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"There's no place like home" A pilot study of perspectives of international health and social care professionals working in the UK

"There's no place like home" A pilot study of perspectives of international health and social... Background: Many countries are reporting health workforce shortages across a range of professions at a time of relatively high workforce mobility. Utilising the global market to supply shortage health skills is now a common recruitment strategy in many developed countries. At the same time a number of countries report a 'brain drain' resulting from professional people leaving home to work overseas. Many health and social care professionals make their way to the UK from other countries. This pilot study utilises a novel 'e-survey' approach to explore the motives, experiences and perspectives of non-UK health and social care professionals who were working or had worked in the UK. The study aims to understand the contributions of international health and social care workers to the UK and their 'home' countries. The purpose of the pilot study is also in part to test the appropriateness of this methodology for undertaking a wider study. Results: A 24-item questionnaire with open-ended and multiple choice questions was circulated via email to 10 contacts who were from a country outside the UK, had trained outside the UK and had email access. These contacts were requested to forward the email to other contacts who met these criteria (and so on). The email was circulated over a one month pilot period to 34 contacts. Responses were from physiotherapists (n = 11), speech therapists (n = 4), social workers (n = 10), an occupational therapist (n = 1), podiatrists (n = 5), and others (n = 3). Participants were from Australia (n = 20), South Africa (n = 10), New Zealand (n = 3) and the Republic of Ireland (n = 1). Motives for relocating to the UK included travel, money and career opportunities. Participants identified a number of advantages and disadvantages of working in the UK compared to working in their home country health system. Respondents generally reported that by working in the UK, they had accumulated skills and knowledge that would allow them to contribute more to their profession and health system on their return home. Conclusion: This pilot study highlights a range of issues and future research questions for international learning and comparison for the health and social care professions as a result of international workforce mobility. The study also highlights the usefulness of an e-survey technique for capturing information from a geographically diverse and mobile group of professionals. Page 1 of 9 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:25 http://www.anzhealthpolicy.com/content/2/1/25 'donor' countries, who also report shortages of health and Background World over, countries use strategies to manage health social care professionals [9,12-15]. Brain drain is deemed workforce shortages such as improving retention, attract- particularly pernicious in developing nations, particularly ing 'non-traditional' entrants and attracting back 'return- African countries, and compounded by the fact that emi- ees' [1]. International recruitment is another popular grating skilled workers are more likely to stay in their host solution to overcoming shortfalls of health providers [2- country [6]. It is well documented that recruitment of 6]. Recruitment strategies aside, health workforce mobil- health personnel from developing countries threatens the ity is increasing, particularly the flow of health and social operation of crucial health programs in these coun- care professionals to and from the UK. tries[3]. Health and social care professionals in the UK 'Brain circulation' Most of the available data surrounding health worker In contrast, recent research indicates international migra- migration relates to the nursing and medical professions. tion of skilled workers is often temporary and the mobil- For instance, in the UK and Ireland there were more over- ity of this workforce generates global benefits by seas additions to the in 2000/2001 UK nursing register improving knowledge flows and satisfying the demand than home country registrants [1] and two thirds of new for skills, often termed 'brain circulation' [9,11,13]. How- registrants to the UK General Medical Council in 2003 ever to date there is little research specifically analysing were from overseas, mostly from outside the European the benefits of skilled migration in health and social care. Economic Area [7]. Less research has been undertaken into the mobility of the allied health and social care work- Push and Pull factors force. It has been suggested that push and pull factors motivate workers to leave one country and seek employment in During the 1990s, registration of non-UK trained physio- another [8,16] where push factors are motives to leave therapists ranged from 26 to 42 percent; sourced mainly home countries such as low pay, limited career opportu- from Australia, South Africa and New Zealand [8]. The nities, unemployment or civil unrest and pull factors are Health Professions Council (HPC), the regulatory body motivations or conditions that attract migrants to other responsible for registration of allied health professionals countries such as demand for workers or a higher standard and clinical scientists in the UK, captures data on applica- of living. This idea has been further developed to catego- tions for registration by profession and country of origin. rise workers as permanent or temporary movers based on In the 2004 / 05 financial year there were 3,515 interna- their motives for leaving their home country [16]. For tional registrations. Nearly one third of these (n = 1,339) example permanent movers may be 'economic migrants' were physiotherapists, followed by radiographers (n = who are attracted to better standards of living and who 681), occupational therapists (n = 668) and biomedical may send money to their home country or 'career scientists (n = 363). These reflect the relative proportions migrants' who are attracted to enhanced career opportuni- of the total registrations for the respective professions. The ties. Temporary movers include those on a 'working holi- major donor 'continents' during the same period were day' where expertise is used to finance travel, or 'the study Europe (excluding the UK) (n = 129), Africa (n = 110), tour' where new knowledge and techniques are acquired Asia (n = 107), followed by Oceania (n = 105) (which for use when they return home. includes Australia and New Zealand) [Source: HPC 2005]. Westcott and Whitcombe [17] suggest that the benefits Australian and New Zealand diaspora offered by the globalisation of occupational therapy have The Australian and New Zealand diasporas have similar not been fully realised, particularly in reference to educa- histories. It is estimated that one million (out of twenty tion. One study has been conducted to inform writers of million) Australians are overseas at any one time [9] and UK speech and language therapy curricula by utilising the the primary destination of resident professionals leaving perspectives of current and past international students Australia and New Zealand on a permanent or long-term [18]. basis is the United Kingdom [9-11]. In addition, recent changes to international immigration laws for skilled pro- The motivations, experiences and perspectives of interna- fessionals has made professional migration more seam- tional health and social care professionals however have less [9,11]. not been thoroughly explored, particularly in reference to workforce dynamics, workforce flexibility [19-23] and the 'Brain drain' understanding and management of the global flow of Not surprisingly, the