HC Deb 23 April 2001 vol 367 cc140-8

Motion made, and Question proposed, That this House do now adjourn.—[Mr. McNulty.]

12.8 am

Mr. Paul Burstow (Sutton and Cheam)

I am grateful for the opportunity to raise the recruitment of overseas nurses to the United Kingdom. There is no doubt that we need to recruit nurses and midwives from overseas. Indeed, the demographic time bomb planted by the previous, Conservative Government means that there is a serious shortage of home-grown nurses and midwives. With something like one in four nurses on the register of the United Kingdom Central Council of Nursing, Midwifery and Health Visiting aged over 50 and the average retirement age at about 55, the shortage of nurses is likely to get much worse before it gets better. Over the next four years, it is estimated that the shortfall of nurses will range between 20,000 and 60,000. It could be even more, depending on how the independent sector develops in the next few years and what implications the new standards for care homes and other institutions will have for additional staffing requirements.

Last year, 10,000 overseas nurses were recruited to this country and registered with the UKCC. I want to make it clear from the outset that I very much welcome the contribution that those nurses and midwives make to this country's health care system, whether in the independent sector or the NHS. Nursing is an international profession, and nurses should have the right to broaden their experience by working in other health care systems.

My purpose in this debate is to highlight two concerns and to try to offer solutions. First, there is growing evidence that for some overseas nurses who come to this country to do a job and provide support and care in our health service, particularly in the independent sector, their experience is one of exploitation. Secondly, despite clear requests from a number of developing countries not to recruit their nurses, the UKCC's figures reveal an accelerating rate of registration of nurses from those countries.

I shall deal first with the exploitation of overseas nurses. There is growing evidence from Unison and the Royal College of Nursing of appallingly poor employment practices in this country. I stress that the problem appears to be concentrated largely in the independent sector and, on the evidence that I have seen, particularly in care homes. Unison tells me that even before arriving in the UK, nurses from the Philippines and other countries find that the recruitment agency that they use to find jobs in this country charges them to be recruited. On top of that, if the recruitment is ultimately to an NHS trust, the trust is asked to pay the agency as much as £1,500 per nurse. The nurses themselves can pay nearly double that, and may be asked to sell their homes, land and other property to finance their move to the UK.

In some cases, agencies charge nurses for UKCC registration guidance, which is free. That is appalling exploitation, and it clearly breaches the Department of Health's guidelines. In some horrific cases, employers go even further, holding on to passports, work permits and UKCC registration cards. They offer misleading and even intimidating immigration advice, such as saying that nurses cannot change employer and will be deported if they do. In addition to those practices, overseas nurses suffer restrictive contract terms and conditions that are less favourable that those of their UK counterparts. They are paid less than UK nurses in the same institutions.

Worse still are misleading contracts. The RCN has examples of cases in which nurses have been sent contracts for prestigious specialist acute hospitals in London, but when they arrive they are carted off to work in an elderly persons' care home. They do not necessarily have the experience of providing geriatric care that is needed for that job. That is a cause for concern. It exploits not only the nurses but those who are receiving care. Both parties lose out. Finally, it takes some overseas nurses an unacceptably long time to secure their registration. They find themselves stuck in limbo, working without registration, particularly in the independent sector, and as a result there is even more pressure on them and they are further exploited.

My second concern is the criticism by the World Health Organisation and several Governments of developing countries that the UK is damaging their health care systems through its recruitment of health care staff. Last year, almost one in five new overseas registrations were from South Africa and the West Indies. The Minister will know that there are serious shortages of nurses and midwives around the world. That was the subject of a seminar organised by the World Health Organisation last November that examined the problem of nurse shortages not only in the UK but throughout the world, in developed and developing countries.

One of the factors identified as driving the problem is the demographic time bomb ticking away in many developed countries' nursing systems—not only our own, but those of countries such as Canada, the United States of America and Australia. In a statement about the shortages, WHO says: Skills drain, where nurses are recruited into developed countries from developing countries, exacerbates the situation. For example, the number of overseas nurses coming to the UK has risen by 48 per cent. in 12 months. In a report on the globalisation White Paper published last month, the Select Committee on International Development states: At the same time, the Secretary of State for Health has also acknowledged that the Department of Health is not responsible for the actions of private recruitment agencies". It quotes the Secretary of State telling the Committee: Sadly, I do not run the nursing agencies that are responsible for such conduct". The Committee added: However, we do not believe that we should rob developing nations of the medical and clinical staff that they desperately need … Throughout the NHS, Trusts, desperate to fill vacancies, turn regularly to private agencies to supply. We recommend that the Government, in its response, provide the Committee with details of how guidelines can be extended to cover the activities of private recruitment agencies. In her evidence to the Committee's inquiry, the Secretary of State for International Development confirmed that private nursing agencies cannot be prevented from recruiting overseas nurses from developing countries that are experiencing acute shortages. However, she said: It would be immoral, would it not, if all the nurses and all the doctors were recruited by the National Health Service, leaving none of those skills in countries like Trinidad and Tobago, Jamaica and so on. Those comments were made despite nursing recruitment from the West Indies almost doubling in one year.

