The UK Home Office recently announced that doctors and nurses are to be excluded from the cap on visas for skilled workers, thus unblocking the supply of much-needed medical staff to help fill vacancies in the National Health Service (NHS).
While this is undoubtedly good for the UK in the short-term, it contradicts the UK’s commitment to global universal health coverage and only temporarily avoids the radical rethink necessary if the government is to continue to provide a reasonable standard of national healthcare.
Instead, some of the additional NHS funding announced by the prime minister needs to be used to develop a sustainable solution.
There is an increasing healthcare workforce crisis in the UK. In 2015 there was a shortage of 15,000 nurses, while the number of general practitioners (GPs) is estimated to have decreased by 657 (1.9 per cent) since 2014. The NHS Centre for Workforce Planning identifies a major demand-supply imbalance by 2020 under a wide range of scenarios and forecasts a deficit of 190,000 clinical posts by 2027 (equivalent to twice the size of the British Army) unless action is taken.
Seeking to plug the gap by encouraging immigration appears to be a reasonable and logical response. However, set against the global picture and likely increasing competition from elsewhere, reliance on immigration is, at best, only a stop-gap.
The world, including the UK, is committed to extending universal health coverage to the global population, whereby everyone has access to the healthcare they need without suffering financial hardship. This requires an expanded and trained workforce. In 2013, the World Health Organization (WHO) projected that by 2030, low- and middle-income countries will have a deficit of 14.5 million healthcare professionals.
Every healthcare professional who emigrates from those countries undermines the global ambition for universal health coverage and thus, while the UK is on the one hand overtly supportive of achieving this, its proposed increased reliance on immigration to bolster the NHS undermines that commitment. OECD countries will also need more healthcare workers as their populations age, and increases in conditions such as obesity place more demands on the system.
The WHO estimates that by 2030, the 31 OECD countries will have a shortage of 750,000 physicians, 1.1 million nurses and 70,000 midwives. The US earlier this year produced estimates of its projected deficit by 2030, which includes a shortage of up to 104,900 physicians.
This worldwide shortage is resulting in a global marketplace, to which the UK is turning. However, so are other OECD countries, and there is no guarantee that the UK will continue to attract healthcare professionals. It may even become a net exporter. Already countries such as Australia seek to recruit from the UK, citing better working conditions, and there is evidence from surveys of medical students and young doctors that UK graduates are increasingly looking to move to the US, Australia, New Zealand and Canada.
Many intend to return to the UK in due course, but the reality is that once settled, in practice return is unlikely. Furthermore, competition will not just come from the OECD countries. Some estimate that 88 per cent of the next billion people to join the middle classes will be in Asia. Asian countries and their middle classes will demand healthcare and be able – and undoubtedly willing – to pay for it. India has recently announced the extension of free healthcare to 500,000 Indians not previously covered. Not only will the supply of healthcare professionals from Asia reduce, but it is likely that Asian countries will seek to attract back those already working here.
Thus, reliance on immigration to underpin the NHS both undermines the UK’s commitment to universal health coverage, is likely to be short-lived and may well be followed by Britain exporting healthcare professionals – reminiscent of the ‘brain drain’ of the 1950s and 1960s. Furthermore, it reduces the pressure to undertake a radical review of how the UK, and indeed the world, delivers health services.
At the global level the UN secretary-general appointed a Commission on Health Employment and Economic Growth to 'stimulate and guide the creation of at least 40 million new jobs in the health and social sectors'. The commission has made 10 recommendations, but none of these challenge the current models of care. NHS England’s draft workforce strategy addresses productivity and efficiency. While it does refer to 'new models', it does not appear to recognize the need for a radical examination of the current structures, which continue to be based on a largely hierarchical doctor-led model.
There are examples both within the UK and globally of alternative models, such as a practice in north Wales that has developed multi-professional teams with operations being led by people who are not healthcare professionals; online primary care services such as Babylon; greater use of advanced practitioners who can work independently of doctors; and support from artificial intelligence and other digital systems.
These are, however, isolated and piecemeal developments and what is needed is a radical review to identify and scale up those which are most appropriate to the health services of individual countries. Relying on stop-gap measures such as immigration or increased supply from medical schools will not, on their own, be sufficient to address the current shortfall.
Lieutenant-General (Retd) Louis Lillywhite, Senior Consulting Fellow, Centre on Global Health Security.
This article was originally published in the Telegraph.