Table of Content Page

United Kingdom

Mobility of Health Professionals

Birmingham City University

Birmingham, United Kingdom, May 2011

Funded by

Grant agreement No.: Health-F2-2008- 223049

This national report was written by

Lee Harvey, [email protected] Quality Research International (emeritus Copenhagen Business School), and

Morag MacDonald, Birmingham City University,

Regional research partner and contact:

Dr. Caren Weilandt +49 (0)228 8104-182 ([email protected])

WIAD - Scientific Institute of the Medical Association of German Doctors (Wissenschaftliches Institut der Ärzte Deutschlands gem. e.V.)

Ubierstrasse 78 53173 Bonn, Germany

Telephone +49 (0) 228 8104-172 (Reception) Telefax +49 (0) 228 8104-1736 Email [email protected]

Sole responsibility lies with the author. Neither the European Commission nor any person acting on behalf of the Commission is responsible for the use which might be made of the following information.

List of contents Page

List of Tables ...... 7

List of Figures ...... 9

Executive summary ...... 10

Introduction ...... 25

1 Basic country information ...... 26

1.1 General population ...... 26 1.2 Geo-political data ...... 28 1.3 Economic indicators ...... 29

2 Health Status and Health System ...... 31

2.1 Health Indicators ...... 31 2.1.1 Mortality ...... 31 2.1.2 Morbidity ...... 32 2.2 Health System: General Information ...... 32 2.2.1 The National Health Service ...... 32 2.2.1.1 Size and structure ...... 33 2.2.1.2 Funding and capacity ...... 35 2.2.2 Private health care ...... 37 2.2.3 Total expenditure on health ...... 38 2.2.4 Hospital beds ...... 39 2.2.5 Demand on medical services: unemployment rate of health professionals and vacancies in the health system ...... 39 2.3 Supply of Health Professionals ...... 40 2.3.1 Doctors: General Medical Council ...... 40 2.3.1.1 Registration with the GMC for UK graduates ...... 41 2.3.1.2 Registration with the GMC for nationals from EEA and Switzerland ...... 42 2.3.1.3 Registration with the GMC for international medical graduates ...... 43 2.3.2 Nurses and midwives: Nursing and Midwifery Council ...... 47

2.3.2.1 Registration with the NMC for UK graduates ...... 48 2.3.2.2 Registration with the NMC for nationals from EEA and Switzerland ...... 48 2.3.2.3 Registration with NMC for international nurses and midwives ...... 49 2.3.3 Dentists: General Dental Council ...... 52 2.3.3.1 Registration with the GDC for UK graduates ...... 52 2.3.3.2 Registration with the GDC for nationals from EEA and Switzerland ...... 52 2.3.3.3 Registration with the GDC for international dentists ...... 53 2.3.4 Pharmacists and pharmacist technicians: Royal Pharmaceutical Society ...... 53 2.3.4.1 Registration with the RPSGB for UK graduates ...... 53 2.3.4.2 Registration with the RPSGB for nationals from EEA and Switzerland ...... 54 2.3.4.3 Registration with RPSGB for international pharmacists ...... 55 2.3.4.4 Registration of Northern Ireland pharmacists ...... 55 2.3.5 Opticians: General Optical Council ...... 56 2.3.5.1 Registration with the GOC for those with UK qualifications ...... 56 2.3.5.2 Registration with the GOC for nationals from the EEA ...... 56 2.3.5.3 Registration with GOC for international applicants ...... 57 2.3.6 Osteopaths: General Osteopathic Council ...... 57 2.3.6.1 Registration with GOsC for UK qualified applicants ...... 58 2.3.6.2 Registration with GOsC for non-UK qualified applicants ...... 58 2.3.7 Chiropractors: General Chiropractic Council ...... 58 2.3.7.1 Registration with GOC for UK qualified applicants...... 59 2.3.7.2 Registration with GOC for applicants with an EU qualification ...... 59 2.3.7.3 Registration with GOC for applicants with a qualification from outside the EC ...... 59 2.3.8 Other health professionals: Health Professions Council ...... 60 2.3.8.1 Registration with HPC for UK qualified applicants ...... 60 2.3.8.2 Registration with HPC for nationals from EEA and Switzerland ...... 60 2.3.8.3 Registration with HPC for international health professionals ...... 60 2.4 Health professional education ...... 61 2.4.1 Doctors ...... 61

2.4.1.1 Tomorrow’s Doctors ...... 63 2.4.1.2 Quality assurance process ...... 64 2.4.2 Nurses and midwives ...... 65 2.4.3 Dentists ...... 67 2.4.4 Pharmacists and pharmacist technicians ...... 68 2.4.5 Opticians ...... 71 2.4.6 Osteopaths ...... 72 2.4.7 Chiropractors ...... 73 2.4.8 Other health professions...... 74

3 Policy Framework ...... 75

3.1 Immigration and emigration policies in general ...... 75 3.2 UK policy initiatives ...... 76 3.2.1 International context for UK policy ...... 76 3.2.1.1 Global Forum ...... 76 3.2.1.2 The Millennium Development Goals and the 0.7% target ...... 78 3.2.2 United Kingdom recent policy developments ...... 79 3.2.2.1 The Crisp Report ...... 79 3.2.2.2 Government response to the Crisp Report ...... 82 3.2.2.3 BMA response to the Crisp Report...... 86 3.2.3 Registrants from the EEA ...... 86 3.2.3.1 Healthcare Professionals Crossing Borders ...... 90 3.3 Shifts in politics and major political parties affecting policy change; approach to health and approach to migration ...... 92 3.4 To what extent policies are enforced, responsibility for the enforcement ...... 92

4 Migration Flows ...... 94

4.1 Introduction: context and issues ...... 94 4.1.1 The Lancet campaign ...... 95 4.1.2 Push and pull factors ...... 97 4.2 General migratory profile: The United Kingdom recent history of migratory health workers ...... 102

4.3 Inflows and Outflows of health professionals: data from the professional councils ...... 111 4.3.1 Doctors ...... 111 4.3.1.1 Views of the British Medical Association ...... 115 4.3.2 Nurses ...... 119 4.3.3 Dentists ...... 122 4.3.4 Pharmacists ...... 123 4.3.5 Opticians ...... 125 4.3.6 Osteopaths ...... 125 4.3.7 Chiropractors ...... 127 4.3.8 Other health professions...... 127 4.4 Workforce planning ...... 127

5 Results of qualitative interviews ...... 131

6 References ...... 132

Annex: Tables ...... 143

Page List of Tables

Table 1: The Economist Political Instability Index of 165 countries ...... 144 Table 2: Estimates of economic data for the UK, monetary values are in 2008 US dollars...... 148 Table 3: Deaths: underlying cause, sex and age-group, 2007: summary ...... 149 Table 4: Health indicators reported by the National Centre for Health Outcomes Development on its Clinical and Health Outcomes Knowledge Base website ...... 151 Table 5: England’s Strategic Health Authorities ...... 157 Table 6: Expenditure on health care (£billion) ...... 157 Table 7: Government public spending on health as a % of GDP and as a % of total government spending ...... 158 Table 8: Average daily number of available and occupied beds by sector, England, 2007–08 ...... 159 Table 9: Average daily number of available and occupied beds by ward classification, England, 2007–08 ...... 159 Table 10: Unemployment rates (as per cent of economically active), UK by sector, 1995–2009 ...... 160 Table 11: Vacancies by Industry: United Kingdom (thousands), seasonally adjusted ...... 163 Table 12: Acceptable English Language Tests and levels ...... 164 Table 13: indicative HPC approved programmes ...... 165 Table 14: Official Development Assistance in 2005 (source: OECD 2005 ) Countries in italics had not set a timetable for 0.7% as of 2005 ...... 166 Table 15: GMC Registrations and Erasures 1998–2009 (May) Top 30 countries of qualification ...... 167 Table 16: GMC Registrations all countries, 1998, 2003, 2008 ...... 168 Table 17: GMC Registrations 1998–2009 (May) by country of qualifcation ...... 170 Table 18: Erasures from the GMC Register 1998–2009 (May) by country of qualifcation and reason for erasure ...... 174

Table 19: Initial admissions to the register from the EU/EEA countries and Switzerland (2004–8) ...... 186 Table 20: Number of international registrations with NMC (and predecessor), 1999–2008...... 187 Table 21: NHS dentists by country of qualification, in England, as at 31 March1997–2006 ...... 189 Table 22: Number of NHS dentists who joined the GDS or PDS by country of qualification, in England, as at year ending 31 March 1997–2006 ...... 191 Table 23: EEA qualified pharmacists registering with the Royal Pharmaceutical Society of Great Britain ...... 192 Table 24: International registrants 2001–06 by country residence examined by the RPSGB Adjudicating Committee ...... 193 Table 25: Where osteopaths practise ...... 194 Table 26: General Chiropractic Council registrants and removals since 2002 ...... 195 Table 27: Number of registrants with the Health professions Council, by occupation, as of 1 April 2009 ...... 196 Table 28: Total number of registrants with the Health Professions Council (and predecessors) by profession 1967–2006 ...... 197 Table 29: Visiting European health professionals temporarily registered in the UK according to directive 2005/36/EC, Registered September 2008–September 2009 ...... 199

List of Figures Page

Figure 1: United Kingdom Population ‘Pyramid’, mid-2007 estimate (total 60,975,000) ...... 26 Figure 2: Components of population change, 1997–2007 ...... 27 Figure 3: Age-standardised mortality rate for all causes by sex, England and Wales ...... 31 Figure 4: Number of patients waiting over 13 weeks for inpatient admission 1998–2008 ...... 35 Figure 5: Referral to treatment patients seen in less than 18 weeks...... 36 Figure 6: Chart showing summary HES inpatient data by month of activity, for final 2006-07 and 2007-08 data, and provisional 2008-09 data ...... 37 Figure 7: International medical graduates (IMGs) and international nursing graduates (INGs) registering for the first time in the UK, 1990–2003 ...... 108 Figure 8: GMC registrations of doctors trained in the UK, EEA or internationally 1998–2008 ...... 112 Figure 9: Number of registrations with NMC (and predecessor) from main supplier countries, 1999–2008 ...... 121

Executive summary

Basic country information

The United Kingdom population as of mid-2007 was estimated at 60,975,000; a 0.6% increase on the previous year. The average age had increased from 37 in 1997 to 39 in 2007. About 20% of the population were children under 16 and 20% were people of retirement age. There are more females than males over the age of 72.

Since 1999 net migration (the difference between long-term migrants entering the UK and those leaving), rather than natural change, has become the main driver of population growth. Net migration accounted for 48% of population change in 2007. However, natural change is increasing again thanks to lower death rates, rising fertility among UK-born women and more women of childbearing age due to inflows of female migrants. The United Kingdom ranks 132 out of 165 on the Economist Political Instability Index (2010); the recent increase in the UK’s instability rating is due to the global financial crisis. The UK is ranked 21st out of 194 countries in the InternationalLiving.com 2010 Quality of Life Index (up from 37th in 2008) and 29th out of 111 countries on The Economist Quality of Life Index.

GDP per person in the UK was around US$36000 in 2008, ranking the UK about 20th in the world. The UK, up to 2008, experienced 15 years of sustained growth, outstripping other Western economies.

Health Status and Health System

Health Indicators

There has been a long-term decline in UK mortality rates over the last century. Male mortality rates have been consistently higher than female rates although they are drawing closer together. Infant mortality and childhood mortality have fallen most dramatically. Around 80 per cent of deaths occurred at ages over 65 in 2000 compared with around 20 per cent in 1901. Patterns of mortality by cause of death have changed: infectious diseases have declined to low levels, but deaths from all cancers accounted for around 25% of deaths.

Health System: General Information

Health care in the UK is a mixture of public and private with over 85% of health care undertaken by the National Health Service (NHS). The NHS was established in 1948, and has at its core the ideal that good healthcare should be available to all, regardless of wealth. The vast majority of funding thus comes directly from taxation. The 2007–8 budget equates to approximately £1500 per head of population. The NHS is comprehensive and is (mainly) free at the point of use. Life expectancy in the UK has been rising and infant mortality has been falling since the NHS was established. The NHS is the world's largest publicly funded health service and the biggest employer in the UK, with more than 1.5 million employees of whom just under half are clinically qualified.

The Department of Health is in overall charge of the NHS with a cabinet minister reporting as secretary of state for health to the prime minister. NHS services in the countries of the UK are managed separately leading to minor differences. Ten strategic health authorities manage the local NHS in England and health is delivered via ‘Trusts’. The current government (2011) want to change this. In 2007–8 the NHS received over £90 billion; an average rise in spending over 60 years of about 3% per year (above inflation). About 60% of the budget goes on staff costs, 20% on drugs and medical supplies and 20% on buildings, equipment, cleaning, catering and training. The NHS deals with one million patients every 36 hours. The waiting times for patients have reduced over the last decade. In 2008–9 there were 13.9 million hospital admissions, of which 4.9 million were emergency admissions. Recent data on expenditure suggest private health accounts for just under a fifth of total health expenditure but given the costs and profits associated with private health, this would be less than one fifth of the patients. It would account for very small proportions in some acute areas and higher proportions in non-essential health areas.

It is estimated that 87.4% of all expenditure on health in the UK was from the government. Health expenditure as a percentage of GDP was 5.11% in 1980 and since then has steadily increased to 7.68% in 2009.

The number of hospital beds in the UK fell from 211,617 in 1984 to 145,218 in 2004 because of changes in treatment. There were 160,297 hospital beds in England in 2007–8 with an 84% occupancy rate.

Unemployment rates in the education, health and public administration sector have tended to be lower than in any other major sector since 1995. Female unemployment in the sector is between 1 and 2% lower than male unemployment. The sector has had a fairly stable ratio of vacancies to employees over the last two years at around 2.3 per hundred employees. However, there are signs of oversupply of health professionals and the likelihood of increasing unemployment in the sector.

Supply of Health Professionals All health professionals in the UK are controlled by a regulatory council, which, inter alia, sets standards, oversees education, registers practitioners and deals with issues of malpractice. There are nine such bodies, each requiring registration to practice. They all have procedures for registration, or temporary registration of non-UK trained practitioners. Doctors: The General Medical Council controls all aspects of medical practice and its primary aim is to safeguard the public. The new procedures require registration with the GMC and a time- limited licence to practice. For UK medical graduates who have completed a 12-month internship there is a requirement to work satisfactorily in an approved practice setting for the first 12 months of full registration. Moving to full registration requires submitting a fully completed and authorised Certificate of Experience, establish their fitness to practise, and pay a registration fee. Registering as a doctor for nationals from the EEA (and Switzerland) is similar and requires evidence of qualifications and the appropriate licence to practise from the EEA country of qualification. The procedures for international medical graduates include a language test requirement and extensive certified evidence on education qualification and fitness to practice. The GMC website

is not particularly welcoming to international medical graduates, warning of immigration rules and limited employment prospects. One respondent, a doctor trained in Lithuania with 25 years experience, reported “no problem at all for me registering as a doctor in UK. The GMC accepted my European diploma and issued a certificate. The real problem was to find a job: essential requirement was UK experience. After one year and thousands of applications sent, I luckily met my agent who trusted me and offered a job. Now I am a hospital doctor with three years of experience in UK.” For another respondent, an Iranian graduated doctor with six years experience working in Iran, the problem is language: “I have to pass many test such as IELTS and PLAB test, then I can work as a GP in the UK.” One of our respondents suggested that the current UK policy, especially with the creation of new medical schools has led to “less reliance on migration”, reinforcing the view that in the past the British NHS needed to import overseas doctors. Now, the respondent noted, “there are limited employment opportunities but not a general awareness of this and people who come to the UK are finding it more difficult”. In addition, immigration rule changes are also impacting on recruitment processes. “There appears to be a blanket requirement for MAs” from immigrants and a “degree of inflexibility in recruitment” has developed. For migrating doctors, “it is more difficult to navigate the system” nowadays. A professor from Malaysia who wanted to come to this country, who is recognised as a world leader in his field and ran his own hospital in Malaysia, could not get a job as a consultant in Britain because of the restrictions imposed, not by the regulatory bodies, but by the Royal Colleges and the BMA. Ridiculously, the Postgraduate Medical Education and Training Board required evidence in the form of a signed-off diary when he was trained, 20 years previously, despite him being eminent surgeon. Nurses and midwives: All nurses and midwives practicing in the UK have to be registered with the Nursing and Midwifery Council (NMC). Registration must be renewed every three years; which includes demonstrating ongoing learning activity relevant to ongoing practice. UK-trained graduates complete and return an Application for Registration and the appropriate fee. The form is sent to the applicant after the NMC receives course completion details and an appropriately signed declaration of good character from the applicant’s higher education institution. Nurses from overseas must hold full and active registration as a nurse or midwife in their home country, which requires a minimum of 12 months post-registration experience after having qualified as a nurse. The NMC uses Directive 2005/36/EC to assess the education and training of all nurses and midwives who were trained in the EU/EEA. Applicants not covered by the Directive take a period of adaptation or an aptitude test. The application process for overseas nurses and midwives, who must have minimum qualifications and English language competence, involves the completion of a compulsory overseas programme. The NMC site is not particularly welcoming to overseas nurses warning of immigration restrictions and limited work opportunities.

One nurse, trained in Ethiopia, with seven years’ experience as well as a public health degree, explained that, “There is some policy I think so that the Nursing and Midwifery Council they wouldn’t accept any overseas nursing programme unless I retrained the nursing programme in this country… Or there is some overseas nursing programme but I couldn’t afford the money for that.”

Migrant nurses from outside the EC that we interviewed who had come to Britain, some as political refugees, indicated two major issues, the lack of posts and the demanding English language competence tests. For some, passing the tests takes so long that they have to take refresher courses because they have not been actively employed as nurses within the period required by the professional body. What often happens is that migrant nurses take lower-level jobs, often for long periods, while they ‘retrain’ as nurses. The story of one migrant from Zimbabwe is indicative: “Back home I was a registered nurse ….When I came here in June 2004, I looked for a place to do my adaptation training. I couldn’t find a place until it was late and my visa was expiring. My decision letter also expired but I got a place to do the training but the visa expired so I was turned down. Instead of going home I just decided to stay and started working as a health care assistant… In February 2009 I was granted refugee status…. Then I did my pre- adaptation course…. But then had problems with the English language test…. I decided to go back to basics and start again. So I applied to the course at [University X]. They used APEL to accredit me so I joined the second year, which I start in April 2011.”

Having to start again as a student is not uncommon. Another respondent, a nurse from the Sudan with 10 years experience including lecturing at university, who came to the United Kingdom to join her husband, has had to retrain. She found that despite her considerable experience, when applying for jobs, she was always asked what experience she had in the British NHS and her work history was disregarded. The experienced nurse from Ethiopia had the same problem, “My previous experience has not been recognised at all.” Even applying for health care assistant jobs “When I applied to agencies they ask me about UK work experience, which I don’t have…. All of them asked me about UK work experience and now I’m doing a work placement to get some experience. It’s been very difficult.” Dentists: All dentists and anyone involved in patient teeth care must register with the General Dental Council (GDC), whether in private practice or the NHS. Registrants must hold a qualification approved by the GDC and inter alia undertake compulsory minimum continuing professional development and have professional indemnity insurance. Most dentists qualified in the UK register with the GDC immediately upon graduation from their dental school. There is no internship requirement. Registration for EEA-qualified dentists is governed by Directive 2005/36/EC and registration requires evidence of identity, qualification, practice and good standing, Graduates from countries outside the EEA whose qualifications are not recognised for full registration are required to take the Overseas Registration Examination. One respondent, a political refugee from Iran, where he trained, with 12 years experience as a dentist had to “pass two ORE exams (dentistry) and achieve IELTS 7 to start working again. Recently I could get IELTS 7 and now I am preparing for the dentistry exams”. Pharmacists and pharmacist technicians: The Royal Pharmaceutical Society of Great Britain (RPSGB) keeps the register of pharmacists and pharmacist technicians. Northern Ireland pharmacists have a separate register and society. Applicants who have qualified within Great Britain from a recognised programme are required to have the application form countersigned and dated by a pharmacist who is registered in the practising part of the register and who is in good standing with the Society. EEA nationals with a European pharmacy qualification are required to provide similar information to British qualified applicants, following Directive 2005/36/EC. An individual evaluation process applies to those who fall outside the Directive. English language competence is also expected but as yet the Society cannot require proof as a

condition of registration. International applicants have to complete an Overseas Pharmacists Assessment Programme, complete pre-registration training approved by RPSGB and pass the registration examination. Opticians: All fully-qualified optometrists and dispensing opticians in the UK must be registered with the General Optical Council (GOC). All optometrists and dispensing opticians, including students, are required to have completed, or currently be studying for, a GOC-approved training course. Continuing Education and Training is also required. Those who obtained their qualification in the EEA apply for mutual recognition of their qualifications. The process is similar to that for UK-trained applicants except that the overseas qualifications sub-committee of the GOC’s Education Committee decide whether the education and training is equivalent to that of a UK-trained dispensing optician or optometrist. Applicants from outside the EEA have to complete an initial assessment examination. If this suggests that the applicant has insufficient knowledge or experience to practise in the UK, the applicant is required to undergo further training for up to one year. Osteopaths: The General Osteopathic Council (GOsC) regulates osteopathy in the UK and maintains the register. Applicants with a UK qualification in osteopathy need inter alia proof of qualification, a character reference, and obtain professional indemnity insurance. Applicants who qualified outside the UK are subject to GOsC vetting to ensure that the qualification is equivalent to UK qualifications. Applicants have to provide evidence of nationality, details of the course undertaken and qualifications and detailed history as a practising osteopath. Chiropractors: The General Chiropractic Council (GCC) regulates the chiropractic profession. Registrants with a British qualification recognised by the GCC complete the registration form, provide a medical report and character reference. Applicants with a qualification from a EU country and who meet the requirements of Directive 2005/36/EC register in a similar manner. Foreign-qualified applicants who hold an equivalent qualification are also required to pass a test of competence prior to registration. Other health professionals: The Health Professions Council (HPC) regulates 14 health professions ranging from arts therapists to practitioner psychologists and radiographers. UK graduates who have completed an approved course are eligible to apply for registration. Evidence required includes proof of identity and address, and that they meet the professional standards. EAA-trained practitioners can apply for Temporary Registration if they wish to provide professional services in the UK on a temporary and occasional basis. Initial registration will be one year and may be renewed annually. This requires provision of details of relevant qualification, experience and registration in other member states. There is a separate register of visiting European health professionals. For non-EEA trained applicants, HPC scrutinises qualifications (for a fee). Each profession at the HPC has its own specific criteria for assessment. There is also an English proficiency requirement.

Health professional education Education of health professionals primarily takes place in British universities (with some exceptions). All education of health professionals has to comply with the specified standards of the different health professions. Doctors: The General Medical Council (GMC) has extensive powers of accreditation and control over medical education. There are 33 GMC recognised medical schools in the UK (including

partnership ventures). The establishment of new medical schools in the UK requires the approval of the Privy Council. Five new schools have been established since 2000 as part of the aim to reduce in-migration of doctors. The GMC, in Tomorrow’s Doctors, sets standards to describe the knowledge, skills and attitudes that new doctors should have. The guidance proposed the development of a curriculum comprising a core component and special study modules. However, the GMC does not prescribe educational approaches to pedagogy. Traditionally, the GMC adopted an inspectorial approach to checking standards but now puts more emphasis on a process of continual engagement and improvement. However, in judging appropriate levels of competence of graduating doctors it requires compliance on: curriculum content, supervision, practical experience and vigilance in ensuring only appropriate students graduate and register. Nurses and midwives: The Nursing and Midwifery Council (NMC) also has a role in education. Programmes are offered in many UK higher education institutions in partnership with local clinically-based service providers. There are almost 500 nursing courses in 74 higher education institutions. Programmes are 50 per cent theory and 50 per cent practical and delivered in equal parts within higher education institutions and clinical settings. Programmes are required to be at the equivalent of at least three years full-time and nursing comprises a one-year Common Foundation Programme and a two-year branch (adult, child, mental health or learning disability) programme. Many universities offer Masters and PhDs in nursing/healthcare. The NMC, in its ongoing quality monitoring, works closely with partner organisations. The approach is inspectorial undertaken by a third party on behalf of the NMC. Dentists: All UK courses leading to registration as a dental professional must be approved by the General Dental Council (GDC). The five-year full-time honours course in dentistry (BDS), which includes clinical practical training with patients, is offered at 14 universities. In addition to dentistry, programmes in dental therapy and dental hygiene are available. The standards the GDC expect dental professionals to have reached are set out in The First Five Years for dentists and Developing the Dental Team for other dentistry qualifications. Programmes are quality assured through an annual monitoring exercise and inspections. The QAA undertook a review of dentistry between 1998 and 2000 and concluded that the quality of dentistry education was excellent. Pharmacists and pharmacist technicians: Pharmacy requires a four-year Mpharm degree, which is offered by about 25 UK universities. Graduates enter pre-registration training for one year and have to pass the Royal Pharmaceutical Society’s registration examination. Quality assurance is by way of periodic (five-year) accreditation, based on whether the provider meets the criteria and provides an appropriate syllabus. Opticians: The General Optical Council (GOC) assesses and approves the quality and content of education provided for those training to practise optometry and dispensing optics. It has approved the undergraduate optometry degree at eight UK universities. Optometry degrees are usually full- time three-year followed by a salaried pre-registration training with a practice under the guidance of a GOC-registered optometrist. A series of assessments are included throughout the placement. The GOC approves training courses in dispensing optics at six institutions. The GOC specifies core curricula for optometry and for dispensing optics that embodies the development of core competencies. GOC periodically visits providers to assess whether the standard of education and assessment are sufficient for practice.

Osteopaths: Training to be an osteopath takes four years full-time or five years part-time, via a bachelor’s or master’s degree in osteopathy. A degree course includes anatomy, physiology, pathology, pharmacology, nutrition and biomechanics, plus at least 1,000 hours of clinical training. There are 10 education institutions awarding qualifications recognised by the General Osteopathic Council. The Osteopathy Benchmark Statement outlines the exacting standards required for osteopathic training. All recognised course providers must submit an annual report to the GosC. The QAA conduct a major review of each course every three to five years. Reports are public. Chiropractors: There are only three providers of chiropractic education in the UK. They offer either a bachelor or master of chiropractic. When the General Chiropractic Council is satisfied that a degree programme meets the criteria agreed with providers, then the Privy Council must give its formal approval for the qualifications to be recognised. The education provider must provide annual reports to the GCC. The full recognition process is repeated every five years. The QAA has not been directly involved in any review of chiropractic programmes. Other health profession: The Health Professions Council (HPC) regulates 14 health professions. Education in these areas varies considerably. Some areas are offered in only a couple of institutions, whereas some, such as physiotherapy is taught in over 30 institutions. The level also varies from pre-degree diploma to a doctorate. Programmes are subject to external scrutiny by the regulatory body and the QAA.

There is a general sense among all stakeholders in the United Kingdom that the world has to measure up to British standards of training. This is reflected in the frustration of experienced professionals who cannot get posts without NHS experience or who are faced with what one respondent called the “labyrinth of deanery, Royal Colleges and BMA system”. There is as one senior executive said, “a lot of snobbery isn’t there. They think that England—we’re the best, and anything below that isn’t any good.” A view repeated by another senior manager, “there was a lot of snobbery around the level of training and equipment in the East [of the EU]. That’s levelling off. So that it becomes easier for people to come in, from the EU, to jobs over here.” Policy Framework

Immigration and emigration policies in general Immigration policies in the UK have a bearing on recruitment of international health professionals. There has been a tightening of UK Immigration rules since 2008, with the introduction of a new points-based system. Immigrants have to fulfil the eligibility requirements for the category of work for which they apply. (This does not apply to EEA nationals). For example, highly skilled workers do not need to have a specific job offer but will need to demonstrate they are highly skilled, have money to support themselves and are able to speak English. Thus a qualified nurse, proficient in English but without sufficient funds may not get the required UK entry clearance.

However, the non-EU health professional interviewed did not suggest that UK immigration rules were a major problem for them (perhaps because they were successfully in the country) but that the language requirement was much more demanding. UK immigration rules were seen as much more of a problem for recruiters. As an Executive Director for Delivery explained. “We can only pull from the designated list of shortage occupations, which is an interesting list because it isn’t updated that often. And, actually, for some of the occupations the numbers are so small. If you look at, say, paediatric liver surgeon, there’s only 10 paediatric liver surgeons in the country and

paediatric liver surgery isn’t regarded as a ‘shortage occupation’, and there’s nobody being trained in paediatric liver surgery at the moment, so if one of our paediatric liver surgeons got knocked down and couldn’t operate we couldn’t bring anybody in from abroad, from the outside of the EU, because it’s not a shortage occupation because liver surgery is considered the same as general surgery but actually there are only 10 people in the country who can do paediatric liver surgery.”

UK policy initiatives Introduction

The UK policy framework for migration of health professionals is heavily influenced by international developments, including the Global Forum on Human Resources for Health, which endorsed the 2005 Kampala Declaration and the associated Agenda for Global Action. The Declaration called on governments to provide adequate incentives to encourage retention in poorer countries and richer countries to prioritise funding to train and recruit sufficient health personnel from within their own country: a policy that the UK had been implementing.

The concern about migration is not new and reflects, most recently, the commitment expressed in the Millennium Development Goals, which reconfirm a forty-year old United Nations General Assembly Resolution. The UN Millennium Project’s analysis indicates that 0.7% of rich countries’ gross national income (GNI) can provide enough resources to meet the Millennium Development Goals but so far, only five countries, have exceeded the target and the US is the next to lowest at 0.22%.

The migration of health professionals has been an expressed concern in the UK and officially the UK now trains enough health professionals for its needs. Nonetheless a major review, the Crisp Report, asserted the need for developing countries to take the lead and own the solutions to the crisis. Crisp argued that the UK could do more by, inter alia, recognising and supporting the valuable work done by UK organisations and individuals in supporting health services and promoting health in developing countries. The report had 16 recommendations, including key ones on migration. The government response welcomed the report and reiterated that the UK would support developing countries in taking the matter in hand. On Recommendation 11, which states that the UK should support international efforts to manage migration, the response asserts that the UK has used codes of practice for several years, although admitting evidence about effectiveness is inconclusive. It suggests, though, that other countries might adopt them. However, more important than codes of practice is training sufficient health workers in developed countries to ensure that recruitment from developing countries is no longer needed. A second aspect of recommendation 11 related to training and the encouragement to have some training and limited periods of work experience in the UK and to create exchange programmes for training. The response was very cautious about taking this forward. Similarly, on Recommendation 12, the Response indicated that enabling migrants from developing countries to return home, for long or short periods, through participation in partnership programmes is a complex issue. The BMA response to the Crisp Report was to welcome the recommendations on migration and urge the government to implement them.

Our interviewees were sceptical of the real impact of codes of practice, reflecting some of the literature that suggested they were systematically circumvented. As one senior manager of a NHS Trust said “Did it make a difference? Well you can look at the numbers. Didn’t change the

numbers. All it did was change your rationale for doing it…. I don’t think it made a big difference. I think people just used the system.” In practice, there are various arrangements to bring non-EU nationals to the United Kingdom for a period of training (usually about two years). Sometimes, the trainees get jobs in the UK. However, one arrangement that tries to avoid any permanent migration was reported by a respondent: “We’ve been talking to the military in Pakistan around how they can run their junior doctors through our two-year junior specialist doctor training programme to get them with a level of skills and a guarantee return so we’re not denuding the country of their doctors. Because they are working for the military, and their contract is with the military, at the end of the two years they go back after completing the training course with us.”

The UK is faced with a different situation in relation to EEA residents than for international migration. The UK’s ten regulatory bodies joined together, in 2002, to form the Alliance of UK Health Regulators on Europe (AURE) to lobby against the original EU Directive that would have permitted healthcare professionals from any EU country to work for up to four months per year without being registered with a UK regulator. It was subsequently amended to require healthcare professionals to register in the host Member State prior to being granted authorisation to practice.

AURE noted the small minority of EEA practitioners who seek to exploit rights of free movement to evade regulatory control and thus urged sharing of up-to-date information about their registrants. AURE also noted the diverse approach to healthcare regulation across the EU and noted that the Healthcare Professionals Crossing Borders initiative had already made a contribution via the Health Regulation website and through improved networking between healthcare competent authorities in Europe. Migration Flows

Introduction: context and issues The migration of health professionals has been characterised as an international crisis; for example, 20% of African-born physicians and 10% of African-born nurses work overseas. This despite Africa having a quarter of global disease but just 3% of the world’s health workforce. However, the Universal Declaration Of Human Rights states that everyone has the right to leave any country, including their own. The World Trade Organization’s General Agreement in Trade Services is also seen as a aggravating the problem by legitimising the commodification of health care: allowing countries to compete and trade not just in health services but also in health professionals.

The United Kingdom is variously portrayed as the villain and as the exemplar of good practice. The Lancet noted that some wealthy countries have taken steps to discourage or eliminate the practice of poaching nurses, citing the UK’s code of practice but suggested that there is evidence, as suggested above, that the code is routinely ignored. General migratory profile: The United Kingdom recent history of migratory health workers

There have been many studies citing data up to 2005 showing the migration of alarming numbers of health professionals from sub-Saharan Africa and other ‘at risk’ countries into the UK, despite the Code of Practice of the Department of Health. In 2005, the UK was a major destination for nurses from Zimbabwe, Malawi, Swaziland, Lesotho, and Ghana. Further, in the four years since the NHS introduced its ban on recruitment 6,104 South African nurses have registered to practise

with the UK’s Nursing and Midwifery Council. (Although South Africa recruits from other African countries). Between 1993 and 2002, the number of non-EU graduates joining the UK Medical Register increased by 78% while the numbers of UK graduates rose 17%. In all 31% of practicing doctors and 13% of nurses were born outside the UK. The number of nurses working for the NHS went up by 48,800 (about 20%) between 1997 and 2003 and 73% of the increase was achieved through international recruitment. In 2002, for the first time, over 50% of new nurses admitted to the Nurse Register were from overseas and more than 2,800 nurses and midwives from countries on the “banned” list registered to practise in the UK in the year to the end of March 2005.

Despite often being cast as the villain the United Kingdom also provides support to developing countries. Further, since 2005, more home-grown health professionals, more recruitment from the EC, changes in immigration policy and a reduction in the increase in staffing in the NHS has resulted in a major reduction in the immigration of international health professionals.

Push/pull and stick/stay factors summary The research suggests the following push and pull factors operate in the case of professionals migrating to (and from) the UK (and other rich countries). They operate in concert, because ‘no matter how attractive the pull factors of the destination country, little migration takes place without substantial push factors driving people away from the source country’ (Kingma, 2007, p. 1293) Pull factors:

 desire for (often greatly) increased income;  better working conditions;

 greater access to enhanced technology;

 an atmosphere of general security and stability;  improved prospects for the family (or joining family members who had previously migrated);

 undertake training (‘scholarships’) only obtainable in recipient countries;  better utilisation of highly specialised skills;

 international mobility (transportation, recruitment drives, visa availability);

 migrant communities in recipient countries (as more and more physicians migrate from a country, they create an environment (a “home from home”) that entices newer migrants from the same country).

Push factors are, in the main the reverse of pull factors but they have also to be sufficiently strong, in concert with push factors to overcome the psychological and social consequences of leaving (or uprooting) ones family, ones friends and ones country of birth. Push factors:

 dysfunctional health systems;

 lack of policy information on health system effectiveness and workforce losses;

 poor salaries;

 lack of job security;

 poor working conditions;  lack of technology;

 urbanisation and steadily worsening situation in rural areas.

These push and pull factors are symptoms of deeper underlying problems, viz. (a) inadequate investment in health systems in developing countries and (b) underdevelopment of training within advanced countries (especially the US and, up to about 2004, the UK) and to some extent overproduction in some less advanced countries (India and Philippines). However, things are changing. The UK takes lots of doctors trained in India. As one recruiter in a major hospital in the West Midlands noted: “They don’t want to come. Particularly, with India, China, Saudi Arabia, looking for more and more staff, and salaries going up in these countries; the rationale for them coming has disappeared. Then we have to think, what are we offering? Now, where we place ourselves is that we offer very high-level specialist training. If you want to do solid-organ transplantation there aren’t many places in India you can do it whereas over here we’re European leaders in solid-organ transplantation in this hospital. Take, for example Walsall, if you’re an Indian doctor, ‘shall I go to Walsall?’ well, actually I’ll not learn much more than if I work in a hospital in India. And now the economic differential isn’t big, because Indian doctors are getting paid a lot more, there’s no reason for them to come over.”

Furthermore, “There’s also big issues about cost of living. The cost of living in this country does put a lot of people off. The cost of living in the south-east is even higher and in terms of migration, people won’t come across.”

Inflows and Outflows of health professionals: data from the professional councils Doctors: Between 1998 and May 2009, the General Medical Council registered 56,987 doctors trained in the UK, 26,609 with qualifications from the EEA and 57,140 doctors with qualifications from outside the EEA. These totals hide a change in trend with very large numbers of international registrations in the mid 2000s but a rapid decline in international registrations since 2003 and a steady upward trend in UK-trained registrants over the ten-year period

The very sharp peak in overseas registrations in 2003, which provoked much of the literature, was mainly made up of international registrations (86%). Of the 11,996 registrations of international medics, twelve countries supplied 11,227 of these. However, 2003 is not representative of the decade of GMC overseas registrations. India was the main provider of international registrants (37.4%) and about a quarter of all overseas registrants during the decade came from India. South Africa and Pakistan were the next highest of the non-EEA countries (with a third of the number of those from India) and German-qualified doctors constituted the fourth largest group of GMC non-UK registrants since 1998.

However, as one respondent stated: “it is becoming harder and harder to recruit doctors by the deaneries because the deaneries have obviously closed to non-EU applicants and they are taking fewer and fewer”. The deaneries are responsible for the management and delivery of postgraduate medical education and for the continuing professional development of all doctors and dentists. This includes ensuring that all training posts provide the necessary opportunities for doctors and dentists in training to realise their full potential and provide high quality patient care.

The deaneries are also responsible for trainers, educational supervisors and educational leaders, their training needs and educational development. As well as migration in, there have been significant numbers of doctors who have migrated out of the UK as suggested by erasures from the register. The total number of UK-trained erasures from the register over the decade is 48,740. During the decade there has been a net increase of doctors from India (12,606), Pakistan (4,062), Nigeria (2,037) Poland (1,533) and Iraq (1,123) and a net decrease from South Africa (-1,940) Australia (-3,414) Ireland (-3,012) and Hong Kong (- 2,110). However, the data is complicated. The BMA stated that immigration is not only a short-term solution to domestic shortages but that the “history of the NHS proves the efficacy of migration as a long-term solution for a country that has an implicit policy not to graduate sufficient doctors to meet its healthcare needs”. Recent policy, they acknowledged, means that the increased undergraduate medical training places will decrease reliance on migrant doctors. Indeed, there is now an oversupply of doctors seeking postgraduate training posts in the UK. However, the BMA is of the view that migrant workers will continue to be required as their workforce modelling suggests that over the period to 2030, the demand for doctors will be met with current planned medical school intake and levels of overall immigration into the training. A senior manager form a large NHS Trust stated, “I’ve seen the boom and bust in terms of home grown staff and bringing in externals and probably the pendulum is about to switch again across to bringing in staff from abroad.”

The BMA, however, noted that the migration of doctors from the EEA has contributed to the oversupply of medical professionals into postgraduate training posts.

The BMA supported the free movement of workers within the EU but considers Directive 2005/36 inadequate because basing a decision about fitness to practice on the length of time individuals have trained rather than on the skills they have acquired is not suitable for the continued development of a modern healthcare system. Further, they argued, regulators must also be allowed to assess the language competence of doctors wishing to join the medical register including EEA-trained registrants.

However, EEA-trained doctors are attractive in a period of financial shortages. One senior manager of an NHS Trust stated that, “What I can get for the price of a junior doctor over here I can get virtually a consultant-level from Europe in terms of the salary. Got to remember that the UK pay the highest salary after America for our doctors.” He added, “I’m very much looking to Europe as being a way of resolving quite a few of these problems because I can get somebody accredited by the University of Frankfurt or Lyon and, because of the European Union, their qualification now allows them, so long as they pass the language test, to receive accreditation over here by the GMC and the GMC can’t refuse them. Over time, unless medical education in this country bucks its ideas up…we may well be looking to the EU market to bring doctors in the future and take fewer and fewer British graduates.”

A manager in a specialist hospital, though, did not think this an issue partly because they were not short of trained applicants and “being a specialist Trust, we find that in terms of pay and employment law we have people here at a higher level”. Nurses: There are about 673,000 nurses and midwives registered with the NMC. There were 1872 admissions to the register from the EU/EEA countries in 2007–8, up 23% on the previous year. Poland was the biggest supplier then Germany and the Republic of Ireland. India has

become the number one international source country for nurses to the UK, after a run of four years that saw the Philippines in that role. Very few international registrants are midwives. In 2002, 50% of new nurses admitted to the NMC register were from overseas and in 2005, 2,800 nurses and midwives came from countries on the “banned” list. Overall, between 1997 and 2003 73% of new registrants were international. The process has been reversed since 2003. Overall, 2007–8 has seen a 28% fall in one year in admissions from countries in central and southern Africa and a 22% rise in admissions from the Indian sub-continent. The Philippines peak of over 7000 registrants in 2002 has decreased to 249 in 2008 and the South African peak (2114) in 2002 decreased to just 32 in 2008. The Indian peak in 2005 of nearly 4000 has dropped to 1000 in 2008.

As one senior manager in a large Trust noted: “Back in 2003–5, we were bringing huge numbers of Filipino nurses; in the region of 300 nurses from the Philippines. Tried to bring in some nurses from South Africa but that wasn’t particularly successful; we had about 40 or 50 South African nurses… Since 2007, we’ve been creating our own nurses. Birmingham’s been particularly successful in recruiting people for the nursing profession and retaining them. Unlike the South East where they have quite major recruitment problems. We haven’t gone abroad for nursing staff since about 2006–7. But we still have quite a high number of Filipino nurses who have stayed with us and South African nurses who are still working with us. A lot of them have married and gained British citizenship and stayed. We saw quite a big turnover of Filipino nurses after two years; a number went home at the end of two years and we picked up some new Filipino nurses then but not much since.”

In contrast, a senior manager at a specialist children’s hospital said: “At the Children’s we don’t [have experience of recruiting from abroad] because we have enough people wanting to work here…. The messages we’re getting from the centre are we don’t want you to recruit from abroad, we need to be looking at the local population. Here, we’ve invested a lot in widening participation, looking at career frameworks, looking at progression routes, trying to build up that local community retention of staff…. And for our nursing provision, if you look at recruits to the universities for the child branch nursing programme they have eight applicants for every post.”

The qualitative interviews also suggested that there is an oversupply of nurses and consequent unemployment. As one recruiter said: “In this country because we’ve already started restriction on the home nurses, training is stopped because currently we’ve got unemployed nurses and the problem is that you either have the tap on or you have the tap off. And the workforce planning isn’t sensitive enough because it’s not a market.” This issue of workforce planning is addressed further below. Dentists: The total number of dentists registered with the GDC as of 6 July 2009 was 35,845. There were 21,111 NHS dentists on a Primary Care Trust list in England, 28% higher than in 1997. NHS dentists may perform as little or as much NHS treatment as they choose. Of those NHS dentists 21% qualified outside the UK: the main source countries being South Africa (4.6%) Sweden (3.8%) Poland (2.1%) Ireland (1.9%). Nearly 46 per cent of new NHS dentists qualified outside the UK in the year to 31 March 2006: the highest proportion in a decade. Poland accounted for 17% while numbers from South Africa have declined steadily from the 2000 high. There has been a steady increase in dentists qualified in Greece and Germany. Overall, there is little evidence of much international migration of

dentists into England from non-European ‘at risk’ countries.

Pharmacists: As of 1st September 2009 there were 50,023 pharmacists and 7,959 pharmacy technicians registered with the Royal Pharmaceutical Society of Great Britain. There were 501 non-UK, EEA qualified registrants in 2007 and 442 in 2008: the largest numbers coming from Poland and Spain. Between August 2007 and July 2008 the Adjudicating Committee of the RPSGB considered 179 applications from pharmacists trained outside the EEA. The limited available data suggests that there was relatively little migration of pharmacists from other countries outside the EEA into the UK with, in 2006, Nigeria topping the list with 36 registrants, India 32 and Ghana 12. Opticians: The General Optical Council has around 23,500 people registered in 2009 but no information was available on country of qualification. Osteopaths: As of April 2009, there were 4,078 registered osteopaths. Most osteopaths work in private practice and over 80% of patients fund their own treatment. Just under 10% of registrants practise abroad, in over 40 countries around the world. During the year 2006–07, there were 203 new registrants, three of whom qualified overseas. In 2007–08 there were 275 new osteopaths, eight of whom qualified outside the UK, including two from the EU/EEA; the remainder were applicants from Australia and Brazil.

Chiropractors: Information provided by the General Chiropractic Council indicated that, since the legislation came into force in 2002, 311 chiropractors applied for registration as holding a relevant unrecognised chiropractic qualification and not all of these have been accepted onto the register. As of 2009, current registrants are overwhelmingly British, with very few registrants from less developed countries. Other health professions: As of 1 April 2009, there were 185,689 practitioners registered with the Health Professions Council, a steady increase in numbers over a forty-year period. There appears to be relatively little in-migration of health professionals covered by the HPC. The year ending September 2009 saw 120 EEA one-year temporary registrations of whom about half were physiotherapists.

Workforce planning One of the biggest issues that emerged from the qualitative interviews was the inadequacy of workforce planning and the concomitant control exercised by the Royal Colleges. The boom and bust in in-migration is, it is argued, a function of the inability to identify workforce needs and plan appropriate training. This, it is further argued, is aggravated by the control of the Royal Colleges restricting numbers of trainees, ostensibly to maintain high salaries.

One Associate Director for Education and Learning was concerned about the lack of effective workforce planning. “I remember that peak when everyone ran off to get overseas employees because we had a shortage of nurses…. I don’t think there was a real emphasis on ensuring workforce planning worked in synergy with education commissioning…. We have to have the right people in the right job at the right time, workforce development is key; everybody says that but it is so hard to do because people find it difficult to predict what the future workforce is going to be like….Rather than look at what they want the functions of the workforce to be doing they look at what have we got now and what do we need more of, so you get more of the same.

Rather than, these are the functions and skills we need, we know the service is going to change and look like XYZ, what do we need to commission now for that?” The lack of adequate workforce planning was seen as inevitably leading to constant swings in the immigration of health professionals. “I think it will go up and down and that’s because we don’t get workforce planning right. We’re not looking at what the skills are that we need.” For another manager, the role of the Royal Colleges was seen as a vital inhibitory force.

“… the Royal Colleges and the deaneries work out how many people we should be training… But the Royal Colleges are guessing, from retirement and natural wastage, how many doctors you’ll need in that speciality in seven years time. In any other industry that would be called a barrier to trade and a barrier to entry. So the people who are deciding the number of ophthalmologists, for example, who will become consultants…is decided by ophthalmologists…. [It] is decided not by what the service needs but what the profession believes they require.”

The respondent elaborated further on the restrictive practices of the Royal Colleges: “We have, effectively, within health, a masonry system. It’s a group of trades. We have the Royal College(s)… the NMC. On top of that you’ve got GMC, BMA and put all that together and you can see why it’s such a closed shop. Regulation needs to be tight, you can’t have anyone coming in looking after your patient… But the transparency isn’t there in the Royal Colleges.… Until we start tackling some of these barriers to entry we’re never going to get that free flow of migration of health professionals.”

As a consequence of the perceived inflexibility due to workforce planning inadequacies or the restrictive practices of the Royal Colleges, hospitals were devising new posts. In both a large general hospital and a smaller specialist hospital, new roles were being developed to overcome shortages of personnel and reduce cost. “In this [specialist] Trust we’re going to be looking at physician assistant and that’s a highbred of an individual who is undergoing intensive training to perform some medical duties but they’re not a doctor.…. They have highly specialist skills in one area. They couldn’t operate outside of that area. And we’re also looking at our advanced nurse practitioner because we’re looking at what: functions do our doctors perform; what functions can we take off them so they can concentrate on what we need them to do; and what functions can we give to the nurses to upskill them? The manager at the large general hospital explained how they had developed new posts: “So we’ve created what we call junior specialist doctors, which is open to applicants worldwide. It mirrors the junior doctors contracts up to the out-of-hours service and for out-of-hours we pay an enhancement we don’t pay junior doctor banding [an expensive form of overtime payment that has to be paid to British graduates]….So we’re beginning to think of more innovative ways how do we attract in doctors which are outside of UK terms and conditions and why are we doing that? Well UK terms and conditions are punitive. We don’t get the doctors that we need and trained to the level that we require them to be trained and they are very, very expensive.…”

Introduction

The British National Health Service (NHS), the single most important legacy of the post-War Labour government, is world famous and jealously guarded in the national psyche. Politicians, especially from the right, have attempted to undermine it, privatise bits of it and even suggested dismantling it, only to face intense opposition. The current ‘financial crisis’ in the United Kingdom has resulted in ‘reform’ proposals for the NHS that are extremely unpopular and that are currently causing a good deal of turmoil. The NHS is a vast organisation and, despite huge state funding, is constantly in need of more money. The NHS trains large numbers of doctors, nurses and other health professionals but also relies heavily on immigrant health professionals. The future is more uncertain now than at any time since the inception of the Service.

1 Basic country information

1.1 General population

According to National Statistics (2008) the United Kingdom population as of mid-2007 was estimated at 60,975,000. The average age had increased during the decade from 37 in 1997 to 39. About 20% of the population were children under 16, and a similar proportion were people of retirement age. Thus, 62% of the total population is working age (aged 16 to 64 for males and 16 to 59 for females) of whom just over half (52%) are below 40. The 1960s ‘baby boomers’ bulge is now moving into the older age bands and women born during the peak years immediately after World War Two have now reached retirement age (at 60 years). This, along with increased life expectancy has resulted in a large proportion of post-40 year olds. This is exacerbated by the low fertility in the mid-to-late 1970s; people now aged 30–36 (Figure 1). Similarly, low fertility rates during the late 1980s and 1990s have resulted in fewer people between the ages of five and 19.

Up to the age of 72, the number of males and females are fairly equal but females outnumber males by 1.2:1 at age 73 and by almost 3:1 by age 90. This reflects the higher life expectancy of women and higher male mortality during the Second World War (Figure 1).

Figure 1: United Kingdom Population ‘Pyramid’, mid-2007 estimate (total 60,975,000)

Note: Each bar represents a particular single year of age and the length shows the population of that age. Sources: Office for National Statistics, General Register Office for Scotland, Northern Ireland Statistics & Research Agency, see National Statistics, 2008 Net migration and other changes include changes in the population due to international migration and changes in the number of armed forces (both foreign and home) and their dependants resident in the UK.

The population continues to grow, an increase of 388,000 (0.6%) between mid-2006 and mid- 2007: an average increase of approximately 1000 people a day. The average annual population growth since 2001 was 0.5% and was 0.3% per year between 1991 and 2001 and 0.2% between 1981 and 1991. The increase is a function of lower death rates, more births and increased migration (Figure 2).

Figure 2: Components of population change, 1997–2007

Natural change (the difference between births and deaths) provided the largest influence on population growth until 1999. Since then net migration (the difference between long-term migrants entering the UK and those leaving the UK) has become the main driver; in the year to mid-2002, for example, it accounted for over 70 per cent of the total population change. This follows a long- term trend of increased immigration that has included the effect of EU enlargement. Both immigration and emigration have increased since 2002, this has contributed to net international migration increasing to 198,000 in 2007, an increase of 36 per cent on the mid-2002 figure of 148,000. However, from 2002, natural change has increased and in the year to mid-2007 it accounted for 48% of the total population change. Natural change has contributed 187,000 to population growth in the year to mid-2007; a three fold increase from the mid-2002 figure of 62,000. The number of births is increasing partly due to rising fertility among UK born women and partly because there

are more women of childbearing age due to inflows of female migrants to the UK. A decrease in deaths over the same period also contributed to the increase in natural change.

1.2 Geo-political data

The United Kingdom ranks 132 out of 165 on the Economist Political Instability Index. Zimbabwe is most unstable (ranked 1st) and Norway least unstable (ranked 165) Table 1, (Annex).

The UK score has increased from 0.6 (out of 10) in 2007 to 4.6 in 2008 mainly as a result of the global financial crisis.

