On 27th November the Guardian published an article headlined
"Brexit has worsened shortage of NHS doctors, analysis shows". The repeated references to this article in the media and on this MB, has prompted me to investigate how justified this claim is.
The Guardian article (Reference 1) began by stating
"Exclusive: More than 4,000 European medics have chosen not to work in NHS since Britain left EU, data reveals". The article stated "Britain has 4,285 fewer European doctors than if the rising numbers who were coming before the Brexit vote in 2016 had been maintained since then, according to analysis by the Nuffield Trust health thinktank which it has shared with the Guardian."
So it is not the case that over 4,000 medics/doctors (Note: the Guardian interchange the terms) have made a conscious decision not to come to the UK, it is that there are fewer medics/doctors have arrived in the UK from the EU (and EFTA), at least according to the Guardian/Nuffield trust health thinktank, since before the referendum.
The sub-heading says
"Exclusive" and
"data reveals", so what is this exclusive data? It is a technical paper published by Nuffield Trust, also on 27th November entitled
"Has Brexit affected the UK’s medical workforce?" (HBAMW) (Ref. 2), which examines how the numbers of doctors in the NHS who come from the EU and the European Free Trade Association (EFTA) changed since the Brexit referendum in 2016. The report is no doubt exclusive to the Guardian because as the report states
"Overall, EU numbers* have remained relatively stable. However, the Guardian asked us to look at whether this still marked a change from trends before the 2016 EU referendum".
(*number of doctors)
The paper considers four selected specialities, which are those with known ongoing recruitment and retention issues, and where staffing data also shows a proportionately high number of staff from the EU and EFTA countries.
So just how exhaustive and conclusive is the HBAMW report? It suggests there are a number of other reasons why fewer EU and EFTA doctors came to the UK after the referendum including change in UK demand for doctors, the pandemic, changes in training, recruitment and retention of UK doctors, but rules these out on the grounds of no confirmatory evidence. The report concludes that whilst
"the effect is subtle" and
"While deeper research into drivers of migration is needed, it appears likely that the decision to leave the EU in 2016 plays a role." "Appears" to play a role does not read like a strong conclusion to me, but don't let that get in the way of another Guardian headline attacking Brexit. The report fails to identify the many other issues I raise below that will have adversely impacted on UK recruitment of EU, particularly Eastern EU, citizens. The report fails to provide any evidence that the recruitment of EU doctors or other medical workers would have continued at the same rate after the Brexit referendum as before the referendum, if the referendum result had been in favour of remaining in the EU. There is simply a presumption that things would have continued as they had been. I trust the analysis I have carried out below provides a
"deeper research into drivers of migration".
The HBAMW report's failure to provide evidence is simply explained in that there is no evidence that if the UK had not left the EU, the same number of EU health workers would have continued to come to work in the UK. As the HBAMW states, there are other drivers of migration at work. As we are repeatedly reminded on this message board there has been austerity measures since the Tories and LibDems came to power in 2010. Just as years of austerity upset many UK workers in the health sector, so it will have upset many foreign workers who may well have chosen to leave due to low pay rather than Brexit. Furthermore employment conditions have changed in many EU countries. Many countries like Germany have exactly the same labour shortages as the UK, if not worse, and are seeking to attract foreign workers. Some EU countries economies have grown more recently such as Poland, and some east European countries' wage levels have improved significantly. Consequently moving to the UK is less attractive than it was, whether or not the UK was an EU member. Finally, the pandemic has changed many people's attitude to work and made them realise that there is a better lifestyle than chasing income, especially in another country away from other family members and friends. I'm sure there are many other reasons that could change migration motives and that simply extrapolating a line on a graph projecting a trend is not sound forecasting. Nor it is sound to presume as some do that what has happened in other countries would have happened in the UK as some authors do with their "doppelgangers".
Whilst Brexit is obviously going to change some minds, there can be little doubt that the government managed to make matters worse. By the time of the referendum one in 10 nursing posts was vacant, twice the number in 2012. There was claimed to be a shortage of 30,000 nurses in 2017. (Ref. 7) That did not happen in a year from the referendum but built up over many years of Tory/LibDem government whilst the UK was a member of the EU. But as with the post Brexit HGV driver shortage, which was made worse by the government introducing IR35 regulations, the nursing shortage was made worse by introducing English language tests. English language tests have been a requirement for nurses from outside of the EU since 2005. In January 2016 these were extended to include nurses from the EU/EEA. There was an immediate adverse impact on recruitment from Europe. The General Medical Council started testing the English language competence of doctors from other European Union countries in June 2014, and as will be shown below, a drop in EU doctor recruitment rate began in 2015.
