Evaluation of Praxis workshop - Amazon S3 · acted as an observer and kept notes on the...

Cuban, ESRC project, Home/Work, 5/2/10

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Evaluation of a workshop: “Advocacy-Based Approaches to the Deskilling of Health Care Professionals”

31st October 2009, Praxis, London

1. Description Dr. Sondra Cuban and the ESRC team of Lancaster University organized a workshop, with central themes of advocacy and empowerment, on 31st October 2009 in London. It was sponsored by Kanlungan, a consortium of Filipino organisations that advocate for Filipinos based in Britain.1 The workshop took place at the Praxis community centre and gathered 14 Filipino care workers with health care professional backgrounds (nurses, midwives, physical and occupational therapists) to discuss issues surrounding the global deskilling of health care workers and facilitate means for their advancement. The workshop aimed to raise awareness and create a supportive atmosphere to help participants continue with their plans for professional development in the UK. The issues discussed and materials provided in the workshop were based on findings from the ESRC study on migrant care workers, which was gathered through the project work.2 The idea was to put it into practice the lessons learnt through a support model that was developed to improve workplace education for English to Speakers of Other Languages.3 The workshop took place on a Saturday, which was considered to be appropriate in order to make it easier for migrant carers, who work many hours over a weekly period, to attend. Praxis with its goal to provide education and training along with help, advice, and advocacy for displaced communities4, is situated near an underground station near the centre of London, to make it accessible for participants (to travel). Conducting a “workplace education” workshop at a community centre would allow participants to discuss issues about the workplace (for example, stress) that they might not express under the watchful eyes of their employers and the employer-sponsored trainers in their own place of work. Participants were paid £10 for attending the workshop, which proved to be an incentive. The workshop started at 11 am with a few minutes of informal conversations to introduce participants and the team, and ended at around 4.30 pm with an informal oral evaluation. The day was filled with activities

1 See: http://www.kanlungan.org.uk/about/ with a big thank you to Jamima Fagta for her recruitment of participants and help in organising the workshop. 2 See: http://www.lancs.ac.uk/fass/projects/homework/index.htm for the Home/Work study 3See: http://www.lancs.ac.uk/fass/projects/homework/Docs/Support%20model%20explained-Final.pdf 4 See Praxis: http://www.praxis.org.uk/index.php?page=4


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surrounding deskilling, including videotaping participants’ stories of struggle and success.5 The working lunch was the highlight for the participants because it gave them an opportunity to listen and discuss career options and hear about health care issues from Michael Duque, Director of the Philippine Nurses Association (PNA-UK)6, who is also on the Home/Work ESRC advisory board. 2. Methodology The main purpose of evaluation is to gather, analyse, and discuss relevant evidence from good data sources to ascertain the quality, worth, and impact on provision or policy development of a project. Whilst one of the purposes of the Home/Work project was to create and test a model and methods for advancing migrant health care professionals, the aim of the evaluation was to analyse the effects of this intervention (the workshop) on the participants and how it could affect policy learning for and about this population as well as the ways it was effective (or not) (see below for outcomes and lessons). While evaluation has limitations, for example, in not being able to verify cause and effects of participant changes due to a particular programme (or workshop), it can reveal strengths and weaknesses and expand options for improving educational practices and policies. In order to evaluate whether the intervention (workshop activities) had an effect on the participants, a number of methods were used during and after the event. The workshop itself was organized principally through a printed workbook, which was given to all participants and included a series of activities7. These activities targeted different areas, such as information on the phenomenon of global deskilling of health care professionals, fraudulent training schools and contact details for important governmental and non-governmental organizations such as unions. Other activities focused on building social networks for advancement, asset mapping of resources, discussing participants’ roles in the global economy, locating transferable skills, and others, (such as articles), that were more conducive for self-study or study groups, after the workshop. The focus of the activities was to build knowledge and awareness about the myriad issues that affect this population and ways to advocate for greater support and social justice, through and with organisations, institutions, communities and social networks. Although the model, and the packet, exemplifies a holistic response to migrant carers’ issues in the UK (from housing to employment practices), a short-term workshop could only cover some of these issues. The members of the team had different roles. Sondra designed, prepared and led the workshop, explained to the participants what was needed in each activity and answered the participants’ questions, as well as conducted the assessments (to be discussed below). Afterwards, she organised a discussion board and wrote references for participants, as well as liaised with Kanlungan organiser, Jamima Fagta, for campaigning purposes. Joy Spiliopoulos, Research Associate on the study and PhD candidate, assisted Sondra in the running of the workshop and acted as an observer and kept notes on the participants’ interactions and comments. Anna Paule, nurse manager and informant for the study, assisted in informing the participants on what was expected from the activities, and also answered questions regarding immigration for example during and after the workshop (on a discussion board). Videographer, Mark Minard8 recorded the interactions between the group and the stories that participants shared about their

