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This story is available for use by the BBC’s local news partners. Please do not share outside of the network. It is under strict embargo until 00:01 on Friday 5 August 2022.

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What’s the story?

The share of homegrown doctors and nurses joining England’s NHS is at its lowest for seven years, BBC Shared Data Unit analysis of workforce data has found.

Some 58% of doctors joining the health service last year came from the UK, with health bosses increasingly turning to international recruitment.

The British Medical Association said the NHS faced a “workforce crisis”.

The government, however, insisted there were record numbers of doctors, a rise of 34% since 2010. While overall numbers have been increasing, critics said declining domestic recruitment was unsustainable to keep pace with demand.

The BBC’s Shared Data Unit analysed workforce data provided by NHS Digital from 2015 to 2021, to investigate if trends we reported following the Brexit referendum in June 2016 continued.

It found the share of UK doctors joining the health service had fallen from 69% in 2015 to 58% last year. Over the same period, the share of new UK nurses fell from 74% to 61%.

Recruitment of doctors from the Rest of the World rose from 18% to 34% over the same period, and that share of international nurses rose from 7% to 34%.


What’s the national picture?

Note: Data released to us under FOI laws covering health services in Scotland, Wales and Northern Ireland was incomplete, but the data supplied can be viewed separately in the dataset and story pack shared with you under embargo.

Use the two tabs below to flick between data for doctors and nurses and health visitors. This breakdown is only available on a national level.

This table (scroll down) shows the changing nature of the NHS workforce from 2015 to 2021 in England.

Here’s a breakdown of the column names for this table:

  • Type: Whether the column describes a member of staff joining or leaving the NHS

  • Staff group: The type of job

  • Nationality group: Whether the employees joining or leaving the NHS came from the UK, from the EU, or from the Rest of the World

  • Dec14_Dec15: The number of people joining or leaving the NHS in the time period

  • PercentageShare_Dec14_Dec15: The proportion of the total number of people joining or leaving the NHS who came from the UK, the EU, or the Rest of the World

You can scroll across to the right of the chart using the scroll bar at the botton.

Please note the unknown values have been removed from the total when making the above calculation.

The last two columns are repeated for the years 2014 to 2021.


Doctors


The percentage of homegrown doctors - UK nationals - joining England’s NHS was at its lowest point for seven years in 2021 - 58% of those doctors joining whose nationalities were recorded.


Nurses and health visitors


The percentage of homegrown nurses - UK nationals - joining England’s NHS was at its lowest point for seven years in 2021 too - 61% of those nurses joining whose nationalities were recorded.


What’s happening in your local NHS trust or CCG?

Use the tabs below to flick between staff who have joined the NHS (‘Joiners’) and staff who have left the NHS (‘Leavers’).

The tables contained within the tabs (scroll down) show the changing nature of the workforce within NHS Trusts and CCGs from 2015 to 2021 in England.

Here’s a breakdown of the column names for this table:

  • UK change 2015-2021: This shows the increase or decrease between the total number of staff who joined the trust from the UK in 2015 compared to the total number of staff who joined from the UK in 2021.

  • UK percent point change 2015-2021: This shows the percentage point increase or decrease between the share of staff joining from the UK in 2015 to the share of staff joining from the UK in 2021

  • EU change 2015-2021: This shows the increase or decrease between the total number of staff who joined the trust from the EU in 2015 compared to the total number of staff who joined from the EU in 2021.

  • EU percent point change 2015-2021: This shows the percentage point increase or decrease between the share of staff joining from the EU in 2015 to the share of staff joining from the EU in 2021

  • World change 2015-2021: this shows the increase or decrease between the total number of staff who joined the trust from the Rest of the World in 2015 compared to the total number of staff who joined from the Rest of the World in 2021

  • World percent point change 2015-2021: This shows the percentage point increase or decrease between the share of staff joining from the Rest of the World in 2015 to the share of staff joining from the Rest of the World in 2021

An example line from this data could read:

At Medway NHS Foundation Trust, the share of UK staff joining the trust dropped by 29.6 percentage points between 2015 and 2021. Over the same period, the share of staff recruited from the Rest of the World rose by 30 percentage points.

Note: organisations with no new joiners or leavers recorded in the initial years of the England data have been excluded.


Joiners

Leavers

What critics have said

Flick between the below tabs to view each quote. All quotes were sourced by the BBC Shared Data Unit and are availabel for partners use.


Dr Amit Kochhar (he/him), British Medical Association (BMA) international committee deputy chair

"The staff working in the NHS are its greatest asset and whether they trained in the UK or further afield, they all make invaluable contributions to patient care.

