These frequently asked questions on the Code of Practice for International Recruitment have been split into three categories.
- Purpose and scope of the Code of Practice.
- Recruitment organisations, agencies, or collaborations on the Ethical Recruiters List.
- Employers and international recruits.
We hope you find these useful and please get in touch with the team if you have further questions.
Purpose and scope of the Code of Practice
The UK and the devolved administrations are committed to recruiting ethically from outside the UK. The Code of Practice implements the World Health Organisation (WHO) Code of Practice. The WHO Global Cope of Practice promotes voluntary principles and practices in the ethical recruitment of international health and social care personnel within member states and advances focus on international cooperation and health system strengthening. For further information about the WHO Global Code, please visit the WHO website.
The Code of Practice applies to all UK health and social care employers (including the NHS, social care, the private sector and local authorities), contracting bodies and recruitment organisations, agencies, and collaborations internationally recruiting to the UK. It applies to the appointment of all health and social care personnel recruited internationally to the UK, such as medical staff, nursing staff, midwives, doctors, dentists, healthcare scientists, allied health professionals, care workers, senior care workers, social workers, residential and domiciliary care workers and support staff.
Yes. The Code of Practice applies to all recruitment agencies supplying health and social care personnel. This includes permanent, locum and temporary employment.
The Code of Practice ensures we uphold the most stringent of ethical international recruitment and employment practices in the UK. This means both protecting the well-being of our international recruits and the health systems of the 47 countries on the WHO Health Workforce Support and Safeguard List 2020. The Code includes these countries on its red list, where active, targeted recruitment should not take place. unless there is a government-to-government agreement to support managed recruitment activities that are undertaken strictly in compliance with the terms of that agreement.
The updated Code goes further to strengthen the UK's approach to ethical international recruitment and responds to new areas of concern, including:
- ensuring consistency and fairness in employment contracts and on the use of repayment clauses
- setting out the routes of escalation for concerns about exploitative recruitment or employment practices and breaches of the code
- ensuring international recruits are provided with the right level of information to enable an informed decision on whether to accept a health or social care job in the UK.
The fundamental core Code principles remain the same. These include banning active recruitment from 47 red listed countries identified by the WHO as having the most pressing health workforce challenges, whilst protecting an individuals’ right to migrate if they make direct applications to vacancies independently.
The UK is committed to working in partnership with and learning from other countries to improve both global and UK health outcomes. Since the Code was last published, the UK government has increased their partnership work through signing mutually beneficial government-to-government agreements with several countries to encourage migration to the UK in a managed way.
No, the red list of 47 countries has not changed. The red list is aligned with the WHO Health Workforce Support and Safeguards List, 2020, which is updated by the World Health Assembly every three years. The next review is expected to take place in 2023.
The red list may also be updated on an ad hoc basis, for example, in response to new government-to-government agreements being signed. When this happens, the country is moved to the amber list, and recruitment may occur only on the terms of the agreement.
Government-to-government agreements will be developed in line with WHO guidance on bilateral agreements and based on the latest evidence, this includes for those on the red list, a health labour market analysis.
The WHO has identified countries with the most pressing Universal Health Coverage-related health workforce needs and these countries are included on the WHO Health Workforce Support and Safeguard List, 2020.
The countries on the list have a Universal Health Coverage service coverage index that is lower than 50 and a density of doctors, nurses and midwives that is below the global median (48.6 per 10,000 population).
Two new best practice benchmarks were added to the Code of Practice in the August 2022 update:
Recruiters, contracting bodies and employers must observe fair and just contractual practices in the employment of international health and care personnel.
This benchmark was added to set out clearly what fair practices are expected to be adhered to by recruiters, contracting bodies and employers when issuing an employment contract.
This includes clarifying that contract substitution – where a contract is changed to less favourable terms and conditions without the consent of the health and care personnel is a breach of the Code of Practice.
Any repayment clause included in an employment contract must abide by the 4 principles of transparency, proportionate costs, timing and flexibility.
