Resources, neo-colonialism and the NHS

Abolition of Slavery, Jamaica 1955

The continuing debate about the NHS — whether it’s about seven-day working or just keeping the service going through the next winter — is almost always about money. With an understanding of Modern Monetary Theory, we now know that the government always has as much money as it needs. So we need to re-frame the issue in terms of resources.

If the government increased NHS spending to the level needed to sort out the winter problems and provide a seven-day service, would there be enough of the necessary additional resources available for the government to buy? There probably isn’t a shortage of medicines or equipment, but there certainly aren’t enough qualified people — clinicians and support staff — available to be bought with the extra money. Most people think, and the politicians promise, that the extra money will cause the missing resources — in this case, people — to pop into existence. The trouble is that most doctors are already working as doctors.

Now that we’ve moved beyond the money bit, we are forced to think about where we are going to get the missing people from. Notwithstanding the claims frequently made by politicians, getting the people locally is going to take time, and for doctors and nurses it’s a 30-year project. That’s because we have to start persuading today’s children that being a clinician — a nurse or a doctor — is a worthwhile and rewarding career (how did Jeremy Hunt do with that when he was in office?) and when they grow up we need to train them.

Well, as we have always done, we will just have to ship the people from abroad, won’t we? We’ve got all the money we need with which to buy them, haven’t we?

That could certainly work reasonably well for us. However, now that we have started thinking about resources rather than money, we need to consider the resource effects in the nation from which we take the trained workers.

There are some 4,000 clinicians from Zimbabwe working in the NHS.1 That’s OK, isn’t it? After all, Zimbabwe has one of the best healthcare systems in the world. They clearly have too many unused resources — thousands of fully trained medical staff — and don’t know what to do with them. We’re probably doing Zimbabwe a favour — if we didn’t take them all those jobless doctors would be begging on the streets of Harare.

Notice how changing the focus to resources, even when it’s done sarcastically, has clarified the issue. If we had talked about money we would have just ended up with competing opinions:

We shouldn’t be relying on the Zimbabwe government to pay for training our doctors and nurses.


Ah, but think of the money those people are making over here — considerably more than they could earn in Zimbabwe. And they will probably send a lot of that money back home. So, on balance, Zimbabwe is probably better off.

Even if that last statement were true (it isn’t), any money that goes to Zimbabwe won’t be translated into more clinicians — the resources we commandeer won’t be replaced at the other end.

We also need to be aware of the disparities in health care between here and Zimbabwe. In 2015 the maternal mortality rate in Zimbabwe was 443 per 100,000 live births (up from 401 the previous year).2 In the UK in 2015 the rate was 9 per 100,000 and falling.3

I can’t prove it, but I would argue that UK government policy creates a shortage of midwives in rural Zimbabwe and leads directly to the death of poverty-stricken mothers and their babies. I note that the UK government made no mention of this when it condemned the recent attempt by the WHO to honour Mugabe.4

And the idea that foreign workers will send money back home shows a lack of empathy that is bordering on racism. Nursing, for example, is not a highly paid profession and nurses working in, say, London won’t be able to save much from their income.5 In fact, they probably won’t have any disposable income and many will have to tolerate living in shared accommodation because they certainly won’t be able to buy or rent a home of their own.6 And yet we expect foreign nurses to be able to save so that they can send money home. Is it because they are simple folk and have no desire to avail themselves of all the expensive distractions in the capital?

Of course, there is a morally acceptable mechanism by which Zimbabwean clinicians could work in the NHS: one in, one out. For every doctor that comes here from Zimbabwe for three years, we send a British doctor there for three years. It’s a fair and reciprocal system that would benefit both countries.

What started off as a debate about NHS funding has morphed into one about resource extraction and that’s a process which has been going on for hundreds of years. The fine Georgian buildings here in Lancaster owe their existence to a related form of resource extraction — it also involved taking people from Africa — and it’s only recently that we have come to accept the damage it did.

The rich in the eighteenth century seemed not to notice the effects of appropriating humans for their own benefit, just like the rich today don’t when they claim that their preference for private healthcare is saving the NHS money. It’s just queue jumping and resource extraction — because a clinician working in a private hospital is one who isn’t working in an NHS hospital.