The methodology for compiling the index consists of two elements: an underlying vulnerability score (1.3 for the UK) and an economic distress score (8.0 for the UK). The index is the mean of the two scores (rounded up). The components for the two parts of the indices are specified as a footnote to Table 1, Annex. All composite indicators are idiosyncratic in their components and the way they are combined into an index and are dependent on available statistics and estimations. The UK is ranked 37th of 194 countries with a score of 68 out of 100 in the InternationalLiving.com 2008 Quality of Life Index. France tops the rating with a score of 85 and Iraq is last with a score of 29. The index comprises the following 9 elements but there is no indication of how these are computed or combined into the final score: cost of living; leisure & culture; economy; environment; freedom; health; infrastructure; risk & safety; climate. In 2005, the UK was ranked 29th out of 111 countries on The Economist Quality of Life Index (Economist 2005) with a score of 6.917 out of 10. It was ranked 13th highest for material wellbeing with GDP per person of US$31,150. Ireland headed the quality of life rankings with a score of 8.333 (and was 4th in GDP per person at $36,790. Luxembourg had the highest GDP per person, $54,690 and 4th highest ranking for quality of life. This, as with other such indicators, is inter alia dependent on available statistics and estimations.

The Quality if Life Index consisted of the following components although it is not clear how they are combined into an index:

1. Material wellbeing: GDP per person, at PPP in $. Source: Economist Intelligence Unit. 2. Health: Life expectancy at birth, years. Source: US Census Bureau.

3. Political stability and security: Political stability and security ratings. Source: Economist Intelligence Unit. 4. Family life: Divorce rate (per 1,000 population), converted into index of 1 (lowest divorce rates) to 5 (highest). Sources: UN; Euromonitor.

5. Community life: Dummy variable taking value 1 if country has either high rate of church attendance or trade-union membership; zero otherwise. Sources: ILO; World Values Survey.

6. Climate and geography: Latitude, to distinguish between warmer and colder climes. Source: CIA World Factbook.

7. Job security: Unemployment rate, %. Sources: Economist Intelligence Unit; ILO.

8. Political freedom: Average of indices of political and civil liberties. Scale of 1 (completely free) to 7 (unfree). Source: Freedom House.

9. Gender equality: Ratio of average male and female earnings, latest available (Economist, 2005).

1.3 Economic indicators

GDP per person in the UK was around US$36000 in 2008. Figures vary depending on source and estimate. The International Monetary Fund (2008) had a figure of US$36523, ranking the UK as 18th in the world. The World Bank (2009), on the basis of dividing the PPP GDP data by the population data, put the figure at US$35445 (ranking 15th). However, the same organization has a GNI per capita figure for 2007 as US$40660. The estimate in the Central Intelligence Agency World Factbook (CIA, 2009) was US$36600, which would rank the UK 24th in their analysis.

Oxford Economics (2008) maintained that UK GDP per capita would overtake the US in 2008. Oxford Economics state that the per capita figure in the UK will reach $48000 (£23,500) in 2008, compared with $47,430 per capita (£23,250 per capita) in the US. This is a much higher estimate than other sources. However, this is part of an upward trend that has been discernible for over a decade.

The improvement in UK relative living standards has been substantial since the early 1990s. In 1993, following the last major recession and the UK’s ejection from the ERM, GDP per capita in the UK was 34% lower than in the US, 33% lower than in Germany and 26% lower than in France.

The increase in the UK’s relative GDP per capita in large part reflects the long period of sustained strong growth that the UK has enjoyed since 1993. More recently, it also reflects the strength of sterling, first vis-à-vis the European currencies and, in the last couple of years, versus the US dollar. However…the UK has been catching up steadily with living standards in the US since 2001—so, it is a well-established trend rather than simply the result of currency fluctuations.

All this has, however, been plunged into reverse and uncertainty by the global economic crisis. The World Factbook’s (CIA, 2009) entry for the UK states:

The UK, a leading trading power and financial center, is one of the quintet of trillion dollar economies of Western Europe. Over the past two decades, the government has greatly reduced public ownership and contained the growth of social welfare programs. Agriculture is intensive, highly mechanized, and efficient by European standards, producing about 60% of food needs with less than 2% of the labor force. The UK has large coal, natural gas, and oil resources, but its oil and natural gas reserves are declining and the UK became a net importer of energy in 2005; energy industries now contribute about 4% to GDP. Services, particularly banking, insurance, and business services, account by far for the largest proportion of GDP while industry continues to decline in importance. Since emerging from recession in 1992, Britain's economy enjoyed

the longest period of expansion on record during which time growth outpaced most of Western Europe. The global economic slowdown, tight credit, and falling home prices, however, pushed Britain back into recession in the latter half of 2008 and prompted the Brown government to implement a number of new measures to stimulate the economy and stabilize the financial markets; these include part-nationalizing the banking system, cutting taxes, suspending public sector borrowing rules, and bringing forward public spending on capital projects. The Bank of England periodically coordinates interest rate moves with the European Central Bank, but Britain remains outside the European Economic and Monetary Union (EMU), and opinion polls show a majority of Britons oppose joining the euro. Other UK economic indicators in the World Factbook are outlined in Table 2 (Annex)

2 Health Status and Health System

2.1 Health Indicators

2.1.1 Mortality

There has been a long-term decline in UK mortality rates throughout the last century, interrupted only by peaks during the two world wars and the depression of the 1930s. Male mortality rates have been consistently higher than female rates although they are drawing closer together (Figure 3).

Figure 3: Age-standardised mortality rate for all causes by sex, England and Wales

Source: Death Registrations

An analysis of statistics from 1901 to 2000, entitled ‘Twentieth Century Mortality Trends in England and Wales’ (Griffiths and Brock, 2003) summarised the key points as follows: Infant mortality and childhood mortality have fallen most dramatically during the last 100 years. Infant mortality rates at the beginning of the century were nearly 30 times higher than those at the end. Childhood mortality rates were nearly 50 times higher in males and 65 times higher in females.

Around 80 per cent of deaths occurred at ages over 65 in 2000 compared with around 20 per cent in 1901.

Patterns of mortality by cause of death have changed throughout the century. Infectious diseases have declined to low levels, with the epidemics of the early part of the century no longer occurring. At the end of the century, deaths from all cancers combined formed around 25 per cent of all deaths in England and Wales, compared with 15 per cent 50 years previously and less than 5 per cent in 1901. This was because mortality from ischemic heart disease and stroke declined substantially while mortality from cancer did not.

There were increases in death rates from ill-defined causes from the 1980s to 1999, although these still formed a small proportion of all deaths in 2000 (2.5 per cent). This was due to the increasing certification of deaths as due to ‘old age’.

Current mortality statistics (2007), by underlying cause, sex and age group are summarised in Table 3 (Annex) 1 (ONS, 2008)

2.1.2 Morbidity

There are no available summary tables of morbidity in the UK, according to the Office of National Statistics and the NHS Information Centre (as indicated in responses to information request). There are a myriad of data tables of specific health indicators reported by the National Centre for Health Outcomes Development on its Clinical and Health Outcomes Knowledge Base website. The full list of available indicators and the next expected update are listed in Table 4 (Annex) along with embedded links.

2.2 Health System: General Information

Health care in the UK is a mixture of public and private with the majority of health care undertaken by the National Health Service (NHS). Private health care accounts for about 15% of patients.

2.2.1 The National Health Service

The NHS was established in 1948, following the Second World War, by the Labour Government and has been the longest lasting legacy of a socialist government in the UK. The NHS has at its core the ideal that good healthcare should be available to all, regardless of wealth. It is a model emulated in other countries. Funding thus comes directly from taxation, which ‘according to independent bodies such as the King’s Fund, remains the “cheapest and fairest” way of funding

1 More information on 21stcentury death rates in the UK can be obtained via The 21st Century Mortality Files - Population denominators for 21st century mortality file. Release date: 24 November 2008. Summary: The 21st Century Mortality Files are a record of mortality in England and Wales from 2001 onwards. They are designed to complement the Twentieth Century Mortality CD-ROM. The files consist of an aggregated database of deaths by age-group, sex, year and underlying cause, and include populations for England and Wales, see http://www.statistics.gov.uk/StatBase/Product.asp?vlnk=10530

health care when compared with other systems’ (NHS, 2009). The 2007–8 budget equates to approximately £1500 per head of population. The ultra-right wing Conservative government headed by Thatcher in the 1990s made several attempts at dismantling the NHS and promoting private health care. However, the NHS remains free at the point of use for all 60 million residents of the UK (with the exception of charges for some prescriptions and optical and dental services). The NHS website (NHS, 2009) claims that the system is ‘one of the most efficient, most egalitarian and most comprehensive’ in the world. Indeed, it covers ‘everything from antenatal screening and routine treatments for coughs and colds to open heart surgery, accident and emergency treatment and end-of-life care’.

Life expectancy in the UK has been rising and infant mortality has been falling since the NHS was established. ‘Both figures compare favourably with other nations. Surveys also show that patients are generally satisfied with the care they receive from the NHS’. Further, ‘people who have had recent direct experience of the NHS tend to report being more satisfied than people who have not’ (NHS, 2009).

2.2.1.1 Size and structure

The NHS is the world's largest publicly funded health service. The NHS is the biggest employer in the UK, with more than 1.5 million employees of whom just under half are clinically qualified, including 90000 hospital doctors, 35000 general practitioners, 400000 nurses and 16000 ambulance staff. ‘Only the Chinese People’s Liberation Army, the Wal-Mart supermarket chain and the Indian Railways directly employ more people’ (NHS, 2009). The Department of Health (DH) is in overall charge of the NHS with a cabinet minister reporting as secretary of state for health to the prime minister. Although funded centrally from national taxation, NHS services in England, Northern Ireland, Scotland and Wales are managed separately. The DH controls England’s 10 Strategic Health Authorities (SHAs), which oversee all NHS activities in England. In turn, each SHA is responsible for the strategic supervision of all the NHS trusts [hospitals] in its area. The devolved administrations of Scotland, Wales, and Northern Ireland run their local NHS services separately.

Some differences in the four countries have emerged but the systems remain similar in most respects and continue to be seen as a single, unified system. The NHS in England is much the biggest part of the system, ‘catering to a population of 50 million and employing more than 1.3m people. The NHS in Scotland, Wales and Northern Ireland employ 158000, 71000 and 67000 people respectively’ (NHS, 2009). Strategic health authorities were created by the government in 2002 to manage the local NHS on behalf of the secretary of state. On 1 July 1 2006 the original 28 SHAs were reduced to 10 with the intention of fewer, more strategic organisations having a stronger commissioning function, leading to improved services for patients and better value for money for the taxpayer Table 5 (Annex). SHAs are responsible for: developing plans for improving health services in their local area; making sure local health services are of a high quality and are performing well; increasing the capacity of local health services; and making sure national priorities are integrated into local health service plans. The SHAs are a key link between the Department of Health and the NHS.

Health in England is delivered via ‘trusts’. There are six types of trusts:

 Acute trusts: manage hospitals and decide on a strategy for how the hospital will develop, so that services improve. Acute trusts employ a large part of the NHS workforce, including nurses, doctors, pharmacists, midwives and health visitors, physiotherapists, radiographers, podiatrists, speech and language therapists, counsellors, occupational therapists, psychologists and healthcare scientists. They employ many other non-medical staff, including receptionists, porters, cleaners, specialists in information technology, managers, engineers, caterers and domestic and security staff. Some acute trusts are regional or national centres for more specialised care. Others are attached to universities and help to train health professionals. Acute trusts can also provide services in the community, for example through health centres, clinics or in people's homes.

 Foundation trusts: are a new type of NHS hospital run by local managers, staff and members of the public. They are tailored to the needs of the local population. Foundation trusts have been given much more financial and operational freedom than other NHS trusts and have come to represent the government’s commitment to de-centralising the control of public services. These trusts remain within the NHS and its performance inspection system. They were not at all popular when first introduced in April 2004, with considerable concern about backdoor privatization of the system. There are now 115 foundation trusts in England  Ambulance trusts: manage the 12 ambulance services covering England, which provide emergency access to healthcare. The NHS is also responsible for providing transport to get many patients to hospital for treatment. In many areas it is the ambulance trust that provides this service

 Care trusts: provide a range of services, including social care, mental health services or primary care services. Care trusts are set up when the NHS and local authorities agree to work together, usually where it is felt that a closer relationship between health and social care is needed or would benefit local care services. Currently there are only a few care trusts, though more will be set up in the future  Primary care trusts: manage front-line health services, including general practitioners (doctors) dentists, opticians and pharmacists. NHS walk-in centres and the NHS Direct phone line service are also part of primary care. There are currently 152 primary care trusts in England. They work with local authorities and other agencies that provide health and social care locally to make sure that the local community's needs are being met. PCTs are now at the centre of the NHS and control 80% of the NHS budget. They are responsible for ensuring all health services are provided, including hospitals, dentists, opticians, mental health services, NHS walk-in centres, NHS Direct, patient transport (including accident and emergency), population screening, and pharmacies. They are also responsible for getting health and social care systems working together for the benefit of patients.

 Mental health trusts: provide health and social care services for people with mental health problems. There are currently 60 mental health trusts covering England. Mental health services can be provided through a GP, other primary care services or through more specialist care including counselling and other psychological therapies, community and family support or general health screening. Specialist care is normally provided by mental health trusts or local council social services departments. Services range from psychological therapy, through to very specialist medical and training services for people with severe

mental health problems. About 0.2% of the population need specialist care for conditions such as severe anxiety problems or psychotic illness. In addition there are Special Health Authorities that provide a service nationwide, such as the National Blood Authority. They are independent, but can be subject to ministerial direction like other NHS bodies. They were established under section 11 of the NHS Act 1977.

2.2.1.2 Funding and capacity

At its launch, the NHS had a budget of £437 million (roughly £9 billion at today’s value). In 2007– 8 it received over £90 billion; an average rise in spending over 60 years of about 3% per year (above inflation). In recent years the rate of increase in expenditure has been 6% or more, which has funded a modernisation programme.

About 60% of the budget goes on staff costs, 20% on drugs and medical supplies and 20% on buildings, equipment, cleaning, catering and training. ‘Nearly 80% of the total budget is distributed by local trusts in line with the particular health priorities in their areas’ (NHS, 2009).

The NHS deals with one million patients every 36 hours: 463 patient each minute. ‘Each week, 700,000 will visit an NHS dentist, while a further 3,000 will have a heart operation. Each GP in the nation’s 10,000-plus practices sees an average of 140 patients a week.’ The waiting times for patients have reduced over the last decade (Figure 4, Figure 5).

Figure 4: Number of patients waiting over 13 weeks for inpatient admission 1998–2008

Source: Monthly monitoring returns

Figure 5: Referral to treatment patients seen in less than 18 weeks.

Source: 18 weeks monthly return

Figure 6 charts the most recent publication of provisional monthly Hospital Episode Statistics (HES, 2009) for NHS Hospitals in England and activity performed in the Independent sector in England. In the year from March 2008 to February 2009 there were: 16.0 million finished consultant episodes (FCEs) (56.6% of which included at least one procedure or intervention) and of these 5.1 million were day cases. In the same period there were 13.9 million admission episodes, of which 4.9 million were emergency admissions (Table 6, Annex).

Figure 6: Chart showing summary HES inpatient data by month of activity, for final 2006-07 and 2007-08 data, and provisional 2008-09 data

Source: HES (2009)

Hospital Episode Statistics (HES), 2009, Provisional monthly HES data for inpatients, available at http://www.hesonline.nhs.uk/Ease/servlet/ContentServer?siteID=1937&categoryID=1122, accessed 25 July 2009.

2.2.2 Private health care

The NHS is available to all people in the United Kingdom. Some people, however, receive treatment in private hospitals and clinics or NHS hospital pay beds in return for annual subscriptions to private health care schemes or by paying directly for specific treatment. Recent

data on the extent of the private sector in the UK is difficult to find. According to the Family Expenditure Survey, which collects information on households covered by private health insurance in the UK, the proportion of all households covered rose from 6 per cent in 1985 to 9 per cent in 1998–99. Households headed by someone from the professional, employer or manager group are the most likely to be covered: 18 per cent were members of such a scheme in 1998–99 compared with 8 per cent of households with a retired household head.

In 2000, 6.9 million people were covered by private health insurance, more than three times the number in 1971 (2.1 million). Most of this rise occurred in the late 1970s and 1980s. However, after a stable period in the 1990s, the number of people with private medical insurance rose by 5 per cent between 1999 and 2000. This rise was entirely due to company paid business, as the number of individual private medical insurance subscribers fell between 1999 and 2000. Private health care services, include private hospitals, doctors and specialists, private medical insurance, dentistry and care of the elderly. It also includes health screening, private nursing care, maternity services, physiotherapy and sports injury clinics. However, there is a lot of emphasis on such things as breast implants, cosmetic surgery, obesity surgery, infertility treatment, paternity testing, orthodontics (Private Health Care UK, 2005–9) and other such areas that are lower down the NHS priority lists. Recent data on expenditure (Table 6, Annex) suggest private health accounts for just under a fifth of total health expenditure but given the costs and profits associated with private health, this would be less than one fifth of the patients. Also, as suggested above, it would account for very small proportions in some acute areas and higher proportions in non-essential health areas.

2.2.3 Total expenditure on health

The most recent available data on expenditure on health care in the UK is presented in an article entitled ‘Expenditure on Health Care in the UK 1997–2007’ by Lewis and Mills (2009) on the National Statistics website (which supersedes 'Expenditure on Health Care in the UK 1997 to 2006' published 14 April 2008). It covers any spending on health care irrespective of who pays for or provides the health care. Table 6 (Annex) is a composite table derived from data in this article. It shows an increasing proportion of GDP being spent on public health and a static proportion on private health. Lewis ad Mills (2009) comment on international comparisons:

ONS provides the ‘Expenditure on health care in the UK’ series to the Organisation of Economic Cooperation and Development (OECD) for inclusion in OECD Health Data, a major source of internationally comparable health statistics. These latest UK data will be published in the 2009 edition and replace those previously provided to the OECD (ONS 2008a). According to OECD Health Data 2008 (OECD 2008), the average percentage of GDP spent on health care for EU15 member states was 9.3 per cent in 2005. This was calculated as a simple average, that is, the sum of the percentages for each member state of the EU prior to 2004 divided by 15. The latest year with data available for all 15 countries is 2005.

The weighted average for EU15 member states was 9.6 per cent in 2005. The weighted average weights the figures from each country according to the size of that country’s GDP. OECD Health Data 2009 will include EU15 averages for 2006 and 2007. This publication is planned for June 2009 The WHO (2006) estimated that 87.4% of all expenditure on health in the UK was from the government, up from 87.1% (2005) and 86.3% (2004).

UK Public Spending (Chantrill, 2009) report public spending for the last 30 years with projections for the next two years. Health expenditure as a percentage of GDP was 5.11% in 1980, rising to 5.63% in 1983 before falling back in the remainder of the Thatcher era to 5.22% in 1990. An increase under Major to 5.56% in 1991 went up further to 6.3% in 1993 before declining to the lowest proportion in 30 years to 4.91% at the end of the Major administration. Since then, under Labour, there has been a steady increase to 7.68% in 2009 and it is projected to reach 8.4% in the next two years (Table 7, Annex). As a proportion of all government spending, spending on health has risen from 11.6% in 1980 to 17.5% in 2009, with a similar pattern of rise and falls to those of the proportion of GDP (Table 7, Annex).

2.2.4 Hospital beds

Total hospital beds are defined by OECD (2009) as all hospital beds which are regularly maintained and staffed and immediately available for the care of admitted patients. The number of hospital beds in the UK fell from 211617 in 1984 to 145218 in 2004. This decline over the twenty years was not a function of expenditure on hospitals but of a change in treatment processes with some techniques that allowed day surgery, for example, and a changed emphasis on the need to remain in hospital during recuperation.

Recent data from the Department of Health indicates 160297 beds in England in 2007–8 with an occupancy rate of 84.3% overall (Table 8, Annex). Most pressure appears to be on beds for mental health and for elderly patients (Table 9, Annex).

2.2.5 Demand on medical services: unemployment rate of health professionals and vacancies in the health system

There are problems in collecting data on unemployment of health professionals in the UK as summary accounts are for education, health & public administration combined (both private and public sectors). Unemployment rates in the education, health and public administration sector have tended to be lower than in any other major sector since 1995. Female unemployment in the sector is between 1 and 2% lower than male unemployment (Table 10, Annex). However, in the first quarter of 2009, 17.6% of all long-term unemployed (more than 12 months) were from the education, health and public administration sector (a rise of 2.3% in a year).

The education, health and public administration sector has had a fairly stable ratio of vacancies to employees over the last two years at around 2.3 per hundred employees. Meanwhile the vacancies per employee in the economy as a whole has declined to 1.6 per hundred and for the service sector as a whole to 1.8. There has been a 31.3% drop in the last year in service sector vacancies as a whole but only a 9.4% drop in the education, health and public administration sector (Table 11, Annex).

2.3 Supply of Health Professionals

All health professionals in the UK are controlled by a regulatory council, which, inter alia, sets standards, oversees education, registers practitioners and deals with issues of malpractice. There are seven regulatory councils and two societies for pharmacy with much the same role and powers as the regulatory councils. The nine organisations are:

 General Medical Council (doctors)

 Nursing and Midwifery Council (nurses)

 General Dental Council (dentists)  General Optical Council (opticians)

 General Osteopathic Council (osteopaths)

 General Chiropractic Council (chiropractors)  Royal Pharmaceutical Society and the Pharmaceutical Society of Northern Ireland (pharmacists)

 Health Professions Council (arts therapist, biomedical scientists, chiropodists/podiatrists, clinical scientists, dietitians, occupational therapists, operating department practitioners, orthoptists, paramedics, physiotherapists, prosthetists/orthotists, radiographers, speech and language therapists)

Each of these requires registration to practice, with varying powers that can be used against those who practice unregistered. They all have procedures for registration, or temporary registration of EU (EEA and Switzerland) nationals and special procedures for international migrants hoping to practice in the United Kingdom.

2.3.1 Doctors: General Medical Council

The General Medical Council is a regulatory body that controls all aspects of medical practice from education and training through to oversight of the profession (Harvey, 2005). It is established by law and its primary aim is to safeguard the public. The procedure for registering and monitoring medical practitioners in the United Kingdom is undergoing changes. This will take several years to complete.

Hitherto, a doctor could not practice in the United Kingdom without being registered with the GMC. In future, not only will registration be required but also a licence to practice in the UK. The

licence will be time limited and there will be a revalidation process, the aim of which is to give patients regular assurance that doctors registered with a licence are up to date and fit to practise. The revalidation element is essentially the new aspect of the process.

Doctors who take a licence will be subject to the requirements of revalidation, when it is introduced. This means they must undertake the periodic renewal of their licence by demonstrating that they are up to date and fit to practise. They will also be required to maintain a link with a Responsible Officer in their area for the purposes of revalidation. Taking a licence also means that it remains a doctor’s responsibility to be familiar with the GMC document Good Medical Practice and to follow the guidance it contains, in the same way that currently registered doctors are expected to do.

The requirement to register and have a licence to practice applies to all medical practitioners undertaking any form of medical practice for which UK law currently requires them to hold GMC registration, whether they practise full time, part time, as a locum, privately or in the NHS, or whether they are employed or self-employed. In the interim period, before licensing is introduced, the GMC have asked all registered doctors to confirm whether or not they want to hold registration with a licence to practise. Doctors were being asked to make this decision by Friday 14 August 2009. Doctors have three options: to seek a licence as well as registration, which will be necessary to practice; to maintain registration but not seek a licence, which, for example, registered doctors working overseas may opt to do; to request removal from the register, which effectively means a cessation of medical practice in the UK and also may restrict any practice overseas where GMC registration is required.

According to the GMC web site (GMC, 2009a):

The first revalidations will not happen before 2011. These are likely to be pilots with volunteers. From there the roll-out of revalidation will be incremental so that we can build on the early learning. At this stage, it is not possible to say when each doctor will be expected to have been revalidated.

2.3.1.1 Registration with the GMC for UK graduates

For UK medical graduates who have completed a 12-month internship there is a requirement to work in an approved practice setting for the first 12 months of full registration. Such a setting is one that has been approved by the General Medical Council as having in place sufficiently supportive and quality assured systems aimed at improving quality.

Following the completion of 12 months in an approved practice setting, new registrants need to provide evidence of satisfactory performance before they are eligible to apply for release from the requirement to work in approved practice setting. Moving to full registration requires submitting a fully completed Certificate of Experience, which must be completed by the authorised officer of the applicant’s medical school or deanery. Further, registrants are asked to complete a set of questions regarding their fitness to practise, the answers to which may require the submission of further evidence to support the application. A registration fee is payable: £410 for full registration and £140 for provisional registration, as of 1 April 2009.

Graduates who have not completed an internship have to undertake an internship during which time they hold provisional registration. There is currently no time limit on the period of provisional registration but such registration restricts the type of employment permitted. After two years of provisional registration the full annual registration fee applies even if still only provisional. All graduates are subject to a GMC-conducted pre-registration identity check during their final years at medical school. Once registered employers and the public can check the registration online on the GMC website using the online List of Registered Medical Practitioners (GMC, 2009b).

2.3.1.2 Registration with the GMC for nationals from EEA and Switzerland

The process of registering as a doctor for nationals from the EEA, Switzerland and other doctors with EC rights, who graduated at EEA or Swiss medical schools and have completed an internship is similar to that of UK graduates. It requires proof of identity, payment of a fee and then evidence of qualifications and the appropriate licence to practise from the EEA country of qualification. The GMC has a sub-site, the ‘EEA qualification evidence guide’ (GMC, 2009d), which indicates the required documents for the country of qualification and the type of registration that is being applied for.

EEA registrants have to provide details of each medical regulatory authority in which they have been registered within the last five years, even if they have not practised in that jurisdiction. A Certificate of Good Standing from each of the medical regulatory authorities is required and the GMC has another subsite that specifies the medical regulatory authority for each country and the contact details (GMC, 2009c).

The Certificate of Good Standing must confirm that the applicant is entitled to practise medicine in the appropriate country and was not disqualified, suspended or prohibited from practising medicine and the regulatory authority is not aware of any matters that call into question the applicant’s good standing. Where there is no medical regulatory authority in the country to issue a Certificate of Good Standing, employer references are required. Details of all of work experience over the last five years are required, both medical and non- medical. If there are any periods during the last five years in which the applicant has not been registered with a medical regulatory authority but has been working in either a medical or non- medical capacity then a reference from each employer is required that specifies the dates of employment and a statement that the employer is not aware of any matters that call into question the applicant’s good standing. It must also indicate that the applicant was not required to hold registration with a medical regulatory authority to undertake the post.

All such documents need to be sent as photocopies at the application stage and then the originals presented in person at the final stage of registration. All documents must be in English and if originally in another language need to be translated, both the translation and original language document need to be presented to the GMC.

2.3.1.3 Registration with the GMC for international medical graduates

The procedures for international medical graduates are the same as those for UK graduates but also include a language test requirement and extensive evidence on education qualification and fitness to practice. International medical graduates are those who are nationals of a country outside the UK, European Economic Area (EEA) or Switzerland who graduated from a medical school outside the UK and do not have EC rights.

The GMC website is not particularly welcoming to international medical graduates. It has a prominent note warning that, as of 6 February 2008, immigration rules restrict international medical graduates’ access to UK postgraduate medical training, and applicants are referred to the Department of Health website.

One respondent explained:

At a very senior level, it is a lot easier to get consultants from abroad. We’ve actually got a Chilean surgeon who works here; we’ve got quite a few Scandinavians, some Germans, a lot of from the Indian subcontinent, Malaysia and from Japan. Because of the type of work we do, being a tertiary centre, we can attract people from all over the world. For medical staff particularly, the issue around the certificate of sponsorship, which is coming out now, the Tier 2 migration level means that we are going to have to cut right back on how many doctors we can bring in, how many specialists from outside of the EU with the change of immigration laws. We got 17 certificates; that’s all we can bring in. Out of a workforce of 7000 that doesn’t give you much leeway. Further, the GMC site warns about employment prospects as follows: Employment Prospects

We strongly recommend that before you apply for the PLAB test or registration that you find out whether you have a realistic chance of obtaining the kind of job you want.

The job market in the UK is very competitive and you should think very carefully about whether you are willing to take the risks involved in competing for posts. Information about the number of applicants for posts categorised by specialty and location can be found at the British Medical Journal Careers website. (GMC, 2009c)

The respondents interviewed suggested that there was no problem with registration as such but a definite lack of posts. One respondent, a doctor trained in Lithuania with 25 years experience, reported “no problem at all for me registering as a doctor in UK. The GMC accepted my European diploma and issued a certificate. The real problem was to find a job: essential requirement was UK experience. After one year and thousands of applications sent, I luckily met my agent who trusted me and offered a job. Now I am a hospital doctor with three years of experience in UK.”

One of our respondents suggested that the current UK policy, especially with the creation of new medical schools has led to “less reliance on migration”, reinforcing the view that in the past the British NHS needed to import overseas doctors. Now, the respondent noted, “there are limited employment opportunities but not a general awareness of this and people who come to the UK are finding it more difficult”. In addition, immigration rule changes are also impacting on recruitment processes. “There appears to be a blanket requirement for MAs” from immigrants and

a “degree of inflexibility in recruitment” has developed. For migrating doctors, “it is more difficult to navigate the system” nowadays. International medical graduate doctors are eligible for two types of registration: provisional and full; the latter for those who have completed an acceptable internship either overseas or in the UK and the former for those who have not completed an acceptable internship. Provisional registration is granted solely for the purpose of completing an acceptable programme. The GMC site (2009c) provides the following details about registration for international medical graduates: An acceptable Primary Medical Qualification

To be acceptable your primary medical qualification must have:

 been awarded by an institution listed in the Avicenna Directory (formerly the WHO Directory of medical schools) or otherwise accepted by us and be currently acceptable to the GMC. (Please note: we do not accept all primary medical qualifications that are listed in the Avicenna Directory. See below for more information)

 been awarded by an institution that has a physical address included in the Avicenna Directory

 been awarded after a course of study comprising at least 5,500 hours (or four years full time equivalent study)

 not involved a course of study undertaken wholly or substantially outside the country that awarded the primary medical qualification

 not involved a course of study undertaken wholly or substantially by correspondence.

For further information and details of qualifications that are not acceptable please read our guidance on acceptable primary medical qualifications. English language capability

This will normally be demonstrated by achieving the required results in the IELTS test: an overall band score of 7 and a minimum score of 7 in speaking and 6 in each of reading, writing and listening. Your IELTS test will only be considered valid for a period of two years.

In some circumstances you may be able to provide alternative evidence of your English language capability, please refer to our English language requirements guidance for further information.

For another respondent, an Iranian graduated doctor with six years experience working in Iran, the problem is language: “I have to pass many test such as IELTS and PLAB test, then I can work as a GP in the UK.”

A senior manager explained the problem from his point of view as a recruiter: Bureaucratically, it is much easier for us, in some ways, to pull from Europe, apart from the language barrier, but pragmatically it is easier for us to pull from the rest of the world because more people speak English and only a small part of Europe speak English to a degree we would accept.

We have had, recently, a junior doctor who came from Poland who passed his PLAB but, following assessment and his ability to use English, it was agreed that he was at the level of a third-year medical student and he was being paid as an FY1. They are pretty few and far between. The problem is that the stories get out, ‘Polish doctor couldn’t speak English’ and then one Polish doctor will become 50 Polish doctors. Yet you never hear about the home doctor who was just as incompetent, because it is hushed up.

The GMC site (2009c) goes on as follows: Fitness to Practise

As part of your application you will be asked to complete a declaration of fitness to practise. It is important that you answer this honestly and provide further information for any question you answer ‘yes’ to. Please see our guidance on the declaration of fitness to practise for further information.

You will also be asked to provide details of your registration for all the medical regulatory authorities of any countries where you have practised or have held registration in the last five years.

Please note: we require details of each medical regulatory authority that you have been registered with, even if you have not practised under their jurisdiction. We will need to see a Certificate of Good Standing (CGS) from each of the medical regulatory authorities that you have listed. In cases where you are no longer registered, this may be known as a certificate of past good standing. Certificates of Good Standing can take some time to arrive, please ensure you have all CGS before you apply for registration.

If you cannot get a Certificate of Good Standing then we may ask you for employers’ references from each employer that you have worked for in that country.

If you are unable to get a CGS or employer’s reference because you have not worked in the last five years we will ask for other evidence of your good standing. You will find more information on this in our application guidance as you apply for registration. Knowledge, skill and experience

You will be asked to provide evidence of your medical knowledge and skill. This can be provided in one of four ways:

 A pass in the PLAB test

For more information please see our PLAB Test guidance. A pass in the PLAB test is only valid for three years. You must have been granted registration by the third anniversary of your PLAB 2 exam or you will need to re-sit the PLAB test.

 An acceptable postgraduate qualification (PGQ). Details of the UK and international qualifications that we accept can be found in our acceptable PGQ guidance. If your qualification is not on this list we will also accept a letter from a UK medical Royal College confirming that an international qualification is equivalent to its own qualification.

 Sponsorship by an approved sponsor. The GMC has a list of organisations and individuals approved to sponsor doctors for the purpose of full registration. If your sponsor is not on this list then you cannot apply using sponsorship as evidence of your knowledge and skill. For further details please see our list of approved sponsors.

 Eligibility for entry onto the Specialist Register, You must have been found eligible to apply for specialist or GP registration by the Postgraduate Medical Education and Training Board (PMETB).

If you are applying for full registration you will also need to provide evidence that you have completed an acceptable internship. You will be asked to provide details of your pre-graduate or postgraduate internship. To be eligible for full registration you must have satisfactorily completed either F1 in the UK, or a period of pre-graduate or postgraduate clinical experience that provides an acceptable foundation for future practice as a fully registered medical practitioner. This will usually be referred to as an internship.

To be acceptable your internship must be either:

 A 12 month programme that includes a minimum of three months in surgery and three months in medicine or

 a programme of at least 10 months duration that includes a minimum of three months in surgery and three months in medicine which also includes an additional period of study of up to two months in order to prepare for an exit exam, together with successful completion of all exit examinations or

 The equivalent of two years full time post qualification experience at a publicly funded hospital in at least two branches of medicine and/or surgery.

For your first 12 months of full registration you will be required to work within an approved practice setting. This means that you will only be able to work in settings that have been approved by us as having in place sufficiently supportive systems and quality assurance systems aimed at improving quality. For more information on approved practice settings, please see our guidance on approved practice settings.

The guidance you are reading is to help you understand the steps that are involved in applying for registration before you decide to work in the UK. You can find step by step instructions on applying for registration in our applying for registration guidance. You should not attempt to complete your application without reading the registration guidance thoroughly to make sure you have all the documentation you need. If you submit your application before you have all the documentation you need this will delay the processing of your application. [Emphasis in original]

A professor from Malaysia who wanted to come to this country, who is recognised as a world leader in his field and ran his own hospital in Malaysia, could not get a job as a consultant in Britain because of the restrictions imposed, not by the regulatory bodies, but by the Royal Colleges and the BMA. Ridiculously, the Postgraduate Medical Education and Training Board required evidence in the form of a signed-off diary when he was trained, 20 years previously, despite him being eminent surgeon.

One senior manager in a large hospital explained the problem they faced with supply and the problems of inflexibility. On average we have 30 to 40 [medical] posts unfilled. In a hospital this size when we have about 700 junior doctors coming through, so proportionately the number is quite small, but the impact they have on us is massive. So a shortfall of 30 or 40 doctors when we’re running junior doctor rotas which are incredibly tight because of the new deal and the European Working Time Directive, which is restricting us to 48 working hours a week for our doctors working, any gap is pretty serious. It is very difficult to get locum doctors, very few around and they are asking huge prices to come and work. Seen something similar in primary care as well, particularly for GPs, and there’s been some well-publicised cases. GPs coming over from Germany, doing a session, and being paid the same as somebody for a week….

Also with the junior doctor hours we’re paying an absolute fortune for people to come in because it’s the only remuneration package I’ve ever seen whereby you get paid 50% of your salary regardless really of the hours you work. So you can be on a full shift, 48 hours a week in 4 or 5 shifts, and you can still get paid a banding on top of that, which is not your out-of-hours payment but could be anything up to 40% of your salary. And the reason it was brought in was to stop the Trusts from abusing junior doctors. Junior doctors were on 96, 118 hours a week. None of our juniors are on more than 48 hours now. So why we’re not paying them just normal enhancements as we pay every other member of staff is beyond me. So there’s a massive financial disincentive for us actually to recruit within the terms and conditions of junior doctors within this country.

2.3.2 Nurses and midwives: Nursing and Midwifery Council

All nurses and midwives practicing in the UK have to be registered with the Nursing and Midwifery Council (NMC). The NMC Register has three parts: nurses; midwives; specialist community public health nurses. The nurses’ part of the Register is divided into four fields of practice: adult nursing; mental health nursing; learning disabilities nursing; children’s nursing. There are about 673,000 nurses and midwives on the register in the UK, about 1 per 100 of the population. Registration must be renewed every three years. Renewal is contingent on the applicant meeting two standards set by the NMC: the continuing professional development standard and the practice standard. To meet these standards nurses must demonstrate that they have undertaken 35 hours of learning activity relevant to their practice and completed 450 hours of practice during the three years prior to the renewal of registration. Whatever the terms of nursing employment, every nurse must provide evidence of meeting these standards in order to maintain their registration as a nurse with the NMC. This applies to all registered nurses and midwives from the UK and abroad.

2.3.2.1 Registration with the NMC for UK graduates

UK-trained graduates registering as a newly qualified nurse or midwife complete and return an Application for Registration form (enclosing a £76 fee). The form is sent to the applicant after the NMC receives course completion details and an appropriately signed declaration of good character from the applicant’s higher education institution. This requires that the applicant makes sure the institution has an up-to-date record of their personal details. The application has to specify the appropriate part of the register.

All subsequent entries of registered qualifications incur a cost (currently £23). This includes enrolled nurses, already registered who subsequently complete conversion courses and anyone who wishes to register a second or subsequent qualification. In 2008 the registrations advice centre answered 594,749 calls, an average of around 3,000 per day. However easy it may have been in the past to be recruited from abroad as a nurse or midwife to work UK, the situation is currently tight.

The NMC website makes it clear that in order to apply for registration nurses from overseas must hold full and active registration as a nurse or midwife in their home country, which requires a minimum of 12 months post-registration experience after having qualified as a nurse.

2.3.2.2 Registration with the NMC for nationals from EEA and Switzerland

Regulations for European Community nurses are different from those outside the EEA.

The NMC assesses the education and training of all nurses and midwives who are EU/EEA nationals and have completed their education in the EU/EEA and who wish to practise in the UK. The European Union (EU) has agreed the minimum standards that nurses responsible for general care (adult nursing in the UK) and midwives must meet in order to be eligible to register as a nurse or as a midwife. These are set out in the Recognition of Professional Qualifications Directive 2005/36/EC (the Directive). There is a listing of qualifications in a guidance document, on the NMC website, that lists the qualifications in each country that meet the standard for automatic recognition (NMC, 2009a). When countries join the EU, they have to make sure that their general nursing and midwifery training programmes meet the minimum standards in the Directive. If a qualification was awarded before the date that this was established for general nursing (29 June 1979) or midwifery (23 January 1983) or before the reference date for when the applicant’s country implemented the EU standards then applicants do not meet the requirements for automatic recognition of their qualification. In which case additional documentation is required to establish ‘Acquired Rights’. This is possible if the qualification although not listed for automatic recognition, was granted in an EEA Member State following training in that Member state and it is certified by an appropriate competent authority, and the applicant can provide a certificate from the competent authority of the home member state confirming that the applicant has lawfully and effectively practised as a general nurse or midwife for at least three consecutive years out of the last five years from the date when the certificate was issued.

If none of the above apply then NMC can assess the applicant’s training and experience using Article 10(b) of the Directive: assessing against Article 31 and Annex V, 5.2.1 for generals nurses and Article 41 and Annex V, 5.5.1 for midwives. This section of the Directive also sets out a framework approach for recognising qualifications other than general nursing and midwifery, depending on the level of qualification. The NMC uses this to assess applications, inter alia, from children’s, mental health or learning disability nurses.

When assessing training and experience under the individual assessment route, where there are significant differences between the training undertaken and that which is required in the UK, the NMC will detail these and the applicant will be invited to make up the differences either through a period of adaptation or through an aptitude test. In order to do this, the NMC require a complete transcript of training from the applicant’s school of training, showing the number of hours of theoretical and clinical study, and numbers of deliveries if a midwife.

There are some specific issues relating to some aspects of training in Poland, Bulgaria and Romania. There is a language competence requirement for all EEA applicants.

2.3.2.3 Registration with NMC for international nurses and midwives

The tone of the website and the accompanying documentation that overseas registrants are expected to read is not particularly welcoming. For example, referring to the new UK immigration requirements for non-EEA migrants, the NMC states that it is not in a position to provide information on the academic level of individual qualifications that have been gained outside the EU as the NMC does not require confirmation of academic levels from non-EEA trained nurses and midwives as part of the registration process.

The NMC assesses the educational length and content of applicants’ training programmes and then uses the Overseas Nurses Programme (ONP) and Adaptation to Midwifery programmes to ensure competence to practise in the UK. We do not consider academic level equivalency when assessing applications. Nurses and midwives who wish to register with the NMC need to be aware that they will, separately, be required to meet the full requirements of the UK’s immigration processes. (NMC, 2009b) The application process for overseas nurses and midwives to join the register (without which practicing as a nurse or midwife is illegal) involves meeting specified minimum standards followed by the completion of a compulsory overseas nursing programme or equivalent programme for midwives.

Overseas nurses candidates apply for registration as a nurse or midwife in the UK even if they live abroad. However, once the application has been approved, implying that the qualification is acceptable, the applicant has to proceed to apply for an Overseas Nursing Programme or Adaptation to Midwifery Programme and will need to be in the UK to attend the university and clinical placement. Applicants for registration must have been practising as a registered nurse or midwife for at least 12 months (full-time or the part-time equivalent) after qualifying and, if qualified for longer than a

year to have practised for at least 450 hours in the previous three years. Those who satisfy other requirements but not practised as a nurse for more than five years have to take a longer version of the Overseas Nurses Programme.

Applicants must, additionally, have successfully completed at least 10 years of school education before starting a post-secondary education nursing or midwifery programme, leading to registration in the home country as a first-level registered nurse or midwife. In the UK, post- secondary school nursing and midwifery programmes generally start at the minimum age of 17.5 years. Applicants who started training younger than 17.5 years than are unlikely to be successful. The specific requirements for nursing require what the NMC call-first-level qualification. They will not accept a second-level nurse qualification or the equivalent, such as, an enrolled nurse, a licensed practical nurse, a vocational nurse, a state certified nurse, a nursery nurse, a nurse midwife technician, a nurse aid. Further, the NMC does not accept medical qualifications as a basis for registration even if this qualification permits the applicant to carry out the duties of a nurse in the home country. The training programme must have been entirely focused on nursing and for all three-year nursing courses, at least half (or 2300 hours) must be in clinical or practical training, and at least one third (or 1533 hours) must be theoretical training. The NMC will not accept nursing qualifications that contain what it considers to be general education.

The specific area of the register that the applicant needs to identify depends on the nature of their experience. For adult (general) nursing, the applicant must be qualified and registered as a general nurse and the qualification should include theoretical and practical instruction in: general and specialist medicine; general and specialist surgery; childcare and paediatrics; maternity (obstetric) care; mental health and psychiatry; care of the elderly; and community/primary care nursing. There are specific other requirements for children’s nursing, mental health nursing and learning disabilities nursing and for midwives.

The general requirements for registration also include English language competence. The NMC strongly recommends that potential registrants from overseas investigate what NMC- approved courses are available and secure a place before travelling to the UK. The NMC also states that: The employment climate in the UK is very changeable. We can not help you find a job or give you references from any of the information you give us. To work as a nurse or midwife in the UK, you must meet immigration conditions. Immigration in the UK is handled by Work Permits UK, so you should contact them for information. We cannot help you with your work permit application. (NMC, 2009)

Once registered with the NMC an applicant can work in the National Health Service or private health. The process is as follows.

The first stage of application requires the applicant to pay an administration fee and to return the initial application form along with certified (signed by a solicitor) photocopies of the registration certificate, passport (details page), birth certificate, marriage certificate (or equivalent). The applicant also needs to send the International English Language Testing System (IELTS) candidate number and test score. Applicants must achieve an overall average score of seven (out of a possible nine) and at least seven in each of the listening, reading, writing, and speaking

sections. NMC considers an IELTS test result to have a validity of no more than two years.

The second stage follows receipt of the first-stage material and the applicant is sent an application pack, which contains the application form, a post-registration experience form, two employment reference forms, a transcript of training form and a registration authority/licensing body form. Detailed information to help the application complete the form is included. The application forms should not be photocopied but certified photocopies of all supporting documents are required, which must be translated if not in English. The signed and dated application form must be completed in English by the applicant and returned within six months of receipt or else face a second application fee. Application forms and documents should be sent by post or special delivery not faxed or emailed.

One nurse, trained in Ethiopia, with seven years’ experience as well as a public health degree, explained that:

There is some policy I think so that the Nursing and Midwifery Council they wouldn’t accept any overseas nursing programme unless I retrained the nursing programme in this country… Or there is some overseas nursing programme but I couldn’t afford the money for that.

Migrant nurses from outside the EC that we interviewed who had come to Britain, some as political refugees, indicated two major issues, the lack of posts and the demanding English language competence tests. For some, passing the tests takes so long that they have to take refresher courses because they have not been actively employed as nurses within the period required by the professional body. What often happens is that migrant nurses take lower-level jobs, often for long periods, while they ‘retrain’ as nurses. The story of one migrant from Zimbabwe is indicative: Back home I was a registered nurse but in this country I’m not registered….When I came here in June 2004. I looked for a place to do my adaptation training. I couldn’t find a place until it was late and my visa was expiring. My decision letter also expired but I got a place to do the training but the visa expired so I was turned down. Instead of going home I just decided to stay and started working as a health care assistant… So, since 2005, I have been working as a health care assistant. In 2008, I applied for refugee status. And then in February 2009 I was granted refugee status. I continued working as a care assistant. I had some problems with my knees. Then I did my pre-adaptation course…. But then had problems with the English language test. First time I got above 7 in writing and speaking but in listening and reading I got 6.5. So I didn’t pass. I did it again in 2010 and got an 8 in speaking, 7.5 in writing and a 7 in listening but failed the reading again. I decided to go back to basics and start again. So I applied to the course at [University X]. They used APEL to accredit me so I joined the second year, which I start in April 2011.

them asked me about UK work experience and now I’m doing a work placement to get some experience. It’s been very difficult.”

2.3.3 Dentists: General Dental Council

All dentists, dental hygienists, dental therapists, dental nurses, dental technicians, clinical dental technicians and orthodontic therapists have, by law, to register with the General Dental Council (GDC) to work in the UK. Registrants must hold a qualification approved by the GDC in order to be eligible to apply for registration.

The GDC fulfils its purpose of protecting the public by regulating dentists and dental care professionals and specifying standards by which such practitioners should work

2.3.3.1 Registration with the GDC for UK graduates

The process of registering with the GDC is less complicated for dentists than for doctors registering with the GMC. Most dentists qualified in the UK register with the GDC immediately upon graduation from their dental school. There is no internship requirement beyond the span of the five-year degree. GDC application packs are distributed by the dental school to potential graduates. Applicants then complete the form and send it directly to the GDC and are registered upon receipt of the application form, fees and supporting documentation from the applicant and the graduation list from the dental school. The application form asks for details of qualification, as well as a health declaration and character reference. Once registered the dental professional must have professional indemnity insurance to practise in the UK. They must also be familiar with the GDC’s Standards for Dental Professionals and commit to upholding them. Furthermore, continuing professional development (CPD) is compulsory and dental professionals must complete a statement of the CPD hours completed each year.

UK graduates who have been working abroad as a dentist between graduation and application for first registration with the GDC must provide an original certificate, less than three months old, from the dental authority of the country in which they were last working as a dentist, which states that they are legally entitled to practise dentistry and that you have not been suspended, disqualified or prohibited from working as a dentist.

2.3.3.2 Registration with the GDC for nationals from EEA and Switzerland

As with other areas of health professionals, registration for EEA-qualified dentists is governed by The European Communities (Recognition of Professional Qualifications) Regulations 2007 and the process for registration mirrors that of doctors, requiring evidence of identity, qualification, practice, good standing and payment of a fee. There are various caveats for those qualified in specific member states with specific additional provisions for recognition of qualifications from Austria, former Czechoslovakia, the Czech Republic, former German Democratic Republic (GDR), Italy, Romania, Spain, former Soviet Union and former Yugoslavia.

2.3.3.3 Registration with the GDC for international dentists

Graduates from countries outside the EEA whose qualifications are not recognised for full registration with the GDC in the UK are required to take the Overseas Registration Examination (ORE). The clinical skills and knowledge of non-EEA graduates are tested against the standard expected of graduate dentists when they first register with the GDC. This means that UK graduates and overseas dentists are expected to have the same basic knowledge and skills. The examination is based on the UK dental curriculum and uses modern assessment methods to ensure a robust and consistent examination. Dentists who pass this examination become eligible to apply for full registration to practise in the UK.

One respondent, a political refugee from Iran, where he trained, with 12 years experience as a dentist had to “pass two ORE exams (dentistry) and achieve IELTS 7 to start working again. Recently I could get IELTS 7 and now I am preparing for the dentistry exams”.

Temporary registration allows dentists who are not eligible for full registration to practise dentistry in the UK in supervised posts for training, teaching, or research purposes only, and for a limited period. Posts approved for temporary registration by the GDC allow dentists to work in dental schools or hospitals. Apart from these approved settings, temporary registration will not allow dentists to work in general or private practice, or in the community dental services.

2.3.4 Pharmacists and pharmacist technicians: Royal Pharmaceutical Society

The Pharmaceutical Society of Great Britain was founded in 1841 to unite the profession into one body, to protect its members' interests and to advance scientific knowledge. In May 1988 it became the Royal Pharmaceutical Society of Great Britain (RPSGB).

Previously, the Society's Byelaws have been made under powers provided either by the Charter or by the Pharmacy Act 1954. Since the Pharmacists and Pharmacy Technicians Order 2007, which has repealed the Pharmacy Act 1954, all the existing Byelaws will be superseded by Regulations or Rules. Registration with the Society is governed by the procedures set out in the Royal Pharmaceutical Society of Great Britain (Registration) Rules 2007 (RPSGB, 2009a).

2.3.4.1 Registration with the RPSGB for UK graduates

Under article 11 of the Pharmacists and Pharmacy Technicians Order, before an applicants can be registered with the Society, they must have appropriate qualifications, training and experience and be fit to practise, which means the applicant is in good health and of good character. Applicants for registration in the Register of Pharmacists are required to specify the part of the register in which registration is sought, provide proof of identity and address, declare an intention to adhere to the standards and understand that if found to have given false or misleading information in connection with the application the applicant may be removed from the register. A registration fee is payable. Persons who have qualified within Great Britain are required to have the application form countersigned and dated by a pharmacist who is registered in the practising part of the register and who is in good standing with the Society.

2.3.4.2 Registration with the RPSGB for nationals from EEA and Switzerland

Nationals of the European Economic Area (EEA) possessing a European pharmacy qualification and who wish to apply to join the Register are required to provide similar information to British qualified applicants. This applies to those who hold a qualification in pharmacy from a Member State of the EEA which is listed in Annex V, section 5.6.2 of Directive 2005/36/EC (or if not listed is regarded as comparable to the qualification listed in the Annex) and which complies with all the Minimum Training Requirements described in Article 44 of Directive 2005/36/EC. It also applies to those who have acquired rights under Article 23 of Directive 2005/36/EC, viz. a qualification in pharmacy from a Member State of the EEA which was started before the reference date specified in the Annex for that Member State and have worked in a Member State in an activity referred to in Article 45 of Directive 2005/36/EC (which is also an activity regulated by that Member State) for at least three consecutive years during the five years preceding the award of the certificate.

Such applicants have to return: a completed, signed and dated questionnaire, proof of identity and nationality duly certified; a health declaration form completed by the applicant and also by a registered Medical Practitioner; a certified copy of the applicant’s diploma (degree certificate) and, if applicable, a certified copy of the license to practise; an application fee of £100. In addition, Evidence of Registration and Good Standing and Confirmation of compliance with the Directives must be sent to the Society directly by the issuing authority.

If an EEA applicant’s pharmacy qualification from a Member State was started before the reference date in the Directive for that Member State and the applicant has not worked for three consecutive years in the last five years as a pharmacist, or the Competent Authority in the member State has confirmed that the qualification does not comply with the minimum training requirements of Article 44 of Directive 2005/36/EC or the pharmacy qualification was obtained outside the EEA or Switzerland but it has been recognised by a Member State and the applicant has been permitted to practise as a pharmacist in that State then the application is reviewed on a case by case basis for ‘registration as a pharmacist through the non-compliant EEA route’. This procedure enables the Society to make a comparative assessment of the applicant’s pharmacy qualifications and work experience as a pharmacist against the UK national requirements for registration. The UK requirement is the UK MPharm degree, 12 months pre-registration training and the Society’s Registration Examination. (The fee for this in 2009 is £350).