International recruitment often requires a great deal of investment from employing organisations, and repayment clauses may sometimes be used in health and social care employment contracts to recover some of these upfront costs if an employee leaves within a given period. This benchmark was added to ensure international health and social care staff are protected against unfair, inconsistent and punitive repayment clauses.
Ethical overseas recruitment ensures a high standard of recruitment practice for overseas recruits and that international recruitment does not weaken the health system of the country of origin or exacerbate existing workforce shortages.
Individuals have the right to migrate for economic or social purposes and the UK should not be seeking to prevent this. Where individual healthcare and social care personnel resident in countries on the WHO Health Workforce Support and Safeguards List 2020 want to move to the UK to work, they can make a direct application to a health and social care employer for a job independently and of their own accord.
NHS Employers maintains the Ethical Recruiters List. Organisations on this list adhere to the guiding principles and best practice benchmarks within the Code of Practice. We also work with employers in the NHS, social care, and independent settings to ensure they recruit ethically from overseas. Health and social care employers must recruit through recruitment organisations, agencies, and collaborations on the Ethical Recruiters List.
The dedicated team who maintains the Ethical Recruiters List performs annual agency reviews and regular spot checks to ensure recruitment organisations, agencies, and collaborations on the list maintain their standards and commitment to the Code. If breaches occur, the team can investigate the organisation and if necessary, an independent panel can decide on any appropriate sanctions. These sanctions can be found in the recruitment organisation, agency or collaboration section of these FAQ’s below and within the Code of Practice.
Although NHS Employers maintains the Ethical Recruiters List, the list should be used by all health and social care organisations engaged in international recruitment, both in the public and independent sectors.
The UK Code of Practice implements the principles set out in the World Health Organisation (WHO) Global Code of Practice on the international recruitment of health and social care personnel.
The Code of Practice belongs to the Department of Health and Social Care and has been in existence since 2001. It was last updated and re-published on 2 August 2022. Each of the UK’s four nations’ devolved administrations adhere to the Code of Practice but have their own Code to reflect individual structures. NHS Employers’ role is to hold the list of Ethical Recruiters List of organisations that adhere to the Code, process applications, undertake routine monitoring, and report back to the Department of Health and Social Care.
It is therefore recommended that recruitment organisations, agencies, collaborations and employing organisations refer to ‘adhering to the Code of Practice for the International Recruitment of Health and Social Care Personnel’, and do not indicate that the Code belongs to NHS Employers by use of name or logo.
The Code does not discriminate against individuals based on their nationality. Ethical recruitment is determined by the country from which the individual is being recruited, rather than the nationality of the individual.
All individuals have the right to migrate for economic or social purposes and the Code does not prevent this. Individuals resident in a country on the Code of Practice red list can make a direct application to health or social care employers by using, for example, NHS Jobs or the Everyday is Different campaign for social care, and can expect equitable and fair treatment during the process like any other applicant. A direct application can only be made in response to a vacancy which is hosted by, and recruited to, the same sponsoring organisation.
By restricting active recruitment of health and social care personnel resident in countries on the red list but ensuring they can apply for jobs directly in the UK health and social care sector, the Code is balancing the mitigation of negative effects from migration on countries facing severe health workforce vulnerabilities with the rights health and social care personnel have to migrate.
A direct application is when an individual makes an application directly and on their own behalf to an employing organisation and not using a third party, such as a recruitment organisation, agency, or collaboration. The candidate must search, apply, interview, and accept the job offer for a role to an employing organisation to be considered direct. A direct application can only be made in response to a vacancy which is hosted by, and recruited to, the same sponsoring organisation.
It is only once a candidate has accepted a job offer, following a direct and independent application to the employing organisation, that a recruitment organisation, agency, or collaboration could be approached by that employing organisation to support with further administration relating to their move to the UK.
The intention of the Code of Practice is to safeguard health and social care workforce in countries with the most pressing needs. It is not intended to restrict nationals of any country from accessing opportunities. Therefore, the Code refers to the country of residence for any international candidate, rather than the candidate’s nationality.