But all these issues are less significant than the root causes of the nursing shortage which is the UK has failed to train sufficient nurses for many years and, as has come to a head in 2022, failed to pay an appropriate wage to attract and retain people in the medical professions.
World Shortage of Medical Staff
As I have repeatedly posted, the UK is not alone in the problems we are experiencing post Brexit, neither are the problems new and only arisen since Brexit. A report published before the referendum, based on 2015 data stated
"demand for nurses is growing so fast that the pipeline of candidates just can’t keep up. Today 8 of the world’s 12 largest economies have a serious nurse shortage." The report (Ref. 8) highlights shortages in the US, UK, Germany, Australia, Canada, Russia, and Japan, and highlighted the UK as the worst. Another report (Ref. 9) in 2016 reported that more than a thousand doctors, nurses and carers are leaving Bosnia and Herzegovina for Germany each year. In France in 2016 French nurses protested about staff shortages and other issues. Reference 10 states
"‘The hospitals are at breaking point. There have been dozens of suicides among staff in the last year". That was in 2015 when French nurses protested and said
"The problem isn’t the number of hours: it’s a lack of staff. We cannot work until we drop.” (Ref. 11) References 12, 13, 14, 15, and 16 describe the medical staff issues in Austria, Czechia, Hungary, Poland, and Romania. In some cases the shortage of medical staff is not self inflicted but due to staff leaving eastern EU states to go to western EU states. Furthermore the situation is worsening, such as in Germany, not getting better. (Ref. 17). Since 2015 nurses in France have voted with their feet and left the health service resulting in one in five public hospital beds closed due to labour shortage crisis last year. (Ref. 18) In the case of doctors in France the issue is they are retiring faster than they are being recruited. Whilst we in the UK are concerned that the increase in the number of doctors is not fast enough to meet demand, in France the number of GPs dropped by 5.6 percent between 2012 and 2021. More than 6 million people, including 600,000 with chronic illnesses, do not have a regular GP and 30% of the population does not have adequate access to health services. (Ref.19)
In September the World Health Organization issued a warning of potential disaster stating
"All countries of the WHO European Region – encompassing 53 Member States across Europe and central Asia – currently face severe challenges related to the health and care workforce". (Ref. 20) In July Le Monde stated
"The shortage of healthcare workers is widespread across the globe. The WHO estimates that there will be a shortage of 15 million health professionals by 2030."(Ref. 21)
In the case of Germany I have gone to greater length in Appendix 1 to review the problems the largest economy in Europe has experienced.
A surf of the internet will quickly reveal the shortage of health workers is not a UK phenomenon but also exists in many countries with strong competition for recruits from Israel, Ireland, New Zealand, Australia, Norway, Canada , Denmark, UAE, and Switzerland who all pay very competitive salaries to attract medical personnel. UK experts are warning that even if the government hits its ambitious recruitment targets there will still be an extreme shortage of staff due to the high rate of employees leaving the NHS.
The Defect in the Nuffield Trust Logic
I have spelt out the issues at length, not because I am engaging in a discourse of "whataboutery", but to point out that it cannot be assumed the the UK would not be facing exactly the same problems today had Cameron won the referendum and the UK had remained in the EU, since most of the EU nations have the same shortages. I think it's extremely naive to suggest returning to the EU will reduce labour shortages in the UK; the pandemic has changed the world we live in.
But above all, my main argument is that the the Guardian article and HBAMW report base their argument that Brexit has caused a shortage on the premise that "the rising numbers who were coming before the Brexit vote in 2016 had been maintained since then". It is clear from all the evidence I have presented that that is a false assumption and there is little if any chance than the rate of recruitment from the EU during the first half of the decade would have continued through the second half of the decade, Brexit referendum or no Brexit referendum. In mathematical terms extrapolation of a fitted regression equation beyond the range of the given data can lead to seriously biased estimates if the assumed relationship does not hold in the region of extrapolation. The HBAMW report takes a trend from pre 2016 and extrapolates it to the post referendum years. It is quite clear from all the evidence that the conditions for employing EU citizens changed radically from the start of the period 2010 to 2021. This applies to both health service workers and those employed in the care sector as I will explain later.
