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Even as migration to Britain from the European Union has dropped to its lowest level since 2012, British health-care services need immigration more than ever. The National Health Service has been facing chronic gaps in staffing; 1 in 8 nursing positions in England is unfilled. To fight those shortages, it has turned to Europe; more than 63,000 EU nationals work for the NHS in England. Now, the strains Brexit is causing within Britain’s European expat community could severely undermine one of Britain’s most cherished institutions. Ironically, the uneasy mood among European NHS employees comes as the proportion of Britons who name immigration as a top issue is at its lowest level since 2001. This suggests that NHS recruiters could have a freer hand to hire Europeans and others to keep the system running even under a more restrictive immigration policy after Brexit. “There's just enormous permission for all of the skilled workers and social care workers and health workers” to be allowed to work in Britain, says Sunder Katwala, who runs the think tank British Future. “People say, ‘I know what's in it for me.’ ”
Eight years after moving to England to work as a nurse in a public hospital, Fabio Vasconcelos is weighing his future. He has a wife, a son, and another child on the way, and owns an apartment in London. “We are invested here,” he says.
As a Portuguese national, his “investment” was upended by the June 2016 referendum that mandated a British exit from the European Union. Mr. Vasconcelos is among millions of continental Europeans who had exercised their rights to live and work in Britain and now face the uncertainty of Brexit, a political decision based in part on hostility to mass migration.
Vasconcelos now works as a consultant to the National Health Service (NHS), helping hospitals to increase their productivity in operating rooms. It’s a career that he values in a country that he thought of as home, but today seems less welcoming. “We were clearly building a future here rather than somewhere else,” he says. “I don’t know what’s going to happen.”
For the NHS, the country’s largest employer, there’s a lot at stake in Vasconcelos’s decision, and that of his European peers.
Even as migration to Britain from the EU has dropped to its lowest level since 2012, its health-care services need immigration more than ever. The NHS has been facing chronic gaps in staffing; 1 in 8 nursing positions in England is unfilled, a shortfall of 41,000. To fight those shortages, it has turned to Europe; more than 63,000 EU nationals work for the NHS in England. Now, the strains Brexit is causing within Britain’s European expat community could bring calamitous effect upon one of the most valued British institutions.
Ironically, the uneasy mood among European NHS employees (and potential employees) comes as the proportion of Britons who name immigration as a top issue is at its lowest level since 2001, a seismic shift in attitudes. Respondents are also far more positive about the contribution of migrants to the economy. This suggests that NHS recruiters could have a freer hand to hire Europeans and others to keep the system running even under a more restrictive immigration policy after Brexit.
“There's just enormous permission for all of the skilled workers and social care workers and health workers” to be allowed to work in Britain, says Sunder Katwala, who runs British Future, a think tank in London. “It's very pragmatic.... People say, ‘I know what’s in it for me.’ ”
Britain’s immigration debate
For much of the 20th century, immigration was an afterthought for most voters. Until the 1960s, migrants from Britain’s former colonies could move here freely; many never even applied for residency or naturalization. “Britain came late to the citizenship game,” says Thom Brooks, a professor of law and government at Durham University.
In the 1970s and 1980s, more people left than arrived in some years. That changed in the 1990s as Britain’s stronger economy attracted more migrants from Europe, particularly from former communist countries. The number of foreign-born residents more than doubled between 1993 and 2013 from 3.8 million to around 7.8 million, according to an Oxford University analysis. Poles now make up Britain’s largest foreign community estimated at nearly 1 million.
Most Londoners took this transformation into their stride. “A quarter of all Poles came to London. I don’t think anyone noticed,” says Mr. Katwala.
In other parts of England and Wales, however, voters felt blindsided by a surge of Eastern European job seekers, even when their absolute numbers were fairly low. The pace of change was too rapid for some and fed a narrative that elites in London and other big cities were ignoring the downside of immigration, including crime and welfare dependency.
This backlash was taken up by the Conservative Party in 2010 and turned into a target to reduce net migration to “tens of thousands” annually. “It’s a focus on population growth. It plays to the idea of a small island nation” with finite resources, says Rob McNeil, deputy director of the Migration Observatory at the University of Oxford.
Among the resources that migrants were accused of straining was the NHS. Stories of overcrowded hospital wards took on an anti-migrant gloss. Right-wing tabloids claimed that British taxpayers were on the hook to treat migrants and asylum seekers from countries with higher incidence of infectious diseases. “Sickly immigrants add £1 billion to NHS bill,” warned the Daily Mail in 2015.
