Over the past few years, the UK has faced its fair share of trials. Today, one of the most pressing is the pressure placed on the National Health Service (NHS). Established in 1948 and funded through taxation, the NHS’s purpose was, and remains, to improve the health and well-being of those in clinical need. Unfortunately, the service faces a crisis today as the provision of resources, funding, and staff has failed to keep pace with the increased needs of a growing and aging population. It is this crisis that underpins the unprecedented number of recent and upcoming strikes.
On April 15th, 2023, the Royal College of Nursing announced a 48-hour strike from 08:00 on April 30th to 20:00 on May 2nd, and there are reports that, unless their demands for increased pay and better working conditions are satisfied, further strikes could run to Christmas. Additionally, junior doctors (medically trained doctors not yet at the consultant level) may join the action. These are but the latest in a long line of disputes from NHS workers about their pay and working conditions which, earlier this year, saw the largest staff walkout in the service’s history. In short, NHS staff are underpaid, overworked, have minimal work-life balance, and feel that not only have they been let down but that because of their deteriorating working conditions, they are now also letting down their patients.
It is no surprise, then, that many are contemplating leaving the profession. For some, this means changing careers. Others, who want to remain healthcare practitioners, see a future overseas, with other countries offering less demanding and far more rewarding careers. Indeed, a 2022 survey of NHS staff found that 3 in 10 workers are considering quitting. It is this potential, the prospect of a mass exodus of highly skilled and expertly trained healthcare professionals from the UK to other destinations, that has got some worried, as Roger Kirby, president of the Royal Society of Medicine, noted during a Health and Social Care Select Committee meeting last year. In other words, the UK is facing the problem of brain drain.
This problem is not unique to the UK, as there is a global shortage of healthcare workers. This shortage, however, is not distributed evenly. For example, according to the World Economic Forum, countries like Norway, Switzerland, and Finland have roughly 22 medical doctors and nurses per 1000 inhabitants, while India, Colombia, and Turkey average out at 3 per 1000 inhabitants. Moreover, while those countries with fewer healthcare workers have varying provisions for training their medical staff, that training opens the door for them to move to other areas and countries with better living standards. Putting it into concrete terms, an estimated fifth of African-born clinicians work in high-income countries. This has enormous implications for those countries that train such physicians, as not only are their healthcare workers poached, but the sizable investment made into them is also lost.
While a negative for the countries losing their newly qualified workers, it is a bonus for those countries who receive them, as they get the benefits of highly skilled medical staff without investing in them—all the benefits for none of the cost (not to mention a benefit for those individual workers). One country that has been a principal beneficiary of this global healthcare worker emigration system is the UK. Indeed, so reliant is the UK on overseas recruitment of doctors and nurses that from April 2012 to March 2022, 47% of new nurses and midwives registered with the Nursing and Midwifery Council came from abroad. We can find similar trends for doctors signing the General Medical Register for the first time. Of course, not all those who come to the UK are from low-to-middle-income countries, but many are.
While some might be concerned about the impacts of brain drain from low-to-middle-income to high-income countries, others of a laissez-faire persuasion may reply that this is simply a sign of a healthy global competitive market; that brain drain “might be seen as the morally neutral consequence of a globalising labour market and its competition for talent.” In other words, countries should make their home nations more appealing if they want to retain their skilled workforces.
I disagree with that view, so now that I have acknowledged it let us put it aside. What is more interesting about the current UK situation, at least ethically, is the irony of the UK worrying it will fall victim to the very thing it has been doing for decades—investing in the training and education of skilled healthcare professionals only to have them lured away by the promise of better working conditions elsewhere. For decades, the UK has relied on attracting clinicians away from the global south with promises of better pay and working conditions. Today, the concern is that its own homegrown and trained doctors and nurses will be tempted by countries offering a better quality of life—countries like Australia and New Zealand.
