Trends in inflow of nurses to the UK
In the period between 1999 and 2003 there was rapid growth in the numbers of nurses from other countries registering to practise in the UK. While the annual number of international nurse registrants entrants has now declined, it remains at historically high levels. In the year up to March 2005, more than 12 000 nurses were admitted to the UK from all overseas countries (Figure 1).
Most of the growth in inflow of nurses to the UK has been from countries outside the European Union (EU). The four most important source countries in 2004/5 were India, the Philippines, South Africa and Australia. The vast majority of nurses coming to the UK are from English-speaking countries of the Commonwealth, or from the Philippines.
In total, between April 1997 and March 2005 there was an aggregate total of more than 80 000 overseas nurses admitted to the UK register. The relative contribution of international nurses to staffing growth in the UK has risen significantly. In the early 1990s: overseas countries were the source of about one in 10 nurses entering the UK register. In recent years, overseas countries have, on average, contributed about four out of 10 of the annual number of new nurse entrants to the UK register [2].
While NMC data can assist in tracking overall trends in the numbers of international nurses becoming eligible to practice in the UK, there are no complete and accurate published data available on where these nurses are located within the UK, if they are actually practising, or what type of work they are undertaking. Overall, about three quarters of all working nurses in the UK are employed in the NHS, the remainder working in the independent (i.e. private) sector, in nursing homes and in the relatively small independent acute hospital sector [2]. Both the NHS and the independent sector have been active in recruiting internationally, but it is not known in any detail where the level of use of international nurses is most prominent. The NHS in England does not record how many international nurses it employs, despite a recent recommendation by the House of Commons Select Committee on Migration [7].
Findings of the survey of international nurses
The decision to focus the survey of international nurses on those working in London was based on an understanding that there was a high concentration in the capital. The use of the RCN membership data base also enabled the questionnaire to be targeted both at nurses working in the NHS and in the independent sector, as RCN membership extends to both sectors.
Demographics of survey respondents
The objective of the survey had been to target nurses who had arrived in the UK within the last few years. While it was not possible to determine this from the available RCN membership information, the date of first joining the RCN was used as a proxy when creating the sample. Most respondents (77%) reported that they had first arrived in the UK since 2001, and nearly all the nurse respondents (96%) reported that they had first arrived in the UK since 2000. All but one reported that they had first worked as a nurse in the UK since 2000. The survey respondents therefore represent a population that had spent four years or less in the UK. Given the significant increase in international nurse arrivals in the UK since 2000, shown in Figure 1, this is not surprising.
The 380 respondents comprised a population with more than 30 different countries of training. The Philippines, Nigeria and South Africa were the three most commonly reported countries of training (Figure 2). A range of other countries in Africa, Asia, North America and Europe were reported, but in all cases the numbers were relatively small. In recent years, the NMC has registered nurses from 70 or more countries.
Most respondents reported that their country of training was the same as their previous country of location, with the exception of some Filipino and Indian nurses who reported that they and previously been working in the Middle East.
For the purposes of country and regional comparison, some of the data analysed in this paper are presented in regional aggregate form, in five regional categories, by country of training: the Philippines, India/Pakistan/Mauritius; South Africa; other sub-Saharan African countries; Australia/New Zealand/United States. These five regional categories account for 349 of the total of 380 respondents.
While there is often an assumption that younger nurses are more likely to be internationally mobile, the age profile of respondents varied markedly by regional grouping. Sixty per cent of the nurses from sub-Saharan Africa and more than 40% from South Africa and India/Pakistan/Mauritius were aged 40 or older; the youngest age profile was reported by the Australia/New Zealand/USA nurses, with more than 60% being aged 34 or younger. Figure 3 highlights the significant variation in age profile between the relatively "younger" Australia/New Zealand/USA group and the older profile of nurses from sub-Saharan Africa.