“The NHS is facing a workforce crisis and since well before the pandemic has struggled to recruit and retain staff. As of December 2021, more than 110,000 posts in secondary care are vacant, almost 8,200 of which are medical posts.

"High vacancies create a vicious cycle: shortages produce environments of chronic stress, which increases pressure on existing staff, and in turn encourages higher turnover and absence.

“The NHS has always been reliant on the commitment and expertise of international medical graduates and the last few years have seen the UK become more reliant on them.

"During the pandemic, international doctors have been on the NHS frontline, contributing their valuable skills and expertise to save the lives of others – with a disproportionate number sadly losing their lives to the virus.

“It is vital that the Government leaves no stone unturned in finding solutions to the NHS workforce crisis – and ensuring that international staff feel welcomed and valued is hugely important in recruiting and retaining them in the long term.

“For example, we know that following the referendum Brexit had a huge impact on the morale of EU NHS staff working in the UK. Our own research from that time showed that four out of ten EU NHS staff were considering leaving the UK following the referendum result in 2016. The top reason doctors cited for this at the time was the UK’s decision to leave the EU.

“The BMA has called on the Government to reduce the financial and bureaucratic barriers faced by international doctors in the UK who contribute their skills and expertise to the UK’s health service.

"Currently, international medical graduates are charged £2,389 – as well as £2,389 for each of their dependents – to apply for indefinite leave to remain, as well as expensive visa fees leading up to that point. We know from our members that the financial and mental burden of the immigration process is immensely debilitating.

“Doctors are cutting their hours or making plans to leave the health service altogether for a range of reasons – including punishing workloads, stress, exhaustion, punitive pensions’ taxation rules, restrictive immigration rules such as the adult dependent relative rules and, sadly, verbal and physical abuse. All of these issues need to be addressed for the NHS make headways in tackling the enormous backlog of patient care.

“The BMA has been a leading voice in a coalition of over 100 organisations, urging the Government to amend the Health and Care Bill to increase accountability for ensuring there are adequate numbers of healthcare staff to meet growing patient demand. Now that this opportunity has been squandered by the Government – despite such compelling consensus behind the need for the amendment from cross-party parliamentarians and former NHS leaders – DHSC’s recent commission for NHS England to publish a long-term workforce strategy must commit to delivering these assessments of current and future workforce numbers.”

Patricia Marquis (she/her), Royal College of Nursing (RCN) Director for England

“The number of unfilled nursing posts in the NHS is unsustainable. Every vacant role makes safe patient care harder to maintain.

“We are seeing a sharp increase in people leaving nursing, with 25,000 leaving the UK register in the last year.

"After a decade of real terms pay cuts, a growing over reliance on international recruitment and limits on education funding, our members are saying enough is enough. Those working in the NHS in England and Wales will have their say in a ballot on industrial action over pay. Ministers must begin to listen.

“Our internationally-recruited nurses are, and have always been, invaluable to our health and care services, but ministers must do more to boost the domestic recruitment of nursing staff. One of the simplest ways to recruit and retain staff is to pay them fairly.”

Kate Shoesmith (she/her), Deputy CEO at the Recruitment & Employment Confederation (REC)

“Staff shortages in the NHS and the wider healthcare sector are the worst they have ever been. However, the shortages were severe even before the pandemic and the fact is that recruitment and retention in healthcare have not been good enough for a long time.

"Between 2015 and 2021, recruitment businesses in the sector consistently highlighted shortages of care workers, nurses and healthcare assistants, as well as support workers and other roles.

“There are lots of reasons for the shortages but healthcare recruitment agencies frequently cite burnout and poor working conditions as the main reason staff leave the NHS, and a desire to work flexibly as a reason why some people take agency shifts instead.

"The shortages cause worse conditions for remaining staff which contributes to a vicious cycle. Brexit has also had an impact, but less so than in other sectors such as hospitality. In healthcare, it has been easier for some time for foreign nationals deemed highly skilled by the immigration system to come from outside the EU to fill some of the gaps.

"It has only been very recently that social carers have qualified under the immigration rules, so we are yet to see an impact there.

“Ultimately, we need a long-term solution which involves a flexible immigration system, so that the NHS has the right skills at the right time to meet patient needs.

“To help shape their workforce planning strategy, the government and the NHS would also do well to collaborate with staffing agencies who understand the concerns of frontline workers and can see the trends in demand for certain skills.”