concept of 'brain drain' resulting health and social care workers. This pilot study aims to from professionals leaving their country of residence to capture preliminary data on the perspectives and motives work overseas has created great concern for 'source' or of health and social care professionals of non-UK origin Page 2 of 9 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:25 http://www.anzhealthpolicy.com/content/2/1/25 Table 1: Profile of Respondents N% Responses Complete 33 Incomplete 1 Profession Physiotherapy 11 32 Social Work 10 29 Podiatry 5 15 Speech and Language Therapy 4 12 Occupational Therapy 1 3 Nurse 1 3 Medical Doctor 1 3 Medical Transcript Editor 1 3 Age Mean 31 (25–55), Median 28 Country of Origin Australia 20 60 South Africa 10 30 New Zealand 3 Rep of Ireland 1 Number of years qualified Mean 7 (2–19), Median 4.5 and training who have at some stage moved to and Inclusion criteria were health and social care professionals worked in the UK. from any country other than the UK, who trained outside the UK and who have previously worked or are currently Methods working in the UK. UK nationals and UK trained health The pilot study used a novel approach to data collection and social care professionals were excluded. The intention to capture a range of views from health and social care of the research was to capture information from this pool workers on their experiences of working in the UK. The of relatively mobile international health and social care data collection relied on the assumption that many for- staff. eign trained workers living in the UK have access to email and that many international workers have wide interna- The 24 item questionnaire included closed and open- tional networks. ended questions and was designed to capture demo- graphic information about the participants, their profes- As a result, we piloted the use of an 'e-survey' which was sion, perceptions of training, career development distributed by the researchers via email to 10 contacts opportunities and learning experiences. It was piloted inviting them to participate on the basis that they had with four expatriate allied health professionals resulting worked in the UK at some stage. The participants repre- in the deletion of two questions. sented a range of disciplines, having worked in different settings (hospital, community etc) and different geo- The survey was initially circulated as a Microsoft Word graphic locations across the UK. The first round partici- attachment. However feedback from some participants pants were accessed through personal and professional indicated that it was not always possible to download or networks. Each of those contacts was asked to forward the open the attachment, so the survey was then embedded e-survey to their international contacts and so on creating into the body of the email. The researchers established a a snowball sampling effect. We allowed a four week time web-site on which detailed information about the frame for replies. This method was chosen over other research was available, including the protocol and details more traditional survey methods as it was a quick and of the researchers and from which further questionnaires inexpensive way to gain preliminary insight into an inter- could be downloaded. All but two surveys were returned nationally diverse and geographically varied group of electronically. These were faxed and posted to the health and social care workers. The purpose of the pilot researchers. study was, in part, to test the appropriateness of this meth- odology for undertaking a wider study. All data were entered into a Microsoft Excel spreadsheet. Numeric data have been presented in descriptive numeri- cal form. Where large amounts of qualitative data were Page 3 of 9 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:25 http://www.anzhealthpolicy.com/content/2/1/25 Table 2: Work details of respondents N% Number of locations worked Mean 3 (1–15), Median 2 One location 14 Two locations 6 Three locations 5 > Three locations 9 Main location in UK London 926 Essex 617 Sheffield 38 Oxford 38 Other (Edinburgh, Worcester, Cambridge, Nottingham, Clacton-on-sea, Cardiff, Gosport, Loughton, Halifax, West Grinstead, Rotherham, Falkirk) Visa difficulties Yes 618 No 28 82 Visa Type * Working Holiday 13 Work Permit / sponsorship 11 Ancestry 6 British Passport 4 Highly skilled migrant programme 1 Other 2 Means of securing job in UK Agency in home country 10 Locum Agency 6 Agency in the UK 15 Advertisement in the home country 4 Advertisement in the UK 6 Word of mouth 7 Other 1 Why work in the UK Travel 29 Money 23 Career 16 Partner 3 Other 4 Areas worked in UK Locum 21 NHS 15 Social Services 10 Private practice 7 Research 5 Self Employed 4 Teaching 2 Current area of work in UK Locum 7 NHS 8 Social Services 9 Private 6 Research 4 Self Employed 2 Teaching 1 N/A 5 Incomplete 1 * May have held more than one visa May have held more than one job Multi-answer question Page 4 of 9 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:25 http://www.anzhealthpolicy.com/content/2/1/25 received, they have been summarised for this paper. For case planning, lack of resources and especially money to provide the purpose of this paper, the phrase 'country of origin' for the needs of service users. (Podiatrist, Australia) refers to the nationality of the professional. I just expected to work and earn money to travel but in reality it is a time when you can really work on your professional devel- Results Response opment, which is what I am doing. (Physiotherapist, Australia) Ten e-surveys were emailed in the first round and responses were received from 34 participants within the Skills and Training one month pilot, of which one was incomplete. The pro- Respondents were asked what skills or training could have file of the respondents is summarised in Table 1. better equipped them to work in the UK and to describe their perceptions of the quality of training in the UK. Few respondents reported difficulties obtaining a UK visa, Many felt they had adequate skills and training to work in the majority using a working holiday visa (available to the UK (n = 15) but highlighted greater knowledge of the Commonwealth citizens aged 17–30) or work permit. health and social care systems would have been beneficial Professionals had worked in a median number of 2 cities particularly those working in social services (n = 6). (range 1–15, mean 3) and usually as a 'locum' where locum work is defined as temporary or contractual My training and skills were of English standards. The only employment. The median time spent in the UK was 3 adjustments I had to develop skills around was to know the cul- years (range 3 months – 8 years, mean 2.5 years). Employ- ture of the community and adjust strategies of intervention. ment was typically gained through a recruitment agency (Speech and language therapist, Australia) in the UK or in their home country. There were 27 profes- sionals still in the UK, most of whom were working in Most perceived that the undergraduate training in the UK Social Services (n = 9), for the NHS full time (n = 8) or as was of a lower standard than their country of origin (n = a locum (n = 7) or in private practice (n = 6). Over half of 23) but that opportunities for continuing professional the respondents (67%, n = 23) reported they would not education were superior in the UK (n = 10). Some felt that stay in the UK permanently. Table 2 summarises these their undergraduate training equipped them more thor- results. oughly to enter the workforce with more confidence in their role than their UK counterparts. Motivation to work in the UK Respondents were asked why they initially chose to work I believe the broad 4 year undergraduate training in Australia in the UK. Travel (n= 29), money (n = 23) and career is