The European Qualifications (Health and Social Care Professions) (Amendment etc.) (EU Exit) Regulations (2019/593) (‘the EU Exit Regulations’) came into force on the day of EU Exit and include provisions for the unilateral automatic recognition of European Economic Area (EEA) and Swiss professional qualifications (referred to as ‘standstill provisions’).
This means that for as long as the EU Exit Regulations remain in place, an annual average of more than 4,000[footnote 1] EEA-qualified doctors, nurses, midwives, pharmacists, dentists and other healthcare professionals can work in the NHS without the need to sit additional professional exams or undergo further assessment by their regulator.
Regulation 14 of the EU Exit Regulations places a legal duty on the Secretary of State for Health and Social Care to review the operation of the listed provisions (Annex A) no earlier than January 2023 and provide a report on the findings within 6 months of the start date.
The findings could include a decision on whether to maintain, reform or revoke the legislation. This report sets out those findings and planned next steps, with a view to ensuring the policy for the recognition of professional qualifications meets the future needs of the health and care sector in the UK.
Prior to 1 January 2021, the end of the UK’s EU Exit transition period, the European Union Directive 2005/36/EC allowed EEA and Swiss professionals to have their qualifications recognised in the UK (and vice versa) with minimal barriers. It ensured that the qualifications of doctors, nurses, midwives, pharmacists, dentists and other healthcare professionals met minimum agreed standards and enabled their automatic recognition by regulatory bodies throughout the EU. Additional treaties ensured the same also applied with the EEA European Free Trade Association (EFTA) states.
As this directive would no longer apply after 31 December 2020, the Department for Health and Social Care put in place the European Qualifications (Health and Social Care Professions) (Amendment) (EU Exit) Regulations 2019 to ensure the UK retained a system of recognition for EEA and Swiss healthcare qualifications that was similar to the previous system for a specified period.
The EU Exit Regulations came into force on 31 December 2020. Under these regulations, UK regulatory bodies have continued to recognise EEA-obtained qualifications without additional tests, other than language skills tests and checks on fitness to practise, where necessary.
The standstill provisions (Regulation 14 of the EU Exit Regulations) placed a legal duty on the Secretary of State for Health and Social Care to review these arrangements no earlier than January 2023 and to publish a report within 6 months of the review’s start date.
Two possible, broad outcomes of the review were considered:
End the standstill provisions. This could either be achieved using a Section 60 order under the Health Act 1999 or by removing the relevant powers as part of wider legislative changes.
Retain the standstill provisions, allowing current recruitment arrangements for EEA-qualified healthcare professionals to continue and adequate time to consider and co-develop meaningful legislative improvements with stakeholders.
To further understand the potential impact of each option and to ensure adequate preparation for the potential outcomes of the review, we collected and analysed relevant available data and undertook significant engagement with key stakeholders including regulatory bodies, devolved governments and NHS England (NHSE) (as a commissioner of services).
From January 2021 to January 2023, we worked with all medical regulatory bodies (see Annex B) to collect quantitative data on the number of EEA-qualified professionals applying to work in the UK since Q1 2021. This analytical exercise aimed to demonstrate the impact of EU Exit on the NHS workforce and highlight any trends that may inform the future direction of policy.
To note, figures from the Health and Care Professions Council (HCPC) show only on the number of applications by nationality as opposed to country of qualification, and so for the purpose of this review they were excluded from inter-regulator comparisons.
In summary, the data (figure 1) showed that while the number of applications by those with EEA or Swiss qualifications was generally lower in 2021 and 2022 than in 2019, the number has been increasing since 2021 Q1. We expect that the COVID-19 pandemic has had an impact on the number of applications over this period.
Figure 1: bar chart showing the number of applications received from applicants with EEA and Swiss qualifications each year in the years 2019, 2021 and 2022
Figure 1 shows that the number of applications was lower in 2021 and 2022 than in 2019, but have increased since 2021 Q1. The GMC and the NMC received the highest number of applications across each year.
Due to volatility between quarters and years, which may be a result of deferred applications during and following the COVID-19 pandemic, it is not possible to model projections of future numbers of applications. There are signs of an upward trend (figure 2) in applications between 2021 and 2022 (though volumes generally remain below 2019 levels), indicating the value of standstill provisions in maintaining a simplified application process and in mitigating a potentially negative impact on the in-flow of EEA-qualified healthcare professionals.