For example, active recruitment is currently permitted in India. However, Nigeria is currently on the red list where no active recruitment is permitted. If an Indian national who is resident in Nigeria approaches a recruitment agency for support, an agency is not permitted to support that candidate into a health or social care role in the UK before a job offer is made by an employing organisation. If, however, a Nigerian candidate resident in India approaches a recruitment agency for support, that agency would be permitted to work with that candidate to secure a health or social care role in the UK.
The Department of Health and Social Care (DHSC) announced that from 11 November 2021 Kenya will be added to the amber list of countries in the Code of Practice for the International Recruitment of Health and Social Care Personnel in England. This means employers and recruitment agencies, including NHS trusts, must stop all active recruitment of health and social care professionals from Kenya to the UK with immediate effect.
If employers have already given a conditional offer to health/social care personnel from Kenya on, or prior to, 11 November 2021, you may continue with the recruitment process. This recognises the investment which has already been made to get the candidate to this stage of the recruitment process and will ensure candidates who are fully expecting to be able to move to the UK to work are treated fairly. While Kenya is not on the WHO Health Workforce Support and Safeguards List, it remains a country with significant health workforce challenges. Adding Kenya to the amber list in the Code will protect Kenya from unmanaged international recruitment which could exacerbate existing health and social care workforce shortages.
The UK and Kenya signed a Bilateral Agreement in July 2021 to provide a framework for future international recruitment. The detailed guidelines for how employers and agencies will be able to ethically recruit health and social care professionals from Kenya to the UK are currently being developed and will be published in due course.
On 22 August 2022, the governments of Nepal and of the United Kingdom signed a Memorandum of Understanding (MOU) on the managed and ethical recruitment of Nepalese healthcare workers to the UK as part of a trial.
The MOU will enable the managed recruitment of Nepalese healthcare workers to a single NHS trust, Hampshire Hospitals NHS Foundation Trust for an initial pilot phase lasting approximately 15 months.
This is the first health worker recruitment agreement signed with a country on the WHO Health Workforce Support and Safeguards List 2020.
For other health or social care employers (including NHS trusts, private providers, social care organisations, or local authorities) or organisations on the Ethical Recruiters List, the MOU does not allow active recruitment from Nepal. Therefore, any active recruitment from Nepal operating outside of the terms of the MOU would be deemed a breach of the Code of Practice.
Further information can be found in this latest news.
Recruitment organisations, agencies, and collaborations (Ethical Recruiters List)
For the purpose of the Code of Practice active international recruitment is defined as the process by which UK health and social care employers (including local authorities), contracting bodies, recruitment organisations agencies, collaborations and sub-contractors target individuals, either physically or virtually, to market UK employment opportunities, with the intention of recruiting to a role in the UK health or social care sector, whether or not it leads to substantive employment.
This can include, but is not limited to, advertising to candidates through all types of communication mediums, incentivisation activities such as referral bonus schemes, and 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.
Other examples of active recruitment include referring candidates who are currently resident in red list countries to an employing organisation, even if they have approached the agency directly. Organisations, agencies, and collaborations should also be vigilant to online activity, particularly responses to social media and web enquiries. If your website enables CVs to be submitted, an agency should include a supporting statement that applications from individuals resident in countries on the Code of Practice red list cannot be accepted.
The only exception to this definition is where a candidate has already been appointed by a UK employer following an independent direct application and selection without the support of a recruitment organisation, agency, or collaboration, as defined below. In this case, if required, these organisations can support and facilitate the employee’s passage to the UK. In such cases it is the responsibility of the recruitment organisation, agency, or collaboration, if challenged, to provide evidence that the services they are providing are permitted under this exception.
Recruitment organisations, agencies, and collaborations that supply international health and social care staff to the UK need to appear on the Ethical Recruiters List.
An employment agency is a business that recruits candidates for vacant positions (permanent or temporary), for health and social care employers in need of personnel.
A recruitment organisation is an organisation that recruits candidates for vacant positions (permanent or temporary) on behalf of a health or social care employer whether or not it is on a commercial basis.
A recruitment collaboration is a group of organisations which have partnered together to pool resources into a central system to recruit candidates for vacant positions within that collaboration, whether or not it is on a commercial basis.
All of the definitions about come under the statutory definition set out in the Employment Agencies Act 1973 section 13(3).
