Guidance

Code of practice for the international recruitment of health and social care personnel in England

Updated 23 March 2023

Foreword

We are pleased to introduce the revised code of practice for recruiting internationally for health and social care organisations in England.

With a projected global shortage of 10 million health workers to achieve universal health coverage in low and lower-middle income countries by 2030, we remain committed to be a force for good in the world, and support better health and care both within and beyond our shores.

We recognise the important role that international health and care workers play in health and care service delivery in the UK and we are committed to ensuring that we recruit from overseas in an ethically responsible manner.

Heath and social care organisations in England do not actively recruit from those countries the World Health Organization (WHO) recognise as having the most pressing health and care workforce-related challenges unless there is government to government agreement to support managed recruitment activities. Through effective bilateral work - such as our memorandums of understanding with the governments of India, Kenya, Malaysia, Nepal, the Philippines and Sri Lanka - we are working in partnership to support well managed migration pathways that deliver benefits to the NHS, the health or care professionals, and the sending country.

We are committed to regularly updating the code. In this edition, you will see that we have responded to concerns that have arisen over the last year, including:

• strengthening the best practice benchmarks to ensure fairness and consistency in employment contracts, and set out principles on the use of repayment clauses in employment contracts
• setting out the routes of escalation for concerns about exploitative recruitment or employment practices and breaches of the code
• providing more clarity on how the code applies to different international recruitment models
• introducing a knowledge test for recruiting organisations applying to be on the ethical recruiters list
• expanding the scenario examples

In actively addressing emerging issues of concern we aim to maintain the highest ethical standards in all international recruitment activity undertaken in the UK.

Maria Caulfield MP, Minister of State for Health, Department of Health and Social Care

Amanda Milling MP, Minister of State (Minister for Asia and the Middle East), Foreign Commonwealth and Development Office

Definitions

Active international recruitment

‘Active international recruitment’ in the code is defined as the process by which UK health and social care employers (including local authorities), contracting bodies, recruitment organisations, agencies, collaborations and sub-contractors target individuals to market UK employment opportunities, with the intention of recruiting to a role in the UK health or social care sector. It includes both physical or virtual targeting, and whether or not these actions lead to substantive employment.

This can include (but is not limited to):

• advertising to candidates through any medium
• incentivisation activities such as referral bonus schemes
• referring candidates to specific vacancies in the UK in return for a fee from the employing organisation - it is illegal under section 6(1) of the Employment Agencies Act 1973 for recruitment organisations of any type to charge fees to the individual applicant for job-finding services

The only exception to this definition is where a candidate has already been appointed by a UK employer following an independent direct application and selection without the support of a recruitment organisation, agency or collaboration (defined below).

In this case, if required, these organisations can support and facilitate the employee’s passage to the UK. In such cases, it is the responsibility of the recruitment organisation, agency or collaboration, if challenged, to provide evidence that the services they are providing are permitted under this exception.

Direct application

For the purpose of this code of practice, a ‘direct application’ is when an individual makes an application directly and on their own behalf to an employing organising. Direct applications do not use a third party, such as a recruitment organisation, agency or collaboration.

Individual health and social care employers may consider direct applications from individuals who are resident in countries on the WHO Health Workforce Support and Safeguards List 2023^{[footnote 1]} (see ‘Annex A: red and amber list countries’ below) if they have made a direct application to a vacancy at their organisation.

A direct application can only be made in response to a vacancy that is hosted by, and recruited to, the same sponsoring organisation.

Resident

For the purpose of this code of practice, ‘resident’ refers to the country an individual is living in when they apply for a health or social care job.

The rules on active recruitment and direct applications are based on the country within which an individual is resident when they apply for a health or social care job, rather than the nationality of the individual or their original country of training.

Employment agency

The term ‘employment agency’ or ‘employment agencies’ is used to describe a business that recruits candidates for vacant positions - permanent or temporary - for health and social care employers in need of personnel. This includes the statutory definition set out in section 13(2) of the Employment Agencies Act 1973 as:

a business (whether or not carried on with a view to profit and whether or not carried on in conjunction with any other business) providing services (whether by the provision of information or otherwise) for the purpose of finding workers employment with employers or of supplying employers with workers for employment by them.

Recruitment organisation

For the purpose of this code of practice, a ‘recruitment organisation’ is an organisation that recruits candidates to vacant positions - permanent or temporary - on behalf of a health or social care employer, whether or not it is on a commercial basis.

Recruitment organisations come under the statutory definition of ‘employment agency’ set out in section 13 (2) of the Employment Agencies Act 1973.

Recruitment collaboration

For the purpose of this code of practice, a ‘recruitment collaboration’ or ‘collaboration’ is a group of organisations that have partnered together to pool resources into a central system to recruit candidates for vacant positions within that collaboration, whether or not it is on a commercial basis.

Collaborations also come under the statutory definition of ‘employment agency’ set out in section 13 (2) of the Employment Agencies Act 1973.

Employer

For the purpose of this code of practice, ‘employer’ means the person or organisation by whom an employee or worker is (or was) employed.

Contracting bodies

For the purpose of this code of practice,’ contracting bodies’ are health or social care providers that contract with health and social care personnel to provide a service, rather than employing them directly. For example, general practitioners who are not salaried may be contracted by NHS England, rather than employed.

Aims and objectives

Aims

This code of practice aims to:

• promote high standards of practice in the ethical international recruitment and employment of health and social care personnel, and ensure all international recruitment is conducted in accordance with internationally agreed principles of transparency and fairness
• protect and promote health and social care system sustainability through international co-operation by ensuring safeguards and support for countries with the most pressing health and social care workforce challenges

Objectives

This code of practice has 4 objectives:

1. To set out principles and best practice benchmarks to be adhered to by all employers - public and independent, contracting bodies, recruiting organisations, agencies and collaborations - when recruiting international health and social care personnel. This will ensure recruitment is undertaken in an ethical, managed and mutually beneficial way, in line with advice from the WHO.
2. To prevent active recruitment to the UK from countries on the WHO Health Workforce Support and Safeguards List 2023 (see ‘Annex A: red and amber list countries’ below) unless there is a government-to-government agreement, which supports managed recruitment activities (see the ‘Government-to-government partnership agreements’ section below). These countries face the most pressing health workforce challenges related to universal health coverage (UHC).
3. To set out the UK government’s approach to supporting international health and social care systems and workforce, and efforts to achieve UHC and the UN sustainable development goals, alongside safeguards on active recruitment from countries with the greatest health workforce vulnerability.
4. To provide reassurance to international personnel that employment with the NHS, local authorities, and other health and social care organisations will offer high standards of induction and support while they work in the UK.

Scope

There are 3 elements to the code of practice:

• the code of practice
• the red and amber country list (see Annex A)
• the ethical recruiters list (see the ‘Ethical recruiters list’ section below)

England and the devolved administrations

The policy for the code of practice for international recruitment of health and social care personnel in the UK is set out in this document.

Each of the UK’s 4 nations’ devolved administrations adheres to the aims, objectives, guiding principles and best practice benchmarks of the code of practice, but holds its own code of practice to reflect the different organisational structures in each nation.

This is the code of practice for international recruitment in England.

Remit of the code of practice

The code of practice applies to the appointment of all international health and social care personnel in the UK, including all permanent, temporary and locum staff in clinical and non-clinical settings. This includes but is not limited to:

• allied health professionals
• care workers
• dentists
• doctors
• healthcare scientists
• medical staff
• midwives
• nursing staff
• residential and domiciliary care workers
• social workers
• support staff

The following organisations must adhere to the code of practice when undertaking international recruitment activity to appoint health and social care personnel:

• all UK health and social care employing organisations (including local authority and integrated care systems), both public and independent:
  • NHS and social care commissioners should ensure that there is compliance when they are setting up local contracts with independent providers
  • where national contracts are signed with the independent sector to increase capacity in the NHS or social care sector, compliance with the code of practice is a contractual obligation
• any recruitment organisation, agency, or collaboration that wishes to supply health and social care personnel to the NHS, local authorities, social care organisations, or any other UK health and social care provider. These organisations should appear on the ethical recruiters list
• any organisation that is employing or supplying health or social care personnel, on a temporary basis or permanent basis, to be deployed for the provision of a service in health and social care

Training programmes

Appointment of healthcare professionals onto postgraduate training programmes listed at Annex C fall outside the scope of the code of practice.

Roles and responsibilities in relation to the code of practice

Department of Health and Social Care

Works with the devolved administrations to set the policy for the code of practice.

Leads on bilateral discussions on the health and care workforce and the negotiation and implementation of government-to-government agreements.

Maintains stakeholder relations with the WHO on international recruitment matters including exchange of information and reporting.

Responds to complaints or other information about the code of practice and any breaches, in conjunction with NHS Employers.

NHS Employers

Manages and hosts the ethical recruiters list of recruiting organisations that adhere to the code of practice to help health and social care employers with their selection process.

Hosts and updates information about the code of practice and the red and amber country list on its website and undertakes communications activity to promote the code of practice.