of very high quality. This allows for multi-skilling and confi- opportunities (n = 16) were the primary motives dence from day one. Therapists trained in Australia tend to be expressed. One respondent answered ...to experience liv- a lot more confident in their skills and are more used to working ing in a country other than my home country.' (Physio- within multidisciplinary teams. (Occupational therapist, Aus- therapist, Australia) tralia) Expectations prior to working in the UK Others felt that each system had its advantages. Respondents were asked what their expectations of work- ing in the UK were prior to their arrival and how they The UK training is more practice based and reflective. SA train- compared to their experience. There were mixed ing is more theory based. (Social worker, South Africa) responses, many reporting they believed the UK would be superior to their home country in terms of resources, pro- UK pre-qualifying training inferior due to shorter course fessional expertise and funding (n = 5) ; others assumed it length. Good first year graduate program compensates for this. would be the same (n = 15). (Physiotherapist, New Zealand) Thought it would be similar to Australia – maybe not quite so Attractiveness of working in the UK advanced with their techniques. Experience was pretty much Respondents were asked what was good about working in what I thought it would be – depends on the different hospitals, the UK. The most attractive features were greater access to which is the same back home. (Speech and language therapist, Continuing Professional Development (CPD), wider vari- Australia) ety of specialisation, more career opportunities and a well-defined career structure. Experiencing a different sys- I thought that the workforce would be more superior and be able tem and culture was also a theme as well as travel and to provide good guidance. I expected there to be far more greater earning power. resources to enable service users to achieve an element of self actualization. Experience: poor management, poor team and Page 5 of 9 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:25 http://www.anzhealthpolicy.com/content/2/1/25 Accessibility to latest research and professional development pass on when I begin working again at home. (Physiotherapist, (remote location of many Australian practices limits this). Australia) Number of jobs available with very acute caseload (far fewer in Aust). Opportunity to develop quickly as a therapist given our Discussion undergraduate skills and general confidence as therapists. Close Method proximity to Europe and travel opportunities. (Speech and lan- The e-survey technique was chosen over other more tradi- guage therapist, Australia) tional survey techniques as it is a quick and cost-effective way to gain preliminary insight into a geographically and Difficulties working in the UK demographically diverse group of professionals. The Respondents were asked what was not good about work- mobility of the diasporas makes them a particularly diffi- ing in the UK. The most unappealing features included cult group to access in a systematic way and, as this study large waiting lists and correspondingly large caseloads, has demonstrated, health and social care workers may poor recognition or respect as a professional, the bureauc- work in a number of different cities during their time racy, the weather, or for some professional groups, racism. away. Additionally the e-survey was deemed the most appropriate method given that this project was proposed Understaffing of all health professions; Too much paperwork as a pilot study with the intention to trial the methodol- and repetition of paperwork; Reduced hospital standards; Dis- ogy to identify pertinent themes for future research, rather tance from home. (Podiatrist, Australia) than generate statistically generalisable findings. Some people find it difficult to accept that although not trained The e-survey technique provided an opportunity to cap- in the UK the level of skill you bring into the profession is of ture a global 'before and after' perspective for many pro- high value. (Social worker, South Africa) fessionals who were now living and working at 'home', in a new city or another new country. These professionals Participants were also asked how the status of their profes- may have proved more difficult to sample using a profes- sion in the UK compared to their country of origin. The sional register such as the Health Professions Council majority (n = 24) felt the status of their profession was which captures 'inflow' registration information only[8]. lower in the UK than in their home country compared to In order that a larger, more systematic e-survey be eight who felt it was the same. repeated, electronic networks for diasporas which exist in some countries [24] could be accessed. Alternatively, pro- I expected to retain the same high status that my profession has fessional newsletters and journals may facilitate a more back home with other professionals and the communities who targeted approach to specific disciplines or groups. appreciate the services provided by the profession. This was completely opposite when I got here (UK) and shocking to me. The limitations of the e-survey approach include the ina- This discrepancy creates difficulties in working with partners to bility to follow-up non-respondents, as once the initial bring about desired change. (Social worker, South Africa) round of surveys had been circulated the researchers had no control over the distribution network. For the same Benefits and suggestions for country of origin reason, no response rate can be calculated as the denomi- When asked how their country of origin could benefit or nator is unknown. learn from their experience of working in the UK, most responded they had gained a much broader skill base and Additionally, it was difficult to avoid the potential sources knowledge of how a different system works. of bias inherent in this type of study. For instance, by cir- culating the survey electronically, we could only access I have such a vast array of experiences now to draw on, both those workers who use email, and there was no way of good and bad which I can take home with me. I think I am knowing how the IT literacy of the respondents impacted much more worldly now. (Physiotherapist, New Zealand) on the response rate. The selection of the initial ten respondents may also have introduced bias, however the I have experienced many management styles, and government researchers reiterate this intention of this pilot study was agendas, and would be able to take the advantages and disad- to identify future research themes. vantages of these systems back to Aust. and formulate better solutions to problems. (Speech and language therapist, Aus- Push and Pull factors tralia) The primary motivations for this group of health and social care professionals to work in the UK were travel, Due to excellent continuing education [in the UK] I feel I will money and career opportunities. These motivations fit have a more up to date knowledge base which I will attempt to with research conducted by Buchan [16], whereby most respondents in this study were 'temporary movers', pursu- Page 6 of 9 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:25 http://www.anzhealthpolicy.com/content/2/1/25 ing 'the working holiday'. This was particularly true for Undergraduate skills and training those from Australia and New Zealand. Equally, respond- There was a clear perception that undergraduate training ents were relatively young. These findings correspond to is comparatively better outside the UK. This may in part be research conducted by Birrell et al [9] who reports 70% of explained by a discrepancy in the length of training under- Australian professionals who work overseas