Procuring an ethical approach? Recruitment of international

health professionalsDr Sophie Gamwell and Dr Davide Calanda

International recruitment of health professionals• Long history as a destination country for health professionals

• Expanded under Labour government 1997-2006 then reduced post 2006

• Since 2010 policy of favouring EU migration except in a few specialist areas

• Nurses face more stringent border controls and NMC testing

Why is this a legal or ethical issue?

• Recruitment across borders and employment law jurisdictions

• Hard law within the UK has focused on the charging of fees using Employment Standards Inspectorate to target unscrupulous employment agencies

Year No of complaints No of infractions No of infractions in

healthcare

per cent of

infractions in

healthcare

2008/9 1,567 2,393 168 10per cent

2009/10 1,714 2,236 169 8per cent

2010/11 958 2,065 261 13per cent

2011/12 643 2,146 268 12per cent

Evidence from nurses?

• A significant proportion of nurses report being charged fees by recruitment agencies (Buchan et al., 2005: 9, Calenda, 2014)

• Nurses also complain about lack of proper information and lack of clarity about their role (Alonso-Garbayo and Maben, 2009: 8; Calenda, 2014)

• Unfair recruitment practices are concentrated in countries of origin

Other ethical dimensions?

• In 1997 Nelson Mandela criticised the UK government for taking vital health workers from South Africa when the country was in the middle of an AIDS epidemic.

• The Labour Government responded by creating a code of practice for the recruitment of international health professionals, which banned direct recruitment from much of the developing world.

• Exemptions were made for sending countries with bilateral agreements such as the Philippines and India.

• In 2004 the Department of Health code of practice on International Recruitment was created, including a set of guidelines for treatment of internationally recruited nurses.

Methodology

• This paper is drawn from two previous studies exploritory

• 2012-2013 research into working conditions of nurses• Survey of 433 Philippine and Indian nurses employed within the UK

• Study of promising practices in ethical recruitment 2013-2015• Interviews with key stakeholders at the NMC, GMC, REC, NHS employers,

London Procurement Partnership, Unison.

• Interviews with 7 key informants at two case study organisations

• Analysis of documentary evidence

• Case studies were also conducted in India and Philippines but that data isn’t presented here.

Recent changes in recruitment health sector

• Sector is consolidating

• Framework agreements dominate employment of agency workers in health and social care

• The first framework agreement for international recruitment of health workers was implemented in 2014 by London Procurement Partnership

• Explicit rationale for creation of new framework agreement was to provide NHS employers with compliant way of recruiting internationally

• Concerns raised by study participants that it was also to push down the cost of international recruitment

Can we learn anything from framework agreements for agency workers?• Cost saving was an important rationale for introducing framework

agreements on agency work

• Improved information and proper reference and DBS checking are other key benefits of centralised procurement of these workers

• Numerous studies have raised concerns about commodification of recruitment process leading to poor matching, increased training and management costs and higher rates of placement failure.

From hard law to experimental governance

• Klein (2008) identified that the soft approach to governance is a more participatory and collaborative model that engages with multiple stakeholders including government, business and not for profit organisations. It seeks strategies like standard setting, self regulation and "the threat of imposition of default “regulatory regimes” to be applied where there is a lack of good-faith effort at achieving desired goals." (Klein, 2008)

What do we know of procurement of international health professionals?• Formal regulation of the sector has proven ineffective.

• LPP has created a framework agreement which restricts access to NHS employers to those agencies willing and able to comply with its requirements – including the DOH 2004 COP.

• This approach centralises the purchasing power of the NHS creating a barrier to entry to the market that relies on organisations establishing their compliance with the COP.

• This moves from investigation and enforcement by external regulators towards internal monitoring and auditing.

Evidence from case studies (1)

• Senior manager involved in creation of 2004 DOH COP.

• Committed to compliance with code from its inception.

• Longstanding commitment to mechanisms for auditing partner organisations in sending and destination countries.

• Encountered poor and unethical practice in operations in sending and destination countries in the past leading to decision to withdraw from the Singapore market and to establish new partner agency in Philippines.

• No significant changes in approach post framework agreement.

• Agency cautiously welcomed the framework agreement as it levelled the playing field and required COP compliance, but concerns that pressure on cost may reduce ethical practice going beyond the COP.

Evidence from case studies (2)

• More recent entrants to international recruitment of health professionals.

• Keen to act in line with COP, despite frustrations around recruitment of A&E doctors in particular.

• Commitment to auditing and continual process improvement.

• Encountered poor and unethical practice in supply chain, esp. sending countries.

• Combination of ethical concerns and the framework agreement meant this organisation withdrew from relationships with recruitment agents in sending countries preferring direct recruitment by word of mouth and recruitment conferences.

• UK based staff regularly travel to recruit in sending countries.

• Considers framework agreement increases importance of complying with COP and may drive “cowboy” operators from sector. Concerned pressure on cost may make ethical recruitment difficult.

Common findings

• Framework agreement increased focus on COP.

• Both organisations agreed that the international supply chain made compliance difficult – especially when they operated in different global markets where different standards applied.

• Both organisations argued managing supply chain had become increasingly important – though one said it was already confident in its arrangements.

• Framework agreement inclusion of COP was seen by both as an important step in improving the reputation of the industry and reducing number of “fly by night” operators.

• Concerns raised about impact of pressure to reduce costs.

Pressure on the margins?

• The inclusion of the COP into procurement framework agreement has increased its profile in the industry.

• Failure to comply with code now has far-reaching implications as it restricts access to biggest employers in the sector.

• It is likely to change practices in the supply chain like it has with one organisation in this study.

• The space for unethical operators will be reduced by this form of experimental governance – if it is appropriately audited.

• potential to also reduce cutting edge ethical practice like at CS1, and to lead to some of the challenges experienced in agency recruitment around the commodification of the recruitment process.

Limits

• Challenges in finding and auditing partner agencies in sending countries is indicative of endemic poor practice.

• This is especially important in countries like Philippines and India that systematically train and export nurses.

• This initiative is likely to improve the standards for nurses accessing the UK market, but there is no evidence of a “spill over” effect in sending countries for nurses accessing other markets such as the middle east.