Provides a dedicated advice and support service to health and care organisations to help them to follow the guiding principles of the code of practice in all their recruitment activities.

Provides a mechanism for stakeholders across the system to promote the code of practice, assess activity and, if necessary, challenge poor practice with employers, recruitment organisations, agencies and collaborations.

Undertakes routine checks on the compliance of a recruitment organisation, agency or collaboration with the code, and responds to complaints or other information with regard to breaches of the code, and takes necessary action as set out in the process for code contraveners at Annex D below.

Local health and social care employers (NHS, local authority, integrated care systems and independent or private sector employing organisations)

Recruit international health and social care personnel in line with the code of practice.

Form a comprehensive plan for induction, pastoral and professional support. This should include preparing their own workforces and workplaces, and ensure international migrants are signposted to appropriate organisations, including the relevant professional body and regulator, for further support, advice and guidance.

Should use recruitment organisations, agencies, or collaborations on the ethical recruiters list that operate in accordance with the code of practice. Although the ethical recruiters list is maintained by NHS Employers, the list should be used by all health and social care organisations engaged in international recruitment, both in the public and independent sectors.

Recruitment organisations, agencies and collaborations

Provide international recruitment services to health and social care employers wishing to employ health and social care personnel from countries outside the UK.

Should appear on the ethical recruiters list and operate in accordance with the code of practice. The list is maintained by NHS Employers.

Should follow the relevant best practice benchmarks in all recruitment practices and maintain their duties with respect to the code of practice. The relevant recruitment lead within each organisation must:

• ensure their contact details are kept up to date on the ethical recruiters list
• submit timely data on recruitment activity when requested by NHS Employers or UK state regulators
• ensure all staff involved in the recruitment of health and social care personnel are aware of and adhere to the code of practice

Health Education England

Establishes institutional partnerships and education exchange schemes, as agreed by the Cross-Whitehall International Recruitment Steering Group, to ensure recruitment is managed and mutual benefits are derived.

Cross-Whitehall International Recruitment Steering Group

Chaired by the Department of Health and Social Care (DHSC) with membership from:

• Foreign, Commonwealth and Development Office (FCDO)
• Department for International Trade (DIT)
• Home Office (HO)
• Department for Business, Energy and Industrial Strategy (BEIS)
• Department for Levelling up, Housing and Communities (DLUHC)
• Health Education England (HEE)
• NHS England (NHSE)
• NHS Employers
• Department of Health for Northern Ireland
• Welsh Government’s Department of Health and Social Services
• Scottish Government

Provides national policy oversight on implementation of the code of practice and collaboration on international recruitment supply activity, ensuring ethical practices across health and social care.

Monitors migrant flows and impact.

Provides oversight of diplomatic and development relationships related to international recruitment and training with partner countries.

Approves any updates and changes to the code of practice in consultation with the WHO. The code of practice will be reviewed annually unless otherwise stated.

World Health Organization

Provides guidance through the WHO Global Code of Practice on the International Recruitment of Health Personnel and, in collaboration with its member states, periodically reviews the WHO Global Code of Practice’s relevance and effectiveness. 

Monitors implementation of the Global Code of Practice by member states and reports on this to the World Health Assembly every 3 years.

Manages, as recommended by its member states, a list of the countries with the most pressing UHC-related health workforce challenges, which is subject to periodic review.

Guiding principles

The 5 guiding principles that underpin the code of practice are set out in this section.

1. International migration of health and social care personnel can contribute to the development and strengthening of health and social care systems to both countries of origin and destination countries if recruitment is managed properly

See the WHO Global Code of Practice on the International Recruitment of Health Personnel.

International recruitment (migrant workers, moving temporarily or permanently for employment) has made a substantial contribution to the delivery of health and social care services across the world, and will continue to play a vital role in the future.

International recruitment is one part of the UK’s Long Term Plan to ensure the NHS has the human resources it needs. Work is underway to support greater numbers of homegrown health and social care staff through training more staff, better retention and encouraging staff who have left to return, to achieve a sustainable health and social care workforce responsive to the UK population’s needs.

Well managed migration ensures that the health and social care systems of both the origin and destination country derive benefits as set out in the ‘Health workforce development and health systems sustainability’ section below.

Good practice, ethical standards, respect for rights and value for money should underpin all international recruitment activities.

Compliance with this code of practice ensures that the international recruitment of health and social care personnel minimises harm to the health and care systems of countries of origin, while safeguarding the rights of health and social care personnel to migrate, and ensures fair and just recruitment and employment practices.

2. Opportunities exist for individuals, organisations, and the health and care systems to train, educate and enhance their clinical practice

International recruits gain from opportunities to develop their skills and, in turn, advance their own careers and economic opportunities. International health and social care personnel bring new and valuable perspectives and learning that enables the transfer of experience and the sharing of ideas.

Collaborative partnerships for training and continuous learning can bring benefits for individuals, organisations and health and care systems of the UK and the country of origin.

3. There must be no active international recruitment from countries on the red list, unless there is an explicit government-to-government agreement to support managed recruitment activities that are undertaken strictly in compliance with the terms of that agreement

Skilled and experienced health and social care personnel are a valuable resource to any country. For some low and lower middle-income countries, increasing the scale of health and social care worker migration threatens the achievement of national health and social care goals.

Countries on the red list must not be targeted for international recruitment, unless there is a government-to-government agreement negotiated and signed by the DHSC on behalf of the UK government and recruitment is consistent with the provisions of the agreement. Where recruitment is restricted solely to the terms of the government-to-government agreement, the country will appear on the amber list. Such agreements can be designed to help regulate or mitigate against any negative impacts of health or care migrant flows to the UK. All agreements will take WHO guidance on the development of bilateral agreements into account.

Government-to-government agreements must take steps to ensure that migration to the UK does not exacerbate existing health and social care workforce shortages in the country of origin, and the country of origin derives proportional benefits as set out in the ‘Health workforce development and health systems sustainability’ section below.

Consideration of evidence will form part of decision-making on agreements, and will include:

• a health labour market analysis for red-listed countries
• engagement with health sector stakeholders in countries of origin
• consultation with the WHO

Notification to the WHO will be made through the global WHO code of practice monitoring processes. Further detail on government-to-government agreements and case studies are available in the ‘Health workforce development and health systems sustainability’ section below.

The UK recognises the importance of providing support for health and care system strengthening to countries facing severe health workforce vulnerabilities. Our health systems partnerships increase the capacity of the health and social care workforce, and support health and social care systems improvements - examples of which are provided in the ‘Health workforce development and health systems sustainability’ section below. Where the UK and a partner country have agreed special recruitment arrangements, a government-to-government agreement sets out specific parameters of support that have been mutually agreed upon.

This does not prevent individual health and social care personnel resident in countries on the red and amber country list from making a direct application on their own behalf to a health and social care employer without using a third party, such as a recruitment organisation, agency or collaboration.

4. Recruitment of international health and social care personnel is monitored and reported on to the Cross-Whitehall International Recruitment Steering Group and the WHO

DHSC will continue to monitor data on health and social care international workforce flows and report to the Cross-Whitehall International Recruitment Steering Group as appropriate. Information will be analysed to understand where recruits have come from, with a particular focus on low and lower middle-income countries, and fragile and conflict-affected states.

Through the steering group, relevant information will be shared with the UK’s FCDO diplomacy network. DHSC also shares reports with the WHO as part of the UK’s global commitment to uphold the principles of the WHO Global Code of Practice. This information directly strengthens understanding of and co-operation on global mobility patterns.

Where trends indicate increases in recruitment from low and lower middle-income countries or fragile and conflict-affected states, further work may take place in partnership with the FCDO to understand the causes and impact of this activity.

5. International health and social care personnel will have the same legal rights and responsibilities as domestically trained staff in all terms of employment and conditions of work. They will have the same access to further education and training, and continuous professional development

All staff, regardless of country of origin or training, have the same legal protections within the workplace.

Relevant employment legislation applies as long as the employee holds a valid permit or appropriate visa.

All health and social care employees will be employed on the same terms and conditions of employment as other domestically trained employees.

Employment legislation protects and guides the conditions of service for all employees, regardless of their country of origin or training.

Health and social care employees must meet and maintain requirements for continued professional regulation.

The opportunity to enhance skills and experience are important features that underpin international health and social care mobility.

International workers employed within the NHS, social care sector, and other health and care organisations that comply with the code of practice will receive high standards of induction and support in their new career equal to other employees.

Best practice benchmarks

It is expected that all health and social care sector employing organisations, recruitment organisations, agencies, collaborations and contracting bodies will comply with the code of practice and will apply the best practice benchmarks set out in this section.

These best practice benchmarks should be read in conjunction with NHS Employers’ international recruitment toolkit. The toolkit is designed to encourage and enable supportive practices and processes for the recruitment of international staff across a wide range of professions.