return and are taken. South African trained social workers have tradition- usually aged between 20 and 30. Also demonstrated in ally had a longer programme of training at undergraduate this study was a trend for internationally trained health level, and their education has been granted the status of workers to fill temporary, locum positions in the NHS. A full degree for longer than their UK equivalents [29]. This report for the UK Chartered Society of Physiotherapists [8] is also true for Australian allied health and social work recognises a key 'pull' factor for overseas physiotherapists undergraduate degrees, many of which are 4 year qualifi- is the relative ease with which they can find comparatively cations compared to the 3 year UK equivalent [30]. As well paid temporary work in the UK, giving them greater these professionals have not directly experienced training choice over the location and duration of employment. in the UK, these findings need to be interpreted cau- These findings are supported by Allan and Larsen [26] for tiously. Given these perceptions, it is not surprising international nurses and O'Hagan [26] for Australian respondents felt their skills and training gained at 'home' medical radiation graduates. The results also reinforce the adequately equipped them to undertake work in the UK perception that South Africans are more likely to be 'per- health and social care sectors. Further research comparing manent movers', a trend recognised by Cerventes [6]. these perceptions to UK trained professionals working in Australia, South Africa or New Zealand would add value Perceptions and Experiences to these findings. When examining the perceptions and experiences of the respondents, it is important to remember their original Continuing Professional Development motivations to move to the UK and how this may affect Many of the respondents reported on the 'value adding' their experiences and perceptions. For example the major- attributes of practicing in the UK. These included the ity of respondents were motivated to move to the UK by extensive opportunity for post qualifying training or Con- the opportunity to travel. Perceptions may then be from tinuing Professional Development (CPD), a more defined the perspective of a holiday maker, working to fund trav- and progressive career structure and greater availability of els rather than from the perspective of a full time specialisation. One study confirms these perceptions, employee working to pay a mortgage, for example. reporting that UK physiotherapists and prospective UK Motives can also change over time depending on different physiotherapy students perceive that the career structure circumstances, for example the motives of and incentives in the NHS and variety in work are desirable qualities of for migrating nurses to the UK have been shown to change NHS physiotherapy as a career [28]. over time as personal and socio-economic conditions alter [25]. Respondents' experience of their 'home' health In many cases local health authorities in the UK offer system and organisational culture would also significantly financial contributions towards tuition fees as well as pro- contribute to the forming perceptions and opinions about tected time to pursue both academic coursework and the UK health organisation and culture. Additionally CPD. The growth in and support for CPD in Britain is in respondents have experienced a mixture of 'British' cul- part due to explicit Department of health NHS policies ture and NHS organisational culture which together have and frameworks which outlined the need for delivery of influenced their perceptions and opinions. high quality care and clinical excellence in the NHS [31,32]. Although Australian professional bodies are Resources equally as attentive to CPD [30], improved access to CPD The qualitative responses demonstrate themes of dissatis- in the UK may also be explained by the size of the British faction and discontent with NHS bureaucracy and lack of health and social care system proportionally providing resources. This has also been reported in the UK with greater numbers of courses for a larger health workforce. claims that people leave the UK public sector primarily Further research is needed to explore this possibility. A due to bureaucracy and paper work, lack of resources, lack smaller and more convenient geographic area for access- of autonomy and feeling undervalued[27]. Similarly, a ing CPD in the UK compared to remote, rural areas of Aus- cohort of UK physiotherapy students and professionals tralia or South Africa may also be a contributing factor. perceived physiotherapy in the NHS to have high levels of South Africa however has not yet developed a coherent stress and workload, staff shortages and poor equipment curriculum that focuses on CPD for social work graduates [28]. [29]. Page 7 of 9 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:25 http://www.anzhealthpolicy.com/content/2/1/25 Professional Status of highly resourceful and skilled professionals, with glo- Undergraduate educational differences may also speak of bal ideas and resources to share with colleagues. It would the issue of professional identity and the reported contrast be valuable to further pursue in depth what this growing between professional status of health and social care work group of internationally skilled health and social care pro- in the UK and other countries. Turner [33] compared the fessionals offer both their country of origin and the UK. As status of physiotherapy in Australia to the UK finding Aus- one respondent commented: tralian general public and physiotherapy students per- ceive physiotherapy to have a higher occupational It's a bit like doing rotations to different departments but to dif- prestige than their UK equivalents. The health and social ferent countries. care professionals who responded to our study indicated that they entered the UK system from a very different pro- Competing interests fessional perspective, accounting in part for the difference The author(s) declare that they have no competing inter- in perceived professional image. Another study [28] of UK ests. physiotherapy students and professionals, showed that they perceive the general public and other health care pro- Authors' contributions fessionals to have a lack of recognition for physiotherapy. AM and SN contributed jointly to the research design and Negative perceptions of professional status have also been data collection. Both authors were involved in the analy- noted within podiatry in the UK [34-37], the USA [39] sis, interpretation of data and preparation of the final and, to some extent, Australia [36]. An interesting discrep- manuscript. AB was consulted about the design of the ancy therefore emerges, whereby the perception of lower research, provided literature, access to networks of clini- professional status in the UK is reported along side the cians and South African perspective. perception of improved pay and career opportunities. 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Sir Paul Nurse, Cancer Research UK Your research papers will be: available free of charge to the entire biomedical community peer reviewed and published immediately upon acceptance cited in PubMed and archived on PubMed Central yours — you keep the copyright BioMedcentral Submit your manuscript here: http://www.biomedcentral.com/info/publishing_adv.asp Page 9 of 9 (page number not for citation purposes) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Australia and New Zealand Health Policy Springer Journals

"There's no place like home" A pilot study of perspectives of international health and social care professionals working in the UK

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Copyright
Copyright © 2005 by Moran et al; licensee BioMed Central Ltd.
