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Doctors protesting in Madrid this month. Photo: AMYTS.
Healthcare crisis

'Non-EU nurses are paying to come here': Ireland's place in global scramble for healthcare staff

The co-founder of Migrant Nurses Ireland said the organisation is aware of instances of non-EU nurses paying to come to Ireland for work.

THE HSE AND a number of private health companies in Ireland have ramped up international recruitment efforts in recent years amid a global shortage of healthcare workers that has left an estimated deficit of one million personnel in Europe. 

Following the HSE’s admission that it missed recruitment targets for last year, The Journal has learned that there are now concerns about staffing the new children’s hospital for its scheduled opening in 2025. Management is facing a deficit of around 500 personnel and they are focusing on recruiting in India and the Philippines to make up the numbers. An overseas trip carried out in November of last year saw over 100 nurses recruited. 

Recruiters working on behalf of private healthcare companies are also looking to the Philippines and locations such as Kerala in India to find qualified staff to work in residential care facilities in Ireland. 

However, the non-profit organisation Migrant Nurses Ireland has serious concerns about a lack of regulation in how migrant healthcare workers are being treated, and a spokesperson has said that they are aware of non-EU nurses “paying recruitment agents in their home countries to come to Ireland.” 

 While Irish health officials are concerned about the mass exit of nurses and doctors trained in Ireland to Australia and elsewhere, other counties are worried about losing their staff to this island. 

Spain’s ambassador to Ireland has said that authorities are highly concerned about Spanish health personnel leaving to work in Ireland, as the country is facing long-term strike action in the health sector, and rising public anger. 

The HSE’S recruitment and retention crisis 

Back in 2010, the WHO issued a Global Code on the International Recruitment of Health Personnel in light of the “global shortage of health personnel”, which it asked member states to commit to. 

The WHO stated that a shortage of qualified healthcare staff represents a “major threat” to certain countries being able to achieve key development goals. 

The code stressed that member states should focus on “retention strategies” in order to reduce their need to rely on migrant workers, and that “destination countries” should discourage active recruitment of staff from developing countries facing critical shortages of health workers. 

It also stated that recruiters and employers acting on behalf of member states should be fair and just in their practices, and that they should make sure migrant workers have accurate information about the post they are being offered. 

In 2020 the WHO released a list of countries which are facing the most pressing health workforce challenges. This list includes 33 African countries including Nigeria and Malawi, Haiti in the Americas, six countries in the Eastern Mediterranean region including Pakistan and Afghanistan, Nepal and Bangladesh in South East Asia, and five populations in the Western Pacific region. 

Back in 2013, Ireland was selected as the winner of the Health Worker Migration Policy Council Innovation Award for its commitment to upholding the principles of the WHO code. 

A report by the WHO Director General published last year on the fourth round of reporting on the implementation of the code found that following the pandemic “many countries are once again turning to international recruitment to rapidly increase domestic capacity”. 

The report further statement that this increase in international recruitment “may lead to increasing vulnerabilities within countries already suffering from low health workforce densities”. 

Today, Ireland’s health system is facing different pressures. As the HSE struggles to retain graduating doctors and nurses, it is under increasing pressure to source migrant workers, and its reliance on agency staff has increased. 

“It’s a case of robbing Peter to pay Paul,” Niamh Humphries, Senior Lecturer at the Royal College of Surgeons in Ireland  says. 

“Rich countries need to be focused on training and retaining graduates, in order to reduce the need for international recruitment, although there is always going to be some level of need for it,” she adds. 

Doctors leaving for Australia 

Rory Holohan, a young doctor from Sligo who took it upon himself to do some research on where his classmates from UCC has ended up, discovered that 62 out of 78 medical students from UCC who graduated in 2021 are currently practising in Australia. 

“A sign of the times is that a lot of my friends were talking about Perth [and] Melbourne from even fourth year,” he said. 

Having researched doctor migration in Ireland for years, Humphries believes that the first step to sorting out the HSE’s staffing woes is to find out why young doctors and nurses are leaving for Australia and other countries. 

“We train around 700 doctors a year, last year 432 of them applied for visas and went to Australia. We don’t know how many have gone to other countries. Although some of them are going because they want to travel, they are also going because they know they will be professionally better off there in terms of resourcing and staffing levels. 

“Pay is also an issue. A lot of medical graduates here start as non-consultant hospital doctors. They are moving around every six months, and they have to sort their tax out each time they keep getting emergency taxed. They have to sort out accommodation, they can’t settle anywhere,” Humphries said. 

The Doctor Migration Project, which Humphries worked on, interviewed 51 Irish doctors in Australia and asked them if they would consider returning. 35 didn’t want to come back, and for those who did, there was typically a familial or personal reason why they wanted to, rather than a professional one. 

“Retainment needs to be as big of a priority as recruitment, and we need to convince doctors who were trained in Ireland to come back,” Humphries said. 

