Can the NHS stick to its commitment to ethical recruitment?

Amid global healthcare staffing shortages, the NHS is relying more heavily on overseas nurses

Amid global healthcare staffing shortages and a UK nurse staffing deficit, the NHS is relying more heavily on recruitment of overseas nurses

Illustration showing arrivals at an airport, with an arrivals board showing a breakdown of nurse numbers coming from different countries
Picture: iStock

The NHS has often looked to overseas nurses to help fill UK staffing gaps.

But what effect does this have on nations that can ill afford to lose vital healthcare staff?

As the government proposes that international recruitment be stepped up ‘significantly’ to help plug a 43,000 shortfall of nurses in England, nursing experts have renewed calls for employers to take an ethical approach to international recruitment.

Staff shortages and Brexit: why overseas recruitment matters to your NHS workplace 

The nursing shortage in England is the ‘most urgent challenge’ facing the NHS workforce, according to the Interim NHS People Plan, which sets out how the health service will recruit and retain staff.

The plan has a target to increase the nursing workforce in England by 40,000 over the next five years, by targeting nurse education, return-to-practice programmes and investing in continuing professional development.

But these measures are no quick fix, so the plan also includes a drive to ‘increase international recruitment significantly to secure rapid increases in supply’.


Nurses and midwives were on the NMC register in March 2019.

Source: NMC

Earlier this year, health and social care secretary Matt Hancock called for a ‘new Windrush generation’ to help fill staffing gaps in the NHS.

Speaking at the launch of the Interim NHS People Plan, Mr Hancock spoke directly to overseas recruits: ‘To that nurse I say: we welcome you, we need you, we want you to come and help us build an NHS that’s fit for the future.’

This global focus comes as the number of nurses from the European Economic Area (EEA) joining the Nursing and Midwifery Council (NMC) register dwindles.

Just 968 nurses and midwives have joined in 2018-19, down from 9,389 in 2015-16, before the Brexit referendum.

How many international nurses work in the UK?

As of March 2019, 73,308 overseas nurses and midwives were on the NMC register, accounting for about one in ten of the total nursing and midwifery workforce.

Table showing nationality of nurses and health visitors working in hospital and community services in England as of March 2019
Nationality of nurses and health visitors
working in hospital and community services
in England as of March 2019
Source: House of Commons briefing paper

While the Interim NHS People Plan stopped short of setting a specific target, an earlier leaked version included plans to recruit 5,000 international nurses a year for the next five years.

Why international recruitment of healthcare staff can be problematic

Relying on international recruitment as a short-term solution to the UK’s nursing supply has raised concerns from health leaders about undermining developing countries.

The fear is that international recruitment could have a detrimental effect on low and middle-income countries, particularly in Africa and Asia, which are facing shortages in their own health workforces.

International Council of Nurses (ICN) chief executive Howard Catton says the UK should remember that it is not alone in its shortage of nurses. 

‘There is a projected global shortage of nine million nurses by 2030,’ he says. ‘That is a significant figure. To put that into context, the current total number of nurses and midwives around the world is about 20 million.

‘Many countries around the world face big healthcare challenges and we are not going to tackle any of them without investment in the health workforce.’

Howard Catton: 'The UK is not alone
in its shortages of nurses'

Therefore, overseas recruitment must be done sensitively, especially in places that can least afford to lose nurses, he says.

He says international recruitment must always be carried out transparently, with consideration of the impact on the country being targeted and its ability to develop or sustain its own health services. 

What rules should NHS recruiters abide by?

In the UK, all healthcare employers are strongly advised to adhere to a code of practice for international recruitment (see box below), which sets out how recruitment should be carried out, and the training and English language skills required of international staff. 

NHS Employers manages a list of commercial recruitment agencies that adhere to the UK code of practice, while the Department of Health and Social Care (DH) and the Department for International Development have drawn up a list of 152 nations that should not be targeted by NHS recruiters, due to their economic status and current numbers of healthcare professionals.


Nurses from the European Economic Area were on the NMC register in March 2019.

Source: NMC

Jamaica, South Africa, Ghana, Nigeria, Uganda, Saudi Arabia and four Indian states all feature on the list.

Yet a recent report by the Tropical Health and Education Trust (THET), based on a 2018 study, revealed that of the 15 countries NHS staff are most commonly recruited from, seven are low- or middle-income countries.

Effects of active recruitment in low- and middle-income countries

‘The UK is also increasingly open to criticism for the impact its recruitment is having on low- and middle-income countries,’ the report warned.

‘Not only do we risk exacerbating inequality and poor health outcomes in low- and middle-income countries, we risk damaging our reputation as a country that is quite rightly praised for the generosity of the support it provides.

‘It is vital that we position ourselves as a trusted partner to these national governments.’

How does the NHS recruit ethically?