There is no active recruitment of health and social care personnel from countries on the red list

The red list is drawn from the WHO Health Workforce Support and Safeguards List 2023. No active recruitment will be undertaken from countries on the red list by:

• UK health or social care employing organisations
• recruitment organisations
• agencies
• collaborations
• contracting bodies
• any international agency sub-contracted to that organisation in the UK

Government-to-government agreements may be signed by the UK government with partner countries to support managed recruitment activities and ensure they are undertaken in compliance with the terms of that agreement.

When a government-to-government agreement is signed with a red-listed country, it is moved to the amber country list.

The red and amber country list is available in Annex A below and on the NHS Employers website. The WHO Health Workforce Support and Safeguards List 2023 is updated by WHO every 3 years, or sooner if required. The red and amber country list may also be updated on an ad hoc basis - for example, in response to new government-to-government agreements being signed.

Employers, recruitment organisations, agencies, collaborations and contracting bodies should check the country list for updates before undertaking any international recruitment.

Health and social care employers may consider direct applications from an individual resident in a country on the red list if that individual is making an application on their own behalf and not using a third party, such as a recruitment organisation, agency or collaboration.

In determining the country that an international candidate is applying from, health and social care employers should consider the applicant’s country of residence and not their nationality.

When considering how to handle direct applications from red or amber list countries, employers should be mindful of their responsibilities under the Equality Act 2010 to treat applicants equitably.

All international recruitment by health and social care employers, agencies, recruitment organisations, collaborations and contracting bodies will follow good recruitment practice and demonstrate a sound ethical approach

Health and social care employers and contracting bodies, when using a recruitment organisation, agency or collaboration, should only contract organisations that comply with the code of practice. A list of those agencies, recruitment organisations and recruitment collaborations - known as the ethical recruiters list - can be found on the NHS Employers website.

International recruitment frameworks - including Workforce Alliance and Healthtrust Europe - ensure compliance with NHS pre-employment standards and grant access to a wide range of experienced international recruitment organisations, all of which operate at a high standard of quality.

The employer will be fully involved in the recruitment process.

All international recruitment will be sensitive to local health and social care needs so that international recruitment from any country should not weaken local health and social care provision.

A recruitment organisation, agency or collaboration will be removed from the ethical recruiters list if, following an investigation, it is found to be breaching the principles of the code of practice. This process is set out in Annex D.

A prerequisite of being on any international recruitment framework is to be on the ethical recruiters list. Any agency that is removed from the ethical recruiters list will be removed from the international recruitment framework.

International health and social care personnel will not be charged fees for recruitment services in relation to gaining employment in the UK

It is illegal under section 6(1) of the Employment Agencies Act 1973 for any recruitment organisation, agency or collaboration based in Great Britain to charge a fee for providing a work-finding service to any person seeking a job. Any such organisation charging fees to an individual for a work-finding service will be reported to the Employment Agency Standards Inspectorate (EAS) using the contact details provided in Annex E.

The EAS has a Great Britain-wide remit - however, any concerns relating to fees or conduct of non-Great Britain-based agencies can also be reported to the EAS using the contact details provided at Annex E.

Any costs incurred by a recruitment organisation, agency or collaboration will be incorporated into the negotiated fee charged to employers and contracting bodies. At their discretion, employers may meet the visa fees a candidate may incur to exit their home country or enter the UK or any professional registration fees.

Employers and contracting bodies will not contract recruitment organisations, agencies or collaborations that charge fees to candidates wishing to be considered for recruitment to the UK. Any recruiting organisation that sub-contract to agencies outside the UK must not use non-UK agencies that charge applicants fees.

All international health and social care personnel will have the appropriate level of English language to enable them to undertake their role effectively and to meet registration requirements of the appropriate regulatory body

If a regulatory body requires an assessed competency in English language for the applicant to be eligible for registration, this should be achieved, where possible, prior to selection interview.

All potential employees will be able to communicate effectively in English to practise safely, and to enable them to communicate appropriately with patients, clients, carers, family and colleagues.

It is lawful for employers, contracting bodies and professional regulators to apply conditions relating to a candidate’s linguistic ability because of the nature of the post to be filled.

The Code of Practice on the English language requirements for public sector workers aims to help public authorities to meet their obligations under Part 7 of the Immigration Act 2016.

All appointed international health and social care personnel must be registered with the appropriate UK regulatory body

Candidates should be advised of the requirements to practise in the UK, and how to obtain relevant professional registration and be signposted to the relevant regulatory organisation. It is the responsibility of the individual recruit to progress the registration process, with support from the relevant regulatory body. Employers and contracting bodies should continue to communicate with their recruit to make sure they are clear about the process and support them to avoid unnecessary delays.

Candidates should be strongly advised to commence the registration process in good time and, if possible, before applying for a post. If a candidate does not have registration at the time of appointment, employers and contracting bodies should factor this in when agreeing contracts and start dates. Employers and contracting bodies should consider approaching the appropriate regulator early in the recruitment process. Early insight on upcoming demand for registration supports the professional regulator to manage capacity.

Employers and contracting bodies must ensure that confirmation of professional registration or notification of any stipulated period of supervised practice is received prior to the candidate taking up the post, where this is stipulated by the regulatory body.

Evidence of duration of any supervised practice required by a regulatory body should be confirmed to the employer where appropriate.

Candidates should be advised of the role of membership representative bodies and the professional support, medical defence and representation they provide.

All international health and social care personnel required to undertake supervised practice by a regulatory body should be fully supported in this process

To enable the health or social care personnel to provide safe and effective care, they will be appropriately supervised and the employer will ensure the workplace supports all staff to demonstrate their competence.

The health or social care personnel will not be charged for any part of supervised practice, and will be employed on the same terms and conditions of employment as other trained employees. Employers and contracting bodies are encouraged to recognise previous relevant experience.

Health or social care personnel will have appropriate opportunities to reach the required standard for UK registration, and will be objectively and fairly assessed.

All international health and social care personnel will undergo the normal occupational health assessment prior to commencing employment

All employment offers will be made subject to occupational health clearance.

Occupational health assessment information is confidential and will only be divulged to the relevant occupational health bodies, or as permitted or required by law.

Successful applicants will be informed of guidelines issued by the relevant regulatory body related to serious communicable diseases.

Employers and contracting bodies will ensure thorough, sensitive, individual risk assessments are conducted for all new international migrants before they work in a clinical environment.

All international health and social care personnel will have appropriate pre-employment checks including those for any criminal convictions or cautions as required by UK legislation

Employers and contracting bodies must carry out pre-employment checks seeking to verify that an individual meets the preconditions of the role they are applying for.

There are 6 NHS employment check standards that outline the type and level of checks employers and contracting bodies must carry out before recruiting staff. Guidance on each check is available on the NHS Employers website.

All health and care providers registering or registered with the Care Quality Commission (CQC) must meet regulation 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This requires providers to make available to the CQC the information set out in schedule 3, which sets out 8 categories of information required to be kept by providers about all persons employed in the provision of services. Applicants will be informed that any individual who has made a false declaration may be dismissed from their post.

All appointments should provide references from current and previous employers and/or education providers.

All personnel will be required to complete a statement informing the employer of any criminal conviction, cautions or binding over. Employers and contracting bodies should undertake the necessary checks for criminal convictions in keeping with that country’s justice system and requirements in the UK.

All international health and social care personnel offered a post will have a valid visa before entry to the UK

Personnel offered a post in the UK must have an appropriate visa that allows them to undertake employment or training.

The cost of any visa may be met by the employer at their discretion.

Health and social care employers, recruitment organisations, agencies, collaborations and contracting bodies should share information about the immigration system and visa application process with candidates as early as possible in the process.

This should include the rules on bringing dependents to the UK, and in particular the rules around sole responsibility and adult dependency, to ensure the candidate is clear about:

• the process
• what evidence they will be expected to provide
• the ramifications if their application is unsuccessful

Appropriate information about the post being applied for will be made available so international health and social care personnel can make an informed decision on whether to accept a job offer

Health and social care personnel will be provided with all the relevant information about the post they have applied for, prior to acceptance, to enable an informed decision on whether they wish to accept a job offer.

Guidance on applying for health and social jobs in the UK from abroad must be made available to a candidate at the earliest opportunity.

Information provided should include:

• the job description and person specification
• the terms and conditions of engagement, including but not limited to:
  • place of work
  • grading structure
  • remuneration and intervals when remuneration is paid
  • days and hours of work
  • annual leave
  • sick pay entitlement
  • notice periods
  • maternity or paternity pay and entitlement
  • details of eligibility and support for training (including mandatory training and development)
  • pension
  • any repayment clause
• the visa application process
• the visa application process for dependents, and an understanding of current restrictive immigration rules, including the rules on sole responsibility and adult dependency
• professional registration processes (contact details for each of the professional regulators and links to further information are provided at Annex F)
• location of job and indication of likely living costs in that area
• access to health services for the candidate and, if relevant, their family
• proximity of relevant religious institutions, if applicable
• access to education for family members
• information on national associations, diaspora groups and communities, and relevant trade unions for further support
• information on this code of practice and how to raise a complaint if they feel any part of this code is breached during the recruitment process, as set out in Annex D below

Health and social care employing organisations and contracting bodies will liaise with recruitment organisations, agencies and collaborations to ensure the information is provided to the candidate so they can take a fully informed decision on whether to accept a job offer.

