Brexit: healthcare losses and gains

Tens of thousands of doctors and nurses working in the UK are likely to leave the country as a result of the UK’s decision to part way with the EU, crippling the NHS. Robin Gauldie reports, exploring how this could help hospitals elsewhere in the European Union.

More than any other slogan, the ‘Vote Leave’ campaign’s promise of £350 million per week of extra funding for the UK’s cash-starved National Health Service (NHS) helped persuade Britons to vote for Brexit. With little more than a year to go before Britain finally quits the European Union (EU), there is no indication that promise will be kept.
Instead, UK chancellor Philip Hammond’s November budget pledged, not £350 million per week, but £350 million for the whole of winter 2017-18 – part of a £2.8-billion increase for the NHS to be spread over the next three years. Critics say that is not enough. Niall Dickson, chief executive of the NHS Confederation, which represents organisations across the UK healthcare system, says the provision ‘falls well short of what is needed to relieve the massive pressures facing the NHS’. “Over the years the NHS has required increases of around four per cent above inflation to deal with demand and maintain services. What the government is promising for next year represents around 1.4 per cent, plus whatever is allocated to cover the lift in the pay cap.”
The NHS, which is already short of staff after a decade of cuts and ‘austerity measures’, could lose more than 40,000 nurses and other medical staff as a result of the UK’s departure from the EU, according to a document leaked from the UK’s Department of Health. Around 12,000 doctors and 20,000 nurses and midwives working for the NHS come from EU countries, and a question mark hangs over their continued right to live and work in the UK after Brexit. Many intend to leave Britain, or have already left. According to official figures, around 10,000 EU workers left the NHS between the Brexit referendum and mid-2017. Those who might have replaced them are increasingly reluctant to move to Britain.

A climate of uncertainty
In March 2017, British newspaper The Guardian reported that the number of EU nurses registering to work in England had dropped by 92 per cent since the Brexit vote. At the same time, the number leaving the NHS had risen by 68 per cent, the newspaper said, citing information compiled from NHS sources. The Royal College of Nursing (RCN), which represents nurses in the UK, said the government has offered ‘no security or reassurance’ that EU staffers working in the NHS will be able to keep their jobs. “Few are able to live with such uncertainty,” said Janet Davies, chief executive and general secretary of the RCN.
The UK’s impending separation from the EU makes the recruitment problem worse, according to Frances O’Grady, general secretary of the British Trades Union Congress (TUC), and it is uncertainty over their future in Britain, not just low pay, that is discouraging EU medical staff from seeking employment in the NHS. “We’ve already seen nursing applications from EU nationals fall off a cliff,” said O’Grady, writing in The Guardian.
The British Government is under increasing pressure, both from within the UK and from EU Brexit negotiators, to guarantee that EU nationals who already live and work in Britain will be able to continue doing so. Prime minister Theresa May and her foreign secretary, Boris Johnson, have both made reassuring noises, but there are fears that such promises will be meaningless if Britain leaves the EU without an agreement on trade and other issues – the so called ‘hard Brexit’, which to many seems increasingly likely. But even if an agreement is reached that embodies such guarantees, Britain has become a less attractive place for medical staff to live and work, and the staffing drain will continue.
Limits on pay increases since 2010 mean NHS nurses earn £2,000 a year less, in real terms, than before the recession, making it difficult for hospitals to retain staff or recruit replacements. In October, Philip Hammond lifted the longstanding one-per-cent cap on pay increases. Whether that will translate into real rises that make up for eight years of stagnation is uncertain.  
There is also plenty of credible, anecdotal evidence that EU nationals working in the UK no longer feel welcome in Britain and fear being treated as second class citizens. Not only EU workers are affected. The mood of xenophobia whipped up by less scrupulous elements of the ‘Leave’ campaign and media has resulted in an upsurge of ‘hate crimes’ against non-white Britons and immigrants from Asia and Africa. That mood may also make it harder for British hospitals to attract staff from Commonwealth countries – traditionally a major recruiting ground – to replace departing EU employees. Nursing staff from poorer Commonwealth nations will likely still be attracted to the UK by the prospect of relatively high wages. In the UK, a nurse earns on average £23,519 (€26,632). In Germany, the average annual pay is around €27,500; in Sweden, around SEK348,000 (€35,000); and in the Netherlands €30,000.

