Guidance

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

Updated 27 March 2025

Definitions

Active international recruitment

‘Active international recruitment’ is the process by which UK health and social care employers (including local authorities) and any other organisation involved in the recruitment (including but not limited to 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 in person and online approaches whether or not these actions lead to substantive employment.

This can include (but is not limited to):

• advertising to candidates through any medium. This includes asking current international employees to share information about vacancies with friends or family in red list countries
• 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

Where a candidate has already been appointed to a specific role by a UK employer following an independent direct application (defined below), recruiting organisations can support and facilitate the employee’s passage to the UK. If required, it is the responsibility of the recruitment organisation, agency or collaboration to provide evidence that the services they are providing are permitted under this exception.

Direct application

A ‘direct application’ is when an individual makes an application to a specific advertised role on their own behalf to an employing organisation. 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 code red and amber list (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 specific advertised vacancy that is hosted by, and recruited to, the same sponsoring organisation.

Resident

‘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 where an individual is residing when they apply for a health or social care job, rather than the nationality of the individual or their original country of training.

Contracting bodies

‘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.

Employer

An ‘employer’ means the person or organisation that employs (or employed) an employee.

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. 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 collaboration

A ‘recruitment collaboration’ or ‘collaboration’ is a group of organisations that have partnered together to pool resources to recruit candidates for vacant positions within that collaboration. This can be 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.

Recruitment organisation

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.

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
• 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, recruitment 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 World Health Organization (WHO).
2. To prevent active recruitment to the UK from countries on the code red list (see ‘Annex A: red and amber list countries’ below) unless there is an overriding 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

The 3 elements to the code of practice are:

• 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 governments

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 governments adheres to the aims, objectives, guiding principles and best practice benchmarks of the code of practice. The ethical recruiters list is managed on a UK wide basis.

To reflect the different organisational structures, there is a separate:

• code of practice for Northern Ireland
• code of practice for Scotland

Wales follows the code of practice for international recruitment for England.

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
• anaesthesia associates
• care workers and senior care workers
• dentists
• doctors
• healthcare scientists
• midwives
• nursing staff
• optometrists
• opticians
• pharmacists
• physician associates
• residential and domiciliary care workers
• social workers
• support staff

Organisations which must adhere to the code of practice when undertaking international recruitment activity to appoint health and social care personnel include:

• all UK health and social care employing organisations (including local authority and integrated care systems), both public and independent. This includes ensuring compliance where:
  • NHS and social care commissioners are setting up local contracts with independent providers
  • national contracts are signed with the independent sector to increase capacity in the NHS or social care sector
• 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

The Department of Health and Social Care (DHSC):

• works with the devolved governments 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 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
• provide 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 and regulatory bodies, for further support, advice and guidance
• use recruitment organisations, agencies, or collaborations on the ethical recruiters list. The list should be used and checked on a regular basis by all health and social care organisations engaged in international recruitment, both in the public and independent sectors
• should ensure that adherence to the code of practice is a contractual obligation of sub-contractors

NHS England:

• leads international recruitment programmes and provides coordination of NHS employers’ international recruitment plans
• provides advice and support as required to NHS employers to help them to follow the guiding principles of the code of practice in all their recruitment activities
• working with NHS Employers, provides guidance on facilitators and barriers to ethical international recruitment, English language acquisition and oversight for induction and pastoral care of international recruits
• establishes institutional partnerships and education exchange schemes to ensure recruitment is managed and mutual benefits are derived

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
• join the ethical recruiters list and operate in accordance with the code of practice

• follow 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 statutory regulators
  • ensure all staff involved in the recruitment of health and social care personnel are aware of and adhere to the code of practice

WHO:

• 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 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 in 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 strategy to ensure the NHS has the workforce it needs. Work is underway to support greater numbers of domestically recruited health and social care staff through training, improving retention and encouraging staff who have left to return, to achieve a sustainable health and social care workforce which reflects the population it serves and can remain 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. 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 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 bilateral agreements on health worker migration and mobility 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.