Danny Mortimer (he/him), chief executive of NHS Employers (part of the NHS Confederation)

“The NHS recognises the long-standing value of international recruitment and the incredibly important contribution colleagues from around the world make to the delivery of health and care for our communities.

“It is also important that we ensure our international colleagues are retained to develop and achieve their potential in the health service.

“However, NHS employers were very concerned about the relentless demand being placed on their teams due to the staffing vacancies which now stand at 110,000 – gaps which cannot and should not be filled through international recruitment alone.

“The NHS is facing chronic workforce shortages, and these are getting worse. These posts urgently need to be filled to make sure our communities receive the best care possible and to alleviate the strain our teams continue to face, against a backdrop of spiraling workloads and ever-growing backlogs of treatments. It is now high time for the Government to commit to a fully funded long term workforce plan for the NHS.”

What the government said in response

England’s Department of Health and Social Care (DHSC) responded as follows to our questions:

SDU Q: Why does the NHS think this happened between 2015 and 2021?

“The workforce varies based on many factors on both local, national, and international basis. Changes between 2015 and 2021 that may have impacted this include more rigorous language tests introduced by the Nursing and Midwifery Council (NMC) around the time of the referendum, which DHSC supports as an important patient safety measure, and the economic recovery of southern European countries. Many nurses from these countries had come to the UK to work when there was limited work available at home.”

SDU Q: Was this tied to the Brexit referendum and sentiment of people feeling welcome in England, according to your research and feedback from NHS staff over this time?

“Following the referendum, the Prime Minister made it clear that EU staff in the health and care sector were welcome and encouraged them to stay. Steps were taken to ensure existing EU staff were able to remain in the UK post-EU Exit. For example, the government launched the EU Settlement Scheme and enabled NHS Employers to provide support for EU staff throughout the transition period.”

SDU Q: Is more recruitment going on in countries in the Rest of the World to make up for this? Is it cheaper for NHS trusts to recruit from the Rest of the World than domestically or from EU & EEA countries in terms of training and agency fees?

“International recruitment has long been part of the NHS workforce strategy and we value the contribution of international staff enormously. Last year more overseas doctors joined the GMC register than domestic ones. Around 190,000 out of 1.35 million staff report a non-British nationality. This is 14.6% of all staff for whom a nationality is known, or one in seven.

“The Nuffield Trust has undertaken comparative assessment of different types of recruitment. The cost of recruiting internationally carries considerable upfront costs, but this can be offset against expensive use of agency staff, but regular use of UK-based agency staff is more expensive in the medium and long term.”

SDU Q: Is there a shortfall of UK doctors joining England’s NHS? If so, why?

“In the past year, we have seen record numbers of doctors working in NHS hospital trusts and clinical commissioning groups. Latest data for January 2022 shows there are over 32,600 (34.2%) more doctors compared to January 2010.

“The government has funded an additional 1,500 undergraduate medical school places each year for domestic students in England - a 25% increase over three years – and there are record numbers of medical students in training. The government is committed to ensuring that the number of medical school places is in line with England’s workforce requirements.”

SDU Q: Around 12% more nurses and health visitors as well as doctors joined the NHS in 2019 than in the previous year with the percentage rises being driven by joiners from the Rest of the World. What happened in 2019 to explain that increase? Was there a particular recruitment drive in countries in the Rest of the World and if so, why?

“Several factors could have led to an increase in international recruitment in 2019, but there was no specific international recruitment campaign. At a local level, NHS trusts improved their international recruitment processes and started to work more collaboratively.

“At a national level, all doctors were added to the Shortage Occupation List and nurses remained on it, while more significant changes were implemented in 2020 to improve the speed and cost of visa applications. At a global level the supply market responded to growing UK demand, particularly from the Philippines and India.”

SDU Q: Earlier this year, dozens of NHS trusts declared critical incidents due to staffing levels amid handling of COVID – is that rooted in the trends we saw in the workforce from 2015-21 and does the NHS think it carried out sufficient recruitment?

“Several critical incidents were declared due to operational pressures earlier this year, some citing staffing as a contributing factor. It is not uncommon for the declaration of critical incidents to be part of the response to managing operational pressures, including seasonal fluctuations in demand and those created by higher COVID sickness absence. Sickness absences reached a peak of 8.8% earlier this year in early January, including 4.6% due to COVID. This is in sharp contrast with the total absence rate of 4.8% in January 2020 (pre-pandemic).”

SDU Q: Did some of these trends in the workforce in the years immediately preceding the pandemic, contribute to the NHS’s ability to respond to the pandemic?