Given the high rates of registration from developing countries, the NHS self-denying ordinance not to recruit actively from such countries is clearly not sufficient. It leaves a loophole through which nursing agencies can drive a coach and horses. The UK is the only country that has a director of international nurse recruitment. That role has the potential to be very positive and I welcome the establishment of the post. It could and should be used to stamp out poor practice and ensure ethical standards of recruitment, but that would require a more ambitious approach on the part of the Government. I shall propose some potential solutions that I hope that the Minister will consider. I believe that we need an ethical recruitment policy that covers not only where we recruit nurses, but how we recruit them.

First, I join Unison in calling for action to tackle the exploitation of overseas nurses by establishing some sort of taskforce comprising representatives from the Department of Health, the Department of Trade and Industry—which has a clear interest in terms of the registration of employment agencies generally—the Home Office, the Overseas Labour Service, the UKCC, the RCN, Unison and independent sector organisations, and others. The taskforce should work to ensure that consistent practice is adopted throughout the entire UK health care system—not only in the NHS, but across the piece. That is not least because of the fact that in our care homes, more than 53 per cent. of all placements are state funded. Public money is being used to pay for the nurses who come to work in those homes and who, all too often, are exploited. It is appropriate that the state is involved in ensuring that good practice and standards are applied.

Secondly, the Department of Health should issue clear instructions to trusts that no agency that charges the individual nurse who seeks to be recruited to work in the NHS should be used. It is one thing to charge the NHS for the use of its service, but quite another to charge the individual nurse for it as well.

Thirdly, the Department should implement a kitemark scheme for nurse agencies, so that the NHS is in no doubt that agencies are in compliance with NHS guidance on recruitment. Those measures would go some way toward addressing the International Development Committee's proposals that guidance should be made broader to include the independent and private sectors.

In conclusion, overseas nurses make a valuable contribution to our health care system. However, there is undoubtedly growing concern not only about the exploitation of nurses, but about the way in which this country is doing harm to developing countries, which have told us clearly that we should not actively recruit from their health care systems because of the damage that that is causing. Recruitment of overseas nurses is not a new phenomenon; what is new is the sheer scale of the recruitment that is taking place and the dramatic increases in the numbers that are being recruited. Given the worldwide shortage of health care professionals, overseas recruitment cannot be a long-term solution to the UK's nursing shortage. At best, it is a sticking plaster and a stop-gap measure while we establish the extra training places and grow our own nurses so that we can fill the vacancies in the NHS. I hope that Ministers will not lightly dismiss the Government's responsibility to ensure ethical recruitment practices and zero tolerance of exploitation of health care workers in this country.

12.21 am
The Minister of State, Department of Health (Mr. John Denham)

I congratulate the hon. Member for Sutton and Cheam (Mr. Burstow) on obtaining this debate on the recruitment of nurses from overseas. It gives me an opportunity to set out the Government's position on the expansion of the nursing work force in the NHS and the role that international recruitment can play in that process. I want to speak about the Government's plan for investing in NHS staff, and to describe the contribution that international nursing recruitment has made and will continue to make to the delivery of high quality clinical services to patients. I hope that in doing so, I can deal satisfactorily with the hon. Gentleman's major points.

NHS staff are a precious resource. They are what makes the health service tick. The biggest constraint that the NHS currently faces is no longer a shortage of financial resources, but a shortage of human resources. It is doctors, nurses, therapists and other health professionals who, together with support staff, keep the service going day in, day out. The massive improvements set out in the NHS plan will, over time, bring an end to years of underfunding and the consequent low morale among key health care professionals.

It is important to understand that the decisions made in the early 1990s, which the hon. Gentleman mentioned, are one of the reasons for the shortfall in the number of nurses. Those decisions drastically reduced the number of student nurses in training. Overall, the number of available training places fell by 28 per cent. When we were elected, it was clear that too few nurses had qualified, and would qualify, as fully trained registered nurses in the next few years. There had been serious damage to the overall nursing work force, which in turn posed a considerable threat to the standards and safety of care afforded to patients.

In addition to saying that such cuts must never happen again, we have established plans to expand the number of health care professionals. They include plans for 20,000 more nurses, as set out in the NHS plan. The recruitment and retention strategy that has been developed to achieve that target will include improved retention of staff, return-to-practice programmes, more training places, and international recruitment.