Recruiters, contracting bodies and employers must observe fair and just contractual practices in the employment of international health and care personnel

On making the job offer, health and social care employers, recruitment organisations, agencies, collaborations and contracting bodies should provide candidates with the exact terms of the contract under which they will be working to enable the candidate to make an informed decision before accepting the job offer.

Changes to an employment contract terms and conditions from those originally agreed upon in the signed formal contract must not be made without prior signed consent of the health and social care personnel.

Contract substitution - where a contract is changed without the consent of the health and social care personnel - is in breach of the code.

Any element of the contract that may differ before and after professional registration - such as salary, repayment clauses, incentives, and reclaim of advances - must be clearly explained in writing before an offer of work is made. This applies regardless of when the formal contract is issued.

Recruiting organisations must ensure the health and wellbeing of health and social care personnel. An employment contract must not be signed under duress, or because of undue influence or coercion.

Any concerns about the welfare and employment rights of health or social care personnel must be reported to the appropriate agency to investigate, as set out in Annex E below.

Any repayment clause included in an employment contract must abide by the 4 principles of transparency, proportionate costs, timing and flexibility

Repayment clauses may be used in health and social care employment contracts to recover some of the upfront costs that the employer has invested in recruiting health or social care personnel if they leave employment within a given period.

Any repayment clause which health and social care personnel could be liable to repay must be clearly set out in writing in the employment contract and abide by the following principles:

Transparency:

• the repayment clause must be set out in the contract or job offer letter and explained in full to the candidate before the job is accepted
• an itemised list of costs to be reclaimed should be provided to show how the amount has been determined
• only genuine evidenced, auditable expenses incurred can be reclaimed
• it must be made clear how the costs will be recouped using an auditable method such as bank transfer or salary sacrifice. Payment in cash is not acceptable
• confirmation must be sought that health and social care personnel did not contribute towards the costs or expenses being reclaimed prior to their arrival in the UK

Proportionate costs:

• the cost must include only those expenses met by the employer on behalf of health and social care personnel. These include but are not limited to:
  • relocation expenses
  • visa fees
  • regulatory exam fees
• costs that the employer is liable to pay as part of the recruitment process must not be reclaimed from health and social care personnel. These include but are not limited to the:
  • agency fee
  • immigration skills charge
  • sponsor licence fee
  • certificate of sponsorship
  • cost of the interview process
• expense costs must not incur any interest on the amount reclaimed
• employers should give health and social care personnel the option to repay the costs or expenses through a monthly repayment plan

Timing:

• a repayment schedule must be provided and rechargeable costs must taper downwards with time - for example, over a 3-year period. An example is set out below:
  • leaving within 0 to 12 months: can be charged 100% of total itemised expenses
  • leaving within 13 to 24 months: can be charged 50% of total itemised expenses
  • leaving within 25 to 36 months: can be charged 25% of total itemised expenses
  • leaving after 36 or more months: no repayable expenses after 36 months of service

Flexibility:

• employers should be flexible about when they levy the repayment clause and consider individual circumstances. Each decision should be made on a case-by-case basis. Examples of when a repayment clause should be waived could include:
  • where the health and wellbeing of a health and social care recruit is being adversely impacted
  • where the health or social care recruit leaves due to bullying, discrimination or poor working conditions
  • if a health or social care recruit’s circumstances have changed beyond their control, either in the UK or in their home country
  • if the health and social care recruit wishes to move roles for career progression

All newly appointed international health and social care personnel will be offered appropriate support and induction. Employers and contracting bodies should undertake pre-employment and placement preparation activity to ensure a respectful working environment

Employers, contracting bodies and potential education providers should ensure they understand the culture, context and system within which the individuals work in their home country before the international health and social care personnel arrives.

The potential financial position of health and social care personnel should be considered, and employers and contracting bodies should be aware that additional support may be required at varying levels depending on each individual situation.

Other staff working in the host organisation should be made aware of the requirement to recruit internationally, and of the support expected of them to encourage a culture in which diversity is valued and respected. Induction should include aspects of cultural awareness, equal opportunities and diversity. Ongoing support should be culturally sensitive and offer career development and opportunities for progression.

Feedback should be sought from currently employed staff and internationally recruited individuals as the employment or placement progresses, and any issues identified and resolved in a timely manner.

Each international recruit must be made aware of how to find help and assistance in all aspects of their appointment. They should undergo a comprehensive programme of induction to ensure that they are clinically and personally prepared to work safely and effectively within the UK health and care system. The provision of a mentor can be helpful. NHS Employers international recruitment toolkit provides advice and good practice guidance on the support required.

Induction programmes should encompass cultural and pastoral support to settle into working and living in the UK. It should include:

• an initial welcoming of staff (and family)
• accommodation
• pay
• registering with a GP, dentist and school
• setting up a bank account
• information relating to professional organisations, union representation, national embassies or high commissions
• introduction to social networks

Employers and contracting bodies should consult guidance on how to enhance their existing risk assessments particularly for at-risk and clinically extremely vulnerable groups within their workforce. The guidance is applicable, with appropriate local adaptations, in all healthcare settings.

Health and social care employers, contracting bodies and recruitment organisations, agencies or collaborations should respond appropriately to applications from international health and social care personnel who are making a direct application

Individuals making enquiries from outside of the UK for a regulated role should be directed to the appropriate regulatory body in the first instance.

Individuals making a direct application to vacant posts, including those residing in red or amber list countries, should be dealt with equitably and fairly. Employers should be mindful of their responsibilities under the Equality Act 2010.

If a recruitment organisation, agency or collaboration are approached by an individual who is resident in a country on the red or amber list, they should signpost them to a relevant jobs board where they can seek out direct application opportunities independently.

Employers and contracting bodies should consider travel arrangements of short-listed candidates when setting the interviews. Interviews can be undertaken in person or via video conferencing if conducted with appropriate safeguards. Telephone interviews are not normally an appropriate method to select health or social care personnel for appointment.

Health and social care employers, recruitment organisations, agencies, collaborations and contracting bodies should record international recruitment activities. This will support the monitoring and measurement of international workforce flows and their impact

It is important to have a national perspective on international recruitment supply and demand to:

• inform policy development, workforce planning, and to understand recruitment processes and attrition rates
• identify best practice in maximising benefits to the UK, the country of origin’s health and social care systems, and health and social care personnel

Health and social care organisations should ensure they record information about their recruitment activity. This includes:

• countries targeted
• planned and actual recruitment numbers
• headcount
• nationality
• country of application
• professions of international recruits in employment

Health and social care organisations are encouraged to respond to all surveys capturing international recruitment activity.

All organisations on the ethical recruiters list must respond to the NHS Employers biannual survey of recruitment activities to aid in monitoring of the code of practice. Information will be shared with the Cross-Whitehall International Recruitment Steering Group. Failure to respond can lead to removal from the ethical recruiters list.

DHSC in England has a UK-designated national authority to contribute to exchange on health worker migration on a global level, including regular progress reports to the WHO, for ongoing monitoring, analysis and policy formulation.

Health and social care employers and contracting bodies are encouraged to share information on any known breaches of the code of practice to internationalrecruitment@nhsemployers.org.

Illustrative scenarios

A guiding principle of the code of practice is that there must be no active recruitment from countries on the red list, unless there is an explicit government-to-government agreement signed by the UK government. This will support managed recruitment activities and ensure they are undertaken in compliance with the terms of that agreement.

In Annex A below, countries on the list are graded red. When a government-to-government agreement is put in place between the UK and a partner country that allows recruitment according to the terms of the agreement, the country’s grading is changed to amber.

The red and amber country list does not prevent individual health and social care personnel resident in countries on the list from making a direct application to health and social care employers, but rather without being targeted by a third party, such as a recruitment organisation, agency or recruitment collaboration.

More information on this is provided in the ‘WHO Health Workforce Support and Safeguards List 2023’ section below. ‘Active recruitment’ and ‘direct application’ are defined in ‘Definitions’ above. The scenario examples below set out how the definitions of active recruitment and direct application are applied in practice.

These scenario examples are not an exhaustive list, but illustrate the types of conduct that are:

• in breach of the code (scenarios 1 to 9)
• permitted under the code (scenarios 10 to 14)

The following scenarios show recruitment activity in breach of the code of practice.

Scenario 1

An agency advertises within Togo - a red list country - and actively supports several candidates resident in that country with their applications, appointments and travel to the UK.

This would be deemed active recruitment and contravenes the guiding principles within the code of practice.

Scenario 2

An agency runs a recruitment fair in Niger highlighting opportunities in the UK. Niger is a red list country and should not be actively targeted for recruitment.

