EPSU/Uni Hertfordshire Report on migration of health & elderly care workers and related trade union initiatives

(Brussels, 28 August 2012)

The study and report “Opportunities and challenges related to cross border mobility and recruitment of the health sector workforce” have been commissioned by EPSU and prepared by the University of Hertfordshire between December 2011 and July 2012.

The growing demand for health and care workers, projected staff shortages and differential pay and working conditions has led to an increase in the mobility of labour across national boundaries in the sector. The accession of New Member states in 2004 and 2007 further increased the potential for migration.

The research comprises three elements. First, it reports the data from a survey of European Public Services Union (EPSU) affiliates. Second, it reports on primary data in the form of face-to-face interviews that were undertaken in the following countries: Belgium, Germany, Ireland, Italy, The Netherlands, Poland, Romania, Sweden and the United Kingdom. Six countries were selected and developed as case studies (Germany, Italy, Poland, Romania, Sweden and the United Kingdom). These were selected on the basis of including sender and receiver countries from a labour perspective, which broadly correspond to established EU members and New Member states (NMS). Third, the report draws on secondary data from reports, academic literature and databases.

Our study focuses on three broad categories of health workers: doctors, nurses, and care workers. It covers hospitals, residential and home care in the public sector, and the for-profit and not-for-profit sectors.

The aims of the report are to

• outline the EU legal and qualifications frameworks related to cross-border mobility

• identify patterns of migration between countries

• investigate the ‘push’ and ‘pull’ factors driving migration

• examine the role of trade unions (TUs) in this process.

• identify key challenges and make recommendations.

Findings relate to the patterns of mobility for outward and inward migration of health and elderly care workers and on factors driving or inhibiting health workforce migration. In addition to health workers the situation and particular challenges for migrant (as a rule female) workers in the field of elderly care - a sector characterised as low paid and low status and often done in a home care context - are looked into.

There are a number of specific difficulties for trade unions in organising care workers, including: the gendered nature of the job; isolation in the home; the uncertain legal status of many migrant care workers; the fragmented provision between the private, public and charity sectors; and the self-employed status of many care workers.

One focus of the report is on the role, activities and initiatives of trade unions to support migrant care workers.

• Where social dialogue and corporatist arrangements were entrenched (Norway, Sweden and Finland, for example), discussions on migration were embedded in this process. In countries without corporatist arrangements there is discussion with the government or government bodies on migration (Bulgaria, Slovakia and the UK).

• Most respondents to the questionnaire reported that no special efforts were made to recruit migrant workers. However, interviews in the UK, Germany, Italy and The Netherlands revealed a range of initiatives to support and give advice to migrant workers and to facilitate their integration.

• There was some limited evidence of cross-border collaboration, particularly in the Nordic network of countries. In the UK, a Polish worker has been seconded from the OPZZ trade union to work with Polish and other migrants from NMS. In Germany, Marburger Bund has a reciprocal agreement with unions in the Czech Republic, The Netherlands and Switzerland.

• Norway has signed up to the EPSU-HOSPEEM (European Public Services Union-European Hospital and Healthcare Employers’ Association) code of conduct, the World Health Organization (WHO) Global Code of Practice on the international recruitment of health personnel and employment of migrant workers. In the UK, there is a Code of Practice for International Recruitment of Healthcare Professionals (2004) issued by the Department of Health. In Finland, Sweden and The Netherlands, employers and unions are signed up to the EPSU-HOSPEEM code.

What are the main insights from the study when it comes to the impact of health and elderly care workers' migration?

• The impacts of health worker migration were experienced by individuals who benefited from employment opportunities that may not be available in the home country. Other possible benefits include: training and experience; better promotion opportunities; and superior working conditions in relation to hours, holidays and workload.

• The problems of losing skilled health workers are being replicated within some parts of Europe and in some specialisms. This is the case particularly in relation to NMS, albeit on a smaller scale than that which exists between developed and developing countries.

• At a general level, outward migration reduces the pool of potential workers for the health service. Within sender countries impacts may be greater in rural areas than in cities. However, it is very important to emphasise that the scale and the impact differ between NMS. While Romania has shortages in specific health workers skills, this was less reported in other countries. The available figures showed that Polish nurses working outside the country were very small.

• One source of resentment in sender countries is that the training and education of health workers is financed by the public purse and that the skills of these workers are then ‘exported’ to receiver countries without any compensation. The reverse is true for receiver countries, which are able to fill shortages in their labour force of health workers with people who were recruited without any investment in their cost of educating and training.

The following recommendations have been drawn up in response to the challenges identified in the study, but have also been elaborated jointly by the research team in conjunction with the EPSU Secretariat.

