In Pursuit of Ethically Sustainable Approaches to International Nurse Recruitment

Prof Ian Kessler of the NIHR Policy Research Unit in Health and Social Care Workforce is Professor of Public Policy and Management at King’s Business School. He introduces a new evaluation from the Unit: International Nurse Recruitment and the Use of Memoranda of Understanding: The Kenya and Nepal Pilots. (1,447 words)

With rising health and care needs as national care systems seek to cope with aging populations, the growing incidence of chronic conditions, and the shock of the Covid pandemic, there has been increasing pressure on the global supply of healthcare workers. Traditionally drawing upon overseas staff, this raises new and important questions for the NHS about how such employees are accessed and managed. The recent NHS England’s Long Term Workplace Plan, 2023, for example, cautions against an over reliance on any specific source of labour. More profoundly, the pressure on the supply of overseas healthcare workers prompts renewed concerns about the ethics of international recruitment as a practice.

Earth seen from space

There has been longstanding debate on the ethics of overseas recruitment by the NHS and other high income countries. This is reflected in international attempts to regulate the practice through, for example, the World Health Organisation Global Code, 2010, designed to ‘establish the ethical international recruitment of health personnel, accounting for the rights, obligations and expectations of source countries, destination countries and migrant health personnel.’ Debate on the ethics of the process has deepened with the new labour supply side pressures, and in response, government-to-government, or bilateral, agreements, whether in the form of Memorandum of Understanding (MoU) or tighter, more formal treaties, have emerged as a potential vehicle for addressing ethical concerns.

Bi-lateral agreements establish reciprocal arrangements between the partner countries engaged in the overseas recruitment of healthcare staff, seeking to ensure that their respective interests are accommodated and addressed. In particular, such agreements can be designed to display sensitivity to the needs of the source country, often a developing nation with relatively modest healthcare capacity and resource. Such agreements are by no means uncontentious. Representative bodies such as the International Council of Nurses have cautioned that they might be used by destination nations to open up a new source of labour from countries protected by international regulation from active overseas recruitment of their healthcare staff.

Late last year the NIHR Policy Research Unit in Health and Social Care Workforce was asked by the Department of Health and Social Care to evaluate the implementation of two new MoUs, one reached with Kenya in 2021 and the other with Nepal in 2022. These MoUs were distinctive in various ways. As a country internationally categorised as Red Listed, Nepal has been shielded from active recruitment from healthcare providers in the NHS. Kenya was, by contrast, a Green Listed country with active overseas recruitment permissible. Under the MoUs both countries became Amber Listed, with active recruitment allowable but managed in accordance with the principles of the agreement.

The Unit evaluation centred on the recruitment of nurses from Kenya and Nepal under the respective MoUs, originally seeking to examine the experiences and lessons of implementation from the perspective of the different stakeholders: the NHS trusts involved; the nurses recruited; and the officials from the government and the regulatory bodies in the two source countries. For various reasons it was not possible to engage with the government officials in either source country, while nurses from Nepal had yet to be recruited. Undertaken at the end of 2023, the study did, however, secure data from: 17 interviewees, such as recruitment leads and nurse educators, drawn from four of the half dozen or so NHS trusts involved in the MoUs pilot, including the single trust recruiting nurses from Nepal; a dozen Kenyan nurses taken on by these trusts under the MOU; and 6 other overseas nurses employed by NHS trusts, whose experiences provided a useful point of contrast with the Kenyan MoU nurses.

For the various the stakeholders involved the distinctiveness of the MoU arrangements mainly kicked-in at the front end of the recruitment process. Officials in the source countries, Nepal and Kenya, took the lead in managing applications and generating a pool of candidates then forwarded to the trusts who took over and selected according to their own procedures. Indeed, once joining their trusts, these MoU nurses were treated very similarly to any other internationally recruited nurse. In the case of the Kenyan nurses, once selected and arriving in the UK, the trusts: provided initial support with accommodation; prepared them for the Objective Structured Clinical Examination (OSCE) taken in matter of weeks after arrival and with a pass required to secure NMC registration; undertook employment checks; and allocated and inducted into clinical teams.