European Economic Area competent authorities are listed on the site (RPSGB 2009b). Any applicant may be required by the Society to provide additional documentation to demonstrate compliance with the Directives. In all cases all documents have to be translated into English and need to be certified as correct translations. English language competence is also expected but as yet the Society cannot require proof as a condition of registration although point out that practicing in the UK without appropriate English language skills could be a breach of the code of practice. In a document entitled English Language Competency, it states:

At present the Society cannot require evidence of English language competency from EEA nationals wishing to register with the Society.

Once on the Society’s register you are bound to practise pharmacy in Great Britain in accordance with the Society’s Code of Ethics and Professional Standards and Guidance. The Code of Ethics seventh principle states at paragraph 7.1 that you must

‘Communicate and work effectively with colleagues from your own and other professions and ensure that both you and those you employ or supervise have sufficient language competence to do this’

The Professional Standards for ‘Accepting positions of Authority’ paragraph 1 states ‘You must accept work only where you have the skills and competence for the tasks to be performed. When taking on any position of authority you must: …have the necessary knowledge, skills and experience, including sufficient language competence, to undertake the role’.

Practising pharmacy in breach of the Society’s Code of Ethics or Professional Standards and Guidance Documents can result in allegations of misconduct before the Society’s Fitness to Practise committees. Where legislation permits the Society to require an English language test prior to registration, the Society, in the interests of public and patient safety requires applicants to demonstrate that they have achieved a score of at least 7 in the Academic level of the International English language testing scheme (IELTS) (RPSGB, 2009c)

2.3.4.3 Registration with RPSGB for international pharmacists

Persons who hold qualifications obtained outside the EEA, or non-EEA nationals who hold European pharmacy qualifications (other than a UK pharmacy qualification), are not entitled to apply for registration with the Society, unless they have first:

(a) completed an Overseas Pharmacists Assessment Programme (OSPAP); (b) subsequently completed preregistration training approved by the Society;

The RPSGB also states that on 15 June 2009 the UK Borders Agency (UKBA) removed the occupation of community pharmacist from the Shortage Occupation List that UKBA uses in determining whether or not to grant work permits to non-EU overseas pharmacists. The RPSGB thus advises international applicants to check the visa situation before starting the qualifying process, i.e., the one-year OSPAP and the one-year pre-registration training (and the Society's registration examination)

2.3.4.4 Registration of Northern Ireland pharmacists

Northern Ireland pharmacists have a separate register and society, the Pharmaceutical Society of Northern Ireland. To register with the RPBGB, Northern Ireland registered pharmacists must get the Pharmaceutical Society of Northern Ireland to send a letter confirming the applicant’s registration and good standing directly to the International Registration department of the Royal Pharmaceutical Society.

In other respects the process of registration with the Pharmaceutical Society of Northern Ireland is similar to that of the Royal Pharmaceutical Society of Great Britain.

2.3.5 Opticians: General Optical Council

The purpose of the General Optical Council (GOC) is to protect the public and promote good eye care. They do that by:

 setting standards for optical education and training, performance and conduct;

 approving qualifications leading to registration;  maintaining registers of individuals who are qualified and fit to practise, train or carry on business as optometrists (including student optometrists), dispensing opticians, specialty practitioners as well as a register of optical businesses;

 investigating and acting where a registrant’s fitness to practise, train, or carry on business is impaired.

All fully-qualified optometrists and dispensing opticians in the UK must be registered with the General Optical Council. It is illegal to practise whilst not registered. The registers are publicly available to search online, or can be viewed at the Council offices.

Before joining the registers, all optometrists and dispensing opticians, including students, are required to have completed, or currently be studying for, a Council-approved training course. They must meet certain standards of education and performance, and comply with the code of conduct for individual registrants. Registrants have to provide a health declaration, and details of any criminal convictions, cautions or investigations, or disciplinary proceedings that have been taken against them or are currently pending. Full registrants must also hold professional indemnity insurance. All registrants with the General Optical Council have to maintain up-to-date skills and knowledge, via a statutory required mandatory continuing education and training (CET) scheme. All full registrants must earn a minimum number of CET points by the end of each three-year cycle to stay on the registers.

2.3.5.1 Registration with the GOC for those with UK qualifications

Registration involves completing an application form for registration, paying the registration fee, currently £219, renewing it annually by 15 March each year, keeping contact addresses up to date, ensure that the applicant has sufficient professional indemnity insurance and has completed the minimum amount of Continuing Education and Training. The application form requires indication of the appropriate training at GOC-approved courses.

2.3.5.2 Registration with the GOC for nationals from the EEA

The procedure for applicants who obtained their qualification in the EEA is to apply for mutual recognition of their optical qualifications by completing an EU registration form. The process is similar to that for UK-trained applicants except that the overseas qualifications sub-committee of the Council’s Education Committee will then decide whether the education and training is equivalent to that of a UK-trained dispensing optician or optometrist.

2.3.5.3 Registration with GOC for international applicants

Applicants from outside the European Economic Area (EEA) have to complete an initial assessment examination. If this suggests that the applicant has insufficient knowledge or experience to practise in the UK, the applicant is required to undergo further training for up to one year. This is called an ‘adaptation period’. If completed successfully, the applicant may then be eligible to join the registers and practise in the UK. The Council, however, currently indicates on its website (GOC, 2009) that:

If you gained your optometry qualification outside the European Economic Area (EEA):

 We no longer deal with applications from outside the EU/EEA. Applicants should contact…the College of Optometrists for further information.

If you are a qualified dispensing optician and gained your qualification outside the EEA:

 Contact the Association of British Dispensing Opticians (ABDO) for guidance on whether you are eligible to practise in the UK.

2.3.6 Osteopaths: General Osteopathic Council

The General Osteopathic Council (GOsC), established by the Osteopaths Act 1993, regulates the practice of osteopathy in the United Kingdom. By law, osteopaths must be registered with the GOsC in order to practise in the UK. The General Osteopathic Council:

 sets and maintains standards of osteopathic practice and conduct, which are set out in its Standard of Proficiency that practising osteopaths are required to meet. These include knowledge of the safe and competent practice of osteopathy, professional ethics and after- care evaluation. A revised version (November 2008) was subject to a consultancy process, that closed 12 July 2009;

 maintains a Register of qualified professionals who are permitted to practise osteopathy in the UK. The title ‘osteopath’ is protected by law, and unregistered practice is a criminal offence. Every year, osteopaths are required to renew their licence to practise. As part of this process the GOsC checks that they have current professional indemnity insurance, remain in good health and of good character, and have met the mandatory requirements of 30 hours of continuing professional development;

 assures the quality of osteopathic education and training (see 4.6 below);  removes from the Register anyone who is unfit to practise

 works with the public and osteopathic profession to promote patient safety and helps patients with complaints about an osteopath Part of the fitness to practise guidance is a strict Code of Practice, which came into effect in May 2005 and is updated regularly to reflect changes in healthcare standards and regulation. The code covers a wide range of areas including the osteopath’s duty of care, relationships with patients, obtaining consent, examining patients and patients’ rights. Failure to comply with the code may result in fitness to practise proceedings being brought against an osteopath.

GOsC is currently developing a scheme for revalidation, to be introduced in 2009–11, which will be linked to the renewal of registration process.

2.3.6.1 Registration with GOsC for UK qualified applicants

For applicants with a qualification in osteopathy from, currently, any of the ten UK-based GOsC- accredited courses, the process is straight forward, requires completing a registration form, a health reference form, providing proof of qualification, a character reference, and obtaining professional indemnity insurance that meets the professional indemnity insurance rules, with a minimum cover of £2.5 million. In addition a Criminal Records Bureau or other police check is required as well as the registration fee (£375 in the first year, £500 in the second year and £750 per year in subsequent years).

2.3.6.2 Registration with GOsC for non-UK qualified applicants

Applicants who qualified as an osteopath outside the UK are subject to GOsC vetting to ensure that the qualification is equivalent to UK qualifications. Applicants have to provide evidence of nationality, details of the course undertaken and qualifications, a detailed history as a practising osteopath and evidence of professional indemnity insurance.

The assessment process used by the Council depends on the applicant’s nationality and the type of services the applicant intends to provide. In some cases applicants are asked to undergo a practical assessment of their skills.

As with all graduates, a UK criminal records check is required but if applicants have lived outside the UK before applying for registration, they also have to provide an additional police check in respect of the country where they were resident.

The Border and Immigration Authority (BIA) requires all osteopathic training institutions that are not publicly funded universities to register with the BIA in order to accept non-UK students. This is subject to a fee and provision of documentation that proves that the institution has been reviewed and validated by one of a number of named public bodies, including the QAA. The Council is lobbying to have this requirement removed.

2.3.7 Chiropractors: General Chiropractic Council

The General Chiropractic Council (GCC) is the body established by the Chiropractors Act 1994 to regulate and develop the chiropractic profession. The three main duties of the GCC are:

 To protect the public by establishing and operating a scheme of statutory regulation for chiropractors, similar to the arrangements that cover other health professionals

 To set the standards of chiropractic education, conduct and practice  To ensure the development of the profession of chiropractic, using a model of continuous improvement in practice.

Since 14 June 2001 the title of 'chiropractor' has been protected by law and it is a criminal offence for people to describe themselves as any sort of chiropractor without being registered with the GCC. The Council has a Standard of Proficiency for the Competent and Safe Practice of Chiropractic and a Code of Practice by which practitioners must abide.

The Professional Conduct Committee of the GCC has the power to:

 admonish the chiropractor

 impose a 'conditions of practice' order

 suspend the chiropractor's registration, or  remove the chiropractor from the Register

The GCC, Chiropractic Professional Associations and the College of Chiropractors have agreed a joint statement explaining the roles of each organisation (GCC 2009a).

2.3.7.1 Registration with GOC for UK qualified applicants

Those who hold a British qualification recognised by the GCC complete the registration form, which also requires satisfying the Registrar that they are of good character and physically and mentally fit (medical report, character reference), as well as proof of qualification and date. The initial Registration fee is £1,250 or £100 for non-practising status. Thereafter, there is an annual Retention of Registration fee of £1,000 or £100 non-practising.

2.3.7.2 Registration with GOC for applicants with an EU qualification

Applicants with a qualification from an EU country and who meet the requirements of Directive 2005/36/EC of the European Parliament and of the Council of 7 September 2005 on the recognition of professional qualifications can register in a similar manner to that of applicants with a British qualification.

2.3.7.3 Registration with GOC for applicants with a qualification from outside the EC

Foreign-qualified applicants who hold an equivalent qualification are also required to pass a test of competence prior to registration (GCC, 2009b). The fee for the test of competence is £1,500. The test is conducted at the University of Glamorgan. The test assesses:

 technical knowledge of chiropractic skills and procedures;

 ability to apply technical knowledge appropriately;

 ability to make appropriate clinical decisions;  knowledge and application of professional ethics and jurisprudence;

 ability to communicate clearly, concisely and appropriately.

2.3.8 Other health professionals: Health Professions Council

The Health Professions Council (HPC) regulates 14 health professions: arts therapist, biomedical scientists, chiropodists/podiatrists, clinical scientists, dietitians, occupational therapists, operating department practitioners, orthoptists, paramedics, physiotherapists, practitioner psychologists, prosthetists/orthotists, radiographers, speech and language therapists. Many of these were formerly part of the Council for Professions Supplementary to Medicine (CPSM), which was replaced by the Health Professions Council on 1 April 2002.

2.3.8.1 Registration with HPC for UK qualified applicants

UK graduates who have graduated from an approved course (in each area) can register by completing an application. Completing an approved course shows that the graduate meets the Council’s professional standards and is eligible to apply for registration. It does not guarantee a graduate will become registered. Additional evidence required include documentation to prove they are whom they say they are; they meet the standards; and the council can contact them if needed.

2.3.8.2 Registration with HPC for nationals from EEA and Switzerland

In accordance with The European Communities (Recognition of Professional Qualifications) Regulations 2007 (EC, 2007), EAA-trained practitioners can apply for Temporary Registration if they wish to provide professional services in the UK on a temporary and occasional basis. Initial registration will be one year in duration and may be renewed annually. The applicant for registration needs to complete a declaration form. This requires provision of details of relevant qualification, experience and registration in other member states, as well as personal indemnity insurance. Documentation required is proof of nationality, attestation(s) of legal establishment, evidence of professional qualifications, proof of two-year professional experience and evidence of no criminal convictions.

There is a separate register of visiting European health professionals that provides details of visiting European health professionals temporarily registered in the UK according to directive 2005/36/EC (HPC, 2009a)

2.3.8.3 Registration with HPC for international health professionals

Health professionals trained outside the EEA can register with the HPC following an application process and scrutiny by the HPC, for which they currently charge £420 as well as the annual membership fee (those with refugee status are exempt from paying the scrutiny fee). Processing of completed applications normally takes 4–6 weeks. The web site explains that: Each profession at the HPC has its own specific criteria for assessment, which are set out in the profession specific elements of the standards of proficiency. The overarching framework applies to all professions and an applicant must satisfy the Registration Assessor in their application how they meet the benchmark Standards of proficiency. This

can be demonstrated through a combination of education, training and experience gained in practise of the profession for which they are seeking registration. Please note that although UK NARIC can be used to determine the academic level of a candidate’s qualifications, it does not relate to content of training courses. Thus a degree in a profession in one country may be of a similar academic level, whilst the subject matter is quite different. Applicants are strongly advised to give as much detail in their application as possible and get their university/college to complete the course information form. Applications should include proof of identity as well as proof of qualifications and experience. Refugees also have to provide a Home Office letter confirming refugee status or leave to remain in the UK (HPC, 2009c). Documents need to be translated into English either by a professional agency or have the translation attested to by a solicitor.

In addition to qualification there is an English proficiency requirement. If English is the applicant’s first language then they are exempt from a requirement to demonstrate English language abilities. If it is not, applicants must sit an English proficiency test and they suggest the International English Language Testing System (IELTS) that can be taken in 180 centres in 110 countries. The English language proficiency tests that the HPC accept are shown in Table 12 (Annex).

2.4 Health professional education

Education of health professionals primarily takes place in British universities (with some exceptions, specifically paramedic training in ambulance centres). All education of health professionals has to comply with the specified standards of the different health professions.

Some regulatory councils control their respective areas of education as part of their legal regulatory remit: as in the case of the General Medical Council. Other regulatory councils in effect accredit courses, known as approving courses, as providing graduates with the appropriate standards of knowledge and competence required by the profession.

2.4.1 Doctors

The General Medical Council (GMC) began to take responsibility for medical education as a result of provision in the Medical Act of 1886. Applicants for registration had to pass a qualifying examination and it became the GMC’s responsibility to oversee the standard of the institutions and the examinations they offered. The GMC’s current responsibilities are an extension of those established in 1886. Its current responsibilities for medical education are set out in the Medical Act 1983, which it fulfils via a statutory Education Committee. The statutory duties of the GMC include:

 determining the extent of the knowledge and skill required for the granting of primary medical degrees in the UK;

 ensuring that the universities provide medical undergraduates with the teaching and learning opportunities necessary to acquire that knowledge and skill;

 determining the standard of proficiency required of the graduating medical student;

 ensuring that the examining bodies maintain this standard at qualifying examinations/assessments;

 determining the patterns of experience that must be undertaken by trainees during the Pre- Registration House Officers (PRHO) year [internship year];

 specifying the form of the certificate to be completed by universities confirming that the required experience has been gained by trainees during the PRHO year.

According to the Act, ‘The Education Committee shall have the general function of promoting high standards of medical education and co-ordinating all stages of medical education.’ The Committee has specific responsibilities for undergraduate medical education delivered in the medical schools and for the first year of practice after graduation (the ‘PRHO year’). The GMC sets the outcomes that students and PRHOs must achieve and it quality assures the medical schools and the providers of PRHO training to ensure the outcomes are achieved. As such, the Education Committee of the GMC has ‘the power to visit universities to make sure that undergraduate teaching is appropriate and to inspect examinations to make sure that the standards expected at qualifying examinations are maintained and improved’ (GMC, 2005a). The GMC, on the basis of the work of the Education Committee, is statutorily obliged to make recommendations to the Privy Council about whether a university should be added to or removed from the list of institutions that can award a registerable UK medical degree (Sections 8 and 9 of the Act). In essence, the GMC not only accredits but controls medical education in the UK. If a school is not accredited, the qualification is effectively useless in the UK. There are 33 GMC recognised medical schools in the UK (including partnership ventures):

Brighton Sussex Medical School

Cardiff University (merged with University of Wales College of Medicine, 2004)

Guy's, King's and St Thomas' School of Medicine, London

Hull York Medical School (HYMS)

Imperial College School of Medicine, London Keele University -School of medicine

London School of Hygiene & Tropical Medicine

Peninsula Medical School Queen's University of Belfast

Royal Free University Medical School, London

St. Andrews University

St. Bartholomew's and Royal London School of Medicine & Dentistry

St. George's Hospital Medical School London

Swansea University University College London Department of Medicine

University of Aberdeen

University of Birmingham

University of Bristol University of Cambridge

University of Dundee Faculty of Medicine, Dentistry, & Nursing

University of East Anglia University of Edinburgh

University of Glasgow

University of Leeds University of Leicester

University of Liverpool

University of Manchester Faculty of Medicine, Dentistry, & Nursing University of Newcastle and Durham University (partnership)

University of Nottingham

University of Oxford University of Sheffield

University of Southampton

University of Warwick The establishment of new medical schools in the UK, which is a rare occurrence, requires the approval of the Privy Council. This will only be granted on receipt of a petition from the GMC, something it has, until recently, not done for decades. Since 2001 four new medical schools have been established in the UK, this on top of the establishment of a faculty of medicine at University of Warwick in 2000. This is part of the process of increasing the output of doctors and reducing the immigration of medics to the UK. The new medical schools are Brighton Sussex Medical School, Hull York Medical School, Peninsula Medical School (Exeter and Plymouth) and University of East Anglia Medical School. Taking this forward the GMC are required to make sure that the graduates from these medical schools can demonstrate the requirements set out in Tomorrow’s Doctors. To do this they are working with the four medical schools in a process that is similar to, but more intensive than, that proposed for the quality assurance of existing medical schools (GMC, 2007).

2.4.1.1 Tomorrow’s Doctors

The GMC sets standards to describe the knowledge, skills and attitudes that new doctors should have. The GMC is also required to ensure that these standards are met before registering people as doctors. The latest standards are set out in Tomorrow’s Doctors, first published by the GMC Education Committee in December 1993, revised in 2002 (with a publication date of 2003) and further revised in 2006. The guidance advocated the development of a curriculum comprising a core component and special study modules.

The main areas covered by Tomorrow’s Doctors are:

 curricular outcomes: the principles of professional practice, outcomes;  curricular content, structure: the scientific basis of practice, treatment, clinical and practical skills, communication skills, working environment, medico-legal and ethical issues, disability and rehabilitation, the health of the public, the individual in society;

 delivering the curriculum: supervisory structures, teaching and learning, learning resources and facilities, student selection, student support, guidance and feedback;

 assessing student performance and competence, principles of assessment, assessment procedures, appraisal, student progress;

 student health and conduct: confidentiality for medical students, the responsibility of medical students to protect patients, the responsibility of other doctors to protect patients, the responsibility of universities to protect patients;

 putting the recommendations into practice: what the law says about undergraduate education, UK law and European Union law. However, despite prescriptive content, the GMC does not prescribe educational approaches to pedagogy. Institutions can adopt, for example, a problem-based approach or a more traditional didactic approach to delivery, or anything in between, subject to quality controls. The GMC considers the diversity of approaches to delivering undergraduate medical education in the UK to be one of the reasons why it is held in such high regard abroad. Having said that, there appears to be a growing pressure towards more student-centred pedagogy.

2.4.1.2 Quality assurance process

Traditionally, the GMC adopted an inspectorial approach to checking standards. However, the GMC is moving away from inspectorial approaches to accrediting courses to quality assurance approaches with more emphasis on a process of continual engagement and continuous improvement. The quality assurance process is being reformed following two rounds of informal visits (the first 1995–1998 and the second, 1998–2001) to all established medical schools. The new quality assurance process asks each medical school how they are meeting the standards set out in Tomorrow’s Doctors. Furthermore, medical education is also subject to evaluation by the Quality Assurance Agency for Higher Education (QAA). The new quality approach is not overly concerned with defining quality or even quality assurance. The key role of the process is not to judge academic excellence per se but to ensure appropriate levels of competence of graduating doctors. To that end it requires compliance on several fronts; notably curriculum content, supervision, practical experience and vigilance in ensuring only appropriate students reach the stage where they may achieve registration. This is not so much about fitness for purpose, as the institutions and the programmes of study are not in a position to determine their own mission-related purpose. It is more about quality as transformation— transformation to competent reflective practitioners. It is also about ensuring that medical education in the UK maintains its excellent status around the world.

2.4.2 Nurses and midwives

As noted above nursing and midwifery is regulated in the UK by the Nursing and Midwifery Council (NMC) and successful completion of nursing and midwifery programmes leads to an academic award and registration on the relevant part of the UK NMC register. Programmes are offered in many of the higher education institutions across the UK in partnership with local clinically-based service providers. Nurse education in the UK is not restricted to institutions with medical schools. Indeed UCAS (2009) lists almost 500 nursing courses for 2010 start located in 74 higher education institutions (excluding animal/veterinary nursing). Nursing and midwifery students undertake programmes of study that integrate theory and evidence-based practice in the classroom and clinical setting. Programmes are 50 per cent theory and 50 per cent practical and delivered in equal parts within higher education institutions and clinical settings, for example in the client or patient’s home, in hospitals, clinics, in schools and in the workplace.

The programmes of study for nursing and midwifery reflect the future clinical roles and responsibilities of the newly qualified health professional and programmes are specifically designed to meet the requirements of the government health departments as well as the needs of local communities Nursing offers the opportunity to train as an adult nurse, children’s nurse, mental health nurse or learning disability nurse.

Nursing programmes are required to be at least three years full-time or the equivalent part-time and are offered at diploma and degree level in England but degree only in the other countries of the UK. There are also opportunities to undertake training at postgraduate level at some higher education institutions. Minimum age of entry to the programmes is 17, with at least 11 years of general education plus specified grades in particular subjects. There are also access courses, particularly aimed at mature returners to higher education. Applicants need to be resident in the UK for at least three years to be eligible to apply for a place on a diploma or degree course. Some higher education institutions now offer opportunities to have previous learning assessed through the accreditation of prior (experiential) learning process, which could lead to the three- year programme being completed in a shorter period. This might apply to graduates, particularly those who have degrees in psychology, life sciences or biology, or to others with appropriate experience.

The three-year full-time BA programmes comprise a one-year Common Foundation Programme and a two-year branch (adult, child, mental health or learning disability) programme. The Common Foundation Programme provides the foundation knowledge that underpins nursing practice and clinical skills necessary for clinical practice. The two-year branch programme builds and further develops knowledge, understanding and skills specific to the roles of the adult, child, mental health and learning disability nurse.

There are some limited opportunities to complete a combined learning disability nurse and social work programme leading to a joint award and qualification. This area of practice requires a very co-ordinated, multi-professional approach. The dual qualification of registered social worker and registered nurse facilitates a more holistic approach to the provision of social and care interventions to clients and their families (British Council, 2008).

Midwifery programmes are delivered over three years and are offered at degree or diploma level in England, and degree level in Northern Ireland, Scotland and Wales. If registered with the NMC as a level 1 nurse (adult) then the programme is a minimum of 18 months. Midwifery education includes the theory and practical skills required to care for pregnant women, delivering babies, educating and supporting parents. The social, political and cultural issues affecting maternity care are also covered.

Many universities offer Masters and PhDs in nursing/healthcare. Some universities offer a taught doctorate with a professional orientation. The Quality Assurance Agency for Higher Education (QAA) is undertaking a major review of healthcare programmes in England as part of a contract with Skills for Health, in partnership with the Department for Health (DH), Nursing and Midwifery Council (NMC), the Health Professions Council (HPC) and the Strategic Health Authorities (SHAs). This does not include areas controlled by the GMC. This review process, known as Major Review, is part of the Partnership Quality Assurance Framework (PQAF) for Healthcare Education. The PQAF consists of five elements: programme approval; ongoing quality monitoring and enhancement; major review; benchmark and quality standards; the shared evidence on which conclusions and judgements are based (QAA, 2009). The Nursing and Midwifery Council, in its ongoing quality monitoring, works closely with partner organisations to provide quality assurance of nursing and midwifery education in the UK. The approach is inspectorial, similar to that undertaken by Ofsted in schools. The actual work is undertaken by a third party on behalf of the NMC. In England, Scotland and Northern Ireland this work is done by HLSP and in Wales by Healthcare Inspectorate Wales (HIW).

HLSP is a member of the Mott MacDonald Group, a world-wide consultancy firm with specialists in education, water, sanitation, infrastructure and the environment. It was established in 1985 and works closely with its sister company, Cambridge Education, applying the latter’s established systems and processes, developed as one of the five providers of Ofsted school inspections, to the healthcare sector.

As the delivery of healthcare and professional training become increasingly delegated, the need for robust and impartial regulation and inspection becomes more important. HLSP has been appointed by the Nursing and Midwifery Council to ensure that nursing and midwifery education meets a consistently high standard across England, Scotland and Northern Ireland. They have been tasked with delivering a new Quality Assurance framework in England. The new Framework has been developed with a range of stakeholders to provide a risk-based approach to monitoring the standards of delivery of NMC-approved programmes

The level of monitoring activity will be targeted and proportionate to levels of risk. This could mean a reduced level of involvement with programme providers that are exceeding the standards required by the NMC. The Framework for QA Monitoring 2008–09 (NMC, 2008) is a list of providers with different levels of risk control (based on the inspections). The three levels are programme providers with:

 acceptable risk control

 well developed risk control  weaker levels of risk control

In the case of the latter:

The NMC will spend more time during monitoring visits with programme providers in this group. This will allow reviewers more opportunity to engage with practice elements of the programme. If reviewers remain concerned about the level of risk control operated by these providers they have the option of a return visit (NMC, 2008). The HIW quality handbook (HIW, 2008) for Programme Approval and Programme Monitoring sets out how the NMC UK-wide QA Framework will be applied in Wales. It also shows how quality assurance events relate to the NMC Professional Standards and Proficiencies and the key risks identified by the NMC.

2.4.3 Dentists

All UK courses leading to registration as a dental professional must be approved by the General Dental Council (GDC).

The five-year full-time honours course in dentistry (BDS) is offered at 14 universities in the UK (British Council, 2008): Cardiff University

King’s College London (University of London)

Newcastle University Peninsula Dental School (open from 2007)

Queen Mary, University of London

Queen’s University Belfast

University of Birmingham

University of Bristol

University of Dundee University of Glasgow

University of Leeds

University of Liverpool (including four-year graduate entry programme in collaboration with the University of Central Lancashire)

University of Manchester

University of Sheffield.

The five-year dentistry degree course includes clinical practical training with patients as well as academic content. Some dental schools offer a ‘pre-dental’ year for students with high grades at A-level but lacking relevant science subjects. Applicants with a degree can be considered for entry on to five-year standard degree courses. They will normally need to hold an upper-second class degree and must usually also have A-level grades close to an institution’s standard requirements. There are also a few four-year accelerated degrees for graduates who hold a

degree (at least at upper-second class level) with a large element of biology and chemistry. Graduates with a degree in biomedical science may also be considered (British Council, 2008). In addition to dentistry, programmes in dental therapy and dental hygiene are available and all are listed on the General Dental Council website. The different dental occupations are:

 Dentist: prevent, identify and treat gum disease and tooth decay; design and fit dentures and plates; take corrective measures for teeth growing abnormally; perform mouth surgery.

 Dental hygienist: clean, polish and scale teeth; give preventative advice; prepare patients for oral operations; educate children and adults in dental care.

 Dental nurse: provide direct clinical assistance to dentist at the chair-side; handle all aspects of dental practice administration, from clerical tasks including patients’ records, reception and keeping the books to care of dental instruments, preparation of fillings and processing X-rays.

 Dental technician and clinical dental technicians: design and fabricate crowns, dentures, metal plates, bridges, orthodontic braces and other appliances prescribed by dentists, using a wide variety of materials and equipment.

 Dental therapist: assist dentists by carrying out simple forms of treatment, such as fillings and taking out first teeth; give guidance on general dental care.

 Orthodontic therapist: Assist dentists by carrying out simple forms of orthodontic treatment, such as taking impressions and adjusting orthodontic braces, and supporting dental work relating to teeth, jaws and face; give guidance on general dental care. (British Council. 2008)

The Council has set out the standards they expect dental professionals to have reached at the end of their education and training: The First Five Years (GDC, 2008) for dentists and Developing the Dental Team for other dentistry qualifications.

New and approved courses, for both dentists and DCPs, are regularly quality assured through an annual monitoring exercise and inspections. The Council provide detailed guidance to course providers. Reports on the findings of the inspectors are published.

The GDC has also recently carried out a review of what its role should be in future in relation to the education of dentists and DCPs. The review was carried out by an Education Strategic Review Group, which reported to the GDC’s Education Committee on 24 April 2008. The Education Committee endorsed the findings of the review and an implementation plan was targeted for February 2009. Furthermore, the learning outcomes for qualifications leading to registration with the GDC have been reviewed.

Back at the turn of the century, the QAA undertook a review of dentistry between 1998 and 2000 and concluded that: “The reviewers find the overall quality of higher education provision in dentistry in England and Northern Ireland to be excellent. All 12 providers visited are Quality Approved” (QAA, 2000, p. 2).

2.4.4 Pharmacists and pharmacist technicians

Pharmacy is a healthcare profession requiring a high level of education and training, principally a four-year Mpharm degree. The Mpharm degree is offered by UK universities. The following universities have fully-accredited Mpharms and accreditation reports are available on line.

Aston University [Birmingham]

Bradford University Cardiff University

De Montfort University [Leicester]

King’s College, University of London Kingston University [Greater London] Liverpool John Moores University

Medway School of Pharmacy, the Universities of Greenwich and Kent http://www.rpsgb.org.uk/pdfs/edmedwaysumrep.pdf Queen’s University, Belfast http://www.rpsgb.org.uk/pdfs/edqueensunibelfastsumrep.pdf

School of Pharmacy, University of London

Sunderland University http://www.rpsgb.org.uk/pdfs/edsunderlandsumrep.pdf The Robert Gordon University [Aberdeen] http://www.rpsgb.org.uk/pdfs/edrobertgordonsumrep.pdf

University of Bath University of Brighton

University of East Anglia [Norwich]

University of Hertfordshire [Hatfield] University of Manchester http://www.rpsgb.org.uk/pdfs/edmanchestersumrep.pdf

University of Nottingham [Malaysia] http://www.rpsgb.org.uk/pdfs/ednottinghammalaysiasumrep.pdf University of Nottingham [Nottingham] http://www.rpsgb.org.uk/pdfs/ednottinghamsumrep.pdf

University of Portsmouth http://www.rpsgb.org.uk/pdfs/edportsmouthsumrep.pdf University of Reading http://www.rpsgb.org.uk/pdfs/edreadingsumrep.pdf

University of Strathclyde [Glasgow] http://www.rpsgb.org.uk/pdfs/edstrathclydesumrep.pdf

The following universities are provisionally accredited. This means that they are new MPharm providers who are admitting students but have not yet graduated any students:

Keele University [Stoke on Trent/Newcastle under Lyme, Staffordshire]

Sunderland University & SEGI [Kuala Lumpur, Malaysia]

University of Central Lancashire [Preston]

University of Huddersfield

University of Strathclyde and the International Medical University [Kuala Lumpur, Malaysia]

University of Ulster

Wolverhampton University

Having achieved an Mpharm, new entrants to the profession enter pre-registration training for one year and pass the Royal Pharmaceutical Society’s registration examination, which is offered twice a year. Only then can a candidate apply to register as a pharmacist.

Quality assurance is by way of accreditation. Accreditation teams comprise of a team leader, academic pharmacy experts, sectoral pharmacy experts and a lay member. Teams are supported by staff from the Society’s education and registration directorate and a rapporteur, who writes the report of an accreditation event.

The Society’s accreditation teams use two documents to judge whether a provider should be accredited or not: accreditation criteria and an indicative syllabus. All criteria must be met (subject to conditions and recommendations) for accreditation to be granted. A provider can be placed on probation if criteria are not met. Ultimately, if that position persists, the Society’s Council can withdraw accreditation.

It takes at least seven years to graduate a cohort of MPharm students and gain full accreditation: before that, providers are either not accredited or provisionally accredited. The process to full accreditation is a follows:

 Step 1 [students minus 3 years]: Initial presentation from university  Step 2 [students minus 2 years]: Consideration of business plan

 Step 3 [student minus 1 year]: Consideration of MPharm in detail. Passing step 3 allows a university to admit students the following year

 Step 4 [first student intake]: Consideration of year 1 of delivery

 Step 5 [second student intake]: Consideration of years 1 & 2 of delivery

 Step 6 [third student intake]: Consideration of years 1-3 of delivery  Step 7 [fourth student intake]: Consideration of all 4 years and ongoing full accreditation

Once a provider has graduated a cohort of students, they are reaccredited periodically. The full and usual period of full accreditation is five years. However, accreditation can be for a lesser period, if there is a good reason for not granting a full period. (RPSGB, 2009d)

If the Society becomes aware of an issue that may affect the accreditation status of an MPharm, it reserves the right to investigate in the public interest. If a concern is found by the Society’s education committee, a provider can be placed on probation.

The Royal Pharmaceutical Society is undertaking a review of pharmacy education policy, including: setting policy for post registration education and revalidation and reviewing education standards and quality assurance systems. This is being developed in partnership with key stakeholders. The development of a pharmacy practice framework is intended to clarify key aspects of the profession's work, both for the public and for members of the profession and their employers.

2.4.5 Opticians

The General Optical Council (GOC) assesses and approves the quality and content of education provided for those training to practise optometry and dispensing optics in the UK. The Council:

 sets criteria for all higher education courses and qualifications in optics that lead to full registration with the GOC;

 approves courses and qualifications that meet these standards;

 undertakes quality-assurance visits to check that education and examination bodies are maintaining and improving standards (GOC, 2009).

The GOC has approved the undergraduate optometry degree at eight UK universities: Anglia Ruskin; Aston; Bradford; Cardiff; City (London); Glasgow Caledonian; Manchester; Ulster. In addition, the Institute of Optometry offers training in part of the programme for optometrists

Optometry degrees are usually four years in total (Scotland five years). The course consists of a full-time three-year (in Scotland four-year) degree course followed by a salaried pre-registration training with a practice under the guidance of a GOC-registered optometrist. A series of assessments are included throughout the placement. Two examining bodies offer examinations leading to qualifications enabling registration with the GOC: the College of Optometrists and the University of Manchester.

The GOC approves training courses in dispensing optics at six institutions: Anglia Ruskin University; Association of British Dispensing Opticians (ABDO) DLI College; Bradford College; City University; City and Islington College; Glasgow Caledonian University

There are several routes to the dispensing optician qualification, all of which are assessed by examinations and assessed work via ABDO in conjunction with the training establishments. Qualified dispensing opticians may undertake a career progression course at the University of Bradford enabling them to graduate with a degree in optometry in approximately 12 months.

To gain a qualification in optometry, dispensing optics, contact lenses or therapeutic prescribing, trainees have to demonstrate that they are proficient in the associated core competencies. The GOC specifies core curricula for optometry and for dispensing optics that embodies the development of these competencies. GOC periodically visits higher education training institutions and providers of assessments in optics that lead to registration with the GOC. Visits, by a panel, are to assess whether the standard of education and assessment offered gives sufficient assurance that students have achieved adequate skills and knowledge to practise safely. A report of the findings is produced, which includes recommendations for improvement. There is a Handbooks detailing how the approval process works. Once an optometrist or dispensing optician is registered with the Council, they may wish to become a specialist practitioner, which involves extra study and clinical practice. Once the specialist training is completed and their competence assessed, practitioners must register their specialty. They are then able to perform additional duties to those of a normal optometrist or dispensing optician

2.4.6 Osteopaths

Training to be an osteopath takes four years full-time or five years part-time. Training courses generally lead to a bachelor’s degree in osteopathy (BSc Hons, B.Ost or B.OstMed) or a master’s degree (M.Ost). There are also courses with accelerated pathways for doctors and physiotherapists. A degree course includes anatomy, physiology, pathology, pharmacology, nutrition and biomechanics, plus at least 1,000 hours of clinical training. There are 10 education institutions awarding qualifications recognised by the General Osteopathic Council (GosC, 2009). The Council works closely with the educational institutions where osteopaths are trained to develop best practice in osteopathic education, training and care. Osteopathy courses must be accredited as Recognised Qualification courses by the GOsC, and they are validated by UK universities. The Council has worked in collaboration with the Quality Assurance Agency for Higher Education, the British Osteopathic Association and the osteopathic educational institutions to develop the Osteopathy Benchmark Statement, which outlines the exacting standards required for osteopathic training. All recognised course providers must submit an annual report to the GosC.

Unlike other areas, much of this training is in specialist colleges rather than universities. New courses are accredited from time to time and when there are courses seeking accreditation information about them is included on the GosC website. Existing courses are:

British College of Osteopathic Medicine, London 4 yrs FT BSc (Hons) Osteopathic Medicine

4 yrs FT B.Osteopathic Medicine

The British School of Osteopathy, London 4 yrs FT M.Osteopathy/B.Osteopathy

5yrs (3 yrs PT + 2 yrs FT) M.Osteopathy/B.Osteopathy

College of Osteopaths, Borehamwood, validated by Middlesex University, 5/6 yrs PT BSc (Hons) Osteopathy

College of Osteopaths, Keele, validated by Keele University,

5 yrs PT BSc (Hons) Osteopathy European School of Osteopathy, Maidstone

4 yrs FT BSc (Hons) Osteopathy

Leeds Metropolitan University 4 yrs FT BSc (Hons) Osteopathy

London College of Osteopathic Medicine (qualified medical doctors)

13 months Member of LCOM London School of Osteopathy

5 yrs PT BSc (Hons) Osteopathy (Accelerated pathway for medical doctors and physiotherapists) Oxford Brookes University - Programme of Osteopathy

4 yrs FT B.Osteopathy (Hons) UCAS

4 yrs FT M.Osteopathy (Hons) UCAS 5 yrs FT BSc (Hons) Osteopathy (Accelerated pathway for medical doctors and physiotherapists)

Surrey Institute of Osteopathic Medicine (SIOM) at NESCOT, Epsom 4 yrs FT BSc (Hons) Osteopathic Medicine.

As part of its ongoing monitoring of standards of education, the GOsC conducts a major review of each course on a regular basis, usually every three to five years. The review is undertaken by the Quality Assurance Agency for Higher Education (QAA) on behalf of the GosC. Reports are public.

2.4.7 Chiropractors

There are only three providers of chiropractic education in the UK: the Anglo-European College of Chiropractic; the University of Glamorgan, Welsh Institute of Chiropractic ; and the McTimoney College of Chiropractic. The GCC’s criteria for the recognition of degrees in chiropractic have been agreed with the current UK providers of chiropractic education. These criteria are reviewed on a regular basis and are designed to ensure that graduates meet the requirements of the GCC’s Standard of Proficiency for the Competent and Safe Practice of Chiropractic and the Code of Practice.

When the General Council is satisfied that a degree programme meets the criteria, the final step in the process is that the Privy Council must give its formal approval for the qualifications to be recognised for the purposes of the Chiropractors Act 1994. Thereafter the education provider must provide an annual report to the Education Committee of the GCC so that it can be sure that the programme continues to meet the criteria and any conditions of recognition. If problems arise that cannot be rectified, then (subject to the approval of the Privy Council) the GCC can remove recognition. The full recognition process is repeated every five years.

Current programmes are:

Anglo-European College of Chiropractic (AECC): Master of Chiropractic (MChiro) McTimoney College of Chiropractic: BSc(Hons) Chiropractic, Master of Chiropractic (MChiro)

University of Glamorgan: BSc(Hons) Chiropractic, Master of Chiropractic (MChiro) Despite the QAA’s role in benchmarking and the development of a Health Professions Framework, it seems not to have been directly involved in any review of chiropractic programmes.

2.4.8 Other health professions

As noted above (3.8.1) the Health Professions Council (HPC) regulates 14 health professions. Education in these areas varies considerably, as is evident in Table 13 (Annex), which shows indicative approved courses and the approximate number of institutions that run them.

Some areas such as the education of prosthetist and orthoptists are taught in only a couple of institutions, whereas physiotherapists and occupational therapists are taught in over 30 institutions each. Also the level of the qualification varies: operating department practitioners require a pre-degree diploma in higher education, while Arts therapists require an MA and practitioner psychologists a doctorate in clinical psychology. It is beyond the scope of this analysis to review the quality monitoring process for all these programmes, other than to reiterate that they are subject to external scrutiny by the regulatory body and the Quality Assurance Agency.

3 Policy Framework

3.1 Immigration and emigration policies in general

Immigration policies in the UK have a bearing on recruitment of international health professionals. There has been a tightening of UK Immigration rules and, as noted above, the regulatory councils alert potential international applicants to the situation, which the applicant has to deal with outside the registration process with the appropriate regulatory body.

The UK Border Agency is responsible for securing the UK borders and controlling migration in the UK, enforcing immigration and customs regulations. They also consider applications for permission to enter or stay in the United Kingdom, citizenship and asylum. The UK has changed its immigration controls and, during 2008 and 2009, introduced a new points-based system. This system replaces most of the existing work-based categories. The process is still in transition and is rather detailed. In essence, there are various categories available to people who want to come to the United Kingdom to work (as opposed to specific job types) and immigrants have to fulfil the eligibility requirements for the category of work for which they apply. (This does not apply to EEA nationals).

For example, Tier 1 applicants include the following subgroups: highly skills workers, entrepreneurs and investors. Highly skilled workers apply under Tier 1 (General) on the points- based system. They do not need to have a specific job offer but will need to demonstrate they are highly skilled, have money to support themselves and are able to speak English.

Immigrants can apply under the highly skilled worker category now if they are:

 already in the United Kingdom with permission to stay (known as 'leave to remain') in an immigration category that allows them to switch into the highly skilled worker category;

 already in the United Kingdom as a highly skilled worker and want to extend the permission to stay within the existing category;

 already in the United Kingdom under the Highly Skilled Migrant Programme (HSMP), and want to extend the permission to stay and are eligible to switch into the highly skilled worker category;

 outside the United Kingdom and are eligible to apply for permission to enter (known as 'entry clearance') under the highly skilled worker category. (Home Office, UK Border Agency, 2009) Applicants from outside the UK, to be accepted into the highly skilled worker category under the points-based system, require to secure sufficient points (75) for attributes, viz. age, qualifications, previous earnings, and experience in the United Kingdom); as well as points (10) for English language; and points (10) for available maintenance (funds).

These requirements appear to be inflexible and thus, for example, a qualified nurse, proficient in English but without sufficient funds may not get the required UK entry clearance. However, the non-EU health professional interviewed did not suggest that UK immigration rules were a major problem for them (perhaps because they were successfully in the country) but that the language requirement was much more demanding. UK immigration rules were seen as much more of a problem for recruiters. As an Executive Director for Delivery explained. “We can only

pull from the designated list of shortage occupations, which is an interesting list because it isn’t updated that often. And, actually, for some of the occupations the numbers are so small. If you look at, say, paediatric liver surgeon, there’s only 10 paediatric liver surgeons in the country and paediatric liver surgery isn’t regarded as a ‘shortage occupation’, and there’s nobody being trained in paediatric liver surgery at the moment, so if one of our paediatric liver surgeons got knocked down and couldn’t operate we couldn’t bring anybody in from abroad, from the outside of the EU, because it’s not a shortage occupation because liver surgery is considered the same as general surgery but actually there are only 10 people in the country who can do paediatric liver surgery.”

3.2 UK policy initiatives

3.2.1 International context for UK policy

The UK policy framework is, given its major role in health professional migration, heavily influenced by international developments.

3.2.1.1 Global Forum

The Global Forum on Human Resources for Health was held in Kampala, Uganda from 2–7 March, 2008, attended by around 1500 people including ministers of health, education and finance and various experts. The first such forum called for immediate and sustained action to resolve the critical shortage of health workers around the world (WHO, 2009). The Forum endorsed the 2005 Kampala Declaration and the associated Agenda for Global Action.

The twelve-point Kampala declaration, inter alia, called on governments to act, in concert with other stakeholders, to resolve the health worker crisis through appropriate strategies, plans and policies (WHO, 2006b). It demanded ‘rigorous accreditation systems for health worker education and training, complemented by stringent regulatory frameworks developed in close cooperation with health workers and their professional organizations’.

Crucially, it acknowledged the reality of health worker migration but wanted countries to put appropriate mechanisms in place to shape the health workforce market in favour of retention: not least by requiring governments to assure adequate incentives and to enable safe working environments that would encourage retention and equitable distribution of the health workforce. Given the anticipated global health workforce shortages the Declaration called on richer countries to prioritise funding to train and recruit sufficient health personnel from within their own country: a policy that the UK had been starting to implement.

The Agenda for Global Action boldly and optimistically maintained that it: will guide the initial steps in a coordinated global, regional and national response to the worldwide shortage and maldistribution of health workers, moving towards universal access to quality health care and improved health outcomes. It is meant to unite and intensify the political will and commitments necessary for significant and effective actions

to resolve this crisis, and to align efforts of all stakeholders at all levels around solutions. (GHWA, 2008, p. 1) In essence, the Agenda provided more detail on the implementation of the Declaration, specifying six interconnected strategies:

1. Building coherent national and global leadership for health workforce solutions. 2. Ensuring capacity for an informed response based on evidence and joint learning.

3. Scaling up health worker education and training.

4. Retaining an effective, responsive and equitably distributed health workforce. 5. Managing the pressures of the international health workforce market and its impact on migration.

6. Securing additional and more productive investment in the health workforce. (GHWA, 2008, p. 1)

On the fifth point, it noted that:

Poorer countries are most affected by the loss of their already scarce health workforce to countries with better conditions and higher salaries. There are increasingly competitive, cross-border pressures in the health sector. These include the growing demand from national health systems in rich countries as well as the growing trade and private commercial investment in health services. In these circumstances, there is a need to find ways to stabilize the health workforce market and reduce the negative impacts of the high mobility of health professionals, thereby improving retention. Individuals have the right to leave any country, including their own [Article 13, Universal Declaration of Human Rights, 1948], in search of better opportunities, but health workers trained with public resources have obligations as defined by individual countries. (GHWA, 2008, p. 4) The Agenda used unequivocal language that imposed (or at least attempted to impose) actions on stakeholders. Thus, in respect to migration:

5.1. Governments will monitor health workforce flows in and out of countries, making such data transparently available and using this information to inform policy and management decisions.

5.2. The World Health Organization will accelerate negotiations for a code of practice on the international recruitment of health workers. This code should be a tool used by countries, regions and health professionals to negotiate agreements. Consistent with the agreed code of practice, destination countries should commit to supporting and enhancing the education and training of health workers both at home and in source countries. Actions should also be taken to realize the untapped potential of the health worker diasporas for improving health services in source countries. 5.3. All countries will work collectively to address current and anticipated global health workforce shortages. Richer countries will give high priority and adequate funding to train and recruit sufficient health personnel from within their own country. 5.4. National governments will be supported to develop coherent policies and build capacity to analyze the implications of trade agreements on the mobility of the health

workforce. This effort will be informed by stakeholder consultation mechanisms within and outside government. 5.5. Stakeholders will test and evaluate innovative interventions in the international health workforce market to assist retention. (GHWA, 2008, pp. 4–5)

3.2.1.2 The Millennium Development Goals and the 0.7% target

Although the concern about migration of health professionals has been raised anew and loudly, it is linked to a longer-term concern and, indeed, commitment from developed countries to less developed ones. It relates to the Millennium Declaration (2000) and the Millennium Development Goals (Millennium Project, 2006a), agreed by 189 countries, which included three goals directly related to health: reducing child mortality; improving maternal health; and combating HIV/AIDS, malaria and tuberculosis. These have become the main focus of international efforts in health.

The Millennium Development Goals themselves reconfirm a forty-year old commitment made in a United Nations General Assembly Resolution agreed in 1970, which stated, inter alia:

In recognition of the special importance of the role that can be fulfilled only by official development assistance, a major part of financial resource transfers to the developing countries should be provided in the form of official development assistance. Each economically advanced country will progressively increase its official development assistance to the developing countries and will exert its best efforts to reach a minimum net amount of 0.7 percent of its gross national product at market prices by the middle of the decade. (UN 1970, paragraph 43) The Millennium Development Goals reconfirm the need for this commitment and the UN Millennium Project’s analysis indicates that 0.7% of rich countries’ gross national income (GNI) can provide enough resources to meet the Millennium Development Goals, which, when first pledged in 1970, would not have been the case. However, sustained growth now makes that possible. Nonetheless, developed countries are still lagging behind their commitment despite constant reaffirmations of it. For example, in March 2002, at the International Conference on Financing for Development that took place in Monterrey, Mexico, world leaders reiterated their commitment in paragraph 42 of the so-called Monterrey Consensus, stating that “we urge developed countries that have not done so to make concrete efforts towards the target of 0.7 percent of gross national product (GNP) as ODA to developing countries.” (UNDESA, 2004, see also Millennium Project, 2006b). A view that was repeated at the World Summit on Sustainable Development held in Johannesburg later the same year. In 2005, the EU confirmed its commitment with all 15 original member states committed to meet the 0.7% target by 2015 and the new members 0.33% by that date.

The view expressed on the Millennium Project site (2006b) is that: If every developed country set and followed through on a timetable to reach 0.7% by 2015, the world could make dramatic progress in the fight against poverty and start on a path to achieve the Millennium Development Goals and end extreme poverty within a generation.

So far only Denmark, Sweden, Norway, The Netherlands and Luxembourg have exceeded the target and the US is the next to lowest at 0.22% (Table 14, Annex).

3.2.2 United Kingdom recent policy developments

The migration of health professionals (medics and those in related health areas) has been an expressed concern in the United Kingdom. The official line is that Britain now trains enough health professionals for its needs. This is a significant reversal of past practice and there has been some scepticism that Britain has lived up to various statements of intent concerning the migration of health professionals.

3.2.2.1 The Crisp Report

The report Global Health Partnerships: The UK contribution to health in developing countries compiled by Lord Crisp at the behest of the Prime Minister, was published on 13th February, 2007 (Crisp, 2007). The report emphasises that the scarcity of trained health workers (a worldwide shortfall of four million) and inadequate health systems are barriers to reaching the Millennium Development Goals. The report asserted the need for developing countries to take the lead and own the solutions to the crisis ‘supported by international, national and local partnerships based on mutual respect’ (Crisp, 2007, p. 2).

While the United Kingdom has shown ‘remarkable intellectual and practical leadership in international development and espoused a very clear focus on supporting country leadership and local ownership’ (Crisp, 2007, p. 2), Crisp argued that the UK could do more by, inter alia, recognising the valuable work done by UK organisations and individuals in supporting health services and promoting health in developing countries and by making it more effective by facilitating and supporting such work. This would involve ‘building strong national and local partnerships around health and making improvements more sustainable’ (Crisp, 2007, p. 2), and drawing on particular UK experience and expertise in public health and health systems, education and training and in making knowledge, evidence and best practice accessible to health workers, policy makers and the public. This is not all altruistic, as Crisp argues that in following this route the UK can ‘learn a great deal for itself about how to meet its own health needs’ (Crisp, 2007, p. 2) as well as broaden the education of health professionals in the UK and build stronger relationships across the globe ‘that will stand the UK in good stead in a changing and risky world’ (Crisp, 2007, p. 20). The latter, as will be explored below, is perhaps a response to criticisms of UK recruitment of health professionals. Crisp, though, was clear about needing to understand the cultural issues and that: “You cannot simply apply UK methods and behaviours. This is not about giving people a UK product but about a process of working together to meet a need” (Crisp, 2007, p. 4).

Crisp argued that despite the considerable involvement and investment in health in the developing world ‘progress is not fast enough, widespread enough or secure enough’ (Crisp, 2007, p. 5). Crisp highlighted much that the United Kingdom does:

The UK Government is one of the world’s leaders in international development, both as a donor—it is the largest single donor in Africa—and as an influence on international policy

and action. Its leadership within G8 on commitments on Africa and the Commission for Africa, its work with global partners such as the World Health Organization and its progressive stances on trade and climate change are well recognised internationally.

