The UK–Philippine trade in nurses: is it ever ethical?

By Megan Anjeri Buxton.

Funding for home-grown nurses has been steadily declining in the UK since the 1980s. The last nail in the coffin came in 2016 when the bursary for nursing students was entirely scrapped. As a result, we have a graduation rate of 27 nurses per 100,000 people. Hardly enough to meet the demands of a generally unhealthy and ageing population – and that’s before the pandemic hit. Practicing nurses are also rightfully fed up with poor employment conditions and low pay and they are leaving in droves. The NHS needs 50,000 more nurses and is looking towards the Philippines to fill a lot of this gap.   

Currently, there are 40,000 Filipino nurses working in the UK, a staggering number that results from an arrangement made between the UK and Philippine governments. Established in 2003, this bilateral agreement provides the UK with Filipino nurses, and the Philippines with compensatory funds from the UK as well as remittances from their overseas workforce. Despite this agreement being purportedly a ‘win-win’, the increasing ‘industrial-complex’ that has come to characterise the trade in nurses is sucking the Philippines dry.  

Context  

For the UK, relying on overseas healthcare personnel is hardly new. Since the NHS came into being in 1948 it has been staffed by workers from the Commonwealth who nursed a nation recovering from war back into health. The UK has a habit of poaching nurses from nations who are most in need. In the past both Ghana and South Africa have condemned the part the UK played in their severe nurse shortages. Similarly, in 2014 the most targeted countries for recruitment to the UK were Spain, Portugal and Italy, each of which were suffering from devastating economic crises.  

Looking abroad for nurses is not surprising for a nation that is founded on the extraction of resources from elsewhere for its own convenience. The financial costs of recruiting an overseas nurse are only ten per cent of what it would cost the UK to train its own. Overseas nurses are also ‘ready-made’, with seven years of training replaced by only the few weeks it takes to recruit one. The externalisation of costs is a sign of the commodification of nurses who are viewed not as humans providing essential healthcare but as goods to be bought and sold.   

The ethics of recruitment  

Although managed by the Philippines Overseas Employment Agency (POEA), the export-led model in the nursing field in the Philippines has led to increasing private-sector involvement. Many nursing schools, or ‘migrant institutions’, train nurses specifically to go overseas. Because they are profit driven many schools have enrolled students far beyond capacity, jeopardising the quality of training. Schools often have business deals with licensure exam review centres. There have been instances where schools have bribed officials from the Professional Regulation Commission of Nursing to leak exam questions. Such corruption has resulted in a system of nurse training that follows industry models. Profit seeking has compromised the quality of care and nurses themselves have been transformed into a mass-produced commodity.   

Within the sector more and more schools have been established that cater only for the export market. This means that the syllabus does not match the needs of healthcare in the Philippines, and that skills become specialised towards western diseases and illnesses. In fact, some recruitment companies that operate internationally have amalgamated with nursing schools, streamlining the export process. As a result, not only is the Philippines losing nurses, but doctors are re-training as nurses and also leaving the country. The Philippines has half the amount of nurses and ten times fewer doctors per capita than does the UK. Over the past decade hundreds of hospitals have closed and the mortality rate has increased to the level it was 30 years ago. For Jaime Galvez-Tan, previously the Executive Director of the National Institutes of Health in the Philippines, this phenomenon is less an example of ‘brain-drain’ than of ‘brain-haemorrhage’.  

In the UK certain measures have been put in place to ensure that recruitment practices remain ethical. The 1999 Department of Health guidelines state that compliance with its code of practice ‘minimises harm to the health and care systems of countries of origin’. The industry in nurse recruitment that has resulted from the bilateral arrangement between the UK and the Philippines appears to fall far short of these guidelines. The ethics of the recruitment agencies – who also follow a profit-based business model – are not dependable when the sector is not regulated by a government body.

Having a code of practice suggests that the UK government should monitor agency recruitment carefully. But a study of NHS Trusts found that few had any information on recruitment activity and most had none at all. A long chain of outsourcing and sub-contracting – from companies involved in initial training to ones that market emigration opportunities, to those that guide nurses through the visa application process, to companies that arrange travel and English Language Tests – makes it difficult to keep track of the specific activities involved in recruitment. The monitoring process for the code of practice is not sufficient to deal with these complexities. It simply ‘encourages’ health and social care organisations to respond to surveys capturing international recruitment activity and to share information on any known breaches of the code of practice. The agencies themselves are only sent an email every two years asking them to ‘confirm their compliance with the principles of the code of practice’ and to supply two referees to confirm that they use the agency and that it complies with the code of practice.

The pandemic has further highlighted the questionable ethics of Filipino nurse employment in the UK. Nurses come to the UK on a Tier-2 visa, which makes their ability to legally reside in the UK dependent on them being in employment. Without a job, their legal residence is withdrawn. As a result, many Filipino nurses have felt under pressure by management to work extra shifts and work in COVID wards as they feel they ‘owe’ the hospital for allowing them to enter and reside in the UK. This has likely contributed to the disproportionately high number of Filipino NHS nurses who have died from COVID. A letter to parliament from the Filipino UK Nurses Association points out that of the 50 Filipino nurses who died last year almost 40 were in a high-risk category and should have been allowed home to shield. 

Overall, then, a picture is painted of a trade agreement that is creating a fatal imbalance in the distribution of nurses between the UK and Philippines. It has led to a training industry that values profit over education, a recruitment industry that is left largely unmonitored and a work environment in the UK that puts Filipino nurses at risk. From origin to destination each leg in this chain is unethical.

Megan Anjeri Buxton is a student on the MSc Migration and Mobility Studies at the University of Bristol.