HBAMW First Graph
The first group of doctors examined in the HBAMW report was anaesthetic specialists. The overall number of EU or EFTA doctors is consistently far higher than in other specialities and the shortage is well known and historic. The RCoA’s annual Medical Workforce Census Report in 2016 showed that between 2007 and 2015 the number of anaesthesia consultants increased by an average of 113 a year, but this was less than half of what is needed to meet demand. (Ref. 3) A Department of Health spokesperson said at the time:
“We don’t recognise the RCoA figures", so nothing new there! More to the point, the Guardian reported before the referendum that there was a critical shortage of anaesthetists (Ref. 4). Over the years the Association of Anaesthetists have spoken out repeatedly and a recent article described the problem of age profile at length but made no reference to Brexit or shortage of EU workers. (Ref. 5) It is true that the processes for EU nationals to work in Britain are now more rigorous after Brexit, and some may be deterred from coming or staying, but is that a bad thing? Surely having the same standards required for EU as for non-EU doctors is a good thing? EU nationals cannot any longer "walk in" to UK jobs and have to comply the same as non-EU nationals.
A report in 2021 described the low morale within the anaesthetists profession and the lack of sufficient training places. (Ref. 6) I would suggest this is a far greater deterrent to EU nationals from coming or staying than Brexit.
Turning to the actual numbers used by the Nuffield Trust to draw their graph of EU/EFTA anaesthetic specialists, the numbers for each year are as follows with the annual increase shown in parentheses:
2010:1,497; 2011:1,560(63); 2012:1,634(74); 2013:1,708(74); 2014:1.793(85); 2015:1,838(45); 2016:1,859(21); 2017:1,878(19); 2018:1,897(19); 2019:1,913(16); 2020:1,990(77); 2021:1.957(-33)
The numbers suggest a gradual increase in the years preceding 2015 with an average increase of 74 pa. However there is a clear change in the trend in 2015 and 2016 before any possible impact of the referendum. This I suggest reflects the general trend across Europe at this time in terms of a shortage of medical workers, not necessarily a Brexit impact. In fact, after a run of lower numbers averaging 19 in the immediate post Brexit referendum period, there is a sharp peak in 2020, the first year of Brexit, with the second highest yearly increase of 77. Could it be that some EU/EFTA anaesthetists were holding back on coming to the UK until the terms of the UK/EU agreement were settled, particularly with regard to citizenship? I respectfully suggest that we just don't know the answer to these questions, and certainly not make judgements on sound bites as most of the media do.
The projected trend on the anaesthetists graph in green indicates that by 2021 there would have been 2,351 specialists had there been no vote to leave. This is an increase of 513 on the 2015 level. That is an increase of over 85 per year, which is quite preposterous. To imply that there would have been an increase in anaesthetists specialist every year at the same rate as the maximum increase in 2014, when most of the western world is struggling for medical staff, is quite absurd and an insult to anyone's intelligence.
HBAMW Second Graph
The second graph in the paper for cardioid-thoracic specialists is even more absurd. As with the first graph, there is a discernible slow down in the recruitment rate in accordance with expectation given what was happening in the world before 2016. The green projected trend indicates an increase in recruitment rate of over 130% (from 311 to 717) from 2015 to 2021 in the event of no Brexit decision which quite frankly beggars belief!
HBAMW Third Graph
The third graph for paediatric specialist is similar to the first graph. There is clearly a decline in the recruitment rate before the referendum. As with graph for anaesthetists the projected trend in the event of a no Brexit result in the referendum indicates a higher rate of recruitment at 95 pa compared with the pre referendum years of 75 pa. which is totally at odds with what was happening across Europe.
HBAMW Fourth and Fifth Graphs
A similar situation is displayed on the fourth and fifth graphs. It would be vexatious of me to keep labouring the same remarks. It is enough to point out that the graph for all doctor specialist indicates that the rate of recruitment in the event of a remain referendum result would have resulted in a recruitment rate of 1,909 pa, 35% higher than the pre-referendum recruitment rate of 1,413 pa, which is utter nonsense.
