It IS racist to worry about "foreign" nurses - a reply to Dr Max Pemberton

Max Pemberton's Daily Mail comment piece “It's NOT racist to worry about foreign nurses” is a truly shameful article of writing. Using the deranged actions of a single individual who happens to be Filipino as an excuse to mount a vicious, scapegoating and largely evidence-free defence of racist attitudes is just lazy journalism. And coming from Pemberton - usually one of the few medical commentators in the Tory press who's willing to actually defend the NHS - it's a double kick in the teeth'. 


For his article Pemberton relies on a couple of anecdotes to demonstrate the supposedly poor language skills of some nurses and medical professionals. He states “too often I have encountered staff on the wards who should not, in my opinion, be in the profession. Their English is poor; they cannot write properly; their communication skills are wanting and I am concerned about their knowledge and understanding.”

Pemberton refers to a “wholly unhelpful over-sensitivity about so-called ‘Angels of Mercy’ “ which is stopping this matter being discussed. Max provides no evidence for this, probably because this "unhelpful over-sensitivity" doesn't exist. The Health Secretary has spent the past several years telling nurses that they are “too posh to wash” and there have been regular attacks and commentary in the press (not least of all, the Daily Mail) on the transition of nursing to an all graduate profession. 

Pemberton actually continues this attack on graduate nurses, blaming graduate degrees for propelling “capable and intelligent nurses” off the wards and into management and specialist roles. He again repeats the “too posh to wash” accusation, adding that these nurses moving up the career ladder want to get away from work “which many now consider below them: Hands-on tasks such as emptying bed pans and changing beds.”

There has been no reticence displayed when it comes to haranguing nurses for their alleged failings. In fact quite the opposite, we are regularly made scapegoat for the systemic failings of government policy in relation to the NHS.

Yet as Pemberton himself mentions, the problems in nursing are structural; staff shortages are chronic, endemic and are not improving. High patient to nurse ratios create impossible working conditions leading to unavoidable patient harm, nurse burnout and high staff turnover. Nurses leave the profession quickly and numbers are not replenished in a sustainable manner.  This is creating a demographic crisis as 47% of nurses are over 45 and could retire in the next 10-15 years, while training places have been cut leading to shortfall of UK trained nurses to fill vacant posts. An RCN London investigation found London hospitals have on average 17% of Band 5 nursing posts vacant at any one time.

Age profiles of the nursing and medical workforce in England

All these factors drive hospitals to recruit overseas. Max worries that hospitals are not being rigorous enough in their recruitment practices, but he makes no mention of the standards nurses are required to meet before coming to practice in the UK. 

For a nurse from outside the EU to gain entry to the nursing register they must sit a written or on-line competency exam, then perform an OSCE (Objective Structured Clinical Examination) a directly observed exam where a senior nurse assesses their clinical practice. In addition they must also have completed the International English Language Testing System and achieved marks of at least 7.0 in the listening and reading section 1, at least 7.0 in the writing and speaking sections and an overall average score of 7 (out of a possible 9).

Many hospitals require nurses recruited from overseas to undertake a 3-6 month conversion course, including a period of observed practice on the wards, before they are allowed to practice without direct supervision.

This information is publicly available on the NHS Careers website and on the NMC website. Why Max didn't reference this in his article is obvious; it actually undermines the argument that the process is not “rigorous” enough.

Pemberton alludes to the proliferation of management positions in the NHS as a problem, as they apparently create avenues for nurses to escape from wards, draining wards of competent (university educated) nurses. The proliferation of management positions is an issue, but not for the reason Max outlines, and its not the fault of nurses but of successive governments and their response to the ongoing crisis in the NHS.

As conditions get worse on wards due to chronic staff shortages, management have instituted more audits and paperwork as a solution to poor care. Paperwork is used to enforce labour discipline - squeezing more work from already overworked staff - while providing extra legal protection against hospitals being sued for negligence due to poor care. This all requires management and enforcement, necessitating more senior managers. Along side this the privatisation and fragmentation of the NHS creates ever more layers of managers to oversee contracts and coordinate the ever more fragmented and competing services. 

These managers have little to do with direct patient care and would be unnecessary if there were a) enough staff on the wards to provide good patient care, and b) governments damaging NHS reforms were reversed. Max is looking only at the symptoms, while ignoring the disease; the working conditions imposed by budgetary constraints leading to falling standards of care, and the restructuring of healthcare provision brought on by privatistation.

What has driven nurses from the wards over the past several years is the concerted effort by NHS Trusts to downband nurses in order to save money; so those specialist nurses at band 7-8, and Senior Nurses at band 6 have been moved down a pay band. An RCN report in March 2014 found almost 4,000 posts had been lost at Band 7 & 8 by mid-2013, while at Barts Health NHS Trust in London, 472 nursing and HCA posts were downbanded in one year alone.

This is what has made nurses feel undervalued and caused an exodus from the wards, not the “daily grind of death and disease” but being taken advantage of and mistreated, being made to do the same work for less pay, along with losing the autonomy and control they previously had over their work when in senior or specialist positions. 

Pemberton mentions the facts that Healthcare Assistants (HCAs) are used to plug the gaps on understaffed wards. This is not a new occurrence, it has been part of managements response to budget constraints for a long time. As more of the NHS budget is absorbed by bureaucracy and PFI, HCAs are less expensive, unregulated labour which can take on the physically intensive and time consuming tasks which nurses don't have the time to do because patient:nurse ratios are appallingly high.

