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Return of the MAC

June 27, 2015

Independent – adjective, originally from the Latin dependere, to hang. In nursing, things have not been hanging very much recently. First, we had the news that the National Institute of Health and Care Excellence (NICE) Safe Staffing Committee had been summarily disbanded and its remit handed to NHS England. Nursing reaction was fast, furious and frequently pointed to the disparity between NICE’s ‘independence’ and NHSE’s perceived thralldom to political expediency.

Then this week, the profession hit the headlines again after a Royal College on Nursing report on international recruitment claimed thousands of nurses will be caught by new immigration rules due to take effect in 2017. All non-European Union nationals who are earning less than £35,000 after six years of residency will be required to leave. (Those who arrived before 2011 are exempt).

Estimates of the number of nurses likely to be affected range from 3,365 (the number of non-EU nurses who registered with the Nursing and Midwifery Council between April 2011 and March 2015) to an alarming 30,000 in the Daily Mirror. And all this during a period of universally-acknowledged nursing shortages. Even the rabidly anti-immigration Daily Mail reported the story in sober language, focussing on its concern at the poor return on the £20.1m the NHS is alleged to have spent on non-EU recruitment.

Alongside this story, the media also revived another one about the Migration Advisory Committee (MAC)’s decision from February this year that nursing should not be categorised as a ‘shortage occupation’. Inclusion on the ‘shortage occupation’ list would mean exemption from the ‘£35,000 a year’ threshold.

Questions about this omission were put to David Cameron while he was visiting Runcorn. He was dismissive. “The committee” he shrugged “is independent”. So that’s that, then. If it was up to me…but (shakes head in gesture of general impotence) these independent committees eh, what can you do? Except that, if its conclusions were as inconvenient as all that, Cameron could always have disbanded the MAC and handed its work to someone more amenable. Like he arguably did with the NICE Safe Staffing Committee.

The reasons for excluding nursing from the shortage list were actually very revealing. Deploying what were purportedly the views of the Royal College of Nursing (RCN), the committee said the College ‘provided evidence that suggested that vacancies were employer-driven rather than a structural problem…It was stated that vacancies were largely caused by recruitment freezes and redundancies due to budgetary pressures, with employers keeping some posts unfilled to keep costs down’ (para 3.125). Dr Peter Carter, RCN General Secretary, told the Nursing Times the College had been ‘significantly misrepresented’.

And here, just for once, I find myself siding with the RCN. It seems highly unlikely that what we find in the report represents the totality of its evidence to the Migration Advisory Committee. To me, it is a description of the pre-Francis dispensation in acute hospitals. As such, it reads more like a preamble to a lengthier discussion of rising demand, historic cuts in nurse education, the demographic time bomb and stress and burnout within the profession that must surely have followed. For the MAC to rely on this partial but convenient summary is extremely worrying.

So we are now in a position where valuable nurses may be excluded from the workforce on the basis of outdated information. Even more ironically, official policy is being made on the back of a tacit acknowledgement that under pressure from central government, Trusts did place patient safety at risk by cutting back on nurses in order to balance the books – and must be doing so still, otherwise this recent decision wouldn’t stand up to scrutiny. Delicious, isn’t it?

But the MAC report also raises important questions about what is meant by ‘independence’. And central to this is an examination of the assumptions that underpin discussions about nursing. Announcing its planned new rules on earnings-linked rights to settlement in the UK, the Home Office press release from 2012 was headlined ‘Automatic settlement for unskilled workers to end’. So low levels of pay coupled with a predominantly female workforce mean that nursing can, when viewed through a classist, sexist lens, be termed an ‘unskilled’ occupation.

Nowhere is this more clearly articulated than in paragraph 3.134, where MAC suggests that for nurses working in care homes, a lower threshold of fluency in English may be acceptable. This is even though the committee noted elsewhere (para 3.133) that requirements in relation to proficiency in the English language were made more stringent by the Nursing and Midwifery Council ‘to ensure greater public protection’.

The logical conclusion of characterising nursing as undemanding in intellectual and practical terms, is that it shouldn’t be too difficult to recruit from the local population. And while MAC is right to say that home-grown solutions should be tried first, its decision represents more than just a long goodbye to thousands of much-needed nurses. It represents an acquiescence in the apparent government consensus that nursing is easy, requires no special skills, anyone can do it and you don’t even need to speak good English. And that, my friends, is not independent thought.

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