Subject
Medicine & Public Health; Public Health; Social Policy
ISSN
1743-8462
eISSN
1743-8462
DOI
10.1186/1743-8462-2-25
pmid
16253132
Publisher site
See Article on Publisher Site

Abstract

Background: Many countries are reporting health workforce shortages across a range of professions at a time of relatively high workforce mobility. Utilising the global market to supply shortage health skills is now a common recruitment strategy in many developed countries. At the same time a number of countries report a 'brain drain' resulting from professional people leaving home to work overseas. Many health and social care professionals make their way to the UK from other countries. This pilot study utilises a novel 'e-survey' approach to explore the motives, experiences and perspectives of non-UK health and social care professionals who were working or had worked in the UK. The study aims to understand the contributions of international health and social care workers to the UK and their 'home' countries. The purpose of the pilot study is also in part to test the appropriateness of this methodology for undertaking a wider study. Results: A 24-item questionnaire with open-ended and multiple choice questions was circulated via email to 10 contacts who were from a country outside the UK, had trained outside the UK and had email access. These contacts were requested to forward the email to other contacts who met these criteria (and so on). The email was circulated over a one month pilot period to 34 contacts. Responses were from physiotherapists (n = 11), speech therapists (n = 4), social workers (n = 10), an occupational therapist (n = 1), podiatrists (n = 5), and others (n = 3). Participants were from Australia (n = 20), South Africa (n = 10), New Zealand (n = 3) and the Republic of Ireland (n = 1). Motives for relocating to the UK included travel, money and career opportunities. Participants identified a number of advantages and disadvantages of working in the UK compared to working in their home country health system. Respondents generally reported that by working in the UK, they had accumulated skills and knowledge that would allow them to contribute more to their profession and health system on their return home. Conclusion: This pilot study highlights a range of issues and future research questions for international learning and comparison for the health and social care professions as a result of international workforce mobility. The study also highlights the usefulness of an e-survey technique for capturing information from a geographically diverse and mobile group of professionals. Page 1 of 9 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:25 http://www.anzhealthpolicy.com/content/2/1/25 'donor' countries, who also report shortages of health and Background World over, countries use strategies to manage health social care professionals [9,12-15]. Brain drain is deemed workforce shortages such as improving retention, attract- particularly pernicious in developing nations, particularly ing 'non-traditional' entrants and attracting back 'return- African countries, and compounded by the fact that emi- ees' [1]. International recruitment is another popular grating skilled workers are more likely to stay in their host solution to overcoming shortfalls of health providers [2- country [6]. It is well documented that recruitment of 6]. Recruitment strategies aside, health workforce mobil- health personnel from developing countries threatens the ity is increasing, particularly the flow of health and social operation of crucial health programs in these coun- care professionals to and from the UK. tries[3]. Health and social care professionals in the UK 'Brain circulation' Most of the available data surrounding health worker In contrast, recent research indicates international migra- migration relates to the nursing and medical professions. tion of skilled workers is often temporary and the mobil- For instance, in the UK and Ireland there were more over- ity of this workforce generates global benefits by seas additions to the in 2000/2001 UK nursing register improving knowledge flows and satisfying the demand than home country registrants [1] and two thirds of new for skills, often termed 'brain circulation' [9,11,13]. How- registrants to the UK General Medical Council in 2003 ever to date there is little research specifically analysing were from overseas, mostly from outside the European the benefits of skilled migration in health and social care. Economic Area [7]. Less research has been undertaken into the mobility of the allied health and social care work- Push and Pull factors force. It has been suggested that push and pull factors motivate workers to leave one country and seek employment in During the 1990s, registration of non-UK trained physio- another [8,16] where push factors are motives to leave therapists ranged from 26 to 42 percent; sourced mainly home countries such as low pay, limited career opportu- from Australia, South Africa and New Zealand [8]. The nities, unemployment or civil unrest and pull factors are Health Professions Council (HPC), the regulatory body motivations or conditions that attract migrants to other responsible for registration of allied health professionals countries such as demand for workers or a higher standard and clinical scientists in the UK, captures data on applica- of living. This idea has been further developed to catego- tions for registration by profession and country of origin. rise workers as permanent or temporary movers based on In the 2004 / 05 financial year there were 3,515 interna- their motives for leaving their home country [16]. For tional registrations. Nearly one third of these (n = 1,339) example permanent movers may be 'economic migrants' were physiotherapists, followed by radiographers (n = who are attracted to better standards of living and who 681), occupational therapists (n = 668) and biomedical may send money to their home country or 'career scientists (n = 363). These reflect the relative proportions migrants' who are attracted to enhanced career opportuni- of the total registrations for the respective professions. The ties. Temporary movers include those on a 'working holi- major donor 'continents' during the same period were day' where expertise is used to finance travel, or 'the study Europe (excluding the UK) (n = 129), Africa (n = 110), tour' where new knowledge and techniques are acquired Asia (n = 107), followed by Oceania (n = 105) (which for use when they return home. includes Australia and New Zealand) [Source: HPC 2005]. Westcott and Whitcombe [17] suggest that the benefits Australian and New Zealand diaspora offered by the globalisation of occupational therapy have The Australian and New Zealand diasporas have similar not been fully realised, particularly in reference to educa- histories. It is estimated that one million (out of twenty tion. One study has been conducted to inform writers of million) Australians are overseas at any one time [9] and UK speech and language therapy curricula by utilising the the primary destination of resident professionals leaving perspectives of current and past international students Australia and New Zealand on a permanent or long-term [18]. basis is the United Kingdom [9-11]. In addition, recent changes to international immigration laws for skilled pro- The motivations, experiences and perspectives of interna- fessionals has made professional migration more seam- tional health and social care professionals however have less [9,11]. not been thoroughly explored, particularly in reference to workforce dynamics, workforce flexibility [19-23] and the 'Brain drain' understanding and management of the global flow of Not surprisingly, the concept of 'brain