“This year we have seen record numbers of staff working in the NHS, including record numbers of doctors and nurses. This is building on from expansion of the NHS workforce over the last decade.”

SDU Q: The data showed an increasing percentage of staff - including nurses and doctors - leaving the NHS consecutively over the past four years who were Rest of the World nationals. Does this suggest people recruited from the Rest of the World are not staying for long in the NHS in England? If so, why is that please? The BMA tells me there are “financial and bureaucratic barriers” faced by international doctors in the UK such as the cost of initial visas then the additional costs of applying for indefinite leave to remain for all their dependents. Do you think the costs of immigration are the main reason?

“Some of the internationally trained staff will inevitably stay in the UK, but many return to their home countries each year. While the cost of applying for permanent residency in the UK – known as Indefinite Leave to Remain - is consistent, there is no obligation on healthcare professionals to apply for this and they can, under the new Points-Based System, remain in the UK on a Health and Care Visa which was a key promise of the government’s manifesto that we have delivered on.

“The government rejects the assertion that immigration restrictions are a key reason for healthcare staff leaving the UK. The visa system is supportive for health and care staff, demonstrated by changes in 2020, such as:

  • Launching the Health and Care visa making it quicker, easier, and cheaper for eligible people to come to the UK with their families.
  • Exemption for those working in the health and care sector from paying the Immigration Health Surcharge.
  • Streamlining the system by removal of the Tier 2 visa cap and resident labour market test.”

SDU Q: I’ve also seen a BMA survey suggesting there was an issue or racism in the NHS towards ethnic minority doctors. Is this part of a wider trend deterring Rest of the World nationals perhaps wanting to stay in the NHS in England?

“The NHS is one of the most diverse organisations in this country and we hugely value the contribution that all staff make to delivering care and supporting patients.

“ Senior and executive NHS leaders are accountable for developing and delivering plans to eliminate inequality in their organisations. The NHS Workforce Race Equality Standard collects data on the experience of ethnic minority staff and provides a framework for employers in the NHS to develop their own action plans to improve everyone’s experience.”

SDU Q: Are there any other factors in play here about immigration status and when certain medical roles could have been included on the shortage occupation list? The Recruitment & Employment Confederation (REC) tells me staff shortages in the NHS and the wider healthcare sector are “the worst they have ever been” but that they were severe even before the pandemic. The REC said between 2015 and 2021, recruitment businesses in the sector consistently highlighted shortages of care workers, nurses, and healthcare assistants, as well as support workers and other roles. The REC added healthcare recruitment agencies frequently cited burnout and poor working conditions as the main reason staff left the NHS and the shortages caused worse conditions for remaining staff which contributed to a vicious cycle. Do you think the REC’s comments are accurate?

“The retention of skilled and experienced staff is very important. The NHS People Plan, published in 2020, is focused on retaining NHS staff by helping organisations to improve their employment offer. This includes a much stronger focus on staff health and wellbeing, more support for flexible working, and a renewed commitment to tackling inequality. The NHS has recently published a toolkit to help employers improve their levels of staff retention.

“Nationally, the NHS faces pressures of workforce shortages and many trusts have relied on their temporary workforce to efficiently manage the fluctuating demands of healthcare. Trusts use their own banks (managed in-house or via management companies) and external agencies to resource extra temporary staff. The REC represents agencies that supply staff to the NHS, and it is not possible to confirm the accuracy of their findings nor how representative they are of all staff leaving substantive NHS employment. Agencies supply a very small proportion of the total NHS staff FTE.”

SDU Q: Are there any concerns about the different training or qualifications of Rest of World nationals joining the NHS in England? I’ve been told by a histopathologist that in order for her colleagues from the Rest of the World to be able to work at and being remunerated at consultant level – in what is a shortage occupation – they need to complete a portfolio of work and experience over two years with the assistance and contribution of colleagues to be approved on the GMC registry.

“The General Medical Council (GMC), responsible for the regulation of all doctors in the UK, sets the international recruitment processes for doctors and ensures that the necessary standards are met to protect patients. Doctors who have not completed approved training in the UK have the option to join the specialist or GP registers – known as the Certificate of Eligibility for the Specialist Register (CESR) Or the Certificate of Eligibility for the GP Register (CEGPR). “Under current legislation, doctors making a CESR or CEGPR application are required to provide a large portfolio of evidence demonstrating competency across the full breadth and depth of the specialty curriculum. This requires upwards of a thousand pages of documentary evidence. The GMC recognises that this is an inflexible and burdensome process and has worked to streamline this process as much as possible within existing legislation. The GMC is actively working with DHSC to amend the legislation which will allow it to develop new, more flexible, and accessible routes to the specialist and GP registers and improve the CESR/CEGPR process.

