reason, both absolute numbers and percentages of known staff have been given ; that is the percentage out of the total number of staff working for the NHS (see Table 4).

Table 4. Changes in EU staff since June 2016 (headcount basis)

Table 4. Changes in EU staff since June 2016 (headcount basis)

Source : NHS Digital data reported in a House of Commons Library report, op.cit.

  • 27 OECD, Health at a Glance, Paris, OECD, 2015.
  • 28 Wadsworth J., Dhingra S., Ottaviano G., Van Reenen J., ‘Brexit and the impact of immigration on the (...)

18 It is worth highlighting the added value to the health sector and more generally to the British economy of EU nationals working in the UK. According to the OECD, the UK has the second largest number of foreign workers in the health sector after the United States.27 The UK has thus benefited from a generally better qualified workforce thanks to this contribution, as they are, on average, more educated than British employees – almost twice as many are graduates. Indeed, 43 % of European nationals have a university degree (only 23 % for the British).28

19 In addition, thousands of EU citizens hold low-level public service positions. These are essential for the proper functioning of health services and for other services related to the functioning of the sector : drivers, housekeepers, cooks, etc. A study by the University of Oxford showed that EU nationals are more willing to work off-shift schedules (nights, Sundays and public holidays) and adjust more easily to an economy that operates 24 hours a day, seven days a week. The departure or non-replacement of European nationals or discouraged international workers will most certainly exacerbate the problems in retaining qualified NHS personnel. A shortage of workers in the health sector has the potential to increase costs and the need for expensive temporary employment services.

  • 29 ONS, Migration Statistics Quarterly Report: November 2018, London, ONS, November 2018, accessed on (...)

20 There is thus a real cause for concern over a reduced number of EU migrants coming into the UK overall. The ONS reported that while the number of EU nationals moving to the UK from June 2017 to June 2018 was greater than departures (a net gain of 74,000 EU immigrants), the differences between departures and arrivals was at its lowest since 2012.29 While EU citizens have been guaranteed that they can stay in Britain (although this is far from certain in the event of a no deal), there are a number of other reasons, apart from the potential difficulties of remaining legally in the UK post Brexit, which may have resulted in a fall in the net number of EU migrants. The first is the rise in xenophobia, unleashed by the debate on Brexit, which is likely to have dissuaded skilled workers from coming to work in a country where the climate has become more hostile to foreign workers. As the Labour Exploitation Advisory Group explained :

  • 30 Labour Exploitation Advisory Group, ‘Lost in Transition, Brexit and Labour Exploitation’, August 20 (...)

A rise in hate crime and hostility post referendum contributes to a general sense of being unwelcome and makes migrant workers feel like ‘second class citizens’ in the UK. This undermines confidence in rights and makes it more difficult to speak out about poor treatment.30

21 The relative growth of other EU economies could also be the reason why there is a fall in the net number of EU migrants coming to Britain. Indeed, Spain is a case in point. After the 2009 financial crisis and the severe recession that ensued, Spanish nationals started to migrate to find work elsewhere in Europe, but with improved conditions they can now find work more easily in their country of origin. It is therefore very difficult to directly relate the fall in the number of EU workers in the NHS to the Brexit effect. The decline in the number of EU migrants working for the NHS could also be for the same reasons as British nationals described above; that is, increased stress and declining working standards.

22 Yet the full effect of Brexit on the retention rate of EU migrants in the NHS is still to be seen. The number of EU migrants coming to work in the UK in the future is certainly likely to decline if there is no longer freedom of movement of people from other EU countries to the UK. So Brexit will most certainly result in the decline of EU nationals as Britain becomes an even more hostile work environment and immigration policies deter EU nationals from coming to the UK.

  • 31 Irish citizens have a specific, privileged status due to the Good Friday Agreement and bilateral ag (...)
  • 32 NHS Digital data reported in House of Commons Library report, op.cit.

