As I suggested yesterday most structured labour markets need to actively welcome people who supply their labour rather than assume that they can be summoned from the deep by the simple workings of a labour market.
There are two aspects to whether people work in the NHS – do they want to work there, and do they want to stay. Today we will deal with the former. The second tomorrow.
One my big themes is that to thrive, the NHS needs much more than extra money. If the English people really love their NHS they are going to have to give more than their taxes. And one group of people who already give more to the NHS than their taxes are those that work for it.
OK they get paid for their work, but most of us recognise that their hard work goes beyond the simple exchange of money for wages and salaries.
This gift of labour comes from beyond these shores and is the gift of people from very many countries in the world. If so many nations in the world had not given some of their best people to us – the NHS could never have thrived. If it were to stop tomorrow, the NHS would stop the day after.
At the high end of the labour market are the doctors. They are an international part of an elite labour force. From the age of 14 upward there is clearly expressed strong wish amongst thousands of young people to work as doctors for the NHS. These teenagers work very hard to get the qualifications to be able to join medical training, become doctors, and work for the NHS. The amount of hard work they do, and not a little passion that they develop, to have a career as a doctor is truly amazing. The amount of hard work and struggle involved indicates that there is little doubt that at this end of the labour market people want to work as NHS doctors.
There is something remarkable going on here. For three or four decades, as the numbers entering higher education have grown, the most difficult courses to get into, the courses where consistently the highest qualifying A levels are necessary, has been medicine.
If A levels mean anything then English society, for all those years, has given its brightest and best to the career of medicine. From the age of 18 they give up their evenings and weekends because they want to be doctors.
For the same period the BMA have fairly consistently said the morale of the medical profession has never been lower. Nonetheless young people have consistently worked themselves into the ground to gain the right to join a profession where morale has never been lower.
As the numbers entering higher education have increased so have the numbers starting training as nurses. There are now entire universities where – in broad terms – non-doctor’s education provides the backbone of the entire institution. And whilst the A levels you need for nurse training are not as difficult as those for medicine, there seems to be sufficient motivation from enough people to enrol. This motivation seems as strong in 2018 as in 1968. People want to train as nurses.
But equally significant as this home-grown motivation is the worldwide motivation to come and work in the NHS. We know that without Irish women coming to work as nurses in the 1940s and 50s the NHS would have foundered in its first decade. West Indian and African women also joined the NHS and helped it expand its capacity throughout its history. These were followed by nurses from the Philippines and from all over the world. Doctors from the Indian sub-continent, many unable to get the consultant posts they had at home, became the backbone of our GP service and in the last two decades doctors and nurses have come from all over Europe.
One of the main labour force issues that the NHS faces in 2018 is that the supply upon which the NHS has been built has come from a changing world.
Some of this change concerned the history of empire. In their parents’ lifetime Britain ran many of the countries that clinical staff left to come and work in Britain.
Some of it was language. People had learnt their profession in English and could come here and use their skills.
And much of it was the NHS itself. Britain had this powerful institution that if you came here to work would ensure that there would be jobs throughout your career. You could depend upon it much more securely than most – for example the voluntary hospitals at home.
More than a decade ago I had a bladder infection that meant I had to go from primary care to A&E and then to outpatients over a period of a few weeks. I saw 24 different members of staff. It’s true that a dozen of these were born in this country, but I suspect if they were asked to self-identify only one would call themselves white British. My experience is not at all unusual.
So for decades people have wanted to come to England to work in the NHS. Because of their work they have added so much value to the NHS that they – more than any other single factor – have saved it. (The fact that, as part of its policy of creating a hostile environment, the British Government has recently decided to make some of these people pay for their own NHS treatment is one of the most shaming things I have seen in my lifetime).
The NHS has become, and will continue to be, dependent on world labour markets to get the staff that it needs. This future dependency means that for the NHS to be sustainable we need – in every generation – tens of thousands of people to want to leave their home country and travel thousands of miles to set up new lives here.
I don’t think we can depend upon this at all. The WHO believe that the world is short of 4.3 million doctors and nurses. It is within this context that we need to place our own NHS shortages. We cannot assume that in the next 15 years people will want to come and work here to the same extent that they have in the past. As the population of East Asia and the Indian sub-continent ages, and as simultaneously these nations become richer, they will spend much more on their health services. It’s likely that India and China will double their health spend. This in turn will mean that in the next decade, their demand for doctors and nurses will increase enormously.
We will be competing with them for trained staff and this includes the staff we are training in this country.
I think the problem we will be facing is not simply that fewer trained members of staff will come here, but many more of our trained staff will want to go and work in the rest of the world. For the past 70 years international labour markets have worked in our favour, but for the next few decades it’s likely they will work against us.