Last week the Department of Health General Secretary Robert Watt told the Public Accounts Committee that the HSE missed its recruitment targets for 2021, despite an unprecedented increase in staff numbers. Roughly 6,000 additional workers were recruited by the end of the year, but this still left the health service under target by 3,332 workers. 

He blamed the difficulties caused by Covid-19 and an international shortage of health workers, and admitted that the shortage of workers is impacting community settings in particular. 

Plans for the new children’s hospital to open in 2025 have already led to staffing concerns. The HSE is currently putting together a workforce plan for the hospital, and carrying out international recruitment campaigns for paediatric staff. 

The Journal has learned that the hospital will need somewhere in the region of 500 additional staff members on top of the combined workforce of the three hospitals that are set to transfer to it. 

So far the HSE has focused its international recruitment efforts on India and the Philippines. A recruitment trip to these countries was carried out last November, which saw over 100 nurses recruited. 

The HSE works with 17 international recruitment companies which source candidates both in the EU and globally. It spent €12 million on recruitment campaigns through these agencies in 2020 and 2021. 

Joe Walsh is the director of Sagesa Spanish Healthcare, a company which is based in Spain and has a contract with the HSE to advertise specific posts. 

“It is true that in nursing for example, Spanish workers are trained to the highest standard and then come out and get some of the worst contracts in Europe,” he said. 

Walsh’s company recruits Spanish workers for both the HSE and private healthcare companies in Ireland. He said that in his experience more workers are moving to work in the private sector “because the language qualification requirements are less demanding”. 

‘Migrant nurses are being charged to come to Ireland’ 

Vinu Kaippilly, from Kerala, India, is one of the co-founders of Migrant Nurses Ireland, a non-profit organisation that aims to promote the interests of nurses who come to work here from overseas. 

He says that non-EU nurses are more open to exploitation in Ireland, and that in the private sector, they are aware of instances when nurses have paid recruitment agents to come to Ireland. 

“People don’t know this is happening. Migrant nurses are being charged to come here by private recruitment agents in their home countries. Many private nursing homes in Ireland know that this is happening, but they don’t say anything, because they are reliant on migrant staff,” Kaippilly said. 

The organisation has other concerns about how migrant healthcare workers are being treated. 

Kaippilly said that some recruitment companies working on behalf of the HSE and the private sector are promising to help with relocation for a few weeks when people land, but that in some cases, this has led to nurses having to share bedrooms. 

“In one case in inner city North Dublin, two nurses were sharing a double bed, and another nurse was in a single bed in the same room. One of them got Covid-19, and then they all did. It is not safe. These workers have given up a lot to come here, so they don’t want to formally complain or speak out, it is difficult to bring this to light,” he explained. 

the migrant nurses ireland confreence The Migrant Nurses Ireland national conference this month.

Migrant Nurses Ireland is also trying to engage with the NMBI and the RSCI to see changes made to the overseas aptitude test, which Kaippilly says is too stressful. 

“You don’t sit this test in your home country. You have to quit your job, move here, and wait to get a call to say you can go in and sit it. You have to reply to that invitation within three hours to secure the appointment. Then, you have two chances to pass the test before you have failed. Sometimes, the recruitment company will only cover the fee for the test if you pass, so this can leave people feeling trapped in Ireland, with nowhere to go. 

“I had to go and collect a nurse who fainted doing the test recently. It is two hours long. You have 14 stations to perform tasks at, and ten minutes at each station with no break. It is too stressful for people who have given up a lot to be here and take it, we would like to see this changed,” he explained.

Why Spanish healthcare workers are coming to Ireland

As well as recruiting workers from outside of the EU, both the HSE and private companies are recruiting in European countries, which is causing concern in Spain, as the country is in the midst of a healthcare crisis of its own. 

“You are attracting  our best healthcare workers with your salaries, it is worrisome. We need nurses and doctors, but we cannot stop them from leaving Spain – it’s a free world,” Spain’s ambassador to Ireland said, while sitting by the fire in the embassy on Merrion Street. 

Ion de la Riva arrived a couple of months ago. It is his first time back in the country in decades – he visited in the eighties before Ireland underwent its “economic transformation”. 

“You are transitioning into a new, digital-led era. This is one of the richest countries in Europe. When Spaniards come here they are attracted to the job opportunities, and the salaries, but some people don’t realise that this country is expensive, that it has housing and health problems that they will have to confront,” he explained. 

 There are around 12,000 Spanish people registered with the embassy, but the country’s consular services believe that the Spanish population in Ireland is closer to 50,000, and that the influx of Spanish workers, particularly in the health sector, is likely to escalate. 

“Brexit made it difficult for doctors and nurses to go to the UK. Here, you speak English, and your salaries are much better. It presents a problem for us because we want to retain healthcare workers, and we are having to recruit doctors from other countries,” de la Riva said. 

Spain’s healthcare crisis 

Spain’s healthcare system works differently to Ireland’s – and it is facing a different kind of crisis. 