Nursing is mainly a primarily a female occupation in most countries. Over 90% of UK-trained nurses are female [8]. There was a higher proportion of male nurses in the international nurse respondents, with 84% being female. Two thirds (66%) of respondents reported they were married. Three quarters of respondents (76%) who reported that they were married or had a partner also reported that they were currently living with their spouse/partner in the UK; one quarter (24%) reported that their spouse/partner was living in their home country.
Two thirds of respondents (66%) reported having children (Figure 4). Most respondents from sub-Saharan Africa (88%), India/Pakistan/Mauritius (77%), South Africa (63%) and the Philippines (53%) reported having children. Only 22% of Australia/New Zealand/USA respondents had children. Of these respondents, 61% had children living with them in the UK and 39% reported children living in their home country. Some respondents reported having children both in the UK and in their home country.
Nearly all the respondents (92%) are qualified and registered to practise in general adult nursing: 10% are registered to practise in mental health nursing, small numbers reported registration as learning disabilities nursing, children's nursing or midwifery. Some respondents are registered to practise in more than one field.
Coming to the UK
Respondents were asked to report the reason that had most influenced them to decide to come to the UK. The key results are shown in Figure 5. The responses highlight some variation by region of origin. All the Australia/New Zealand/USA nurses indicated that the main reason that they were in the UK was personal, linked to travel and experiencing a different way of life. The results from the other regional groups question the assumption that nurses are moving only for financial reasons: many report that the factor that most influenced them to move was professional development. Some nurses from Africa and India/Pakistan/Mauritius reported social reasons as being the main driver – linked primarily to joining family already in the UK. No nurses from the Philippines reported this reason for coming to the UK. This is not surprising, as there is no history of migration from the Philippines to the UK and the post-colonial ties that exist between the UK and anglophone Africa and Asia are absent.
Two thirds of all the respondents indicated that a recruitment agency had been involved in their move to the UK. Relatively fewer nurses who had previously been located in sub-Saharan Africa had made use of an agency, but nearly all Philippines-based nurses (96%), South African nurses (83%) and most nurses who had been based in the Middle East and in India/Pakistan/Mauritius reported that a recruitment agency had been involved in their move. Filipino nurses were most likely to report that the agency was based in their home country (i.e. Philippines); for nurses from the other regional groups, the agency was more likely to have been international or based primarily in the UK.
Nearly three out of every four nurses (72%) who reported using an agency had to pay for at least part of the services provided by the agency (i.e. the recruiting employer was not covering all the recruitment/registration/travel costs). Filipino (74%) and India/Pakistan/Mauritius nurses were most likely to report that they had paid. Most Australia/New Zealand/USA nurses (78%) reported they did not have to pay for any services provided by agencies. The most commonly reported payments were direct fees to the agency; adaptation fees to the Nurses and Midwives Council in the UK, and transport fees to travel to the UK to take up their job.
Supervised practice/adaptation
Three quarters of the respondents (76%) reported that they were required to complete a supervised practice course/period of adaptation in the UK in order to be eligible to practise as a nurse in the UK. The requirement to undertake supervised practice/adaptation varied significantly depending on country of training (Figure 6). Nearly all Australian/New Zealand/USA and South African nurses reported that they were not required to undertake a course prior to registration to practise in the UK, but all nurses from India/Pakistan/Mauritius and nearly all from the Philippines and sub-Saharan Africa reported that they had to take a course/period of adaptation.
In the majority of cases, this course was reported to have been taken while the nurses were working for private sector nursing homes (nurses from India/Pakistan/Mauritius and sub-Saharan Africa) or in NHS hospitals (nurses from the Philippines).
Current employment
Two thirds (69%) of respondents were working in NHS hospitals in London, 13% were working in the private sector hospitals and 10% were working in private sector nursing homes (Figure 7). Very few respondents were working either for general practices or in NHS community nursing. In part this may be explained by the fact that some NHS community nursing posts require post-basic professional qualifications that are not available in other countries. Filipino nurses were most likely to be working in NHS hospitals; as were the majority of nurses from other regions apart from sub-Saharan Africa (where many were working in the private sector), South Africa (where 40% reported they were working in the private hospital sector) and Australia/New Zealand/USA (where some reported they were working directly for nursing agencies).