It’s not just the rich who need to reassess their attitudes. One of the arguments for continued membership of the European Union, or at least continued freedom of movement, is that the NHS ‘needs’ fully trained clinicians from the rest of Europe. Does that mean the health service in Romania, one of the poorest countries in the EU, doesn’t need the 3,775 Romanians currently employed in the NHS?7

To put that number into context, consider midwives: in 2016 the UK had 33,317 midwives, that’s 48 midwives per 100,000 population; Romania had 3,337 midwives, 17 per 100,000 population.8 Politicians, newspaper columnists and the public seem to be blissfully unaware that disparities like this exist within the European Union and that they are getting worse.9 Their perception is simply that we don’t have enough midwives and that we have a right to take them from elsewhere. Even liberal-minded commentators can’t see the colonial overtones in this sort of thinking.10

We could certainly do with more midwives, but that doesn’t mean that we should steal them from countries which have less. We should be training our own.11

Furthermore, if we assume that the figures for midwives are indicative of the relative size of the health services here and in Romania we can get some idea of how the exodus must look from the Romanian perspective. What would the public reaction be in the UK if 30,000+ NHS staff left to go and work in Romania?

One thing for certain is that we would shift the focus of our attention away from the individual. When we ship people here for our own benefit we explain away the injustices in terms of the person — how they will be paid more, have a higher standard of living and benefit from greater opportunity. Were it the other way around we would be talking about families being broken up, resources being wasted on training and a nation deprived of its people.

If we are going to stop depriving other nations we are going to have to learn to live within our means — not in terms of money, but in terms of people. Remember, we have a sovereign currency and suffer no lack of financial resources, but there is most definitely a finite amount of real resources in the country.

So, if we want 1,000 more midwives we will have to identify 1,000 other jobs we can do without. And if we decide that we need to preserve all the work currently being done in the public sector it will be up to the government to encourage people to move from the private sector.

You can see why the discussion is always kept away from resources — because it shines a light on the unfairness in the system. Instead, the discussion is steered towards one about the availability of money — because it makes solving the problems seem so much easier. And if the problem turns out to be a bit too hard to fix, then there’s also a ready-made excuse:

I’m sorry, but there’s no money left.

Modern Monetary Theory shows that lack of money is never an issue, but that doesn’t necessarily solve all our problems. An MMT-aware approach does, however, help us identify structural difficulties and shows us that we need to start planning now for the country we want to have in 30 years’ time.

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1. See NHS staff from overseas: statistics, 7 February 2018, House of Commons Library.
2. See Zimbabwe – Maternal mortality ratio, Knoema.
3. See United Kingdom – Maternal mortality ratio, Knoema.
4. See British government leads barrage of criticism after World Health Organisation names Robert Mugabe a ‘goodwill ambassador’, 21 October 2017, The Independent.
5. No, I won’t be drawn into all that stuff about nurses having to rely on food banks (Theresa May skewered on live TV…, 30 April 2017, Daily Mirror). It’s just the sort of thing that is bound to come back and bite (Watch as ‘foodbank’ nurse is confronted…, 18 June 2017, Daily Record).
6. Assuming that their shared accommodation hasn’t been sold off to property developers. See NHS privately planning to develop Royal Free nurses’ home into luxury flats, 18 May 2018, The Guardian.
7. Numbers from House of Commons Library as above. Granted, not all the Romanians in the NHS are going to be clinicians; some will be in administrative roles. But we should still apply the same analysis because a Romanian working as a receptionist in a UK hospital is one less person working to further the public purpose in Romania.
8. See Nursing and caring professional, Eurostat.
9. The same Eurostat dataset shows that in Romania between 2007 (when it became a full member of the EU) and 2016 the number of midwives fell by 1,392 — a drop of 30%. In the same period the number of midwives in the UK rose by 1,904. Note also that the UK has by far the most midwives of any country in the EU — Germany is next with 23,000.
10. One example of many: Brexit deal must allow NHS to recruit and retain European staff, 4 May 2018, The Guardian.
11. Yes, I know the government pledged recently to train 3,000 more midwives (See Hunt to unveil plan for women to have same midwives through pregnancy, 25 March 2018, The Guardian). But that doesn’t even leave us standing still because it’s over four years and 3,000 midwives left the NHS last year (See From Brexit to the birth rate: why midwives are leaving the NHS – and causing a crisis, 12 September 2018, The Guardian).