The agency does not actually hire anyone. This would still be deemed active recruitment and contravenes the guiding principles within the code of practice.

Scenario 3

An agency or organisation with multinational contracts advertises in Uganda - a red list country. They highlight that they are recruiting to a different country (not the UK), however they also have contracts in the UK.

It later transpires that the agency facilitated a candidate’s arrival to work in the UK. This would still be deemed active recruitment and contravenes the guiding principles within the code of practice.

Scenario 4

An employment agency is approached by an individual resident in Bangladesh - a red list country - who has been referred to the agency by their friend who is working as a social care nurse in the UK. The agency supports the individual with their application and makes a bonus payment to their friend for the referral.

This is in breach of the code of practice. An agency should not facilitate the recruitment process unless the candidate has already been appointed by the employer through a direct application, at which point the employer may seek support from an agency with the remaining part of the recruitment process.

In addition, referral fee schemes are deemed to be active recruitment and are not permitted in countries on the red country list.

Scenario 5

An NHS collaboration hub puts out a general advertisement for 15 nurse vacancies across various NHS trusts within the collaboration. The hub receives 456 applications across all the vacancies advertised and appoints several nurses resident in Nigeria to jobs in multiple NHS trusts within the collaboration. Nigeria is a red list country.

This is a recruitment collaboration, and appointing nurses resident in a red list country would be deemed active recruitment and contravenes the guiding principles within the code of practice.

Scenario 6

A social care provider is recruiting on behalf of a number of other social care providers. The vacancies are at a number of care homes in the UK. The social care provider receives 30 applications for one of the roles at a care home in London and appoints a candidate resident in Bangladesh - a red list country.

This would be deemed as active recruitment and in breach of the code of practice as the social care provider is acting in the capacity of a recruitment organisation, having recruited on behalf of another provider.

Scenario 7

An agency is approached by a resident in Pakistan - a red list country - seeking work in the UK as a doctor. The agency supports their recruitment into a medical role at a UK independent healthcare provider. This would be deemed active recruitment and contravenes the guiding principles within the code of practice.

In this situation, the agency should signpost the candidate to a relevant jobs board such as NHS Jobs or similar so they can seek out direct application opportunities independently.

Scenario 8

NHS Employers conducted a spot check on an agency on the ethical recruiters list following a random number generator. The agency, which was also on a framework, was found to have promoted on their social media sites that they hosted a recruitment fair in Pakistan - a red list country - for healthcare roles into a private hospital in the UK.

NHS Employers investigates this through their informal process and it is then escalated to a formal investigation, as set out in Annex D.

A panel is convened to examine the evidence from both the agency and NHS Employers. The formal investigation concludes that a breach of the code of practice occurred.

The panel recommends to DHSC that the agency be removed from the ethical recruiters list for at least a year before the agency can reapply, which is upheld.

NHS Employers update the ethical recruiters list to reflect the removal of the agency and ensure it remains up to date.

Scenario 9

A nurse resident in India is successful in obtaining a nursing job in a UK hospital. On receiving the formal contract, she queries the repayment clause included for £14,000 if she leaves the job within 5 years. No information has been provided on how the sum of £14,000 has been calculated or if it reduces over time.

She asks the employer for a breakdown of what it includes. The employer gives a verbal breakdown over the phone of the costs including agency fee, sponsor application fee and relocation costs. The employer says if she does not sign the contract today, the job will be offered to someone else.

The employer is in breach of the code as they have not been transparent about the costs included in the clause. This should be provided in writing, with an itemised breakdown, and should only include proportionate costs incurred by the employer on behalf of the recruit - not costs the employer is liable to pay as part of the recruitment process.

The repayment clause should also taper down with time - for example over a 3-year period - to take account of the level of service provided by the nurse during her employment.

An employment contract must also not be signed under duress or because of undue influence or coercion.

The following scenarios show acceptable recruitment activity under the code of practice.

Scenario 10

A nurse resident in Sudan - a red list country - makes a direct application to a job advert in the NHS unassisted. He is interviewed by the trust and deemed successful for the post, subsequently travelling to the UK on receipt of his visa.

This activity did not include any active recruitment and therefore does not contravene the code of practice.

Scenario 11

A doctor from Haiti - a red list country - is resident in Canada, having relocated there 5 years ago. An agency advertises in Canada, and the doctor is recruited in the cohort and wishes to come to the UK.

This activity is not in breach of the code of practice - ethical recruitment is determined by the country from which the individual is resident in, rather than the nationality of the individual or their original country of training.

Scenario 12

A social worker resident in Chad - a red list country - makes a direct application to a specific vacancy advertised by a local authority in the UK and is successfully appointed. The local authority requires the support of an employment agency to facilitate the social worker through the remaining part of the recruitment process.

This activity is not in breach of the code of practice as the social worker had already been appointed by the local authority when they approached the agency for support with the remaining part of the recruitment process.

Scenario 13

An NHS trust that is part of an NHS collaboration hub puts out its own advert for a mental health nurse vacancy on NHS Jobs independent of the collaboration. The advert is not targeted at any country. The NHS trust receives 250 applications and appoints a mental health nurse resident in Ghana - a red list country.

In this scenario, the NHS trust advertising the vacancy is the same NHS trust requiring the vacancy to be filled.

As the NHS trust is not working as part of a recruitment organisation or collaboration for the purpose of filling the role and the advert was not actively targeted at any country, this activity would not be deemed active recruitment and is not in contravention of the code of practice.

Scenario 14

A social care provider puts out an advert for a number of staff to fill various specified vacancies within its own nursing homes. The advert is not targeted at any country. The provider receives 60 applications and appoints 3 senior care workers resident in the Philippines - a green list country - and 3 senior care workers resident in Nigeria - a red list country.

In this scenario, the nurses resident in Nigeria made a direct application for the advertised post, meaning they applied independently and on their own behalf.

The advert was not actively targeted at any country and was not managed through a recruitment organisation, agency or collaboration.

Therefore, this activity would not be deemed active recruitment and is not in breach of the code of practice.

WHO Health Workforce Support and Safeguards List 2023

The red country list in Annex A below is drawn from the WHO Health Workforce Support and Safeguards List 2023. These countries face the most pressing health workforce challenges related to UHC.

Country identification follows the methodology contained in the 10-year review of relevance and effectiveness of the WHO Global Code of Practice on the International Recruitment of Health Personnel (A73/9). Consistent with the WHO Global Code of Practice principles and articles, and as explicitly called for by the WHO Global Code of Practice 10-year review, the listed countries should be:

• prioritised for health personnel development and health system related support
• provided with safeguards that discourage active international recruitment of health personnel

Countries on the list should not be actively targeted for recruitment by health and social care employers, recruitment organisations, agencies, collaborations or contracting bodies unless there is a government-to-government agreement in place to allow managed recruitment undertaken strictly in compliance with the terms of that agreement.

Countries on the WHO Health Workforce Support and Safeguards list are graded red in the code. If a government-to-government agreement is put in place between a partner country, which restricts recruiting organisations to the terms of the agreement, the country is added to the amber list. If a country is not on the red or amber list, then it is green.

Green graded countries with government-to-government agreements in place are listed separately in Annex B below.

The agreement may set parameters, implemented by the country of origin, for how UK employers, contracting bodies and agencies recruit.

The red or amber country list does not prevent individual health and social care personnel resident in countries on the list making a direct application to health and social care employers for employment in the UK of their own accord, and without being targeted by a third party, such as a recruitment organisation, agency or recruitment collaboration. Workforce flows from countries on the red and amber country lists will be monitored and, where trends indicate an increased level of recruitment activity, DHSC will work in partnership with the FCDO to understand the causes and impact of this activity, and consider taking appropriate supportive actions.

The informal and formal escalation stages of investigation followed if it transpires that recruitment activity contravenes the code of practice is set out at Annex D below.

The red country list replaces the list of developing countries that should not be actively recruited from in the previous (pre-2021) codes of practice.

Red, amber and green grading of countries

Whether active recruitment is permitted from a country is determined by it’s red, amber or green (RAG) grading as follows:

Red

No active recruitment permitted. Red countries are listed in Annex A.

Amber

Managed recruitment permitted and undertaken strictly in compliance with the terms of the relevant government-to-government agreement. Active recruitment outside of the government-to-government agreement is not permitted. Amber countries are listed in Annex A below.

Green

Active recruitment permitted. The UK has several government-to-government agreements with green graded countries to set parameters for how UK employers, recruitment organisations, agencies, collaborations and contracting bodies recruit. Organisations are encouraged to recruit on the terms of the government-to-government agreement. Green graded countries that have a government-to-government agreement with the UK are listed separately in Annex B below.

Criteria for determining red list countries

In 2023, the WHO Secretariat published the WHO Health Workforce Support and Safeguards List 2023, which comprises 55 countries.

The countries listed have a UHC service coverage index that is lower than 55 and a density of doctors, nurses and midwives that is below the global median (49 per 10,000 population).