23 Notwithstanding the reliance on EU nationals, the NHS actually relies more on nationals from outside the EU. Foreign nationals account for 12.5% of NHS employees (139,000 workers). While as a region, the EU is the most highly represented (62,000) or 5.6%, 45,000 employees come from Asia and 21,000 from Africa. The most highly represented single nationality is Indian (19,142), then Filipinos (16,807) ahead of Irish (13,132)31, Polish (8,896), Portuguese (6,899) and Spanish (6,160).32

  • 33 BMA, ‘Visa cap blocks thousands of medical applications’ 16 May 2018, accessed on 22 January 2019: (...)
  • 34 HM Government, ‘The Uk’s future skills-based immigration system, CM972, London: Crown, December 201 (...)

24 However, there is particular concern that stringent immigration laws will make it very difficult to continue to recruit EU workers once they are subject to the same conditions as other immigrants. Until June of this year, the strict immigration quotas meant that doctors wishing to come to the UK from non–EU countries were restricted in number because of a cap on visas given to skilled workers (so called tier 2 visas). The UK is even more reliant on foreign doctors than any other category of worker. However, owing to the cap on skilled workers, 1,518 applications for visas by foreign doctors were turned down in the first quarter of 2018. There has been a fall from 30% to 26% of non-British doctors which could be in part related to these more stringent immigration conditions.33 Difficulties also remain in employing lower level or lower paid NHS staff. Indeed, there is also a minimum salary threshold of £ 30,000 per annum and below that level businesses and employers cannot hire workers from outside the European Union. Employers also have to prove that they have not been able to recruit British workers for the particular position on offer, which obviously makes it more difficult and time consuming to hire non-British workers.34 This condition will apply to EU workers once Britain leaves the EU.

25 The next section will thus look at both measures to retain EU workers and to avoid a future decline in staff. It will also consider national measures taken to help fill the gap in anticipation of future recruitment problems post Brexit.

Solving the staffing crisis post-Brexit

  • 35 Home Office, Doctors and nurses to be taken out of Tier 2 visa cap, 15 June 2018, accessed on 22 Ja (...)

26 On account of a fear of a mass exodus of foreign workers from Britain or, at the very least, a gradual decline because of the difficulty in recruiting non-British staff once Britain leaves the EU, there has been increasing pressure on Prime Minister Theresa May to make it easier to recruit NHS staff from overseas. In June 2018, the home secretary Sajid Javid confirmed that the government would relax the cap on skilled workers specifically for medical professionals.35 The then Health and Social Care secretary Jeremy Hunt recognized the importance of this measure and the contribution of overseas staff:

  • 36 Home Office, Doctors and nurses to be taken out of Tier 2 visa cap, op.cit.

Overseas staff have been a vital part of our NHS since its creation 70 years ago. Today’s news sends a clear message to nurses and doctors from around the world that the NHS welcomes and values their skills and dedication. It’s fantastic that patients will now benefit from the care of thousands more talented staff.36

  • 37 HM Government, ‘The Uk’s future skills-based immigration system, op.cit.

27 While such measures would probably have been taken in any case given staff shortages in the NHS, future considerations on being able to continue to recruit new staff from EU countries weighed even more heavily on this decision. However, the future obligation for EU citizens to have to apply for a visa to work may be dissuasive despite such measures. Moreover, for the moment, there is also no intention to relax the minimum pay band to ensure that lower level NHS staff can be employed from outside Britain.37

  • 38 Hughes L., ‘UK to scrap £65 application fee for EU citizens to stay’ Financial Times, 21 January 20 (...)

28 It has also been important to reassure EU migrants currently working in the UK that they can stay. The UK Government has sent clear messages that the legal rights of EU nationals living in the UK will be properly protected. Amidst great uncertainty which perhaps encouraged some to leave the UK before this notice was issued, the Home Office sent a letter to EU citizens to reassure them that their right to remain in the UK would be safeguarded (see Appendix). In January 2019, Prime Minister Theresa May announced that no fee would be charged for applications to stay in the UK after Brexit.38 This move was very important because there is a degree of uncertainty about whether European citizens currently resident in the United Kingdom can benefit from the Vienna Convention on the Law of Treaties of 1989, which stipulates that the acquired rights of individuals cannot be withdrawn if new treaties between countries are signed.

  • 39 House of Lords, ‘The long-term sustainability of the NHS and adult social care’, London, Committee (...)
  • 40 House of Lords, ‘The long-term sustainability of the NHS’, op.cit.