Moreover, there is little subtlety to this desire to lure UK doctors. As one job advertised by the Tasmanian Health Service read, “Are you a UK-based junior doctor who wants job stability, great remuneration and the clinical support you need to develop your career?” (The advert has now been altered, but you can still see this opener in the preview). Moreover, it is not surprising that the offer tempts many UK clinicians. While NHS nurses and doctors strike or contemplate striking over working conditions and pay, Australian employers offer double the salary for fewer hours worked, with better career development opportunities and flexibility regarding leave and work-life balance. As Adrian Boyle, president of the Royal College of Emergency Medicine, notes, “There are high levels of burnout so doctors are reducing their hours or they are leaving; basically we have the most amazing medical training programme for Australia.” This worry echoes those expressed by low-to-middle-income countries when faced with a similar problem; those investing in training doctors, nurses, and other critical professionals are not benefitting.
Such a loss of healthcare workers from the UK to places like Australia would, if not addressed, have significant negative impacts on the NHS. Healthcare services are only as good as the people they employ. If they do not have enough people to function properly, then patients suffer, sometimes mildly, other times fatally.
The idea that the UK can, for decades, reap the rewards of brain drain, but then, once it potentially becomes a victim rather than a recipient, cry foul is hypocritical at best. Of course, the brain drain potentially faced by the UK is contextualized differently than those countries where it has typically recruited healthcare staff. Specifically, the UK has far more resources at its disposal. It is one of the world’s wealthiest countries with vast material and financial resources at its disposal, which it has accumulated over centuries. The countries from whom it often recruits—such as India, the Philippines, Nigeria, etc.—have not had the same opportunities (indeed, many of them were, at one point, colonized by the British). Despite facing some of the same healthcare issues as wealthier countries, developing nations also confront numerous unique challenges while operating on an uneven global playing field. The global south has a greater disease burden than the global north but far fewer resources to address them.
All this is not to say that the UK is wrong to worry about losing healthcare workers to other countries. Without those workers, those in need suffer and die. This is categorically bad, and the UK government and NHS leaders should take steps to prevent such devastating outcomes. However, if we are like Hannah Arendt and think hypocrisy is not just a political but also a moral wrong (what she calls the “vice of vices” in On Revolution), then it seems that the UK cannot have its cake and eat it too. It cannot accept the poaching of healthcare workers from less prosperous nations for the past few decades for its benefit and then rail against countries like Australia and New Zealand when they do the same. As far as I can see, this leaves it with two alternatives.
Either, the UK holds firm on its historical practice of importing healthcare workers and swallows the hard reality that it is becoming a less desirable destination in the global marketplace for workers from other countries looking to emigrate and for its own trained staff. Alternatively, it says that poaching critical healthcare staff, when leading to actual harm to its populace, is a moral wrong. The latter, however, would require it also to recognize its historical wrongdoing and the material harms it has inflicted upon those countries from whom it has recruited—countries who struggle to meet their own healthcare needs, let alone export staff to wealthier nations. Additionally, this second option would also mean coming out, at least partially, against the global neoliberal marketplace to a degree, which would be politically tricky.
What is the UK to do, then? Whether it owns its previous moral transgressions or doubles down on them, the simple fact is that NHS workers are leaving the profession, and the service is becoming crippled by this understaffing. If the UK wants to prevent staff from being lured by other careers or counties, it must become more competitive and offer better working conditions or put in place measures to prevent skilled worker emigration (the latter being a political minefield and potentially unethical in itself). Many see being a doctor, nurse, care worker, ambulance driver, or the myriad of other roles which the NHS relies upon to do its daily business as not just a job but a calling. However, heeding one’s call does not pay the bills, help one raise a family, secure a future, or sufficiently ease the pain when one does the job of 4 people. Pay and working conditions need to improve. If they do not, the UK may discover what it is like to be on the other side of the brain drain phenomenon.
Richard B. Gibson is Editor of the Current Events in Philosophy and the Bioethics series. He is a bioethicist with research interests in human enhancement, emergent technologies, novel beings, disability theory, and body modification.