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 WHO

4. Recruitment of international health and social care personnel is monitored through published immigration, regulator and employer data

DHSC will continue to monitor data on health and social care international workforce flows alongside other government departments, devolved governments and employer stakeholders including NHS England and NHS Employers. Information will be analysed to understand the country of origin of recruits.

DHSC and the Foreign, Commonwealth and Development Office (FCDO) will continue to share information with the UK’s FCDO diplomacy network. DHSC also shares reports with 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 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 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 if the role is regulated by UK law.

The opportunity to enhance skills and experience are important to 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

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.

These best practice benchmarks should be read in conjunction with NHS Employers’ international recruitment toolkit. The toolkit is designed to embed 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 and amber country list is available in Annex A below and on the NHS Employers website. The red list is drawn from the WHO Health Workforce Support and Safeguards List 2023. No active recruitment of health and care staff will be undertaken from countries on the red list. 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.

Employers and recruiting organisations 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 a direct 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.

Guidance on how employers can publicise international recruitment activities while keeping in line with the code of practice is provided by NHS Employers.

International recruitment 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.

A recruitment organisation, agency or collaboration may 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.

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.

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.

NHS Employers will share organisation information (including name and postcode) with frameworks, DHSC and the Employment Agency Standards Inspectorate (EAS) for the purposes of adding and removing organisations on the ethical recruiters list.

The employer will be fully involved in the recruitment process.

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 organisation charging fees to an individual for a work-finding service should be reported to EAS using the contact details provided in Annex E.

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 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 incurred by a candidate 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.

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, before the selection interview.

Employers and contracting bodies must undertake the necessary checks to ensure any English language test results are verified and genuine using the available online verification services.

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 this is required to meet the demands of the post.

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.

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 body. 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 start the registration process in good time, ideally 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 into upcoming demand for registration supports the regulatory body to manage capacity.

Employers and contracting bodies must ensure that they have received confirmation of professional registration, including notification of any stipulated period of supervised practice, from the candidate before they take up the post.

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

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

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

Newly appointed staff must be appropriately supervised and the employer must ensure the workplace supports all staff to demonstrate their competence.

Employees 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.

Staff will have appropriate opportunities to reach the required standard for UK registration, and will be objectively and fairly assessed.

International health and social care personnel will undergo the normal occupational health assessment before starting 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 that thorough and sensitive individual risk assessments are conducted for all new international migrants before they work in a clinical environment.

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 the 6 checks 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 CQC the information set out in schedule 3, which sets out 8 categories of information required to be kept by providers about all people 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, caution or binding over where relevant to the role. 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.

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

Overseas recruits 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 and recruiting organisations 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

Care workers and senior care workers on a Health and Care Worker visa are not eligible to bring dependents to join them unless they are on a Health and Care Worker visa that they applied for before 11 March 2024.

Appropriate information about the post being applied for will be made available so candidates can make informed decisions

Candidates will be provided with all the relevant information about the post they have applied for, before they accept it, to enable them to make informed decisions.

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 for candidates and dependents, and an understanding of current restrictive immigration rules, including the rules on sole responsibility and adult dependency
• professional registration processes (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 in a timely manner.

Recruiters, contracting bodies and employers must observe fair and just contractual practices

On making the job offer, employers and recruiting organisations 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’s terms and conditions must not be made without prior signed consent of the staff member. 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 staff. 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.

Repayment clauses must be transparent, proportionate, time-limited and flexible

Repayment clauses may be included in 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.

Repayment clauses must be clearly set out in writing in the employment contract and abide by the principles of:

• transparency
• proportionate costs
• timing
• flexibility

To be transparent:

• 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 before they arrived in the UK

To ensure costs are proportionate:

• 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

To ensure the timing of repayment clauses is appropriate:

• 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

To be flexible:

• employers should consider when they levy the repayment clause and take individual circumstances into account. 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

Further guidance on the use of repayment clauses in employment contracts is available on the NHS Employers website.

Newly appointed employees will be offered appropriate support and induction. Employers and contracting bodies should undertake pre-employment and placement preparation 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 staff member arrives.