29 Beyond measures to retain EU workers, there is also a move to try and reduce the dependency on foreign workers and recruit more British workers. A House of Lords Select Committee on the Long Term Sustainability of the NHS report notes that there has been a long-standing reliance on foreign nationals in the NHS.39 The committee states that the long-term solution is for the government to ensure the supply of well-trained health and social care workers from within the country. The report noted an absence of a national long-term strategy which could secure the necessary trained staff needed in health and social care over the next 10-15 years. They pointed to the fragmented nature of staff planning across the country as an issue still to be solved.40

  • 41 Health Foundation, ‘Health Foundation response to government announcement of additional NHS funding (...)
  • 42 Maguire D., ‘Nursing student numbers: should we panic yet?’ Kings Fund, 14 February 2018, accessed (...)
  • 43 Maguire, ‘Nursing student numbers…’, op. cit.

30 However, despite the government pledging extra money to fill the gap in funding in the NHS in the 2017 and 2018 Autumn Statements, with extra funding to rise to £ 20.5 billion in 2023/2, this money will be directed at front-line NHS services and will exclude some other vital areas in desperate need of funding such as workforce training.41 To be fair, the government did promise a 25 % rise in NHS training placements and university placements in 2017 and 2018. Yet in 2017 the government also scrapped the bursaries available to nurses to study towards a degree. From August 2017 nursing students started to pay university fees and fees on loans like other students. The objective behind introducing fees was that it should create more training places because the universities would be able to set their own fees and thus generate more income to create more nursing placements.42 However, it is feared that this measure has discouraged potential nurses from studying and has actually resulted in a decrease in the number of places offered at universities. The number of nursing courses in England fell by 700 places (approximately 23%) between September 2016 and September 2017. However, the government argues the same was true when university fees for other courses were increased in 2012, but places then subsequently increased above the previous threshold. It is thus hoped that the number of places and applicants will recover.43 Nevertheless, while the government is intent on increasing training places, universities may find it increasingly difficult to provide safe educational supervision for students on placements.

31 While training staff is important, creating commitment whether it be within the UK or from overseas is also essential. The increased uncertainty and the added pressures of the profession is making this very difficult. The lack of effective policies to support training of UK professionals and the declining attractiveness of the profession mean that more needs to be done to train and retain UK workers, especially faced with the potential loss of overseas staff post Brexit.

Conclusion

32 Following the results of the 2016 referendum and the invoking of article 50 by Prime Minister May to leave the European Union, the public health sector is facing increasing uncertainty about EU staff retention levels. It is difficult to measure the number of EU nationals who have left the NHS. However, one of the main reasons for voting leave was to reduce the number of immigrants living and working in Britain. The restriction on free movement of people and workers is also a specific requirement and a firm red line which has so far not been crossed in negotiations by Theresa May’s government. It will thus be more difficult for EU nationals to work for the NHS in post-Brexit Britain, even though rules on quotas for skilled immigrants in the health sector have been relaxed. The effects of such loss of workers will be significant for the NHS because of the difficulties of retaining workers in a context of deteriorating working conditions. While not all sectors of the health service have lost staff, some specific sectors like nursing have experienced a severe loss of workers. Several solutions have been put forward towards solving this issue. Unsurprisingly enough, most of them are geared at attracting more British nationals into the profession rather than extra measures to encourage international workers to take up employment in the NHS. However, wholesale reforms are needed to make for a more integrated NHS open to change and ready to deal with institutional weaknesses including negative behaviour (such as bullying or management pressure). Substantially increasing the pay in the NHS will also be important to attract both British and international workers post Brexit.

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Bibliographie

Baker, C., ‘NHS Staff from Oversea: Statistics’, Briefing Paper No 7738, 10 October 2018, House of Commons Library.

British Medical Association, ‘Visa cap blocks thousands of medical applications’, 16 May 2018, accessed on 22 January 2019: https://www.bma.org.uk/news/2018/may/visa-cap-blocks-thousands-of-medical-applications .

Department of Health, Managing the supply of NHS clinical staff in England, London, National Audit Office, 2016.