5 See: http://www.lancs.ac.uk/fass/projects/homework/praxis_video/praxis_video.htm 6 See: http://www.pna-uk.com/index.html 7 See Packet: http://www.lancs.ac.uk/fass/projects/homework/Docs/Deskilling%20packet.pdf 8 See Moving Essence: http://www.movingessence.net/ArtisticOverview.pdf


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experiences of working and advancing (or not) in the UK. Finally, Ozias Goodwin assisted in setting up the video sound equipment during the event. As mentioned, different methods were used for evaluating this event. The filming of the workshop allowed for reflection on the issues discussed and further dissemination for campaigning purposes. Photographs were also taken for publicity purposes and as part of the field notes; in order to film and photograph the participants, consent forms were handed out before the workshop, with only 2 out of 14 participants refusing, on the basis that they did not want to be recognised. Observation and field notes were used to record participant interactions and responses, and as a counterpoint to interviews and assessments, which were also conducted. An attitude assessment, given to each participant during the beginning of the workshop, and an interview and assessment about two months later (in December 2009), helped the researchers to understand the effects of the workshop (as an intervention) by observing differences in the participants’ responses; the assessments were designed to elicit attitudes regarding workplace relations, immigration, support, knowledge of rights---all of which were reflected in the support model components (based on the ESRC study), specifically for different levels of empowerment (personal, social, and political). These issues were also in the content of the deskilling workshop and were reflected in the packet, which focused heavily on developing both collective and self-efficacy around advancement activities.9 The post-assessment was carried out over the telephone and had added questions exploring issues of discrimination in the workplace (which arose in the workshop, and was determined by another small-scale study conducted on migrant carers to be one too) and an evaluation of the workshop. Finally, the participants’ responses were compared with those of a control group in a cohort study; a group of 13 care workers, mostly Filipinos, but also Polish, who struggled with workplace discrimination issues as well as immigration were used as a control group because of the similar traits they held to the intervention group. The control group were given one interview and one assessment---the second one being the same as the training group. By comparing and contrasting the control group’s responses with the responses of the intervention (workshop) group, it would be possible to see if attitudes could be shaped through offering education that focused on adjusting for the aforementioned issues. It should be mentioned that the control group was not in fact denied the intervention (workshop) on purpose; whilst they may not have benefited directly from the interviews, their data on discrimination was used by a reputable non-profit organisation to campaign for better employment laws amongst migrant carers.10 Lastly, a statistical consultant at Lancaster University assisted in the initial design of the attitude survey and consultant, Monika Glaz, analysed the data in this cohort study.11 With this knowledge, it would be possible to better understand how future workplace education courses could be organized to inform/assist in advocacy regarding migrant carers’ professional advancement—a topic that is little dealt with in most ESOL workplace education courses (to be discussed below). Assessments

9 See assessments at: http://www.lancs.ac.uk/fass/projects/homework/findings.htm 10 These interviews, for the non-profit agency, were conducted by the ESRC team and anonymised to protect all participants. A few of the participants volunteered to be part of a media campaign on the exploitation of migrant carers. See: http://www.guardian.co.uk/society/2009/dec/02/migrant-workers-care-older-people and http://www.oxfam.org.uk/applications/blogs/pressoffice/?p=8655 and the report at: http://www.oxfam.org.uk/resources/policy/trade/downloads/bp_ukpp_who_cares_210110.pdf 11 The cohort study analysis will be put on the web 3/10


