We are an international workforce in the NHS, politicians and management like to celebrate this. They talk about multi-culture, while at the same time pitting one group of workers against another when it comes to cuts to wages and services. We have to develop a collective strength to oppose the cuts from above – and the fact that we come from different regions of the world might actually help us. We conducted interviews with colleagues from India and Ghana. Below you can read the story of a Southmead fellow worker from Spain, who worked in various places.

I grew up in Spain, in Barcelona. Before I started studying nursing, I studied one year of pharmacy. I wanted to do research, but they said to me that there were not many opportunities in general. I didn’t like the fact that I would work in the pharma industry. I wanted to do something that was meaningful for people or make the lives of people better, not to make the company richer. I also wanted something that was more hands-on and a broader spectrum of things. That’s why I changed to studying nursing. 

The training was very hard at the beginning. The difference to doing other degrees is that from the very beginning you start working. I was very young, I didn’t have any work experience. I was 20 years old and then all of a sudden you have the responsibility for a lot of people, in an environment that is not known to have a lot of resources and you don’t have the skills yet. In the first year you are just at university, but then they send you to hospitals. You don’t just lack knowledge, but also personal skills, how to deal with people who are hungry, how to deal with aggression and how to deal with grief. They don’t teach you that. 

In Spain they also send you to work in different areas, like GP clinics and so on. In your last year you specialise, e.g. you start working in intensive care units (ICUs). They ask you for your preferences and I mainly did ICUs. During your three years training you don’t get paid anything. To study at that time, the 2010s, it was €1,200 per year, which is probably cheap compared to the UK. You basically have to live with your parents. In Spain, 99% of us were in our 20s. There were some people who worked while studying nursing, but these people were doing part-time studies, but you end up doing seven days a week. 

In Spain, there are a lot of student unions. When I studied they increased the university fees by 50%. We had a lot of strikes during that year and a lot of meetings about what to do. In reality that didn’t change anything, you still have to pay that amount of money nowadays, but at least they didn’t increase it even more. The strikes mainly affected the universities, meaning, we stopped going to classes. There would be demonstrations inside the uni or in the streets. On some days the uni would be closed, as teachers would not attend. We still went to work in the hospitals, though, because people wanted to learn and to get the experience. 

Work in Turkey

During my last year at university I had done an Erasmus exchange. I was in Turkey for five months in 2015, 90% of the time working in a public hospital, in the ICU. I always had a nurse to work with. There was a bit of a language barrier, because most of the Turkish nurses didn’t speak English. With the help of Google Translate and other staff translating, we managed to communicate. The doctors spoke English. The ICU work was very similar to the work in Spain. The work practice and technological standard was the same. There is an international science behind hospitals and how you treat patients. The difference is that in Turkey you look after three ICU patients and in Spain after two and in the UK often only after one, in case they are intubated. It impressed me how hard the nurses worked in Turkey. 

Comparatively, nurses in Turkey were also better paid than in Spain or England, when you compare it to the national minimum wage, but even the national average wage. They also had more job stability. That surprised me. The competencies of the nurses were more similar to Spain, while I think the UK is lagging behind regarding what a nurse can do. For example, in Spain and Turkey nurses placed arterial lines to measure the blood pressure, in particular if the doctors are busy. In the UK you don’t do that. The nurses in Spain and Turkey have more autonomy in that regard. Since I have been working in the UK, nurses have been encouraged to do more stuff, to be more proactive in their roles, but it has not been compensated for in monetary terms through higher pay.

Moving to the UK

In the last month before qualifying, an agency came to the university. They recruited people to work abroad. They also advertised in Facebook groups and so on. The economic situation was difficult at the time, so the university agreed to send out emails to students, advertising for the recruitment agency. You then had to go to the job centre, where the agency had booked a room. This private company was doing interviews for a NHS hospital in Taunton, Somerset. They were doing interviews in Seville and in Barcelona. At the time the financial crisis in southern Europe was still lingering, so they hired mainly from there. Now they will hire from further afield. The company is based in Ireland, but they recruit for hospitals around the world, mainly of course in so-called rich countries. I didn’t have to pay them any fees.