drain' resulting health and social care workers. This pilot study aims to from professionals leaving their country of residence to capture preliminary data on the perspectives and motives work overseas has created great concern for 'source' or of health and social care professionals of non-UK origin Page 2 of 9 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:25 http://www.anzhealthpolicy.com/content/2/1/25 Table 1: Profile of Respondents N% Responses Complete 33 Incomplete 1 Profession Physiotherapy 11 32 Social Work 10 29 Podiatry 5 15 Speech and Language Therapy 4 12 Occupational Therapy 1 3 Nurse 1 3 Medical Doctor 1 3 Medical Transcript Editor 1 3 Age Mean 31 (25–55), Median 28 Country of Origin Australia 20 60 South Africa 10 30 New Zealand 3 Rep of Ireland 1 Number of years qualified Mean 7 (2–19), Median 4.5 and training who have at some stage moved to and Inclusion criteria were health and social care professionals worked in the UK. from any country other than the UK, who trained outside the UK and who have previously worked or are currently Methods working in the UK. UK nationals and UK trained health The pilot study used a novel approach to data collection and social care professionals were excluded. The intention to capture a range of views from health and social care of the research was to capture information from this pool workers on their experiences of working in the UK. The of relatively mobile international health and social care data collection relied on the assumption that many for- staff. eign trained workers living in the UK have access to email and that many international workers have wide interna- The 24 item questionnaire included closed and open- tional networks. ended questions and was designed to capture demo- graphic information about the participants, their profes- As a result, we piloted the use of an 'e-survey' which was sion, perceptions of training, career development distributed by the researchers via email to 10 contacts opportunities and learning experiences. It was piloted inviting them to participate on the basis that they had with four expatriate allied health professionals resulting worked in the UK at some stage. The participants repre- in the deletion of two questions. sented a range of disciplines, having worked in different settings (hospital, community etc) and different geo- The survey was initially circulated as a Microsoft Word graphic locations across the UK. The first round partici- attachment. However feedback from some participants pants were accessed through personal and professional indicated that it was not always possible to download or networks. Each of those contacts was asked to forward the open the attachment, so the survey was then embedded e-survey to their international contacts and so on creating into the body of the email. The researchers established a a snowball sampling effect. We allowed a four week time web-site on which detailed information about the frame for replies. This method was chosen over other research was available, including the protocol and details more traditional survey methods as it was a quick and of the researchers and from which further questionnaires inexpensive way to gain preliminary insight into an inter- could be downloaded. All but two surveys were returned nationally diverse and geographically varied group of electronically. These were faxed and posted to the health and social care workers. The purpose of the pilot researchers. study was, in part, to test the appropriateness of this meth- odology for undertaking a wider study. All data were entered into a Microsoft Excel spreadsheet. Numeric data have been presented in descriptive numeri- cal form. Where large amounts of qualitative data were Page 3 of 9 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:25 http://www.anzhealthpolicy.com/content/2/1/25 Table 2: Work details of respondents N% Number of locations worked Mean 3 (1–15), Median 2 One location 14 Two locations 6 Three locations 5 > Three locations 9 Main location in UK London 926 Essex 617 Sheffield 38 Oxford 38 Other (Edinburgh, Worcester, Cambridge, Nottingham, Clacton-on-sea, Cardiff, Gosport, Loughton, Halifax, West Grinstead, Rotherham, Falkirk) Visa difficulties Yes 618 No 28 82 Visa Type * Working Holiday 13 Work Permit / sponsorship 11 Ancestry 6 British Passport 4 Highly skilled migrant programme 1 Other 2 Means of securing job in UK Agency in home country 10 Locum Agency 6 Agency in the UK 15 Advertisement in the home country 4 Advertisement in the UK 6 Word of mouth 7 Other 1 Why work in the UK Travel 29 Money 23 Career 16 Partner 3 Other 4 Areas worked in UK Locum 21 NHS 15 Social Services 10 Private practice 7 Research 5 Self Employed 4 Teaching 2 Current area of work in UK Locum 7 NHS 8 Social Services 9 Private 6 Research 4 Self Employed 2 Teaching 1 N/A 5 Incomplete 1 * May have held more than one visa May have held more than one job Multi-answer question Page 4 of 9 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:25 http://www.anzhealthpolicy.com/content/2/1/25 received, they have been summarised for this paper. For case planning, lack of resources and especially money to provide the purpose of this paper, the phrase 'country of origin' for the needs of service users. (Podiatrist, Australia) refers to the nationality of the professional. I just expected to work and earn money to travel but in reality it is a time when you can really work on your professional devel- Results Response opment, which is what I am doing. (Physiotherapist, Australia) Ten e-surveys were emailed in the first round and responses were received from 34 participants within the Skills and Training one month pilot, of which one was incomplete. The pro- Respondents were asked what skills or training could have file of the respondents is summarised in Table 1. better equipped them to work in the UK and to describe their perceptions of the quality of training in the UK. Few respondents reported difficulties obtaining a UK visa, Many felt they had adequate skills and training to work in the majority using a working holiday visa (available to the UK (n = 15) but highlighted greater knowledge of the Commonwealth citizens aged 17–30) or work permit. health and social care systems would have been beneficial Professionals had worked in a median number of 2 cities particularly those working in social services (n = 6). (range 1–15, mean 3) and usually as a 'locum' where locum work is defined as temporary or contractual My training and skills were of English standards. The only employment. The median time spent in the UK was 3 adjustments I had to develop skills around was to know the cul- years (range 3 months – 8 years, mean 2.5 years). Employ- ture of the community and adjust strategies of intervention. ment was typically gained through a recruitment agency (Speech and language therapist, Australia) in the UK or in their home country. There were 27 profes- sionals still in the UK, most of whom were working in Most perceived that the undergraduate training in the UK Social Services (n = 9), for the NHS full time (n = 8) or as was of a lower standard than their country of origin (n = a locum (n = 7) or in private practice (n = 6). Over half of 23) but that opportunities for continuing professional the respondents (67%, n = 23) reported they would not education were superior in the UK (n = 10). Some felt that stay in the UK permanently. Table 2 summarises these their undergraduate training equipped them more thor- results. oughly to enter the workforce with more confidence in their role than their UK counterparts. Motivation to work in the UK Respondents were asked why they initially chose to work I believe the broad 4 year undergraduate training in Australia in the UK. Travel (n= 29), money (n = 23) and career is of very high quality. This allows for multi-skilling and confi- opportunities (n = 16) were the primary motives dence from day one. Therapists trained in Australia tend to be expressed. One respondent answered ...to experience liv- a lot more confident in their skills and are more used to working ing in a country other than my home country.' (Physio- within multidisciplinary teams. (Occupational therapist, Aus- therapist, Australia) tralia) Expectations prior to working in the UK Others felt that each system had its advantages. Respondents were asked what their expectations of work- ing in the UK were prior to their arrival and how they The UK training is more practice based and reflective. SA train- compared to their experience. There were mixed ing is more theory based. (Social worker, South Africa) responses, many reporting they believed the UK would be superior to their home country in terms of resources, pro- UK pre-qualifying training inferior due to shorter course fessional expertise and funding (n = 5) ; others assumed it length. Good first year graduate program compensates for this. would be the same (n = 15). (Physiotherapist, New Zealand) Thought it would be similar to Australia – maybe not quite so Attractiveness of working in the UK advanced with their techniques. Experience was pretty much Respondents were asked what was good about working in what I thought it would be – depends on the different hospitals, the UK. The most attractive features were greater access to which is the same back home. (Speech and language therapist, Continuing Professional Development (CPD), wider vari- Australia) ety of specialisation, more career opportunities and a well-defined career structure. Experiencing a different sys- I thought that the workforce would be more superior and be able tem and culture was also a theme as well as travel and to provide good guidance. I expected there to be far more greater earning power. resources to enable service users to achieve an element of self actualization. Experience: poor management, poor team and Page 5 of 9 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:25 http://www.anzhealthpolicy.com/content/2/1/25 Accessibility to latest research and professional development pass on when I begin working again at home. (Physiotherapist, (remote location of many Australian practices limits this). Australia) Number of jobs available with very acute caseload (far fewer in Aust). Opportunity to develop quickly as a therapist given our Discussion undergraduate skills and general confidence as therapists. Close Method proximity to Europe and travel opportunities. (Speech and lan- The e-survey technique was chosen over other more tradi- guage therapist, Australia) tional survey techniques as it is a quick and cost-effective way to gain preliminary insight into a geographically and Difficulties working in the UK demographically diverse group of professionals. The Respondents were asked what was not good about work- mobility of the diasporas makes them a particularly diffi- ing in the UK. The most unappealing features included cult group to access in a systematic way and, as this study large waiting lists and correspondingly large caseloads, has demonstrated, health and social care workers may poor recognition or respect as a professional, the bureauc- work in a number of different cities during their time racy, the weather, or for some professional groups, racism. away. Additionally the e-survey was deemed the most appropriate method given that this project was proposed Understaffing of all health professions; Too much paperwork as a pilot study with the intention to trial the methodol- and repetition of paperwork; Reduced hospital standards; Dis- ogy to identify pertinent themes for future research, rather tance from home. (Podiatrist, Australia) than generate statistically generalisable findings. Some people find it difficult to accept that although not trained The e-survey technique provided an opportunity to cap- in the UK the level of skill you bring into the profession is of ture a global 'before and after' perspective for many pro- high value. (Social worker, South Africa) fessionals who were now living and working at 'home', in a new city or another new country. These professionals Participants were also asked how the status of their profes- may have proved more difficult to sample using a profes- sion in the UK compared to their country of origin. The sional register such as the Health Professions Council majority (n = 24) felt the status of their profession was which captures 'inflow' registration information only[8]. lower in the UK than in their home country compared to In order that a larger, more systematic e-survey be eight who felt it was the same. repeated, electronic networks for diasporas which exist in some countries [24] could be accessed. Alternatively, pro- I expected to retain the same high status that my profession has fessional newsletters and journals may facilitate a more back home with other professionals and the communities who targeted approach to specific disciplines or groups. appreciate the services provided by the profession. This was completely opposite when I got here (UK) and shocking to me. The limitations of the e-survey approach include the ina- This discrepancy creates difficulties in working with partners to bility to follow-up non-respondents, as once the initial bring about desired change. (Social worker, South Africa) round of surveys had been circulated the researchers had no control over the distribution network. For the same Benefits and suggestions for country of origin reason, no response rate can be calculated as the denomi- When asked how their country of origin could benefit or nator is unknown. learn from their experience of working in the UK, most responded they had gained a much broader skill base and Additionally, it was difficult to avoid the potential sources knowledge of how a different system works. of bias inherent in this type of study. For instance, by cir- culating the survey electronically, we could only access I have such a vast array of experiences now to draw on, both those workers who use email, and there was no way of good and bad which I can take home with me. I think I am knowing how the IT literacy of the respondents impacted much more worldly now. (Physiotherapist, New Zealand) on the response rate. The selection of the initial ten respondents may also have introduced bias, however the I have experienced many management styles, and government researchers reiterate this intention of this pilot study was agendas, and would be able to take the advantages and disad- to identify future research themes. vantages of these systems back to Aust. and formulate better solutions to problems. (Speech and language therapist, Aus- Push and Pull factors tralia) The primary motivations for this group of health and social care professionals to work in the UK were travel, Due to excellent continuing education [in the UK] I feel I will money and career opportunities. These motivations fit have a more up to date knowledge base which I will attempt to with research conducted by Buchan [16], whereby most respondents in this study were 'temporary movers', pursu- Page 6 of 9 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:25 http://www.anzhealthpolicy.com/content/2/1/25 ing 'the working holiday'. This was particularly true for Undergraduate skills and training those from Australia and New Zealand. Equally, respond- There was a clear perception that undergraduate training ents were relatively young. These findings correspond to is comparatively better outside the UK. This may in part be research conducted by Birrell et al [9] who reports 