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The assessments (attitude surveys) were given out to the participants at the beginning of the workshop to complete. They comprised 16 statements, for which participants needed to evaluate by using numbers 1-5 on the Likert scale and by expressing their views from ‘strongly disagree’ (1) to ‘strongly agree’ (5). The instructions were to use their initial feeling to answer the questions. Findings of the pre-assessment demonstrated that the group generally displayed a positive attitude towards the issues (on the assessment) and were confident in their English language skills and being able to find support from themselves and families (where applicable). After the workshop a discussion board was set up and moderated by Anna and Sondra for workshop participants. The intention was to enable participants to follow up with questions they had from the workshop and address them online and receive answers; it was not clear whether or not this had much effect on many participants since there was low and infrequent participation. However, what the post-assessment showed was that participants gave higher responses on the Likert scale towards agreeing and strongly agreeing on the Likert scale, especially on issues such as understanding the phenomenon of global deskilling, building networks of support, needing the assistance of a personal adviser, and others.12 While it is not possible to conclude that the workshop and the discussion board, in and of themselves, produced stronger answers in positive attitudes (demonstrating self-efficacy), there may be a relationship. 3. Specific Aims The purpose of organizing this workshop was two-fold: 1) to test the model of support which resulted from the an analysis of the data from Cumbria 2) to use the lessons learnt from the project in hopes of improving situations for migrant care workers all over England--ones who share similar stories with those of the interviewees in Cumbria. The model of support was based on an analysis of the support networks, strategies, and issues of the participants in the ethnographic research project conducted in Cumbria and which illustrated mechanisms that worked, and gaps in support, which were needed. According to this model, the participants in the Cumbrian project exchanged mainly emotional supports through their dense co-ethnic local networks as well as ones abroad, but there were gaps in informational, material, and educational supports that limited the degree to which they could advance. This phenomenon appeared to be linked to their personal, social, and political sense of power to make changes. The personal constitutes a sense of self-efficacy in being able to accomplish a career goal, whilst the social entails a sense of citizenship and access to, and usage of, public services. Political empowerment encompasses the resources and capability to collectively organise with other migrant carers in the same situation to campaign for better policies and laws around immigration, employment, housing, etc. These migrants, in the Cumbrian study, were bonding and bridging to personal networks and building social capital within them, but they were not often linking to other sources of support that could further advance them and assist them to make needed changes that could enhance their political empowerment. There was a question as to whether or not this issue was rurally based, or was more directly linked to their status as ‘migrant carers.’ The control and training groups demonstrated that urban-based migrant carers struggle with many of the same issues as rural ones (like the ones in Cumbria) although some of them were exacerbated such as travel problems. Therefore there was a need to fill in the gaps by linking migrant carers to other institutions where they could further exploit their skills and knowledge to professionally advance. Despite the fact that the migrant care workers, in this case, are using their resources, albeit limited, to overcome difficulties and to advance, they are

12 See pre and post assessment analysis at: http://www.lancs.ac.uk/fass/projects/homework/findings.htm (TBA 2/10)


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lacking important support to advance from the state and the community and from professional associations. Through organizing the materials for the participants of the workshop based on the gaps/needs identified from the carers in Cumbria, the event offered information and support on issues of professional advancement, personal self-efficacy, and gave the opportunity to the participants to create links with others in the group. This last issue was crucial in creating a grassroots movement to campaign for better treatment and rights, especially when linked to the two organisations represented at the workshop, Kanlungan and PNA-UK, as well as UNISON and GMB (discussed in the workshop and presented in the packets). 4. Themes From the Workshop The themes which emerged from the workshop (and which were evident in the post-interview and assessments) were: immigration issues and work/student permits, poverty, isolation, unemployment in the Philippines, the feeling of entrapment in the workplace, lack of appreciation of skills (by the government), discrimination in the workplace and a lack of knowledge regarding rights. These issues, which the participants chose to discuss through questions posed throughout the workshop and in open discussions drawn from the group, importantly, enabled the participants to realise that not being able to reach their professional aspirations in the UK was not a personal flaw. Instead they began to realise that the system heavily impacted their status and stasis, as one carer stated, “it’s like I am stagnant in one place.” Half of the participants, for example, were allowed entry in to the UK under a student route (tier 4), which allowed for little flexibility regarding work and study options in the future and provided next to no security for upward mobility, whilst the excessive requirements of obtaining sufficient marks for the IELTS examinations placed these carers (many of whom were already fluent in English) in a situation of uncertainty and potential exploitation by recruitment agencies, employers and training schools, as they strove for higher and higher scores to match the Nurse Midwifery Council’s new demands. Discrimination in the workplace was also an issue for the participants; the participants felt they needed more information on student and worker rights and how to enforce them. Additionally, insecurity in financial means positioned migrant carers in disempowering situations that alienated them from each other, for example, working many hours and shifts that left them little time to discuss these issues from across care homes. The workshop aimed to elicit some of the issues that the carers faced, especially in the private care sector (where many participants, both rural and urban, worked), and strategies and resources for trying to change them. 5. Outcomes