Review of the list

The WHO Health Workforce Support and Safeguards List is reviewed every 3 years or sooner if required (the next update is expected to be published in 2026). It is updated alongside the regular progress reports to the World Health Assembly on WHO Global Code of Practice implementation.

The UK code of practice red and amber country list may be updated on an ad hoc basis - for example, in response to new government-to-government agreements being signed. All agreements will take WHO guidance on the development of bilateral agreements into account.

Changes in a country’s RAG grading

Red or green to amber

A red list country can become amber if a government-to-government agreement is put in place to allow recruitment of health and social care personnel strictly to the terms of the agreement.

The government of any red-graded country may approach DHSC, FCDO, HEE or another system partner with a proposal for a workforce partnership. All agreements are negotiated by the DHSC on behalf of the UK government. It is not appropriate for recruitment organisations, agencies and collaborations to be involved in any part of this process.

If the agreement is approved and implemented, the country will be listed as amber and managed recruitment of health and social care personnel is undertaken in compliance with the terms of that agreement.

There are a small number of green graded countries where an increase in international recruitment may exacerbate existing health and social care workforce shortages. Where this is the case, the same process outlined above will be followed to change the grading of a green country to amber. This means any international recruitment to the UK is managed in compliance with the terms of the government-to-government agreement.

Health workforce development and health systems sustainability

The WHO estimates a 15 million health workers shortage in 2020, projected to decline to 10 million by 2030, in low and lower-middle income countries to achieve UHC. The WHO Expert Advisory Group (see the WHO Global Code of Practice on the International Recruitment of Health Personnel (A73/9)) urges all WHO member states to mobilise the necessary investments in the education, recruitment and retention of health workers to effectively deliver UHC.

This code of practice sets out both the UK’s approach to safeguards against active recruitment from countries with the greatest UHC-related health and care workforce vulnerability, and support for health and social care workforce and health systems. There are different mechanisms through which the UK provides this support in low income and lower middle-income countries.

Government-to-government partnership agreements with the UK

A government-to-government partnership agreement is established through a memorandum of understanding (MoU) signed by the DHSC on behalf of the UK government and the partner country’s government.

These types of agreements enable recruitment of health and care staff in a managed and mutually beneficial way.

Each individual MoU on health workforce will depend on the partner country’s health workforce needs and context.

Government-to-government agreements provide opportunities for collaboration and mutual benefit. This can take the form of:

• direct reimbursement
• exchange of skills, knowledge and processes
• support and investment in training and education
• investment in jobs in the country of origin

Government-to-government agreements should ensure that migration to the UK does not exacerbate domestic workforce shortages. The agreement should seek to strengthen health workforce development in the country of origin.

A government-to-government agreement can allow managed recruitment in red list countries. This may be particularly beneficial where there are high rates of individuals making direct applications, giving the sending government greater control and oversight of migration. The agreement can include provisions to strengthen the health or care workforce in the country of origin, whether through education, investment in jobs or other forms of support.

In agreeing these government-to-government agreements, the UK will engage with relevant stakeholders in partner countries.

Government-to-government agreements will be based on the latest evidence, including, for those on the red list, a health labour market analysis.

The UK will notify WHO of partnership agreements through the WHO Global Code of Practice monitoring processes to support good practice.

Case study 1: UK-Philippines Memorandum of Understanding

The UK and the Philippines have a long-established bilateral relationship on healthcare workforce recruitment. In October 2021, a new UK-Philippines MoU was signed to reaffirm the ongoing partnership.

The MoU formalises the relationship at government level for Filipino nurses to work in the NHS, ensuring they are recruited ethically, supported to reach their full potential, and that their mental and physical wellbeing is protected.

The MoU also allows recruitment to the UK to be managed, minimising risks to the Philippine’s health system.

Health Education England - educating, training and developing the health workforce

HEE works with some countries, responding to requests for support on workforce development, creating placements for professional groups, matching NHS workforce need with international training requirements, and seeking out new bilateral relationships to strengthen workforce development in the NHS and outside the UK.

Examples of educational programmes that bring doctors and nurses to the UK to work - often with a view to returning to their countries of origin with improved clinical skills - are provided in case studies 2 and 3 below.

Case study 2: Thai-UK medical training partnership

The Thai-UK Medical Training partnership offers bilateral exchanges of healthcare staff. Current agreements are between the UK and Thailand, facilitated by HEE and the Association of Thailand Medical Schools.

Thai doctors have the opportunity to undertake a 3-year clinical fellowship in an NHS hospital with the option of undertaking a masters-level qualification.

NHS public health trainees have the opportunity to undertake a one-year research placement, focused on noncommunicable diseases (NCDs) at prestigious university hospitals in Thailand as part of their training.

Case study 3: Medical Training Initiative

The Medical Training Initiative is a successful programme aiming to improve the skills of the medical workforce in low and middle-income countries. Funded by HEE and sponsored by the Academy of Medical Royal Colleges, it provides 1,500 places a year - prioritised for doctors from low and lower middle-income countries to experience training and development in the NHS - for up to 2 years.

Doctors should return to their home countries where service users and colleagues benefit from the skills and experience they have obtained in the UK.

UK’s Official Development Assistance for human resources for health

In eligible countries, the UK provides Official Development Assistance (ODA) to reduce poverty, tackle instability and create prosperity in developing countries. UK ODA investments in health systems support low and lower-middle income countries to make progress towards UHC and wider health-related sustainable development goals. This includes support for the development of the health workforce and the implementation of national health workforce strategies.

Channels of support include bilateral health programmes that directly support national governments or civil society partners with financing or technical collaboration in response to national health workforce challenges. This includes:

• health workforce education and training
• curriculum development
• continuing professional development
• qualification development
• national workforce policy
• strengthening related ministry of health policy and planning functions such as public financial management

Human resources support is also provided through centrally managed, multi-country programmes and through multilateral institutions such as the Global Fund, Gavi, the Vaccine Alliance, Global Financing Facility, World Bank, WHO and other UN agencies.

ODA-funded research programmes build understanding on how to invest in sustainable and resilient health workforces in different settings.

Ethical recruiters list

NHS Employers updates and maintains a list of recruitment organisations, agencies and collaborations that operate in accordance with the code of practice.

Health and social care local employers and contracting bodies should only use recruitment organisations, agencies or collaborations who are on the code of practice ethical recruiters list.

Although the ethical recruiters list is maintained by NHS Employers, the list should be used by all health and social care organisations engaged in international recruitment, both in the public and independent sectors.

Application procedure

Recruitment organisations, agencies or collaborations wishing to apply for inclusion on the code of practice ethical recruiters list are required to complete an online application form and a knowledge test of this code of practice. The application form confirms:

• the organisation’s commitment to fully adhere to the code of practice and comply with the Employment Agencies Act 1973 and associated conduct regulations including responding to the bi-annual collection of data
• the business practice of the organisation
• a declaration of all associated business activities and references relating to the recruitment of health and social care personnel
• permission for the Employment Agencies Standard Inspectorate to share details with DHSC and NHS Employers of any inspection and remedial action taken

After submitting the online application form, applicants will be sent a link to a knowledge test to complete. This will consist of 15 questions, requiring a pass rate of 13 out of 15. This will confirm that applicants have read and understood the code of practice, and how it is applied in different settings.

NHS Employers will request the EAS Inspectorate share details with DHSC and NHS Employers of any previous inspections of the organisation and any remedial action taken.

If, after contact with the EAS Inspectorate, assessment of the application and knowledge test and resolution of any queries, an organisation is not successful in being placed on the ethical recruiters list, they will be advised of the reason in writing via email. Organisations have 3 attempts at the knowledge test. If an organisation does not pass the third attempt, it must wait 3 months before it can re-apply, and it must show that it has changed its business practice to be placed on or back on the list.

The organisation responsible for processing applications and monitoring the ethical recruiters list reserves the right to introduce a fee for recruitment organisations, agencies or collaborations to be on the ethical recruiters list for the code of practice at a future point in time.

How the ethical recruiters list is monitored

This section outlines the abridged version of how NHS Employers monitors recruitment organisations, agencies or collaborations on the code of practice. Detailed processes are housed by NHS Employers.

Review of the ethical recruiters list

The procedure for monitoring recruitment organisations, agencies and collaborations for their adherence to the principles of the code of practice is as follows:

Every year, when the code of practice is reviewed by DHSC, NHS Employers contacts all recruitment organisations, agencies and collaborations via email (allowing them 10 working days to respond) asking them to review any changes to the code and renew their commitment to its guiding principles and best practice benchmarks.

If an organisation does not respond to the first letter within the timeline outlined in the letter, they will receive a second letter asking for the same information and will have a further period of time to respond.

If NHS Employers does not receive a reply to the second letter within a specified time period, this will result in the organisation being removed from the list. If removed, an organisation will only be allowed to re-apply after a period of 3 months, and will need to go through the full application process.

Health or social care organisations are encouraged to make a note of this procedure and ensure that their recruitment organisation, agency or collaboration complies with it when they receive their initial letter.