• To improve the transparency of processes and the effectiveness of the actual cross-border recognition of qualifications and provide information on administrative procedures for the recognition of qualifications.

• Training care workers and certification of their skills and qualifications and comparability of both across Europe, the integration of home-care workers into local public service networks; and to identify and work with community groups and non-governmental organisations (NGOs).

• To identify where information exists on salaries and the contractual rights and obligations of doctors, nurses and care workers; to review the accessibility of information (languages, format); and to explore if there are initiatives to set up a point of information-collecting of this type of information.

• For EPSU affiliates to investigate the possibility of including into their range of services offered for migrant care workers (of a specific profession) the checking of work contracts and/or employment conditions.

• To explore the possibility of reciprocal agreements for temporary membership in trade unions.

• Where there are substantial numbers of unorganised migrant workers, to explore strategies for organising, recruiting and integrating migrant workers, and to review the outcomes of any related campaigns.

• For trade unions to improve training for shop stewards/representatives of staff in work councils and their awareness on questions and challenges related to ethical recruitment practices, to the employment, contractual issues, working and pay conditions as well as to the induction of migration workers in the health care sector

• Free and appropriate ongoing language support by employers and/or public authorities in receiver countries, and for language support to be provided both as part of vocational training and as stand-alone language classes.

• For EPSU affiliates to continue with awareness-raising about the contents and potential of the EPSU-HOSPEEM Code of Conduct on Ethical Cross-Border Recruitment and Retention and to monitor its use, based on the joint EPSU-HOSPEEM Evaluation Report (2012).

• For public authorities and employers to systematically monitor the work of employment agencies to help safeguarding ethical recruitment practices and to take sanctions against them should exploitative practices be detected, as set out in the EPSU-HOSPEEM Code of Conduct on Ethical Cross-Border Recruitment and Retention

• For trade unions to promote the International Labour Organization (ILO) convention on domestic workers.

• For EPSU affiliates to improve the cooperation with governments and public authorities at all levels to work towards better legal protection of working and employment conditions of migrant care workers in private households, in small or medium sized enterprises or self-employed (including the bogus self-employed) as it is as a rule difficult or impossible to reach out to them or to have them covered by collective agreements

• Inclusion of social/labour clauses on wages as agreed in collective agreements or legislation and other working and pay conditions in public contracts for private (not-for-profit and for-profit/commercial) providers in the context of public procurement procedures to support the principle ‘Equal pay for equal work’ on a given territory.

• For the EU to encourage and push national governments to invest in health care in order to improve the sustainable financing of health care systems, the quality of health services, the attractiveness of health professions and the working conditions of those health workers not migrating/staying behind

• To review any existing compensatory arrangements between sender and receiver countries and to consider the elaboration of compensation mechanisms/agreements, involving employers’ associations, the institutions administering health care systems (social insurances or national health services), relevant national ministries and, where appropriate, EU institutions.

• To promote fair treatment for non-EU health workers through, for example, the right to vote in local elections in the host country after four years of residency (consistent with the practice in most EU countries) and facilitating access to naturalisation/citizenship in the host country.

• Giving support to or affiliation to appropriate organisations committed to promoting anti-racism and anti-xenophobia and to consider producing materials that set out the value of migrant workers in particular to health and social services and to combat myths of migration.

- Report with Appendices - in EN only

- Executive Summary and (Draft) Recommendations (recommendations to be discussed with, if need be amended and adopted by the EPSU affiliates at the Standing Committee "Health and Social Services" on 23 October 2012) - available in EN/FR/DE/CZ/ES/IT/ROM/RU/SV


In case you are interested on another facet of the topic of migrant health and elderly care workers from a social partners' and trade unions' perspective, please find more information (documents and relevant links) below on the EPSU-HOSPEEM Code of Conduct on Ethical Cross-border Recruitment and Retention, signed in 2008 and evaluated as to its use and implementation in 2012.

- Report on use and implementation of the EPSU-HOSPEEM Code of Conduct on Ethical Cross-border Recruitment and Retention (2008)

N.B.: The document with the revisions and additions done in July 2012 by the EPSU Secretariat - see above under Ad. 3 - has been adopted in the meeting of the working group 3/2012 on 5 September 2012 by the EPSU affiliates and HOSPEEM members present

- Follow up on EPSU-HOSPEEM Code of Conduct on Ethical Cross-border Recruitment and Retention

- EPSU-HOSPEEM Code of Conduct on Ethical Cross-border Recruitment and Retention (2008) – available in EN, FR, DE, BG, CZ, ES, FIN, HU, NL, PL, ROM, RU and SV

The research commissioned was done with the financial assistance of the European Commission

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