SDU Q: NHS Employers told me it was “also important that we ensure our international colleagues are retained to develop and achieve their potential in the health service”. Do you believe repayment clauses are good practice to achieve this aim? Do other staff recruited domestically face similar repayment clauses? If not, is this practice discriminatory if it is only applied to international recruits?

“DHSC published a revised Code of Practice for International Recruitment on 25 February 2021 to guarantee the most stringent ethical standards when recruiting health and social care staff from overseas. The code is clear that international health and social care personnel must not be charged fees for recruitment services in relation to gaining employment in the UK. Costs incurred by a recruitment agency should be incorporated into the negotiated fee charged to employers and contracting bodies.

“DHSC understands repayment clauses are used by some organisations to recoup upfront costs if candidates choose to leave shortly after arriving in the UK. These are legal and our Code of Practice is clear the terms and conditions should be made explicitly clear to candidates prior to arrival. However, we would be concerned if repayment costs were disproportionate or punitive.”

SDU Q: Are people unhappy with their pay and conditions? The RCN told me: “Ministers must do more to reduce our disproportionate reliance on valued colleagues from overseas and boost long-term domestic recruitment of nursing staff. This must begin with pay and funding for nursing education…[and] for the government to give nursing a 5% pay award above the rate of inflation this year.” Do you agree the NHS needs to boost its long-term domestic recruitment of nursing staff? Do you agree with the RCN’s suggestions of how to achieve that?

“NHS staff – from doctors and nurses to paramedics and porters – have rightly received a 3% pay rise this year, which has increased nurses’ pay by £1,000 on average. And we will consider the pay review bodies reports carefully when we receive them.

“DHSC has provided record investment for the health service and there are record numbers of nurses (over 313,600) and staff overall (1.2 million) working in the NHS, according to the latest provisional data up to January 2022. Compared to January 2021, there are over 4,200 more doctors and over 12,100 more nurses working in the NHS.

SDU Q: While this analysis covers a time period pre-dating the new GP contract, are any of these trends in the workforce from 2015-2020 linked to dissatisfaction with the extended access to general practice, according to any feedback from NHS staff?

“DHSC does not hold information on trends that pre-date the GP contract, or general practice staff feedback on extended access provision.”

SDU Q: Are there concerns going forward that the workforce can continue to grow at the pace it needs to, amid proposed changes to student loans deterring people pursuing medical qualifications for example?

“The government has funded an additional 1,500 undergraduate medical school places each year for domestic students in England - a 25% increase over three years and there are record numbers of medical students in training.

“The government is committed to ensuring that the number of medical school places is in line with England’s workforce requirements and continues to monitor the effectiveness of current arrangements. Medicine continues to be a heavily oversubscribed subject and given the number of applicants to medical schools each year we do not foresee a shortfall in the number of applicants to medical school places.”

SDU Q: NHS Employers also told me the government needed “to commit to a fully funded long term workforce plan for the NHS” – do you agree a workforce plan is needed? What effect will the removal of amendment 29 of the Health and Care bill have, requiring the government to publish, every two years, independent assessments of required health, social care and public health workforce numbers for England for the following five, 10 and 20 years?

“Following on from expansion over the last decade, growth of the NHS workforce continues to be a priority for this government, as demonstrated by the manifesto commitments to deliver 50,000 more nurses. As of January 2022, there were 29,100 more nurses than in September 2019. The government is over halfway towards achieving this manifesto commitment, helping put the NHS on a sustainable long-term supply of nursing staff.

“NHS England has invested in several schemes to expand the general practice workforce by retaining and recruiting doctors and we are on track to deliver over 26,000 more primary care professionals.

“In July 2021 DHSC commissioned Health Education England to work with partners and review long term strategic trends for the health and regulated social care workforce. This will review and renew the long-term strategic framework for the health workforce, to help ensure we have the right numbers, skills, values and behaviours to deliver world leading services and continued high standards of care. For the first time ever, the framework will also include regulated professionals working in social care, like nurses and occupational therapists.

“DHSC has commissioned NHS England and Improvement to develop a Workforce Strategy and the key conclusions of this work will be published in due course.

“Further to the above, the report already provided for in clause 35 in the Health and Care Bill will increase transparency and accountability of the workforce planning processes across the NHS and will be a useful reference document for stakeholders and the system.”