Spot checks

NHS Employers conducts regular spot checks to monitor compliance with the code of practice. Organisations can be spot checked if:

• they are selected by a random number generator
• they are on a list for regular monitoring
• NHS Employers has been made aware of a potential breach

The spot checks include but are not limited to:

• checking information available on Companies House
• checking the organisation’s website can be reached and all activities align with the code of practice
• checking the organisation’s social media presence and all activities align with the code of practice

Information on the numbers and outcomes of spot checks are routinely shared with the DHSC.

Removal from the ethical recruiters list

A recruitment organisation, agency or collaboration will be removed from the ethical recruiters list if, following an investigation, it is found to be breaching the principles of the code of practice.

Each case will be investigated on an individual basis and an abridged version of the escalation process for informal and formal investigations can be found in Annex D below. This process includes an appeals procedure. Detailed processes are housed securely by NHS Employers.

Information on any breach will be shared with the Employment Agencies Standard Inspectorate.

Use of the NHS Employers logo

NHS Employers logo is protected and recruitment organisations, agencies and collaborations - even those that are successfully placed on the ethical recruiters list - are not permitted to display the logo on their business materials, documents, websites or social media accounts.

Recruitment organisations, agencies and collaborations are also reminded that inclusion on the list does not imply that they belong to a group that are either preferred suppliers or recommended by the DHSC or NHS Employers. It does not guarantee they will be engaged by health or social care organisations to recruit on their behalf.

Annex A: red and amber list countries

Countries on the WHO Health Workforce Support and Safeguards List are graded red, which means no active recruitment is permitted from these countries.

If a government-to-government agreement is put in place between the UK and a partner country, it will restrict UK employers, contracting bodies, recruitment organisations, agencies and collaborations to the terms of the agreement. The country will be added to the amber list and recruitment can happen only on the terms of the agreement.

The WHO Health Workforce Support and Safeguards List is updated by WHO every 3 years, or more frequently if required.

Changes to the red and amber country list may be made on an ad hoc basis as government-to-government agreements are signed. All agreements will take WHO guidance on the development of bilateral agreements into account.

It is recommended that employers, recruitment organisations, agencies, collaborations and contracting bodies check the red and amber country list for updates before any recruitment drive.

Green graded countries - which have signed a government-to-government agreement with the UK for international health and social care workforce recruitment - are listed separately in Annex B.

Red and amber countries

Red countries - active recruitment is not permitted

• Afghanistan
• Angola
• Bangladesh
• Benin
• Burkina Faso
• Burundi
• Cameroon
• Central African Republic
• Chad
• Comoros
• Congo
• Congo, Democratic Republic of
• Côte d’Ivoire
• Djibouti
• Equatorial Guinea
• Eritrea
• Ethiopia
• Gabon
• Gambia, The
• Ghana
• Guinea
• Guinea-Bissau
• Haiti
• Kiribati
• Lao People’s Democratic Republic
• Lesotho
• Liberia
• Madagascar
• Malawi
• Mali
• Mauritania
• Micronesia, Federated States of
• Mozambique
• Niger
• Nigeria
• Pakistan
• Papua New Guinea
• Rwanda
• Samoa
• Senegal
• Sierra Leone
• Solomon Islands
• Somalia
• South Sudan
• Sudan
• Tanzania, United Republic of
• Timor-Leste
• Togo
• Tuvalu
• Uganda
• Vanuatu
• Yemen, Republic of
• Zambia
• Zimbabwe

Amber countries - international recruitment is only permitted in compliance with the terms of the government-to-government agreement

• Kenya
• Nepal

Annex B: green countries with government-to-government agreement in place with the UK

Active recruitment is permitted from green graded countries. Green countries are any country not on the red or amber list at Annex A above.

The green country list below includes those countries that have a government-to-government agreement with the UK in place for international health and care workforce recruitment. Green-graded countries without a government-to-government agreement with the UK are not published in the code of practice for England.

The government-to-government agreement may set parameters, implemented by the country of origin, for how UK employers, contracting bodies, recruitment organisations, agencies and collaborations recruit. These organisations are encouraged to recruit on the terms of the government-to-government agreement.

The green country list will be updated as new government-to-government agreements are signed with the UK. It is recommended employers, contracting bodies, recruitment organisations, agencies and collaborations regularly check the list for updates prior to embarking on any recruitment campaign.

Green graded countries with a government-to-government agreement for managing international health and care workforce recruitment are:

• India
• Malaysia
• Philippines
• Sri Lanka

All health workforce government-to-government agreements above are published in the Government-to-government agreements on health and social care workforce recruitment collection.

Annex C: postgraduate training programmes outside of scope of the code of practice

Appointment of healthcare professionals onto the following postgraduate training programmes fall outside the scope of the code of practice:

Foundation, medical specialty or dentistry training programme

• acute care common stem (ACCS)
• acute internal medicine
• allergy
• anaesthetics
• audio vestibular medicine
• aviation and space medicine
• cardiology
• cardio-thoracic surgery
• chemical pathology
• child and adolescent psychiatry
• clinical genetics
• clinical neurophysiology
• clinical oncology
• clinical pharmacology and therapeutics
• clinical radiology
• combined infection training
• community sexual and reproductive health
• core psychiatry training
• core surgical training
• dermatology
• diagnostic neuropathology
• emergency medicine
• endocrinology and diabetes mellitus
• forensic histopathology
• forensic psychiatry
• gastroenterology
• general (internal) medicine
• general practice
• general psychiatry
• general surgery
• genito-urinary medicine
• geriatric medicine
• haematology
• histopathology
• immunology
• infectious diseases
• intensive care medicine
• internal medicine training
• medical microbiology
• medical oncology
• medical ophthalmology
• medical psychotherapy
• medical virology
• neurology
• neurosurgery
• nuclear medicine
• obstetrics and gynaecology
• occupational medicine
• old age psychiatry
• ophthalmology
• oral and maxillofacial surgery
• otolaryngology
• paediatric and perinatal pathology
• paediatric cardiology
• paediatric surgery
• paediatrics
• palliative medicine
• pharmaceutical medicine
• plastic surgery
• psychiatry of learning disability
• public health medicine
• rehabilitation medicine
• renal medicine
• respiratory medicine
• rheumatology
• sport and exercise medicine
• thoracic surgery
• trauma and orthopaedic surgery
• tropical medicine
• urology
• vascular surgery

Dental training programme

• dental and maxillofacial radiology
• dental core training
• dental foundation training
• dental public health
• mono specialties
• oral and maxillofacial pathology
• oral medicine
• oral surgery
• orthodontics
• paediatric dentistry
• restorative dentistry
• special care dentistry

Other programmes

• Foundation pharmacist programme
• Healthcare science (scientist training programme)
• Healthcare science (higher scientist training programme)

Annex D: process for code of practice contraveners

This section describes an abridged version of the informal and formal escalation stages of investigation when NHS Employers becomes aware of recruitment and/or associated activity that contravenes the code of practice. The detailed process is housed securely by NHS Employers and applies to all recruitment organisations, agencies and collaborations. Employing organisations who are reported as being in breach of the code will also be investigated. This will include the informal stage as outlined below, as well as discussions with DHSC and NHSE, and possible additional investigations if activities were supported by a recruitment organisation, agency or collaboration as outlined below.

If there are any concerns about potential breaches to the code, please contact internationalrecruitment@nhsemployers.org.

NHS employing organisations are reminded that NHSE nursing, midwifery and allied health professional international recruitment funding is currently provided on the condition that they adhere to the code of practice in all international recruitment activity.

Informal stage

NHS Employers receives information about an organisation - either through random checks or another manner - that indicates a potential breach of the code of practice.

NHS Employers carries out desktop research and other checks (including but not limited to conducting a spot check on Companies House, the organisation website and social media presence) to determine whether there is any evidence to pursue further investigation. NHS Employers also considers if any other breaches or investigations have been previously recorded as well as their knowledge test as part of their initial application to the code of practice (for those who joined after August 2022).

If appropriate, the organisation is contacted via email to clarify their business activities and how it may have breached the code of practice, and is given 10 working days to respond.

The reply from the organisation and any supporting evidence will be reviewed and considered against the guiding principles and best practice benchmarks of the code of practice.

The organisation’s response is considered and, depending on the response, NHS Employers may consider:

• to close the informal investigation
• if the organisation may be given an opportunity to correct their behaviour by giving an informal warning and additional spot checks made
• if the formal procedure needs to begin

Formal stage

Where a formal investigation is required, any relevant information (including media articles, social media activity, promotional or website material) from the organisation under investigation in relation to alleged wrongdoing or contact from an employer, framework provider, trade union representative or other stakeholder will be collated, and saved securely and in accordance with any relevant data protection laws to aid future investigations.

This information will be shared with the organisation in a formal letter. The formal letter will be addressed to the most senior person listed in the organisation details, as provided to NHS Employers, and sent to the organisation.

An independent panel is convened, and a date is set for the panel to meet.