Figure 2: quarterly time series line graph showing number of applications received from applicants with EEA and Swiss qualifications over the year 2021 and 2022
Figure 2 shows an upward trend in the number of applications received from applicants with EEA and Swiss qualifications over the year 2021 and 2022. Volumes still remain below 2019 levels and the GMC and the NMC received the highest number of applications across each quarter and year.
We have also conducted a targeted consultation with stakeholders, including regulators, devolved governments and NHSE, as a commissioner of services, to understand the impact of the possible approaches to the standstill provisions.
Some respondents expressed a preference for preserving standstill arrangements, on the basis that it would avoid any negative impact on the number of EEA-qualified applicants coming to work in the UK.
The majority of regulators were in favour of extending the standstill provisions in the short-term, to avoid operational issues that would arise if automatic recognition arrangements were to end in 2023. For example, it would not be possible to immediately process all EEA-qualified applicants through existing routes for international medical graduates without significant delays. However, some regulators, particularly those with larger applicant numbers, suggested that there is no justification for maintaining 2 routes for applicants (one for EEA-qualified applicants and another for all other internationally qualified applicants) in the long-term and they would ultimately seek to process all applicants through the same route.
In summary, most stakeholders support the standstill provisions being kept in place, at least for a period, suggesting an opportunity to reconsider this arrangement in the future, which would be subject to legal analysis and further policy work. This approach would avoid unnecessary operational issues and changes to registration processes that could discourage or delay EEA applicants.
Regulators also suggested making other legislative amendments, including those to:
- extend standstill provisions to Gibraltar qualifications
- secure emergency cross-border working between Northern Ireland and the Republic of Ireland, as set out under Additional considerations, below
- increase regulator flexibility in accepting European qualifications where patient safety concerns exist, or where divergence occurs as a result of new qualifications being added to the EU Mutual Recognition of Professional Qualifications Directive 2005 (MRPQ Directive) annex
Extending the standstill provisions would allow time to explore the legislative improvements suggested by regulators in the consultation and the viability of delivering them in the next 2 to 3 years.
Retained EU law
The Retained EU Law (Revocation and Reform) Bill 2023 was introduced to Parliament on 22 September 2022. The bill will assimilate retained EU law into domestic law on 31 December 2023 unless it is included in the bill’s revocation schedule or revoked ahead of this date. The bill also makes it easier to modify retained EU law by downgrading the status of retained direct EU legislation and granting powers to amend, revoke and replace retained EU law until 2026.
The EU Exit Regulations themselves do not fall within the scope of the bill, but some of the provisions that give effect to the EU Exit Regulations are retained EU law. This interconnecting retained EU law related to professional qualifications is not listed in the bill’s revocation schedule. As such, unless further action is taken to revoke the retained EU law relevant to the standstill provisions, it will be assimilated into domestic law on 31 December 2023.
The findings of the review of the standstill provisions, therefore, also decide whether the department will amend, revoke or replace retained EU law in professional qualifications.
Wider regulatory reform
The Department for Health and Social Care is currently undertaking a wider regulatory reform programme that will make significant changes to professional regulation legislation. This includes giving regulators greater flexibility to improve their existing international registration processes, while maintaining their focus on robust public protection.
This programme provides opportunities in future to make targeted reforms to the standstill provisions on an individual regulator basis.
Devolution and the Windsor Framework
Most of the identified legislation in this area is reserved to UK government. However, the Scottish Government has devolved competency for post-2006 professions and professional regulation is a transferred matter in respect of Northern Ireland (NI).
Engagement with devolved governments on the review options showed a clear preference for retaining the standstill provisions to ensure operational stability and UK-wide cohesion across the regulatory landscape.
In the absence of a Northern Ireland Executive, the Northern Ireland Department of Health’s Permanent Secretary has powers to take limited decisions if previously agreed to by the Northern Ireland Health Minister. If the EU Exit Regulations were reformed or revoked, it would constitute a policy change for Northern Ireland, requiring sign-off from the Executive. Therefore, there would be NI-GB divergence until an Executive is reformed.
