There is a long history of using overseas-trained clinical staff within the NHS, but how can the recruitment process be improved to avoid the mistakes that have been highlighted by recent inquests? ANDREW ANASTASIOU comments on the key issues and offers some valuable advice.
Overseas-trained clinical personnel play a vital role as part of the fabric of the NHS. With a chronic shortage of doctors, nurses and allied health professionals in the UK, and not enough new entrants into the profession to meet the increasing demands of the growing and ageing population, the NHS has long since been reliant on the skills of healthcare professionals who were born and trained overseas. This trend is set to grow exponentially in the coming years. Sometimes, however, this has proven controversial. Recent high profile cases, such as the substandard practice which led to the tragic death of David Gray1, have encouraged heated debate about how overseas professionals can effectively demonstrate their competence to work within the health service. The challenge for procurement heads is how to achieve the best outcomes when recruiting overseas professionals to their hospital or clinic; how to identify the right people for the right roles; and provide a smooth and effective induction.
Immigration and the NHS
International healthcare professionals have been fundamental to the infrastructure of the NHS since its earliest days. Its inception in postwar Britain coincided with the beginning of a wave of immigration from the Commonwealth and Colonies. The burgeoning health service welcomed skilled new arrivals with open arms. The 1960s saw a deliberate policy of encouraging the immigration of overseas health staff to ensure the smooth running of the NHS, and this continued into the following decades. Today, General Medical Council figures show that more than 91,000 of the UK’s 243,900 registered doctors gained their medical qualification outside Britain. Last year, 1,800 EU nurses who received their training outside the UK joined the Nursing and Midwifery Council Register, along with 500 nurses who trained outside the EU. This trend is set to grow as there are simply not enough UK school leavers entering the caring professions to keep up with the healthcare needs of a population in which pensioners now outnumber under-16-year-olds. More recently, the introduction of the European Working Time Directive, which limits junior doctors to a 48-hour working week, has put a significant strain on hospital rotas and resulted in some disgruntled juniors leaving the NHS for work abroad, where they can receive more comprehensive on-the-job training. Against this background, the UK needs international healthcare professionals more than ever and without them, the NHS would not be able to function. It is little wonder, therefore, that the Government’s proposed cap on immigration is causing great concern among many NHS Trusts who fear that they will not be allowed to recruit as many overseas professionals as they need for the smooth running of their hospitals and a high standard of patient care. With the existing UK healthcare workforce ageing (over a third of nurses, for example, will retire in the next decade), and junior doctors leaving the NHS in ever larger numbers, it is to be hoped that the Government will re-think the cap when it comes to vital international healthcare staff.
The Queen’s English?
Recent developments in EU law have also led to big changes to the immigration of international healthcare professionals, and the methods by which they must demonstrate their competence to practise in the UK. In 2006, sweeping changes to UK immigration policy drastically curtailed the rights of overseas qualified doctors from non-European Union (EU) countries to practise in the UK. This led to a change in immigration dynamics, with many more doctors coming from within the EU than outside it. But coinciding with this development, European Law designed to promote free movement of individuals within the EU relaxed language and competence testing standards for EU workers entering the UK. Healthcare professionals trained outside the EU must study for the demanding International English Language Testing System (IELTS) and must achieve the highest grade (7.0) before they can be considered for clinical work in the NHS. Even professionals who were born and trained in English speaking countries, such as Australia and New Zealand, must sit IELTS. But EU regulation means that professionals trained within the EU do not have to pass IELTS before applying for work in the NHS – even if English is not their first language. And the Nursing and Midwifery Council has recently announced that it will no longer impose a mandatory three to six months training period on EU nurses before they come to work in the UK for fear of falling foul of EU law. It is not difficult to see the contradictions in a system in which, for example, an Australian nurse, whose first language is English, has to demonstrate his or her fluency by means of a lengthy and costly examination process, while a Spanish-born nurse does not. It is easy to see that such a system will not always necessarily serve the best interests of patients, or indeed overseas professionals themselves, who must be confident and secure in their environments to practice to the best of their abilities.