The formal step in the process is to:

• outline the initial findings from the informal stage
• provide them with the evidence that has been gathered
• give the organisation concerned a right to reply

The organisation will have 10 working days to provide a formal written response. NHS Employers may consider a short extension to the 10-day response time frame, in exceptional circumstances, at their discretion.

The panel receives relevant documentation 5 working days before the panel meeting.

The independent panel will consider all the evidence presented and, where appropriate, will recommend sanctions to the DHSC, which may include temporary or permanent removal from the ethical recruiters list. Other sanctions may include:

• the organisation will remain on the ethical recruiters list. However, they will be subject to monthly spot checks for up to one year or additional training imposed
• a formal warning that a repeat of the same activity (or other code breaches) will result in removal from the code of practice
• requirement for additional training and a re-sit of the knowledge test

DHSC approves the independent panel’s recommended sanction and next steps.

NHS Employers formally writes to the organisation outlining the outcome and decision on any sanctions.

Generally, a one-year waiting period comes into effect before the recruitment organisation, agency or collaboration can apply to be placed back on the list. However, the sanction may be to permanently remove the organisation from the code of practice.

It is at the discretion of NHS Employers as to whether this waiting period should be extended or any applications should be immediately refused in future. They will consider:

• repeated breaches
• the measures put in place to prevent future breaches
• the organisation’s co-operation in any investigations

To re-apply, an organisation will need to provide evidence that it has changed its business practice.

The organisation will either be accepted or declined.

If declined, the organisation will need to wait an additional 12 months before re-applying.

Appeal stage

On receiving the formal notification letter from the independent panel from the formal stage, the organisation can appeal to NHS Employers by providing any further relevant information for consideration within 10 working days.

The purpose of the appeal procedure is to review the process and reason for the decision to remove an organisation from the list when the organisation believes the process was improperly administered or the decision was unjustified.

The appeal panel will be independent of any previous decision-making in the process. The panel will include:

• NHS Employers staff member at director level
• NHS Confederation staff member at assistant director level
• NHS Employers or other stakeholder staff member at programme lead or manager level

The appeals process should be completed within 4 weeks of receiving the written appeal unless there are circumstances that warrant an extension. In these circumstances, the appeals panel should inform the organisation in writing of the reasons and, where possible, the timescale of the delay.

The panel members will consider the appeal submission and any evidence together with the original papers supplied by the NHS Employers’ investigation team.

Panel members can ask for additional information or clarification from either the organisation or the NHS Employers’ investigation team.

Consideration should be given to the following:

• whether the primary investigators clearly demonstrated that a breach or breaches of the code of practice has taken place - the evidence should support this - and the decision to remove the organisation from the ethical recruiters list is proportionate
• whether there is any possibility that the information on which the original decision was based is incorrect
• whether the organisation has been given an opportunity to respond and provide an explanation of their actions
• whether the organisation disproved the evidence or raised serious doubt about its validity
• whether the process has been handled appropriately by NHS Employers

The panel will make a majority decision whether to uphold or reject the appeal. It may also make other specific recommendations. When the review is completed, the organisation will be notified of the outcome in writing by NHS Employers.

If the appeal is upheld, the sanction will be removed or adjusted in line with the appeals panel decision and relevant stakeholders will be notified of any sanction applied.

Actions by appeals panel

Panel members do not have to consider the appeal together in a formal face-to-face meeting but should meet if requested by one of the panel members.

Annex E: reporting concerns about the welfare and employment rights of health and social care personnel

All concerns relating to the welfare and employment rights of health and social care personnel must be reported to the appropriate authority as set out below.

Gangmasters Labour Abuse Authority

The Gangmasters Labour Abuse Authority is set up to protect vulnerable workers from exploitation.

Anyone can report information in confidence about an employer who may be exploiting the welfare and rights of health or social care personnel by:

• telephone: 0800 432 0804
• email: intelligence@gla.gov.uk

Employment Agency Standards Inspectorate

The Employment Agency Standards Inspectorate regulates employment agencies and businesses, and enforces minimum standards of conduct in the recruitment sector.

Anyone can report concerns about the conduct of a recruitment organisation, agency or collaboration based in Great Britain - including if they are charging work-finding fees or they, or someone they know, have not been paid for all hours worked - by:

• telephone: 020 7215 4477 and ask to speak to an Employment Agency Standards (EAS) inspector
• email: eas@beis.gov.uk
• completing the online form to complain about pay and work rights

EAS has a Great Britain-wide remit - however, any concerns relating to fees or conduct of non-Great Britain-based agencies can also be reported to the Employment Agency Standards Inspectorate using the contact details provided above.

Acas

Acas provides advice on the legal minimum wage, working hours and employment agencies.

Any health or social care personnel who thinks that they might be being underpaid or their employer has unsafe working practices can report concerns in confidence by:

• telephone: 0300 123 1100
• completing the online form to complain about pay and work rights

Care Quality Commission

The Care Quality Commission (CQC) is the independent regulator of healthcare and adult social care services in England.

Health or social care personnel with concerns about the care being provided by their employer can report this to the CQC. Before contacting the CQC, health or social care personnel may want to:

• speak to their line manager or a senior member of staff about their concerns
• read their employer’s whistleblowing policy, which will give them information on what to do

The CQC’s quick guide to whistleblowing or guidance for workers gives helpful advice on speaking out about poor care and what protection health care personnel will have from the law. To report a concern:

• complete the CQC online form: give feedback on care
• email: enquiries@cqc.org.uk
• telephone: 03000 616 161

Further support

Health and social care personnel can also seek support from international diaspora associations.

A full list of international nursing associations can be found on page 73 of the International Recruitment Toolkit and in Annex D of Applying for health and social care jobs in the UK from abroad.

Annex F: professional regulator contact details and links to further guidance

Nursing and Midwifery Council (NMC)

General telephone enquiries and fitness to practise: 020 7637 7181
Registration enquiries: 020 7333 9333
International enquiries: 020 7333 6600
Email: overseas.enquiries@nmc-uk.org
How to register with the NMC
NMC: information for employers

General Medical Council (GMC)

Telephone: 0161 923 6602
Email: gmc@gmc-uk.org (all enquiries)
How to register with GMC
Information to help employers understand their obligations around employing and contracting with doctors

Health and Care Professions Council (HCPC)

Telephone: 0300 500 6184
Outside of the UK: 0207 582 5460
Registration enquiries email: registration@hcpc-uk.org or international@hcpc-uk.org (for international applications)
How to register with HCPC

General Dental Council (GDC)

Telephone: 0207 167 6000
GDC: online contact form
How to register with GDC

General Pharmaceutical Council (GPhC)

Telephone: 0203 713 8000
Email: info@pharmacyregulation.org (all enquiries)
GPhC: online contact form
How to register with GPhC

General Optical Council (GOC)

Telephone: 0207 580 3898
General enquiries email: goc@optical.org
Registration enquiries email: registration@optical.org or international@optical.org (for international applications)
How to register with GOC

General Chiropractic Council (GCC)

Telephone: 0207 713 5155
General enquiries email: enquiries@gcc-uk.org
Registration enquiries email: registrations@gcc-uk.org
How to register with GCC

General Osteopathic Council (GOsC)

Telephone: 0207 357 6655
General enquiries email: info@osteopathy.org.uk
International registration enquiries email: assessment@osteopathy.org.uk
How to register with GoSC

Pharmaceutical Society of Northern Ireland (PSNI)

Telephone: 028 9032 6927
General enquiries email: info@psni.org.uk
Registration enquiries email: registration@psni.org.uk
How to register with PSNI

Social Work England (SWE)

Telephone: 0808 196 2274
Email: enquiries@socialworkengland.org.uk (all enquiries)
How to register with SWE

Other information and guidance

Applying for health and social care jobs in the UK from abroad provides support for prospective overseas candidates when seeking jobs in the UK health or social care sectors.

Nurses and midwifes

The Royal College of Nurses guide provides information for international nurses coming to the UK for the first time and for those already working here.

NHS Employers provides a collection of national resources and guidance to support international nurses.

NHS Employers provides information on the process for entering the UK for overseas nurses and midwives.

Doctors and dentists

The British Medical Association guide provides information for international medical graduates or students and on the process for getting a job in the UK.

NHS Employers provides information on the recruitment of overseas doctors and dentists.

The National Advice Centre for Postgraduate Dental Education (NACPDE), hosted by the Royal College of Surgeons, provides information for overseas qualified dentists.

Allied health professionals

NHS Employers provides information on the recruitment of overseas allied health professionals.

Employers

The NHS Employers’ international recruitment toolkit is designed to encourage and enable supportive practices and processes for the recruitment of international staff across a wide range of professions.

Social care

Skills for Care hosts information and guidance supporting providers across adult social care to recruit from overseas ethically.

The Local Government Association and the Associate of Directors of Adult Social Care have produced the overseas recruitment bite size guide for social care providers in England.

1. This list will be updated alongside regular progress reports to the World Health Assembly on WHO global code of practice implementation, every 3 years. ↩