A number of the workshop participants appeared to feel more personally empowered by the workshop simply because they were brought together with others facing similar problems and could share and exchange information and feelings. This point was reported at the end of the workshop and in the post-assessment interview. Additionally, participants said they gained information regarding community and national organizations from the lecture (by Michael Duque) and benefited by listening to other stories of struggle and success and the discussions. The online discussion board that followed the workshop also enabled some participants to post questions in Tagalog for which Anna would answer and give suggestions, this way enhancing knowledge and the feeling of support. Finally, participants requested references from Sondra to help with their work applications, which was a direct benefit for those who needed this support.

Themes • Immigration • Work/student permits • Poverty and unemployment in

the Philippines • Feeling of entrapment • Lack of appreciation of skills • Discrimination • Lack of knowledge of rights


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The IELTS, to reiterate, was discussed as a major obstacle in gaining sufficient employment in the health professions with a score of 7 now required by most professional associations. Participants exchanged ideas about how to deal with it during the workshop. One participant stated, after the workshop was over:

‘Last night I was surfing the net [for] the IELTS test. I’m surfing for tips, how to make good in the exam. I’m really planning to take the exam, the most important thing. I’m going to taking the test again to get closer to what I want.’

6. Evaluation of workshop The workshop was successful in bringing a small group of Filipino care workers together to address some of the issues that they had in common, such as uncertainty regarding immigration status and advancing professionally as well as many other issues. The respondents appeared to feel empowered, in personal and social ways; by becoming members of a group they could identify with, and obtain and share information about support available in their communities and nationally to advance. Some of the respondents expressed an enthusiasm about continuing their professional journeys in the UK. Below are some of the responses given at the end of the workshop; encouraging was the fact that the participants asked for the next date for another workshop:

- ‘Happy that I came today, so many students, same experiences’ - ‘Rare to be gathered, really great thing, helps emotionally’ - ‘Part of the group’ - ‘Very informative’

During the post-assessment interviews, this is what some of the participants expressed regarding the value of the workshop:

- ‘It changed my view. Before my previous background I’m looking after children, but now I’m looking forward to working as a midwife in the NHS, or a health care job’ - ‘Through the workshop it opened my mind. I know there are organizations to be my support groups and there’s a lot more. I learnt also about different conditions about people, Filipinos here, different visas which working here, clearer picture that we have a good future in this country. There are lots of processes, a lot of steps, it might (not be) that easy but we can be nurse here and gives me ideas. I get the chance to talk to the president of the PNA and asked questions and they helped me. Next year I will come back as a nurse and not as a student. We came here not just to study but to work. It gives me the positive view to reach a goal. It makes me happy to work here but deep inside I have this goal and I know I can achieve this goal.’ 7. Conclusion and Further Recommendations


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Workplace education that truly advances migrant workers to new opportunities would need to be offered in the health and social care sectors. Whilst organisations like Skills for Care focuses typically on inculcating skills and advancing training for all workers in the care sector, and campaigning for more courses, little attention has been given to drawing on the skills, knowledge, and expertise (i.e., digital literacy) migrant carers in particular have, and building on them for advancement purposes; most Skills for Life curriculum focuses on passing national literacy tests that have little market value and does not lead directly to advancement in to the health professions (for example, to adaptation opportunities). The same is true for the National Vocational Qualifications (NVQ). The NVQs have been replaced by a new qualifications and credit framework, which incorporates validation principles for social care but, again, does not lead in to health care professions.13 An infrastructure is nonexistent and needed for migrant carers to move from social care directly in to health care. ESOL policies could be a bridge to migrant carers’ advancement through the formation of professional education as well as professional diasporic networks for them. However, the policies tend to focus either on general vocational education (rather than on the professions, or careers) or on citizenship education, but little else as funding declines.14 The policies also don’t explicitly develop support structures for facilitating learning amongst this population, for which little information is known. Many migrant carers in the Cumbrian study said they wanted business English, advanced level English grammar, technical writing, adaptation and IELTS courses, and other specialty health care courses. Yet ESOL policies, especially of the workplace variety, focus most on their ‘language problems’. Although studies on migrant care workers have shown that more training is needed to improve cultural adjustment in to the workplace, little attention has been paid to the quality of education and whether or not it leads to advancement for the workers.15 Moreover, workplace programmes are now under fire due to the misplaced assumption that they lead to increased productivity; a recent study showed that short-term workplace courses have had poor hard impacts with more soft outcomes such as confidence and greater educational participation amongst students. Whilst ESOL students’ improved their language scores the authors concluded that their gains were probably more attributable to outside factors. ESOL students were also found to be more highly qualified than non-ESOL populations.16 The findings of the evaluation demonstrated that workers were able to express themselves fully outside of the workplace in a context where they felt secure. An obvious way forward then would be to offer workplace classes or workshops in community centres, where employers would not be able to control the curriculum, as the literature on this