Dustmann, C., Fratini, T., ‘The Fiscal Effects of Immigration to the UK’, CReAM Discussion Paper No. 22/13, 2013.

Ellis, Rosa, ‘Data: Why NHS Workers Quit’, Unison, 6 June 2018 https://www.unison.org.uk/news/ps-data/2018/06/data-nhs-workers-quit/ , accessed on 14 January 2019.

Fèvre, R., Nichols, T., Prior, G., & Rutherford, I., ‘The fair treatment at work report: Findings from the 2008 survey’, Employment relations research series no. 103, Crown, London, 2009.

Fèvre, R., Lewis, D., Robinson, A. & Jones, T., Trouble at Work, London: Bloomsbury, 2012. 

General Medical Council, ‘The state of medical education and practice in the UK’, London, General Medical Council, 2018.

Health Foundation, ‘Health Foundation response to government announcement of additional NHS funding’, 16 June 2018, accessed on 22 January 2019, https://www.health.org.uk/news-and-comment/news/health-foundation-response-to-government-announcement-of-additional-nhs-funding .

HM Government, The Uk’s future skills-based immigration system, CM972, London: Crown, December 2018.

HM Treasury, ‘Around one million public sector workers to get pay rise’, 24 July 2018, accessed on 21 January 2019: https://www.gov.uk/government/news/around-one-million-public-sector-workers-to-get-pay-rise .

Home Office, Doctors and nurses to be taken out of Tier 2 visa cap, 15 June 2018, accessed on 22 January, https://www.gov.uk/government/news/doctors-and-nurses-to-be-taken-out-of-tier-2-visa-cap .

House of Lords, ‘The long-term sustainability of the NHS and adult social care’, London, Committee Office, House of Lords, 5 April 2017.

Hughes, L., ‘UK to scrap £ 65 application fee for EU citizens to stay’ Financial Times, 21 January 2019.

Kirk, A., ‘Paramedics take 40,000 days off sick with stress as strain on NHS takes toll’, The Observer, 25 April 2015.

Kline, R. Lewis, D., ‘The price of fear: estimating the financial cost of bullying and harassment to the NHS in England’, Public Money and Management, 24 October 2018.

Labour Exploitation Advisory Group, ‘Lost in Transition, Brexit and Labour Exploitation’, August 2017.

Maguire, David, ‘Nursing student numbers: should we panic yet?’ Kings Fund, 14 February 2018, accessed on 22 January 2019, https://www.kingsfund.org.uk/blog/2018/02/nursing-student-numbers-should-we-panic-yet .

National Audit Office/Department of Health, ‘Managing the Supply of NHS Clinical Staff in England’, National Audit Office, 4 December 2016.

NHS Digital, ‘NHS Hospital & Community Health Service (HCHS) workforce statistics’, 2018, https://digital.nhs.uk/data-and-information/publications/statistical/nhs-workforce-statistics.

NHS Improvement, ‘Evidence from NHS Improvement on clinical staff shortages: A workforce analysis’, London: NHS Improvement, 2016.

OECD, Health at a Glance, Paris, OECD, 2015.

ONS, Migration Statistics Quarterly Report: November 2018, London, ONS, November 2018.

Rimmer, Abi, ‘Staff stress levels reflect rising pressures on NHS, says NHS leaders’ British Medical Journal, 360: K1074, 6 March 2018.

Robinson, D., Perryman, S., Healthy Attitudes: Quality of Working Life in the London NHS 2000–2002, Institute of Employment Studies, 2004.

UK Parliament, NHS Loss Working Days, 21 June 2017, accessed on 18 January 2019: https://www.parliament.uk/business/publications/written-questions-answers-statements/written-question/Commons/2017-06-21/335/.

Wadsworth, J., Dhingra, S., Ottaviano, G., & Van Reenen, J., ‘Brexit and the impact of immigration on the UK’, CEP Brexit Analysis n° 5, London, London School of Economics, 2016.

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Annexe

The Home Office’s message to EU citizens in Britain

From: « The Home Secretary » <hocommunications@communications.homeoffice.gov.uk>
Date: 21 June 2018 at 18:10:08 BST

Subject: Message from the Home Secretary to EU citizens
Reply-To: <no-reply@communications.homeoffice.gov.uk>

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Notes

1 NHS Digital data reported in a House of Commons Library report: Carl Baker ‘NHS Staff from Oversea: Statistic’s, Briefing Paper No. 7738, 10 October 2018, House of Commons Library.