The types of organisations that are required to appear on the Ethical Recruiters List was expanded in the August 2022 update of the Code. This was to ensure that the broad range of recruitment models that are in exitance are reflected in the Code.
Details on how to apply to the Ethical Recruiters List can be found in the application section which details the multi-stage application process.
- The first is an online application form. The application form confirms:
- commitment to fully adhere to the and comply with Employment Agencies Act 1973 and associated conduct regulations.
- business practices
- a declaration of all associated business activities and references relating to the recruitment of health and social care professionals.
- permission for the Employment Agencies Standard Inspectorate to share details with DHSC and NHS Employers of any inspection and remedial action taken.
- After submitting the online application form, applicants will need to complete a knowledge test. This will consist of 15 questions, requiring a pass rate of 13/15. This will confirm that applicants have read and understood the code of practice and how it is applied in different settings.
- NHS Employers will contact the EAS Inspectorate to share details with DHSC and NHS Employers of any inspection and remedial action taken.
If, after assessment of information from the EAS Inspectorate, the application, knowledge test, and resolution of any queries, an organisation is not successful in being placed on the Ethical Recruiters List, they will be advised of the reason in writing via email. Organisations have three attempts at the knowledge test. If an organisation does not pass the third attempt, it must wait 3 months before it can re-apply and must show that it has changed its business practice to be placed on or back on the list.
The organisation responsible for processing applications and monitoring the Ethical Recruiters List reserves the right to introduce a fee for recruitment organisations, agencies, or collaborations to be on the Ethical Recruiters List for the Code of Practice at a future point in time.
NHS Employers aims to process applications within 10 working days of receipt of information received from the EAS Inspectorate.
No. Referral bonus schemes are deemed to be active recruitment and are not permitted in Code of Practice red list countries which can be found in annex A of the Code.
If you suspect or have evidence that an organisation is actively targeting or has targeted individuals from countries on the Code red list, please email the team. NHS Employers strongly encourages employers to share any information on Code of Practice breaches.
Recruitment organisations, agencies, or collaborations should not be targeting individuals or cohorts of potential staff using another organisation in a country which features on the Code red list. This contravenes the Code of Practice and NHS Employers encourage this information to be shared by emailing the team.
No, this is not okay. Significant trust is placed on sponsors, and they have a duty to act in accordance with the immigration rules. The Home Office sponsorship guidance on page 38 states: "If you are an employment agency, you can apply for a sponsor licence but only to sponsor migrant workers who will be directly employed by you in connection with the running of your business. You cannot sponsor a migrant if you will then supply them as labour, to another organisation, regardless of any genuine contractual arrangement between the parties involved."
NHS Employers will notify the Home Office if it is found an organisation is not acting in accordance with the immigration rules.
NHS Employers regularly monitor those on the Ethical Recruiters List and employing organisations’ recruitment activity. If a breach in the Code is detected, NHS Employers can impose a range of sanctions such as:
- monitoring the agency and organisation for a period of time
- a formal warning that a repeat or further breach could result in removal from the Code of Practice
- requirement of training, re-sitting the Knowledge Test, and subsequent evidence of training processes where staff have breached the Code of Practice
- notification to NHS England that a breach has taken place
- full removal from the Code of Practice for a period of time or permanently, with frameworks and NHS organisations to be notified.
If a recruitment organisation, agency, or collaboration is removed from the Code of Practice, this would impact their ability to recruit individuals into health and social care roles in the UK.
If a recruitment organisation, agency, or collaboration is on a framework and is subsequently removed from the Code of Practice, this could also affect their framework status.
An organisation will only be removed from the Ethical Recruiter List if, following a thorough investigation, it is identified that they are in breach of the Code of Practice. An organisation may appeal against this removal following the process set out in the Steps of Escalation at Annex B.
No. The Code of Practice explicitly states that a recruitment organisation, agency, or collaboration will not charge any applicant seeking employment within the UK any fee related to gaining such employment. Any recruitment organisation, agency, or collaboration registered within the UK charging fees to applicants will be in contravention of statutory employment agency legislation and will be reported to relevant authorities for further investigation. Employers should also satisfy themselves that UK recruitment organisations, agencies, or collaborations with whom they contract are not in any partnership agreement with recruitment organisations, agencies, or collaborations in other countries who allow fee charges to individuals solely for the purpose of placement within the UK.