As a result, immigration, border security, and the NHS ended up playing significant roles in the 2016 Brexit debate. The Leave campaign’s slogan of “Take Back Control” resonated with British voters who felt powerless to stop EU migrants whom they saw as competing for jobs and housing, particularly in smaller cities and towns.
“The referendum was a vote of no confidence in how immigration had been handled in this country for the last 15 years,” says Katwala.
And the NHS had a memorable walk-on role in the referendum: Leave campaigners claimed wrongly that Britain paid £350 million ($460 million) a week to the EU and that this money could be redirected to the NHS.
Migrants and the NHS
Studies have found no evidence that immigration taps the NHS’s resources, however. Migrants from the European Economic Area – the EU plus Iceland, Norway, and Liechtenstein – “contribute much more to the health service and the provision of social care in financial resources and through work than they consume in services,” the government’s independent Migration Advisory Committee wrote in a 2018 report.
In the same report, the authors note that EEA migrants on average pay more in taxes than they receive in benefits, but that this didn’t apply to workers with a household income of less than £30,000 a year. “A more selective approach to EEA migration, which is not available under free movement, could provide an even more positive impact of migration on the public finances.”
But while migration hasn’t been shown to play a detrimental effect on the NHS, Brexit has been casting a shadow over the health service. Since Brexit, the recruitment of EU nurses has stalled: In 2015-16, nearly 1 in 5 new hires were Europeans. In 2017-18, this fell to 7.9 percent, according to NHS data.
Barts Health NHS Trust runs five hospitals in East London, serving some of Britain’s most deprived communities, and employs 24,000 staff, including volunteers and consultants. Around 1 in 10 permanent staff are EU nationals. While some have left since Brexit, others have replaced them, easing the pressure, says Michael Pantlin, director of human resources at Barts.
Turning off the tap of EU talent would be a disaster for health services. “Frankly we wouldn’t be able to cope. Something would have to change,” he says.
Last month the government issued a long-delayed white paper on post-Brexit immigration at what it calls “sustainable levels.” Among other proposals, it set a salary floor of £30,000 a year for long-term work visas. By doing so, it shuts out low-paid workers who come to Britain to make hotel beds, prepare sandwiches, and slaughter chickens.
But it also slams the door on many of the foreign nurses and non-clinical staff on which NHS Trusts like Barts have come to depend. “You’ve got a big raft of jobs which are well below that sort of salary,” says Mr. Pantlin, noting that newly qualified nurses earn under the threshold.
The government has pledged to expand university nursing programs, which recruiters say is helpful but not a quick fix. “The reason we’re so reliant on overseas talent is that we haven’t invested enough in our training services for many years,” says Pantlin.
‘Are we a welcoming nation?’
Still, the idea that Britons would turn away foreign nurses to satisfy a migration target is misplaced, argues Katwala. In focus groups held in 60 cities in 2017-18, participants were largely supportive of hard-working migrants who came with skills, including EU nationals already here. Roughly one-third took the opposite view that cutting migration should be the goal.
“There is an enormously broad consensus on the value of skilled migration,” he says.
What exactly counts as skilled, and where to draw the salary line, is contested. Migrants who work as builders and cooks are seen by some, but not all, as competing with native-born. Fruit pickers get a pass because parents don’t see their own kids in those jobs, says Katwala.
As for nurses and doctors, they are sympathetic figures, particularly in the context of the NHS, a national institution that no government can be seen to undermine. Analysts say this could mean flexibility in issuing visas for skilled workers – at the cost of a migration target that Prime Minister Theresa May has clung to long after other Conservatives concluded it was unrealistic and an economic drag.
Last week, Britain began rolling out a long-term residency program for EU citizens and their families. More than 3 million people could be eligible to apply, though it’s unclear how many will and what happens to those who fail to register by June 2021.
Barts has tried to reassure staff that they are welcome. Given the enormity of the decision, and the nagging uncertainty of Brexit, it was mostly a symbolic offer, says Pantlin. But the dilemma is theirs.
“Beyond policy, there is ‘Are we a welcoming nation?’ ” he says. “And that sometimes speaks volumes, more than policy.”
[Editor's note: An earlier version of this article misstated the timing of the referendum that mandated a British exit from the European Union. It was June 2016.]