Getting the best results
The system is clearly in need of reform. In the meantime, fortunately, there are many steps that heads of procurement can take when sourcing and recruiting candidates from overseas in order to ensure quality, competence, and a great induction experience for both client and candidate:
• It is cheaper and more effective to outsource. Partner with a wellestablished recruitment company with global networks and operations and proven experience in international recruitment of the type of candidate group you are seeking. Full service recruitment process outsourcers, like HCL International, take care of the whole process from the initial advertising for, and screening of, suitable candidates, all the way to helping the candidates make the transition to the UK and settle into their new community and job. Outsourcing in this way will be more cost effective and will be likely to have better outcomes than attempting to keep the project with your HR department, who may not have the requisite time, experience and overseas contacts.
• Be ethically aware. Choose a recruiter that adheres to the Department of Health’s guidelines on ethical international recruitment. This means that they will only source candidates from countries which are on the NHS approved list and will not try to “poach” healthcare staff from countries where there is a great need and severe shortage of healthcare staff.
• Be picky. You may not be able to insist that EU candidates sit an IELTS exam but you can draw up a list of criteria that you want your recruitment agency to use when screening staff, and make testing for clinical and conversational English top of the list. You can devise an oral and written test with the recruiter and even ask for a recording of their initial conversations with candidates so you can make a shortlist.
• Be aware of clinical comparators and differences. The candidate must have the relevant qualifications, skills and experience for the role but clinical practice differs from culture to culture so always looks for comparatives and equivalents. What the NHS would call general practice, for example, is in other EU countries often referred to as family, general or internal medicine, and the doctor may have been hospital rather than clinic based. Once again, a good recruitment agency will be able to match the right candidate to your vacancy based on their experience of close or equivalent clinical practice in their source country.
• Cover the basics. The agency should provide you with mandatory documentation for each candidate including: all required certification, a passport and proof of right to work in the UK, a valid CRB check, insurance certificates, copies of all qualifications, and full health clearance. All doctors – no matter where they trained – must hold a GMC licence before they can take up work in the UK. Nurses should register with the NMC. Allied health professionals will have their own regulatory bodies dependent on their discipline.
• Be involved. When negotiating the contract with the agency, make sure that a trip to the source country and participation in the recruitment drive is part of the fee, as you need to be able to interview the agency’s shortlisted candidates yourself, face-to-face (or at least on the phone if necessary). Conducting the final stage interviews yourself will enable you to apply your own controls on language ability, skills and experience. Do not leave it all up to the agency. Only your HR department and your clinical directorship are in a position to know, once all skills and qualification requirements have been met, who exactly will be a good fit in your organisation.
The process does not stop with the recruitment of the new staff to your payroll, however. A good induction is equally important. A healthcare professional’s ability to practise is only as good as his or her confidence and security in a new environment. Organisations which fail to provide a fool-proof induction period will inevitably find themselves dissatisfied.
• Ensure a smooth transition. Once again, a good agency will help you. HCL International walks candidates, step-by-step, through the transition process – from helping them find suitable accommodation in the UK, to meeting them off the plane, helping them open a bank account and helping them integrate into their new communities. You can aid this process by being aware of a new recruit’s personal needs – are they aware of local amenities, have they got to know people in their local community? Help them socialise by organising team nights out – if your budget permits – it will also help your existing team bond with the new members more effectively.
• Provide a full and detailed clinical induction. On the rare occasions when an organisation is not happy with their new recruits, it is almost always because they have not been fully inducted and their learning requirements have not been taken into account at the outset. This is ultimately the responsibility of the medical director or ward sister. Get your new recruit working in a supervised practice environment for the first few shifts, identify where they are strong and where they need to improve.
• Be culturally aware. Some overseas nurses come from a traditional nursing culture, where the doctor is king and where bedside manner and providing complete care for the patient is everything. Some nurses trained to a high clinical standard at home are frustrated when they are not allowed to perform techniques like cannulation before they have met the required assessment criteria to ensure patient safety. Make the most of your new recruits’ existing skillset, ensure they are thoroughly assessed and encourage them to develop new soft skills within a supportive team culture.
Finally, do not forget that your existing team has a lot to learn from your new recruits. An added benefit of international recruitment is that it can bring new life to a team with the sharing of different ideas for best practice and different perspectives on therapeutic intervention.
1 “Doctor Daniel Ubani unlawfully killed overdose patient”, 4 February 2010, www.guardian.co.uk/society/2010/ feb/04/doctor-daniel-ubaniunlawfully- killed-patient • Andrew Anastasiou is a director at recruitment specialist, HCL International.
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