Some healthcare services in the Republic of Ireland operate on an all-island basis, which may involve cross-border practice. This means that there are times when medical practitioners based in the Republic of Ireland will want or need to practise across the border in Northern Ireland.
Before the UK left the EU on 31 December 2020, Section 18 and Schedule 2A of the (then current) Medical Act 1983 provided a pathway to temporary and occasional full registration for visiting medical practitioners from EEA member states. This pathway was a requirement of the Recognition of Professional Qualifications Directive (2005/36/EC) and gave medical practitioners who were lawfully established in another member state an entitlement to provide temporary and occasional services in the UK.
Medical practitioners who gained temporary and occasional registration under Section 18 were exempt from registration fees and revalidation and could renew their registration every 12 months. Temporary and occasional registration allowed medical practitioners to practise across the whole of the UK, but this registration type was also occasionally used by medical practitioners based and practising primarily in the Republic of Ireland to work on a temporary and occasional basis in Northern Ireland.
Post-EU Exit, medical practitioners based in the Republic of Ireland who want to work in Northern Ireland need full General Medical Council registration, as they will be working in the UK. If their practise in Northern Ireland is permanent or regular, they are therefore required to apply for full permanent UK registration. Following EU Exit and the removal of temporary and occasional arrangements, regulators’ legislation does not support healthcare professionals needing to work in Northern Ireland on an occasional or ad hoc basis, to provide emergency care.
If the EU Exit regulations were to be reformed or revoked, further legal analysis would be required on the impact of the Windsor Framework, but it is also expected that separate policy and operational guidance would be required for healthcare professionals based in the Republic of Ireland who want or need to practise in Northern Ireland without the need to be dual-registered in both jurisdictions.
Consideration may also need to be given to whether to establish a new route to registration for EEA and Swiss professionals by amendment to the Medical Act 1983, and the Nursing and Midwifery Order 2001, which are reserved.
The evidence considered throughout the review, including stakeholder engagement, collated data and the wider policy considerations, leads us to conclude that option B will provide the optimal outcome for patients, regulators and the wider healthcare workforce.
Retaining the standstill provisions for a temporary period of 5 years, will support the department’s ambition to attract and recruit overseas healthcare professionals, without introducing complex and burdensome registration routes.
EEA qualified healthcare professionals will be able to continue to register with the relevant professional regulator, without the need to sit additional professional exams, mitigating delays to registration and employment in the NHS.
In pursuing option B, the department will:
- explore the legislative improvements suggested by regulators in the consultation and the viability of delivery between 2024 and 2026
- determine what is required to establish emergency cross-border working arrangements on the island of Ireland
- determine whether to carry out a further review of the operation of the standstill provisions in 5 years’ time, as part of the wider programme of regulatory reform
Annex A: listed provisions in Regulation 14 of the EU Exit Regulations
|Reserved or devolved
|The Medical Act 1983 (Amendment) Order 2002
|Implements Directive 2001/19/EC and Directive 93/16/EEC
|Reserved to UK government
|Postgraduate Medical Education and Training Order of Council 2010
|Eligibility criteria for entry in the GP or specialist register-implements Directive 2005/36/EC
|Reserved to UK government
|Pharmacy Order 2010
|Established the General Pharmaceutical Council for Great Britain
|Nursing and Midwifery Order 2001
|Framework for regulation of nursing and midwifery and established the Nursing and Midwifery Council
|Reserved to UK government
|European Primary and Specialist Dental Qualifications Regulations 1998
|Makes provision about training for specialist dental qualifications and the recognition in the United Kingdom of specialist dental qualifications awarded elsewhere
|Reserved to UK government
Annex B: list of regulatory bodies engaged
General Chiropractic Council
General Dental Council
General Medical Council
General Optical Council
General Osteopathic Council
General Pharmaceutical Council
Health and Care Professionals Council
Nursing and Midwifery Council
Pharmaceutical Society of Northern Ireland
Social Work England
Based on 2021 and 2022 data. This figure does not include the additional annual average of 1,119 applicants to the HCPC, as the HCPC collects data based on nationality, rather than the country of qualification. ↩