- The UK has a long history of recruiting international health professionals but tightened restrictions post-2006, favoring EU migration. - Recruiting across borders raises legal and ethical issues, especially around charging recruitment fees. Complaints from nurses suggest issues with lack of information and unclear roles. - A 2014 framework agreement for international health worker recruitment aimed to provide a compliant way for NHS employers to recruit internationally while pushing down costs, raising concerns about potential effects on ethical practices. - Case studies found the agreement increased focus on existing codes of practice but pressure on costs could reduce ethical recruitment; regulating the complex international supply chain remains a challenge.

1. Procuring an ethical approach?
Recruitment of international
health professionals
Dr Sophie Gamwell and Dr Davide Calanda

2. 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

3. 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

4. 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

5. 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.

6. 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.

7. 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

8. 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.

9. 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)

10. 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.

11. 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.

12. 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.

13. 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.

14. 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.

15. 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.