We have already made progress. Between 1997 and 2000, the number of qualified nurses in the NHS increased by more than 17,000. From September 1999 to September 2000 alone, there was an increase of 6,300 nurses. We will build on that, and increase the number of nurses by 20,000 by 2004. In addition, we expect that by 2004, as a result of the increased number of training places, more than 45,000 new nurses and midwives will come out of training, alongside 13,000 therapists and other health professionals.

So there is an increase in the number of nurses coming into the NHS, and it will continue in future. That is backed by an expansion of nurse training places. By 2004, 5,500 more nurses, midwives and health visitors will be trained each year than are being trained today. In itself, that is an improvement on the position when we were elected, but it takes three years to train a nurse, and a further two years to achieve an experienced and qualified intensive care nurse. That is one of the reasons why we want to attract returners to the profession. Almost 7,000 qualified nurses have returned to the NHS since February 1999, and another 2,000 are preparing to return.

While we await the benefits from the increased number of student nurses, and attract returners to the NHS, international recruitment will provide an invaluable resource, bridging the gap during the years of training, education and gaining clinical expertise.

The NHS has a long history of recruiting from abroad, and there are already many networks throughout the world for good co-operation and exchange of health care personnel. International recruitment by NHS organisations has been especially useful in areas where recruitment has proved difficult or where new developments require new or extra staff.

It is essential to ensure that effective and appropriate international recruitment is perceived as a direct benefit not only to NHS patients but to the employing organisation, the individual nurse, colleagues in the rest of the team and the recruit's home country.

Let me give a couple of examples that are relevant to the hon. Gentleman's constituency. They show that we acknowledge some of the problems that he raised. The Epsom and St. He[...]lier NHS trust has undertaken international recruitment, mainly by recruiting nurses from the Philippines and Finland. In October 2000, the trust asked three commercial international recruitment organisations to advise on the number of nurses who could be appointed to the trust on short-term contracts of between six months and two years. The purpose was to ensure that the trust could provide 102 extra beds in preparation for the winter. The trust selected the recruitment organisation BUPA, which provided nurses from the West Indies and South Africa. In response to concerns raised by the trust about recruiting from those areas, BUPA reassured it that the nurses had already been selected and were "on its books" before the publication of the Department of Health's guidance for international nursing recruitment in November 1999.

The nurses arrived at the end of 2000, and I understand that they provide high standards of care to patients. The regional recruitment and retention co-ordinator has subsequently worked directly with the trust to ensure that international recruitment is managed according to the guidance. The trust has also appointed a senior nurse for recruitment and retension. Although international recruitment allowed considerable expansion of services to patients throughout the winter, nurse recruitment now focuses on the local labour market.

St. George's Hospital NHS trust, which is also in the hon. Gentleman's constituency, discovered that a Filipino nurse was asked to pay a £1,000 fee directly to a commercial recruitment organisation in the Philippines. St. George's, in my view rightly, decided that it would not use that organisation again.

Mr. Burstow

The Minister is right that St. George's was correct to cease using that agency. However, would it not be better for the Department to issue clear instructions to trusts to do likewise in all cases?

Mr. Denham

I want to speak about the policies that are already in place and the further policies that we will introduce to deal with the problem. I shall briefly explain the current system, whereby nurses come to work in the United Kingdom. First, they must register with the United Kingdom Central Council for nurses, midwives and health visitors. During the year that ended in March 2000, there were more than 17,000 applications to the UKCC, of which 1,416 were admitted to the professional register from the European Community, and just under 6,000 from countries outside Europe. In the previous year, there were fewer applications.

It is important to stress that the successful applications to join the UKCC register do not necessarily represent nurses in employment in the UK. They include people who have never taken up employment here—those who take up temporary work, for example, in the working holiday arrangements, as well as those who take up full-time employment in the NHS and the independent and voluntary sectors.

As the NHS has expanded the number of nursing posts in line with developing service for patients, the opportunities for international recruitment have increased. That development formed the basis for the publication of the guidance on international nursing recruitment in the NHS in 1999. It made it clear that international recruitment should be cost-effective, based on good practice, and undertaken only on an ethical basis. The guidance specifically states that NHS employers should not actively recruit from developing countries that are experiencing nursing shortages. The only exceptions to that policy are nurses who seek an opportunity for development as part of a recognised programme approved by the relevant Government authorities in the country concerned, and employers who consider an unsolicited application directly from an individual potential recruit.