The UK has also developed its international role in health in recent years with active collaborations with a number of countries over issues as varied as health protection, health security, policy development and trade. Several of its agencies—such as the Health Protection Agency (HPA)—play important roles internationally. (Crisp, 2007, p. 5) The report added:

UK institutions have a long history of involvement in health in developing countries, stretching back into colonial times. The London School of Hygiene and Tropical Medicine was established in 1899. It contributes with many others—such as the Liverpool School, the leading universities and the Overseas Development Institute—to the UK’s excellent academic record in this area. They have been supported by the Medical Research Council, active in tackling infectious diseases for several decades, and the Wellcome Trust, a major funder of research on international health. Many major UK NGOs—Oxfam, Save the Children, the British Red Cross, Care, Christian Aid, Merlin, Plan, Action Aid, and Sightsavers, for example—play leading roles internationally. There are thousands of smaller voluntary organisations and more than 100 links between NHS organisations and their associated academic partners with organisations in developing countries. (Crisp, 2007, p. 5)

Nonetheless, despite these interventions there is an ongoing issue of short-termism of funding, of initiatives that are ‘simply misguided and ineffective and where all their gains evaporated quickly’ leading to a despairing view ‘that “despite all the effort over the years, nothing has really changed and nothing will really change”’ (Crisp, 2007, p. 5). Crisp is more optimistic, seeing, for example, ‘a renaissance in Africa—with less conflict, more stability and more growth’ (Crisp, 2007, p. 5). However, in making these valid points, Crisp does not get to the heart of the migration problem. Nor, as shown below, does the government have much to say directly on the issue in the foreword to its response to the Crisp report. Nonetheless, the Crisp report had 16 recommendations, all listed below (in abbreviated form, the full recommendations are in Appendix 1) to provide an indication of the range and balance of the perceived future policy in international health; which seen as a holistic problem, not just one of migration. The key recommendations on migration into the United Kingdom are recommendations 11 and 12. Others aim to address the issue of migration out from the United Kingdom and the facilitation of return and continued or renewed registration to practice in the United Kingdom. (Section 3, above, outlined the international registration procedures of the regulatory councils). Recommendation 13 also presents an image of the United Kingdom as taking a global perspective.

Recommendation 1: There should be greater ministerial oversight of the links between health and development by giving the inter-Ministerial group on health capacity in developing countries a stronger remit to develop joint working, and by supporting this with closer working between officials.

Recommendation 2: An NHS framework for international development should be created that sets out the principles and rationale for NHS involvement in international partnerships … Recommendation 3: A global health partnership centre should be established—preferably in an existing organisation—as a ‘one-stop-shop’ source of information for governments and health organisations alike, which would actively seek to make connections and promote and share good practice and learning. Recommendation 4: An electronic exchange should be piloted—the global health exchange, a sort of Health Bay based on the principles of eBay and Free Bay—which could be used to match requests for help with offers…. Recommendation 5: New partnership arrangements with voluntary organisations should be set up to support staff wishing to volunteer abroad for a period and then return to the NHS by: Reviewing arrangements to improve opportunities and remove disincentives ….Negotiating revised arrangements with the NHS Pensions Agency…[ensuring] continued employment or re-employment for NHS staff who volunteer … Recommendation 6: In response to humanitarian emergencies: A database should be commissioned on which health professionals with agreed competencies could register…The NHS…should assist in and coordinate the release of staff and the cover needed for them as necessary. Recommendation 7: In order to enable health workers to gain international experience and training…an NHS framework for international development should explicitly recognise the value of overseas experience and training for UK health workers and encourage educators, employers and regulators to make it easier to gain this experience and training …The Department of Health should work with the regulatory bodies and others, as appropriate, to create arrangements for revalidation and accreditation for UK professionals working abroad for long periods but planning to return to the UK. Recommendation 8: Developing countries, as part of their poverty reduction plans and/or health sector plans, should be encouraged to review…what sorts of partnerships the country needs and wants, what purposes they will serve and how they will be monitored; with what organisations they want to be linked…. Recommendation 9: To reap the maximum possible international development gains from health partnerships, the UK Government should…continue to support THET in its role in developing links between health organisations, working with wider community partnerships and spreading good practice…. Recommendation 10: DFID [Department for International Development ] should meet with representatives of the HPA, the HCC, NICE, the HSCIC, representatives of the private sector and others to review how practically they could help strengthen health systems and agree plans for doing so. Recommendation 11: The UK should support international efforts to manage migration and mitigate the effects on developing countries of the reduction in training and employment opportunities in the UK by:

 Using codes of practice, country-level agreements and other means to shape and manage the migration of health workers and encourage all other developed countries to do the same

 Continuing to provide, by agreement with developed countries, some training and limited periods of work experience in the UK

 Creating exchange programmes for training and work experience for UK and developing countries health workers. Recommendation 12: The UK should assist migrants from developing countries to contribute to health in their home country by:

 Enabling migrants from developing countries to return home—for long or short periods—through participation in partnership programmes

 Creating an NHS service scholarship programme, perhaps as part of an existing one such as the Commonwealth Scheme, specifically to support service improvement in developing countries. It would be open to candidates from developing countries— resident at home or abroad—over a five-year period while they worked on service development in their own country and developed their own experience and expertise with support from the UK and local institutions. Recommendation 13: The UK should see itself as having a responsibility as the employer of a global workforce and seize the opportunity to help developing countries educate, train and employ their own staff… Recommendation 14: The UK should give increased emphasis to the use of ICT and other new technologies in improving health and health services in developing countries … Recommendation 15: The UK should, in developing the health elements of its development research strategy, ensure a focus on the practical application of evidence, proven good practice in delivery and the systematic spread of good practice. Recommendation 16: The UK should find ways to use its particular experience and expertise to…work with the international community on ways of organising healthcare knowledge and making it accessible to practitioners and the public…. (Crisp, 2007, pp. 9– 19) Crisp (2007, p. 5) saw the report Health is Global: Proposals for a UK government-wide strategy as designed ‘to position the UK for dealing with health in a globalising and joined-up world’

3.2.2.2 Government response to the Crisp Report

Just after the Crisp report, Donaldson and Banatvala (2007) published ‘Health is global: proposals for a UK Government-wide strategy’ in The Lancet. It outlined the broad parameters of the UK Department of Health thinking about global health, listed an extensive selection of initiatives that the United Kingdom initiated or backed and raised a large number of questions about how to research and take forward the issue of global health. Amongst these questions were:

How can internationally coordinated action be best promoted at European Union and global levels to address the push and pull factors leading to migration of health staff? (Donaldson and Banatvala, 2007, p. 860)

The government response from the Department of Health and the Department for International Development, reflected some of the Donaldson and Banatvala thinking and was published in March 2008 (DH/DfID, 2008). The foreword, made much of the United Kingdom involvement in health in developing countries,

We welcome Lord Crisp’s report. This cross-government response to Lord Crisp’s recommendations identifies a number of opportunities where the UK can contribute even more effectively to building health capacity in developing countries. We believe that there are significant benefits for developing countries, and indeed the UK health economy, that come from long-term sustainable partnerships in the health sector. What Lord Crisp has to say about developing countries investing in their own peoples’ health, about the shortage of trained health workers and weak health systems resonates strongly – and needs underlining. If poor people as individuals are to benefit from the report’s analysis it is this Government’s responsibility to spell out these messages at every opportunity, in developing as well as industrialised countries. We will ensure his key recommendations are taken forward with the minimum of delay. (DH/DfID, 2008, p. 2)

The tenor of this foreword is not to critique the United Kingdom role but to strongly advocate developing countries take the matter in hand and that the United Kingdom will support this. In response to the specific recommendations that addressed the migration issue, the Response was somewhat equivocal.

On Recommendation 11, which states that the UK should support international efforts to manage migration and mitigate the effects on developing countries of the reduction in training and employment opportunities and refers to the need for codes of practice, the response states:

We have used codes of practice for several years and the UK was the first developed country to introduce a code of practice for the international recruitment of healthcare professionals. This work has highlighted the need to protect fragile health economies from inappropriate recruitment by more developed countries. (DH/DfID, 2008, p. 42) However, despite the use of codes for ‘several years’ there have been accusations of the United Kingdom violating such codes (discussed below). It is thus instructive that the response adds:

More important than codes of practice is training sufficient health workers in developed countries to ensure that recruitment from developing countries is no longer needed. (DH/DfID, 2008, p. 42)

This is an appropriate ideal that all committed to the ‘international crisis’ would doubtless support. However, one of the suggestions rather misses the point as the response states: ‘Toughening up on work permit requirements also helps’, but this suggests that the emphasis is back on migration and taking steps to curb it. Such an approach, the remainder of the sentence, though, accepts has limitations:

—but of course can have a downside in restricting genuine opportunities for training. In addition, it is crucial that we help developing countries provide the environment that

encourages their healthcare workers to stay in their own country—and, particularly, remain in the health sector. (DH/DfID, 2008, p.42) Such proclamations, of course, run up against Article 13 of the Universal Declaration of Human Rights (UN, 1994). Nonetheless the Response is bullish in claiming that health worker migration into the United Kingdom is under control: As part of the NHS Plan 2000, we have invested substantially in increased training, and the UK now trains all the healthcare professionals it needs. The need for international recruitment has all but ceased. (DH/DfID, 2008, p. 42) And yet the Response also admits that a recently-commissioned review (Buchan and McPake, 2007) of the effectiveness of the 2004 Department of Health Code of Practice (DH, 2004) (a stronger version of the original 2001 Code) ‘was inconclusive about the impact of the Code of Practice on developing countries, in large part because by the time the Code was in place, active recruitment to the NHS from overseas had significantly reduced.’ (DH/DfID, 2008, p. 43)

However, this is not to disparage Codes but, now that the United Kingdom is supposedly self- sufficient as far as health workers are concerned, rather to promote them for everyone else’s use.

Nevertheless, we do see some merit in the political signals that such codes generate. If carefully formulated, multilateral codes may help other developed countries promulgate policies that reduce their need to recruit from developing countries. We have been working, with others, on a European Union (EU) Code of Conduct. Multi-state codes of conduct, such as this and the Commonwealth Code, can, however, be a challenge, as countries have diverse health systems and differing concepts of ethical recruitment. A plethora of codes can also result in an individual country having to respond to a range of ethical recruitment policies, standards and practices. (DH/DfID, 2008, p. 43) The Commonwealth Code was not one that the United Kingdom endorsed because ‘we believed it made commitments that could not be fulfilled. Only 21 of 54 countries have signed up to it.’ (DH/DfID, 2008, p. 43, footnote 26). The Response continued by suggesting the need for a global code, which it was hoped would be an outcome of the 2008 World Health Assembly, and is an action item for the WHO.

A second aspect of recommendation 11 related to training and the encouragement to have some training and limited periods of work experience in the UK and to create exchange programmes for training. The response stated:

We are cautious about scaling up training, work experience and exchange programmes as part of our mainstream international development policy, without significant evidence of their benefits. While we recognise that UK-based training and work experience is perceived by many as desirable, it has not always been appropriate to the needs of individuals or the health delivery system of the individual’s own country. We also have concerns about its cost-effectiveness and its contribution to outward migration. In many cases, the money used on these often very expensive initiatives is better used for in- country training, including distance learning.

Entry for UK-based training in the health and development sectors is subject to UK immigration regulations, and particularly the new points-based system. Those wishing to host partnership and training schemes in the UK may be affected by new regulations for

the accreditation and registration of approved sponsors, expected to be in place by 2008. Changes introduced by the Home Office on 6 February 2008 will impose a condition on new migrants applying through the Tier 1 arrangements, prohibiting them from taking up employment as a doctor in training unless there is no suitable UK or European Economic Area (EEA) applicant. DH is consulting on whether to impose such a condition on existing migrants.

DH will continue to work with the Border and Immigration Agency, DFID, the Foreign and Commonwealth Office (FCO) and the Royal Colleges to examine options for a fair and effective system that could enable graduate doctors outside the EEA, including developing countries, to come to the UK for periods of further training. This will build on the opportunities already available through the Medical Training Initiative. In addition, on the occasions where UK-based training is needed, we will continue to provide opportunities by funding the Commonwealth Scholarship and Fellowship Plan (managed by the Commonwealth Scholarship Commission) and DelPHE. Our funding to the Medical Research Council (MRC) and to the Wellcome Trust enables these organisations to run research fellowships. It is crucial these training and capacity building initiatives clearly contribute to longer-term institutional and country plans. We will ask the Links Centre to map UK training initiatives. We are likely to evaluate the effectiveness of these training initiatives in future. (DH/DfID, 2008, pp. 43–44)

On Recommendation 12, the Response indicated that enabling migrants from developing countries to return home, for long or short periods, through participation in partnership programmes is a complex issue and that they are exploring various mechanisms. The key element here is the time limit on leaving and re-entering the United Kingdom. As to the suggestion to create an NHS service scholarship programme’ this got short shrift:

We do not agree that a new programme is required. DFID already supports the Commonwealth Scholarship and Fellowship Plan, which includes awards in the health sector. Recent evaluations of the Commonwealth scheme are positive—especially when professional development is done in country or through distance learning, and that training is relevant to country needs and is part of broader capacity building. (DH/DfID, 2008, p. 46)

On recommendation 13, that the UK should see itself as having a responsibility as the employer of a global workforce and seize the opportunity to help developing countries educate, train and employ their own staff, the Response noted:

We recognise the role that health workers from overseas have played and continue to play in the UK health service. However, this has been part of a general international trend towards greater employment mobility, which exists across many professions, and we are by no means unique in being a global employer.

However, we agree that as part of the UK-wide commitment to development (and in line with World Health Assembly Resolution WHA 57.19 on the international migration of health personnel), government and other sectors should, wherever possible, support international efforts to scale up the education, training and employment of health workers in developing countries in line with good development practice. While DFID leads on this internationally, other government departments and bodies, and non-governmental

agencies (such as academic bodies, the private sector and NGOs) can also make substantial contributions. We anticipate non-government sectors will be planning how to take forward Lord Crisp’s recommendations that are relevant to them. (DH/DfID, 2008, p. 47)

3.2.2.3 BMA response to the Crisp Report

In its evidence to the House of Lords on the economic impact of migration (discussed below) the BMA (2007) commented on the Crisp Report as follows:

According to an estimate by the World Health Organisation there is currently a global shortage of approximately 4.3 million health workers. Developing countries are among the most affected. In 2005, the BMA called for collaboration between developed and developing nations to address this crisis. In 2005 the BMA organised an international conference on the global health workforce. This resulted in a call to action on the healthcare skills drain. The government, in recognising that individuals have the right to migrate, must balance this right with the rights of home country populations to have access to healthcare professionals. We therefore welcome recommendations 11, 12 and 13 made by Lord Crisp in his report, "Global Health Partnerships: the UK contribution to health in developing countries" and we urge the Government to implement them.

3.2.3 Registrants from the EEA

The UK is faced with a different situation in relation to EEA residents. Each of the ten regulatory bodies in the UK oversees registration of health professionals from the EEA (see Section 3, above). The processes differ from those for overseas registrants because of the nature of the mobility of labour within the EU and the associated EU directives.

The UK’s ten regulatory bodies joined together, in 2002, to form the Alliance of UK Health Regulators on Europe (AURE). This was in response to the draft EU Directive entitled "Mutual Recognition of Professional Qualifications." Issued in 2002, which AURE considered posed “a new threat to patient safety” (AURE, 2002). The press release that accompanied the inauguration of AURE, stated:

Under the current proposals, healthcare professionals from any EU country would be allowed to work for up to four months per year, every year, in the UK, without being registered with a UK regulator. In practice this means that if there was a problem with the care a person received, the UK regulators would have no powers to take action against the individual. Nor would there be any means of preventing the same problem from happening again (with another patient).

The Directive also proposes to water down existing public protection safeguards. Each regulator needs to be able to assure the public that everyone coming onto its register is able to practise safely. The Alliance wants to see an effective mechanism put in place, which ensures high standards of practice in education, training and communication across the EU. The current proposals do not meet this need. (AURE, 2002)

In the event, the intense lobbying by AURE, citing the respective council’s legal obligations to protect patients, led in 2003 to the Legal Affairs Committee of the European Parliament voting in favour of amendments that require a healthcare professional to register in the host Member State prior to being granted authorisation to practice, an amendment welcomed by AURE (2003). The European Union Health Policy Forum’s (EHPF, 2003, pp. 4–8) Recommendations on Mobility of Health Professionals included the following recommendations:

 A stronger legal basis for public health should be created to better implement a high level of health protection as a key objective of the European Union in all Community policies. With this in mind, we suggest that the role of DG Health and Consumer protection as the reference point for health issues should be reinforced. Every effort should be made to ensure that DG Health and Consumer protection is closely associated with the work of other DG’s, which impacts upon a high level of health protection in the European Union from the earliest stages.

 The mobility of health professionals has an important health impact, which should be adequately addressed and evaluated, from a health perspective. It therefore appears particularly important to implement clear and transparent procedures for the recognition of professional qualifications. In particular the following should be noted:

o Short-term mobility (free provision of services) should be subject to the rules of the host Member State in order to protect patients’ interests and rights

o Collaboration between national authorities should be improved

o Efficient updating procedures should be put in place to reflect scientific progress, with the official involvement of the professions, to ensure that any update or any issue linked to education and training that requires change meets the needs of professionals and patients

o The scope of automatic recognition should be guaranteed to maintain high quality standards. The application of automatic recognition should be extended in recognition of ongoing scientific progress.

 Life-long learning, continuous formal education and continuous professional development (CPD procedures) should be used to facilitate the mobility of professionals. Networks and best practices on such life-long learning should be strengthened.

 An EU system for the collection of good quality, comparable data on the consequences of free movement of healthcare workers from the perspective of the quality of health services in the EU should be developed

 Governments should focus their strategies on the growing needs of domestic health professions

 Recruitment guidelines should be developed and action taken to exclude aggressive recruitment of health professionals

 An EU system of proof of good conduct should be created

 Sectoral social dialogue should be recognised as a valuable tool in addressing the issues about recruitment retention, the ageing workforce and the identification of skills needed

 Clear and simple rules on liability exclusively based on a non-fault system should be

established. Patients should have insurance to receive adequate compensation

 Health information should be included on the health card while guaranteeing a high level of confidentiality to ensure the best interests of the citizen.

AURE (2007) noted that the UK benefits from the high level of mobility, receiving many dedicated professionals who contribute positively to health and social care in the UK. However, mobility brings challenges as well as opportunities. Most European healthcare professionals, AURE noted, are highly competent individuals contributing to safe, good quality, healthcare across Europe. Further, healthcare in Europe benefits from health professionals being able to work and share their expertise in other European countries.

However, there will always be a small minority who seek to exploit rights of free movement in order to evade regulatory control. The European Commission and Member State regulators must work together to facilitate the free movement of the competent majority, while protecting EU citizens against the small number of professionals who may put them at risk. (AURE, 2007, p. 5) AURE (2007, para 6) considered that the “primary focus for regulators is sharing information about the professional status and competence of individuals who are registered, or who may seek registration, in other EEA Member States, or who hold simultaneous registration in several jurisdictions.” This exchange of information is, for AURE, “fundamental to the protection of patients and the public from health professionals whose competence is impaired”. They cite Article 56.2 of Directive 2005/36/EC on recognition of professional qualifications, which states: “The competent authorities of the host and home Member States shall exchange information regarding disciplinary action or criminal sanctions taken or any other serious, specific circumstances which are likely to have consequences for the pursuit of activities…” and maintain that that this obligation needs to be strengthened. For AURE, the Directive did not go far enough and experience shows that the provisions of the Directive are open to varied interpretation based on national approaches to information management and privacy laws. Some regulators are “impeded in the extent of their information exchange because of rigid national interpretations of data protection legislation. This means that patient safety considerations may sometimes be treated as secondary to personal data protection” (AURE 2007, para 11). Citing two cases of practitioners deregistered in the UK who went on to practice in other EC countries, they claimed that it is imperative for competent authorities to be able to hold, request and act on full and up-to- date information about practitioners. The diversity in regulatory approach across Europe demonstrates the need for new European legislation to provide clarity as to when regulators must put patient safety ahead of data protection considerations and share information in a collaborative, efficient and transparent way. It is also imperative that regulators have a responsibility to act on such information so as to make patient protection and public safety their paramount concern. (AURE 2007, para 15) AURE thus wanted the European Commission to explore the establishment of a legal duty upon regulators to share information with each other. A duty would ensure that patient safety is central to the free movement of health professionals in Europe. The response calls attention to differing regulatory statuses across Europe, noting that, for example, chiropractors and osteopaths are regulated in some Member States (such as the UK)

but not in others. Where a profession is not regulated it is vital, the response asserts, that regulators in a country are clear who they can approach in a non-regulated country for information about the practitioner’s education, training, professional standards and work history, and other relevant information. Similarly, there are differences in the scope of practice within the same profession from one Member State to another. “The scope of practice carried out by opticians in the UK, for example, is wider than that undertaken by opticians in a number of other EU countries. Similarly, the type of treatment provided in the UK by chiropractors or nurses can, in some countries, only be undertaken by doctors. Patients need to be made aware of where differences lie before they access healthcare in other Member States as the type of care they receive may differ from their expectations” (AURE, 2007, para 22).

In the response, AURE (2007, para 18) maintain that “At the most basic level, patients have a right to access information about the registration status and any disciplinary record of their healthcare professionals. At present some regulators are more transparent than others in making information from their registers publicly available and easily accessible.” The response points out that the councils that make up AURE have publicly accessible and searchable web-based lists of registered practitioners, which provides an easy and accessible way for the public, patients and health service contractors to check the registration status of practitioners. AURE wants all health regulators in Europe to be required to make up-to-date information about their registrants available to the public. Such information should at least cover professional indemnity, complaints mechanisms, professional standards and scope of practice. AURE wants the European Commission to support regulators and others in making this information available and accessible to the public, to patients, to other regulators and healthcare providers. In response to questions about where responsibility should lie for cross-border health care AURE (2007, para 29) noted the diverse approach to healthcare regulation across the European Union. “In some Member States regulatory functions are fragmented across different organisations or government departments, and in some they are decentralised to the regional level. In others, regulatory responsibilities are integrated within a single organisation. Where there is fragmentation or decentralisation, or both, it may be difficult for regulators to access full registration and disciplinary information quickly and accurately about individuals who are seeking registration elsewhere.” Referring to the Healthcare Professionals Healthcare Professionals: Crossing Borders Crossing Borders initiative (see below), they noted that it has already made a contribution to providing clarity on the correct source of information through two mechanisms. First, the Health Regulation website (http://www.healthregulation.org/), which is developed, managed and hosted by the UK Health Professions Council. Second, through improved networking between healthcare competent authorities in Europe. However, they insist that the European Commission still has a vital role to play in making comprehensive information available.

Despite the changes in the original draft directive, respondents still suggested that Directive 2005/36/EC is inadequate. “The EC Directive is limited; not as helpful as it could be on issues of language and training levels.” It was also pointed out by one respondent that although NHS Trusts cannot require language competency assessment from EC applicants when recruiting, they can build it into subsequent staff training. However, respondents did not think, despite some scare stories about language and patient safety, that there is any significant safety issue in relation to the recruitment of EC-trained doctors. As one respondent said, “In the end the

contracts are put in place by the NHS trusts and they need to be confident in the skills and abilities of the people they employ.”

3.2.3.1 Healthcare Professionals Crossing Borders

AURE led the Healthcare Professionals Crossing Borders initiative, which involves all healthcare regulators in the EEA, and commenced in 2005 during the UK Presidency of the EU. It actually began in 2004 as a patient safety initiative of the Dutch Presidency of the EU. In December 2004 regulators of all healthcare professions from across the EEA met in Amsterdam. They made a commitment to work together to improve registration and disciplinary information exchange between competent authorities to provide assurance that health professionals moving from one member state to another were fit and safe to practise.

The subsequent UK Presidency of the EU adopted patient safety as a key priority. Following many months of collaboration with EEA healthcare regulators, the Department of Health in England and the Alliance of UK Health Regulators on Europe (AURE) hosted the European Consensus Conference in October 2005. The initiative, informally and on a voluntary basis, established a model for proactive and reactive information sharing between regulators. AURE wanted to progress this further, as is clear from their response to the European Commission Consultation regarding Community action on health services (AURE, 2007).

AURE (2007, para 9) claimed that regulators across Europe welcomed the Healthcare Professionals Crossing Borders initiative and engaged in developing and implementing the Edinburgh Agreement of October 2005 in which healthcare competent authorities who gathered in Edinburgh during the UK’s Presidency of the EU, set out agreements to improve and extend information exchange and collaboration. The Edinburgh Agreement set out a number of actions that regulators agreed to implement by the coming into force of Directive 2005/36/EC on Recognition of Professional Qualifications, in October 2007. Proposals included developing and implementing the European Template for Certificate of Current Professional Status and exchanging registration and disciplinary information on a case-by-case or proactive basis where it is in the public interest.

Regulators also met at a series of EU-wide Crossing Borders meetings held in Brussels, Helsinki and Berlin to discuss and agree areas of further collaboration. They collaborated on a joint- statement submitted in response to the European Commission’s consultation on’ Community Action on Healthcare Services in Europe’ in January 2007. The Crossing Borders initiative was recognised and welcomed by the European Parliament in its report on Health Services, in May 2007.

Regulators from several European countries have already begun utilising the European Certificate of Current Professional Status.

This has the potential to contribute to greater consistency of registration and disciplinary information exchange between competent authorities, at the point of registration, for healthcare professions providing cross-border healthcare. It also contributes to patient safety in Europe by providing some assurance for regulators that individuals are fit, competent and safe to practise when they seek registration in another European country.

In addition, the initiative has been successful in raising awareness among all healthcare regulators of the importance of effective information exchange between regulatory authorities in the context of Directive 2005/36/EC. (AURE 2007, note to para 9)

AURE (2007, para 10) noted that Healthcare Professionals Crossing Borders is the only European level forum that brings together competent authorities from all regulated healthcare professions from across the EEA to discuss regulatory matters. It also has the potential to be a sounding board for emerging European policy on healthcare regulation.

In 2007, the Portugal Agreement replaced the Edinburgh Agreement. The new Agreement was finalised at a ‘Crossing Borders’ meeting held in Lisbon on 8th October 2007, during the 2007 Portuguese Presidency of the EU. The intention was to implement the three-part agreement by October 2009. The agreement stated: Agreement 1. Identifying Shared Principles of Regulation:

a) Competent authorities should ensure that patient safety is of over-riding importance within their model of professional regulation. b) The pursuit of safe and high quality practice by health professionals should shape the continued development of health regulation across Europe.

c) Competent authorities should identify common or shared concepts and values of healthcare regulation through a series of focused European level discussions.

d) Competent authorities should collectively consider how the five principles of good regulation —accountability, transparency, proportionality, consistency, targeting—may contribute to the effective development of healthcare regulation in Europe, through a series of European level discussions. Agreement 2. Transparent and Accessible Healthcare Regulation:

a) Competent authorities should run a website signposted and accessible via the www.healthregulation.org website.

b) Competent authorities will share experience in the development of web-based information and publicly transparent lists of registered professionals and identify good practice.

c) Competent authorities should work to develop real-time web-based publicly searchable lists of registered professionals.

d) Competent authorities should work towards making all notifications of disciplinary hearings and decisions public, where legally possible. e) Competent authorities will continue to adopt and implement the European template for a Certificate of Current Professional Status, as appropriate, as agreed within the Edinburgh Agreement. f) Competent authorities will continue to work towards adopting the HPCB Memorandum of Understanding on Case by Case and Proactive information exchange. Agreement 3. Competence Assurance of European Healthcare Professionals:

a) Competent authorities will identify best practice from existing competence assurance and performance enhancement initiatives from across the globe. b) Competent authorities will undertake an audit of all existing or proposed competence assurance and performance enhancement initiatives within the EEA.

c) Competent authorities should, where possible, work to develop appropriate competence assurance and performance enhancement initiatives based on global good practice.

d) Competent authorities should develop appropriate information exchange tools to provide assurance to other competent authorities of current practitioner performance competence when practitioners seek to practise in other member states.

e) All competent authorities should take proactive steps to make new registrants familiar with the relevant professional standards, codes and guidance on registration that apply in their jurisdiction.

f) All competent authorities should make their standards, codes and guidance publicly available. (HPCB, 2007, Hyphenation missing in original)

3.3 Shifts in politics and major political parties affecting policy change; approach to health and approach to migration

The UK has had a Labour government since 1997 so there has been no party political change to impact on recent policy on migration of health workers. Should a Conservative government be returned in 2010, it is unlikely they will significantly change policy on migration, although they may well spend less money on the National Health Service.

3.4 To what extent policies are enforced, responsibility for the enforcement

There is dispute over whether the UK adheres to the code of practice, as discussed below (section 4). There has been ‘adherence’ to the policy of training more health professionals within the UK.

As one of the respondents summed up the situation: there re a range of policies including more home grown health professionals, changing employment prospects for immigrants, the code of practice, changing immigration rules, changing recruitment processes, all of which add up to a complex process as the policies all interact and have impacts in different an unintended directions. Policies are interlinked, despite often being seen in isolation.

There is a real issue of interwoven policies and those attempts to tackle immigration cannot be separated from Immigration policies and rule changes on one hand and issues such as the training régimes for new doctors on the other…. The Border Agency rules, for example, impact on the possibility of UK trained doctors working abroad because hospitals are not keen to allow secondments of this sort as they can no longer get overseas doctors to fill the gaps due to immigration rules.

Responsibilities for employers and other actors have changed as a result of the new immigration rules, points system….The fusion of policies can lead to inadvertent shortages, especially at a local level.

4 Migration Flows

4.1 Introduction: context and issues

The migration of health professionals has been characterised as an international crisis that has led to various efforts to develop global strategies. These include concerns expressed by the World Health Organisation, the United Nations and the European Union among others. The United Kingdom is variously portrayed as the villain and as the exemplar of good practice in relation to migration of health professionals. Given the prominence of the United Kingdom in much of the debate, it is important to examine the broader global context. However, it should be noted that migration is a human right under Article 13 of the United Nations Universal Declaration Of Human Rights (UN, 1994)

Everyone has the right to freedom of movement and residence within the borders of each State.

Everyone has the right to leave any country, including his own, and to return to his country. Using data for the year 2000, Clemens and Pettersson (2008) estimated that approximately 65,000 African-born physicians and 70,000 African-born professional nurses were working overseas in a developed country, including the United Kingdom, which is the major destination country. They noted that this represents “about one fifth of African-born physicians in the world, and about one tenth of African-born professional nurses” (Clemens and Pettersson, 2008, p. 1). However, the fraction of African health professionals abroad varies enormously by country of origin, from 1% to over 70% according to the occupation. Further, some of these migrants leave their country but do not leave Africa, as South Africa is also a destination country as well as a departure country. Dacuycuy (2008, pp. 2–3) notes:

The World Health Report in 2006 shows the extent of such disparities. 24% of the global disease burden plague Africa but it is home to just 3% of the world’s health workforce. In contrast, disease burden in the Americas amounts to just 10% but health expenditures represent 50% of global expenditures…37% of the world’s workforce are concentrated in the Americas (WHO, 2006). Augmenting the health workforce is costly and time- dependent. In a WHO-commissioned study, cost and shortage projections have been computed for selected developing countries, most notably in Africa. The financial requirements are staggering. By 2015, the African region will need 255,000 physicians, almost a million nurses and 3,200 midwives. Total costs of education has been estimated at 18.5 billion dollars with incremental operating costs around 5.2 billion dollars (Verboom et al., 2006). Despite the high concentration of health workers in the Americas, shortages or imbalances remain. Based on OECD data, Australia [had a shortage of] 6,000 registered nurses in 2004. The US is projected to require some 800,000 nurses in 2020. Its neighbor, Canada, has registered a demand of some 16,000 registered nurses. Relative to the US projected demand for nurses in 2020, the required number of health workers in Africa by 2025 will be 1.325 million.

In conclusion, Dacuycuy (2008, pp. 24) suggests, inter alia, that if the ‘initial state of the health system is already degraded, then emigration will exacerbate its deterioration but it does not represent the sole or proximate cause of the problem’.

4.1.1 The Lancet campaign

Successive editorials in The Lancet and various contributions to the journal have reinforced the ‘crisis’ perspective of the migration of health professionals, which has almost become a mantra.

In its editorial of 28th May 2005, entitled ‘Migration of health workers: an unmanaged crisis’ (Lancet, 2005, p. 1825), it noted that: For some years now voices have been raised demanding a more responsible attitude from rich countries that are recruiting health-care workers from developing countries with severe shortages of trained personnel. Health-care systems in sub-Saharan Africa urgently need to be strengthened in order to make any significant steps towards the Millennium Development Goals. A fundamental prerequisite for any functioning system is its professional workforce. Many African-trained doctors and nurses are seeking and finding employment and postgraduate training opportunities in developed countries, such as the USA, Canada, and the UK.

It kept the ball rolling in its editorial of 8th April 2006, entitled ‘The crisis in human resources for health’, when it welcomed the World Health Organization’s (WHO) decision to highlight human resources in its 2006 World Health Report (WHO, 2006a).

Strong worldwide commitment to meeting the 2015 targets for the Millennium Development Goals has led to a massive mobilisation of resources for global health, particularly HIV/AIDS. But big vertical initiatives, such as immunisation and large-scale treatment programmes, which tackle the major causes of ill health in developing countries, are now suffering not from lack of money but from the shortage of health workers to administer the programmes. (Lancet, 2006a)

However, the editorial expressed disappointment with the WHO report as it did not provide the kind of detailed data on human-resource gaps and needs that would help governments make resource decisions, which is a stated aim of the report. The editorial argues that the WHO contribution ‘goes little further than a substantial report published in 2004 by the Joint Learning Initiative—an organisation of over 100 academics who attempted to quantify the scale of the problem and make the case for action’ (Lancet, 2006a, p. 1117).

In its editorial a month later, 3rd June 2006, (Lancet, 2006b), entitled ‘Poaching nurses from the developing world’, it cited the WHO claim that 57 countries in the developing world have severe shortages of health workers and that four million additional doctors, nurses, midwives, and public- health workers are needed to address the health needs in these nations. But what chance have such initiatives, if wealthy nations continue to hire doctors, nurses, and other health professionals from poorer nations? The latest example is a little-noticed provision put into an immigration bill that just passed the US Senate that removes limits on the number of nurses who can enter the USA to work. During the past 10–12 years, more than 50,000 foreign nurses have immigrated to the USA, according to the Center for

Immigration Studies. Nevertheless, the shortage of qualified nurses in the USA continues unabated, with the American Hospital Association reporting 118,000 current vacancies, a number the government expects to increase to a staggering 800,000 by 2020. Strangely, Americans who wish to train as nurses are being turned away from nursing schools that cannot find teaching staff. According to the American Association of Colleges of Nursing, more than 32,000 students were refused entry into baccalaureate level nursing programmes in 2005 because there is no one to teach them—not surprising, since a new graduate working in a clinical setting can earn a higher starting salary than a faculty nurse with a master’s or doctoral degree. (Lancet, 2006b, p. 1791)

Not all the immigrant health professionals to the United States come from poor countries; many migrants are being attracted from rich developed nations. The editorial pointed out the disparity of need between richer and developing countries for health workers and also referred to a United Nations report that maintained that the drain of health workers is effectively subsidising care in the rich world. The editorial noted that some African countries were demanding a subsidy for nurses they supplied. ‘Clearly, further migration of workers will be disastrous for developing countries.’ (Lancet, 2006b, p. 1791) The editorial accepted that:

Some wealthy countries have taken steps to discourage or eliminate the practice of poaching nurses. In 2001, the UK’s Department of Health adopted a code of practice that promotes “ethical recruitment” and restricts recruitment from 150 developing countries, including many in Africa and Asia. But there is evidence that the code is routinely ignored. (Lancet, 2006b, p. 1791)

In the USA, a guaranteed supply of nurses from abroad means that hospitals do not have to raise nurses’ wages and improve their working conditions; likewise, universities will feel no pressure to raise the salaries of academics in nursing faculties. A report by the Institute for Women’s Policy Research, Solving the Nursing Shortage through Higher Wages (Lovell, 2006), suggested that the nursing shortage continues as a result of collusion among hospital administrators to keep wages down and of longstanding gender-based wage discrimination. A similar comment in The Lancet, suggested that the

migration crisis is partly induced by OECD supply shortages which in turn have been powerfully influenced by organised medical associations such as the American Medical Association (AMA). Several times in the past 50 years, the AMA and even some medical deans resisted medical school expansions which have contributed to swings in physician supply in the USA (Blumenthal, 2004). Such incidental resistances, often based on professional power ideologies and perceptions, can make workforce planning difficult, and thus undermine the ability of policymakers and their researchers to “grasp” the science of lagged effects of physician supply interventions. A comment in The Lancet, earlier that year, had pointed out that not only are many health-care professionals ‘lost from the least developed countries to richer countries, but many, particularly the highly skilled, are lost to high-paying agencies within the least developed countries’ (Davey et al., 2006, p. 629)

The editorial of 23 February 2008 opened with a deliberately shocking account of the situation in a Ugandan hospital ‘as a stark reminder of the reality of the human resources for health crisis in sub-Saharan Africa’ (Lancet, 2008, p. 623). The special issue, discussing health professional

migration, coincided with the first Global Forum on Human Resources for Health, which was convened by the Global Health Workforce Alliance (GHWA) in Kampala, Uganda. The editorial clearly welcomed this forum. It claimed that, in launching the Global Action Plan for Human Resources for Health (GHWA, 2008), GHWA aims to guide action over the coming decade, providing ‘an opportunity to make a real and lasting impact on the human resources crisis’ through its role as a tool to measure progress and monitor accountability. ‘There is a great deal at stake’, the editorial continued, ‘Africa carries 25% of the world’s disease burden yet has only 3% of the world’s health workers and 1% of the world’s economic resources’ (Lancet, 2008, p. 623). The World Trade Organization’s General Agreement in Trade Services is seen as a aggravating the problem by legitimising the commodification of health care, allowing countries to compete and trade not just in health services but also in health professionals. The editorial points out, that other factors are at play and the haemorrhaging of health professionals from sub-Saharan Africa and Asia is not limited to crossing borders. The private sector and the non-governmental organisations often pay more than the public sector and, in addition, urbanisation, political instability, unfavourable socioeconomic factors, poor working conditions, lack of training and inadequate equipment and medicines all contribute to migration of health professionals.

However, a major problem is the active recruitment of health professionals from resource poor countries. Here the United Kingdom is cited as an example.

despite international ethical codes, many rich nations benefit to the detriment of poorer countries in order to ensure that there are enough health workers to prop up their own health systems. For example, Ghana has lost £35 million of its training investment in health professionals to the UK, saving the UK £65 million in its own training costs between 1998 and 2002. (Lancet, 2008, p. 623) Despite acknowledging the complexity of the issue, and quoting old date, The Lancet takes an unequivocal stand on the issue by asserting that rich countries should stop actively recruiting from poorer nations. The human resources crisis may be undoubtedly complex but this still does not obscure right from wrong. Richer countries can no longer be allowed to expoit [sic] and plunder the future of resource-poor nations. (Lancet, 2008, p. 623) Indeed, Mills et al. (2008) argued that active recruitment of health workers from African countries should be viewed as an international crime.

4.1.2 Push and pull factors

There has been a succession of articles from the late 1990s, exploring the issue of the migration of health workers from less developed to developed countries. They were prefaced by concerns in the mid-1980s about migration and getting migrants back to their countries of origin (Agarwal and Winkler, 1984; Keely, 1986; Bautista, 1986). Recent articles include, Brown and Connell (2004) on the migration patterns and factors in the South Pacific Island Nations; Walt et al., (2002) on four Caribbean territories; Record and Mohiddin (2006) explored the economic impact of the medical ‘brain drain’ and Muula et al. (2006) examined the financial losses from the migration of nurses from Malawi; and Astor et al. (2005, p. 2492) examined the migration of

physicians from the perspective of Colombia, Nigeria, India, Pakistan and the Philippines. They reported a clear: desire for increased income, greater access to enhanced technology, an atmosphere of general security and stability, and improved prospects for one’s children were the primary motivating factors for physician migration. A majority of respondents believed that physicians in developing counties [sic] are provided with highly specialized skills that they can better utilize in developed countries, but respondents were ambivalent with respect to the utility of educational reform. Responses varied significantly by country with regard to whether physician migration results in physician shortages, but there was widespread agreement that it exacerbates shortages in rural and public settings. With respect to policy options, increasing physician income, improving working conditions, requiring physicians to work in their home countries for a period following graduation from medical school, and creating increased collaboration between health ministries in developed and developing countries found the most favor with respondents. Kanjanapan (1995), earlier, had shown, without critical comment, that Asians are a dominant group in the immigration of professionals to the United States. A more recent view from Cooper and Aiken (2006) argued for US self-sufficiency in health care professional training as well as providing assistance to developing countries to train and retain adequate numbers of health professionals. Crucially they note that:

One half of all of the nurses and physicians in English-speaking countries practice in the United States, yet future shortages of both professions are projected. Because the United States has failed to create sufficient educational capacity for its own needs, it is dependent on foreign health professionals. The magnitude of this dependency has a significant impact on the health care systems of source countries, particularly developing countries, from which the majority of foreign nurses and physicians coming to the United States emigrate. Even emigration from the United Kingdom and other developed countries affects developing countries because it triggers recruitment from developing countries to replace this emigration. (Cooper and Aiken, 2006, p. 66)

Further, Cooper and Aiken argued that: Migrant health workers are faced with a set of options that are a combination of economic, social and psychological factors and family choices. They trade decisions related to their career opportunities — and to financial security for their families — against the psychological and social costs of leaving their country, family and friends. The comments of health workers themselves reflect the "push and pull" nature of the choices underpinning these "journeys of hope". . (Cooper and Aiken, 2006, p.) A view reflected in Kingma’s (2007, p. 1293) study, in which she argued that ‘International migration is a symptom—even an exaggeration—of the larger systemic problems that make nurses leave their jobs and, at times, the health sector’. She argued that ‘no matter how attractive the pull factors of the destination country, little migration takes place without substantial push factors driving people away from the source country’. Migration is a difficult decision, she suggested: Nurse migration is pushed, pulled, and shaped by a constellation of social forces and determined by a series of choices made by a multitude of stakeholders. International

mobility is a reality in a globalized world, one that will not be regulated out of existence. It becomes an issue only in the context of shortages or migrant exploitation and abuse. If South–North migration is to be reduced, the need to migrate must be addressed rather than artificially curb the flows. If migrant exploitation is to be eliminated, the recruitment process (including recruitment agencies) must be regulated and workers’ rights must be upheld. The challenge of ensuring sufficient numbers of nurses in health services around the world will only be met when serious attention is focused on retention issues—equal opportunity salary scales and significant improvements in health sector working conditions. Until they are addressed, retention problems will continue to sabotage training and recruitment efforts. Injecting migrant nurses into dysfunctional health systems—ones that are not capable of attracting and retaining domestic-educated staff—is not likely to meet the growing health needs of national populations. (Kingma, 2007, p. 1293)

However, Dovlo (2005) argues that reducing push factors is an expensive business that most sub-Saharan countries cannot afford. Policy-makers in sub-Saharan Africa must feel helpless when they are completely unable to match either the remuneration or the working conditions found in recipient countries. A self-sustaining cycle ensues: as more and more physicians migrate from a country, they create an environment (a “home from home”) that entices newer migrants from the same country. The helplessness is reinforced by a lack of information on workforce losses for policy-making. Dovlo (2005) tends to emphasise the pull factors. Noting that despite some migration between rich countries and some between poor countries most tends to be from poorer to richer: from countries with physician densities of about 17 per 100,000 population to countries with densities of 300 per 100,000 population. This he refers to as the ‘inverse care law’, which means “countries that need the most health care resources are getting the least.” He asks why this occurs, especially “when there appears to be a glut of physicians in the recipient countries?” Citing Vujicic et al. (2004), he implicates salary disparities, with pay levels up to “24 times higher in recipient countries than they are in source countries”. A situation that results, in some cases of trained doctors retraining as nurses (McVicar, 2002) , which Dovlo notes “doubly wastes the resources poor countries invest into training physicians”. In the end, it is the most deprived who become more deprived as migration from poorer to richer countries is also mirrored in internal migration from rural to urban areas, which leaves the rural poor with fewer health professionals (Martineau et al., 2002). Dovlo (2005) notes that some recruitment is indirect:

Often, health professionals leave to undertake training only obtainable (or seductively offered as “scholarships”) in rich recipient countries. Several years later, the metamorphosis from student to migrant is complete, but the migrant professionals may remain on payrolls in their home countries for several years. Thus, barely affordable initiatives towards capacity-building result instead in further losses of capacity In a more recent review of the situation in the Philippines, Cheng (2009) cites a survey that found that 80% of doctors working in the Filipino public sector had applied or intended to apply to work overseas and 90% of municipal health officers were set to leave to work abroad. These workers were, in some cases, reskilling as they:

were planning to leave not as doctors but as nurses, because it is nurses that the major recruiting countries—the USA, the UK, Ireland, Saudi Arabia, and Singapore—are seeking and luring with promises of pay well above a Filipino public doctor’s salary. (Cheng, 2009, p. 111)

Choo (2003) had earlier warned of this trend, stating that unofficial estimates suggested that, in 2003, about 2000 doctors in the Philippines switched professions, driven mainly by much higher salaries as nurses in, for example, the US than as doctors in the Philippines.

Officially, the Philippines does not have a nurse shortage, rather it has an oversupply but it is the: best and brightest—from specialist doctors and nurses, nursing educators, to even engineers and teachers—who are leaving to work as nurses overseas. (Cheng, 2009, p. 111) The number of nurse training schools has risen from 170 in the 1990s to 471 in 2008 providing full nursing courses, of which 45 provide abridged courses for doctors wishing to become nurses. Further, 60% of nursing schools are focusing on “second-timers”—people with professional training who wish to become nurses in order to get work overseas.

It also seems that the nurse training has become a lucrative, if unscrupulous business, at the student’s expense. In the 1970s and 80s, 80–90% of students in Filipino institutions passed but that dropped to 40–50%. However, this mean conceals huge disparities with at least 20 nursing schools failing to get a single student through the examinations.

However, as one of our respondents pointed out, the UK had established memoranda of understanding with the Philippines and with South Africa about recruitment; it was not as though the UK was surreptitiously draining away health professionals. Indeed, “memos of understanding is a good system and has benefits and is more sustainable and better thought out than when they don’t exist”.

Ogilve et al. (2007), from the University of Alberta, undertook a comprehensive analysis of the literature and argued that that the international migration of health professionals involves human rights that compete with societal needs and that creative policy approaches are required to ensure that the individual rights of health professionals do not compromise the societal right to health. Labonté et al. (2006, p. 1) had, a year earlier, studied migration from sub-Saharan Africa to Canada and concluded:

Reducing pull factors by improving domestic supply and reducing push factors by strengthening source country health systems have the greatest policy traction in Canada. The latter, however, is not perceived as presently high on Canadian stakeholder organizations’ policy agendas, although support for it could grow if it is promoted. Canada is not seen as “actively recruiting” (“poaching”) health workers from developing countries. Recent changes in immigration policy, ongoing advertising in southern African journals and promotion of migration by private agencies, however, blurs the distinction between active and passive recruitment. Eastwood et al. summed up the ‘pull’ and ‘push’ factors impacting on health professional migration.

Push factors

 Lack of opportunities for postgraduate training  Underfunding of health-service facilities

 Absence of established posts and career opportunities

 Poor remuneration and conditions of service, including retirement provision  Governance and health-service management shortcomings

 Civil unrest and personal security

Pull factors

 Opportunities for further training and career advancement

 The attraction of centres of medical and educational excellence

 Greater financial rewards and improved working conditions  Availability of posts, often combined with active recruitment by prospective employing countries (Eastwood et al., 2005, p. 1895)

Overall, the research suggests the following push and pull factors operate in the case of professionals migrating to (and from) the United Kingdom.

Pull factors:

desire for (often greatly) increased income; better working conditions;

greater access to enhanced technology;

an atmosphere of general security and stability; improved prospects for the family (or joining family members who had previously migrated);

undertake training (‘scholarships’) only obtainable in recipient countries; better utilisation of highly specialised skills;

international mobility (transportation, recruitment drives, visa availability);

migrant communities in recipient countries (as more and more physicians migrate from a country, they create an environment (a “home from home”) that entices newer migrants from the same country).

Push factors: dysfunctional health systems;

lack of policy information on health system effectiveness and workforce losses;

poor salaries;

lack of job security; poor working conditions;

lack of technology;

urbanisation and steadily worsening situation in rural areas. These push and pull factors are symptoms of deeper underlying problems, viz. (a) inadequate investment in health systems in developing countries and (b) underdevelopment of training within advanced countries (especially the US and, up to about 2004, the UK) and to some extent overproduction in some less advanced countries (India and Philippines).

However, things are changing. The UK takes lots of doctors trained in India. As one recruiter in a major hospital in the West Midlands noted: “They don’t want to come. Particularly, with India, China, Saudi Arabia, looking for more and more staff, and salaries going up in these countries; the rationale for them coming has disappeared. Then we have to think, what are we offering? Now, where we place ourselves is that we offer very high-level specialist training. If you want to do solid-organ transplantation there aren’t many places in India you can do it whereas over here we’re European leaders in solid-organ transplantation in this hospital. Take, for example Walsall, if you’re an Indian doctor, ‘shall I go to Walsall?’ well, actually I’ll not learn much more than if I work in a hospital in India. And now the economic differential isn’t big, because Indian doctors are getting paid a lot more, there’s no reason for them to come over.”

4.2 General migratory profile: The United Kingdom recent history of migratory health workers

According to the British Medical Association, in 2008, a quarter of all health professionals in the UK come from outside the European Community and two thirds of medical staff were trained in the UK.

Chikanda (2005) identified the ‘alarming rate’ of migration of nursing professionals from developing countries such as Zimbabwe to industrialised countries, a situation that has not been eased by the economic collapse of the country. In 2005, the UK was the major destination for nurses from Zimbabwe and the favoured destinations within Africa are Botswana and South Africa. She pointed out that, in Africa, nurses form the backbone of the healthcare delivery system and their migration has a huge negative impact on health service provision. This is aggravated by public to private health sector migration of nurses. This route is primarily due to the totally inadequate resourcing of public health. Besides offering better services to patients [in urban areas], albeit at a higher fee, the private health sector also provides an escape route for the disgruntled public health sector nurse professionals who find the salaries offered by the public sector unattractive. In fact, the migration of nurses to the private sector has been viewed as partially

responsible for the decline in the quality of healthcare services offered by the public sector. The argument might be made in the context of massive out-migration that this ‘safety valve’ does at least keep medical professionals in the country. Nurses who have failed to move to the private sector are engaged in part-time work in the private sector and are often exhausted by the time they attend their shifts at their health institutions. It has been demonstrated that the overall picture of nurses employed nationally has been one of decline. Notwithstanding the fact that nurses have been moving to the private sector, others have chosen to remain in the public sector for a number of reasons. The findings suggest that some nurses who fail to migrate through recruitment agencies are using private sector employment as a stepping stone for an eventual move to an international destination…. (Chikanda, 2005, p. 173) In a publication the same year, Watkins (2005) showed a rapid escalation in the recruitment of healthcare professionals, in the early 21st century, from developing countries to the UK.

Between 1993 and 2002, the number of non-EU graduates joining the UK Medical Register increased from 2,500 to 4,456 (78% increase), whilst the numbers of UK graduates rose from 3,675 to 4,288 (17% increase); currently, [according to the GMC] 32,118 of the doctors on the UK Medical Register are from developing countries (21% of the total). Interestingly, the number of successful candidates in Part II of the Professional and Linguistic Assessment Board (PLAB) test has increased from 606 in 1998 to 5,207 in 2003 and the Postgraduate Medical Education and Training Board (PMETB) will, in future, allow any combination of qualifications and/or training and experience gained anywhere in the world to be evaluated for direct entry to the General Medical Council (GMC) Specialist Register. These developments are bound to increase the numbers of overseas doctors applying for GMC registration. In 2002, for the first time, over 50% of new nurses admitted to the Nurse Register were from overseas, many of them from needy developing countries (NMS, 1989–2002). Some examples are seen in the numbers coming from Nigeria and Zimbabwe, which increased three-fold and nine-fold respectively between 1998 and 2002; similar trends are seen in the figures for physiotherapists (Buchan and Dovlo, 2004). (Watkins, 2005, p. 241) This escalation has occurred despite the Code of Practice of the Department of Health, which, although voluntary, was supposed to restrict such migration but has, she claimed, been ineffective. The migration had deleterious effects on the source countries and she cited falling staffing levels in a hospital in Malawi and the high rate of emigration of medical graduates from the University of Ghana. However she added:

The staff shortages in the UK are aggravated by the rapidly rising number of locally trained nurses emigrating, mainly to Australia, Canada and the USA. The USA is actively recruiting nurses from the UK and elsewhere, aiming for an extra million between now and 2012 (RCN, 2004). In 2002–3, they recruited 2,224 nurses from the UK, compared with 1,089 in 2001–2, and 474 in 2000–1 (RCN, 2004; NMC, 2002). They are also recruiting significant numbers from Canada, which itself has an increasing shortage (Nelson, 2004). Thus, the richest nations can import staff from both developed and developing countries, and the ultimate losers are always the poorest countries with the lowest staffing levels.

