The £490 million question: is this the new cost of overseas health workers post-Brexit?

The government's lack of clarity over how the UK's immigration system will work after Brexit could leave the NHS spending up to half a billion pounds per year on international recruitment, explains RCP president-elect Dr Andrew Goddard.

As the March Brexit deadline approaches we are still little the wiser on how the new horizon will look. We know a little more about a no-deal scenario’s potential impact on health, but what we still have scant detail on is the impact to workforce. With the clock ticking we’ve done some of our own research and reviewed the possible implications and costs if freedom of movement ends and the government brings together EU and international immigration systems.

Valuing NHS staff from overseas

It’s a fact that in the current climate our health service simply couldn’t function without EU and international staff that come to work in the NHS. Based on the best system-wide data available, in the year to September 2017, 12,303 EU nationals started work in the NHS and 14,032 staff joined the NHS from outside of the EU. 

The contribution and dedication of staff from overseas is huge, and we must show our continued appreciation by championing their commitment to the NHS at every opportunity.

With research indicating workforce is at breaking point, anything that impacts the NHS’s ability to recruit talented, hardworking professionals is a major risk. We know there are no overnight fixes to our staffing challenges. In the short to medium term there are no alternatives other than to increase international recruitment and ensure resources are put in place to retain current staff. 

It’s a fact that in the current climate our health service simply couldn’t function without EU and international staff that come to work in the NHS.

Dr Andrew Goddard, RCP president-elect 

The recent relaxation of tier 2 visas shows that the government recognises the vital contribution of EU and international staff, but Brexit creates a major risk. Deal or no deal we will have to ensure that we are all doing our bit to make the UK a destination of choice for those looking to relocate.

New bureaucracy, new costs

However, with less than 9 months until the UK leaves the EU, we still have no idea what the future immigration landscape will look like. So let’s look at what we do know. Under the current tier 2 system, the total costs of a 3-year visa, health surcharge, immigration skills charge and certificate of sponsorship is £4,409. What’s more, during the 2017 general election the Conservatives pledged to triple the health surcharge and double the immigration skills charge by 2020, bringing the total amount for a 3-year visa and associated costs to £8,609, and that’s before any inflationary costs.

Simple calculations show that unless the government acts now the NHS faces a significant new cost pressure. If we modelled last year’s 12,303 EU staff that joined the NHS in 2017, and applied the tier 2 immigration system or a similar model, the NHS would have to find £105 million a year to recruit staff that previously attracted no immigration costs. If you then add in visa renewal costs for 60% of these staff at the end of their 3-year visas, the cost increases by a further £45 million, creating a total of £150 million, and that’s before you add in the costs to the NHS for processing any new bureaucracy. 

In reality it’s likely that EU joiners will want to relocate to the UK with their family. So for simplicity if we assume that all EU joiners over 25 will be accompanied by two family members the bill becomes £140 million, and a further £15 million for those under 25 relocating on their own. If we then assume that 60% of joiners will renew their visas after 3 years the costs grow by a further £69 million, totalling a staggering £225 million.

Who pays the bill?

Add in international recruitment from non-EU joiners, with 85% bringing family members, and the total costs within 3 years could be as much as £490 million a year. Currently the costs are split between employer and employee but where will the responsibility for these potential new costs fall? With staff shortages at crisis levels and an increasingly competitive health jobs market, some NHS trusts will likely feel the pressure to cover the full costs of dependants. Others may have to contribute towards those costs.

That’s up to £490 million that could be better spent on developing our current staff, delivering high-quality patient care, delivering integration and driving forward vital quality improvement work.

Dr Andrew Goddard, RCP president-elect 

Either way it’s clear that the NHS could soon be spending millions and millions more and up to an extra half a billion pounds just to maintain current, already inadequate staffing numbers. That’s up to £490 million that could be better spent on developing our current staff, delivering high-quality patient care, delivering integration and driving forward vital quality improvement work. In current spending terms this almost half a billion pounds equates to putting 3,000 students through medical school or funding half the NHS’s estimated high-risk backlog maintenance bill.

Our challenge to government is clear: set out the timetable for the publication of the proposed new immigration system, minimise bureaucracy and costs for the NHS and social care or fund any new government-created cost pressures, and maintain the removal of doctors and nurses from any planned visa caps.

The NHS can’t keep guessing; it needs certainty now, not more costs. 

Dr Andrew Goddard, RCP registrar and president-elect