2 NHS Digital, ‘NHS Hospital & Community Health Service (HCHS) workforce statistics’, 2018, https://digital.nhs.uk/data-and-information/publications/statistical/nhs-workforce-statistics.

3 NHS Digital data reported in a House of Commons Library report: Carl Baker, op.cit. 2018.

4 NHS Improvement, ‘Evidence from NHS Improvement on clinical staff shortages: A workforce analysis’, London, NHS Improvement, 2016.

5 National Audit Office/Department of Health, ‘Managing the Supply of NHS Clinical Staff in England, National Audit Office, 4 December 2016.

6 Ellis, R., ‘Data: Why NHS Workers Quit’, Unison, 6 June 2018, https://www.unison.org.uk/news/ps-data/2018/06/data-nhs-workers-quit/ accessed on 14 January 2019.

7 The Mid Staffordshire failure of care, which led to an enquiry, involved a hospital in Mid Staffordshire where hundreds of hospital patients died as a result of substandard care and staff failings between January 2005 and March 2009. Investigations showed that patients lay in wards starving, thirsty and in soiled bedclothes. Other patients received the wrong medication or none at all. Receptionists were taking decisions about which patients should be treated and nurses were reported to be incapable of using equipment and were therefore switching it off.

8 NHS data published in Abi Rimmer, ‘Staff stress levels reflect rising pressures on NHS, says NHS leaders’ British Medical Journal, 360: K1074, 6 March 2018.

9 NHS Digital reported by health minister Philip Dunne on the Parliament website: NHS Loss Working Days, 21 June 2017, accessed on 18 January 2019: https://www.parliament.uk/business/publications/written-questions-answers-statements/written-question/Commons/2017-06-21/335/ .

10 Kirk A., ‘Paramedics take 40,000 days off sick with stress as strain on NHS takes toll’, The Observer, 25 April 2015.

11 Kline R., Lewis D., ‘The price of fear: estimating the financial cost of bullying and harassment to the NHS in England’, Public Money and Management, 24 October 2018.

12 Fèvre R., Nichols T., Prior G., Rutherford I., ‘The fair treatment at work report: Findings from the 2008 survey’, Employment relations research series no. 103, Crown, London, 2009.

13 Fèvre R., Lewis D., Robinson A., Jones T., Trouble at Work, London, Bloomsbury, 2012. 

14 NHS England, 2017, see www.nhsstaffsurveys.com/Page/1064/Latest-Results/2017-Results , reported in Roger Kline and Duncan Lewis, ‘The price of fear…”, op.cit.

15 Robinson, D. and Perryman, S. (Eds), (2004), Healthy Attitudes: Quality of Working Life in the London NHS 2000–2002 (Institute of Employment Studies).

16 HM Treasury, ‘Around one million public sector workers to get pay rise’, 24 July 2018, accessed on 21 January 2019: https://www.gov.uk/government/news/around-one-million-public-sector-workers-to-get-pay-rise .

17 General Medical Council, ‘The state of medical education and practice in the UK’, London, General Medical Council, 2018.

18 NHS Digital data reported in House of Commons Library report, op.cit.

19 Ibid.

20 Department of Health, Managing the supply of NHS clinical staff in England, London, National Audit Office, 2016, p. 4.

21 NHS Digital data reported in House of Commons Library report, op.cit.

22 These figures are estimated for nationalities which are known. For 7% of NHS staff, the nationality is reported as unknown. NHS Digital data reported in a House of Commons Library report, op.cit.

