The UK’s health and social care sector is chronically dependent on migration. The NHS and social care providers – which support vulnerable adults, children in need or at risk, and elderly people – employ 11% of the UK’s 2.1 million EU migrant workers. For a sector already suffering massive staff shortages, and reeling from six years of austerity, that’s a pretty significant figure.
The rights of many of these migrants to remain in the UK have still not been guaranteed following the EU referendum. But the big question on Brexit is whether the sector can continue to rely on migrant labour, and that very much depends on the type of divorce Britain is left with.
Mark Dayan, policy and public affairs analyst at the Nuffield Trust, an independent health charity, says there are three main options being talked about.
The first is an immigration system similar to the one currently used for non-EU migrants. It only takes skilled workers, and only allows them to settle permanently in the UK if they earn above £35,000 (€40,400). That’s unless - like nurses but unlike other key workers in health and social care - they’re on the official shortage occupation list.
The second is a work permit system, in which each industry is assigned a migrant quota. This could be a politicised process, Dayan says, because “every sector is going to say, ‘we still need our immigrants’”.
The third option is closest to the EU’s freedom of movement, but migrants would only be allowed to come to the UK if they’ve already secured a job. Given the government’s huge target to reduce net migration, this may not be politically feasible.
‘Doctors have an easy time in migration systems’
Morale among doctors is low. A lengthy dispute over new contracts for a seven-day NHS led to a spate of young medics heading out to Australia, where the terms and conditions of employment are better.
Migrant doctors are also disgruntled. A February poll by the General Medical Council found that 60% of doctors from the EEA (European Economic Area) are thinking of leaving the UK, and 91% of those said it it’s due to Brexit.
UK health secretary Jeremy Hunt wants Britain to be self-sufficient in medical staff by 2025. This month he unveiled plans for the biggest ever expansion of the workforce, including training 1,500 extra doctors a year and requiring them to work in the UK for five years after completing their training.
But in the short term, problems persist: doctor vacancies increased by 60% between 2013 and 2015. And Britain relies on foreign-born doctors more than any other major EU country: 35% of NHS doctors were born abroad, around 10% in other EU countries.
And yet doctors - highly qualified, with high salaries - are not the section of the workforce Dayan is worried about when it comes Brexit. “Doctors usually have quite an easy time of getting through migration systems,” he explains.
‘A boom and bust approach to nurse staffing’
Despite being on the shortage occupation list, nurses are now predominantly being recruited from within the EU. The tightening of migration laws in 2010 made it much more complicated to recruit from further afield, Dayan explains. The same difficulties could occur after Brexit, even if NHS trusts are still allowed to hire EU nurses.
“Migration crackdowns can have quite wide-ranging effects, beyond just the letter of the law,” he says.
In 2015, 4.5% of NHS nurses were EU nationals, up from just 1% in 2009. There was a sharp drop in the number of applications immediately following the Brexit vote. Estephanie Dunn, regional director of the Royal College of Nursing, a trade union, says many migrant nurses are feeling vulnerable, undervalued and unwelcome, and argues that unless the government guarantees their future, it risks losing them.
There are around 24,000 NHS nursing vacancies - some 9% of the workforce. The profession is characterised by pay restraint, an ageing workforce and high levels of stress.
“Nursing is a big global market. UK nurses are actively being recruited to work overseas,” says Dunn. “Traditionally, the NHS has relied on a boom and bust approach to nurse staffing and it’s not an effective way to manage nurse supply.”
The government’s big initiative for a homegrown nursing workforce is the abolition this year of bursaries for trainees. This, Dayan explains, lifts the cap on the number of university places available for nursing degrees. But it’s an untested policy, and applicants might well be put off by having to pay tuition fees of up to £9,000 (€10,400) a year.
When it comes to migration policy, the one thing the NHS does have on its side is public opinion. “There is a recognition that the NHS needs migrant labour and also making the NHS function well is a high political priority,” says Dayan. “I’m more concerned that social care [which in the UK is overseen by local government, but provided by private sector organisations] won’t get the migrant labour it needs.”
Low pay in social care
There are around 90,000 social care job vacancies on any one day, according to Skills for Care, the organisation responsible for workforce development in adult social care in England.
The Institute for Public Policy Research (IPPR), a London-based think-tank, says about 6% of people employed in social care - some 60,000 workers - are EEA migrants. Around 20,000 of those have arrived since 2012.
Carys Roberts, IPPR research fellow on social policy and author of a report published in February on the social care crisis, argues that Brexit not only puts their future in doubt, but also that of non-EU migrants, who make up 19% of the workforce (191,000 people).
“The referendum registered dissatisfaction among voters of migration in general,” she says, adding that this might lead to the government putting further limits on immigration in addition to leaving the single market.
With demand increasing due to an ageing population, the IPPR also predicts that the UK will need to attract 1.6 million health and social care workers up to 2022. In a post-Brexit climate this will be more difficult than ever: social care is classed as unskilled labour, so fails to make it onto the national shortage list. It’s also not a popular career choice among Brits.
“Work in social care is very low paid,” says Roberts. “There are few opportunities for progression into better paid roles. On the flipside, caring roles come with a lot of responsibility, have suffered reputational scandals, and require very good people skills. That’s not a combination that’s particularly attractive.”
Local government has borne the brunt of austerity cuts in recent years, and many social care providers say the price councils offer for state-funded care contracts doesn’t even cover their costs. Three-quarters of councils commission care workers to make home visits of just 15 minutes, and in many cases staff under pressure spend as a little as five minutes with their vulnerable clients. A BBC investigation has found that a quarter of the UK's home care providers are at risk of insolvency, while 95 UK councils have had home care contracts cancelled by private providers.
Roberts believes that all EU citizens currently residing in the UK should be allowed to stay, and that the health and social care sector will collapse unless migration policy, at least in the short term, allows for continued recruitment from the EU.
Dayan agrees: “We need a system which allows for several thousand nurses, probably several hundred physiotherapists, and several thousand social care workers to continue to migrate from the EU for at least a few years after Brexit.”
But in the long term, as Roberts explains, the best solution is to improve the quality of jobs in health and social care, making them more attractive to UK workers.