13 See for example: http://www.skillsforcare.org.uk/qualifications_and_training/qualificationsandcreditframeworkQCF/qualificationsandcreditframeworkQCF.aspx 14 Cooke, M. and Simpson, J. TheFutureofESOL?AspeculativecommentaryadecadeafterSkillsforLife.BasicSkillsBulletin,79,December2009andCooke, M. & Simpson, J. Challenging agendas in ESOL: Skills, employability and social cohesion.’ Language Issues 20/1, (19-30.) 15 Cangiano et al. (2009). Migrant Care Workers in Ageing Societies: Research Findings in the United Kingdom 16 Wolf, Alison et al (2009). Enhancing 'Skills for Life': Adult Basic Skills and Workplace Learning: Full Research Report. ESRC End of Award Report, RES-139-25-0120. Swindon: ESRC See also: http://www.esrc.ac.uk/ESRCInfoCentre/PO/releases/2009/november/literacy.aspx


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subject highlights.17 The same literature has also shown that the curriculum tends to focus on issues that are related specifically to the immediate workplace in which the training/educational course is offered, neglecting other workplaces and situations to which workers aspire. Moreover, the goals are strictly to offer Standard English language socialisation in order to increase workers’ economic productivity in the workplace with cost savings to employers as the ultimate goal. Even contextualised ESOL programmes, or ‘whole workplace approaches’ have their downsides when the focus is on participants obtaining functional skills prescribed by the workplace environment and little else. The authors in a Canadian study (Duff, Wong, & Early 2002)18, discovered that many linguistic and non-linguistic forms of communication were needed in the actual multilingual social care workplace that didn’t always correspond to the formal curriculum and monolingual pedagogy. In other words, contextualisation is not enough; a more political orientation is needed to incorporate the realities of workplaces, including discrimination and other societal barriers, or what is commonly known as the ‘hidden curriculum.’ An evaluation of an ESOL contextualised programme in a workplace of migrant social care workers by the author showed that learners already held many of the skills that the curriculum contained and the benefits they received were mainly social—they bonded with one another and created solidarity as deskilled workers, finding their voices and sharing stories and experiences that challenged their roles and value to employers. Yet their resistance to the curriculum was covert rather than overt. At the same time, the barriers that prevented them from obtaining a professional education and advancing were not dealt with in the curriculum, including the rigid managerial approaches in their workplaces that limited their time and abilities to study.19 The evaluation indicated, that participants had few if any opportunities to take courses, aside from the NVQ and other standard trainings, which were mandated. Many of the students, former health professionals, as mentioned previously, had professional dispositions, expertise and a wide range of health care skills and so brain waste in the workplace (and in society for that matter) was evident. Few workplace programmes truly help students to professionally advance through creating bridges, although several studies, focusing on migrants and refugees show promise.20 Although the workshop seemed to have individually benefited the participants, especially in terms of offering emotional and social supports, as mentioned above, it would seem that, because of its general character, it could not offer sufficient information on political empowerment such as immigrant rights—ones which were changing drastically and greatly impacted the professional trajectories of migrants and which educational or training courses, alone, may be limited in dealing with. In the future, workshops on 17 See the work of: Gallo (2004), Burt (2003), Fenwick (2007, 2008), Duff, Wong & Early (2002) in the U.S. and Canada and Roberts in England (2004) 18 Duff, P.A., Wong, P. & Early, M. (2002). Language learning for work and life: The linguistic socialisation of immigrant Canadians seeking careers in healthcare. The Canadian Modern Language Review, 57 (1): 9-57. 19 Cuban, S. (2009). “Talking was a great experience:”Gendered Communication in ESOL Workplace Education. International Review of Education. September issue, 22, 579-596. 20 See: Advising for Adaptation: A Guide to Personal AdviserMediated IAG, Careers, and Skills Adaptation Supports for Migrants and Refugees (NIACE), Best Practice in the Recruitment and Employment of Migrant Workers in the Social Care Sector in Merseyside (Liverpool Social Care Partnership, Oxfam and Migrant Workers Northwest) and Employability Pathways: An Integrated Approach and Experiences of New Migrants (University of Birmingham, Centre for Urban and Regional Studies)