Staff shortages
For EU workers who repatriate part of their earnings from their jobs in Britain, the decline of sterling since the Brexit vote also means the money they send home is worth substantially less, with £1 worth €1.13 in December 2017, compared with a high of €1.44 in mid-2015, a year before the referendum. Meanwhile, as the UK’s economy falters, EU economies are strengthening. Some central and eastern European countries have improved pay and conditions in recent years to increase retention of nurses and other health workers, according to the Health at a Glance 2017 report released in November by the Organisation for Economic Co-operation and Development (OECD). Hungary phased in a 20-per-cent pay rise for nurses and doctors between 2012 and 2015. The Czech Republic also increased hospital workers’ pay, while the Netherlands has seen a steady growth in remuneration for nurses, according to the OECD.
In 2014, a European Commission report (Mapping and Analysing Bottleneck, Vacancies in EU Labour Markets) cited the drift of healthcare workers to the UK as a major cause of staff shortages in the healthcare sectors of ‘new’ EU countries. Meanwhile, a shortfall in the number of people training to become health workers affected most of the ‘EU15’ countries, including Britain. Across the EU, 21 countries reported shortages in their healthcare workforce, the report said.
Other sources indicate that the Netherlands alone will face a 45,000-person shortfall in healthcare sector workers by 2025, while Germany must expect a shortfall of more than 200,000 by 2030. By 2020, the EU overall may have one million fewer healthcare professionals than it needs to serve an ageing population. Experts like Paul De Raeve, Secretary General of the European Federation of Nurses Associations, which represents nurses in 27 European countries, warn that low pay and tough working conditions are causing nurses to leave their profession. Could an exodus of thousands of doctors, nurses and other medical staff from Britain help the rest of the EU to solve its staffing problems?
A survey by the British Medical Association (BMA) has found that almost half of all EU doctors working in the UK are considering leaving. Nearly one-fifth have made firm plans to relocate elsewhere. Another 29 per cent said they were ‘unsure’ whether they would stay in Britain. “The top three reasons cited for considering leaving were the UK’s decision to leave the EU, a current negative attitude toward EU workers in the UK and continuing uncertainty over future immigration rules,” the BMA stated. The survey pinpoints Germany, Spain and Australia as the three countries doctors would most like to move to. “If you want to take a look into the future of the German labour market, look at the hospitals and retirement homes. There are endless jobs for certified nurses,” said Chris Pyak, managing director of  Immigrant Spirit, a Dusseldorf-based recruitment agency for medical and other professionals. “When I was working in German hospitals in the 1990s, there were 200 applicants for every job. Nowadays, there are only three applicants for every 10 jobs,” he stated, citing figures from the Arbeitagentur, Germany’s government-run job-seekers’ agency.
“We have seen a substantial increase in applications from the UK. These are usually professionals with special skills, such as intensive care nurses. If they own a degree from an EU university, their education is legally of equal value to a German medical education,” he said. “But there is one challenge: to work in the medical field you need to speak German at B2 level and you need to pass a German medical terms exam. These are legal requirements. So, we face an absurd situation: Germany needs about 100,000 additional nurses in the next few years, but English-speaking nurses still face obstacles to working in Germany, because of the language requirements.” The issue is not unique to the UK, Pyak said. “We also see an increase in enquiries from the US, since many international professionals don’t feel secure there anymore.”

An uncertain future
“The number of EU doctors looking to return to their home country would seem to be significant,” said Paul Brooks, who launched his international recruitment agency EU Health Staff in 2004 to bring medical staff from the ‘new’ EU countries such as Romania, Bulgaria, Hungary and Poland to the UK and other wealthier EU states. He expanded his services to recruit EU hospital doctors for organisations in Germany, Sweden, the UK and Ireland and GPs for practices in Australia, New Zealand and Canada. “I think that a lot of EU doctors working in the UK have retained contacts with their home country and original hospital, and so haven’t needed an agency to help them get a job back home,” he said. “Some of these countries now pay their doctors much better, so they may be willing to return. Others, such as Bulgaria, still give their doctors very low salaries, so I think they’ll stay in the UK. Germany is looking for doctors and I think quite a few German doctors have returned there. Some of the other Eastern European nationalities will have gone there as well.
According to Brooks, the system of recruiting doctors from overseas to the UK has got jammed up by a combination of Brexit, which has reduced the value of the pound versus European currencies and increased the perception of a bias against EU migrants; more complex registration requirements at the General Medical Council and NHS England; and stultifying NHS bureaucracy surrounding international recruitment. As with all other issues surrounding Brexit, the future remains uncertain. But it seems likely that short-staffed hospitals in other EU countries may benefit from Britain’s losses.