So after finishing the uni in June, I almost immediately started working in the UK, so I never had any work experience in Spain. I went for economic reasons, in terms of job security, and for the experience. I had the feeling that after Turkey I wanted to repeat the experience of working abroad. You get hired with other people from your country, so that helps – you already have friends with you. They give you accommodation for the first three months and they give you one month of training. It was quite reassuring, that is what made me take the step forward. 

I also went abroad because in Spain, when you start working, you get only very short contracts. It’s all very unstable, in the sense that you might be working in places that you don’t have any idea about. You are newly qualified and they put you two weeks in ICU, three weeks in oncology, then three weeks in trauma. You go from one place to the other. This also means that nurses who work there permanently are less interested in showing or teaching you things, because they know that you will be gone again soon. This undermines team spirit and solidarity. This was putting me off. Another difference to the UK is that in Spain you earn more in public hospitals than in private ones. The basic pay in Catalunya is around 33,000 Euros, without a shift or weekend bonus. That’s about as high as in the UK, but you don’t get a stable job contract. They pay you extra when each contract runs out, perhaps 50 Euro after a three week contract terminates, but as I said, it is pretty unstable.

They didn’t specify which wards they needed people for in Taunton. I told them that they could put me on any ward, but not in the emergency department or in admission. And they put me in admission! It’s just that I never worked in admission before, plus working abroad for the first time and all. First I wanted to quit, but after a while it was okay.

For the first month, we would go to the library of the hospital every day, where we had a month of induction. They started from the very basics, about the structure of the NHS and of the hospital and so on, to the differences in medication between Spain and the UK.

They were hiring people every month. In August 2019, 20 of us from Spain arrived. In October some Italians came, in December it was nurses from Spain again. So for a year and a half, every month, Spanish and Italian health workers were recruited. They were all going to the same NHS trust. You form closer links with the guys you had the induction month with. During the first month they would pick you up from your accommodation with a mini-van. They gave you a small room, in a student accommodation. Four rooms shared a kitchen, there was a gym, a football and basketball pitch. They gave you maximum support, they would even go to the bank with you to help open an account, or to the rental agency, to find an accommodation. We even appeared in the local newspaper, because this hospital never had any nurses from Spain. And we had a meal with the boss of the hospital. In the meantime in Spain, the nurses who left were replaced by migrant nurses from Latin America.

Things have changed a lot since then. There are less resources and now people are less eager to accept people from other countries. When Brexit happened, things became a bit more shaky. Some people had bad experiences when going into town. The standards have fallen, also within the NHS. When I started working in the UK ten years ago, most things seemed better than in Spain: staff ratio, work load, pay incentives, working times, career prospects. But over the last ten years things have degraded a lot. The turn-over of staff is massive, or at least it used to be – and no one bats an eye. It doesn’t seem to be a priority of management to lower the rate of turn-over. In Spain, most people who have a permanent contract have been there for 20 years – it is difficult to find that in the UK. Turn-over is high, because the conditions have worsened. When I arrived and worked on the wards I had to look after six patients, now ten is the norm. You often have to stay longer, because you can’t finish all your tasks. I guess the relation between doctors and nurses is still better here in the UK, compared to Spain, where doctors assume that nurses can work more independently. 

The connections between Spanish nurses in the UK is informal. Most of the nurses from Spain are really young, in their mid-20s or so. Most of them don’t see the UK as a place where they will stay. They are passing through. So they have never created formal associations. Still, the connections are very important, because when you start you have a lot of questions or doubts about how things are working here. Having people that have the same doubts or questions is very good, because they can all help to solve your problems. It is good to have this community. I am in touch with nurses who went back to Spain and we compare conditions. 

The impact of Brexit

Brexit has little to do with why nurses from Spain go back home. Most of us arrived before Brexit, so we could all get settled status. The reason is that health care in the UK has deteriorated and it has improved in Spain. So the economy has picked up and the government is a little bit more keen to invest in healthcare, at least compared to the UK. And living costs went up in the UK and people won’t stay here to earn £100 more than back home in Spain. 

Nurses who have worked in the UK for ten years have a better standing when going back home to Spain. They will have more confidence working in different parts of the health system. But the main point here is that when you are applying for jobs in the public health sector in Spain, it works with a point system. The more experience you have, the more points you get. If you apply, the people with the most points get the contract. When you start newly qualified, you have zero points, so you get the cheapest contract, like two weeks over Christmas. Once you have more points, you get better contracts, like six months or more. Before Brexit, because the UK was in the European Union, your time worked in the UK would count as experience in Spain. This would add points for you, when applying. Since Brexit, the work experience in the UK does not translate into points in Spain. This is, in fact, a Brexit-related factor for why people might not stay here.