Watkins called for urgent action to reverse the trend, suggesting that while the Code of Practice remains voluntary it well not solve the problem and other measures, including promoting the retention of locally trained staff in the U.K., are urgently required. In the wake of a UN report, International Migration and the Millennium Development Goals, (UNFPA, 2005) warning that the loss of qualified medical personnel to the wealthier industrialised nations is overwhelming the developing world’s health-care systems, The Lancet published a World Report entitled ‘Britain accused of ignoring nurse-recruitment ban’ (Bevan, 2005). The article noted accusations, from South Africa, against Britain for breaking its promise not to poach nurses from developing countries and leaving their hospitals and clinics struggling to cope with staff shortages. This, despite Britain having pledged to help developing countries boost their health workforce by banning recruitment of nurses, by both public and private health recruiters, from at least 150 named states. The accusation was that Britain used private agencies to recruit into the NHS. The Department of Health maintained that controls were in place that were the strictest in the developed world and that no exceptions to the policy were permitted.

However, according to the UK’s Nursing and Midwifery Council,

it accepted 272 new nurses and midwives from Ghana onto its register last year [2004], 69 from Swaziland, which is one of the poorest countries in Africa, and has one of the highest HIV-infection rates, and 43 from Lesotho, a similarly impoverished country.

According to the latest figures from the NMC, more than 2,800 nurses and midwives from countries on the “banned” list registered to practise in the UK in the year to the end of March 2005. (Bevan, 2005, p. 1915)

Bevan accepts that many of these nurses would have initially been hired by private hospitals and nursing homes. However, most end up in the public sector, moving to better-paid jobs in the NHS. This, the King’s Fund recently condemned as a form of back-door recruitment.

One recent advertisement placed in a leading South African nursing journal offered 2- year contracts, free flights, and help with visa and work permits for nurses to work in “private upmarket nursing homes in England, Scotland Wales and Northern Ireland”. The same agency advertised for professional nurses to work in operating theatres and intensive care units for various private hospitals. (Bevan, 2005, p. 1915)

Bevan claims that South African nurses are often attractive to UK employers as most speak good English and are trained to a similar standard as British nurses, a point reinforced by Farham (2005, p. 199) ‘South Africa, ironically, because of the quality of its medical education, loses enormous numbers of doctors every year. South Africa has always lost health professionals overseas or from the public to the private sector. But, over the past decade, things have definitely got worse.’

Bevan claims that, for the nurses, the primary motive is money. ‘An experienced theatre nurse in South Africa earns around £7000 a year. In the UK, they could earn up to five times that amount’ (Bevan, 2005, p. 1915).

Bevan states that in the four years since the NHS introduced its ban on recruitment:

6,104 South African nurses have registered to practise with the UK’s Nursing and Midwifery Council while in the first four months of this year, a further 379 asked its South African equivalent to provide proof of their qualifications to the UK—usually the first step towards moving there.

Even a new requirement by the NMC that all overseas nurses have to undergo a minimum 20-day training course in the UK before they can be registered has not halted the flow of trained nurses to the UK. Many South African nurses are already registered with the NMC but have remained in South Africa, perhaps until their children are old enough to be left. For others the rewards are so great that they are willing to fork out the cost of going to the UK and doing the course themselves. (Bevan, 2005, p. 1915)

What Bevan ignores is the in-migration of health professionals to South Africa in the past, not least from Zimbabwe, albeit Eastwood et al. (2005) claimed that South African policy has now corrected that. Kingma (2005) noted, in an article written in French, that:

Today, foreign-educated health professionals represent more than a quarter of the medical and nursing workforces of Australia, Canada, the United Kingdom and the United States. Destination countries, however, are not limited to industrialised nations. For example, 50 per cent of physicians in the Namibia public services are expatriates and South Africa continues to recruit close to 80% of its rural physicians from other countries. …International migration is often blamed for the dramatic health professional shortages witnessed in the developing countries. A recent OECD study, however, concludes that many registered nurses in South Africa (far exceeding the number that emigrate) are either inactive or unemployed. These dire situations constitute a modern paradox which is for the most part ignored. Despite the general agreement about the crisis of migration, Chipwete and Ramaiah, (2005) pointed out that some newly-trained nurses and doctors have paid for their own training in private institutions. In India, for example, there was a healthy private medical sector training doctors and nurses for the UK and US. It would seem unfair to inhibit these people, who have no direct obligation to the state, from migrating where they like. They ask, ‘how do you differentiate them? Or do we create or propagate a system where only those with the financial capability can fulfil their potential?’ Further they pose the question: ‘what about those who have “served their time” and fulfilled mandatory public service in their country? Where do they fall?’ Eastwood et al. (2005, p. 1893) maintained that the ‘inadequate health systems of sub-Saharan Africa have been badly damaged by the emigration of their health professionals’, noting that this has been ‘a process in which the UK has played a prominent part’. They point to opportunities for the United Kingdom, in 2005, to ‘take the lead in addressing that damage, and in focusing the attention of the G8 on the wider problems of health-professional migration from poor to rich countries’.

They added that, in recent years, international migration of health professionals has not only grown considerably, but is often permanent. They referred to a 1998 UN Conference on Trade and Development/WHO study that estimated that 56% of all migrating doctors flow from developing to developed nations, while only 11% migrate in the opposite direction; the imbalance is even greater for nurses (Chanda, 2002).

They addressed Walt’s (1998) conjecture that the greatest challenges to health stem from the global liberalisation of trade with the resultant movement of goods and services (including health workers) within the world economy. They suggested that liberalisation of trade has an effect but there are more fundamental issues that underlie migration. Nonetheless, they are condemnatory of the World Bank stance, which proposed that: “health services are another area in which developing countries could become major exporters by temporarily sending their health personnel abroad”. Eastwood et al. (2006, p. 1895), deplore the fact that essential public health services have not been exempted from public expenditure cuts ‘as a condition of World Bank/International Monetary Fund assistance’. A fact made even more annoying by ‘some governments in sub- Saharan Africa giving greater priority to other spending, including military expenditure’.

The serious consequences that result from loss of health professionals for some countries are becoming increasingly recognised and are now being widely discussed in the public media. What has not been so widely recognised is that the effects are most severe for the English-speaking countries of sub-Saharan Africa. As others had stated, Eastwood et al. also reinforced the need for more self-sufficiency in the UK noting that 31% of practising doctors and 13% of nurses were born outside the United Kingdom and that 8000 of the recent additional 16000 staff in the NHS were qualified abroad. The UK has a special role in both the genesis of the problem and its solution, since large numbers of the migrating health workers come to the UK. One obvious issue is the “vacuum” of the large numbers of job vacancies in the UK, resulting from the inadequate supply of UK-trained doctors and nurses. Data from 2002 show that among the 11,234 new registrations with the General Medical Council nearly half were from non-European Union countrieshttp://www.thelancet.com/journals/lancet/article/PIIS0140-6736(05)66623- 8/fulltext - bib5 (GMC, 2003–4). (Eastwood et al. 2005, p. 1894)

Eastwood et al. indicated that there is a similar pattern for nurses: 25% of non-European Union nurse registrants, in 2002–03, were from the “proscribed” list of developing countries appended to the Department of Health Code of Practice for International Recruitment. It is current policy that these countries will not be targeted for active recruitment by the National Health Service (NHS) (DH, 2004). They provided some data on migration to the UK. In 2003, UK work permits were approved for 5,880 health and medical personnel from South Africa, 2,825 from Zimbabwe, 1,510 from Nigeria, and 850 from Ghana, despite these countries being included among those proscribed for NHS recruitment. (House of Commons Hansard, 2004) Eastwood et al. maintain that the United Kingdom is appropriating human capital at zero cost for its health service saving about a quarter of a million pounds per doctor and not having to wait five years while they train. Reflecting Watkins (2005) and Bevan (2005), Eastwood et al. also critique the codes of practice, drawing on Buchan and Dovlo’s (2004) report that the code has significant weaknesses and loopholes, which make it easy to circumvent, as the code fails to include private employers and recruiting agencies. They note the announcement of the Health Minister, John Hutton, in August, 2004 to improve the code but suggest that strengthening the code alone will not overcome the demand from UK hospitals They suggest actions are aimed at restricting both pull and push factors, notably to increase training, increase aid and technical assistance and help, through joint action, to develop more in-country training and support.

Eastwood et al. referred to the recent expansion in United Kingdom medical schools but wondered whether it would be sufficient to reverse the UK’s long-standing dependence on doctors trained overseas. Similarly, they called for reassessment of the UK’s chronic dependence on nurses and other health professionals trained overseas. They urged the Medical Workforce Standing Advisory Committee to clarify what numbers of doctors and other health professionals in training are necessary to eliminate the UK’s dependence on recruitment of health professionals from sub-Saharan Africa.

In our view, urgent consultation is needed between the UK, relevant EU countries, the USA (where more than 23% of physicians were trained outside the country, including more than 5,000 doctors from sub-Saharan Africa (Hagopian et al., 2004), Canada, Australia, and New Zealand, and WHO about the need for norms for the minimum numbers of health professionals in training in developed countries. These standards would ideally be referenced to the desired level of national health care provision, or, alternatively, gross domestic product per person. Without such internationally agreed minimum training targets for developed countries, the most vulnerable countries will continue to lose a large proportion of their health workers. At the same time, some developed countries, such as the UK, will continue to lose their own health professionals to other developed countries, not least to the USA, thereby fuelling their own need to recruit from developing countries. (Eastwood et al., 2005, pp. 1899)

Pond and McPake (2006) examined the migration crisis by looking at the roles of four OECD countries, of which one was the United Kingdom. There was a sharp rise in expenditure on the NHS in 1998, following the election of a Labour government the year before. Targets were set and extended during the period up to 2004, with at 10% increase for nurses (35000) and 25% increase in general practitioners and consultants (15000) by 2008 (DH, 2000).

The key strategies to increase staffing were the retention of current staff and return of those working elsewhere; recruitment of newly qualified health professionals into the NHS from UK training institutions; and recruitment of doctors and nurses into the NHS from international sources.

The first strategy depended on ‘improving the salaries, benefits, and other terms of service of UK health professionals’ (Pond and McPake, 2006, p. 1449), which occurred but not as the authors explain, to the extent that Department of Health press releases had claimed. Drawing on the UK Department of Health website they noted: ‘The real increase in the basic minimum salary for most grades of doctors and nurses averaged only 1.3% per year between 1997 and 2004. With the exceptions of the new consultant contract awarded in 2004, which increased minimum consultant pay by 21%, and a 6.3% increase awarded to grade D clinical nurses in 1999, no other increase amounted to more than 2% per year’ (Pond and McPake, 2006, p. 1449),

Office of Manpower Economics data suggest that 9.2% of registered nurses left the NHS in the 2002–03 period and that 3800 nurses (1.3% of the stock) returned from overseas to the NHS. Both estimates have been stable over recent years suggesting no effect of pay increases on retention or return (Buchan and Seccombe, 2003). Comparable statistics are not available with which to assess retention of physicians. (Pond and McPake, 2006, p. 1449)

The second strategy meant an increase in training and the number of English nursing and midwifery training commissions increased by 62% between 1996–97 and 2003–04 (Buchan and Seccombe, 2003), which reversed the sharp decline in nursing graduates during the first half of the 1990s resulting in a the 1992 graduation rate being achieved by 2002.

In 1998, the government also committed to increasing the number of medical students by 1000 (20% of the 1997 level) by 2005 (BBC, 1998). In fact by 2002, the annual number of acceptances to medical school had increased by a third (UCAS, undated), four new medical schools were opened in 2002 (GMC, 2002), and in 2003, medical school acceptance was 50% higher than in 1997 (Pond and McPake, 2006, p. 1450),

The third strategy involved international recruitment and there was an increase in recruitment from 1998 so that the number of international nursing graduates almost matched the number of domestically produced nurses by 2001 (Figure 7). In that year, the NHS launched a global advertising campaign to attract foreign-trained consultants and general practitioners.

By 2003, the number of newly registered physicians trained overseas doubled, whereas the number educated in sub-Saharan Africa tripled. (Pond and McPake, 2006, p. 1450)

Figure 7: International medical graduates (IMGs) and international nursing graduates (INGs) registering for the first time in the UK, 1990–2003

Source: Pond and McPake, (2006), data originally from registration statistics of the Nursing and Midwifery Council and General Medical Council.

Overall, they claim, the number of nurses working for the NHS went up by 48,800 (about 20%) between 1997 and 2003.

73% of this increase was achieved through international recruitment. The effect on specific countries can be substantial. From 1998 to 2003, the Nursing and Midwifery Council registered 8% of the total nursing workforces of Malawi and Ghana (NMC, 2004; Global Atlas of the Health Workforce, 2004). The number of NHS physicians increased by 17500 (roughly 21%) (DH, 2005). On the assumption that physician retention and return did not change, the statistics suggest that 80% of the growth in the NHS physician workforce can be attributed to international recruitment (GMC, 2003; NMC, 2004). More than half the increase in doctors was achieved in the 2 years following the launch of the global recruitment campaign. Of the additional overseas-trained physicians registered during 2002 and 2003, 24% came from sub-Saharan Africa. (Pond and McPake, 2006, p. 1450) Pond and McPake (2006) cited work by Mensah et al. (2005), Buena de Mesquita and Gordon (2005) and Mensah et al. (2005) that has, in their view, put ‘justifiable pressure on the UK to respond to the implications of its policies for human resource availability in the poorest countries’ (Pond and McPake, 2006, p. 1450) because the UK benefits more than other high-income countries from health worker emigration from the poorest countries. However, they do not leave the blame here noting that, moral responsibility aside: other countries too control policy levers that ultimately affect the outcome. Although sub- Saharan Africa might not be the dominant origin of the influx of foreign-born nurses to the USA, that country’s health labour market is likely to be an important driver of what has been called the medical carousel (Bundred and Levitt, 2000) a singularly inappropriate metaphor in view of the absence of cyclical characteristics of the pattern, or happy result. The so-called carousel might instead be viewed as a hierarchy of inter-related labour markets, with countries such as the USA sitting near the top of that hierarchy and attracting immigrant health staff from lower-income countries, which in turn fill the gap with migrants from still lower-income countries. The matching of local training levels, demand, and pay and other working conditions in any country further up the hierarchy will ameliorate the exodus from lowest-income countries. (Pond and McPake, 2006, p. 1452)

The authors suggested that the Department of Health’s Code of Practice on recruitment (DH, 2001, 2004) has had some small success and that ‘other policies related to work permits, visas, and licensing seem to increase the costs of immigration and constrain health-worker flows from low-income countries’ (Pond and McPake, 2006, p. 1452), such constraints seem to be effective in France. However, like Eastwood et al., they suggest that there is another factor and that is language; with Anglophone Africa seeing higher levels of out migration than other countries in the continent. It is interesting to note that in France—another country whose language is widely used in undergraduate medical education—only around 5% of practising doctors qualified overseas. (Eastwood et al., 2005, p. 1895)

On balance though:

the numbers of health workers migrating from sub-Saharan Africa to the UK have recently been an order of magnitude greater than the numbers migrating to the USA. Confronted with labour shortages or lobbying from the health care industry, however, policymakers in various OECD countries have [according to the OECD (2002) and Berland (2002)] shown a willingness to ease immigration, licensing requirements, or both, for internationally trained health workers. (Eastwood et al. 2005, p. 1895)

Much of this attack on UK policy refers to practices prior to 2005 and as will be shown below (Section 4.3), the pattern of immigration of health professionals has changed dramatically. Despite often being cast as the villain of the peace, the United Kingdom also provides support, as Glassman et al. (2008) point out:

There are good examples of more careful planning of HRH scale-up that can make a difference to the effectiveness of these investments and the success of policy makers in attracting additional resources. Malawi’s government, backed by the UK Department for International Development, is in the midst of a 6-year plan to increase salaries in the health sector by 50% on average. This policy, which is part of an emergency human resources plan, was developed only after a careful analysis of the health labour market found a mismatch between high government demand for HRH and a large available pool of skilled workers in the private sector who were unwilling to work for the public-sector salaries offered. Buchan et al. (2008), sum up the situation to 2006 in the UK, as follows: …In the late 1990s shortages of skilled staff were a main obstacle to improving services in the NHS [through which most health care is delivered]. The response by government was to “grow” the NHS workforce. There are four main policy options to “grow” the workforce: increase home based training; improve retention rates of current staff (to reduce need to recruit additional staff); improve “return” of staff currently not practising; and internationally recruit health professionals. International recruitment was used to achieve rapid growth in the NHS workforce. It was facilitated by fast tracking work permits for health professionals, by targeting recruits in specified countries, using specialist recruitment agencies, and by co-ordinating local level recruitment within the NHS.

NHS international recruitment was also underpinned by a Code of Practice. One key point of the Code is that developing countries should not be targeted for active recruitment by the NHS, unless the government of that country formally agrees.

Whilst the period from 1999 to 2005 was one of unprecedented staffing growth for the NHS in England, from 2005 onwards, this growth in staff numbers came rapidly to an end.

Financial deficits emerged in the NHS from 2004-05 onwards, which the UK Parliament Health Committee attributed, in part at least, to the costs of workforce expansion, and costs of new pay contracts for NHS staff. There have been subsequent changes in the UK migration policy, which also have impacted [on] international recruitment. Medicine, nursing and other health professions are no longer classed as 'shortage’ professions. This has lead inevitably to a significant

reduction in the inflow of international clinicians to the UK NHS. (Buchan et al., 2008, pp. 6–7) More recent reflection by one of our respondents suggests that “the UK Code of Practice has been very positive”. The UK Code “isn’t perfect because it is voluntary”. Further, it has been drawn up “and ‘put out there’ without it being proactive”. In short, the Code is positive but could have been promoted and pushed more forcefully. However, “it is one of the best tools out there despite its faults”. The UK Code “isn’t a constraining code and private recruitment agencies declined to be involved in setting it up. Of course, once in the UK health professionals can subsequently be recruited into the NHS and are in the UK system; it has a cascade effect. This process is not [despite what some claim] one that was an intentional route undertaken by the NHS to recruit people” to get round the Code. The respondent was also enthusiastic about the potential, internationally, of the World Health Organisation Code of Practice. However, this was promised in 2007 and is taking a very long time to appear and the indications are that it will not be robust enough. Getting agreement on the WHO code “has been quite difficult and there will never, probably, be full agreement”.

The WHO Code could be a big factor but at the moment it is shaping up to fall short in a number of areas. Could be fantastic but no measures for real investigation of the issue, i.e. no unit to be set up combing through the data to see what is really going on….The Department of Health [in the UK] need to push more on the WHO Code .We are a significant player—leader—so could do more to move it along and make it stronger…. The WHO has a good reputation and could make a difference but appears to lack the desire to really be interventionist in the drafting of their Code of Practice.

4.3 Inflows and Outflows of health professionals: data from the professional councils

4.3.1 Doctors

Between 1998 and May 2009, the General Medical Council registered 56,987 doctors trained in the UK, 26,609 with qualifications from the EEA and 57,140 doctors with qualifications from outside the EEA. These totals hide a change in trend with very large numbers of international registrations in the mid 2000s but a rapid decline in international registrations since 2003 and a steady upward trend in UK-trained registrants over the ten-year period. (Figure 8).

The articles reviewed above suggest that there was a high proportion of non-United Kingdom and non-EEA doctors registered in the United Kingdom. There is a degree of consistency but much of the reporting focuses on the period up to 2003, which as will be shown below, represented a peak in the registration of overseas doctors. For example, Pond and McPake (2006) claimed that between 1998 and 2002 the annual number of acceptances to medical school had increased by a third and that medical school acceptance was 50% higher than in 1997. This optimistic note was trumped by Buchan and Dovlo (2004) who claimed that while there was a 17% increase in United Kingdom graduates from 3,675 to 4,288 between 1993–2002, the number non-EU graduates joining the UK Medical Register increased by 78% from 2,500 to 4,456 and that 32,118 doctors on the UK Medical Register were from developing countries (21% of the total). Further, the

number of successful candidates on the PLAB test of linguistic competence in English increased from 606 in 1998 to 5,207 in 2003. Eastwood et al. (2005) claimed that 31% of practising doctors were born outside the United Kingdom, (despite the fact that the GMC database does not have accurate data on place of birth, only place of qualification). Eastwood et al. also claimed that nearly half of the 11,234 new registrations in 2002 were from non-European Union countries. Current data indeed shows that there were 5,148 registrations, in 2002, of doctors who had qualified outside the EEA (46% of Eastwood et al.’s total of 11,234).

As noted, data from the General Medical Council on new registrations by country of qualification, supplied mid-2009 shows a clear drop in the registration of overseas doctors in the United Kingdom (Figure 8).

Figure 8: GMC registrations of doctors trained in the UK, EEA or internationally 1998–2008

14000

12000

10000

8000

6000

4000

2000

0 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

UK EEA International

The very sharp peak in overseas registrations in 2003 was mainly made up of international registrations (86%). Of the 11,996 registrations of international medics, twelve countries supplied 11,227 of these of which, 3,206 were qualified in South Africa, 2,982 in India, 2,106 in Australia, 635 in Pakistan, 578 in New Zealand, 524 in Hong Kong, 419 in Jamaica, 275 in Singapore, 176 in Nigeria, 134 in Sri Lanka, 109 in Egypt and 83 in Iraq.

However, this year is not representative of the decade of GMC overseas registrations. For example, half the decade’s registrations of South African doctors were in 2003 and nearly all of those from Hong Kong. Since 1998, more than a third of overseas international registrations have been of doctors who qualified in India (37.4%), which constitutes a quarter of all overseas registrants (Table 15, Annex). South Africa (11.3%) and Pakistan (10.3%) were the next highest

of the non-EEA countries, followed by Australia (7.3%), Nigeria (4.5%), Egypt (2.9%), Iraq (2.5%) Sri Lanka (2.3%), New Zealand (2.1%), Jamaica (1.9%), Sudan (1.3%) and Hong Kong (1.2%). There was a steep decline in international registrations from 2003 to 2006 and a levelling off at just above the level of EEA registrations. The latter increased from 2003 to 2005 and then decreased steadily. Overall though, EEA registrations have increased from 25% to 50% of the total overseas registrations over the decade. Most EEA qualified registrations since 1998 have come from Germany (18.9% of all EEA registrations since 1998), Greece (12.4%), Italy (10.7%), Poland (9.4) and Ireland (8.1%). Doctors who qualified in Germany constitute the fourth largest group of GMC non-UK registrants since 1998 (Table 15, Annex)

Current (2008) registrations of overseas-trained doctors show a very different pattern to that of 2003, which caused so much concern (Table 16, Annex). It should be noted that annual registrations indicate changes in migration patterns but this is different to the total number of registrants. For example, in 2008, there were 6770 (57.41%) new registrations from United Kingdom qualified medics, 2181 (18.50%) from EEA countries and 2841 (24.09%) International registrations. This compares with the total registered numbers in 2008 of 156,574 (63.2%) from the United Kingdom, 22,310 (9.0%) from the EEA and 68,754 (27.8%) International (based on data from the GMC). Total registrations, though, can be misleading as they may include people who retain registration but are not actively practicing in the United Kingdom.

As one respondent stated: It is becoming harder and harder to recruit doctors by the deaneries because the deaneries have obviously closed to non-EU applicants and they are taking fewer and fewer”. The deaneries are responsible for the management and delivery of postgraduate medical education and for the continuing professional development of all doctors and dentists. This includes ensuring that all training posts provide the necessary opportunities for doctors and dentists in training to realise their full potential and provide high quality patient care. The deaneries are also responsible for trainers, educational supervisors and educational leaders, their training needs and educational development.

Add to that the vagaries of Royal College recognition, as the respondent pointed out: In a lot of ways its easier now because of the equivalency issues. It’s interesting because the Royal College of Surgeons recognise the qualification of a Pakistani-trained surgeon as being equivalent but the Royal College of Physicians don’t recognise Pakistani physicians as being equivalent. So, whereas we can bring doctors over from Pakistan for surgery fairly easily because the GMC can’t turn them down because they’ve got equivalency recognised by the Royal College of Surgeons, we can’t bring medical doctors, can’t bring physicians because the Royal College of Physicians don’t recognise them.

As well as migration in, there have been significant numbers of doctors who have migrated out of the UK. When out-migration is also taken into account a rather different picture emerges.

Direct data on migration out, though, is not available but the GMC records erasure from its register and the reason for such erasure. The GMC has provided the data by country of qualification of doctors for the last decade (Full data in Table 17, Annex). Erasures do not

necessarily relate directly to migration abroad but are an indicator. The reasons for erasure from the register include: voluntary erasure; failure to maintain an effective address; fitness to practise erasure; and failure to pay the annual retention fee. Figures for 2008 and 2009 are high due to age exemption being abolished and a large number of previously exempt doctors choosing to voluntarily erase or allow their payments to fail. This also accounts for the slight raise in deceased notices as the GMC received a few more when sending out the letters about the ending of age exemption. Also, some of these erased doctors will have since restored to the medical register (Full erasure date Table 18, Annex). The total number of UK-trained erasures from the register over the decade is 48,740, although 20,000 of those have been in the last two years as a result, probably, of the end of age exemption. There have, since 2000, been about 1,000 UK-trained registrants a year who have relinquished registration and this may in part be because of emigration to practice permanently elsewhere.

The picture of registrations and erasures shows that (bearing in mind erasure is not the same as emigration and some erasures may be subsequently restored) there is a significant net increase of doctors from India (12,606 over the decade), Pakistan (4,062), Nigeria (2,037) Poland (1,533) and Iraq (1,123) (Table 15, Annex). However, there has been a net decrease from South Africa (- 1,940) despite all the articles and claims about the UK taking South African doctors. Of course, the erased South African-trained doctors may have moved to other EU countries or to the USA, for example, rather than returned to South Africa. It may be that recruitment to the UK is but a stepping-stone for South African-trained doctors. There has been an even larger net loss of Australian registrants over the decade (-3,414) and of Irish registrants (-3,012). Other net losses from the register include Hong Kong (-2,110), New Zealand (-887), Greece (-326), Spain (-257), Netherlands (-252) Jamaica (-74), Belgium (-30) and Sri Lanka (-7).

However, the situation is not straightforward as one of our respondents explained. After the Medical Act of 1978 the system of reciprocity was abolished so that doctors from countries such as Australia, New Zealand, South Africa, Malaya, Singapore and Hong Kong had to hold one of about twenty ‘recognised’ qualifications. This would not have resulted in an increase in erasures but it would account for the decrease in new registrants after 1980. This means that the higher numbers of erasures are a result of historically higher numbers of registered doctors from those countries coming to the end of their careers. There was a brief increase in numbers of international graduates in 2003–04 due to the Medical Act amendment that meant that the direct route to full or provisional registration enjoyed by doctors with ‘recognised’ qualifications was abolished meaning that doctors from those countries would have to apply for limited registration in the first instance. However, this also meant much lower numbers of applicants in following years.

Other factors such as limited registration replacing temporary (which brought with it the necessity to provide evidence of English language capability), increase in fees, and the ending of age exemption all meant a general decrease in overseas applicants and increase in erasures.

Ireland is quite unique as since 1927 there was an agreement (after they gained independence) that an Irish qualification was to be treated as equal to a UK one for the purposes of registration. This came to an end in the mid-1980s meaning they were then

to be treated as any other EEA applicant. Also, for the first part of last century Ireland was part of the UK so they had to have registration with us anyway and the historical relationship even after independence meant that many retained registration. Basically we would have had a large stock of Irish qualified doctors that from the mid-1980s and then the mid-90s would have started to dwindle and drift off the register or choose to erase/restore rather than retain registration indefinitely. The cost of maintaining registration with both authorities would have become prohibitive. The statistics for 2008 and 2009 are a reaction to the ending of age exemption in the same way we have a huge leap in the numbers of UK doctors erasing in this period.

For European doctors in general the increase of fees and other such factors could play a part. We have decreased in total numbers over the last five years or so and are back down to 2003–04 levels at the moment so there is a general decline in applicants and increase in erasures.

Another respondent referred to the increased emigration of new doctors following modernisation, “The deaneries have had the fiasco which was modernising medical careers two or three years ago, when we haemorrhaged doctors out of this country into Canada, America, New Zealand, Australia.”

4.3.1.1 Views of the British Medical Association

The British Medical Association (BMA) is an independent UK trade union and voluntary professional association, with a total membership of over 139,000, that represents doctors from all branches of medicine all over the UK. The BMA has closely followed developments around cross-border mobility since the mid-2000s. Along with AURE, it “pro-actively and successfully opposed plans to allow EU doctors to practise in the UK for up to four months without registering with the GMC” (BMA, 2009).

Among other things it provided evidence to the House of Lords Economic Affairs Committee Inquiry into the economic impact of immigration in 2007 and submitted a response to the European Commission’s recent proposal and contributed evidence to the House of Lords Sub- Committee G inquiry into the EU Commission’s proposed directive on the application of patients’ rights in cross-border healthcare (November 2008).

4.3.1.1.1 Evidence to the House of Lords Economic Affairs Committee Inquiry into the economic impact of immigration

In its response to the inquiry into immigration, published in December 2007, the BMA focused on medical migration noting that:

It has long been considered that a disproportionate number of Staff and Associate Specialist (SAS) posts, that do not contain postgraduate training, are filled by migrant doctors. This is often because UK doctors do not wish to join these grades as they believe they have been given a commitment to be trained to consultant level. Trusts have created Trust Grade posts, to fill service gaps, which have non-standard terms and conditions of service. Doctors employed in these posts are not protected by national

terms and conditions of service and may be employed on poorer terms. Such posts are often filled by migrant workers. (BMA, 2007)

The BMA point out that the existence of national terms and conditions for the majority of medical posts in the NHS means that recruiting migrant workers is not associated with reduced labour costs but that such recruitment means the UK will not have paid for their undergraduate medical education, a saving of £250,000 per doctor. The BMA expressed reservations about the possible exploitation of migrant doctors in the private sector. The BMA stated that immigration is not only a short-term solution to domestic shortages but that the “history of the NHS proves the efficacy of migration as a long-term solution for a country that has an implicit policy not to graduate sufficient doctors to meet its healthcare needs”. Recent policy, they acknowledged, means that the increased undergraduate medical training places will decrease reliance on migrant doctors. The BMA further state that:

As a result of the increase in UK medical graduates, there is now an oversupply of doctors seeking postgraduate training posts in the UK. There are still shortages in service grade and consultant posts. The Work Permits (UK) shortage occupations list, issued on 23 July 2007, included salaried GPs and nearly 50 specialties at consultant level, including anaesthetics, dermatology, neurology, paediatrics, and trauma and orthopaedic surgery. The relevance of the shortage occupation list is that when employers apply for a work permit for a potential employee they do not need to satisfy the resident labour market test showing that there was no suitable resident worker before being granted a work permit. (BMA, 2007)

The BMA is of the view that migrant workers will continue to be required for some decades. The BMA’s workforce modelling suggests that over the period to 2030, the demand for doctors will be met with current planned medical school intake and levels of overall immigration into the training grades. This is dependent on the assumption that doctors in the training grades progress to consultant levels and GP posts, and have the flexibility to move between training and non-training SAS grade posts as required to stabilise demand and supply.

However, a senior manager form a large NHS Trust stated, “I’ve seen the boom and bust in terms of home grown staff and bringing in externals and probably the pendulum is about to switch again across to bringing in staff from abroad.”

Responding to the question of whether immigration impacts on availability of training posts the BMA responded:

The UK has a long history of using migrant staff, and particularly so in the medical workforce. It is estimated that a third of the NHS medical workforce are international medical graduates, i.e. they qualified outside the European Economic Area (EEA). Historically, this group of migrants has been welcomed to the UK and their valuable contributions have been recognised. Following the recent restructuring of medical training in the UK, it has become apparent that there are far more doctors (UK, EEA and migrant) wishing to undertake postgraduate training posts in the UK than there are posts available. Given the policy of open competition for medical training posts—a position that the BMA

supports—this has resulted in some UK medical graduates being unable to secure run- through postgraduate training posts. (BMA, 2007) The BMA (2007) further add that the migration of doctors from the EEA has “also contributed to the over-supply of medical professionals into postgraduate training posts, something which has not been accounted for or assessed in workforce planning.” Furthermore, in addition to benefiting from free movement between member states, the BMA noted that, with the exceptions of Romania and Bulgaria EEA qualified doctors have a more straightforward route to registration than doctors who have graduated outside the EEA. The BMA maintained that doctors subject to the immigration rules, who are currently in the UK, have a valid expectation to train or work in the NHS and should be treated equally with UK and EEA nationals and other resident workers. The BMA has repeatedly drawn attention to the government’s responsibility to highlight the decreasing opportunities available to international doctors prior to them coming to the UK. The recent change in immigration law has affected many doctors; it was appalling that the government ‘offered no opportunity for organisations representing affected doctors to communicate their views about the changes, and failed to comply with its duty to examine the race relations issues involved’, as stated in the High Court ruling on 9 February 2007. (BMA, 2007)

A survey of BMA members supported a fair deal for international doctors and international medical students who qualify in the UK. Over half (54.4%) of respondents stated that international medical graduates working within the NHS should not be prevented from competing for training posts.

The BMA asserted support for a policy of self-sufficiency but stated that effective workforce planning is needed, where workforce patterns are based on need and not artificially restricted on the grounds of affordability. It is also essential to take into account current and planned medical school intake, coupled with future migration and immigration. The BMA (2007) stated that it “recognises the extremely valuable contribution that migrant workers make to the NHS medical workforce and would welcome government policy acknowledging the same.” It called on the government to clarify its immigration policy. The immigration rules for postgraduate doctors in training were amended in April 2006 with serious consequences for many migrant doctors. Since this time there has been a lack of clarity about how doctors in certain immigration categories, including the Highly Skilled Migrant Programme, should be considered during recruitment processes. It is vital that absolute clarity of the employment and immigration rules and how they affect migrant doctors is provided as soon as possible and is disseminated widely.

4.3.1.1.2 Response to European Union sub-committee G inquiry into the EU Commission’s proposed directive on the application of patients’ rights in cross-border healthcare

The BMA agrees with the principle of cross-border patient mobility and welcomed the proposal for a directive on the application of patients’ rights in cross-border healthcare. The BMA’s evidence suggested that the legal clarification of the position of EU patients is vital. The present legal

uncertainty about patient mobility has resulted in unequal access to care abroad. National healthcare systems should be designed and organised in a way that ensures that all patients have access to high-quality care close to home and without undue delay. However, the BMA agreed that when this is not possible, patients should have the option to travel to another EU member state for treatment that is paid for by their home healthcare system. However, the BMA pointed to the considerable difference in EU healthcare systems and called on the European Commission to ensure that the proposal does not impose an unnecessary administrative burden or financial costs that would be detrimental to the provision of safe, high- quality healthcare for all. Patient safety and the provision of high-quality clinical care should be the overriding priorities of any new legislation. Thus the BMA welcomed the emphasis on quality and safety throughout the proposal. It also welcomed the establishment of guidelines that would facilitate the implementation of a common set of quality and safety principles and would welcome the participation of healthcare professionals in the writing of these guidelines. Indeed, the BMA would encourage the introduction of a set of minimum quality standards for healthcare in Europe, overseen by the European Commission, in order to ensure the highest possible level of healthcare across the continent.

In the view of the BMA, it is essential to respect non-discriminatory national rules and processes that are used to effectively plan healthcare in the various member states. Hence, they supported the fact that the proposals safeguard the gatekeeper function of GPs in the UK and respect a member state’s right to define its own national basket of care. The BMA has concerns regarding the possibility that healthcare may be more expensive abroad and that the patient would be expected to pay the difference in cost.

Whilst we agree with the principle that the level of reimbursement should be no more than the cost of treatment in the home healthcare system, we believe that this co- payment may have a negative impact on equality of access. Thus the BMA calls on member states to ensure that patients are not prevented from exercising their rights to cross border treatment due to financial constraints.

In addition, the BMA expressed concerns over the lack of clarification on continuity of care and the linked issue of language and translation provision as well as the impact of the proposal on current NHS provisions such as: the ability of patients to obtain care across national UK borders; the issue of ‘top-up payments’; and the NHS Healthcare Travel Cost Scheme.

The BMA noted that the proposal presents opportunities to improve access to information on the quality of healthcare across the EU and on the types of treatment offered. It suggested that the sharing of patient data, the use of e-Health and systems of compensation and redress need to be examined further.

4.3.1.1.3 BMA response to the European Commission Green Paper on the European Workforce for Health, February 2009

The BMA reasserted their basic position as outlined above but under the heading ‘professional mobility’ state:

The BMA supports the free movement of workers which is enshrined in EU law and which can enhance the professional experience of the EU health workforce. The BMA is concerned that Directive 2005/36 on the Recognition of Professional Qualifications is no longer fit for purpose due to the changing nature of modern medicine. It is essential that a system is introduced which emphasises a healthcare professional’s continuing fitness and suitability to practice in the receiving country. Basing a decision on fitness to practice on the length of time individuals have trained rather than on the skills they have acquired is not suitable for the continued development of a modern healthcare system. This Directive also prohibits the regulatory authorities in an EU member state from assessing the language competence of doctors from other parts of Europe who wish to practice in that country. In the interests of patient safety, it is essential that doctors are able to communicate with their patients and that the regulatory authorities are able to assess the fitness to practice of each doctor in their jurisdiction. Regulators must also be allowed to assess the language competence of doctors wishing to join the medical register regardless of whether they qualified within the EU or externally.

The BMA also calls for the Directive to be revised in order to introduce a legal duty on all medical regulators to share registration and fitness to practice information proactively with other regulators in Europe. Regulatory authorities have established initiatives to ensure that national regulatory authorities are able to work collaboratively such as the Healthcare Professionals Crossing Borders initiative and such work should be further built on. (BMA, 2009)

4.3.2 Nurses

Despite requests for information from the Nursing and Midwifery Council (NMC), data has not been forthcoming. The following information is extracted from various sources.

There are about 673,000 nurses and midwives registered with the NMC.

There were 1872 admissions to the register from the EU/EEA countries in 2007–8, up 23% on the previous year (1520) (Table 19, Annex). By far the most came from Poland, then Germany and the Republic of Ireland, although numbers from Italy have risen rapidly, up to 92 in 2007–8. The numbers from Poland increased significantly from 2005, as did registrants from Slovakia and the Czech republic, albeit dropping off of late.

In 2008, over 2000 nurses and midwives from outside the EEA (that is those who have not been registered and practised in another EU Member State for three years) registered with the NMC. The data on international registrations has been compiled from the published NMC statistical analyses of registrations for the available years 2004–5, 2005–6, 2006–7 and 2007–8. However, these report international registrations in different ways. The reporting in 20007–8 is of all international registrations. For the 2006–7 the reporting is of the ‘top 25’ countries for the year ending March 2007. For 2004–5 the reporting is for the top 25 from 2002–3 to 2005–6 and for 2004–5 it is also of the top 25 but from 1998–99 to 2004–5. However, some countries appear and disappear in these top 25 constructions and the West Indies is included as a composite in early tables is replaced by component islands in later tables. It is also unclear when missing data means that there was some migration but the data is not recorded because it was not then in the

top 25 or that the actual figure is zero. Where the data implies a clear zero that has been added in italics (Table 20, Annex). Otherwise a blank should not necessarily infer that there were no registrations from that country. The italicised countries did not appear in ‘top 25’ listings but are in the latest inclusive registration statistics. The totals in the 2004–5 table in the NMC publications (Table 14 in NMC, 2005–6) do not match those in the later tables (for the same reported years) (Table 20, Annex).

India has become the number one source country for nurses and midwives to the UK, after a run of four years that saw the Philippines in that role (Table 20, Annex). There are clear and marked decreases in the numbers of nurses migrating to the UK. In 2002, as noted above, Buchan and Dovlo (2004) for the first time, over 50% of new nurses admitted to the NMC register were from overseas (a year in which the US recruited 2224 nurses from the UK). Bevan (2005) maintained that 2,800 nurses and midwives from countries on the “banned” list registered to practise in the UK in the year to the end of March 2005; out of a total of about 11,000. As Pond and McPake (2006) pointed out, the number of nurses working for the NHS went up by 48,800 (about 20%) between 1997 and 2003 and 73% of this increase was achieved through international recruitment. The process has been reversed since 2003. Overall, 2007–8 has seen a 28% fall in one year in admissions from countries in central and southern Africa and a 22% rise in admissions from the Indian sub-continent. Of the main provider countries in the earlier part of the decade, the Philippines peak of over 7000 registrants in 2002 has decreased to 249 in 2008 and the South African peak (2114) of the same year has decreased to a trickle (32) over the same period (Figure 9). The Indian peak of 2004–5 of nearly 4000 has dropped to 1000 in 2007–8.

Figure 9: Number of registrations with NMC (and predecessor) from main supplier countries, 1999– 2008

8.000

7.000

6.000 Australia 5.000 India Philippines 4.000 New Zealand

3.000 Nigeria South Africa 2.000

1.000

Most international registrants are nurses rather than midwives; for example, only 22 of the 11477 new overseas-trained registrants in 2004–2005 were midwives, this is because of restrictions on admission to the register for midwives from most countries outside the EEA.

There is inadequate date on migration of nurses from the United Kingdom. The main receiving countries based on limited evidence appear to be Ireland, Germany, Spain and France within Europe and Australia, Canada, New Zealand the USA and the Middle East, particularly the Gulf States, outside Europe. It is difficult to say how much this is UK nationals emigrating, or non-UK qualified professionals returning home or moving onto a third country (NMC, 2004). As one senior manager in a large Trust noted:

Back in 2003–5, we were bringing huge numbers of Filipino nurses; in the region of 300 nurses from the Philippines. Tried to bring in some nurses from South Africa but that wasn’t particularly successful; we had about 40 or 50 South African nurses… Since 2007, we’ve been creating our own nurses. Birmingham’s been particularly successful in recruiting people for the nursing profession and retaining them. Unlike the South East where they have quite major recruitment problems. We haven’t gone abroad for nursing staff since about 2006–7. But we still have quite a high number of Filipino nurses who have stayed with us and South African nurses who are still working with us. A lot of them have married and gained British citizenship and stayed. We saw quite a big turnover of

Filipino nurses after two years; a number went home at the end of two years and we picked up some new Filipino nurses then but not much since. In contrast, a senior manager at a specialist children’s hospital said:

At the Children’s we don’t [have experience of recruiting from abroad] because we have enough people wanting to work here…. The messages we’re getting from the centre are we don’t want you to recruit from abroad, we need to be looking at the local population. Here, we’ve invested a lot in widening participation, looking at career frameworks, looking at progression routes, trying to build up that local community retention of staff…. And for our nursing provision, if you look at recruits to the universities for the child branch nursing programme they have eight applicants for every post.

This is further compounded by approaches abroad, especially in the United States. As one respondent said: The United States are not recruiting enough and there is an even bigger dislocation between the training and the education side and the provider side. The providers are trying to get them as cheap as possible. So the occupation is not so attractive and they will have a massive shortfall. What will happen, we’ll probably hit a nursing shortage in two or three year’s time.

This issue of workforce planning is addressed further below.

4.3.3 Dentists

All dentists and dental professionals must be registered with the General Dental Council (GDC) before they can work in the United Kingdom, whether they work in the NHS, in private practice or any other form of practice.

The total number of registered dentists in the UK as of 6 July 2009 was 35,845. In the past the GDC did break down the number of dentists from specific countries (EEA only) but that is no longer collated.2

In 2006, a report on dentists in the National Health Service in England was published. The report entitled NHS Dental Activity and Workforce Report England 31 March 2006 (The Information Centre, 2006), covers treatment provided under the General Dental Service (GDS) and Personal Dental Service (PDS), often referred to as 'high street dentist', in England up to 31 March 2006, the day before the new NHS dental contract was introduced.

2 The Freedom of Information enquiry elicited the following response re country breakdown: ‘I have contacted out Database Dept. to find out if there is a way of retrieving it [country of qualification]. If they are able to provide any such data then I will forward it to you.’ No such data received

There were 24.7 million patients registered with an NHS dentist as at 31 March 2006 an increase of half a million (2.4%) than at the same point in 2005. Forty-five per cent of adults and 64% of children were registered.

As of 31 March 2006, there were 21,111 NHS dentists on a Primary Care Trust list in England, up3 6.6% on 2005 and 28% higher than in 1997. An NHS dentist may perform as little or as much NHS treatment as he or she chooses or has agreed with a Primary Care Trust. In some cases an NHS dentist may appear on a PCT list yet not perform any NHS work in that period.

As of 31 March 2006, 63% of all NHS dentists were male. The percentage of female dentists was higher in the younger age groups: 53% of NHS dentists aged under 30 were female.

Of those NHS dentists at 31 March 2006, there was no country recorded for around 7%. Where the country of qualification was known, 21% of all dentists qualified outside the United Kingdom (Table 21, Annex). South Africa provided the highest proportion of NHS dentists who qualified overseas with 4.6% all dentists where the country of qualification was known; Sweden was second with 3.8%, Poland 2.1% Ireland 1.9% and Greece 1.1%. Nearly 46 per cent of new NHS dentists (where the country of qualification was known) qualified outside the UK in the year to 31 March 2006. This is the highest proportion recorded in the last ten years. Those who qualified in Poland accounted for 17% of new entrants. Notably, new entrants from South Africa have declined in numbers steadily from the 2000 high of 172 to just 22 dentists in 2006. There has been a similar but not quite so sharp drop in dentists qualified in Sweden. The influx from Poland began in 2005 with the expansion of the EC. There has been a steady increase in dentists qualified in Greece and Germany and a more recent increase from Spain (Table 22, Annex).

Overall, there is little evidence of much international migration of dentists into England from non- European ‘at risk’ countries other than South Africa, which had reduced greatly by 2006. The data do not include dentists who operate entirely privately or who work in the other three countries of the UK.

4.3.4 Pharmacists

As of 1st September 2009 there were 50,023 pharmacists and 7,959 pharmacy technicians registered with the Royal Pharmaceutical Society of Great Britain. Of the pharmacists, 41,673 were practicing (58.4% female), while most, 7,923 of the technicians were practicing. A total of 38,356 of all registered pharmacists operated in England (76.7%), 9% in Scotland, 4.3% in Wales and 9.5% overseas (RPSGB, 2009e). Information provided by the society indicate 501 non-UK, EEA qualified registrants in 2007 and 442 in 2008: the largest numbers coming from Poland and Spain (Table 23, Annex).

According to the Society’s Your Register publication, (RPSGB, 2008), non-European, internationally-qualified pharmacy graduates must enter the register via the RPSGB Adjudicating Committee. The role of the Adjudicating Committee is to examine the comparability of the applicants’ degree course with the UK MPharm and to decide the route applicants should take to

the register. Between August 2007 and July 2008 the Adjudicating Committee considered 175 standard applications and 4 non-standard applications (those applicants whose pharmacy degree is not comparable to British Bachelor degree level or who cannot provide the necessary application documentation). All non-standard applicants were interviewed by the committee. In the academic year 2007–8 170 students joined the OSPAP course at the four Universities offering the course (Sunderland, Aston, Brighton and The Robert Gordon University in Aberdeen). Of those, 166 entered pre-registration training.

The Society also provided another table (as a tif document) that indicates, it seems, the country of international applicants between 2001–06 (Table 24, Annex). The Society explained, via correspondence from the Records Manager that:

Unfortunately we are not able to provide you with the details of which countries the pharmacists on our registers come from at any given time. Nationality at the time of first registration is recorded but that is not necessarily the same as the country in which they studied or originally came from, or indeed their nationality at the time of searching the register. The process for an overseas qualified pharmacist (from outside the European Union) to join our register, requires them to successfully complete a 1 year course (OSPAP) in the UK, followed by a year of pre-registration training; they then have to pass the Society's registration examination. The applicants can withdraw from the process at any stage. There is currently no time limit on them starting pre-registration training following the successful completion of the OSPAP. They have 18 months from completion of their pre-registration training to enter the exam. They can have 3 attempts at passing the exam but can withdraw their exam entry before sitting and then take at a later date. Often applicants start the process and fail at some stage, for example, to get a visa renewal or family circumstances change, so they do not progress at the time but make a new application at a later date, when their circumstances have changed again. We cannot be sure that all the overseas applicants we have processed through our international registration department reach the register, so the information we hold on them would need to be cross referenced with the information on the register (the databases cannot interrogate each other). The register is a constantly changing record; people come and go for a variety of reasons and at various times during a year. Ascertaining which country every pharmacist on the register has qualified on a given day would be an intensive task involving looking at each individual file (we have about 3270 electronic records for those qualified outside the EU), noting their country of qualification, looking at the register (which is on a different database) and manually recording the country of qualification of everyone that is on the register that day. It could then be that the information would be obsolete for example, the following day. EU nationals generally go straight onto the register once their application is approved. Again, they come and go from our registers and information might only be valid for that day. This limited data suggests that there was relatively little in migration of pharmacists from other countries outside the EEA, with, in 2006, Nigeria topping the list with 36, India 32 and Ghana 12.

4.3.5 Opticians

As of 2009, the General Optical Council registers around 23,500 optometrists, dispensing opticians, student opticians and optical businesses. Detailed data on the numbers of registered opticians and their country of qualification is difficult to obtain. The Registration Supervisor of the General Optical Council replied to a request for information: We do not have this data stored consistently or in a straightforward way. We cannot track down information about registrants who have moved abroad, unfortunately the only way of doing this (as we do not specifically record such data) is via searching our database according to address changes. Due to the restrictions of the search facility it is not feasible to do this. We have only started to record country of qualification on our data base recently. And so would not be able to get data as far back as 1998. I will however look into what data can be gathered that might be of use to you. I would also recommend contacting the College of Optometrists as they carry out the Non EEA/EU examinations that all Optometrists from outside the EEA/EU must take in order to work in the UK. The information they provide may however not correlate directly to registered optometrists as not all register post examinations.

I will get back to you with any additional information I can find as soon as possible. Kind regards,

Unfortunately no data was forthcoming.

4.3.6 Osteopaths

As of April 2009, there were 4,078 osteopaths on the UK Statutory Register of Osteopaths (2,130 male, 1,948 female). The majority of osteopaths are aged between 31 and 50, although the profession includes all ages between 21 and 70. Countries of residence of registrants: England (85.2%), Scotland (3.1%), Wales (2.2%), Northern Ireland (0.4%) and overseas (and operating abroad) (9.1%).

Most osteopaths work in private practice. Osteopathy remains principally a form of private healthcare with more than 80% of patients funding their own treatment. Costs vary but typically are around £35 for a 30-minute session. Most major private health insurance policies provide cover for osteopathic treatment. In 2007, private health insurance accounted for 10.4% of payments for osteopathic treatment.

Public opinion surveys show that 88% of respondents to survey thought the NHS should or did provide osteopathic treatment (GOsC, 2006; 2006–07).

Excerpts from the Annual Reports of the General Osteopathic Council (GOsC) for the 2007 and 2008 indicate that the overwhelming majority of osteopaths working in the UK were trained in the UK. The 2006–07 Annual Report states During the financial year 2006–2007, 203 new osteopaths were added to the Register – 200 graduates from UK Osteopathic Educational Institutions and three from overseas.

The net gain of 113 osteopaths resulted from the further addition of 12 osteopaths through restoration and 102 removals – only two of which were as a result of disciplinary action.

The number of UK graduates has increased steadily each year, and the number of potential registrants for 2007–2008 is the highest yet. Comparing the age range of osteopaths at 31/03/2005 to that of today, it can be seen that in all but the 21–30 age range, numbers have increased. The majority of osteopaths fall into the 31–50 age groups, and there are now potentially more than 200 osteopaths who may retire in the next two to three years. The 2007–08 Annual Report states:

We currently register just over 4,000 osteopaths. As at December 2007, 53% of osteopaths were male and 47% female, showing a slight variance on the 2006 ratio of 55% male and 45% female. Looking to the future, the trend suggests an increasing proportion of female osteopaths entering the profession: for example, the graduate intake to the UK Register for 2007 indicated that females accounted for 51% and males 49%. A data collection exercise planned for late 2008 will enhance the Register’s ethnicity and disability profile.

This year we registered 275 new osteopaths, of which: 267 trained in the UK and hold a recognised qualification; 8 have qualifications achieved outside the UK, including 2 from the EU/EEA; the balance were applicants from Australia and Brazil (Table 25, Annex). During this reporting period, 111 osteopaths were removed from the Register, for the following reasons:

 Retirement from practice: 4

 Resignation (for reasons such as moving abroad, full-time parenting or ill-health): 68

 For failing to renew their registration through non-payment of the annual registration fee: 38

 Deceased: 1

 As a result of a disciplinary hearing: 0

The 2007–08 Annual Report comments on its overseas members, thus: The GOsC registers a relatively high number of individuals who are practising abroad – in over 40 countries around the world. If required by a registering body outside the UK, the GOsC will issue a Certificate of Current Professional Standing. This confirms that an osteopath is or was registered with the GOsC and will indicate if there are any outstanding complaints against that osteopath. As osteopathy becomes more widely regulated around the world, it is hoped similar information will be shared by registering bodies outside the UK with the GOsC, with respect to osteopaths applying from abroad to join the GOsC’s UK Register.