23 NHS Digital data reported in House of Commons Library report, op.cit. As the report underlines, the issue with many of the figures given about departures of EU nationals or increases in the number of EU nationals coming to work in the public health sector in the UK is that there are a large number of NHS workers for whom the nationality is unaccounted. However, in recent years, the number of NHS workers whose nationality is unknown has been reduced thanks to improved data compilation. Yet this actually raises problems in calculating the increase or decrease of EU nationals working for the NHS and can cause inaccuracies in reporting. In order to improve accuracy, the House of Commons library has thus given figures as a percentage of known categories because the number of workers with “unknown” nationality was higher in 2016 (just before the referendum) compared to 2018. Nevertheless, it is not possible to be completely accurate on the scale of the change because there are still some staff whose identity remains unknown (and may well be EU migrants too). Nevertheless, using such a method means that the change in the percentage of EU nationals since the referendum can be calculated with a higher degree of accuracy.

24 NHS Digital data reported in House of Commons Library report, op.cit.

25 Ibid.

26 Ibid.

27 OECD, Health at a Glance, Paris, OECD, 2015.

28 Wadsworth J., Dhingra S., Ottaviano G., Van Reenen J., ‘Brexit and the impact of immigration on the UK’, CEP Brexit Analysis n° 5, London, LSE, 2016.

29 ONS, Migration Statistics Quarterly Report: November 2018, London, ONS, November 2018, accessed on 21 January 2018: https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/internationalmigration/bulletins/migrationstatisticsquarterlyreport/november2018 .

30 Labour Exploitation Advisory Group, ‘Lost in Transition, Brexit and Labour Exploitation’, August 2017.

31 Irish citizens have a specific, privileged status due to the Good Friday Agreement and bilateral agreements.

32 NHS Digital data reported in House of Commons Library report, op.cit.

33 BMA, ‘Visa cap blocks thousands of medical applications’ 16 May 2018, accessed on 22 January 2019: https://www.bma.org.uk/news/2018/may/visa-cap-blocks-thousands-of-medical-applications .

34 HM Government, ‘The Uk’s future skills-based immigration system, CM972, London: Crown, December 2018.

35 Home Office, Doctors and nurses to be taken out of Tier 2 visa cap, 15 June 2018, accessed on 22 January, https://www.gov.uk/government/news/doctors-and-nurses-to-be-taken-out-of-tier-2-visa-cap.

36 Home Office, Doctors and nurses to be taken out of Tier 2 visa cap, op.cit.

37 HM Government, ‘The Uk’s future skills-based immigration system, op.cit.

38 Hughes L., ‘UK to scrap £65 application fee for EU citizens to stay’ Financial Times, 21 January 2019, accessed on 5 February 2019: https://www.ft.com/content/3a471db4-1d95-11e9-b126-46fc3ad87c65 .

39 House of Lords, ‘The long-term sustainability of the NHS and adult social care’, London, Committee Office, House of Lords, 5 April 2017.

40 House of Lords, ‘The long-term sustainability of the NHS’, op.cit.

41 Health Foundation, ‘Health Foundation response to government announcement of additional NHS funding’, 16 June 2018, accessed on 22 January 2019, https://www.health.org.uk/news-and-comment/news/health-foundation-response-to-government-announcement-of-additional-nhs-funding.

42 Maguire D., ‘Nursing student numbers: should we panic yet?’ Kings Fund, 14 February 2018, accessed on 22 January 2019, https://www.kingsfund.org.uk/blog/2018/02/nursing-student-numbers-should-we-panic-yet.

43 Maguire, ‘Nursing student numbers…’, op. cit.

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Table des illustrations

Titre Table 4. Changes in EU staff since June 2016 (headcount basis)
Crédits Source : NHS Digital data reported in a House of Commons Library report, op.cit.
URL http://journals.openedition.org/osb/docannexe/image/3216/img-1.png
Fichier image/png, 86k
URL http://journals.openedition.org/osb/docannexe/image/3216/img-2.jpg
Fichier image/jpeg, 120k
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Louise Dalingwater, « NHS staffing shortages and the Brexit effect », Observatoire de la société britannique, 24 | 2019, 67-86.

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Louise Dalingwater, « NHS staffing shortages and the Brexit effect », Observatoire de la société britannique [En ligne], 24 | 2019, mis en ligne le 01 mai 2020, consulté le 05 août 2020. URL : http://journals.openedition.org/osb/3216 ; DOI : https://doi.org/10.4000/osb.3216

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Louise Dalingwater

Professeur de civilization britannique à l'Université Paris 4 Sorbonne

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