Working in Saudi Arabia

I worked in Saudi Arabia for only three, four months, before Covid started. I found the job through the same agency that found me the job in the UK. I had some Spanish friends that were a little bit tired of the situation  in the UK, but they didn’t want to go back to Spain yet. So they were looking into other opportunities and then the Middle East is an opportunity with good economic conditions. So I joined these friends, the community was much smaller, compared to the UK. They gave you accommodation in Saudi Arabia, where you could stay as long as you wanted. Alternatively they would give you money to rent a place. My basic wage in the intensive care unit was 4,500 US Dollars a month. They pay you 200 USD for transport and another 200 USD if you work in special departments, like ICU. You don’t have to pay taxes on this and they pay extra for overtime. 

I was working at the biggest hospital in Saudi Arabia. Hiring nurses from Europe was a kind of prestige thing for them. They try to change their economy, so they boost tourism, sport or the health care industry. The hospital is public in theory, but they focus on rich people and international health tourism. They want to attract rich people from the Middle East who would normally have their surgery in London or New York – so they hire health workers and doctors from western countries. They partly want to absorb their knowledge, but it is also a prestige thing.

There were also workers from India, the Philippines and Korea. The hospital was run in English, so these workers also have an interest to gain experience in an English environment to then migrate further to the US mostly, a bit less to the UK or Australia. The wages they pay in Saudi Arabia are based on your nationality or ethnic background. The people who are paid the most are the Americans and the Saudi Arabians. For them America is top. You get paid a little bit less if you are from English speaking countries, like Canada, Northern Ireland. Again, you get paid a little bit less if you are from Europe. And from there wages drop a lot. If you are from Korea, you still get more than someone from India. I was there for a month, earning 5,000 USD and there were nurses from the Philippines who had been there for ten years, who had even learned a bit of Arabic, and they were paid half of that! It was surprising. I thought everybody was getting paid the same. It is a racist system, or at least it depends on your passport – there was an African guy with a Finnish passport, and he was paid the Finnish wage. And the guys from the Philippines and the Arabs, they lived completely separate lives, there was a wall between them. 

When Covid hit I went back to the UK. My friends stayed there and completed the year, as they pay you an extra month’s wage for completion. 

The question of strikes

I was here during the nurses strikes in 2022/23. It is very difficult to go on strike when you are a nurse, pretty much impossible really. A lot of people in Spain say that the best time to go to a hospital is when there is a strike, because then you have at least a guaranteed minimum service, which is often better than the regular service on non-strike days. Where I was working during the strike, the impact on the wards was minimal. There is probably more impact in theatres or in outpatients clinics, areas that work with appointments. I don’t know how we can strike as nurses, we have to find a creative way. I read once about a struggle in Austria or Germany, where ambulance workers or workers in private hospitals would just not do the paper work that was necessary for the company to cash in the money from the health insurance. So they were still doing their work, but they impacted the company economically and put pressure on it. Here you might strike for a day, but then you pick up the work the following day and make up for it. 

In Spain there are regular strikes by nurses, two years ago the nurses in Catalunya forced the government to accept a 35-hour week. There is a lot of talk about strikes amongst nurses from Spain in the UK, but many might rather go back home than struggle for better conditions here. At the same time there is more sensibility towards these questions, also regarding more political things, such as the war in Gaza. I know a lot of the Spanish nurses who have gone to different anti-war demonstrations, perhaps also because we understand ourselves as part of the Mediterranean and close to the Arabic world. Here in the UK we would join, but not lead the protests.

In general we have to make people aware of what is happening. Sometimes nurses or public sector workers don’t want to make people aware of what’s happening, because they think that people will blame them for not doing their job or because they think that people are going to be scared when they hear what is happening with their services. There is no need for making people panic, but, for example when I was working in A&E and the waiting time was 14 hours long, I told them that it is 14 hours long. I would say it is 14 hours because we only have two doctors and they don’t hire more, although we have more patients. You should not cover things up. You have to speak out and also tell them why, otherwise people are looking for answers elsewhere and might blame immigrants. As workers, we have to let people know what is happening.