4.3.7 Chiropractors

Information provided by the General Chiropractic Council (2009) indicated that, since the legislation came into force in 2002, 311 chiropractors applied for registration as holding a relevant unrecognised chiropractic qualification under the GCC (Registration of Chiropractors with Foreign Qualifications) Rules 2002. Some of these have subsequently withdrawn their application or have been refused registration. Limitations in databases make it difficult to be more precise.

Overall, as of 2009, the nationality of current registrants and of those who have been removed from the register (either moved abroad or allowed registration to lapse) shows an overwhelming number of British and very few registrants from less developed countries (Table 26, Annex).

4.3.8 Other health professions

As of 1 April 2009, there were 185,689 practitioners registered with the Health Professions Council (Table 27, Annex).

The total number of practitioners has increased steadily over forty years (Table 28, Annex).

There appears to be relatively little migration of health professionals covered by the HPC, although detailed data on international practitioners is not available.

Currently, the HPC has 120 EEA one-year temporary registrations (registered September 2008– September 2009) (Table 29, Annex) Physiotherapists make up about half all the temporary registrations with the HPC.

As one respondent noted, “We did look to bring over some radiographers but that didn’t come off because of the barriers to entry thrown up by the Royal Colleges.”

4.4 Workforce planning

One of the biggest issues that emerged from the qualitative interviews was the inadequacy of workforce planning and the concomitant control exercised by the Royal Colleges. The boom and bust in in-migration is, it is argued, a function of the inability to identify workforce needs and plan appropriate training. This, it is further argued, is aggravated by the control of the Royal Colleges restricting numbers of trainees, ostensibly to maintain high salaries. One Associate Director for Education and Learning was concerned about the lack of effective workforce planning.

I remember that peak when everyone ran off to get overseas employees because we had a shortage of nurses…. I don’t think there was a real emphasis on ensuring workforce planning worked in synergy with education commissioning. If you’ve been around along as most of us in the NHS all the buzz words are we must get workforce planning right, we have to have the right people in the right job at the right time, workforce development is key; everybody says that but it is so hard to do because people find it difficult to predict what the future workforce is going to be like. And they don’t necessarily take into account at the appropriate time the lead-in time for educational commissioning. Rather than look at what they want the functions of the workforce to be doing they look at what have we

got now and what do we need more of, so you get more of the same. Rather than, these are the functions and skills we need, we know the service is going to change and look like XYZ, what do we need to commission now for that?

The respondent further elaborated.

The difficulty was that workforce planning was predominantly done as a number- crunching exercise in a cupboard by a workforce planner and now there is recognition that now you need to have clinical input, you need to have other data, you need to take into consideration the demographics of your population, you need to think about what new technologies are coming on board to help you make those informed decisions. That data may have been there but I don’t think the health service was savvy enough to make use of that. The lack of adequate workforce planning was seen as inevitably leading to constant swings in the immigration of health professionals. “I think it will go up and down and that’s because we don’t get workforce planning right. We’re not looking at what the skills are that we need.” For another manager, the role of the Royal Colleges was seen as a vital inhibitory force.

“We’re training more—its not even that simple—because the Royal Colleges control the number of people coming out at the top end. So the Royal Colleges and the deaneries work out how many people we should be training through run-through training. (In this country once you’ve finished your medical degree so you go into run-through training, which is Foundation year 1, Foundation year 2, Specialist year 1, Specialist year 2 going all the way through to, in seven years time, regardless of your level and ability and so long as you don’t do anything really wrong, in seven years time you become a consultant.) But the numbers coming in the bottom of the funnel are controlled by the Royal Colleges who are guessing, from retirement and natural wastage, how many doctors you’ll need in that speciality in seven years time. In any other industry that would be called a barrier to trade and a barrier to entry. So the people who are deciding the number of ophthalmologists, for example, who will become consultants, and you got to remember it not only effects the number of jobs in the NHS but also the supply in the private sector, is decided by ophthalmologists. So they decide how many people go into training. So you’ll have all of these people entering training, and they’ve increased the numbers, that will go into run-through training posts, which they run-through at very, very high cost running all the way through into consultant numbers, which is decided not by what the service needs but what the profession believes they require.”

The respondent elaborated further on the restrictive practices of the Royal Colleges:

We have, effectively, within health, a masonry system. It’s a group of trades. We have the Royal College of Surgeons, Royal College of Physicians, Royal College of Obstetricians. We’ve even got the Royal College of Clinical Perfusionists, these aren’t even doctors. We’ve got the Royal College of Therapists, Royal College of Physios, Royal College of OT, the NMC. On top of that you’ve got GMC, BMA and put all that together and you can see why it’s such a closed shop. Regulation needs to be tight, you can’t have anyone coming in looking after your patient, and people have to have a standard they have to meet. But the transparency isn’t there in the Royal Colleges. What incentives do they have to open up the market? Well they don’t. That’s why it’s very difficult. We wanted to

bring in clinical perfusionists from Spain because we had a shortage of clinical perfusionists and the number of clinical perfusionists was being kept relatively small (these are people who work in theatre). There is a closed shop of clinical perfusionists and you’ve now got a college of clinical perfusionists who have set their own criteria, which makes it incredibly difficult to recognise anybody coming from Europe. They are not being discriminatory. They are saying you got to have these qualifications that only UK perfusionists have. Until we start tackling some of these barriers to entry we’re never going to get that free flow of migration of health professionals. As a consequence of the perceived inflexibility due to workforce planning inadequacies or the restrictive practices of the Royal Colleges, hospitals were devising new posts. In both a large general hospital and a smaller specialist hospital, new roles were being developed to overcome shortages of personnel and reduce cost.

In this [specialist] Trust we’re going to be looking at physician assistant and that’s a highbred of an individual who is undergoing intensive training to perform some medical duties but they’re not a doctor. And they can perform those duties within a defined area…. They have highly specialist skills in one area. They couldn’t operate outside of that area. And we’re also looking at our advanced nurse practitioner because we’re looking at what: functions do our doctors perform; what functions can we take off them so they can concentrate on what we need them to do; and what functions can we give to the nurses to upskill them? The manager at the large general hospital explained how they had developed new posts:

So we’ve created what we call junior specialist doctors, which is open to applicants worldwide. It mirrors the junior doctors contracts up to the out-of-hours service and for out-of-hours we pay an enhancement we don’t pay junior doctor banding [an expensive form of overtime payment that has to be paid to British graduates]…. So we’re beginning to think of more innovative ways how do we attract in doctors which are outside of UK terms and conditions and why are we doing that? Well UK terms and conditions are punitive. We don’t get the doctors that we need and trained to the level that we require them to be trained. They are very, very expensive…The Foundation Year 1 doctor now, basically all they can do is take a history, they can clerk a patient, they can’t do anything else; which is fine—doctors in training I’m more than happy with that—but I don’t see why I should be paying them £40,000 per year to do that when I could get someone from abroad as a junior specialist doctor with a much higher level of training for the same money who can do far more. There are big, big issues around the way that medical education is run in this country, which is creating disincentives to actually appoint our own juniors.

The respondent also explained how a specialist consultant post also advantaged the overseas applicant. If you come through our system we have a special consultant post whereby if you join as special consultant your terms and conditions are as a consultant even though you haven’t got CCT, which is the certificate of completion of training and which the GMC insist on to become a consultant but we recognise you as a consultant even though you haven’t got CCT but have got equivalency in our eyes. If they’re working for us they get their

incremental points every year. If they weren’t working for us they would sit at the top of the associate specialist and over time would fall further and further back and once they do get their CCT through article 14, which is a way around going through the run-through training, which is incredibly bureaucratic and difficult, and there are many obstacles as they can possibly create via the PMETB, Postgraduate Medical Education and Training Board, which is the council that meets and you have to go and present your case to get your ticket as a consultant. If you spend three years fighting to get recognition as a consultant because you’ve got equivalency, when you start as a consultant you start at the bottom of the grid. If you do it here you’re into your third year and when you get your CCT we recognise it and we don’t send you back to the beginning again; you continue right through. So there’s no financial detriment to you. I don’t know whether there’s an equal pay issue elsewhere when they get their CCT [and have to start at the bottom]. But that’s not been tested.

Another respondent, who had also done some research into workforce planning, considered it to be the major factor influencing migratory flows:

Millions have been spent on workforce planning (in the NHS). … Every PCT and Acute has to return guesstimated numbers of the workforce they need in ten years’ time. And then the SHA pull that together—it’s done nationally—and it comes up with the picture that in 2021 we will need 20,000 doctors being churned out of our medical schools. That’s how workforce planning is done. It doesn’t take into account anything else. You just put your finger in the air and guess what you need. Nursing’s slightly better; it’s a three-year lead-in time. But ten years for doctors. But things happen and it doesn’t. For example, look at birth rates so need to increase midwifery training. It doesn’t look at anything that could happen whatsoever, that could have an effect. It doesn’t look at alternative careers that may be needed. It doesn’t look at anything. And that’s how all nursing and medical places are commissioned. And what about drop-out rate [from programmes]. I think they take into account a 5% drop-out. That’s stupid. On a bad year you could loose up to 50% on nursing courses. Which is why you’ve suddenly got these peaks and troughs where we go overseas and we recruit. Because half the nurses dropped out three years before, the birth rate’s gone up, so we need more midwives, people are living longer, they’re older, they need more support: none of that’s taken into account. And yet they’ve spent billions on workforce planning. We have a team of five people, with 13000 staff, working on workforce planning. So if you look at it from that end you can see how an individual trust says that there is no-one there really reviewing what their workforce needs are and how best they can achieve them. … So in a nutshell, NHS workforce planning.

5 Results of qualitative interviews

Results are integrated into the text above as recommended in the email correspondence

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Annex: Tables

Table 1: The Economist Political Instability Index of 165 countries Rank Country Underlying Economic Index score 2007 score vulnerability distress 1 Zimbabwe 7.5 10.0 8.8 8.8 2 Chad 7.1 10.0 8.5 7.5 3 Congo (Democratic Republic) 8.3 8.0 8.2 7.2 4 Cambodia 7.9 8.0 8.0 6.0 4 Sudan 7.9 8.0 8.0 7.0 6 Iraq 8.8 7.0 7.9 7.9 7 Cote d'Ivoire 7.5 8.0 7.8 7.8 7 Haiti 7.5 8.0 7.8 6.8 7 Pakistan 7.5 8.0 7.8 5.8 7 Zambia 7.5 8.0 7.8 6.8 7 Afghanistan 7.5 8.0 7.8 6.8 7 Central African Republic 7.5 8.0 7.8 5.8 13 North Korea 5.4 10.0 7.7 3.7 14 Bolivia 8.3 7.0 7.7 5.7 14 Ecuador 8.3 7.0 7.7 6.7 16 Angola 6.3 9.0 7.6 5.6 16 Dominican Republic 6.3 9.0 7.6 5.6 16 Ukraine 6.3 9.0 7.6 4.6 19 Bangladesh 7.1 8.0 7.5 4.5 19 Guinea 7.1 8.0 7.5 6.5 19 Kenya 7.1 8.0 7.5 6.5 19 Moldova 7.1 8.0 7.5 4.5 19 Senegal 7.1 8.0 7.5 6.5 19 Guinea Bissau 7.1 8.0 7.5 6.5 19 Nepal 7.1 8.0 7.5 6.5 19 Niger 7.1 8.0 7.5 5.5 27 Bosnia and Hercegovina 7.9 7.0 7.5 6.5 28 Liberia 8.8 6.0 7.4 5.4 29 Venezuela 6.7 8.0 7.3 4.3 29 Timor Leste 6.7 8.0 7.3 4.3 31 Sri Lanka 7.5 7.0 7.3 4.3 32 Sierra Leone 8.3 6.0 7.2 5.2 33 Argentina 6.3 8.0 7.1 4.1 33 Kyrgyz Republic 6.3 8.0 7.1 5.1 33 Madagascar 6.3 8.0 7.1 6.1 33 Myanmar 6.3 8.0 7.1 4.1 33 Panama 6.3 8.0 7.1 5.1 33 Tajikistan 6.3 8.0 7.1 6.0 39 Colombia 7.1 7.0 7.0 6.0 39 Lebanon 7.1 7.0 7.0 5.0 39 Peru 7.1 7.0 7.0 6.0 39 South Africa 7.1 7.0 7.0 4.0 39 Thailand 7.1 7.0 7.0 6.0 44 Lesotho 7.9 6.0 7.0 6.0 44 Nigeria 7.9 6.0 7.0 7.0 44 Mali 7.9 6.0 7.0 5.9 47 Burkina Faso 5.8 8.0 6.9 6.9 47 Burundi 5.8 8.0 6.9 5.9 47 Cameroon 5.8 8.0 6.9 4.9 47 Papua New Guinea 5.8 8.0 6.9 5.9 47 Mauritania 5.8 8.0 6.9 3.8 52 Honduras 6.7 7.0 6.8 4.8 52 Indonesia 6.7 7.0 6.8 3.8 54 Philippines 4.6 9.0 6.8 4.8 55 Turkey 7.5 6.0 6.8 5.7 56 Eritrea 5.4 8.0 6.7 2.7 56 Estonia 5.4 8.0 6.7 5.7 56 Gambia 5.4 8.0 6.7 2.7 56 Latvia 5.4 8.0 6.7 5.7 60 Guyana 8.3 5.0 6.7 5.6 61 Algeria 6.3 7.0 6.6 4.6 61 Guatemala 6.3 7.0 6.6 5.6 61 Macedonia 6.3 7.0 6.6 3.5

Rank Country Underlying Economic Index score 2007 score vulnerability distress 64 Malaysia 7.1 6.0 6.5 6.5 64 Uganda 7.1 6.0 6.5 3.5 66 Russia 5.0 8.0 6.5 3.4 67 Paraguay 5.8 7.0 6.4 3.4 67 Romania 5.8 7.0 6.4 5.4 67 Serbia 5.8 7.0 6.4 5.4 67 Montenegro 5.8 7.0 6.4 3.3 71 Greece 4.6 8.0 6.3 3.3 71 Uzbekistan 4.6 8.0 6.3 8.3 73 Congo (Brazzaville) 7.5 5.0 6.3 6.3 73 Georgia 7.5 5.0 6.3 5.2 75 Albania 5.4 7.0 6.2 4.2 75 Belize 5.4 7.0 6.2 5.2 75 Iran 5.4 7.0 6.2 3.2 75 Turkmenistan 5.4 7.0 6.2 5.1 79 Croatia 6.3 6.0 6.1 4.1 79 Equatorial Guinea 6.3 6.0 6.1 3.1 79 Mexico 6.3 6.0 6.1 5.1 79 Yemen 6.3 6.0 6.1 3.1 83 Hungary 4.2 8.0 6.1 2.1 83 Lithuania 4.2 8.0 6.1 4.1 83 Saudi Arabia 4.2 8.0 6.1 3.1 83 Mongolia 4.2 8.0 6.1 4.0 87 Bulgaria 5.0 7.0 6.0 4.0 87 Jamaica 5.0 7.0 6.0 3.9 89 Benin 5.8 6.0 5.9 4.9 89 Ghana 5.8 6.0 5.9 3.9 89 Nicaragua 5.8 6.0 5.9 5.9 89 Tanzania 5.8 6.0 5.9 4.8 93 Namibia 6.7 5.0 5.8 4.8 94 Armenia 4.6 7.0 5.8 3.8 94 Syria 4.6 7.0 5.8 4.7 96 Malawi 5.4 6.0 5.7 4.7 96 Mozambique 5.4 6.0 5.7 5.6 98 Morocco 6.3 5.0 5.6 4.5 99 Bahrain 5.0 6.0 5.5 4.5 99 Cape Verde 5.0 6.0 5.5 2.5 99 Israel 5.0 6.0 5.5 3.5 99 Kuwait 5.0 6.0 5.5 3.5 99 Slovakia 5.0 6.0 5.5 2.5 104 Spain 2.9 8.0 5.5 4.4 105 Brazil 5.8 5.0 5.4 4.4 106 Egypt 3.8 7.0 5.4 4.4 106 Jordan 3.8 7.0 5.4 5.3 108 Togo 4.6 6.0 5.3 3.3 108 Bhutan 4.6 6.0 5.3 2.3 110 France 2.5 8.0 5.3 1.3 110 Iceland 2.5 8.0 5.3 1.3 110 United States of America 2.5 8.0 5.3 3.2 113 Azerbaijan 5.4 5.0 5.2 4.2 113 El Salvador 5.4 5.0 5.2 3.2 115 Uruguay 3.3 7.0 5.2 4.1 116 Gabon 6.3 4.0 5.1 3.1 117 Chile 4.2 6.0 5.1 4.1 117 Ethiopia 4.2 6.0 5.1 4.1 117 Laos 4.2 6.0 5.1 2.1 117 South Korea 4.2 6.0 5.1 2.0 121 Italy 2.1 8.0 5.0 4.9 122 Rwanda 5.8 4.0 4.9 3.9 123 Portugal 1.7 8.0 4.8 1.8 124 Belarus 4.6 5.0 4.8 2.8 124 China 4.6 5.0 4.8 3.8 124 Kazakhstan 4.6 5.0 4.8 3.8 127 Botswana 5.4 4.0 4.7 2.7

Rank Country Underlying Economic Index score 2007 score vulnerability distress 127 Swaziland 5.4 4.0 4.7 4.2 127 Trinidad and Tobago 5.4 4.0 4.7 2.7 130 Malta 3.3 6.0 4.7 2.7 130 Singapore 3.3 6.0 4.7 1.7 132 Ireland 1.3 8.0 4.6 0.6 132 United Kingdom 1.3 8.0 4.6 0.6 134 Tunisia 4.2 5.0 4.6 4.6 135 India 5.0 4.0 4.5 4.5 136 Poland 2.9 6.0 4.5 3.5 137 Libya 4.6 4.0 4.3 2.3 137 Sao Tome & Principe 4.6 4.0 4.3 4.3 139 Taiwan 2.5 6.0 4.3 1.3 139 Vietnam 2.5 6.0 4.3 2.3 141 Cuba 3.3 5.0 4.2 2.2 142 Cyprus 4.2 4.0 4.1 2.1 142 Qatar 4.2 4.0 4.1 4.1 142 Seychelles 4.2 4.0 4.1 5.1 142 United Arab Emirates 4.2 4.0 4.1 2.1 146 Belgium 2.1 6.0 4.0 2.0 146 Hong Kong 2.1 6.0 4.0 1.0 146 Netherlands 2.1 6.0 4.0 1.0 149 Oman 3.8 4.0 3.9 2.9 150 Germany 1.7 6.0 3.8 1.8 150 Japan 1.7 6.0 3.8 0.8 150 Slovenia 1.7 6.0 3.8 1.8 153 Czech Republic 3.3 4.0 3.7 2.7 154 Australia 1.3 6.0 3.6 0.6 154 Austria 1.3 6.0 3.6 0.6 154 Luxembourg 1.3 6.0 3.6 0.6 154 New Zealand 1.3 6.0 3.6 0.6 158 Costa Rica 2.1 5.0 3.5 1.5 158 Mauritius 2.1 5.0 3.5 2.5 160 Switzerland 0.8 6.0 3.4 0.4 161 Finland 0.4 6.0 3.2 1.2 161 Sweden 0.4 6.0 3.2 1.2 163 Canada 1.7 4.0 2.8 1.8 164 Denmark 0.4 4.0 2.2 0.2 165 Norway 0.4 2.0 1.2 0.2

Source: Economist (2009) http://viewswire.eiu.com/site_info.asp?info_name=social_unrest_table&page=noads&rf=0 The index score is the mean of the underlying vulnerability and economic distress scores (rounded up). The three components of the economic distress indicator are: 1. Growth in incomes: Growth in real GDP per head in 2009. 0 if forecast growth in real GDP per head is positive, with minimal risks that it could be negative; 1 if a fall in GDP per head is forecast or there is a significant risk of that occurring, but the decline is less than by 4%; 2 if a forecast decline in GDP per head is greater than by 4% or there is a significant risk that this could occur. Weighting 40% Source: Economist Intelligence Unit. 2. Unemployment: Unemployment rate, %. 0 if forecast unemployment rate is less than 6% and there are only minimal risks that it could be higher than 6%; 1 if a forecast unemployment rate is higher than 6% or there is a significant risk of that occurring, but the rate does not surpass 10%; 2 if a forecast unemployment rate is higher than 10% or there is a significant risk that this could occur. Weighting 40% Sources: Economist Intelligence Unit; International Labour Organisation. 3. Level of income per head: Measured by GDP per head at PPP, US$ in 2007, on the assumption that richer countries can more easily withstand economic distress 0 if more than US$12,000; 1 if between US$3,000 and US$12,000; 2 if less than US$3,000. Weighting 20% No source stated. The twelve components of underlying vulnerability are: 1. Inequality: Measured by Gini coefficient 0 if lower than 40; 1 if 40-50; 2 if higher than 50 Sources: World Bank, World Development Indicators 2008; Economist Intelligence Unit estimates. 2. State history: Measured according to date of independence 0 if before 1900; 1 if between 1900 and 1950; 2 if after 1950

Source: CIA, Factbook. 3. Corruption: Economist Intelligence Unit ratings 0 for low; 1 for moderate; 2 for high Source: Economist Intelligence Unit. 4. Ethnic fragmentation: Ethnic fractionalisation index (0 to 100 scale) 0 if lower than 30; 1 if 30 to 50; 2 if higher than 50 Source: Alesina Alberto et al., 2003, "Fractionalization", NBER Working Paper 9411. 5. Trust in institutions: Percentage of population that trusts/has confidence in parliament 0 if more than 50%; 1 if 30-50%; 2 if less than 30% Sources: The Euro, Latino, Africa and Asia Barometer polls; World Values Survey. 6. Status of minorities: High rates of economic or political discrimination against minorities. Based on latest available assessment and scoring on 0 (no discrimination) to 4 (extreme discrimination) scale by Minorities at Risk Project (MRP). The MRP defines extreme discrimination (score of 4) if any minority group is subject to public policies that constitute formal exclusion and/or recurring repression, and that substantially restrict the groups' economic opportunities or political participation. There is significant discrimination (score of 3) if minority group suffers from significant poverty and under- representation owing to prevailing social practices by dominant group. 0 if low or no discrimination (MRP scores lower than 3); 1 if significant discrimination (if score of 3 by for any minority by MRP); 2 if extreme discrimination (if score of 4 for any minority by MRP) 7. History of political instability: Significant episodes or events of political instability (regime change) as recorded by Political Instability Task Force (PITF) 0: if no recorded episode; 1 if one major episode; 2 if two or more episodes Source: PITF database. 8. Proclivity to labour unrest: Risk of labour unrest 0 if low; 1 if moderate; 2 if high Source: Economist Intelligence Unit, Risk Briefing. 9. Level of social provision: Measured on the basis of the "expected" infant mortality rate; based on residuals from a regression of the natural logarithm of the infant mortality rate on the logarithm of GPP per head US$ at purchasing power parity (PPP) for 2006. 0 if the actual infant mortality rate is lower than predicted, or if the actual rate does not exceed the predicted rate by a significant margin; 1 if ratio between actual and predicted infant mortality rate is greater than 1.1 but less than 1.5 ; 2 if ratio between actual and predicted infant mortality rate is greater than 1.5 Sources: Economist Intelligence Unit; World Bank, World Development Indicators 2008. 10. A country's neighbourhood: Based on the average vulnerability index (calculated on the basis of all indicators except the neighbourhood indicator) for all of the country's geographic neighbours. 0 if index is less than 5.8 ; 1 if index is 5.8 to 6.3; 2 if index is higher than 6.3 Source: Economist Intelligence Unit. 11. Regime type : Based on classification of political regimes, according to the Economist Intelligence Unit's Index of Democracy 0 if either a full democracy or authoritarian regime ; 2 if either a non-consolidated, "flawed" democracy or a hybrid regime (neither a democracy nor an autocracy) Source: Economist Intelligence Unit. 12. Regime type and factionalism: The interaction of regime type with the existence of political factionalism (according to Polity IV database). According to Polity, factionalism is defined as polities with parochial (possibly, but not necessarily, ethnic-based) political factions that regularly compete for political influence to promote particularist agendas and favour heavily group members to the detriment of a common agenda. 4 if a country is both an intermediate regime and suffers from factionalism; 0 if not Somehow these 12 elements are converted to a score out of 10 but the Economist web site isn’t clear on how this occurs given that theoretically scores could range from 0–26.

Table 2: Estimates of economic data for the UK, monetary values are in 2008 US dollars Indicator 2008 2008 2007 2006 world rank GDP (purchasing power parity) 7 $2.231 trillion $2.215 $2.151 trillion trillion GDP (official exchange rate) $2.787 trillion GDP - real growth rate: 196 0.7% 3% 2.8% GDP per capita (PPP) 31 $36,600 $36,500 $35,500 GDP - composition by sector agriculture:0.9% industry: 22.8% services: 76.2% Labor force 17 31.2 million Labor force - by occupation: agriculture 1.4% industry: 18.2% services: 80.4% Unemployment rate 66 5.5% 5.3% Population below poverty line 14% Investment (gross fixed): 136 16.7% of GDP Budget revenues: $1.107 trillion expenditures: $1.242 trillion Public Debt 41 47.2% of GDP Inflation rate 58 3.8% 2.3% Market value of publicly traded 5 $3.859 trillion* shares: Oil consumption 13 1.763 million bbl/day Electricity consumption 12 348.5 billion kW h Natural gas consumption 8 91.1 billion cu m Table derived from data in World Factbook, 2009. *31 December 2007

Table 3: Deaths: underlying cause, sex and age-group, 2007: summary

Underlying cause Age group (excludes deaths under 28 days for individual causes) All <1 1 – 4 5 – 9 10 –14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–74 75–79 80–84 85–89 90–94 95 and M 240,787 1,889 339 182 226 797 1,218 1,360 1,778 2,579 3,685 4,908 6,985 11,295 16,213 20,438 27,392 37,495 43,078 35,434 17,699 5,797 All causes, all ages F 263,265 1,456 235 121 192 357 453 543 817 1,407 2,380 3,354 4,718 7,375 10,791 13,524 20,379 32,223 47,188 53,319 40,636 21,797 All causes, ages under 28 M 1,268 1,268 ------days F 1,014 1,014 ------M 239,519 621 339 182 226 797 1,218 1,360 1,778 2,579 3,685 4,908 6,985 11,295 16,213 20,438 27,392 37,495 43,078 35,434 17,699 5,797 All causes, ages 28 days and over F 262,251 442 235 121 192 357 453 543 817 1,407 2,380 3,354 4,718 7,375 10,791 13,524 20,379 32,223 47,188 53,319 40,636 21,797 M 3,479 49 34 9 3 10 15 23 29 56 80 87 97 117 177 172 293 504 676 599 336 113 I Certain infectious and parasitic diseases F 4,690 27 27 11 7 13 14 15 26 35 47 45 63 84 116 171 331 543 883 1,124 789 319 M 72,970 10 45 53 45 85 97 140 203 354 751 1,231 2,284 4,439 6,956 8,886 10,845 12,905 12,092 7,898 2,963 688 II Neoplasms F 67,110 7 32 30 46 62 92 131 226 550 1,007 1,647 2,465 4,058 5,838 6,620 8,315 10,307 11,123 8,703 4,389 1,462 III Diseases of the blood M 435 6 6 6 - 4 9 6 7 7 18 16 22 24 27 30 34 58 50 50 37 18 and blood-forming organs and certain disorders involving the immune mechanisms F 594 3 5 2 10 2 2 6 5 6 10 13 17 24 29 39 52 58 87 92 86 46 M 3,248 20 27 10 11 17 24 24 33 50 47 82 85 144 173 268 388 558 559 435 227 66 IV Endocrine, nutritional and metabolic diseases F 3,966 15 15 10 14 15 29 33 30 26 51 59 73 109 119 188 335 510 673 765 572 325 M 5,390 - - - 1 18 83 130 164 141 145 109 87 70 87 120 240 564 1,082 1,285 818 246 V Mental and behavioural disorders F 11,192 - - 1 3 6 19 28 39 42 33 29 40 32 63 99 269 819 1,971 3,055 2,998 1,646 M 7,560 38 40 29 36 62 63 62 78 105 136 184 191 266 373 504 768 1,233 1,503 1,249 509 131 VI Diseases of the nervous system F 8,795 24 35 21 16 31 42 28 46 70 112 140 174 277 329 416 638 1,129 1,746 1,842 1,194 485 M 3 ------1 1 1 - - VII Diseases of the eye and adnexa F 4 1 - - - - - 1 ------1 - 1 - VIII Diseases of the ear M 6 ------1 - - 1 1 - - - - - 2 - - 1 - and mastoid process F 7 ------1 - - - - 2 - 1 - 1 1 - 1 IX Diseases of the M 82,015 40 24 7 10 38 65 101 195 425 805 1,368 2,138 3,488 5,122 6,533 9,450 13,611 16,398 13,794 6,543 1,860 circulatory system F 88,323 22 11 6 13 24 30 57 94 184 347 523 763 1,233 2,026 3,177 5,802 10,732 17,753 21,774 16,219 7,533 X Diseases of the M 31,514 36 25 14 16 23 24 19 30 97 150 269 386 792 1,332 2,090 3,197 5,017 6,681 6,208 3,685 1,423 respiratory system F 37,460 35 27 9 13 11 17 25 37 59 110 170 276 518 1,011 1,497 2,562 4,596 7,033 8,234 6,876 4,344 XI Diseases of the M 12,007 13 9 5 7 4 14 50 122 274 529 653 896 1,041 1,059 1,044 1,111 1,434 1,633 1,320 619 170

digestive system F 13,663 15 6 3 7 2 13 26 63 146 292 359 472 570 731 714 1,041 1,705 2,433 2,613 1,739 713 XII Diseases of the skin M 591 ------3 2 5 7 15 18 35 49 48 81 119 125 64 20 and subcutaneous tissue F 1,231 - - - 1 - 1 1 3 1 7 5 9 17 24 37 80 159 223 304 247 112 XIII Diseases of the M 1,284 2 3 1 2 3 - 5 6 3 14 16 20 33 69 76 127 185 268 264 132 55 musculo-skeletal system and connective tissue F 3,020 - 1 - 3 4 6 5 5 12 13 19 21 57 73 111 234 348 575 689 560 284 XIV Diseases of the M 4,690 5 2 - 1 2 5 10 4 16 15 34 41 65 124 182 365 696 1,022 1,110 693 298 genitourinary system F 6,611 3 1 1 3 1 3 2 9 20 18 31 38 60 106 167 351 691 1,284 1,620 1,449 753 XV Pregnancy, childbirth F 47 - - - - 3 5 7 11 12 9 ------and the puerperium XVI Certain conditions M 103 99 2 1 1 ------originating in the perinatal period F 77 73 3 - 1 ------XVII Congenital M 655 119 42 12 12 17 22 22 15 34 35 37 40 49 63 35 22 24 30 17 6 2 malformations, deformations and chromosomal abnormalities F 580 111 33 11 13 16 9 14 19 20 35 23 27 50 63 21 29 31 19 21 13 2 XVIII Symptoms, signs M 2,765 150 18 2 4 6 30 35 49 74 58 84 70 100 81 49 56 58 198 397 680 566 and abnormal clinical and laboratory findings, not elsewhere classified F 8,265 89 8 - 1 9 8 12 19 29 32 26 42 35 24 29 41 89 509 1,381 2,608 3,274 XX External causes of M 10,804 34 62 33 77 508 767 732 840 941 896 730 613 649 535 400 448 564 766 682 386 141 morbidity and mortality F 6,616 17 31 16 41 158 163 152 185 194 257 265 238 251 237 238 298 506 874 1,101 896 498 Source: Mortality Statistics. Deaths registered in 2007: DR_07, Review of the National Statistician on deaths in England and Wales, 2007. Laid before Parliament pursuant to Section 19 Registration Service Act 1953. Office for National Statistics (ONS), Series DR, available at http://www.statistics.gov.uk/downloads/theme_health/DR2007/DR_07_2007.pdf accessed 20 July 2009: derived from Table 5.

Table 4: Health indicators reported by the National Centre for Health Outcomes Development on its Clinical and Health Outcomes Knowledge Base website Indicator Title Last updated Next expected update

Abortions 2008.12 (Dec) 2009.10 (Oct)

Abortions by gestational age 2008.12 (Dec) 2009.10 (Oct)

Abortions performed in the NHS and privately 2008.12 (Dec) 2009.10 (Oct)

ACE inhibitor therapy for patients with diabetes mellitus 2009.05 (May) 2010.03 (Mar) ACE inhibitor therapy for patients with heart failure due to left 2009.05 (May) 2010.03 (Mar)

ventricular dysfunction

ACE inhibitor therapy for patients with myocardial infarction 2009.05 (May) 2010.03 (Mar) ACE inhibitor / ARB therapy for patients with chronic kidney 2009.05 (May) 2010.03 (Mar)

disease and hypertension

Acute sickness 2008.06 (Jun) 2009.10 (Oct)

Adults on prescribed medication 2008.06 (Jun) 2009.10 (Oct)

Adults who are overweight 2009.05 (May) 2009.10 (Oct)

Alcohol consumption 2009.05 (May) 2009.10 (Oct) Antiplatelet / anti-coagulant therapy for patients with atrial 2009.05 (May) 2010.03 (Mar)

fibrillation Antiplatelet / anti-coagulant therapy for patients with coronary heart 2009.05 (May) 2010.03 (Mar)

disease Antiplatelet / anti-coagulant therapy for patients with stroke or 2009.05 (May) 2010.03 (Mar)

transient ischaemic attack

Asthma review among patients with asthma 2009.05 (May) 2010.03 (Mar)

Abortions 2008.12 (Dec) 2009.10 (Oct)

Abortions by gestational age 2008.12 (Dec) 2009.10 (Oct)

Abortions performed in the NHS and privately 2008.12 (Dec) 2009.10 (Oct)

ACE inhibitor therapy for patients with diabetes mellitus 2009.05 (May) 2010.03 (Mar) ACE inhibitor therapy for patients with heart failure due to left 2009.05 (May) 2010.03 (Mar)

ventricular dysfunction

ACE inhibitor therapy for patients with myocardial infarction 2009.05 (May) 2010.03 (Mar) ACE inhibitor / ARB therapy for patients with chronic kidney 2009.05 (May) 2010.03 (Mar)

disease and hypertension

Acute sickness 2008.06 (Jun) 2009.10 (Oct)

Adults on prescribed medication 2008.06 (Jun) 2009.10 (Oct)

Adults who are overweight 2009.05 (May) 2009.10 (Oct)

Alcohol consumption 2009.05 (May) 2009.10 (Oct) Antiplatelet / anti-coagulant therapy for patients with atrial 2009.05 (May) 2010.03 (Mar)

fibrillation Antiplatelet / anti-coagulant therapy for patients with coronary heart 2009.05 (May) 2010.03 (Mar)

disease Antiplatelet / anti-coagulant therapy for patients with stroke or 2009.05 (May) 2010.03 (Mar)

transient ischaemic attack

Asthma review among patients with asthma 2009.05 (May) 2010.03 (Mar)

Beta blocker therapy for patients with coronary heart disease 2009.05 (May) 2010.03 (Mar)

Blood glucose levels in patients with diabetes mellitus 2009.05 (May) 2010.03 (Mar)

Blood pressure in patients with coronary heart disease 2009.05 (May) 2010.03 (Mar)

Blood pressure in patients with diabetes mellitus 2009.05 (May) 2010.03 (Mar)

Blood pressure in patients with stroke or transient ischaemic attack 2009.05 (May) 2010.03 (Mar)

Body Mass Index 2008.06 (Jun) 2009.10 (Oct)

Breast screening programme coverage 2005.07 (Jul) 2009.07

Care review among patients with dementia 2009.05 (May) 2010.03 (Mar)

Census count of resident population by age and sex 2004.07 (Jul) 2009.10 (Oct)

Cervical screening programme coverage 2005.07 (Jul) 2009.07 (Jul)

Cholesterol levels in patients with coronary heart disease 2009.05 (May) 2010.03 (Mar)

Cholesterol levels in patients with diabetes mellitus 2009.05 (May) 2010.03 (Mar) Cholesterol levels in patients with stroke or transient ischaemic 2009.05 (May) 2010.03 (Mar)

attack

Cigarette smoking 2009.05 (May) 2009.10 (Oct)

Communal establishments and their populations 2004.07 (Jul) 2009.10 (Oct)

Composition of the Census count of resident population 2004.07 (Jul) 2009.10 (Oct)

Comprehensive care plan for patients on mental health register 2009.05 (May) 2010.03 (Mar)

Conceptions 2008.12 (Dec) 2009.10 (Oct)

Controlled blood glucose levels in patients with diabetes mellitus 2009.05 (May) 2010.03 (Mar)

Controlled high blood pressure in patients with hypertension 2009.05 (May) 2010.03 (Mar)

Cotinine level 2009.05 (May) 2009.10 (Oct)

Cytology: cervical cancer screening 2009.05 (May) 2010.03

Deaths at home from all cancers 2008.12 (Dec) 2009.12 (Dec)

Deaths at home from all causes 2008.12 (Dec) 2009.12 (Dec)

Deaths at home from bladder cancer 2008.12 (Dec) 2009.12 (Dec)

Deaths at home from breast cancer 2008.12 (Dec) 2009.12 (Dec)

Deaths at home from cervical cancer 2008.12 (Dec) 2009.12 (Dec)

Deaths at home from colorectal cancer 2008.12 (Dec) 2009.12 (Dec)

Deaths at home from lung cancer 2008.12 (Dec) 2009.12 (Dec)

Deaths at home from oesophageal cancer 2008.12 (Dec) 2009.12 (Dec)

Deaths at home from prostate cancer 2008.12 (Dec) 2009.12 (Dec)

Deaths at home from stomach cancer 2008.12 (Dec) 2009.12 (Dec) Deaths within 30 days of a hospital procedure: coronary artery 2009.05 (May) 2010.03 (Mar)

bypass graft Deaths within 30 days of a hospital procedure: surgery (non- 2009.05 (May) 2010.03 (Mar)

elective admissions) Deaths within 30 days of emergency admission to hospital: 2009.05 (May) 2010.03 (Mar)

fractured proximal femur Deaths within 30 days of emergency admission to hospital: 2009.05 (May) 2010.03 (Mar)

myocardial infarction

Deaths within 30 days of emergency admission to hospital: stroke 2009.05 (May) 2010.03 (Mar)

Dependent children in households 2004.07 (Jul) 2009.10 (Oct)

Depression severity assessment at outset of treatment 2009.05 (May) 2010.03 (Mar)

Diastolic blood pressure 2008.06 (Jun) 2009.10 (Oct)

Economic position of residents 2004.07 (Jul) 2009.10 (Oct)

Educational qualifications 2004.07 (Jul) 2009.10 (Oct) Emergency hospital admissions and timely surgery: fractured 2008.06 (Jun) 2009.07 (Jul)

proximal femur Emergency hospital admissions: acute conditions usually managed 2008.06 (Jun) 2009.07 (Jul)

in primary care

Emergency hospital admissions: all conditions 2008.06 (Jun) 2009.07 (Jul)

Emergency hospital admissions: children with asthma 2008.10 (Oct) 2009.10 (Oct)

Emergency hospital admissions: children with gastroenteritis 2008.06 (Jun) 2009.07 (Jul) Emergency hospital admissions: children with lower respiratory 2008.06 (Jun) 2009.07 (Jul)

tract infections Emergency hospital admissions: chronic conditions usually 2008.06 (Jun) 2009.07 (Jul)

managed in primary care

Emergency hospital admissions: diabetic ketoacedosis and coma 2008.10 (Oct) 2009.10 (Oct)

Emergency hospital admissions: neuroses 2008.10 (Oct) 2009.10 (Oct)

Emergency hospital admissions: schizophrenia 2008.10 (Oct) 2009.10 (Oct)

Emergency hospital admissions: stroke 2008.06 (Jun) 2009.07 (Jul)

Emergency readmissions to hospital within 28 days of discharge 2008.10 (Oct) 2009.10 (Oct) Emergency readmissions to hospital within 28 days of discharge: 2008.12 (Dec) 2009.12 (Dec)

fractured proximal femur Emergency readmissions to hospital within 28 days of discharge: 2008.12 (Dec) 2009.12 (Dec)

hip replacement surgery Emergency readmissions to hospital within 28 days of discharge: 2008.12 (Dec) 2009.12 (Dec)

hysterectomy Emergency readmissions to hospital within 28 days of discharge: 2008.12 (Dec) 2009.12 (Dec)

stroke

Epilepsy review among patients on drug treatment for epilepsy 2009.05 (May) 2010.03 (Mar)

Estimates of resident population 2008.12 (Dec) 2009.10 (Oct)

Ethnic group and country of birth 2004.07 (Jul) 2009.10 (Oct) Exercise testing / specialist referral for patients with newly 2009.05 (May) 2010.03 (Mar)

diagnosed angina

Fat consumption 2009.05 (May) 2010.03 (Mar)

Fertility 2008.12 (Dec) 2009.10 (Oct) FEV1 checks for patients with chronic obstructive pulmonary 2009.05 (May) 2010.03 (Mar)

disease Follow-up of non-attendance at annual review among patients with 2009.05 (May) 2010.03 (Mar)

psychoses

Fruit and vegetable consumption 2008.06 (Jun) 2009.10 (Oct)

General Health Questionnaire GHQ12 score 2008.06 (Jun) 2009.10 (Oct)

GP relevant population estimates 2009.05 (May) 2010.03 (Mar)

Health of providers of unpaid care 2004.07 (Jul) 2009.10 (Oct) Health review and treatment checks among patients with 2009.05 (May) 2010.03 (Mar)

psychoses

High blood pressure 2008.06 (Jun) 2009.10 (Oct)

Hospital episodes (admissions): Accidents 2008.06 (Jun) 2009.10 (Oct)

Hospital procedures: cataract removal 2008.10 (Oct) 2009.10 (Oct)

Hospital procedures: lower limb amputations in diabetic patients 2008.06 (Jun) 2009.07 (Jul)

Hospital procedures: orchidopexy 2008.10 (Oct) 2009.10 (Oct)

Hospital procedures: primary hip replacement 2008.06 (Jun) 2009.07 (Jul)

Hospital procedures: primary knee replacement 2008.10 (Oct) 2009.10 (Oct)

Hospital procedures: revision hip replacement 2008.06 (Jun) 2009.10 (Oct)

Inability to work due to permanent sickness 2004.07 (Jul) 2009.10 (Oct)

Incidence of all cancers 2009.05 (May) 2010.05 (May)

Incidence of all central nervous system anomalies 2008.10 (Oct) 2009.07 (Jul)

Incidence of all skin cancers 2009.05 (May) 2010.05 (May)

Incidence of anencephalus 2008.10 (Oct) 2009.07 (Jul)

Incidence of bladder cancer 2009.05 (May) 2010.05 (May)

Incidence of breast cancer 2009.05 (May) 2010.05 (May)

Incidence of cervical cancer 2009.05 (May) 2010.05 (May)

Incidence of cleft palate and/or cleft lip 2008.10 (Oct) 2009.07 (Jul)

Incidence of colorectal cancer 2009.05 (May) 2010.05 (May)

Incidence of Down syndrome 2008.10 (Oct) 2009.07 (Jul)

Incidence of lung cancer 2009.05 (May) 2010.05 (May)

Incidence of malignant melanoma 2009.05 (May) 2010.05 (May)

Incidence of measles 2008.12 (Dec) 2009.12 (Dec)

Incidence of meningococcal meningitis 2008.12 (Dec) 2009.12 (Dec)

Incidence of oesophageal cancer 2009.05 (May) 2010.05 (May)

Incidence of prostate cancer 2009.05 (May) 2010.05 (May)

Incidence of skin cancers other than malignant melanoma 2009.05 (May) 2010.05 (May)

Incidence of spina bifida 2009.02 (Feb) 2009.07 (Jul)

Incidence of stomach cancer 2009.05 (May) 2010.05 (May)

Incidence of tuberculosis 2008.12 (Dec) 2009.12 (Dec)

Incidence of whooping cough 2008.12 (Dec) 2009.12 (Dec)

Indices of Deprivation 2007 2008.10 (Oct) To be confirmed Inhaler technique checks for patients with chronic obstructive 2009.05 (May) 2010.03 (Mar)

pulmonary disease

Life expectancy 2009.02 (Feb) 2009.12 (Dec)

Limiting long-term illness 2004.12 (Dec) 2009.10 (Oct)

Limiting longstanding illness 2008.06 (Jun) 2009.10 (Oct)

Live births in NHS hospitals 2008.12 (Dec) 2009.10 (Oct)

Lone parent families with dependent children 2004.07 (Jul) 2009.10 (Oct)

Low birthweight births 2008.12 (Dec) 2009.10 (Oct)

Major accidents 2008.06 (Jun) 2009.10 (Oct)

Maternal mortality 2008.12 (Dec) 2009.12 (Dec)

Micro-albuminuria testing in patients with diabetes mellitus 2009.05 (May) 2010.03 (Mar)

Mortality from accidental falls 2008.12 (Dec) 2009.12 (Dec)

Mortality from accidents 2008.12 (Dec) 2009.12 (Dec)

Mortality from acute myocardial infarction 2008.12 (Dec) 2009.12 (Dec)

Mortality from all cancers 2008.12 (Dec) 2009.12 (Dec)

Mortality from all causes 2008.12 (Dec) 2009.12 (Dec)

Mortality from all circulatory diseases 2008.12 (Dec) 2009.12 (Dec)

Mortality from asthma 2008.12 (Dec) 2009.12 (Dec)

Mortality from bladder cancer 2008.12 (Dec) 2009.12 (Dec)

Mortality from breast cancer 2008.12 (Dec) 2009.12 (Dec)

Mortality from bronchitis and emphysema 2008.12 (Dec) 2009.12 (Dec) Mortality from bronchitis, emphysema and other chronic obstructive 2008.12 (Dec) 2009.12 (Dec)

pulmonary disease

Mortality from causes considered amenable to health care 2008.12 (Dec) 2009.12 (Dec)

Mortality from cervical cancer 2008.12 (Dec) 2009.12 (Dec)

Mortality from chronic liver disease including cirrhosis 2008.12 (Dec) 2009.12 (Dec)

Mortality from chronic renal failure 2008.12 (Dec) 2009.12 (Dec)

Mortality from chronic rheumatic heart disease 2008.12 (Dec) 2009.12 (Dec)

Mortality from colorectal cancer 2008.12 (Dec) 2009.12 (Dec)

Mortality from coronary heart disease 2008.12 (Dec) 2009.12 (Dec)

Mortality from diabetes 2008.12 (Dec) 2009.12 (Dec)

Mortality from epilepsy 2008.12 (Dec) 2009.12 (Dec)

Mortality from fracture of femur 2008.12 (Dec) 2009.12 (Dec)

Mortality from gastric, duodenal and peptic ulcers 2008.12 (Dec) 2009.12 (Dec)

Mortality from Hodgkin's disease 2008.12 (Dec) 2009.12 (Dec)

Mortality from hypertensive disease 2008.12 (Dec) 2009.12 (Dec)

Mortality from infectious and parasitic disease 2008.12 (Dec) 2009.12 (Dec) Mortality from ischaemic heart disease other than acute myocardial 2008.12 (Dec) 2009.12 (Dec)

infarction

Mortality from land transport accidents 2008.12 (Dec) 2009.12 (Dec)

Mortality from leukaemia 2008.12 (Dec) 2009.12 (Dec)

Mortality from lung cancer 2008.12 (Dec) 2009.12 (Dec)

Mortality from malignant melanoma 2008.12 (Dec) 2009.12 (Dec)

Mortality from oesophageal cancer 2008.12 (Dec) 2009.12 (Dec)

Mortality from pneumonia 2008.12 (Dec) 2009.12 (Dec)

Mortality from prostate cancer 2008.12 (Dec) 2009.12 (Dec)

Mortality from skin cancers other than malignant melanoma 2008.12 (Dec) 2009.12 (Dec)

Mortality from skull fracture and intracranial injury 2008.12 (Dec) 2009.12 (Dec)

Mortality from stomach cancer 2008.12 (Dec) 2009.12 (Dec)

Mortality from stroke 2008.12 (Dec) 2009.12 (Dec)

Mortality from suicide 2008.12 (Dec) 2009.12 (Dec)

Mortality from suicide and injury undetermined 2008.12 (Dec) 2009.12 (Dec)

Mortality from tuberculosis 2008.12 (Dec) 2009.12 (Dec)

Mortality in infancy 2008.12 (Dec) 2009.10 (Oct) National Statistics Socio-Economic Classification (NS-SEC) as 2004.07 (Jul) 2009.10 (Oct)

defined by own occupation

Neuropathy testing in patients with diabetes mellitus 2009.05 (May) 2010.03 (Mar)

Normal blood pressure in patients with chronic kidney disease 2009.05 (May) 2010.03 (Mar)

Obesity 2008.06 (Jun) 2009.10 (Oct)

Obesity among GP patients 2009.05 (May) 2010.03 (Mar)

ONS Area Classification 2007.11 (Nov) To be confirmed

Oral health in children: decayed teeth 2008.10 (Oct) 2009.07 (Jul) Oral health in children: decayed teeth in children with active dental 2008.10 (Oct) 2009.07 (Jul)

decay

Oral health in children: decayed/missing/filled teeth 2008.10 (Oct) 2009.07 (Jul) Oral health in children: decayed/missing/filled teeth in children with 2008.10 (Oct) 2009.07 (Jul)

dental decay

Oral health in children: filled teeth 2008.10 (Oct) 2009.07 (Jul)

Oral health in children: missing teeth 2008.10 (Oct) 2009.07 (Jul)

Oral health in children: percentage with active dental decay 2008.10 (Oct) 2009.07 (Jul)

Oral health in children: percentage with dental decay 2008.10 (Oct) 2009.07 (Jul)

Oral health in children: the Care index 2008.10 (Oct) 2009.07 (Jul)

Patients with epilepsy on drug treatment and convulsion free 2009.05 (May) 2010.03 (Mar)

Pensioners in households 2004.07 (Jul) 2009.10 (Oct)

Perinatal mortality 2008.12 (Dec) 2009.10 (Oct)

Peripheral pulse checking in patients with diabetes mellitus 2009.05 (May) 2010.03 (Mar)

Postneonatal mortality 2008.12 (Dec) 2009.10 (Oct) Potentially avoidable mortality associated with specified medical 2008.12 (Dec) 2009.12 (Dec)

conditions amenable to surgical intervention

Prevalence: all cancers 2009.05 (May) 2010.03 (Mar)

Prevalence: asthma and prescribed medication 2009.05 (May) 2010.03 (Mar)

Prevalence: asthma with measures of variability or reversibility 2009.05 (May) 2010.03 (Mar)

Prevalence: atrial fibrillation 2009.05 (May) 2010.03 (Mar)

Prevalence: atrial fibrillation confirmed by ECG or specialist 2009.05 (May) 2010.03 (Mar)

Prevalence: chronic kidney disease 2009.05 (May) 2010.03 (Mar)

Prevalence: chronic obstructive pulmonary disease 2009.05 (May) 2010.03 (Mar) Prevalence: chronic obstructive pulmonary disease confirmed by 2009.05 (May) 2010.03 (Mar)

spirometry

Prevalence: coronary heart disease 2009.05 (May) 2010.03 (Mar)

Prevalence: dementia 2009.05 (May) 2010.03 (Mar) Prevalence: depression in patients with diabetes and/or coronary 2009.05 (May) 2010.03 (Mar)

heart disease

Prevalence: diabetes mellitus 2009.05 (May) 2010.03 (Mar)

Prevalence: epilepsy 2009.05 (May) 2010.03 (Mar)

Prevalence: heart failure 2009.05 (May) 2010.03 (Mar) Prevalence: heart failure confirmed by echocardiogram or specialist 2009.05 (May) 2010.03 (Mar)

assessment

Prevalence: hypertension 2009.05 (May) 2010.03 (Mar)

Prevalence: hypothyroidism 2009.05 (May) 2010.03 (Mar)

Prevalence: learning disabilities 2009.05 (May) 2010.03 (Mar)

Prevalence: psychoses 2009.05 (May) 2010.03 (Mar)

Prevalence: stroke or transient ischaemic attacks 2009.05 (May) 2010.03 (Mar)

Provision of unpaid care 2004.07 (Jul) 2009.10 (Oct)

Record of seizure frequency among patients with epilepsy 2009.05 (May) 2010.03 (Mar)

Referral of patients with stroke for further investigation 2009.05 (May) 2010.03 (Mar)

Religion 2004.07 (Jul) 2009.10 (Oct)

Renal function testing in patients with diabetes mellitus 2009.05 (May) 2010.03 (Mar)