The State of the NHS
The whole of the medical world is under extreme pressure due to labour shortages, the war in Ukraine, also partly due to the global supply chain issues including medicines, the coronavirus, high energy prices, production costs, the list is endless. While the UK has a shortage of hospital beds, France has a surplus of empty beds, with a fifth not in use due to staff shortages. (Ref. 22) Germany also has a medical staff shortages (Ref. 23), a serious medicine shortage, (Ref. 24) and major financial issues. (Ref. 25)
The UK needs to attract people from a far wider and larger labour pool like India and the Far East. Having said that a quarter of all new nurses in the UK were trained in poorer countries with more severe staffing shortages, which is a practice we should not be engaged in, without at least taking reciprocal measures. (Ref. 26)
The state of the NHS is dire, but in no way attributable to Brexit. I am not suggesting Brexit has done anything to help the NHS. The NHS is broken; its been slowly breaking since the 2008 financial crisis and the cutbacks. The waiting times in A&E, for cancer treatment, and for elective treatment draw the true picture. There is no indication in the Health Foundation graphs in reference 27 that Brexit changed the trends the NHS was on prior to the pandemic. The Guardian stated in December that the state of the health service is due to a decade of under funding. (Ref. 28)
The final straw has been the pandemic which created a backlog, burnt out the staff, and has lead to a huge increase in demand due to deteriorating conditions of the sick, and a dramatic increase in mental illness. There have been people saying the NHS is broken for years (Ref. 29) as evidenced by increasing waiting times and staff shortages. The pandemic could not have struck at a worse time.
Job satisfaction has dropped significantly in the last two years. (Ref. 30 If the Guardian could find a reason to blame Brexit it would) We should not tar the whole of the NHS with the same brush. There are good service providers and bad. People started talking about postcode lottery for service since the early years of the Tory/Liberal Democrats government in 2014. (Ref. 31 "we are seeing the return of the postcode lottery" ) Since then there have been regular reports of postcode lottery treatment for cancer treatment, child treatment, drug availability, etc. In my own area there are hospitals with a good reputation and those with a bad one, but it now seems even those who have had a good reputation are being overwhelmed.
Bed-blocking
It has been argued on this MB that Brexit has contributed to the NHS problems by creating a shortage of East European workers in care homes, resulting in the long-term occupation of hospital beds due to a shortage of suitable care elsewhere.
During the first decade of the century a number of East European states joined the EU and large numbers of their citizens moved to the UK for work. There were even stories of doctors leaving their home lands to work in supermarkets in the UK as they could earn more money stacking shelves than practising medicine in their homelands. This applied most notably to Poles and Romanians.
The picture changed considerably during the second half of the second decade of the century.
It is often claimed that many European citizens returned home after the referendum; this is not correct. In June 2022 there was an estimated 2,176,000 EU nationals working in the UK, higher than March 2016 when there were 2,144,000 before the referendum. It is not true that the number of European workers in the UK dropped after the referendum. The number continued to rise to a peak in March 2020 of 2,415,000. There was then a substantial fall due to the pandemic as people were laid off work and many returned to their homelands to be with their families. What is also true is that there was a sharp drop in the numbers of EU citizens arriving in the UK after the referendum. This was because of the significant improvement in working conditions in eastern Europe. Polish gross wages had been increasing steadily since the start of the millennium. In the time from the referendum to the start of the pandemic, Polish gross wages increased by a third. (Ref. 32)
The rise in gross wages in Romania has been even more dramatic with them almost doubling since 2017. (Ref. 33)
These higher wages are driven by the rapid growth of the East European economies in recent years. Poland's GDP has increased by 29% since 2017 and hardly saw any impact from the pandemic. (Ref. 34) The upturn in the Polish economy began at around the same time as the Brexit referendum. Polish unemployment in 2013 was over 10% and had been rising most years. From 2014 however Polish unemployment started to fall and was below 5%, a drop of 50% by 2017. (Ref. 35). It continued to fall until the pandemic, and still remains one of the lowest in Europe below even Germany. Poland, Hungary, Romania, Czechia, Bulgaria, and Slovakia today all have lower unemployment that the EU average, which is a totally different situation to a decade ago when the UK was recruiting large numbers from Eastern Europe. (Ref. 36)
This has in turn be driven by huge regional aid from the EU. (Ref. 37) During the years 2018 to 2021 Poland received over 47 billion Euros in net funding, a great deal coming from UK tax payers.