A UK-wide Code of Practice for the International Recruitment of Healthcare Professionals, overseen by the Department of Health and Social Care has been in place since 2004 to ensure ethical recruitment practices in the NHS.

Though it is not legally binding, all healthcare organisations are strongly advised to adhere to the code.

Key points of the code include:

  • International recruitment should not compromise the healthcare systems of developing countries. Developing countries should not be targeted for recruitment, unless there is an explicit government-to-government agreement
  • Any recruitment agency that wishes to supply the NHS must comply with the code
  • International healthcare professionals will have a level of knowledge and proficiency comparable to that expected of someone trained in the UK
  • Recruits will demonstrate a level of English language proficiency needed for safe and skilled communication with patients, clients, carers and colleagues
  • International healthcare professionals will have equitable support and access to further education, training and continuing professional development compared with other employees


THET is concerned that NHS trusts may be using agencies that are not on the NHS Employers approved list and which may recruit from countries that are supposed to be protected.

Meanwhile, Mr Catton says codes of practice might not have enough ‘teeth’: ‘If you have a code but people aren’t compliant, what are the consequences and penalties?’

Earn, learn and return: how the NHS can upskill the global nursing workforce

Salford University chair in global social justice Louise Ackers was on the steering group for the THET report, and has worked for the past decade in health systems change in Uganda.

Professor Ackers says there are schemes designed to bring nurses and doctors to the UK from countries with low resources, which are intended to be mutually beneficial to both countries.

‘If we bring young nurses over from Jamaica, India or Uganda, say for three years, there is a high chance these nurses will find a partner, settle in the UK and not want to leave'

Louise Ackers, Salford University chair in global social justice

The UK recruits overseas nurses to work in the NHS and, in exchange, the nurses are trained and enriched with additional skills and knowledge to take to their own countries. 

Such schemes include the Health Education England (HEE) Global Learner’s Programme – billed as an ‘earn, learn and return’ scheme – which was launched in 2018.

This programme involves agreements between the UK government and several middle-income countries, including states in India such as Kerala, St Vincent and the Grenadines, and Jamaica.

Agreements with more countries, including Pakistan, are in the pipeline. 


Nurses on the NMC register in March 2019 were from outside the EEA 

Source: NMC

HEE says 1,700 nurses have applied to join the programme so far and 770 have been appointed. 

Of these, 600 are undertaking post-appointment checks, which include NMC registration and visa applications, and 170 are now working in the NHS.

HEE plans to expand the programme and bring in 1,500 nurses next year.

Ethical dilemmas behind global recruitment schemes

Yet even these government-mandated schemes, which are a product of active collaboration with other countries, are viewed as problematic by some.

Louise Ackers
Louise Ackers: ‘Bringing people here to train
won't solve problems in their own country’

For one thing, Jamaica, Pakistan, and St Vincent and Grenadines are all on the World Health Organization (WHO) list of countries where active recruitment is discouraged. 

Beyond this, there are other aspects of these schemes that pose ethical dilemmas, suggests Professor Ackers.

‘If we bring young nurses over from Jamaica, India or Uganda, say for three years, there is a high chance these nurses will find a partner, maybe have a baby, settle in the UK and not want to leave. Sending them back would raise real ethical issues.

‘On another level, I have doubts about how beneficial the training aspect is to low-resource settings. I don’t think the main problem is that their nurses are not skilled enough, and in ten years working in Uganda, I can tell you that isn’t the problem. 

‘The main problem is to do with resource management. There are an awful lot of nurses in Uganda with a huge amount of skills, but they are unable to use them on the ground.’

New skills cannot always be transferred to a setting with poor resources 

Professor Ackers uses the example of infection prevention and control: the theory may be difficult to put into practice when working in an environment with no running water, hand gel or towels. 

‘Bringing people here to train is not going to solve problems to do with how resources are being managed in their own country – one nurse on a ward might have 20 patients and even with training won’t have time to move between them.

‘It is easy to fetishise training as an answer, there is an assumption we have in the West when we go to low-resource settings that the people there don’t know what to do.’

An HEE spokesperson told Nursing Standard: 'It’s important to us that anything related to recruitment in countries on the WHO and NHS lists meets the highest ethical standards.

Co-development and partnerships may improve ethical recruitment

‘This means consistently co-developing proposals with partner governments, relevant professional bodies, and members of the profession itself. 

‘Co-development ensures any programme meets the needs of national strategies and ensures that participants who return are returning to roles that recognise their experience and support them to put their learning into practice.’

A DH spokesperson said the government is committed to supporting greater international recruitment as part of the Interim NHS People Plan.  

‘We have comprehensive guidance for recruiters and we work closely with WHO on ethically recruiting healthcare professionals from overseas,’ the spokesperson said.

‘These schemes are in line with its code of practice and in agreement with other governments.’

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