More than half of the respondents (57%) had already made one change of employer since beginning work as a nurse in the UK. The main direction of employment mobility had been from the private sector and nursing home sector to the NHS. Of those who have made a move, three quarters (75%) report that their first employment in the UK was as a nurse in the private/independent sectors.
Pay and grading
At the time of the survey, all NHS nurses working in clinical practice were paid according to a single national pay/grading system ("clinical grading"). This system is based on grading structure from grade "A" (lowest) to grade "I" (highest). Three quarters of respondents reported that they were paid on the NHS clinical grading system. Some private sector employers also use the clinical grading system. Data on reported clinical grade enable an assessment of variation in pay rates by different regional grouping.
Nearly all the respondents who were paid according to clinical grading reported that they were paid on either clinical grade D (36%) or grade E (51%). These are the two main grades for staff nurses (the primary job category for registered nurses). There was evidence of variation by region of training: more than half of the nurses from sub-Saharan Africa (53%) were graded at the lower level of D, as were nearly half of the nurses from India/Pakistan and Mauritius. Two thirds (65%) of Filipinos reported that they were graded at the higher level of grade E. None of the nurses from Australia and New Zealand reported that they were paid at grade D: more than half of this group were paid at grade F or above. Similar variation in grading outcome has been reported in other, more recent, surveys of UK nurses [9].
Respondents were asked to indicate if their current clinical grade was appropriate, given their role and responsibilities (Figure 9). Just over half (53%) of those who were graded indicated that they believed their grade was appropriate, but this dropped to only 31% of nurses from sub-Saharan Africa and 34% of nurses from South Africa.
Most of the nurses were the major or sole "breadwinner" contributing to household income. One third (37%) were contributing all of the household income, a further quarter (25%) contributed more than half, and a further one in five (20%) contributed about half (Figure 10).
More than half of the respondents (57%) reported that they regularly sent remittances to their home country, but the pattern of remitting varied significantly by regional grouping (Figure 11). Three quarters of Filipino nurses (73%) regularly remit money home, as do more than half of nurses from sub-Saharan Africa and from South Africa. Nurses from Australia/New Zealand/USA and India/Pakistan/Mauritius were much less likely to report that they were remitting money. In the former case this may be linked to the fact that they are more likely to be single, and more likely to be planning only a short stay in the UK (see below). In the latter, it may be linked to the fact that these nurses have their families with them in the UK. Nurses from South Africa and the Philippines were most likely to report that they remitted a high proportion of their income – in both cases, about half of respondents were remitting either between 26% and 50% or more than 50% of their income.
The average full-time pay for a nurse in the UK in 2004 was approximately GBP 24 500 [10] (nurses in London earn more because of a regional supplement).
Career plans
Respondents were asked to indicate how long they planned to remain in the UK as a nurse (Figure 13). The majority (60%) indicated that they planned to stay for at least five years, with a further quarter (25%) indicating that they planned to stay between two and five years. Australia/New Zealand/USA nurses were least likely to be planning to stay long-term and proportionally more South African nurses reported planning to stay for two to five years than for longer periods.
Most respondents (83%) require a work permit to work in the UK and nearly all (91%) indicated that if their permit was extended they would wish to stay longer in the UK.
Respondents were also asked if they were considering a move to another country. Just under half (43%) reported that they were considering a move (Figure 14). Nearly two thirds of Filipinos (63%), more than half of Australia/New Zealand/USA nurses and 40% of South African nurses were considering a move. Nearly all the Filipino nurses (83%) who were thinking of moving reported that they were considering moving to the USA, while Australia/New Zealand/USA nurses and nurses from South Africa were most likely to be considering moving "back home". Overall the USA was the most often reported potential destination, cited by more than half of the potential movers; Australia was the next most commonly reported possible destination.
One third of the respondents (32%) had been contacted by a recruitment agency within the last six months and offered work outside the UK, including half of all the Filipino nurses (who were mainly being offered work in the USA).
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