70% of explained by a discrepancy in the length of training under- Australian professionals who work overseas return and are taken. South African trained social workers have tradition- usually aged between 20 and 30. Also demonstrated in ally had a longer programme of training at undergraduate this study was a trend for internationally trained health level, and their education has been granted the status of workers to fill temporary, locum positions in the NHS. A full degree for longer than their UK equivalents [29]. This report for the UK Chartered Society of Physiotherapists [8] is also true for Australian allied health and social work recognises a key 'pull' factor for overseas physiotherapists undergraduate degrees, many of which are 4 year qualifi- is the relative ease with which they can find comparatively cations compared to the 3 year UK equivalent [30]. As well paid temporary work in the UK, giving them greater these professionals have not directly experienced training choice over the location and duration of employment. in the UK, these findings need to be interpreted cau- These findings are supported by Allan and Larsen [26] for tiously. Given these perceptions, it is not surprising international nurses and O'Hagan [26] for Australian respondents felt their skills and training gained at 'home' medical radiation graduates. The results also reinforce the adequately equipped them to undertake work in the UK perception that South Africans are more likely to be 'per- health and social care sectors. Further research comparing manent movers', a trend recognised by Cerventes [6]. these perceptions to UK trained professionals working in Australia, South Africa or New Zealand would add value Perceptions and Experiences to these findings. When examining the perceptions and experiences of the respondents, it is important to remember their original Continuing Professional Development motivations to move to the UK and how this may affect Many of the respondents reported on the 'value adding' their experiences and perceptions. For example the major- attributes of practicing in the UK. These included the ity of respondents were motivated to move to the UK by extensive opportunity for post qualifying training or Con- the opportunity to travel. Perceptions may then be from tinuing Professional Development (CPD), a more defined the perspective of a holiday maker, working to fund trav- and progressive career structure and greater availability of els rather than from the perspective of a full time specialisation. One study confirms these perceptions, employee working to pay a mortgage, for example. reporting that UK physiotherapists and prospective UK Motives can also change over time depending on different physiotherapy students perceive that the career structure circumstances, for example the motives of and incentives in the NHS and variety in work are desirable qualities of for migrating nurses to the UK have been shown to change NHS physiotherapy as a career [28]. over time as personal and socio-economic conditions alter [25]. Respondents' experience of their 'home' health In many cases local health authorities in the UK offer system and organisational culture would also significantly financial contributions towards tuition fees as well as pro- contribute to the forming perceptions and opinions about tected time to pursue both academic coursework and the UK health organisation and culture. Additionally CPD. The growth in and support for CPD in Britain is in respondents have experienced a mixture of 'British' cul- part due to explicit Department of health NHS policies ture and NHS organisational culture which together have and frameworks which outlined the need for delivery of influenced their perceptions and opinions. high quality care and clinical excellence in the NHS [31,32]. Although Australian professional bodies are Resources equally as attentive to CPD [30], improved access to CPD The qualitative responses demonstrate themes of dissatis- in the UK may also be explained by the size of the British faction and discontent with NHS bureaucracy and lack of health and social care system proportionally providing resources. This has also been reported in the UK with greater numbers of courses for a larger health workforce. claims that people leave the UK public sector primarily Further research is needed to explore this possibility. A due to bureaucracy and paper work, lack of resources, lack smaller and more convenient geographic area for access- of autonomy and feeling undervalued[27]. Similarly, a ing CPD in the UK compared to remote, rural areas of Aus- cohort of UK physiotherapy students and professionals tralia or South Africa may also be a contributing factor. perceived physiotherapy in the NHS to have high levels of South Africa however has not yet developed a coherent stress and workload, staff shortages and poor equipment curriculum that focuses on CPD for social work graduates [28]. [29]. Page 7 of 9 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:25 http://www.anzhealthpolicy.com/content/2/1/25 Professional Status of highly resourceful and skilled professionals, with glo- Undergraduate educational differences may also speak of bal ideas and resources to share with colleagues. It would the issue of professional identity and the reported contrast be valuable to further pursue in depth what this growing between professional status of health and social care work group of internationally skilled health and social care pro- in the UK and other countries. Turner [33] compared the fessionals offer both their country of origin and the UK. As status of physiotherapy in Australia to the UK finding Aus- one respondent commented: tralian general public and physiotherapy students per- ceive physiotherapy to have a higher occupational It's a bit like doing rotations to different departments but to dif- prestige than their UK equivalents. The health and social ferent countries. care professionals who responded to our study indicated that they entered the UK system from a very different pro- Competing interests fessional perspective, accounting in part for the difference The author(s) declare that they have no competing inter- in perceived professional image. Another study [28] of UK ests. physiotherapy students and professionals, showed that they perceive the general public and other health care pro- Authors' contributions fessionals to have a lack of recognition for physiotherapy. AM and SN contributed jointly to the research design and Negative perceptions of professional status have also been data collection. Both authors were involved in the analy- noted within podiatry in the UK [34-37], the USA [39] sis, interpretation of data and preparation of the final and, to some extent, Australia [36]. An interesting discrep- manuscript. AB was consulted about the design of the ancy therefore emerges, whereby the perception of lower research, provided literature, access to networks of clini- professional status in the UK is reported along side the cians and South African perspective. perception of improved pay and career opportunities. 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Sir Paul Nurse, Cancer Research UK Your research papers will be: available free of charge to the entire biomedical community peer reviewed and published immediately upon acceptance cited in PubMed and archived on PubMed Central yours — you keep the copyright BioMedcentral Submit your manuscript here: http://www.biomedcentral.com/info/publishing_adv.asp Page 9 of 9 (page number not for citation purposes)

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Australia and New Zealand Health PolicySpringer Journals

Published: Oct 27, 2005

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