Prior to the Brexit vote, many Remain campaigners warned that “a vote to Leave is a vote to put our NHS in jeopardy” because it has “become increasingly reliant on EU nationals to keep it on its feet”. There has been no halt to the dire predictions since the vote to Leave: reportedly the NHS “could lose 25,000 workers because of [the] EU vote”, while Nick Clegg claimed that “if we told all the doctors, nurses and other valued staff from other EU countries that they were no longer welcome here” it would bring about a “public health emergency” and the NHS could even “collapse”. The Guardian has claimed that there is already a “haemorrhaging” of “foreign staff” and “a record number [of EU nationals] are quitting the NHS”, with Vince Cable informing a nationally televised BBC Question Time audience that “10,000 [EU Nationals] have already walked away from the NHS because they don’t feel they are needed or wanted anymore”. There are “threat[s] to throw out people we absolutely cannot do without,” according to Polly Toynbee, and “Brexit is poisoning the NHS” according to Suzanne Moore. The Huffington Post says “Brexit has led to huge fall in [EU NHS] numbers“, quoting a prominent NHS nurse claiming that EU staff may even leave the Brexit nightmare of the UK for Saudi Arabia, while the British Medical Association published a blog claiming there was a “scourge of post-Brexit xenophobia”. I was very worried and distressed by these claims. I truly value the contribution EU and other foreign nationals make to the delivery of healthcare and the fabric of the nation, and my wife has worked for the NHS all her adult life. I even started to fear that perhaps I’d contributed in some small way by volunteering for Vote Leave and voting for Brexit. But, just like in healthcare, misdiagnosis of a problem can lead you to deliver the wrong treatment. And since we all remember the overblown hype of “Project Fear”, I wanted to know for sure: are these alarming claims actually true? Relying almost solely on the NHS’s own data for research, I quickly became convinced many of these claims are outright false, or at minimum very misleading. Here is what I found out: Overall NHS staff levels have grown more than twice as fast as UK population growth Between Dec 2013 and April 2017, total NHS England staff levels increased by 74,676 (+6.72%), taking the NHS workforce of 1.18 million. These are net figures, new starters minus leavers (roughly like the entire working-age population of Oxford putting on an NHS lanyard). During this period the UK population grew by roughly 2.4% (64.1m to 65.6m), and those aged 60+ grew 4.53% (12.06m to 12.61m) – population figures from the ONS. This is a useful context when evaluating any staff shortages. There are more EU nationals working in the NHS than ever before As of 30 June 2017, there are 61,891 EU nationals in the NHS, or 5.2% of the workforce. This is a huge 55.4% increase in the last 3.5 years – +22,084, up from 39,807 in Dec 2013 – and EU nationals have risen 8 times faster than other NHS staff. EU nationals have increased since the Brexit vote As of 30 June 2016, EU nationals were 58,698 or 5% of the NHS workforce. So exactly one year after the referendum vote (after which a hate crime wave was allegedly unleashed) there are 3,193 more EU nationals working in the NHS. These increases are even higher if you choose the beginning of the referendum campaign as a starting point. It is true that the growth rate in EU nationals has slowed down, but this can be explained by many factors as well as Brexit, particularly in the case of EU nurses. The NHS is still less reliant on EU nationals than the UK average In the whole UK, EU nationals make up 7.40% of the workforce (Mar 2017). Whilst the NHS is of course reliant on the valuable contribution of EU staff, at 5.2% it is roughly 30% less reliant than the wider UK economy – rather than a special case – and so it is unfair to make the claim that the NHS should be uniquely able to skip immigration obligations, citizenship tests or language proficiency requirements for its employees. This lack of unusual reliance is supported by pro-immigration Professor Ian Manning, Chair of the Independent Migration Advisory Committee, who gave evidence to the House of Lords in Nov 2016 stating that: “the share of EEA workers in health and social care is lower than the national average, so this is not actually a sector which is hugely exposed”. That the NHS is increasingly “reliant” on EU nationals is true, but only slightly faster than the overall UK trend (in Dec 2013: EU/NHS: 3.58%; EU/UK: 5.66%). The NHS is more reliant on Rest of World (RoW) nationals than the UK average As of June 2017, 75,681 NHS workers, or 6.4% of the workforce are non-British or non-EU, compared to only 3.9% in the rest of the UK. They are overwhelmingly from the Commonwealth (India, Pakistan, Nigeria, Ghana, Australia, Jamaica), Asia (Philippines, Malaysia), or the Republic of Ireland (the 3rd largest number of foreign nationals, with which the UK has a Common Travel Area pre-dating the EU). Relatively speaking, of course the world is a lot bigger than the EU, but many NHS Trusts report that RoW recruitment tends to result in better staff retention compared to EU staff. For comparison there are 14 Luxembourg citizens working in the entire NHS, and 2,014 