Residents in households 2004.07 (Jul) 2009.10 (Oct)

Retinal screening in patients with diabetes mellitus 2009.05 (May) 2010.03 (Mar) Returning to usual place of residence following hospital treatment: 2008.12 (Dec) 2009.12 (Dec)

fractured proximal femur Returning to usual place of residence following hospital treatment: 2008.12 (Dec) 2009.12 (Dec)

stroke

Self-assessed general health 2008.06 (Jun) 2009.10 (Oct)

Smoking among patients with selected conditions 2009.05 (May) 2010.03 (Mar)

Smoking cessation advice for smokers with selected conditions 2009.05 (May) 2010.03 (Mar) Social class as defined by occupation of household reference 2004.07 (Jul) 2009.10 (Oct)

person

Standard of health in preceding 12 months 2004.07 (Jul) 2009.10 (Oct)

Stillbirths 2008.12 (Dec) 2009.10 (Oct)

Survival following diagnosis of bladder cancer 2008.12 (Dec) 2009.07 (Jul)

Survival following diagnosis of breast cancer 2008.12 (Dec) 2009.07 (Jul)

Survival following diagnosis of cervical cancer 2008.12 (Dec) 2009.07 (Jul)

Survival following diagnosis of colon cancer 2008.12 (Dec) 2009.07 (Jul)

Survival following diagnosis of lung cancer 2008.12 (Dec) 2009.07 (Jul)

Survival following diagnosis of oesophageal cancer 2008.12 (Dec) 2009.07 (Jul)

Survival following diagnosis of prostate cancer 2008.12 (Dec) 2009.07 (Jul)

Survival following diagnosis of stomach cancer 2008.12 (Dec) 2009.07 (Jul)

Systolic blood pressure 2008.06 (Jun) 2009.10 (Oct)

Thyroid and renal function testing in patients on lithium therapy 2010.03 (Mar) 2009.05 (May)

Thyroid function tests in patients with hypothyroidism 2009.05 (May) 2010.03 (Mar)

Total period abortion rate as percent of the potential fertility rate 2008.12 (Dec) 2009.10 (Oct)

Treated and controlled high blood pressure 2008.06 (Jun) 2009.10 (Oct)

Vaccination for measles, mumps and rubella 2009.05 (May) 2010.03 (Mar)

Vaccination for whooping cough 2009.05 (May) 2010.03 (Mar) Vaccination: influenza, for patients with chronic obstructive 2009.05 (May) 2010.03 (Mar)

pulmonary disease

Vaccination: influenza, for patients with coronary heart disease 2009.05 (May) 2010.03 (Mar)

Vaccination: influenza, for patients with diabetes mellitus 2009.05 (May) 2010.03 (Mar) Vaccination: influenza, for patients with stroke or transient 2009.05 (May) 2010.03 (Mar)

ischaemic attack

Wheeze or diagnosed asthma 2008.06 (Jun) 2009.10 (Oct)

Years of life lost due to mortality from accidental falls 2008.12 (Dec) 2009.12 (Dec)

Years of life lost due to mortality from accidents 2008.12 (Dec) 2009.12 (Dec)

Years of life lost due to mortality from all cancers 2008.12 (Dec) 2009.12 (Dec)

Years of life lost due to mortality from all causes 2008.12 (Dec) 2009.12 (Dec)

Years of life lost due to mortality from all circulatory diseases 2008.12 (Dec) 2009.12 (Dec)

Years of life lost due to mortality from asthma 2008.12 (Dec) 2009.12 (Dec)

Years of life lost due to mortality from bladder cancer 2008.12 (Dec) 2009.12 (Dec)

Years of life lost due to mortality from breast cancer 2008.12 (Dec) 2009.12 (Dec)

Years of life lost due to mortality from bronchitis and emphysema 2008.12 (Dec) 2009.12 (Dec) Years of life lost due to mortality from bronchitis, emphysema and 2008.12 (Dec) 2009.12 (Dec)

other COPD

Years of life lost due to mortality from cervical cancer 2008.12 (Dec) 2009.12 (Dec) Years of life lost due to mortality from chronic liver disease 2008.12 (Dec) 2009.12 (Dec)

including cirrhosis

Years of life lost due to mortality from colorectal cancer 2008.12 (Dec) 2009.12 (Dec)

Years of life lost due to mortality from coronary heart disease 2008.12 (Dec) 2009.12 (Dec)

Years of life lost due to mortality from diabetes 2008.12 (Dec) 2009.12 (Dec)

Years of life lost due to mortality from epilepsy 2008.12 (Dec) 2009.12 (Dec) Years of life lost due to mortality from gastric, duodenal and peptic 2008.12 (Dec) 2009.12 (Dec)

ulcers

Years of life lost due to mortality from Hodgkin's disease 2008.12 (Dec) 2009.12 (Dec)

Years of life lost due to mortality from hypertensive disease 2008.12 (Dec) 2009.12 (Dec) Years of life lost due to mortality from infectious and parasitic 2008.12 (Dec) 2009.12 (Dec)

disease

Years of life lost due to mortality from land transport accidents 2008.12 (Dec) 2009.12 (Dec)

Years of life lost due to mortality from leukaemia 2008.12 (Dec) 2009.12 (Dec)

Years of life lost due to mortality from lung cancer 2008.12 (Dec) 2009.12 (Dec)

Years of life lost due to mortality from malignant melanoma 2008.12 (Dec) 2009.12 (Dec)

Years of life lost due to mortality from oesophageal cancer 2008.12 (Dec) 2009.12 (Dec)

Years of life lost due to mortality from pneumonia 2008.12 (Dec) 2009.12 (Dec)

Years of life lost due to mortality from prostate cancer 2008.12 (Dec) 2009.12 (Dec)

Years of life lost due to mortality from renal failure 2008.12 (Dec) 2009.12 (Dec) Years of life lost due to mortality from skin cancers other than 2008.12 (Dec) 2009.12 (Dec)

malignant melanoma

Years of life lost due to mortality from stomach cancer 2008.12 (Dec) 2009.12 (Dec)

Years of life lost due to mortality from stroke 2008.12 (Dec) 2009.12 (Dec)

Years of life lost due to mortality from suicide 2008.12 (Dec) 2009.12 (Dec) Years of life lost due to mortality from suicide and injury 2008.12 (Dec) 2009.12 (Dec)

undetermined

Years of life lost due to mortality from tuberculosis 2008.12 (Dec) 2009.12 (Dec) Crown Copyright, May 2009

Table 5: England’s Strategic Health Authorities SHA Population North East 2,545,073 North West 6,827,170 Yorkshire and The Humber 5,038,849 East Midlands 4,279,707 West Midlands 5,334,006 East of England 5,491,293 London 7,428,590 South East Coast 4,187,941 South Central 3,922,301 South West 5,038,200

Table 6: Expenditure on health care (£billion) Total Public Private Current Capital expenditure expenditure Year £b % £b %* % £b %* % % % GDP GDP GDP GDP GDP 1997 55.1 6.6 44.2 80.4 5.3 10.8 19.6 1.3 52.2 6.3 2.8 0.3 1998 58.8 6.7 47.2 80.4 5.4 11.5 19.6 1.3 55.8 6.3 3.0 0.3 1999 64.3 6.9 51.8 80.6 5.6 12.5 19.4 1.3 60.8 6.5 3.5 0.4 2000 68.7 7.0 54.5 79.3 5.6 14.2 20.7 1.5 65.6 6.7 3.1 0.3 2001 74.2 7.3 59.4 80.0 5.8 14.8 20.0 1.5 71.3 7.0 2.9 0.3 2002 81.6 7.6 65.2 79.9 6.1 16.4 20.1 1.5 77.8 7.2 3.8 0.3 2003 88.7 7.8 71.1 80.1 6.2 17.6 19.9 1.5 84.6 7.4 4.1 0.4 2004 96.7 8.1 78.9 81.6 6.6 17.8 18.4 1.5 92.8 7.7 3.9 0.3 2005 103.2 8.2 84.5 81.9 6.7 18.7 18.1 1.5 98.7 7.9 4.4 0.4 2006 111.7 8.5 91.7 82.0 6.9 20.1 18.0 1.5 106.7 8.1 5.0 0.4 2007 117.9 8.4 96.4 81.7 6.9 21.5 18.3 1.5 112.3 8.0 5.6 0.4 * % of total health expenditure Source: Office for National Statistics

Table 7: Government public spending on health as a % of GDP and as a % of total government spending

Health Care-total Total public Health care Health care expenditure spending expenditure as % expenditure as % Prime Year GDP (£billions) (£billions) (£billions) of GDP of total spending Minister 1980 230.800 11.8 103.9 5.11 11.36 Thatcher (C) 1981 253.154 13.4 116.1 5.29 11.54 Thatcher (C) 1982 277.198 14.4 128 5.19 11.25 Thatcher (C) 1983 302.973 17.1 132.7 5.64 12.89 Thatcher (C) 1984 324.633 18.1 140.5 5.58 12.88 Thatcher (C) 1985 355.269 19.4 150.9 5.46 12.86 Thatcher (C) 1986 381.782 20.5 158.6 5.37 12.93 Thatcher (C) 1987 421.559 22.1 164.6 5.24 13.43 Thatcher (C) 1988 470.748 24.3 173.6 5.16 14.00 Thatcher (C) 1989 517.075 26.8 179.9 5.18 14.90 Thatcher (C) 1990 560.887 29.3 200.9 5.22 14.58 Thatcher (C) 1991 589.739 32.8 218.2 5.56 15.03 Major (C) 1992 614.776 37.1 236.2 6.03 15.71 Major (C) 1993 645.500 40.7 260.6 6.31 15.62 Major (C) 1994 684.067 42.9 276.5 6.27 15.52 Major (C) 1995 723.080 37.5 298.9 5.19 12.55 Major (C) 1996 768.905 39.2 309.4 5.10 12.67 Major (C) 1997 815.881 40.6 318.3 4.98 12.76 Major (C) 1998 865.710 42.5 324.9 4.91 13.08 Blair (L) 1999 911.945 45.8 328.1 5.02 13.96 Blair (L) 2000 958.931 48.3 339.3 5.04 14.24 Blair (L) 2001 1003.300 52.7 361.8 5.25 14.57 Blair (L) 2002 1055.790 58.4 385.3 5.53 15.16 Blair (L) 2003 1118.240 66.2 415.2 5.92 15.94 Blair (L) 2004 1184.300 74.9 451.4 6.32 16.59 Blair (L) 2005 1233.980 82.9 487.8 6.72 16.99 Blair (L) 2006 1303.920 89.7 502.2 6.88 17.86 Blair (L) 2007 1343.750 94.5 543.3 7.03 17.39 Blair (L) 2008 1419.550 102.0 575.4 7.19 17.73 Brown (L) 2009 1439.000 110.5 631.3 7.68 17.50 Brown (L) 2010 1411.000 119.0 654.7 8.43 18.18 2011 1461.000 122.7 690.3 8.40 17.77 C= conservative Government. L = Labour Government

Table 8: Average daily number of available and occupied beds by sector, England, 2007–08 Sector Available beds Occupied beds % occupancy All ward types 160,297 135,132 84.3 General & acute (acute plus geriatric) 121,780 103,915 85.3 6.1.1.1 Acute 101,080 85,119 84.2 Geriatric 20,700 18,795 90.8 Mental illness 26,929 23,244 86.3 Learning Disabilties 3,147 2,576 81.8 Maternity 8,441 5,397 63.9 Source: Department of Health form KH03, Published 26 September 2008.

Table 9: Average daily number of available and occupied beds by ward classification, England, 2007–08

Ward classification Available beds Occupied beds % occupancy All ward types 160,297 135,132 84.3 Intensive care: neonates 1,734 1,257 72.5 Intensive care: paediatric 306 217 71.1 Intensive care: wholly or mainly adult 3,667 2,953 80.5 Terminally ill / palliative care: wholly or mainly adult 411 316 76.8 Younger physically disabled 512 392 76.7 Other general & acute: neonates and children 8,314 5,315 63.9 Other general & acute: elderly: normal care 19,239 17,562 91.3 Other general & acute: elderly: limited care 1,462 1,233 84.4 Other general & acute: other 86,137 74,670 86.7 Maternity 8,441 5,397 63.9 Mental illness: children: short stay 505 355 70.4 Mental illness: children: long stay 18 15 80.1 Mental illness: elderly: short stay 6,577 5,320 80.9 Mental illness: elderly: long stay 2,417 2,007 83.0 Mental illness: other ages: secure unit 3,159 2,885 91.3 Mental illness: other ages: short stay 11,372 10,112 88.9 Mental illness: other ages: long stay 2,880 2,551 88.6 Learning disabilities: children: short stay 185 107 57.9 Learning disabilities: children: long stay 23 17 73.8 Learning disabilities: other ages: secure unit 554 508 91.8 Learning disabilities: other ages: short stay 1,053 774 73.5 Learning disabilities: other ages: long stay 1,332 1,169 87.8 Source: Department of Health form KH03, Published 26 September 2008. These tables include all data and amendments received up to 24 September 2008. Dorset Healthcare NHS Foundation Trust was unable to supply data for 2007-08 by 24 September 2008 and estimates were made by the Department of Health:

Table 10: Unemployment rates (as per cent of economically active), UK by sector, 1995–2009

Distribut- ion, Hotels Banking, Education, Overall Agriculture and Transport Finance Health Unemploy and Energy Manufact- Construc- Restaur- and Insurance and Public Other All ment Fishing and Water uring tion ants Comms. etc. Admin. Services Services Rates (%)1 A-B C,E D F G-H I J,K L-N O-Q G-Q All 1995 Q1 9.0 7.4 8.5 8.8 13.7 8.7 6.9 5.7 3.9 8.0 6.3 Q2 8.6 6.5 7.7 7.9 13.0 8.0 7.2 5.8 3.8 6.7 6.0 Q3 8.9 6.2 7.0 7.9 12.3 8.0 7.4 5.7 4.1 7.1 6.1 Q4 8.1 5.8 5.6 7.5 12.2 7.5 6.6 5.5 3.6 7.3 5.7 1996 Q1 8.3 6.1 7.6 7.9 13.1 7.8 6.9 5.5 3.4 7.7 5.8 Q2 8.2 5.1 7.8 7.8 12.0 7.7 6.0 4.7 3.5 8.1 5.6 Q3 8.3 4.7 8.1 7.1 11.4 7.7 5.4 5.0 3.6 7.9 5.6 Q4 7.7 4.9 8.6 6.5 10.4 7.2 5.4 4.5 3.5 7.2 5.2 1997 Q1 7.4 5.3 7.9 6.1 10.7 7.0 5.9 4.1 3.2 6.8 5.0 Q2 7.1 5.3 7.8 5.9 9.6 6.6 5.2 4.2 3.2 5.7 4.8 Q3 7.1 5.0 6.0 5.5 8.7 6.3 4.2 4.4 3.4 6.2 4.7 Q4 6.4 4.9 4.8 5.3 7.7 5.9 4.3 3.8 2.9 5.5 4.3 1998 Q1 6.4 5.0 5.3 5.8 7.4 6.1 4.7 3.8 2.8 5.6 4.3 Q2 6.2 3.3 3.8 5.6 6.9 5.9 4.9 3.3 2.9 5.5 4.2 Q3 6.5 2.6 3.4 5.8 6.5 5.8 4.6 3.6 2.9 5.4 4.2 Q4 6.0 4.2 4.4 5.7 6.4 5.4 4.6 3.6 2.5 5.4 4.0 1999 Q1 6.2 4.8 6.7 6.0 7.3 6.0 4.7 3.6 2.4 5.4 4.1 Q2 6.0 3.4 6.4 6.0 6.6 5.4 4.5 3.8 2.3 4.5 3.8 Q3 6.1 4.1 5.1 5.7 6.2 5.3 4.2 3.6 2.6 4.5 3.9 Q4 5.6 4.0 3.8 5.1 6.2 5.2 3.9 3.4 2.4 4.5 3.7 2000 Q1 5.8 4.2 3.4 5.7 6.0 5.6 3.7 3.3 2.4 4.9 3.8 Q2 5.4 4.6 3.3 5.2 6.2 5.1 3.4 3.3 2.0 3.8 3.4 Q3 5.5 4.1 4.2 4.9 4.8 5.2 3.1 3.0 2.2 4.2 3.5 Q4 5.1 4.8 3.4 4.6 5.0 5.0 3.2 2.8 2.0 4.1 3.3 2001 Q1 5.1 4.6 3.4 4.7 5.5 5.2 4.2 2.8 1.9 4.1 3.4 Q2 4.9 4.5 3.0 4.9 4.2 4.8 3.9 2.7 1.6 3.9 3.1 Q3 5.3 4.3 3.5 4.7 4.0 4.8 4.1 3.4 2.0 3.8 3.4 Q4 5.0 4.3 2.9 4.6 4.2 4.8 4.0 3.4 1.9 4.3 3.4 2002 Q1 5.2 3.3 4.0 5.4 5.0 5.4 4.3 3.7 1.9 4.3 3.6 Q2 5.0 2.9 3.5 5.2 4.9 5.1 4.0 3.8 1.8 4.1 3.5 Q3 5.5 3.6 5.0 5.1 4.8 5.4 4.0 3.5 2.4 4.1 3.8 Q4 5.0 3.4 2.9 4.6 4.2 5.0 4.1 3.4 2.1 4.1 3.5 2003 Q1 5.2 3.6 3.7 5.5 4.8 5.2 4.1 3.8 2.0 4.5 3.6 Q2 4.8 3.8 2.3 5.0 4.1 5.1 3.9 3.5 1.8 3.8 3.4 Q3 5.3 1.6 2.9 4.9 3.6 5.2 4.1 3.6 2.0 4.4 3.6 Q4 4.8 2.1 2.9 4.5 4.3 4.6 3.7 3.5 1.9 3.8 3.3 2004 Q1 4.8 2.6 3.7 4.5 4.4 4.9 3.7 3.5 1.9 4.4 3.4 Q2 4.7 3.5 3.3 4.6 4.1 4.6 4.0 2.9 1.8 3.6 3.1 Q3 4.9 2.4 2.7 3.6 3.2 4.5 3.9 3.4 2.0 3.2 3.2 Q4 4.6 3.4 2.2 3.6 4.0 4.6 4.0 3.5 1.7 3.2 3.2 2005 Q1 4.7 3.3 2.7 4.2 3.8 4.9 3.9 3.7 1.7 3.3 3.3 Q2 4.6 4.1 3.0 4.3 3.6 4.8 4.0 3.1 1.8 3.1 3.2 Q3 5.0 3.2 2.1 4.6 3.2 5.1 4.0 3.1 2.0 3.2 3.3 Q4 5.0 3.0 2.6 4.6 3.4 5.1 3.7 3.3 1.9 4.1 3.3 2006 Q1 5.2 3.1 3.1 4.9 3.9 5.7 4.0 3.5 2.1 3.9 3.6 Q2 5.4 2.9 2.3 4.8 4.4 6.0 3.7 3.7 2.1 3.7 3.7 Q3 5.7 3.0 3.1 4.5 4.3 6.1 3.6 3.2 2.3 3.7 3.7 Q4 5.4 2.5 1.4 4.7 3.9 5.6 3.8 3.4 2.2 3.6 3.6 2007 Q1 5.5 3.5 1.1 5.1 4.3 6.3 4.1 3.4 2.3 3.9 3.8 Q2 5.3 2.0 2.8 4.4 3.9 6.4 3.6 3.0 2.1 3.7 3.7 Q3 5.6 1.5 2.0 4.6 3.1 6.1 3.9 3.1 2.1 3.7 3.6 Q4 5.0 2.0 1.9 4.1 3.1 5.1 4.0 2.9 2.2 4.1 3.4 2008 Q1 5.2 2.7 2.0 4.6 4.1 5.6 4.2 3.1 2.1 4.2 3.6 Q2 5.3 2.2 2.9 4.9 4.3 5.7 4.7 2.7 2.2 4.0 3.6

Q3 6.1 2.9 2.5 4.9 5.3 6.2 4.4 3.3 2.5 4.3 3.9 Q4 6.2 3.1 2.4 6.0 6.6 6.3 4.7 3.9 2.3 4.2 4.0 2009 Q1 7.1 4.4 3.7 7.5 8.4 7.8 5.2 4.9 2.5 5.3 4.8 Male 1995 Q1 10.4 7.7 9.3 9.2 14.5 10.2 7.2 6.1 5.4 10.1 7.7 Q2 10.1 7.1 8.6 8.4 13.8 9.7 7.7 5.9 5.1 7.5 7.3 Q3 10.2 6.5 7.3 8.3 13.0 9.4 7.9 5.9 5.4 8.3 7.4 Q4 9.5 6.9 5.6 7.9 12.9 8.9 7.0 5.7 4.7 8.6 6.9 1996 Q1 9.9 6.1 8.1 8.2 13.8 9.2 7.6 6.3 4.7 9.7 7.3 Q2 9.7 6.0 8.3 7.9 12.8 9.5 6.6 5.4 4.8 9.7 7.1 Q3 9.6 5.1 8.9 7.3 12.0 9.1 5.8 5.8 4.8 9.5 6.9 Q4 8.8 5.4 8.4 6.7 11.0 8.6 5.6 4.9 4.7 9.1 6.4 1997 Q1 8.4 5.4 7.6 6.1 11.4 7.9 6.0 4.4 4.3 8.4 6.0 Q2 8.0 5.1 7.3 6.0 10.1 7.4 5.4 4.3 4.3 7.2 5.7 Q3 7.8 4.7 6.0 5.5 9.1 7.0 4.4 4.7 4.4 7.1 5.5 Q4 7.1 4.4 4.6 5.3 8.2 6.7 4.6 4.2 3.8 7.5 5.2 1998 Q1 7.1 4.8 5.4 5.8 7.8 6.6 5.1 4.0 3.5 6.6 5.1 Q2 6.8 3.5 3.6 5.6 7.2 6.4 5.1 3.4 3.6 6.8 4.9 Q3 7.1 2.6 3.6 5.9 6.8 6.7 4.8 3.5 3.4 7.3 4.9 Q4 6.7 4.0 4.9 5.7 6.7 6.1 4.9 4.0 2.9 6.9 4.7 1999 Q1 6.9 4.9 6.8 6.2 7.5 6.4 5.0 3.9 3.0 6.6 4.8 Q2 6.7 3.6 6.8 6.1 6.8 6.0 4.8 4.0 2.5 5.1 4.4 Q3 6.6 4.0 5.6 5.8 6.4 5.8 4.4 3.7 3.0 4.8 4.4 Q4 6.1 4.4 3.2 5.0 6.4 6.0 4.0 3.6 2.8 5.1 4.3 2000 Q1 6.3 5.0 3.3 5.7 6.4 6.2 4.0 3.7 2.7 5.9 4.4 Q2 6.0 5.4 3.4 5.3 6.6 5.8 3.5 3.4 1.8 4.7 3.9 Q3 5.9 4.5 4.2 4.7 5.0 5.8 3.2 3.2 2.1 5.0 3.9 Q4 5.6 5.2 3.9 4.8 5.2 5.8 3.4 2.9 1.9 4.8 3.7 2001 Q1 5.7 4.8 3.6 4.7 5.7 5.9 4.3 3.0 1.8 4.6 3.9 Q2 5.4 5.1 2.6 4.9 4.4 5.5 4.0 2.8 1.9 4.2 3.6 Q3 5.8 4.4 3.3 4.8 4.2 5.3 4.0 3.6 2.3 4.7 3.9 Q4 5.5 4.7 2.8 4.5 4.3 5.5 3.8 3.6 2.3 4.7 4.0 2002 Q1 5.9 3.4 4.3 5.5 5.3 6.0 4.0 4.1 2.3 5.3 4.3 Q2 5.6 3.0 4.2 5.2 5.1 5.3 3.9 4.0 2.2 4.9 4.0 Q3 6.0 3.6 5.3 5.0 5.0 5.7 4.1 3.7 2.8 4.7 4.2 Q4 5.4 3.3 2.4 4.5 4.3 5.2 4.4 3.7 2.2 4.6 4.0 2003 Q1 5.9 4.0 3.5 5.5 5.0 6.0 4.4 4.0 2.3 5.3 4.3 Q2 5.4 4.4 2.4 5.2 4.2 5.9 3.9 4.0 1.9 4.3 4.1 Q3 5.7 1.2 2.7 5.1 3.7 5.7 3.9 4.2 2.2 4.0 4.1 Q4 5.3 1.8 3.1 4.6 4.5 5.0 3.8 3.9 2.2 4.0 3.8 2004 Q1 5.3 2.7 3.3 4.5 4.5 5.3 4.0 3.6 2.1 4.9 3.9 Q2 5.1 3.5 3.7 4.6 4.2 4.9 4.1 3.0 1.8 4.3 3.5 Q3 5.2 2.6 2.9 3.4 3.3 5.0 3.9 3.5 2.2 3.3 3.7 Q4 5.0 3.8 1.7 3.4 4.1 5.1 3.8 3.6 2.0 3.6 3.6 2005 Q1 5.2 4.0 2.4 4.2 3.8 5.5 3.9 4.0 1.7 3.8 3.9 Q2 5.0 4.7 3.0 4.3 3.7 5.0 3.9 3.2 1.9 3.3 3.5 Q3 5.3 3.7 2.5 4.6 3.3 5.4 3.6 3.1 2.1 3.6 3.6 Q4 5.5 3.3 2.4 4.7 3.5 5.3 3.4 3.4 2.2 5.1 3.8 2006 Q1 5.7 3.6 2.6 5.0 4.3 5.7 4.0 3.7 2.1 4.4 4.0 Q2 5.8 3.0 2.2 5.1 4.6 5.9 3.7 4.1 2.0 3.7 4.0 Q3 6.1 3.2 2.8 4.5 4.4 6.1 3.8 3.4 2.5 3.7 4.0 Q4 5.7 2.9 1.5 4.8 3.9 5.9 3.7 3.3 2.3 4.0 3.9 2007 Q1 5.9 3.7 0.8 5.4 4.5 6.5 4.0 3.6 2.6 4.0 4.2 Q2 5.6 1.9 2.4 4.5 4.1 6.6 3.5 3.2 2.4 4.1 4.1 Q3 5.8 1.7 1.3 4.9 3.1 6.1 3.8 3.2 2.2 4.0 3.9 Q4 5.3 2.0 1.7 4.2 3.1 5.1 3.8 2.9 2.4 4.5 3.6 2008 Q1 5.6 2.9 2.2 4.7 4.3 6.2 4.0 3.0 2.1 4.7 3.9 Q2 5.8 2.3 2.0 5.0 4.5 6.0 4.7 2.8 2.4 4.5 4.0 Q3 6.6 2.7 1.9 5.1 5.5 6.6 4.3 3.5 2.9 4.6 4.4 Q4 6.9 3.6 2.3 6.3 7.0 6.8 4.7 4.1 2.6 4.6 4.6 2009 Q1 8.0 5.0 3.3 7.9 8.9 8.7 5.4 5.2 2.5 5.5 5.5 Female 1995 Q1 7.1 6.5 4.9 7.8 5.8 7.2 6.2 5.4 3.1 6.2 5.1 Q2 6.8 4.8 3.9 6.6 5.0 6.4 5.3 5.7 3.2 5.9 4.9

Q3 7.2 5.1 5.6 7.0 4.9 6.7 5.6 5.4 3.4 5.9 5.0 Q4 6.4 2.6 5.6 6.5 5.7 6.2 5.4 5.2 3.1 6.2 4.7 1996 Q1 6.3 6.2 5.6 7.1 6.4 6.5 4.7 4.6 2.7 6.0 4.5 Q2 6.4 2.7 5.5 7.3 4.8 6.1 4.1 3.9 2.9 6.7 4.4 Q3 6.7 3.4 4.7 6.6 5.5 6.5 4.2 4.1 3.0 6.5 4.5 Q4 6.3 3.4 9.4 6.0 4.9 5.9 4.6 3.9 3.0 5.6 4.2 1997 Q1 6.2 5.1 8.9 6.2 3.3 6.1 5.4 3.7 2.6 5.5 4.1 Q2 6.0 5.6 9.6 5.7 4.0 5.9 4.4 4.0 2.7 4.4 4.0 Q3 6.2 5.7 6.1 5.3 4.2 5.7 3.3 4.0 2.9 5.4 4.1 Q4 5.4 6.3 5.7 5.2 3.2 5.2 3.5 3.3 2.5 3.8 3.6 1998 Q1 5.6 5.6 4.7 5.9 3.0 5.6 3.4 3.5 2.5 4.6 3.7 Q2 5.4 2.5 4.3 5.7 3.7 5.5 4.3 3.1 2.5 4.4 3.7 Q3 5.7 2.5 2.5 5.8 2.9 5.1 4.3 3.6 2.7 3.8 3.7 Q4 5.1 4.9 2.6 5.5 2.9 4.7 3.9 3.2 2.3 4.0 3.3 1999 Q1 5.4 4.5 6.3 5.8 5.2 5.6 4.0 3.2 2.1 4.5 3.5 Q2 5.1 2.4 4.8 5.5 4.5 4.8 3.7 3.6 2.1 4.0 3.3 Q3 5.5 4.1 3.8 5.3 4.0 4.7 3.7 3.5 2.5 4.3 3.5 Q4 5.0 2.5 5.8 5.3 3.9 4.4 3.6 3.1 2.3 4.0 3.2 2000 Q1 5.3 1.2 3.6 5.9 2.8 5.1 3.0 2.9 2.3 4.1 3.3 Q2 4.7 1.8 3.1 5.0 2.8 4.5 3.0 3.1 2.0 3.0 3.0 Q3 5.1 3.0 4.0 5.5 2.8 4.7 2.6 2.8 2.3 3.4 3.1 Q4 4.5 3.6 1.7 4.2 3.0 4.3 2.6 2.7 2.1 3.5 2.9 2001 Q1 4.4 3.8 2.5 4.8 4.0 4.4 3.8 2.7 2.0 3.6 2.9 Q2 4.2 2.7 4.5 4.8 2.4 4.1 3.7 2.6 1.5 3.5 2.6 Q3 4.8 4.2 4.1 4.6 1.9 4.4 4.5 3.1 1.9 3.0 2.9 Q4 4.4 3.3 3.3 4.7 2.6 4.0 4.4 3.2 1.8 4.0 2.9 2002 Q1 4.4 3.1 2.3 5.4 2.7 4.9 5.1 3.2 1.7 3.5 3.1 Q2 4.3 2.6 0.6 4.9 2.7 4.9 4.3 3.5 1.7 3.5 3.1 Q3 4.9 3.5 3.6 5.4 2.9 5.1 3.9 3.2 2.3 3.6 3.4 Q4 4.5 3.8 4.7 4.9 2.9 4.8 3.1 3.1 2.0 3.6 3.1 2003 Q1 4.4 2.0 4.5 5.4 3.0 4.4 3.1 3.5 1.9 3.8 3.0 Q2 4.1 1.6 2.3 4.6 3.5 4.3 3.7 2.9 1.7 3.5 2.8 Q3 4.8 3.2 3.7 4.4 2.3 4.7 4.6 2.9 1.9 4.7 3.1 Q4 4.2 2.9 2.2 4.2 2.8 4.1 3.4 3.0 1.7 3.6 2.8 2004 Q1 4.3 2.4 5.1 4.4 2.7 4.6 2.8 3.4 1.8 3.9 3.0 Q2 4.2 3.6 1.4 4.5 3.2 4.4 3.5 2.7 1.7 3.0 2.7 Q3 4.6 1.6 1.9 4.2 2.2 4.0 3.9 3.3 1.9 3.1 2.8 Q4 4.2 2.1 3.7 4.3 2.6 4.1 4.7 3.4 1.6 2.8 2.7 2005 Q1 4.1 1.0 3.8 4.3 3.4 4.4 3.8 3.3 1.7 2.9 2.8 Q2 4.2 2.2 3.1 4.5 2.4 4.6 4.1 3.0 1.8 3.0 2.9 Q3 4.5 1.5 0.8 4.5 2.2 4.8 5.0 3.0 2.0 2.9 3.0 Q4 4.5 2.0 3.2 4.5 3.0 4.8 4.5 3.1 1.8 3.1 2.9 2006 Q1 4.7 1.6 5.0 4.8 0.6 5.6 3.9 3.2 2.0 3.4 3.3 Q2 4.9 2.4 2.7 4.0 2.6 6.2 3.5 3.3 2.2 3.7 3.5 Q3 5.3 2.5 3.8 4.5 3.2 6.1 3.2 3.0 2.2 3.8 3.4 Q4 5.1 1.2 1.2 4.4 4.0 5.3 4.3 3.5 2.2 3.3 3.3 2007 Q1 5.1 3.0 1.8 4.2 2.3 6.2 4.2 3.2 2.2 3.8 3.5 Q2 4.9 2.2 4.1 4.1 1.5 6.2 3.9 2.7 2.0 3.3 3.3 Q3 5.3 1.0 4.0 4.0 2.1 6.1 4.1 2.9 2.1 3.4 3.3 Q4 4.8 2.0 2.5 3.7 3.3 5.1 4.5 3.0 2.1 3.6 3.2 2008 Q1 4.7 2.0 1.2 4.1 2.8 5.0 4.8 3.3 2.1 3.7 3.2 Q2 4.7 2.1 5.5 4.7 2.1 5.4 4.7 2.6 2.2 3.6 3.2 Q3 5.6 3.3 4.5 4.3 3.7 5.7 4.8 3.1 2.4 4.0 3.5 Q4 5.5 1.7 2.8 5.1 2.4 5.7 4.9 3.8 2.2 3.8 3.6 2009 Q1 6.1 1.8 5.3 6.2 3.6 6.9 4.4 4.6 2.5 5.1 4.1 1 Includes people who did not state their previous industry group.

Table 11: Vacancies by Industry: United Kingdom (thousands), seasonally adjusted Quarter Year All vacancies All services Education, health and public administration 000’s Ratio per 000’s Ratio per 000’s Ratio per 100 100 100 employees employees employees Apr-Jun 2007 646 2.5 571 2.7 143 2.1 Apr-Jun 2008 652 2.5 571 2.7 160 2.4 May-Jul 2008 627 2.4 551 2.6 159 2.3 Jun-Aug 2008 609 2.3 536 2.5 159 2.3 Jul-Sep 2008 598 2.3 529 2.5 161 2.4 Aug-Oct 2008 582 2.2 518 2.4 160 2.4 Sep-Nov 2008 558 2.1 501 2.3 161 2.4 Oct-Dec 2008 530 2.0 479 2.2 159 2.3 Nov-Jan 2009 505 1.9 457 2.1 161 2.4 Dec-Feb 2009 482 1.8 437 2.1 157 2.3 Jan-Mar 2009 465 1.8 424 2.0 153 2.3 Feb-Apr 2009 452 1.7 413 1.9 150 2.2 Mar-May 2009 443 1.7 405 1.9 148 2.2 Apr-Jun 2009 429 1.6 392 1.8 145 2.1 Change on quarter -35 -0.1 -32 -0.1 -9 -0.1 Change % -7.6 -7.4 -5.6 Change on year -222 -0.9 -179 -0.8 -15 -0.2 Change % -34.1 -31.3 -9.4 Standard Industrial Classification (2003) Source of data: ONS (2009) http://www.statistics.gov.uk/pdfdir/lmsuk0709.pdf, based on Table 22.

Table 12: Acceptable English Language Tests and levels Language centre Speech and language All other professions therapists*

CAMBRIDGE ESOL Certificate of proficiency in Certificate in advanced English English (CPE) (CAE) CAMBRIDGE INTERNATIONAL . International General Certificate

EXAMINATIONS of Secondary Education (IGCSE) 0500 (1st language) Grade C CAMBRIDGE INTERNATIONAL . International General certificate of

EXAMINATIONS Secondary Education (IGCSE) 0510 (2st language) Grade C INTERNATIONAL ENGLISH 8.0 with no element below 7.0 with no element below 6.5 LANGUAGE TESTING SYSTEM 7.5

(IELTS) HONG KONG EXAMINATIONS AND . Hong Kong Certificate of

ASSESSMENT AUTHORITY (HKEAA) Education Examinations (HKCEE) Syllabus B Grade A TEST OF ENGLISH AS A FOREIGN 670 600 LANGUAGE (TOEFL) - PAPER TEST TEST OF ENGLISH AS A FOREIGN 290 250 LANGUAGE (TOEFL) - ELECTRONIC TEST TEST OF ENGLISH AS A FOREIGN Minimum score of 118/120 Minimum score of 100/120 LANGUAGE (TOEFL) Internet Based Test (IBT) TEST OF ENGLISH FOR 990 810 INTERNATIONAL COMMUNICATION

(TOEIC) * Speech and language therapists: this Standard applies to both EEA and International applicants. This requirement is higher for speech and language therapists than for all other professions, as communication in English is a core professional skill (see 2b.4 of the standards of proficiency).

Table 13: indicative HPC approved programmes Profession Indicative qualification Approx. number of institutions offering the approved qualification Arts therapist MSc Art Psychotherapy, MSc Art Therapy, 16 Ma/MSc Music Therapy, MA Dramatherapy Biomedical scientists BSc (Hons)/MSc Applied Biomedical Science 21

Chiropodists/podiatrists BSc (Hons) Podiatry, BSc (Hons) Podiatric 14 Medicine Clinical scientists One UK-approved programme via the 1 Certificate of Attainment awarded by the Association of Clinical Scientists Dietitians PgDip/BSc (Hons)/MSc Dietetics, BSc (Hons) 15 Human Nutrition & Dietetics Occupational therapists Pg Dip Occupational Therapy BSc (Hons) /MSc 34 Occupational Therapy BSc (Hons) Occupational Therapy with Sociology/Psychology/Ergonomics Operating department Dip HE Operating Department Practice 31 practitioners Orthoptists BSc (Hons) Orthoptics, B.Med Sci (Hons) in 2 Orthoptics Paramedics FdSc Paramedic Science, Diploma Professional 21 + IHCD (part of Development in Paramedic Practice, BSc Edexcel) at (Hons) Adult Nursing and Paramedic Sciences, various ambulance Foundation Degree in Paramedic Science, services IHCD Paramedic Award, Certificate of Higher Education in Emergency Medical Care, BSc Paramedic Care Physiotherapists PgDip/ BSc (Hons)/ BHSc (Hons) /MSc 32 Physiotherapy, PgDip/MSc Rehabilitation Science Practitioner Doctorate in Clinical Psychology (D.Clin.Psy) 32 psychologists Prosthetists/orthotists BSc (Hons)/ MSci in Prosthetics and Orthotics 2

Radiographers BSc (Hons) Radiography, BSc (Hons) 28 Diagnostic Radiography and Imaging, BSc (Hons) Radiotherapy & Oncology, BSc (Hons) Therapeutic Radiography Speech and language Pg Dip/Bsc/MSc Speech and Language 18 therapists Therapy, BSc (Hons) Human Communication, BSc (Hons) Speech Pathology and Therapy, BSc (Hons) in Clinical Language Sciences

Table 14: Official Development Assistance in 2005 (source: OECD 2005 ) Countries in italics had not set a timetable for 0.7% as of 2005 Country Aid as % of GNI Norway 0.93 Sweden 0.92 Luxembourg 0.87 Netherlands 0.82 Denmark 0.81 Belgium 0.53 Austria 0.52 United Kingdom 0.48 Finland 0.47 France 0.47 Switzerland 0.44 Ireland 0.41 Germany 0.35 Canada 0.34 Italy 0.29 Spain 0.29 Japan 0.28 New Zealand 0.27 Australia 0.25 Greece 0.24 United States 0.22 Portugal 0.21 Table adapted from http://www.unmillenniumproject.org/documents/07_OECD_2005.pdf

Table 15: GMC Registrations and Erasures 1998–2009 (May) Top 30 countries of qualification Rank Country of qualification Number Percentage Cumulative Number of Net registered of all percentage erasures registrations 1998–2009 registrations (see Table since 1998* (May) since 1998 X.AAAA) 1 India 21362 25.5 25.5 8756 12606 2 South Africa 6454 7.7 33.2 8394 -1940 3 Pakistan 5893 7.0 40.3 1831 4062 4 Germany 5015 6.0 46.2 4657 358 5 Australia 4172 5.0 51.2 7586 -3414 6 Greece 3299 3.9 55.2 3625 -326 7 Italy 2857 3.4 58.6 2481 376 8 Nigeria 2558 3.1 61.6 521 2037 9 Poland 2512 3.0 64.6 979 1533 10 Ireland 2167 2.6 67.2 5179 -3012 11 Egypt 1636 2.0 69.2 954 682 12 Iraq 1411 1.7 70.8 288 1123 13 Sri Lanka 1316 1.6 72.4 1323 -7 14 Hungary 1314 1.6 74.0 446 868 15 New Zealand 1174 1.4 75.4 2061 -887 16 Spain 1105 1.3 76.7 1362 -257 17 Jamaica 1090 1.3 78.0 1164 -74 18 France 940 1.1 79.1 709 231 19 Romania 910 1.1 80.2 181 729 20 Czech Republic 896 1.1 81.3 268 628 21 Belgium 789 0.9 82.2 819 -30 22 Sudan 749 0.9 83.1 262 487 23 Netherlands 707 0.8 84.0 959 -252 24 Sweden 679 0.8 84.8 570 109 25 Hong Kong 671 0.8 85.6 2781 -2110 26 Russian Federation 630 0.8 86.3 101 529 27 Austria 579 0.7 87.0 388 191 28 Syrian Arab Republic 563 0.7 87.7 122 441 29 Libyan Arab Jamahiriya 554 0.7 88.4 154 400 30 Iran, Islamic Republic Of 545 0.7 89.0 106 439 some of the erasures may have reregistered hence the net figure is indicative not accurate

Table 16: GMC Registrations all countries, 1998, 2003, 2008

PMQ Country (EEA in Italics) 1998 2003 2008 Total** India 1567 2982 596 21362 South Africa 823 3206 49 6454 Pakistan 319 635 554 5893 Germany 478 383 185 5015 Australia 548 2106 80 4172 Greece 300 348 228 3299 Italy 230 245 280 2857 Nigeria 222 176 309 2558 Poland 27 19 203 2512 Ireland 282 191 108 2167 Egypt 218 109 160 1636 Iraq 101 83 113 1411 Sri Lanka 83 134 115 1316 Hungary 23 41 169 1314 New Zealand 178 578 16 1174 Spain 90 121 91 1105 Jamaica 221 419 8 1090 France 63 109 59 940 Romania 40 37 233 910 Czech Republic 6 31 93 896 Belgium 94 101 35 789 Sudan 69 61 95 749 Netherlands 93 59 56 707 Sweden 52 58 40 679 Hong Kong 38 524 3 671 Russian Federation 27 38 58 630 Austria 19 60 31 579 Syrian Arab Republic 39 33 37 563 Libyan Arab Jamahiriya 81 37 25 554 Iran, Islamic Republic Of 10 42 42 545 Myanmar 29 77 45 544 United States 54 44 30 504 Bangladesh 31 37 49 488 Bulgaria 15 14 120 480 Singapore 44 275 8 421 Slovakia 4 5 37 415 Ukraine 9 19 59 379 Malta 16 18 60 354 Lithuania 2 28 307 Switzerland 12 34 34 295 Zimbabwe 10 54 14 271 Denmark 19 28 18 270 Jordan 9 21 30 262 Portugal 10 13 28 177 Canada 13 9 14 176 Malaysia 6 22 13 172 Serbia 15 16 7 168 Ghana 30 8 11 163 Turkey 7 19 11 163 Finland 12 16 7 155 Nepal 21 25 150 Latvia 4 13 141 Philippines 4 17 20 128 Brazil 10 8 15 126 Yemen 6 24 9 119 Colombia 3 6 10 101

Norway 5 8 10 96 Argentina 2 9 11 93 China 6 2 12 93 Japan 7 7 9 92 Zambia 9 13 3 86 Afghanistan 5 7 11 80 Uganda 2 6 5 80 Kenya 9 8 3 79 Israel 11 10 5 71 Belarus 2 2 11 67 Algeria 2 7 15 66 Estonia 1 9 66 Grenada 2 4 7 65 Saudi Arabia 13 3 2 57 Iceland 5 7 1 51 Other countries <50 since 1998 * 63 81 122 266 Total EEA 1898 1956 2181 26609 Total all 6852 13952 5022 83749 * 73 countries provided fewer than 50 registrations each in the decade 1998-2009 (May). ** total since 1998

Table 17: GMC Registrations 1998–2009 (May) by country of qualifcation

% total 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Total by % (EEA + PMQ Country Country international Int) Afghanistan 5 3 5 1 5 7 11 10 8 11 11 3 80 0.14 0.096 Albania 1 1 3 2 2 2 1 6 3 5 2 1 29 0.05 0.035 Algeria 2 5 5 2 1 7 3 7 10 7 15 2 66 0.12 0.079 Angola 1 1 1 1 1 5 0.01 0.006 Antigua and Barbuda 1 1 0.00 0.001 Argentina 2 2 7 9 9 9 12 12 12 7 11 1 93 0.16 0.111 Armenia 2 3 1 5 7 5 4 2 2 4 1 36 0.06 0.043 Australia 548 282 267 276 331 2106 12 64 104 65 80 37 4172 7.30 4.982 Azerbaijan 1 1 1 1 1 3 2 1 11 0.02 0.013 Bahrain 3 2 2 2 4 1 3 3 2 22 0.04 0.026 Bangladesh 31 26 20 32 32 37 59 78 52 64 49 8 488 0.85 0.583 Belarus 2 4 3 4 3 2 8 9 10 10 11 1 67 0.12 0.080 Belize 1 1 5 7 0.01 0.008 Bolivia 2 1 2 1 6 0.01 0.007 Bosnia and Herzegovina 7 6 6 1 4 5 2 3 3 3 3 43 0.08 0.051 Brazil 10 8 11 8 4 8 10 15 16 14 15 7 126 0.22 0.150 Burundi 1 3 3 7 0.01 0.008 Cameroon 1 1 1 2 2 4 2 3 2 1 1 20 0.04 0.024 Canada 13 14 11 10 12 9 19 25 25 20 14 4 176 0.31 0.210 Cayman Islands 1 5 4 3 13 0.02 0.016 Chile 3 4 6 1 3 1 6 2 5 2 3 1 37 0.06 0.044 China 6 3 6 3 9 2 8 19 11 9 12 5 93 0.16 0.111 Colombia 3 8 8 12 8 6 14 11 12 6 10 3 101 0.18 0.121 Congo, The Dem Republic of The 1 3 1 1 2 5 2 1 16 0.03 0.019 Cook Islands 1 1 2 0.00 0.002 Costa Rica 1 1 1 1 4 0.01 0.005 Croatia 2 8 3 3 3 5 3 5 4 5 1 3 45 0.08 0.054 Cuba 4 3 7 4 3 3 4 6 5 6 1 46 0.08 0.055 Côte D'Ivoire 1 1 2 0.00 0.002 Dominica 2 2 1 5 0.01 0.006 Dominican Republic 1 2 3 5 3 5 5 1 2 1 28 0.05 0.033 Ecuador 1 1 1 1 1 1 1 7 0.01 0.008 Egypt 218 206 205 147 98 109 109 127 98 106 160 53 1636 2.86 1.953 El Salvador 1 1 0.00 0.001 Ethiopia 6 5 3 3 5 2 3 4 3 1 2 1 38 0.07 0.045 Fiji 1 1 2 0.00 0.002 Gabon 1 1 0.00 0.001 Georgia 3 2 1 3 3 12 0.02 0.014 Ghana 30 30 21 13 12 8 13 15 5 3 11 2 163 0.29 0.195 Grenada 2 3 2 2 4 12 16 5 6 7 6 65 0.11 0.078

Guatemala 2 1 1 4 0.01 0.005 Guinea 1 1 0.00 0.001 Guyana 1 2 1 3 4 3 3 2 1 20 0.04 0.024 Haiti 1 1 2 0.00 0.002 Honduras 1 1 0.00 0.001 Hong Kong 38 12 29 13 46 524 2 3 4 671 1.17 0.801 India 1567 1980 2036 1713 1891 2982 3644 2920 1179 686 596 168 21362 37.39 25.507 Indonesia 1 1 1 2 1 1 7 0.01 0.008 Iran, Islamic Republic Of 10 18 30 34 42 42 81 107 68 58 42 13 545 0.95 0.651 Iraq 101 118 158 130 139 83 128 165 134 101 113 41 1411 2.47 1.685 Israel 11 4 3 6 6 10 5 8 7 6 5 71 0.12 0.085 Jamaica 221 107 121 69 118 419 1 10 5 8 8 3 1090 1.91 1.302 Japan 7 4 8 10 9 7 9 12 7 6 9 4 92 0.16 0.110 Jordan 9 11 23 21 27 21 24 39 31 19 30 7 262 0.46 0.313 Kazakhstan 1 1 3 1 1 7 3 5 3 25 0.04 0.030 Kenya 9 6 9 9 11 8 7 8 7 1 3 1 79 0.14 0.094 Korea, Dem. People'S Republic 1 1 1 1 1 1 6 0.01 0.007 Kuwait 3 8 3 2 1 1 1 3 4 1 27 0.05 0.032 Kyrgyzstan 1 1 2 1 5 0.01 0.006 Lebanon 1 4 2 2 4 2 6 5 6 5 2 39 0.07 0.047 Liberia 1 2 1 4 0.01 0.005 Libyan Arab Jamahiriya 81 56 77 61 49 37 57 44 33 30 25 4 554 0.97 0.662 Macedonia 2 1 1 3 3 3 1 1 15 0.03 0.018 Malawi 2 8 4 6 7 2 4 4 4 1 1 1 44 0.08 0.053 Malaysia 6 12 20 12 22 22 15 16 16 11 13 7 172 0.30 0.205 Mauritius 1 2 3 0.01 0.004 Mexico 3 4 1 1 5 3 1 8 6 1 33 0.06 0.039 Moldova, Republic Of 1 1 3 2 4 8 19 0.03 0.023 Mongolia 1 1 1 3 0.01 0.004 Montserrat 1 2 3 2 1 1 10 0.02 0.012 Morocco 1 1 2 1 5 0.01 0.006 Mozambique 2 2 0.00 0.002 Myanmar 29 50 54 61 54 77 67 42 26 34 45 5 544 0.95 0.650 Nepal 1 1 7 21 32 33 16 10 25 4 150 0.26 0.179 Netherlands Antilles 1 2 1 1 2 7 0.01 0.008 New Zealand 178 65 93 65 103 578 4 16 28 15 16 13 1174 2.05 1.402 Nicaragua 1 1 2 0.00 0.002 Nigeria 222 222 242 196 179 176 229 288 174 233 309 88 2558 4.48 3.054 Oman 2 4 5 2 2 2 2 2 8 6 1 36 0.06 0.043 Pakistan 319 275 302 313 468 635 983 911 475 483 554 175 5893 10.31 7.037 Palestinian Territory Occupied 2 4 4 1 1 12 0.02 0.014 Panama 1 1 2 0.00 0.002 Papua New Guinea 1 2 3 0.01 0.004 Paraguay 2 2 0.00 0.002 Peru 3 7 2 2 1 1 5 1 1 3 1 27 0.05 0.032