The hon. Gentleman asked about applications to the UKCC since 1999. When the guidance was published in 1999, some NHS employers would already have had international recruitment campaign commitments and established contracts with commercial recruitment organisations. Inevitably, there was a time lag between the publication of the guidance and its impact on the international recruitment policies of individual local NHS employers, and I gave the hon. Gentleman an example of that. This meant that nurses may have taken up their job offers in the UK up to a year after being appointed.

As the hon. Gentleman recognised, in January the Department of Health appointed a director of international recruitment to oversee the application of the guidance. The job of the director will be to co-ordinate the international recruitment efforts throughout England's eight regions, ensuring consistent standards and cost-effective best practice in employment. She will also develop agreements between Governments, ensuring international co-operation and the recruitment and exchange of health care professionals. Finally, an extremely important part of her remit is to ensure that developing countries are protected from targeted recruitment, and that the NHS does not actively recruit from, for example, the Republic of South Africa or the West Indies.

The director of international recruitment is working with the leaders of the professions and with other Departments to ensure that international recruitment in the NHS not only meets the Department's guidance but tackles service priorities and complies with NHS quality standards. The Department's guidance is intended to ensure that international recruitment fulfils its proper role in staffing the NHS, and that it is done on a proper, ethical basis.

There is cause for serious concern that some commercial agencies have targeted developing countries for international recruitment. The Department has been working with NHS employers and reputable commercial recruitment organisations to produce a code of practice that reinforces the requirement that international recruitment must never be carried out against the interests of host countries. A wide consultation involving NHS employers, professional bodies, trade unions and, specifically, commercial recruitment organisations is nearing completion. The Government will expect all recruitment organisations to adhere to the code of practice. In addition, I believe that the independent and voluntary sectors will wish to join forces with the NHS to ensure that agencies who engage in unscrupulous or poor practice are forced out of the market.

The code will require NHS employers to have proper plans in place to decide which countries they may recruit from, and which they must not target. The code will also state strict rules for commercial recruitment organisations that have contracts with the NHS. That means that in future, NHS employers will not contract with agencies that actively recruit from developing countries such as South Africa and the West Indies. It is worth pointing out that we are, I believe, the only developed country—indeed, the only country in the world—that has a policy on international recruitment that reflects ethical considerations, as well as those based on value for money and good practice. That is a significant achievement for Britain.

We must not forget that health care professionals have always been a highly mobile and marketable work force. Many professionals, including nurses, travel abroad of their own volition, some coming to England and many to other parts of the world. The NHS needs to respond appropriately to applications from such individuals. The Royal College of Nursing has expressed its concern about policies that infringe nurses' freedom to work where they like. The RCN has recommended that guidance should not stop individual nurses from coming to work in the UK should they wish to do so. Our guidance endorses that approach.

The hon. Gentleman mentioned exploitation in the private sector, and I have already said that we believe that the development of the code of practice in conjunction with the reputable organisations in the field will do much to raise standards right across the spectrum of international recruitment, whether to the NHS or to the independent sector, and to put a considerable degree of pressure on the independent sector to abide by similar standards.

I would need to look in detail at the points raised by the hon. Gentleman, and he may wish to write to me. Several of the instances that he mentioned certainly sounded, at first hearing, like clear legal breaches and not just poor conduct. They sounded, to me at least, like abuses of some of the work permit regulations, and I would be happy to consider whether what is needed is simply more effective enforcement, or whether wider measures need to be addressed. Clearly, we do not wish to see exploitation of nurses coming to work here from overseas. I too acknowledge the valuable role played in the NHS by those who have come here in recent years. We wish to ensure that theirs is a positive and valuable experience.

I want to mention the success of our Government-to-Government agreement within Europe—the Anglo-Spanish programme. The pilot programme in the north-west of England followed an agreement reached with the Spanish Government, enabling the NHS to employ some of Spain's surplus nurses and doctors. Currently 87 nurses from Spain are working in the NHS, and about 35 more are working in the private sector. The programme is being rolled out to London and the south-east, and we hope to recruit a further 500 nurses from Spain as soon as is practicable.

Many NHS employers have established mutually beneficial links with countries that are developing their health care systems. We are keen to encourage schemes enabling staff from many countries to benefit from spending two or three years in the NHS. The contribution that such staff make is often outstanding, and goes a long way to promote personal development, as well as the nursing profession as a whole.

I hope that I have described adequately the effective measures that we have in train to tackle the issues raised by the hon. Gentleman, and made clear the important role that international recruitment will play in ensuring that the NHS and its patients have the staff that they need. I hope that I have also made clear the Government's commitment to expanding the training and supply of nurses, so that we shall no longer be in the position that we have been in during the past few years as a result of the cuts in nurse training made under the previous Government.

Question put and agreed to.

Adjourned accordingly at twenty-four minutes to One o'clock.