Brain Drain? Come Again.

James Staunton, Partner at Instinctif on global nursing talent.

In the run up to the election, Boris Johnson repeatedly pledged to build 40 new hospitals over 10 years. The Conservative manifesto went as far as to say the party was proud “to have begun work on building 40 new hospitals across the country”. The plans included a £2.7 billion investment for six hospitals over five years while a further 34 hospitals will share an initial £100 million in funding to start developing future projects.

There were some questions about whether the six initially funded ones were actually new hospitals, or refurbishments, or additions to existing ones – but to my mind that misses the elephant in the room. Who is going to staff these hospitals?

Even if 12 of the 40 are going to be relatively small, cottage hospitals, the manpower demands will be immense given there is already such an enormous shortage of staff. There are currently 44,000 nursing vacancies in the NHS according to the Guardian. Leaked government documents suggest this could reach 70,000 in five years. A study by the Health Foundation, a charity, warns there could be a shortage of 100,000 staff within a decade.

Separate proposals to attract 50,000 new nurses looks utterly unachievable to me.

First, the best advert for the profession is nurses themselves. But they are increasingly reluctant to recommend the job to anyone else: just 16 per cent of full time salaried nurses say the stress of the job puts them off recommending the profession to others. Even agency workers, who are generally happier with their lot, say the same (albeit on a smaller scale) – with only 20 per cent being prepared to recommend the profession.  One of the emotional pulls towards the profession is being neutralised.

Second, universities have been able to attract fewer nursing trainees since the bursary for nursing degrees was abolished in 2017.  Economic factors have been bleeding demand, too.

Third, according to specialist nursing recruiter Randstad, one in six nurses say work stress and its effect on their mental health is forcing them to consider leaving the profession in the next year. That will mean progress will be needed just to keep at current levels – let alone to start addressing the actual shortfall.

Given that these factors have either been turning off the talent taps that should be filling up the pool – or pulling out the plug, how should recruiters go about trying to tackle the shortage?  Assuming we aren’t going to force nurses to promote careers in the NHS at gunpoint and that the government’s free bursaries won’t be remotely large enough?  The answer is to identify new pools of talent. That means looking abroad.

The number of foreign nurses coming to work in Britain has doubled recently. The official figures show more 7,125 nurses who trained abroad registered for work in the UK in 2018/19 – up from 3,525 the year before. The vast majority of nurses coming to Britain from overseas were trained outside the EU. They include 1,791 nurses joining the Nursing and Midwifery Register from India, and 3,118 from the Philippines.

It’s not enough. But, despite this, recruiting healthcare professionals from abroad still gets a bum rap. A controversial target of hiring 5,000 foreign nurses a year for at least 15 years was cut over the summer. The British government has pledged not to recruit from Indian states which are in receipt of UK aid. These sorts of pledges are done with the best intentions. But they are misguided. They are being made based on a fundamentally flawed analysis.

Some opponents of immigration fret that it will increase inequality. They worry about poaching the best foreign talent or causing a “brain drain” in the donor country. Some think it unjust that people from poor countries might come to rich ones to work. But if the migrants thought that, they would not come.

The most obvious benefits for relatively low-skilled economic migrants are, unsurprisingly, economic. When they move from a poor country to a rich one, their wages swiftly become a lot like those of similarly skilled workers in the place they have moved to, and nothing like those of their place of origin. A recent piece in the Economist quoted a study of Tongans who entered a random lottery to work in New Zealand which found that those who won visas and moved earned nearly 300 per cent more than those who did not – in the first year. So while workers from a poor country who start at the bottom in a rich one will, statistically, make their new home more unequal, their moving will reduce global inequality.

What is more, the lure of earning big money overseas changes the incentives for people in poorer countries. Responding to the opportunity to work abroad and the higher wages that represents, more people might pursue nursing degrees. It prompts people to get educated and acquire marketable skills. This is known as the “migration prospect” effect. As a result, despite massive emigration, the Philippines has more nurses per capita at home than the UK and nurses per capita have grown much faster than population in many Pacific countries too, including Fiji and Kiribati. A study by Frédéric Docquier and Hillel Rapoport concluded that “high-skill emigration need not deplete a country’s human-capital stock” – and, if well handled, can actually make the sending country richer.

After all, migrants send money home – a lot of it. The munificent flow of remittances (the practice of foreign workers sending money to relatives back home) from millions of expat citizens from the four “Visegrad” states of central Europe (the Czech Republic, Hungary, Poland and Slovakia) who now live and work in the EU – especially in Germany, Austria or Britain – have helped drive the remarkable successes of their economies.

For many countries, remittances are more than that. They’re a lifeline. Some half a billion dollars in remittances are sent to Bangladesh from Britain each year, according to the World Bank. In Venezuela, net remittances have risen from $200m in 2016 to $2 billion in 2018. In Egypt, remittances grew by a fifth to $26.4 billion last year. Remittances are more than 10 per cent of GDP in 28 countries. In 2017, Jamaica received more in remittances – $2.3 billion – than its income from exports of goods. Remittances from Jamaicans abroad accounted for around 16 per cent of GDP in 2018; they are even higher in Tajikistan (30 per cent), Haiti (34 per cent), and Tonga (39 per cent). The World Bank says remittances to low- and middle-income countries reached a record high of $529 billion in 2018, up nearly 10 per cent from the previous year. In 2019, they will be the largest source of external financing for such countries and are set to reach $550 billion this year. They are already three times greater than foreign aid.

And unlike donor funds, remittances tend to flow directly to the intended recipients, rather than being squandered or embezzled by corrupt officials.

Furthermore, remittance flows are more reliable than foreign investment. Indeed, they are helpfully countercyclical. When a crisis erupts, foreign investors flee. But migrants feel doubly compelled to help their relatives back home. As the Economist points out, an engineer who makes $7,000 a year in Zambia might make $70,000 in America and send back more than the entire amount he used to earn at home.

Migrants also stay in touch with their home countries. Some spend a decade or two abroad, and then go back to start a business with the knowhow they have acquired in a more advanced country. That is, roughly speaking, according to the Economist, how the Indian information-technology industry started. Mukesh Ambani, India’s richest industrialist, is a Stanford drop-out. Jack Ma, the founder of Alibaba, China’s biggest e-commerce firm, found out about the internet on a trip to America. A study by the Kauffman Foundation, a think-tank, found that two-thirds of Indian entrepreneurs who return home after working in America maintain at least monthly contact with former colleagues, swapping industry gossip and sharing ideas.

The “pillaging local skills” narrative doesn’t stand up to scrutiny. The movement of skilled workers from poor countries to rich ones is nothing to fear. In the long run, it will benefit both.

Policy needs to change. Attitudes need to change. And recruiters shouldn’t feel guilty when they find a new pool of talent elsewhere in the world.


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