The potential financial position of health and social care employees should be considered.

Employers should ensure diversity and inclusion policies are appropriate and that employees understand their duties to abide by them, encouraging a compassionate and inclusive culture. 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/or social care system. The provision of a mentor can be helpful. The 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. They should cover:

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

Employers and recruitment organisations 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 is 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.

International recruitment activities should be recorded to 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.

Organisations on the ethical recruiters list are required to submit timely and accurate data on recruitment activity when requested by NHS Employers or UK statutory regulators. All organisations on the ethical recruiters list must respond to the NHS Employers data collection of recruitment activities when requested, to aid in monitoring of the code of practice.

Failure to respond will result in removal from the ethical recruiters list, without the need for an independent panel.

Submission of 3 consecutive nil returns to the NHS Employers data collection will result in removal of the organisation from the ethical recruiters list, without the need for an independent panel. Organisations are permitted to reapply as soon as they are able to recruit internationally.

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

Illustrative scenarios

The scenario examples below set out examples of how the guidance in the code and its definitions can be applied in practice. The examples are not an exhaustive list, but illustrate the types of conduct that are:

• in breach of the code (scenarios 1 to 8)
• permitted under the code (scenarios 9 to 12)

Scenario 1 - advertising in a red list country

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 is active recruitment and contravenes the guiding principles within the code of practice.

Scenario 2 - active recruitment not leading to substantive employment

An agency runs a virtual 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 - recruitment organisation and red list applicants

A social care provider is recruiting on behalf of several 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 is 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 4 - agencies and candidates residing in red list countries

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 is 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 5 - repayment clauses

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.

Scenario 6 - advertising to candidates who have been previously short listed for another vacancy

An NHS trust advertises a vacancy and receives 610 direct applications. It appoints one successful candidate and keeps a short list of those who applied and met the criteria. All the applicants are resident in countries on the red list. When advertising another role, the recruiting manager contacts those on the short list and invites them to apply. This is active recruitment and contravenes the guiding principles within the code of practice.

Scenario 7 - friends and family referrals from red list countries

A recruiting manager sends an email out to all staff and asks them to share details of a vacancy with friends and family, irrespective of whether those friends and family are situated in a red list country. This results in candidates in red listed countries being made aware of the job and applying. This is active recruitment and contravenes the guiding principles within the code of practice.

Scenario 8 - contracts with third party providers (sub-contractors)

An NHS trust contracts with an external provider to perform physiotherapy services within the trust. The external provider has advertised vacancies in Zimbabwe, which led to the successful appointment of a member of staff from Zimbabwe. This member of staff is employed by the external provider to provide physiotherapy services within the NHS trust. They are not employed directly by the NHS trust. However, independent providers are covered by the code of practice, and this is active recruitment and contravenes the guiding principles within the code of practice. The NHS trust has a responsibility to ensure that the third party provider adheres to the code of practice, and this should feature in the contractual obligations between the trust and the third-party provider.

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

Scenario 9 - applicants with red list nationality resident in green list countries

A doctor from Haiti - a red list country - is resident in Canada. 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 10 - agency supporting recruitment following a direct application and appointment

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 11 - a trust part of a collaboration advertising independently of the collaboration

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 12 - direct applications

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.

Code of practice red, amber and green countries

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 red list should not be actively targeted for recruitment unless there is a government-to-government agreement in place to allow managed recruitment undertaken strictly in compliance with the terms of that agreement. The agreement may set parameters, implemented by the country of origin, for how UK employers, contracting bodies and agencies recruit.

If a government-to-government agreement is put in place between the UK and a partner country, which restricts recruiting organisations to the terms of the agreement, the country is added to the UK’s 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.

Individuals from red or amber list countries can make a direct application to UK employers of their own accord. They must not be 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 FCDO to understand the causes and impact of this activity and consider taking appropriate supportive actions.

Red, amber and green grading of countries

Whether active recruitment is permitted from a country is determined by its red, amber or green 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.

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 bilateral agreements into account.