Philippines 4 2 2 9 8 17 16 15 13 15 20 7 128 0.22 0.153 Russian Federation 27 31 31 40 49 38 89 107 79 65 58 16 630 1.10 0.752 Saint Kitts And Nevis 4 1 1 3 1 10 0.02 0.012 Saint Lucia 2 1 1 1 2 3 10 0.02 0.012 Saudi Arabia 13 6 9 6 5 3 3 2 1 5 2 2 57 0.10 0.068 Senegal 1 2 3 0.01 0.004 Serbia 15 11 10 16 11 16 22 30 20 9 7 1 168 0.29 0.201 Sierra Leone 1 2 5 4 1 5 4 7 1 30 0.05 0.036 Singapore 44 18 21 16 28 275 2 5 2 8 2 421 0.74 0.503 Somalia 1 1 4 2 1 1 1 1 12 0.02 0.014 South Africa 823 392 434 547 892 3206 4 11 38 42 49 16 6454 11.30 7.706 Sri Lanka 83 82 96 101 147 134 186 155 90 79 115 48 1316 2.30 1.571 Sudan 69 71 59 40 38 61 83 73 47 70 95 43 749 1.31 0.894 Syrian Arab Republic 39 45 61 64 52 33 55 67 55 47 37 8 563 0.99 0.672 Taiwan, Province Of China 1 3 2 1 1 8 0.01 0.010 Tajikistan 1 3 2 1 1 8 0.01 0.010 Tanzania, United Republic Of 5 2 2 3 3 3 3 2 1 1 4 29 0.05 0.035 Thailand 3 4 2 3 4 4 3 3 2 28 0.05 0.033 Togo 1 1 0.00 0.001 Tunisia 2 3 1 2 1 6 2 1 2 20 0.04 0.024 Turkey 7 8 7 7 16 19 16 26 27 15 11 4 163 0.29 0.195 Turkmenistan 1 2 1 4 0.01 0.005 Uganda 2 4 5 7 9 6 10 17 5 8 5 2 80 0.14 0.096 Ukraine 9 13 11 25 24 19 61 54 44 45 59 15 379 0.66 0.453 United Arab Emirates 2 2 2 1 2 6 4 7 8 3 37 0.06 0.044 United States 54 66 62 43 42 44 46 36 31 35 30 15 504 0.88 0.602 Uruguay 1 1 2 1 1 6 0.01 0.007 Uzbekistan 2 3 2 4 5 6 4 6 3 1 36 0.06 0.043 Venezuela 3 1 4 1 3 4 6 9 4 3 1 2 41 0.07 0.049 Viet Nam 3 3 0.01 0.004 Yemen 6 8 8 11 12 24 15 13 6 6 9 1 119 0.21 0.142 Zambia 9 9 3 7 12 13 11 13 1 5 3 86 0.15 0.103 Zimbabwe 10 13 22 27 29 54 46 27 15 8 14 6 271 0.47 0.324 International MGs Total 4954 4411 4685 4275 5148 11996 6330 5825 3163 2609 2841 903 57140 100.00 68.228 Austria 19 27 33 45 77 60 83 76 58 52 31 18 579 2.18 0.691 Belgium 94 93 54 56 60 101 98 68 59 50 35 21 789 2.97 0.942 Bulgaria 15 20 23 14 14 14 37 48 27 92 120 56 480 1.80 0.573 Czech Republic 6 6 15 33 27 31 206 228 118 106 93 27 896 3.37 1.070 Denmark 19 20 16 20 35 28 34 40 20 12 18 8 270 1.01 0.322 Estonia 2 1 1 1 12 25 12 2 9 1 66 0.25 0.079 Finland 12 12 28 18 18 16 11 11 10 9 7 3 155 0.58 0.185 France 63 52 50 63 103 109 150 122 89 54 59 26 940 3.53 1.122 Germany 478 355 369 303 353 383 772 861 549 314 185 93 5015 18.85 5.988 Greece 300 254 216 219 247 348 478 387 286 233 228 103 3299 12.40 3.939 Hungary 23 18 28 19 21 41 189 320 228 194 169 64 1314 4.94 1.569

Iceland 5 3 5 3 2 7 15 6 1 3 1 51 0.19 0.061 Ireland 282 309 266 215 188 191 173 145 124 116 108 50 2167 8.14 2.587 Italy 230 215 197 195 194 245 307 275 281 304 280 134 2857 10.74 3.411 Latvia 2 1 4 3 4 21 52 25 11 13 5 141 0.53 0.168 Lithuania 1 1 2 1 2 38 129 65 31 28 9 307 1.15 0.367 Malta 16 26 29 17 17 18 32 39 55 40 60 5 354 1.33 0.423 Netherlands 93 76 56 44 49 59 70 66 64 59 56 15 707 2.66 0.844 Norway 5 6 9 11 9 8 12 12 7 5 10 2 96 0.36 0.115 Poland 27 29 32 18 21 19 498 745 532 339 203 49 2512 9.44 2.999 Portugal 10 15 13 5 8 13 19 9 21 22 28 14 177 0.67 0.211 Romania 40 27 39 30 31 37 65 74 87 175 233 72 910 3.42 1.087 Slovakia 4 2 3 7 4 5 71 127 95 46 37 14 415 1.56 0.496 Slovenia 3 1 3 3 5 7 3 5 3 33 0.12 0.039 Spain 90 84 78 88 115 121 107 114 94 93 91 30 1105 4.15 1.319 Sweden 52 50 54 51 56 58 135 75 48 46 40 14 679 2.55 0.811 Switzerland 12 11 7 10 28 34 38 44 32 35 34 10 295 1.11 0.352 EEA MGs Total 1898 1715 1622 1492 1682 1956 3674 4103 2994 2446 2181 846 26609 100.00 31.772 Total by Year 6852 6126 6307 5767 6830 13952 10004 9928 6157 5055 5022 1749 83749 100.000 % of Total that were International 72.30 72.00 74.28 74.13 75.37 85.98 63.27 58.67 51.37 51.61 56.57 51.63 % of Total that were EEA 27.70 28.00 25.72 25.87 24.63 14.02 36.73 41.33 48.63 48.39 43.43 48.37 United Kingdom 4244 4320 4454 4277 4400 4731 4732 5164 5620 6134 6770 2141 56987

Table 18: Erasures from the GMC Register 1998–2009 (May) by country of qualifcation and reason for erasure

Number of Doctors Total PMQ Country Reason for erasure 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Administrative Reason 288 299 430 374 611 305 341 323 512 255 169 216 4,123 Deceased 5 7 17 15 13 19 16 26 11 13 17 2 161 Australia Erased after Fitness to Practise panel 1 1 1 1 1 1 6 hearing Having relinquished registration 282 234 281 234 293 162 363 448 263 155 147 434 3,296 Australia Total 575 540 729 623 918 486 721 797 787 423 334 653 7,586 Administrative Reason 5 8 9 6 15 29 34 31 50 31 35 16 269 Deceased 2 1 1 1 1 6 Austria Erased after Fitness to Practise panel 2 2 hearing Having relinquished registration 2 5 3 4 1 9 6 16 14 15 23 13 111 Austria Total 7 13 14 10 17 38 41 48 64 47 60 29 388 Administrative Reason 6 4 5 2 7 4 10 7 14 10 8 46 123 Deceased 4 3 3 1 6 4 4 2 3 4 3 37 Bangladesh Erased after Fitness to Practise panel 1 1 1 1 4 1 9 hearing Having relinquished registration 8 7 6 14 9 3 10 6 9 8 19 90 189 Bangladesh Total 18 11 15 19 18 14 24 17 26 25 32 139 358 Administrative Reason 1 1 1 1 1 5 Belarus Having relinquished registration 2 1 1 4 Belarus Total 1 2 1 2 2 1 9 Administrative Reason 35 54 47 34 63 41 40 69 73 54 45 12 567 Belgium Deceased 1 2 3 Having relinquished registration 34 22 23 15 18 16 17 18 21 17 32 16 249 Belgium Total 69 76 70 49 81 57 57 87 95 71 77 30 819 Administrative Reason 1 1 1 2 1 6 Brazil Having relinquished registration 1 2 4 1 2 1 11 Brazil Total 1 1 1 2 5 3 3 1 17 Administrative Reason 4 7 4 6 6 4 22 3 27 2 4 57 146 Canada Deceased 6 5 2 4 2 2 3 24 Having relinquished registration 4 2 4 2 8 8 1 3 5 8 53 98 Canada Total 8 9 8 14 14 17 25 10 29 9 15 110 268 Administrative Reason 1 1 1 1 1 2 1 8 Colombia Deceased 1 1 Having relinquished registration 1 1 2 1 5 Colombia Total 1 1 1 1 1 1 2 4 2 14

Administrative Reason 6 9 10 11 23 9 22 13 23 15 19 11 171 Deceased 1 1 2 4 Denmark Erased after Fitness to Practise panel 1 1 hearing Having relinquished registration 4 5 6 2 3 3 2 4 7 8 6 13 63 Denmark Total 11 15 16 13 26 12 26 17 31 23 25 24 239 Administrative Reason 23 32 52 45 51 31 24 20 59 38 44 61 480 Deceased 4 4 3 6 3 2 3 10 7 1 9 2 54 Egypt Erased after Fitness to Practise panel 2 2 1 2 1 1 3 1 4 5 1 23 hearing Having relinquished registration 44 28 38 35 46 25 37 14 20 23 13 74 397 Egypt Total 73 66 94 88 101 58 65 47 87 66 71 138 954 Administrative Reason 6 13 9 5 15 6 10 14 8 6 7 5 104 Deceased 1 1 Finland Erased after Fitness to Practise panel 1 1 hearing Having relinquished registration 5 4 5 10 9 6 3 3 5 5 4 2 61 Finland Total 11 17 14 15 24 12 13 17 13 11 12 8 167 Administrative Reason 16 36 35 33 60 35 38 60 105 63 56 36 573 Deceased 1 1 1 4 1 3 3 1 3 1 19 France Erased after Fitness to Practise panel 1 1 1 3 hearing Having relinquished registration 10 11 3 6 6 4 8 11 8 7 17 23 114 France Total 27 48 39 44 67 42 46 74 113 71 77 61 709 Administrative Reason 162 229 185 185 327 200 166 157 354 335 391 164 2,855 Deceased 3 2 4 3 2 6 1 2 5 6 8 42 Germany Erased after Fitness to Practise panel 1 4 4 2 2 13 hearing Having relinquished registration 155 154 169 125 150 114 75 91 148 187 199 180 1,747 Germany Total 320 385 359 313 479 320 242 250 511 532 600 346 4,657 Administrative Reason 3 2 3 5 4 2 4 2 6 2 7 2 42 Deceased 1 1 Ghana Erased after Fitness to Practise panel 1 1 hearing Having relinquished registration 4 2 7 1 3 6 1 4 3 1 32 Ghana Total 7 5 10 6 7 8 4 2 7 6 11 3 76 Administrative Reason 132 194 251 169 284 155 189 248 334 278 304 125 2,663 Deceased 2 2 1 1 6 Greece Erased after Fitness to Practise panel 1 1 1 1 4 hearing Having relinquished registration 80 69 94 87 81 63 60 87 87 73 93 78 952 Greece Total 212 264 346 256 366 219 251 337 421 351 398 204 3,625 Hong Kong Administrative Reason 160 185 187 141 358 122 99 146 197 92 106 102 1,895

Deceased 1 1 1 2 2 1 7 4 1 1 1 22 Having relinquished registration 63 57 78 78 118 52 59 76 42 37 69 135 864 Hong Kong Total 224 243 266 219 478 176 159 229 243 130 176 238 2,781 Administrative Reason 4 2 1 3 12 4 7 11 59 68 117 37 325 Deceased 2 1 3 Hungary Erased after Fitness to Practise panel 1 1 2 hearing Having relinquished registration 6 6 3 6 8 11 14 33 29 116 Hungary Total 4 2 1 9 18 7 13 21 70 84 151 66 446 Administrative Reason 3 4 5 7 12 3 8 6 3 2 1 54 Iceland Deceased 1 1 Having relinquished registration 1 1 2 3 1 3 1 1 2 15 Iceland Total 4 4 6 9 15 1 4 11 7 4 2 3 70 Administrative Reason 196 203 213 213 378 184 240 146 516 335 572 857 4,053 Deceased 40 44 42 45 27 59 51 90 64 47 91 33 633 India Erased after Fitness to Practise panel 6 5 11 9 14 21 2 3 17 11 14 12 125 hearing Having relinquished registration 242 202 221 208 273 216 171 181 219 279 376 1,357 3,945 India Total 484 454 487 475 692 480 464 420 816 672 1,053 2,259 8,756 Administrative Reason 4 9 11 8 15 11 15 7 11 13 22 21 147 Deceased 2 1 3 4 4 1 2 1 2 20 Iraq Erased after Fitness to Practise panel 2 1 1 1 3 2 2 12 hearing Having relinquished registration 4 5 10 9 10 11 3 11 7 6 13 20 109 Iraq Total 8 18 21 18 26 26 23 22 19 24 38 45 288 Administrative Reason 148 141 133 122 296 147 348 130 428 136 134 355 2,518 Deceased 49 54 60 80 66 100 71 175 63 55 72 27 872 Ireland Erased after Fitness to Practise panel 1 1 2 3 5 1 13 hearing Having relinquished registration 80 60 89 79 102 96 94 101 72 60 103 840 1,776 Ireland Total 277 256 283 281 466 343 513 406 566 251 314 1,223 5,179 Administrative Reason 104 136 149 132 240 143 145 122 192 154 212 92 1,821 Deceased 1 2 3 2 4 1 2 1 3 1 20 Italy Erased after Fitness to Practise panel 2 1 3 hearing Having relinquished registration 39 55 85 44 52 52 35 48 51 42 68 66 637 Italy Total 143 192 236 179 294 199 181 172 246 197 283 159 2,481 Administrative Reason 37 58 70 81 155 74 54 81 129 101 68 29 937 Deceased 1 1 2 1 1 2 8 Jamaica Erased after Fitness to Practise panel 1 1 hearing Having relinquished registration 24 14 16 9 43 14 23 24 15 14 15 7 218 Jamaica Total 61 73 87 90 198 90 78 106 146 116 83 36 1,164

Administrative Reason 1 2 1 1 3 4 2 5 2 6 5 6 38 Jordan Having relinquished registration 1 3 1 1 2 2 2 7 5 2 4 2 32 Jordan Total 2 5 2 2 5 6 4 12 7 8 9 8 70 Administrative Reason 1 1 3 3 3 2 3 1 4 2 2 8 33 Deceased 1 1 1 2 5 Kenya Erased after Fitness to Practise panel 2 2 hearing Having relinquished registration 1 1 1 1 1 1 1 6 13 Kenya Total 2 1 4 4 5 4 5 1 5 3 3 16 53 Administrative Reason 6 1 1 1 1 2 1 2 2 17 Lebanon Deceased 1 1 Having relinquished registration 2 1 2 1 2 1 4 13 Lebanon Total 6 1 3 1 3 2 4 1 2 2 6 31 Administrative Reason 5 8 12 3 13 4 6 3 7 11 16 8 96 Deceased 1 1 1 3 Libyan Arab Jamahiriya Erased after Fitness to Practise panel 1 1 hearing Having relinquished registration 6 6 2 4 2 3 4 7 8 6 5 1 54 Libyan Arab Jamahiriya Total 11 14 14 7 15 8 10 10 17 18 21 9 154 Administrative Reason 21 13 9 13 10 12 12 10 20 1 3 15 139 Malaysia Deceased 1 1 2 3 2 9 Having relinquished registration 18 15 7 9 12 5 5 5 2 6 8 17 109 Malaysia Total 39 29 16 22 22 17 18 17 25 7 11 34 257 Administrative Reason 1 1 2 5 8 4 13 2 20 6 7 18 87 Malta Deceased 2 1 1 3 4 2 4 2 3 3 2 27 Having relinquished registration 1 2 3 4 5 2 3 4 5 7 6 58 100 Malta Total 4 4 6 12 13 10 18 10 27 16 16 78 214 Administrative Reason 22 18 13 18 23 11 9 9 20 11 17 34 205 Deceased 1 2 1 1 1 1 6 4 1 2 1 21 Myanmar Erased after Fitness to Practise panel 1 2 1 4 hearing Having relinquished registration 16 10 8 16 17 14 17 5 8 12 14 54 191 Myanmar Total 39 29 23 35 41 26 27 20 32 26 33 90 421 Administrative Reason 98 80 46 65 87 47 37 38 38 30 38 19 623 Deceased 1 1 1 1 1 1 6 Netherlands Erased after Fitness to Practise panel 1 1 1 1 1 1 6 hearing Having relinquished registration 42 31 37 27 34 21 16 23 22 18 20 33 324 Netherlands Total 140 111 85 93 122 70 53 63 61 49 58 54 959 Administrative Reason 74 75 96 90 126 81 93 91 154 49 41 43 1,013 Deceased 2 6 6 5 4 14 3 10 10 2 6 2 70 New Zealand Erased after Fitness to Practise panel 1 1 2 hearing

Having relinquished registration 65 66 81 58 64 50 81 124 116 66 60 145 976 New Zealand Total 141 147 183 153 195 145 178 225 280 117 107 190 2,061 Administrative Reason 34 25 23 25 51 33 21 20 24 35 29 25 345 Deceased 3 1 2 1 2 3 3 15 Nigeria Erased after Fitness to Practise panel 1 1 1 2 2 3 1 11 hearing Having relinquished registration 17 18 13 14 18 7 10 11 10 5 15 12 150 Nigeria Total 52 43 37 43 70 40 33 32 38 45 50 38 521 Administrative Reason 4 3 1 2 10 4 6 2 10 3 4 5 54 Norway Having relinquished registration 5 1 1 4 2 1 2 3 3 2 24 Norway Total 9 4 2 6 10 4 8 3 12 6 7 7 78 Administrative Reason 55 71 69 42 83 58 48 29 100 69 100 201 925 Deceased 8 5 10 16 2 7 9 18 16 11 15 10 127 Pakistan Erased after Fitness to Practise panel 1 2 1 2 4 2 1 13 hearing Having relinquished registration 45 54 62 42 59 40 27 29 47 41 64 256 766 Pakistan Total 109 130 141 102 144 106 84 76 165 125 181 468 1,831 Administrative Reason 1 1 1 1 1 1 1 7 Peru Having relinquished registration 1 1 1 3 Peru Total 1 1 1 2 1 1 1 2 10 Administrative Reason 7 1 3 4 7 4 14 6 118 197 256 135 752 Deceased 6 1 3 6 3 4 6 4 3 2 3 1 42 Poland Erased after Fitness to Practise panel 1 1 1 3 hearing Having relinquished registration 2 1 4 5 6 3 1 8 14 26 52 60 182 Poland Total 15 3 10 16 16 11 21 18 135 225 312 197 979 Administrative Reason 9 8 6 7 24 8 5 9 14 11 12 10 123 Portugal Deceased 1 1 Having relinquished registration 5 1 1 1 1 1 1 2 2 3 4 22 Portugal Total 14 9 7 8 25 8 6 10 16 14 15 14 146 Administrative Reason 2 11 9 3 10 3 7 11 11 10 41 15 133 Erased after Fitness to Practise panel Romania 1 1 hearing Having relinquished registration 2 1 1 3 3 6 3 3 2 15 8 47 Romania Total 2 13 10 4 13 6 13 14 14 13 56 23 181 Administrative Reason 1 7 1 4 4 2 7 1 4 4 18 12 65 Deceased 1 3 1 5 Russian Federation Erased after Fitness to Practise panel 1 1 2 hearing Having relinquished registration 1 2 4 1 2 2 2 5 10 29 Russian Federation Total 2 8 4 5 8 3 9 1 6 9 23 23 101 Administrative Reason 1 2 1 2 2 3 2 1 14 Saudi Arabia Having relinquished registration 2 1 2 1 1 1 1 9

Saudi Arabia Total 3 2 2 4 1 1 1 2 3 3 1 23 Administrative Reason 33 35 41 31 51 32 27 48 51 28 29 11 417 Deceased 2 3 1 6 Singapore Erased after Fitness to Practise panel 1 1 hearing Having relinquished registration 26 17 22 19 31 13 35 50 23 15 15 11 277 Singapore Total 59 52 63 50 82 45 64 101 74 43 46 22 701 Administrative Reason 344 374 401 348 605 242 311 349 686 419 292 394 4,765 Deceased 10 15 14 17 14 27 19 36 18 20 24 11 225 South Africa Erased after Fitness to Practise panel 1 1 2 1 2 7 hearing Having relinquished registration 221 205 200 255 344 202 276 324 273 247 292 558 3,397 South Africa Total 575 594 615 620 963 472 607 709 979 687 610 963 8,394 Administrative Reason 71 96 82 62 124 55 61 59 54 55 100 48 867 Deceased 1 1 2 Spain Erased after Fitness to Practise panel 1 1 hearing Having relinquished registration 55 50 72 41 28 30 24 26 36 41 51 38 492 Spain Total 126 147 154 103 153 85 85 86 90 96 151 86 1,362 Administrative Reason 25 21 32 27 41 25 38 31 106 38 42 159 585 Deceased 3 3 7 4 6 1 4 14 18 10 13 13 96 Sri Lanka Erased after Fitness to Practise panel 1 1 1 1 1 1 6 hearing Having relinquished registration 32 36 45 28 44 30 33 39 21 29 34 265 636 Sri Lanka Total 61 61 85 59 91 56 75 85 146 78 89 437 1,323 Administrative Reason 7 8 6 9 17 24 11 6 20 18 27 13 166 Deceased 1 1 2 1 1 1 1 8 Sudan Erased after Fitness to Practise panel 1 2 1 4 hearing Having relinquished registration 8 5 11 15 9 6 3 4 1 7 7 8 84 Sudan Total 15 13 18 25 27 30 16 11 24 27 34 22 262 Administrative Reason 21 31 32 23 46 29 24 34 51 36 44 38 409 Deceased 1 1 Sweden Erased after Fitness to Practise panel 1 1 hearing Having relinquished registration 9 6 6 8 9 10 8 9 18 20 26 30 159 Sweden Total 30 37 38 31 56 39 32 44 69 56 70 68 570 Administrative Reason 1 1 8 10 20 16 17 8 81 Deceased 1 1 3 1 6 Switzerland Erased after Fitness to Practise panel 1 1 hearing Having relinquished registration 1 2 3 6 5 9 6 20 14 66 Switzerland Total 1 1 1 2 2 4 14 18 29 23 37 22 154

Administrative Reason 5 4 3 4 15 3 5 5 3 5 11 9 72 Deceased 1 1 2 Syrian Arab Republic Erased after Fitness to Practise panel 1 1 2 hearing Having relinquished registration 5 4 4 5 5 2 3 2 2 6 4 4 46 Syrian Arab Republic Total 10 8 7 9 20 5 10 8 5 11 16 13 122 Administrative Reason 4 2 1 3 1 1 2 1 5 6 26 Deceased 2 2 Uganda Erased after Fitness to Practise panel 1 1 2 hearing Having relinquished registration 1 1 1 1 1 5 Uganda Total 5 2 1 2 3 1 1 3 1 1 5 10 35 Administrative Reason 480 798 327 620 1,177 528 2,065 590 2,415 616 1,145 2,436 13,197 Deceased 767 828 806 972 702 1,161 780 1,499 822 708 1,021 346 10,412 United Kingdom Erased after Fitness to Practise panel 6 12 14 15 19 14 18 25 20 22 26 18 209 hearing Having relinquished registration 645 685 916 1,036 1,441 1,078 915 967 788 919 1,868 13,664 24,922 United Kingdom Total 1,898 2,323 2,063 2,643 3,339 2,781 3,778 3,081 4,045 2,265 4,060 16,464 48,740 Administrative Reason 3 1 2 8 6 3 4 7 6 14 54 Deceased 3 2 5 United States Erased after Fitness to Practise panel 1 1 hearing Having relinquished registration 1 2 1 5 4 3 1 3 6 8 34 United States Total 3 1 3 3 13 7 6 6 7 11 12 22 94 Administrative Reason 4 3 1 1 1 1 1 8 1 21 Erased after Fitness to Practise panel Zambia 1 1 hearing Having relinquished registration 3 1 1 2 7 Zambia Total 7 3 2 1 2 1 2 10 1 29 Administrative Reason 1 1 1 5 1 2 2 7 4 24 Zimbabwe Deceased 1 1 Having relinquished registration 1 1 2 1 2 3 3 2 2 17 Zimbabwe Total 2 1 2 7 1 3 5 5 10 6 42 Administrative Reason 1 5 3 5 2 3 2 10 9 18 13 71 Bulgaria Deceased 1 1 Having relinquished registration 1 1 2 1 2 3 3 4 17 Bulgaria Total 1 1 6 4 7 3 3 2 12 12 21 17 89 Administrative Reason 7 5 1 13 Estonia Deceased 1 1 1 3 Having relinquished registration 1 4 1 6 Estonia Total 1 1 4 8 7 1 22 Administrative Reason 1 1 4 2 2 10 Israel Deceased 1 1

Having relinquished registration 1 2 1 4 Israel Total 1 1 2 4 4 3 15 Administrative Reason 2 1 1 2 3 8 6 3 6 32 Ukraine Deceased 1 1 1 4 1 8 Having relinquished registration 1 1 3 5 1 3 3 17 Ukraine Total 1 1 4 2 4 2 8 4 8 8 6 9 57 Administrative Reason 3 1 1 1 6 Deceased 1 1 Bosnia And Herzegovina Erased after Fitness to Practise panel 1 1 hearing Having relinquished registration 1 1 1 3 Bosnia And Herzegovina Total 1 3 2 3 2 11 Administrative Reason 1 3 1 1 8 3 38 34 46 19 154 Czech Republic Deceased 1 1 2 1 2 2 5 2 3 3 22 Having relinquished registration 1 1 3 1 4 13 21 16 32 92 Czech Republic Total 1 1 3 5 5 4 10 12 53 58 65 51 268 Administrative Reason 1 2 2 6 1 1 6 5 13 16 53 Deceased 1 1 2 1 1 2 8 Iran, Islamic Republic Of Erased after Fitness to Practise panel 1 1 2 hearing Having relinquished registration 4 1 1 2 4 1 3 1 3 9 14 43 Iran, Islamic Republic Of Total 4 2 4 4 11 3 1 5 8 11 22 31 106 Administrative Reason 1 2 2 1 1 1 8 Kuwait Having relinquished registration 1 1 1 1 4 Kuwait Total 1 1 3 3 1 2 1 12 Administrative Reason 1 1 1 1 2 5 7 7 3 28 Serbia Deceased 1 1 Having relinquished registration 1 1 1 1 1 1 2 8 Serbia Total 1 2 1 2 1 1 2 2 5 7 8 5 37 Administrative Reason 2 1 1 3 3 3 3 3 5 24 Turkey Deceased 1 1 2 4 Having relinquished registration 1 1 1 1 3 2 10 19 Turkey Total 1 1 3 1 1 5 4 5 6 5 15 47 Administrative Reason 2 2 1 1 1 3 10 Venezuela Having relinquished registration 1 2 1 1 1 6 Venezuela Total 1 2 2 1 2 1 2 4 1 16 Administrative Reason 1 1 1 1 1 1 1 4 11 Argentina Having relinquished registration 1 1 2 4 7 15 Argentina Total 2 1 1 1 2 1 2 5 11 26 Administrative Reason 1 1 Croatia Deceased 1 1 Having relinquished registration 1 1 4 6

Croatia Total 1 1 1 1 4 8 Dominican Republic Administrative Reason 1 1 Dominican Republic Total 1 1 Administrative Reason 1 1 1 3 Mexico Having relinquished registration 1 1 1 3 Mexico Total 1 1 1 2 1 6 Tunisia Administrative Reason 1 1 1 3 Tunisia Total 1 1 1 3 Panama Having relinquished registration 1 1 2 Panama Total 1 1 2 Administrative Reason 2 1 28 21 29 14 95 Slovakia Deceased 1 1 2 Having relinquished registration 1 1 1 2 6 5 9 9 34 Slovakia Total 1 2 1 2 1 1 2 34 26 38 23 131 Administrative Reason 1 2 1 1 1 2 8 Afghanistan Having relinquished registration 1 2 3 Afghanistan Total 1 1 2 1 1 1 4 11 Administrative Reason 2 1 2 2 2 5 1 15 Algeria Having relinquished registration 1 1 2 Algeria Total 2 1 1 2 2 3 5 1 17 Administrative Reason 1 1 2 1 2 1 8 Thailand Having relinquished registration 2 3 2 1 8 Thailand Total 3 1 2 1 3 4 2 16 Bolivia Having relinquished registration 1 1 1 3 Bolivia Total 1 1 1 3 Administrative Reason 1 1 Ecuador Having relinquished registration 1 1 Ecuador Total 1 1 2 Administrative Reason 1 1 Grenada Having relinquished registration 1 1 1 1 1 5 Grenada Total 1 1 1 2 1 6 Antigua And Barbuda Administrative Reason 1 1 Antigua And Barbuda Total 1 1 Cameroon Administrative Reason 1 1 Cameroon Total 1 1 Administrative Reason 1 1 1 1 4 Cuba Having relinquished registration 1 1 Cuba Total 1 1 1 2 5 Administrative Reason 1 1 1 3 Kazakhstan Having relinquished registration 1 1 Kazakhstan Total 1 1 2 4

Administrative Reason 1 1 Albania Having relinquished registration 1 1 2 Albania Total 1 2 3 Administrative Reason 1 1 2 4 Armenia Deceased 1 1 Having relinquished registration 1 1 2 Armenia Total 1 1 1 1 3 7 Bahrain Administrative Reason 2 1 1 4 Bahrain Total 2 1 1 4 Administrative Reason 1 1 2 Indonesia Having relinquished registration 1 1 1 3 Indonesia Total 1 1 2 1 5 Administrative Reason 2 2 Liberia Having relinquished registration 1 1 Liberia Total 2 1 3 Papua New Guinea Administrative Reason 1 1 1 3 Papua New Guinea Total 1 1 1 3 Administrative Reason 1 1 Taiwan, Province Of China Having relinquished registration 1 1 Taiwan, Province Of China Total 1 1 2 Administrative Reason 1 1 1 3 Unspecified Deceased 2 2 Unspecified Total 1 1 1 2 5 Administrative Reason 1 1 Tanzania, United Republic Of Deceased 1 1 Tanzania, United Republic Of Total 1 1 2 Costa Rica Having relinquished registration 1 1 1 3 Costa Rica Total 1 1 1 3 Morocco Having relinquished registration 1 1 Morocco Total 1 1 Mozambique Having relinquished registration 2 2 Mozambique Total 2 2 Administrative Reason 1 1 1 3 1 7 Slovenia Having relinquished registration 1 1 1 1 2 6 Slovenia Total 1 1 1 2 2 3 3 13 Administrative Reason 1 1 2 Uruguay Having relinquished registration 1 1 Uruguay Total 1 1 1 3 Administrative Reason 1 1 4 6 China Deceased 1 1 Having relinquished registration 1 2 1 4

China Total 1 1 1 1 2 5 11 Administrative Reason 1 1 2 Congo, The Dem Republic of Erased after Fitness to Practise panel 1 1 The hearing Having relinquished registration 1 1 Congo, The Dem Republic of The Total 1 1 2 4 Administrative Reason 1 2 7 14 5 29 Latvia Deceased 1 1 Having relinquished registration 1 4 2 7 Latvia Total 1 4 7 18 7 37 Administrative Reason 16 29 29 21 95 Lithuania Deceased 1 1 Having relinquished registration 3 12 4 1 20 Lithuania Total 1 19 41 33 22 116 Administrative Reason 1 3 2 2 8 Chile Having relinquished registration 1 1 2 5 9 Chile Total 1 1 1 3 4 7 17 Administrative Reason 2 1 1 2 2 8 Malawi Having relinquished registration 1 2 3 Malawi Total 1 2 1 1 2 4 11 Oman Administrative Reason 1 1 3 1 3 9 Oman Total 1 1 3 1 3 9 Uzbekistan Administrative Reason 1 2 3 Uzbekistan Total 1 2 3 Administrative Reason 1 1 2 Yemen Having relinquished registration 1 1 2 Yemen Total 2 1 1 4 Administrative Reason 1 1 2 Ethiopia Having relinquished registration 1 1 Ethiopia Total 1 1 1 3 Administrative Reason 1 1 Japan Having relinquished registration 1 1 2 4 Japan Total 1 2 2 5 El Salvador Administrative Reason 1 1 2 El Salvador Total 1 1 2 Guatemala Administrative Reason 1 1 Guatemala Total 1 1 Montserrat Administrative Reason 1 1 Montserrat Total 1 1 Cook Islands Administrative Reason 1 1 Cook Islands Total 1 1

Gabon Administrative Reason 1 1 Gabon Total 1 1 Administrative Reason 4 4 6 14 Nepal Having relinquished registration 4 3 7 Nepal Total 4 8 9 21 Administrative Reason 3 1 1 5 Philippines Deceased 1 1 Having relinquished registration 1 2 3 Philippines Total 3 3 3 9 Administrative Reason 2 2 Sierra Leone Having relinquished registration 1 1 Sierra Leone Total 1 2 3 Azerbaijan Administrative Reason 2 2 Azerbaijan Total 2 2 Cayman Islands Administrative Reason 1 1 Cayman Islands Total 1 1 United Arab Emirates Administrative Reason 1 1 United Arab Emirates Total 1 1 Macedonia Deceased 1 1 Macedonia Total 1 1 Erased after Fitness to Practise panel Somalia 1 1 hearing Somalia Total 1 1 Angola Administrative Reason 1 1 Angola Total 1 1 Belize Administrative Reason 1 1 Belize Total 1 1 Viet Nam Administrative Reason 1 1 Viet Nam Total 1 1 Korea, Dem. People's Having relinquished registration 1 1 Republic Korea, Dem. People'S Republic Total 1 1 Moldova, Republic Of Having relinquished registration 2 2 Moldova, Republic Of Total 2 2 Total by Year 5,943 6,501 6,741 6,834 9,832 6,631 8,178 7,811 10,796 7,335 10,182 25,435 107,707

Table 19: Initial admissions to the register from the EU/EEA countries and Switzerland (2004–8) Country 2004–05* 2005–06* 2006–07 2007–08 Poland 133 442 578 456 Germany 159 141 Republic of Ireland 89 68 Slovakia 22 64 84 48 Czech Republic 23 65 66 52 Italy 54 92 Lithuania 17 74 47 34 Spain 41 37 Sweden 36 31 Hungary 22 63 29 34 Greece 27 14 Denmark 24 27 Finland 24 24 Netherlands 23 25 France 21 33 Austria 20 12 Portugal 20 49 Belgium 18 13 Malta 7 16 16 19 Switzerland 16 7 Latvia 0 17 14 7 Norway 12 16 Romania 57 382 Estonia 5 13 7 0 Bulgaria 25 168 Cyprus 2 7 6 0 Gibraltar 5 0 Iceland 2 0 Slovenia 0 3 0 0 England ** NA NA NA 83 TOTAL 231* 764* 1520 1872 * Accession countries only ** This category represents EU citizens trained in England or UK nationals who trained outside the EU. Until September 2008, nurses and midwives who were EU citizens but who trained outside the EU could be assessed through the EU registrations route if they wished. This mainly affected overseas nurses and midwives who were married to UK nationals and Commonwealth citizens who held UK passports. From September 2008, this category of nurses and midwives will apply for registration via the Overseas registration route. Source: Based on Table 8 NMC (2006); Table 8 NMC (2007); Table 8 NMC (2008)

Table 20: Number of international registrations with NMC (and predecessor), 1999–2008

Pre NMC Since inception of NMC All Top 25 countries Top 25 countries countries Country 1998–99 1999–00 2000–1 2001–2 2002–03 2003–04 2004–05 2005–06 2006–07 2007–08 Australia 1,335 1,209 1,046 1,342 920 1,326 981 751 299 262 Belarus 3 Botswana 4 0 87 100 39 90 91 44 NA 2 Brazil 2 Cameroon 11 12 Canada 196 130 89 79 52 89 88 75 31 24 China 0 0 60 66 80 52 Gambia 8 3 Ghana 40 74 140 195 251 354 272 154 66 38 Guyana May be included in W. Indies 86 NA 0 Hong Kong 2 India 30 96 289 994 1,830 3,073 3,690 3,551 2,436 1020 Iran 10 18 Israel 4 Jamaica see West Indies 78 NA 2 Japan 20 37 34 30 21 14 Kenya 19 29 50 155 152 146 99 41 37 19 Lesotho 0 50 43 27 NA 0 Malawi 1 15 45 75 57 64 52 41 NA 3 Malaysia 8 0 Mauritius 6 15 41 62 59 95 102 71 27 19 Nepal 71 43 73 75 148 117 New Zealand 527 461 393 443 282 348 289 215 74 62 Nigeria 179 208 347 432 509 511 466 381 258 154 Pakistan 3 13 44 207 172 140 205 200 154 42 Philippines 52 1,052 3,396 7,235 5,593 4,338 2,521 1,541 673 249 Romania 0 0 0 57 see EEA see EEA Saudi Arabia 28 0 Sierra Leone 24 14 3 Singapore 0 0 28 35 NA 2 South Africa 599 1460 1086 2114 1,368 1,689 933 378 39 32 Swaziland 81 69 0 Sri Lanka 23 36 47 28 7 Thailand 3 Trinidad&Tobago see West Indies 32 NA 0 Uganda 10 4 USA 139 168 147 122 88 141 105 98 21 35 West Indies 221 425 261 248 208 397 352 Zambia 15 40 88 183 133 169 162 110 53 51 Zimbabwe 52 221 382 473 485 391 311 161 90 49 Others 203 329 472 605 418 514 380 375 N/A 0 TOTAL 3,621 5,945 8,403 15,064 12,499 13,608 10,985 8,673 2309 TOTAL (Table 14 '05) 12,730 14,122 11,477 Dates are year ending 31st March. Countries in italics may have had some registrants in the period 2002–7 but not in top 25 for either the period 2002–6 or for 2007.

Source, Table 7 of NMC (2007–8), NMC (2006–7), NMC (2005–6) (covers 2002–6) Source Table 14 of NMC (2004–5) for period 1998–2003 and blue figures up to 2006 West Indies broken up into (unspecified) component territories from 2005–6 Note discrepancy in totals between NMC publications.

Table 21: NHS dentists by country of qualification, in England, as at 31 March1997–2006 Country of 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Qualification United 13,900 14,097 14,288 14,506 14,699 14,851 14,912 14,940 15,136 15,405 Kingdom South Africa 465 530 657 766 813 846 862 870 898 896 Sweden 212 364 468 574 620 673 682 701 729 747 Poland 0 0 0 0 0 0 0 0 119 402 Ireland 543 531 546 505 464 448 422 395 376 369 Greece 26 34 48 53 57 68 87 109 167 206 Germany 12 17 22 32 42 45 54 69 110 154 Australia 173 167 169 165 163 154 143 143 143 130 New 124 120 128 133 137 129 118 121 110 103 Zealand Spain 1 4 2 2 1 1 3 31 70 102 Denmark 41 44 53 61 76 86 93 97 103 101 Portugal 1 1 1 3 6 4 5 13 41 67 Malaysia 47 47 49 48 48 44 37 40 51 54 Italy 5 17 19 19 22 21 25 28 38 42 Hungary 0 0 0 0 0 0 1 1 23 34 Lithuania 0 0 0 0 0 0 0 0 12 34 Finland 10 9 13 22 25 26 31 30 30 28 Belgium 9 10 18 18 26 28 28 25 27 27 Netherlands 26 28 29 30 25 24 24 25 27 24 Norway 1 6 7 17 21 24 27 25 27 24 France 9 9 12 19 17 19 18 19 19 21 Czech 0 0 0 0 0 0 0 0 6 11 Republic Slovenia 0 0 0 0 0 0 0 0 3 11 Estonia 0 0 0 0 0 0 0 0 3 10 Malta 4 3 3 3 3 3 3 2 4 9 Latvia 0 0 0 0 0 0 0 0 1 6 Hong Kong 1 2 2 2 2 3 2 2 3 3 Statutory 280 281 277 294 315 335 351 380 451 548 Exam [1] EEA (not 1,185 1,351 1,511 1,604 1,637 1,669 1,661 1,730 2,087 2,559 including UK)

Total 1,990 2,224 2,523 2,766 2,883 2,981 3,016 3,126 3,591 4,163 overseas [2] Known 15,890 16,321 16,811 17,272 17,582 17,832 17,928 18,066 18,727 19,568 total Unknown 580 611 664 716 771 825 873 960 1,070 1,543 [3] Total 16,470 16,932 17,475 17,988 18,353 18,657 18,801 19,026 19,797 21,111 % UK 87.5 86.4 85.0 84.0 83.6 83.3 83.2 82.7 80.8 78.7 qualified Notes: 1. Statutory Exam indicates the exam taken by dentists whose home qualification is not recognised by the UK. By its nature, it does not specify a country of qualification but confirms that it is different from all country-specific qualifications. 2. Total overseas includes dentists whose status is shown as Statutory Exam. 3. Unknown consists of dentists whose country of qualification is recorded as "Awaiting Entry" or is blank.

Source: Table 8, The Information Centre, 2006, NHS Dental Activity and Workforce Report England: 31 March 2006, available at http://www.ic.nhs.uk/webfiles/publications/dwfactivity/NHSDentalActivityWorkforce230806_PDF.pdf, accessed, 18 September 2009, Copyright © 2006, The Information Centre, Dental Statistics.

Table 22: Number of NHS dentists who joined the GDS or PDS by country of qualification, in England, as at year ending 31 March 1997–2006 Country of 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 qualification United 851 877 930 993 1,063 1,052 1,002 983 1,013 898 Kingdom Poland 0 0 0 0 0 0 0 0 123 286 Greece 3 11 16 14 17 20 31 43 73 60 Germany 2 8 8 15 18 12 14 28 55 55 Sweden 132 173 147 142 102 109 49 66 56 50 Spain 0 3 0 1 0 1 4 32 45 48 Ireland 66 64 66 51 46 43 41 45 45 35 Portugal 0 0 0 2 4 1 1 10 33 31 South 68 104 170 172 119 109 101 78 66 22 Africa New 17 8 20 26 29 20 15 18 12 8 Zealand Italy 1 13 8 5 6 6 7 7 15 7 Denmark 10 5 13 13 19 16 14 14 15 6 Malta 0 0 0 0 0 0 0 0 2 6 Australia 18 18 30 22 32 26 23 26 14 5 Czech 0 0 0 0 0 0 0 0 6 5 Republic Latvia 0 0 0 0 0 0 0 0 1 5 Malaysia 0 0 4 3 7 2 3 6 10 5 Belgium 4 4 8 3 9 2 0 1 4 3 France 2 2 4 8 1 4 2 3 3 3 Finland 9 2 10 12 11 8 7 6 4 2 Hong Kong 0 1 0 0 0 1 0 0 1 0 Netherlands 4 3 5 2 0 1 1 2 2 0 Norway 1 5 3 11 7 6 4 1 5 0 Statutory 8 13 13 26 34 33 38 45 92 117 Exam [1] EEA (not 234 293 288 279 240 229 175 258 487 602 inc UK) Total 345 437 525 528 461 420 355 431 682 759 overseas [2] Known total 1,196 1,314 1,455 1,521 1,524 1,472 1,357 1,414 1,695 1,657 Unknown 58 54 68 77 83 87 96 120 205 582 [3] Total 1,254 1,368 1,523 1,598 1,607 1,559 1,453 1,534 1,900 2,239

Notes: 1. Statutory Exam indicates the exam taken by dentists whose home qualification is not recognised by the UK. By its nature, it does not specify a country of qualification but confirms that it is different from all country-specific qualifications. 2. Total overseas includes dentists whose status is shown as Statutory Exam. 3. Unknown consists of dentists whose country of qualification is recorded as "Awaiting Entry" or is blank. Source: Table 10, The Information Centre, 2006, NHS Dental Activity and Workforce Report England: 31 March 2006, available at http://www.ic.nhs.uk/webfiles/publications/dwfactivity/NHSDentalActivityWorkforce230806_PDF.pdf, accessed, 18 September 2009, Copyright © 2006, The Information Centre, Dental Statistics.

Table 23: EEA qualified pharmacists registering with the Royal Pharmaceutical Society of Great Britain Country 2007 2008 Austria 3 0 Belgium 2 1 Cyprus 0 0 Czech Rep 7 13 Denmark 6 4 Estonia 2 3 Finland 0 2 France 7 9 Germany 16 12 Greece 6 2 Hungary 2 13 Iceland 1 1 Northern Ireland 3 29 Republic of Ireland 28 7 Italy 48 40 Latvia 5 3 Liechtenstein 0 0 Lithuania 5 13 Luxemburg 0 0 Malta 5 5 Netherlands 2 3 Norway 0 1 Poland 207 118 Portugal 15 13 Slovakia 9 10 Slovenia 1 0 Spain 107 91 Sweden 5 6 Switzerland 0 1 Bulgaria 3 16 Romania 6 26 Totals 501 442

Table 24: International registrants 2001–06 by country residence examined by the RPSGB Adjudicating Committee Adjudicating 2001 2002 2003 2004 2005 2006 Australia 1 Bosnia 1 Brazil 1 Bulgaria 2 1 Canada 1 3 1 1 1 Czech 2 1 China 1 1 Croatia 1 Cuba 2 1 Egypt 3 1 2 2 4 2 Ethiopia 1 1 Germany 1 Ghana 2 16 12 12 19 12 lndia 4 6 15 15 12 32 Iran 4 1 1 1 lraq 5 6 6 4 5 1 Israel 1 1 ltaly 1 Jamaica 1 1 Japan 2 1 Jordan 1 2 2 5 1 Kenya 3 1 3 1 4 Lebanon 1 Libya 1 Macedonia 1 Malasya 1 5 4 4 3 Malta 1 Mauritus 3 1 Nigeria 18 48 30 22 36 36 Pakistan 5 4 10 9 6 Palestinia 1 Philipines 1 1 Poland 1 Romania 1 Russia 1 1 1 Saudi Arabia 1 1 Serbia 1 1 Singapore 1 1 Slovakia 1 South Africa 63 54 31 7 7 3 Spain 1 2 1 1 Sri Lanka Sudan 1 1 1 Taiwan 1 Tanzania 2 1 2 Thailand 1 1 Turkey 1 1 Uganda 1 USSR

Table 25: Where osteopaths practise Country N % England 3484 85.5 Scotland 121 3.0 Wales 88 2.2 Northern Ireland 17 0.4 Republic of Ireland 101 2.5 Rest of the world 263 6.5 Total 4074 100 [Figures reflect UK-registered osteopaths as at Sept. 2008] % rounded

Table 26: General Chiropractic Council registrants and removals since 2002 Country All registrants Removed from Net registrants % of total of (nationality) since 2002 register since (2009) net registrants 2002 (2009) United Kingdom 2236 332 1904 76.7 Australia 214 78 136 5.5 Canada 119 37 82 3.3 United States 111 43 68 2.7 Denmark 68 13 55 2.2 Ireland 79 25 54 2.2 South Africa 64 16 48 1.9 New Zealand 43 13 30 1.2 Sweden 38 19 19 0.8 Netherlands 19 5 14 0.6 Germany 20 5 15 0.6 Norway 28 16 12 0.5 Italy 18 7 11 0.4 Finland 13 9 4 0.2 France 14 4 4 0.2 Belgium 7 5 2 0.1 Greece 7 5 2 0.1 Israel 6 3 3 0.1 Japan 2 0 2 0.1 Korea 2 0 2 0.1 Malaysia 5 3 2 0.1 Slovakia 2 0 2 0.1 Austria 1 0 1 0.0 China 1 0 1 0.0 Croatia 2 1 1 0.0 Cyprus 2 1 1 0.0 Czech Republic 1 0 1 0.0 Georgia 1 0 1 0.0 India 2 1 1 0.0 Latvia 1 0 1 0.0 Namibia 1 0 1 0.0 Zimbabwe 2 1 1 0.0 Russia 1 0 1 0.0 Romania 2 1 1 0.0 Switzerland 1 0 1 0.0 Poland 1 1 0 0.0 Portugal 1 1 0 0.0 Spain 1 1 0 0.0 Iceland 1 1 0 0.0 Uganda 1 1 0 0.0 Totals 3138 648 2484 100.0 Source: General Chiropractic Council (GCC), 2009, Private Correspondence, 30 June 2009.

Table 27: Number of registrants with the Health professions Council, by occupation, as of 1 April 2009 Profession Registrants Arts therapist 2,576 Biomedical scientists 22,381 Chiropodists / podiatrists 12,581 Clinical scientists 4,405 Dietitians 6,700 Occupational therapists 30,122 Operating department practitoners 9,587 Orthoptists 1,278 Paramedics 15,019 Physiotherapists 42,676 Prosthetists / orthotists 877 Radiographers 25,318 Speech and language therapists 12,169 Total 185,689

Table 28: Total number of registrants with the Health Professions Council (and predecessors) by profession 1967–2006

YEAR AS CH CS DT ML OD OR OT PA PH PO RA SL RG TOTAL

2006 2,309 12,799 3,999 6,260 21,322 8,538 1,234 26,855 12,343 40,005 816 22,164 10,725 - 169,369 2005 1,992 10,741 3,719 5,757 21,158 7,670 1,277 26,376 11,316 36,978 821 22,360 10,348 - 160,513 2004 2,048 10,264 3,450 6,070 19,803 - 1,234 24,191 10,224 36,812 780 20,491 9,467 - 144,834 2003 1,992 9,013 3,408 5,782 21,895 - 1,328 24,576 9,334 35,643 786 21,484 8,900 - 144,141 2002 1,903 8,810 3,323 5,469 21,541 - 1,304 23,238 8,778 34,035 763 20,655 8,035 - 137,854 2001 1,787 8,673 3,311 5,217 21,390 - 1,303 22,197 8,892 31,235 748 20,073 7,303 - 132,129 2000 1,455 8,447 - 4,999 21,174 - 1,287 21,006 - 30,602 734 19,696 - - 109,400 1999 - 8,262 - 4,690 21,000 - 1,263 19,692 - 29,313 699 19,067 - - 103,986 1998 - 7,963 - 4,454 20,804 - 1,243 18,502 - 27,975 - 18,511 - - 99,452 1997 - 7,782 - 4,267 20,910 - 1,206 17,716 - 26,569 - 18,271 - - 96,721 1996 - 7,624 - 4,003 21,008 - 1,169 16,504 - 26,264 - 18,003 - - 94,575 1995 - 7,401 - 3,853 20,963 - 1,109 15,297 - 26,072 - 17,429 - - 92,124 1994 - 7,270 - 3,640 21,069 - 1,104 14,340 - 25,259 - 17,171 - - 89,853 1993 - 7,111 - 3,472 20,830 - 1,092 13,702 - 23,757 - 16,846 - - 86,810 1992 - 6,896 - 3,307 20,832 - 1,074 12,952 - 23,260 - 16,563 - - 84,884 1991 - 6,737 - 3,150 20,724 - 1,071 12,026 - 22,445 - 16,302 - - 82,455 1990 - 6,555 - 3,012 21,052 - 1,044 11,327 - 22,020 - 16,111 - - 81,121 1989 - 6,358 - 2,827 20,567 - 1,028 10,665 - 21,168 - 15,594 - - 78,207 1988 - 6,159 - 2,668 20,446 - 1,000 9,915 - 20,376 - 15,165 - - 75,729 1987 - 5,995 - 2,526 20,011 - 963 9,238 - 19,366 - 14,690 - - 72,789 1986 - 5,789 - 2,352 19,406 - 948 8,559 - 18,900 - 14,209 - - 70,163 1985 - 5,599 - 2,188 19,138 - 935 7,890 - 17,758 - 13,816 - 678 68,002 1984 - 5,513 - 2,085 17,950 - 898 7,256 - 16,748 - 13,637 - 580 64,667 1983 - 5,345 - 2,011 17,170 - 880 6,746 - 15,885 - 13,233 - 534 61,804 1982 - 5,215 - 2,012 16,176 - 859 6,262 - 15,234 - 13,116 - 513 59,387 1981 - 5,169 - 1,876 15,586 - 839 5,970 - 14,678 - 12,720 - 502 57,340 1980 - 5,081 - 1,778 14,786 - 804 5,537 - *15,510 - *13,539 - *523 57,558 1979 - 5,116 - 1,742 14,236 - 813 5,357 - *15,228 - *13,001 - 447 55,940 1978 - 4,995 - 1,602 13,556 - 770 5,064 - 13,418 - 11,492 - 424 51,321 1977 - 4,964 - 1,475 12,774 - 757 4,800 - 12,786 - 11,245 - 403 49,204 1976 - 4,976 - 1,391 12,050 - 796 4,652 - 12,614 - 12,037 - 386 48,902 1975 - 4,879 - 1,249 11,083 - 780 4,367 - 12,410 - 10,639 - 381 45,788 1974 - 4,847 - 1,147 10,185 - 730 4,036 - 11,936 - 9,729 - 362 42,972 1973 - 4,809 - 1,060 9,526 - 689 3,824 - 11,480 - 9,376 - 346 41,110 1972 - 4,745 - 1,000 8,830 - 660 3,620 - 10,984 - 8,646 - 341 38,826 1971 - 4,657 - 930 7,918 - 620 3,359 - 10,611 - 8,171 - 322 36,588

1970 - 4,631 - 848 7,060 - 611 3,155 - 10,216 - 7,760 - 313 34,594 1969 - 4,604 - 764 6,382 - 613 2,984 - 9,808 - 7,459 - 315 32,929 1968 - 4,578 - 717 6,024 - 546 2,808 - 9,456 - 7,131 - 317 31,577 1967 - 4,530 - 670 5,596 - 261 2,627 - 9,171 - 6,617 - 315 29,787

YEAR AS CH CS DT ML OD OR OT PA PH PO RA SL RG TOTAL Key AS Arts Therapists CH Chiropodists CS Clinical Scientists DT Dietitians ML Medical Laboratory Scientific Officers (Biomedical Scientists) OD Operating Department Practitioners OR Orthoptists OT Occupational Therapists PA Paramedics PH Physiotherapists PO Prosthetics & Orthotists RA Radiographers SL Speech & Language Therapists RG Remedial Gymnasts

Table 29: Visiting European health professionals temporarily registered in the UK according to directive 2005/36/EC, Registered September 2008–September 2009 Biomedical scientist 13 Chiropodist/podiatrist 1 Dietitian 13 Occupational therapist 11 Operating department 1 practitioner Orthoptist 2 Paramedic 2 Physiotherapist 53 Radiographer 21 Speech and language therapist 3 Total 120 Source: HPC, 2009x,