The Czech Republic has also seen an economic miracle with GDP rising by 44% since 2016 despite suffering during the pandemic. (Ref. 38)
Even Hungary, which significantly lags behind the other East European economies has seen a significant step up in wages since the time of the UK referendum. (Ref. 39)
It is little wonder given the economic upturn of Eastern Europe, coupled with Germany's demand for labour that fewer East European citizens now want to come to the UK and many want to return to their homeland.
Blaming Brexit is a fallacy. East Europeans came to this country a decade ago, seeking higher wages, which they can now get in the homelands. The shortage of care home staff today is also driven by workers leaving for higher paid work in supermarkets, etc. like the East Europeans were doing a decade ago.
Guardian Article 27th November
To return to the original article in the Guardian, the Department of Health and Social Care spokesperson said:
“This analysis is inaccurate and we don’t recognise or agree with its key conclusions. We are making significant progress in training and recruiting a record number of nurses, doctors and healthcare professionals. There are over 9,000 more nurses working in the NHS and there are over 26,000 more hospital doctors now than in 2016.” (Ref. 1)
The graph displayed in the Guardian article on 27th November (Ref. 1) is the same as the fifth graph in the Nuffield Trust HBAMW paper. The graph shows that the annual increase in the number of specialist doctors reduced after 2014 to 696 in 2015 and 736 in 2016. For all the reasons stated above it is logical that the increase in recruits from the EU would decline and not continue at the pre 2015 rate of 1,592 pa, or indeed the rate of 1,909 claimed by the extrapolated green dashed/ red line. The projection that there would have been 41,321 doctors by 2021 had the UK voted to remain in the EU is preposterous.
If the rate of increase had remained at the average of the 2015 and 2016 increases, i.e. 716 per annum, then by 2021 the total would have been 34,181. This projected total is actually significantly less than the actual total of 37,035 in 2021. That is to say since Brexit the rate of increase in recruitment of specialist doctors from the EU/EFTA during the five years after the year of the Brexit referendum was actually higher than both the year preceding referendum, and the referendum year 2016.
Interesting that the Guardian are saying in this article that Brexit has damaged recruitment of medical staff from the EU, but then a couple of weeks later on 14th December, they describe at great lengths the health crisis throughout Europe as
"a perfect healthcare storm that is likely to get worse before it gets better" (Ref. 19). Just where in Europe does the Guardian expect the NHS to recruit from? It is quite an achievement for the NHS to have continued to recruit from Europe at all and speaks well of just how attractive the UK still is. The Guardian article on 14th December describes conditions in some European countries which are quite alarming for people considering holidaying there.
Nuffield Trust Article 19th December
In a later article on 19th December the Nuffield Trust wrote about the UK
"Shutting off the ‘relief valve’ of EU migration". (Ref. 40)
This is a downright falsehood. There is no barrier to employment from the EU for medical jobs which are top of the governments needed jobs list needed jobs (Ref. 41) and positively encouraged to come to the UK, and in fact increased numbers have come from the EU and EFTA in recent years compared with 2015 as the Nuffield Trust and Guardian graphs show.
In the December article the Nuffield trust admit that there have been
"increased recruitment drives from the rest of the world" and blame the government for not taking sufficient compensatory action. Nuffield Trust made no mention of increased recruitment drives in the rest of the world in their HBAMW article. So yet again it is illogical for the Nuffield Trust to
"suggest" Brexit has made issues worse in the NHS, in fact in this later article, if you read the article carefully, the Nuffield Trust are blaming the government for mismanaging Brexit by failing to take adequate measure rather than blaming Brexit per se. The article repeats the comment
"The effects of Brexit appear to have added to the severe challenges and problems the NHS currently faces." I believe I have demonstrated above that appearances can be deceptive, and are wrong in this case.