Health workforce development and health systems sustainability

WHO estimates a projected shortfall of 11 million health workers 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 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 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 will depend on the partner country’s health workforce needs and context.

Government-to-government agreements:

• provide opportunities for collaboration and mutual benefit
• 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
• 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 MoU

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
• they are supported to reach their full potential
• their mental and physical wellbeing is protected

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

NHS England - educating, training and developing the health workforce

NHS England 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 NHS England and the Consortium of Thai 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: NHS Humber and North Yorkshire Integrated Care Board partnership with the Kerala state

NHS Humber and North Yorkshire Integrated Care Board has supported an ethical and mutually beneficial partnership arrangement between Norka Roots – the Kerala state representative agency body and a number of NHS trusts across Yorkshire and the Humber.

The MoU was signed in October 2022 followed by a number of recruitment events in Kerala.

The MoU is enabling a safe migration pathway for the recruitment of clinicians, including nurses, doctors and allied health professionals, reducing agency costs and enabling the partnered organisations to collaborate and support each other in research, staff exchanges and training.

Case study 4: 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 NHS England and sponsored by the Academy of Medical Royal Colleges, it provides up to 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
• other UN agencies

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

Case study 5: Global Health Workforce Programme

The UK is providing £20 million ODA through the Global Health Workforce Programme to optimise, build and strengthen health workforces in Ghana, Kenya, Nigeria, Malawi, Ethiopia and Somaliland. The programme aims to make a real difference in strengthening the performance of health systems through:

• funding WHO to provide strategic support to country governments to supply evidence-based workforce plans and capacity building
• funding Global Health Partnerships (formerly THET) to deliver health partnerships between the UK and these countries to improve curriculum, regulation and retention

This supports health outcomes, UHC and global health security.

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, known as the ethical recruiters list.

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. Information on the application process for the ethical recruiters list is available on the NHS Employers website.

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

The process for monitoring organisations and their adherence to the code of practice is set out on the NHS Employers website.

Health or social care organisations are encouraged to check the ethical recruiters list before working with any employer, organisation or collaboration. This is to ensure the organisation in question remains on the ethical recruiters list at the time of any recruitment exercise.

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.

Information on any breach will be shared with EAS. Information on removals will be shared with framework providers following the resolution of the appeals procedure or after the time limit for submitting an appeal has passed. Organisation information, such as names and postcodes, will be shared with DHSC, EAS and relevant framework providers only to enable accurate record matching and removal from the framework. Users of the ethical recruiters list may be notified that the list has been updated, but no organisations will be named.

Failure to respond to the data collection from NHS Employers will result in removal from the ethical recruiters list, without the need for an independent panel.

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 before 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
• cardiothoracic 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
• genitourinary 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. This applies to all recruitment organisations, agencies and collaborations listed on the ethical recruiters list. 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 NHS England, and possible additional investigations if activities were supported by a recruitment organisation, agency or collaboration as outlined below.

If you have any concerns about potential breaches to the code, contact internationalrecruitment@nhsconfed.org.

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 checking the result of the knowledge test the organisation took 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 decide to:

• close the informal investigation
• give the organisation an opportunity to correct their behaviour by giving an informal warning and making additional spot checks
• begin the formal procedure

Formal stage

Where a formal investigation is required, any relevant information (including data submissions, 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 the organisation under investigation 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 DHSC, which may include temporary or permanent removal from the ethical recruiters list. Other sanctions may include:

• the organisation remaining on the ethical recruiters list, but being 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 as well as completing the full application process.

The organisation will either be accepted or declined.

If declined, the organisation will need to wait an additional 12 months before re-applying. If there have been persistent infringements, or a particularly severe or repeated breach contravening the code of practice, this could lead to an increased ban on re-applying of up to 3 years, or a permanent ban.

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 the reason why they believe the sanction to be inappropriate, unproportionate and/or unfair within 10 working days.

The purpose of the appeal procedure is to review the process and reason for the sanctions imposed, including the decision to remove an organisation from the list, when the organisation believes the process was improperly administered or the decision was unjustified. The purpose of the hearing is not for the appeal panel to rehear the evidence presented to the independent panel hearing.