The key difference is Spain’s health service is free for most people. The European Health Observatory on Health Systems and Policies states that the Sistema Nacional de Salud (SNS) is based on the principles of “universality, free access, equity and fairness of financing”. 

In comparison, it says that Ireland’s health system is characterised by a complex overlap between “public and private providers and payers” that results in a “two-tier system”,  which creates substantial waiting lists.  

The observatory further notes that despite serious budget constraints following the financial crash, the Spanish healthcare system still covers 99.1% of the country’s population. 

The SNS is a decentralised system. Seventeen regional health authorities make decisions on resource allocation and operational planning. The SNS Interterritorial Council is made up of the Government’s Health Minister and seventeen regional ministers, and it oversees national planning and regulation. 

This means that the strain the health service is under can differ greatly in different parts of the country. Thousands of primary care doctors have been striking in Madrid for over two months. 

Ander Garcia, spokesperson for the Association of physicians and higher graduates of Madrid (AMYTS), says that public anger over the state of Spain’s health system has reached a boiling point. 

“Madrid has the least investment in primary care of all the regions. GPs are attending seventy to eighty patients a day. That is incredible when you consider that the World Health Organisation recommends that doctors attend a maximum of thirty to forty patients. 

“Our doctors are suffering from burnout and depression to the extent where they have to take sick leave from work. We have 7000 members – we are seeing this on a wide scale. 

“The conditions here are truly horrible. People wait for weeks to see a doctor, so they go to the emergency departments. People wait for over a year for surgeries that cannot wait, so where they can they go private. There are people being treated in hospital corridors, and when it rains, the hospitals flood.

“If Ireland is experiencing a healthcare crisis, I cannot imagine it is like the one we are facing. The system has collapsed,” Garcia said. 

Like the Spanish Ambassador to Ireland, who said that he was surprised to be offered private health insurance in Spain as part of his job benefits when the country should be “protecting the public system”, Garcia is concerned about the growth of the private healthcare system in Spain. 

“Some people believe that the government is running down the health service so the private sector can get bigger. I don’t know if that is the case, but nevertheless, it is growing,” he said.  

Garcia is right – last year Spaniards spent more money on private health insurance than ever before, to the tune of €10.5 billion, an increase of 7%. 

‘They earn in one week what we earn in a month’ 

Ana Giminez is a 58-year-old primary care doctor in Madrid who has been out striking every Wednesday. She says that private healthcare cannot offer a solution to the problems Spain’s health service is experiencing, nor can it stop doctors and nurses leaving for Ireland and other countries,  where she says they earn in “in one week, what we earn in a month”. 

“We have a left wing government. If they want private healthcare to take over, that is not what they are telling us. The private system is not big enough to ‘swoop in’ and remedy the situation,” she said. 

WhatsApp Image 2023-02-17 at 11.20.24 Ana Giminez, a doctor in Madrid.

Giminez says that if it weren’t for her age, and her two children, she would leave Spain to work in Ireland or another country, and she encourages younger doctors to go and work overseas. 

“We are not okay here. We are doing very badly, and the politicians do not want to hear about it. Yesterday they proposed changing primary care so nurses can see people without doctors – this is not a real solution. 

“We are struggling to retain specialist doctors, and young doctors. Ireland is becoming more popular to go to because we know the pay is good. We don’t know how many doctors go there specifically, but we do know that more doctors in training are applying for certificates to work abroad. Every year roughly 1000 more doctors ask for this. Last year 4000 doctors applied for it,” Giminez said. 

The doctor said that in turn, the SNS is trying to recruit doctors from North Africa and Latin American countries. 

“They think they can cover all the jobs with doctors from these countries, because their health systems are worse than ours. The problem is, after a while working here they realise they can get paid more in Ireland, in Germany, in France, and they are not tied to Spain, so it is easy for them to go. 

“The question is how do we retain staff, and make working life better here, not depending on foreign workers. I don’t think the government has an answer,” Giminez said. 

‘I am happier working in Ireland’ 

Domingo Ly, a 62-year-old doctor who worked for 30 years in Spain, emigrated to the UK, and then to Ireland for work once his children had moved out of home. 

Ly left the UK when the IR35 came into effect, which changed the amount of tax NHS contractors paid. He believes that in the UK, migrant doctors are given more difficult work loads, which in his view, amounts to some doctors who come from overseas being “abused within the system”. 

Ly’s experience of working here differs to that of the non-EU nurses that Kaipilly supports through Migrant Nurses Ireland. 

In Ireland, Ly sees a patient every fifteen minutes in a family practice in Cavan. This is a relief for him after seeing upwards of 50 patients a day in Spain. 

“I enjoy my work more here, I have more time for my patients, and I get paid more, it’s a win win for me,” Ly said. 

“I still speak to my old colleagues in Madrid. They are all on strike, in several other areas the situation is the same. Ninety percent of the doctors I know would like to leave to come to Ireland. But they cannot, because they have children they do not want to uproot, for younger doctors, it makes complete sense,” he added. 

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