NHS Staffing
Before ending however I think it is relevant to provide a few additional facts to remove any idea that the UK is short of NHS staff due to Brexit. There are repeated inferences in the media that there has been a mass exodus of EU workers, particularly health and welfare workers, since the Brexit referendum. Given the improved pay and employment prospects in Eastern Europe and the increased demand for health staff and low paid employees in Germany and the other major economies in Europe that would not be surprising. The number of EU nurses and health visitors has declined since the 2016 referendum but this reduction has been more than compensated by a huge increase in Asian and African nurses and health visitors. There has been an increase in non UK nurses of well over 18,600, which is a 26% increase, whilst at the same time an increase of over 8% in UK born nurses and health visitors. Regrettably the actual rate of employment of new starters is much higher but offset be the high level of leavers. (Ref. 42)
Care should be taken in interpreting the numbers in reference 42. The number of EU workers by place of birth in the NHS has increased from 58,700 at the time of the referendum to over 70,700 last June, which might appear to be a 20% increase in six years. But in 2016 there were a great many more employees whose birthplace was unknown and numbers will have transposed from unknowns into other categories.
During October the government announced that the number of NHS employees has continued to increase to record levels. (Ref. 43)
"There are over 1.2 million full-time equivalent staff working in NHS trusts and clinical commissioning groups in England – over 31,000 more people compared to a year ago, up by over 2.5%. Latest data published by NHS Digital shows that, compared to August 2021, there are also over 3,700 more doctors and over 9,100 more nurses working in the NHS."
Summary
The Guardian and Nuffield Trust claims that Brexit has damaged NHS recruitment are based on a false premise that had the referendum result been a vote to remain, or had there been no referendum, the same rate of recruitment would have continued post 2016 as prior to 2016.
There is clear evidence that the rate of recruitment from the EU/EFTA started to slow down prior to 2016. This can be explained by the increased demand for medical staff by other countries, notably Germany, a significant improvement in wages and the economies of the East European countries, tighter employment rules for doctors and nurses in 2014 and 2016 respectively.
The Nuffield report graphs indicate higher rates of recruitment would have occurred post the Brexit referendum than pre 2016 had there been a vote to remain. These extrapolations are, as the Department of Health and Social Care stated, inaccurate and in my opinion fanciful.
Appendix 1
Germany's Health Service Issues
Germany’s hospitals have been experiencing a shortage of nursing staff for several years. Having consistently recruited a steady amount of foreign doctors up to the first decade of the 21st century, there was than a sharp increase in recruitment which will have attracted many East European doctors who might otherwise have come to the UK. (Ref. 44)
A 2018 survey of more than 3000 German nurses revealed that 86% of nurses complain that they could not adequately care for their patients, 85% could not keep their breaks, 80% could not even comply with the hygiene guidelines and 75% already had filed an official overload letter to their HA. (Ref. 45) Germany’s answer was like the UK to hire foreign workers with a major world wide recruitment drive that began in 2013, obviously reducing the chances of the UK to hire workers from Europe and probably contributing to the reduction in recruitment from the EU from 2015 onwards . In 2020 Health Minister Jens Spahn made an effort to ease the hiring of foreign workers, but the coronavirus pandemic brought this recruitment drive to a halt. (Ref. 46)
Consequently European countries were hit by a double whammy of increased workload and reduced ability to hire extra staff. In 2021, there were approximately 14,000 vacant positions for registered nurses in German clinics, with an additional 8,000 vacancies in intensive care units (Ref. 47). At the time of the UK referendum Germany had a shortage of nearly 4,000 staff that got exponentially worse, which would have made it more difficult for all other counties to hire staff. (Ref. 48)
"The government has announced "the biggest hospital reform in 20 years. Fixing the system is badly needed, but will it work?" This is not the UK government being spoken about, but the German government on 12th June last year when German Health Minister Karl Lauterbach revealed details to reform the country's overstretched hospital system; he said this was the beginning of a revolution. (Ref. 49)
By September last year the German press were reporting
"hospitals are suffering massively from COVID-19-related staff absences and ward closures. Many staff members, especially in nursing, have left the profession or are no longer available to the same extent as before after two years of taking on the huge additional workload. As a result, beds are often left empty because there are not enough nursing staff to meet minimum staff-to-patient ratios." (Ref. 50) The same as in France where one in five public hospital beds were last year closed due to labour shortage crisis. (Ref. 51)
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