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 normally 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 whether:

• the primary investigators clearly demonstrated that on the balance of probability a breach or breaches of the code of practice has taken place and the sanction imposed, such as the decision to remove the organisation from the ethical recruiters list, is proportionate
• there is any possibility that the information on which the original decision was based is incorrect
• the organisation has been given an opportunity to respond and provide an explanation of their actions
• the organisation disproved the evidence or raised serious doubt about its validity
• the process has been handled appropriately by the investigation team and the independent panel

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.

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:

• calling the Acas helpline
• completing the online form to complain about pay and work rights

Gangmasters and Labour Abuse Authority

The Gangmasters and Labour Abuse Authority (GLAA) 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. You can report issues to GLAA either by telephone or email.

Employment Agency Standards Inspectorate

EAS 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. You can contact EAS using the contact details on the EAS website, or complete the online form to complain about pay and work rights.

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

Modern slavery and exploitation helpline

The charity Unseen operates the UK modern slavery and exploitation helpline for anyone to report concerns or get information, advice and guidance about any modern slavery issue.

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 CQC. Before contacting 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

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. Anyone can report a concern to CQC about an experience of care, or a concern about a service they work for.

Further support

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

A list of international nursing and midwifery associations is provided on the NHS England website.

A list of international doctor associations is provided in Annex A of Applying for health and social care jobs in the UK from abroad, part 2: living and working in the UK - what you need to know as a health and care worker.

If you work in the adult social care sector and your sponsor has had their licence revoked, support is available in your local region. Read the guidance on the support offer to international adult social care workers whose employer’s sponsor licence has been revoked for more information.

Annex F: professional regulator details and links to further guidance

General Chiropractic Council (GCC)

Regulates chiropractors

How to register with GCC

General Dental Council (GDC)

Regulates:

• dentists
• clinical dental technicians
• dental hygienists
• dental nurses
• dental technicians
• dental therapists
• orthodontic therapists

GDC: online contact form

How to register with GDC

General Medical Council (GMC)

Regulates medical practitioners

How to register with GMC

Information to help employers understand their obligations around employing and contracting with doctors

General Optical Council (GOC)

Regulates:

• optometrists
• dispensing opticians

How to register with GOC

General Osteopathic Council (GOsC)

Regulates osteopaths

How to register with GoSC

General Pharmaceutical Council (GPhC)

Regulates pharmacists and pharmacy technicians in Great Britain (England, Wales and Scotland)

How to register with GPhC

Health and Care Professions Council (HCPC)

Regulates:

• arts therapists
• biomedical scientists
• chiropodists or podiatrists
• clinical scientists
• dietitians
• hearing aid dispensers
• occupational therapists
• operating department practitioners
• orthoptists
• paramedics
• physiotherapists
• practitioner psychologists
• prosthetists or orthotists
• radiographers
• speech and language therapists

How to register with HCPC

Nursing and Midwifery Council (NMC)

Regulates:

• registered nurses and midwives
• nursing associates in England only

How to register with NMC

NMC: information for employers

Social Work England (SWE)

Regulates social workers in England

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 midwives

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 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, 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.

Employers can consult NHS Employers’ guidance on the process for reclaiming expenses from individuals recruited from overseas who leave your employment.

Support information for the code of practice

NHS Employers has a range of support materials on the code of practice, including:

• a quick guide to support your understanding of the code of practice for the International Recruitment of Health and Social Care Personnel
• frequently asked questions on the code of practice for those on the ethical recruiters list, health and care employers, and international recruits
• international recruitment top tips for employers working with recruitment organisations, agencies or collaborations
• information on the application process for the ethical recruiters list and how the list is monitored

Social care

Skills for Care hosts information and guidance supporting providers across adult social care to recruit from overseas ethically. This includes the international recruitment toolkit for social care aimed at social care providers in England.

Adult social care workers who have been affected by sponsor licence revocation should contact their regional partnership using the details in the guidance above on the support offer to international adult social care workers whose employer’s sponsor licence has been revoked.

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