Again, where foreign nurses or foreign HCAs become a problem in this is hard to see. 

Pemberton mentions a HCA who couldn't speak English working on a dementia ward. That is definitely a worry (how common it is is debatable, I've spent the last two and a half years working in a elderly care ward and never met a HCA who didn't have a good grasp of English)  but the ultimate responsibility for that lies with trust management for putting them on that ward in the first place.  If management are effectively pulling people off the street with minimal training to staff wards and care for vulnerable patients, that is titanic a failure of their duty of care.  Again this is probably another casualty of the cuts as training budgets are slashed. But this is management negligence, not a fault with foreign language speakers.

Victorino Chua is eventually raised as an example of the danger of recruiting staff whose background cannot be checked. At the time, there were not stringent checks performed on Chua, but the NMC has since instituted the more thorough checks outlined above. After Chua's arrest the NMC reviewed the paperwork of all 11,500 Filipino nurses on the register, and no issues were found. So much for the epidemic of foreign nurses on forged documents coming to work in the UK. 

Whether more stringent checks would have stopped Chua is up for debate. If his qualifications were valid and he had passed the checks, what then? There are plenty of examples of qualified British medical staff who have committed appalling crimes; Harold Shipman, Beverly Allitt, Colin Norris, Benjamin Green and others. All were qualified to practice. Dale Bolinger, convicted of plotting to rape, murder and eat a teenage girl, is an American national. Yet the Daily Mail's coverage of him made little of his nationality, and didn't spur on any commentary about the dangers of "foreign" nurses. Perhaps because “Cannibal Nurse” Dale Bolinger is white, while “Stepping Hill Poisoner” Victorino Chua is not? Of note, Chua is a naturalised British citizen, but that fact was largely omitted by the press as it doesn't fit the narrative of demonising “foreign” nurses.

Chua practiced nursing for 10 years in the Philippines before coming to the UK. He worked at two nursing homes before starting into his job at Stepping Hill hospital. No concerns were raised about his clinical nursing practice during this time, although he had severely fallen out with colleagues on at least one occasion, resulting in disciplinary action. Nothing pointed towards him being incompetent at his job, and it wasn't incompetence which made him murder those patients.

Chua's appalling crimes had nothing to do with him being a “foreign” nurse or with him not being qualified to practice. These were the actions of a disturbed individual horrifically abusing their position of power. Its not further checks on “foreigners” that will stop individuals like that, but actually increasing numbers of nurses on wards so that patients can be properly monitored and cared for. The intentionally poor care given by the tiny number of psychopaths who slip through the system can be more easily identified once we eliminate the everyday poor care which results from chronic understaffing and an under-resourced NHS.

This is the main problem with the article, while pretending to be about Victorino Chua, it is not really about him at all. An exploration of what motivated this one individual to commit these terrible acts, what went wrong with the investigation, whether the NMC made mistakes and what can be done about it - this would all be fair comment. But the article isn't about that. It's about nurses who supposedly don't speak English and graduates who don't want to empty bedpans. That is what makes it racist (and also sexist and to some extent elitist, because Max worries out loud that 'mere' nurses may be taking on jobs that were formerly the preserve of doctors). Rather than offer well thought out solutions, it takes a swipe at overseas born NHS staff in a thoroughly racist manner.

Pemberton then levels the charge of “reverse colonialism” against the NHS, for taking nursing and medical staff from countries that need them. Overseas staff coming to work here isn't “reverse colonialism” though, we aren't being “colonised”. Its just good old fashioned colonialism: Britain as a wealthy imperialist nation exploits poorer countries to strip them of their natural resources; in this case their highly educated and trained workforce. The UK gets all the benefit of this highly skilled labour, with none of the cost of training them. This is a continuation of Britain's colonial relationship with many of these countries, just in a new form.

Points are raised about foreign doctors and nurses not understanding the local culture and language, but this isn't a massive issue. These things can be learned with time, and there is probably as big a cultural divide between an Oxford educated doctor, and a working-class patient, as there is between a nurse trained overseas and their British-born patient. 

And lets examine critically this idea of the “foreign” nurse. Many of the nursing staff I work with who were originally from overseas have been in the country for decades. Some have been here longer than I've been alive. Many have become naturalised British citizens during this period, settled here, and had children. Some of them actually trained here, having come over and worked as HCAs or in nursing homes, before going to a British nursing school. Who in these circumstances qualifies as a “foreign nurse”? My guess is for the Daily Mail, it largely depends on the colour of your skin, not how long you've been here, where you trained or whether you're a citizen.

Why even use this term, except to alienate and otherise people in a racist manner. If someone comes from overseas comes to work here as a nurse, they are simply a nurse and are a welcome addition to our society.

Our most recent wave of arrivals are a large number of Spanish and Portuguese nurses. Many have come here as they cannot find work in their own countries health service due to the ruinous effects of austerity. Whatever concerns people may have about their language skills are best answered by investing in adequate language training, not by front page vilification.

Its an incredibly difficult and brave thing to travel abroad for work, to leave your friends and family and everything you know behind and travel huge distances to a foreign country. Doing that to come into a stressful and taxing job like nursing is even harder. 

Our nurses deserve respect and support, not this ridiculous racist vilification. Victorino Chua's crimes are appalling, and he should spend the rest of his life in jail as punishment. However the terrible nature of his crimes doesn't excuse the way they have been exploited to vilify migrants and nurses. The least Max Pemberton owes nurses is an apology. It would be better also if he didn't write for the Daily Mail ever again.