Australians. If the NHS is really “over-reliant” on non-UK staff, it is on Indian doctors (who equal 23 EU states combined), Filipino nurses (more than 24 EU states combined) and cricket-challenged Australian ambulance staff (more than every EU nation combined). Yet these rarely get mentioned when talking about the contribution of foreign NHS staff and the openness of the UK to the world after Brexit. EU nurses appear to be a special case While the percentage of EU nurses has more than doubled from 3.2% to 6.8% in the last four years, their numerical growth has stalled and even slightly declined post-referendum (21,664 in June 2017, from 21,826 in June 2016). But, this appears unique to EU nurses as RoW nurses increased from 25,283 to 25,990 and UK Nurses increased from 246,756 to 248,862. So is the fall in EU nurses down to Brexit? It seems unlikely since EU nationals also increased in every other role – support roles (+1,309), science/technical (+902), doctors (+470), ambulance (+138), managers (+38) and midwives (+28). In addition, the changes in EU nurses vary considerably by nationality – Spanish (-518), Portuguese (-228), Romanian (+248), Polish (+120), Greek (+57). Are Spanish Nurses leaving due to Brexit, but Romanians joining in spite of it? Given only certain nationalities of EU nurses have fallen in number, a more plausible explanation is the introduction of the IELTS (an English Language Test) in Jan 2016. This was acknowledged as a factor by the Migration Advisory Committee and NHS Trusts themselves, the independent Health Foundation and the Chief Executive of the Nursing and Midwifery Council (NMC), who told Parliament that: “we have seen a reduction in the number [of nurses] applying to join and a small number seeking to leave. We can speculate as to what that is about; it could be the language test; it could be Brexit or it could be all sorts of things. At the moment we do not know”. Improvements to unemployment in Spain and Portugal may also play a role. EU nurse numbers (and their falling registration levels with the NMC) should be also put in the context that they have risen by 118% from only 9,942 as recently as March 2013, and that the Chief Executive of NHS Employers gave evidence to the House of Lords that EU recruitment was a: “get out of jail free card… for not plan[ning] our workforce properly” that the NHS should be “rightly criticised” for. Claims of widespread xenophobia are ridiculous Amid the EU hysteria, the potential for Brexit Britain to make the NHS more welcoming to the wider world is being completely ignored. In 2014 the NHS lost 549 RoW staff, and this was part of a 3-year long decline in their relative numbers. Throughout 2016 and post-referendum this dramatically turned around and the NHS added 3,428 RoW staff – with growth tripling from 2015. Can anyone give a plausible mechanism that explains how Britons living in one of the most tolerant countries in Europe and the world are racist and xenophobic towards Lithuanians but not Nigerians? Intolerant towards Polish but not Filipinos? Plus, the UK has almost identical numbers of foreign-born doctors and nurses to Canada, yet Her Majesty’s Government in Ottawa somehow manages to maintain a healthcare system and survive outside of a transnational political organisation, so why can’t London? Why is NHS Brexit coverage so misleading? These facts seem jarring compared to mainstream media coverage. So why do I think they get it so consistently wrong, always in an alarmist direction? There are a few main reasons: No goal for EU nationals in the NHS is ever specified and change is assumed to be a priori bad: What is the right number of EU staff that should be working in the NHS? 3%? 10%? 25%? Are they supposed to grow forever, or never change? Why are EU nationals implicitly better than other Rest of World nationals? Shouldn’t healthcare be based on what is best for the patient, not the nationality of the healthcare professional? Much of the media and many politicians are still opposed to Brexit and are prepared to weaponise the NHS to undermine and weaken the result: This is even if that means unnecessarily scaring NHS staff with misleading stories about widespread xenophobia and their EU colleagues “leaving in droves”. This is quite immoral and very dangerous politically. This bias also results in reliance on transparently partisan sources, cherry-picked data and arbitrary dates for comparison, to create the most alarmist picture possible. When reading an NHS scare story, I find it helpful to ask – are those dates truly comparable? Is this data publicly available and/or directly from the NHS? Is it in context? Does this author or publication have a track record of correct predictions? And would they be happy if they found out their alarmist predictions were wrong? ‘Little Europeans’: Much commentary implicitly equates “European Union” with “foreign”, a biased viewpoint which places the EU at the centre of importance at the expense of the rest of the world. They don’t consider the hurt an Indian doctor may feel when he/she sees that – unlike them – a Latvian nurse shouldn’t have to affirm their loyalty to the UK and its laws, and should receive substantial financial subsidy to boot. Interviewed for a misleading alarmist article in the Observer, the Chief Executive of The Royal College