Encouraged to participate by and working with the DHSC as pilots, the trusts involved saw the MoU arrangements as having practical organisational benefits. The schemes provided a new and manageable channel for international recruitment: trusts had discretion over how many nurses they recruited under the MoUs, with some taking on just a handful of Kenyan nurses to date, and one trust into the third or fourth cohort of such recruits. With source country government officials and regulatory bodies involved in managing the applications, trusts also felt there was an element of quality control in the nurses forwarded to them for selection. As a trust interviewee stressed:

“It’s having a dedicated government link; that’s one of the biggest advantages… it’s like they’ve almost selected the nurses who want to go, and also can go. They are assessing their labour market and actually providing the nurses that would be surplus to that labour market,”

In addition, recruiting alongside the source countries under the MoU, trusts felt there was a higher degree of ethical assurance. Prospective nurses from Red Listed or indeed any developing country were free to directly apply for posts in NHS, leaving trusts uncertain as to whether or how this impacted on source countries. Under the MoU, and particularly its front end arrangements, there was greater NHS trust confidence that source country interests and needs had informed the nurses presented to them for selection. As one trust interviewee noted:

“We get a lot of candidates coming to us wanting to be recruited but they’re from a Red-Listed country where we’re not allowed to recruit unless it’s a direct application. Where you’ve got an MoU you’ve got the assurance… the approval to say, “Absolutely, it’s fine to recruit.”

For the Kenyan nurses the MoU arrangements had value in providing an ordered process, managed by a trusted point of contact in the form of the government, able to provide information, advice, and support. As one such nurse stated:

“Everything is structured. You have a point of call where you can go to because it’s been through the government… (if you) applied on your own, then you felt that you had nobody to fall back to you, you had to fight your own battle.”

Recruited as cohorts, the Kenyan MoU nurses also welcomed the mutual support and security provided by such a set -up, as they came to the UK and their NHS trusts in unfamiliar, typically challenging circumstance.  It was an experience in sharp contrast to that of our study’s non-MoU overseas nurse interviewees, who often felt isolated and without peer support on arrival in the UK.

The challenges of the MoUs tended to revolve around the front-end administrative arrangements. For the trusts there were occasionally procedural delays in managing applicants, as source country government officials ‘juggled’ different responsibilities. Such delays were also experienced by the Kenyan nurse applicants, with one noting, ‘I tried to apply, but they took their time.’ These nurse concerns were compounded by a perceived lack of procedural transparency at the front-end, creating uncertainty about the rationale for the decisions made by government officials. These general administrative problems should not distract for the substantive challenges faced by the Kenyan nurses on arriving in the UK, and being dealt with by the destination UK NHS trusts: the difficulties in finding long term affordable accommodation; adjusting to a new work and healthcare culture, with its unfamiliar status hierarchies; coping with the residual prejudice, occasionally discrimination, still sadly evident at the workplace. These were, however, challenges faced by many an overseas nurse coming to the UK, and not attributable to the MoU arrangements.

It remains early days in the implementation of the MoUs with Kenya and Nepal, and indeed under the latter the nurses are yet to arrive. Moreover, the absence of views on the arrangements from the source country officials, remains an important ‘piece of the jigsaw’ still to be provided. However, on the evidence of the NHS trust and Kenyan nurse interviews conducted as part of the Unit evaluation, the MoUs appear to be generating mutual benefits. They are founded on a sensitivity to the needs and interest of different stakeholders in the source and destination countries, contributing  to the ethics of the process.

Prof Ian Kessler of the NIHR Policy Research Unit in Health and Social Care Workforce is Professor of Public Policy and Management at King’s Business School.

This publication

Kessler, I., Samsi, K., & Moriarty, J. (2024). International Nurse Recruitment and the Use of Memoranda of Understanding: The Kenya and Nepal Pilots. NIHR Policy Research Unit in Health and Social Care Workforce, The Policy Institute, King’s College London.

And see the Unit news item (6 May 2024) on this publication for links to related international work from us.

Acknowledgements and Disclaimer

This research is funded by the National Institute for Health and Care Research (NIHR)
Policy Research Programme, through the NIHR Policy Research Unit in Health and Social Care Workforce, PR-PRU-1217-21002. The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care. We are most grateful to all those who contributed and participated in the study.

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