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deskilling should focus more on informing migrant carers of their rights in the UK, and providing direct links to immigration and employment campaigns, as protection from unethical recruitment and retention practices dictated by the points based system, and exploitive employers and training agencies that are part of the migration care industry. The participants in the workshop attempted to advance as best as they could but they needed more information; one of the participants mentioned that she needed information on how to change her status in the UK from carer to health care professional:

‘Improve my knowledge, encourage me and motivate me to update my knowledge, wanting what interests me, my status at the moment. I want to do more but I’m still in my working visa as a carer’ It is not surprising that the participants emphasised their individual investments, as many were isolated in working environments where they could not talk openly about these issues and acquire collective support and information. Also the ‘personal responsibility’ mantra is currently promoted in the media and in neo-liberal social policies, such as the personalisation agenda, of which the carers were aware. Yet, their deskilling, they came to see, was not something they could take responsibility for, since they were unable to assert their health care knowledge by virtue of the fact that their qualifications were rendered invisible by the state. One participants said: ‘I think I need more information and training, very important for us so we can practice what we learnt, you can practice it here’ Participants confirmed the effects of immigration in blocking advancement opportunities and the need for greater political advocacy. The students in particular, were trapped in situations where they found it difficult to locate other opportunities aside from the NVQs. They wanted to pass the IELTS, and change their status from a tier 4, as well as change jobs but the cards were stacked against them. In the media, for example, students are treated first and foremost as terrorist suspects rather than qualified professionals who seek greater opportunities in a new country. The participants’ problems demonstrated the institutional obstacles and systemic conditions that block their mobility. In order to become visible, and find a collective voice, migrant carers need to mobilize so as not to be caught ‘just stagnant in one place’ as one participant expressed. There are some model union programmes that emphasise political empowerment of care workers. UNISON’s Migrant Worker’s Participation Project is a good example.21 This educational programme is linked to wider political campaigns. Recommendations that enlarge the social policies on immigrants working in social care would be to:

• Campaign for carer and senior carers’ immigration rights, with Kanlungan and other organisations such as MigranteUK and UNISON leading the way.

• Advise the Migration Advisory Committee on the situations of migrant carers and the ways they are blocked from advancing in their professions, leading to brain waste, over and beyond the Skills for Care agenda

• Assist in the grassroots organising of carers and their rights with established local agencies (CAB for example)—in information-sharing and education about their

21 See the evaluation report of the Migrant Workers Participation project at: http://www.unison.org.uk/acrobat/B4847.pdf


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employment, immigration, housing, training, education, and social rights in general

• Make links with advocacy organisations in other countries to assist migrants with decision-making, risk-assessments, and other important issues that affect their livelihood in new countries

• Protest the Points Based System and the ways it discriminates against migrants. For example, join ‘Students not Suspects’ at: http://studentsnotsuspects.blogspot.com/ and challenge the new (2010) tier 4 regulations that restrain students from entering the UK and receiving additional supports whilst in it

• Support local councils to bring migrant carers together to break their isolation and gain advocacy resources through local communities

• Allow appeals for students in immigration and employment cases • Thorough investigations and punitive actions for training agencies and colleges

that are part of quangos with recruitment agencies that lure migrants on student routes to pay exorbitant fees and then close down and reopen somewhere else (‘Phoenix syndrome’—see Balita Pinoy)

• Use the Gangmasters License to enforce employment laws and improve them (see Oxfam report footnoted here, Who Cares?)

• Campaign to lower the IELTS score, or allow more flexibility with the score, to enable more migrant carers to achieve a passing rate through the NMC (currently it is a 7, raised from a 6.5)

• Investigate unethical recruitment practices that bring qualified professionals to England to work in low-paying and low-skilled positions

• Removal of obstacles to obtain working visas and more fluid transfer to levels of the PBS, from tier 4 to tier 2, as well as leave to remain and citizenship

• Collaborate with organisations like the Overseas Nurses Network, UNISON, GMB, Public Services International and other agencies which advocate for migrant health care workers

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