of Nursing exemplified this by claiming that Brexit “risks turning off the supply of qualified nurses from around the world” – with “world” apparently synonymous with “EU”. A London-centric viewpoint: The majority of journalists, media organisations and politicians are based in the capital. The situation in the NHS there is far different to the rest of the country. Instead of around 5% EU nationals, it is closer to 11-12%. The Royal Brompton and Harefield Trust based in Chelsea/Uxbridge has 19.6% EU staff – the highest in England – whilst Derbyshire CHS covers 1 million patients but has only 0.6% EU staff – the lowest in England. Some London Trusts with a high numbers of EU staff also provide essential services to elsewhere in the country (e.g. Great Ormond Street Hospital for Children – 14.2% EU staff). The vastness and diversity of the NHS is just another reason why it is important to be precise and careful when talking about it, so even if this more charitable interpretation is a factor, a lot of media coverage would still be a problem. Corrective forces are weak: The top leaders of NHS organisations and many politicians probably think a ‘crisis’ atmosphere will help them get additional staff or funding, propose their pet policies, or enable them to dodge criticism for any healthcare scandals (they also don’t want to have to address their recent enormous reliance on EU nationals as a quick substitute for poor workforce planning). The vast majority of the public are genuinely concerned about the NHS and the effect of Brexit – but only because they don’t know the facts and are bombarded with scare stories on a near daily basis. Rank and file NHS staff are just trying to get through the day. And everyone is on egg shells to avoid saying anything negative about our ‘national religion’. This leaves few forces incentivised to correct the record. Is it moral to rely on someone else to train and supply our healthcare workforce? The NHS Sustainability Committee carried out a 9-month investigation into the future of the NHS between July 2016 and April 2017. It heard testimony from dozens of NHS witnesses, and received thousands of pages of written evidence. Their report comes to the unequivocal conclusion that: “[NHS] workforce strategy has been poor with too much reliance on overseas recruitment. … the Government should go to greater lengths to secure a reliable supply of well-trained professionals and other health and social care workers from within this country” (Paragraph 122). It also quotes Ian Cumming, the Chief Executive of Health Education England on the morality of being reliant on other countries – many poorer than ours – for healthcare workers: “We believe that, as the fifth-largest economy in the world, we have a moral duty to produce the healthcare workforce that we require for our National Health Service, and we should not be reliant on recruiting from other countries. That is absolutely not the same as saying that we do not welcome the opportunity for people from other countries to come and learn here and work with us” (Paragraph 115) The following examples illustrate that reliance on foreign nationals is not an unqualified good, and the positives and negatives should be carefully considered: Greece: since 2009, the NHS has doubled its cohort of Greek doctors to around 1,700. This is more NHS doctors than 16 EU nationalities combined. The Euro crisis and collapse of the Greek economy is surely the main contributing factor. Perhaps pro-EU campaigners should focus on ensuring that Greece is capable of retaining Greek doctors, rather than the NHS? Malawi: For a population of 17.2 million, Malawi has only has only between 265-618 doctors in the entire country. The NHS has 211 Malawian staff of whom 20 are doctors. Is the NHS employing Malawi’s “desperately needed” medical staff – which a BMJ study estimated costs them millions in lost training investment – really the best way we can help? Conclusions Before looking into the NHS’s data, I thought this drumbeat of alarmist claims may well be correct – I can only imagine what they must sound like to EU nationals working in the NHS, and their friends and family members. So it isn’t that surprising they are still looking for reassurance and it is right to sympathise with their situation. But, I found almost the exact opposite to what is claimed: more EU staff, more since Brexit, and also a vote of confidence in Brexit Britain from many other nationalities. This convinces me that many of those who are making these claims are spending far more time falsely scaring people than accurately reassuring them, and using the NHS as cover to try and reverse Brexit – a disservice to the very organisation and people they claim to care about. Instead of taking that approach, it would be better if both Remain and Leave voters could come together to work out how to improve healthcare in the UK, armed with the real facts about the NHS. Data is compiled from NHS Digital, from: 6 Jan 2017 | 4 April 2017 | 28 July 2017 | 7 Sep 2017 | 14 Sep 2017 | 22 Sep 2017. Figures are only for NHS England, though I have also analysed data from Scotland, Wales and Northern Ireland and it shows similar trends; however, it is much harder to aggregate. There are also substantial regional and role differences by nationality, only briefly mentioned here.