No. Agencies, organisations, or collaborations must not refer any candidate resident in a country on the Code red list to any health or social care employer in the public or private sector. Instead, they can sign post the candidate to the NHS Jobs portal or the Everyday is Different campaign and advise candidates they must find and apply for a vacancy and be offered the position of their own accord.
If a recruitment organisation, agency or collaboration is operating under a different name to its parent company or is a trading arm of a wider organisation, this will not affect your application but must be declared in the initial application to join the Code of Practice. Your trading name must be disclosed and appear on the Ethical Recruiters List. Furthermore, it is important that company information is kept up-to date: the recruitment organisation, agency or collaboration is obliged to inform NHS Employers of any changes to company information, including (but not limited to) the name, contact information for the Managing Director, contact information and any website changes.
Employers in both the public and private health and social care sectors should only use recruitment organisations, agencies or collaborations that have signed up to the UK Code of Practice and who appear on the Ethical Recruiters List. Being on the Code of Practice Ethical Recruiters List demonstrates that your organisation is an ethical international recruiter and that you adhere to the guiding principles of the Code.
It should be noted that being on the Ethical Recruiters List does not give you access to potential contracts within the NHS. We are also unable to provide specific details of recruitment leads within the NHS. It is the role of the recruitment organisation, agency, or collaboration to establish and cultivate relationships with public and private health providers.
Employer and international recruits
Recruitment organisations, agencies, and collaborations on the list commit to recruiting ethically from overseas. They do not actively target individuals from countries on the Code of Practice red list and will effectively support candidates to come to the UK, offering high levels of assistance. For information on what good overseas recruitment is and examples of best practice, visit the NHS Employers International Recruitment toolkit. This also explains the benefits of choosing a recruitment organisation, agency, or collaboration on an approved framework.
All employing organisations are strongly encouraged to only use recruitment organisations, agencies, and collaborations that appear on the Code of Practice Ethical Recruiters List. By working with organisations that adhere to the Code, you as an employing organisation have the reassurance that all recruitment by the recruitment organisation, agency, or collaboration is conducted ethically. The Code applies to both the public and private sector and to that end, it is important that all employing organisations work together to prevent recruitment practices that are unfair or that damage the health and social care systems of countries on the red list.
No. Health and social care employers must only use recruitment organisations, agencies, or collaborations included on the Ethical Recruiters List to recruit internationally.
By working with a recruitment organisation, agency, or collaboration that adhere to the UK Code of Practice for International Recruitment, an employing organisation has the reassurance that all recruitment is conducted ethically. The Code applies to both the public and private sector and to that end, it is important that all employing organisations work together to prevent any recruitment practices, that are unfair or could damage the health and social care systems of countries on the Code red list.
A recruitment organisation, agency, or collaboration may only support a candidate following a successful, independent, and direct application to the employing organisation. That is to say that if an individual has independently applied directly for a vacancy in a health and social care organisation, the employer may enlist the support of a recruitment organisation, agency or collaboration to help with the remaining part of the recruitment process after an appointment has been made. A direct application can only be made in response to a vacancy which is hosted by, and recruited to, the same sponsoring organisation.
No. The Code of Practice considers these individuals in the same way as any other health or social care personnel working or resident in a country on the Code red list, that is to regard them as a potential loss to the healthcare workforce of that country. Ethical recruitment is determined by the country from which the individual is being recruited, rather than the nationality of the individual.
Yes. If a candidate resident in a country on the Code red list sees a vacancy in the UK without any targeted recruitment activity having taken place, they are within their rights to apply directly to the health or social care setting and if successful, travel to the UK under the appropriate visa.
It is at the employer’s discretion whether they meet the cost of visa.
It is the responsibility of the appointed individual to ensure that they secure any visa required to exit their home country and/or gain entry to the UK. It is at the employer’s discretion whether they meet the cost of visa and/or professional registration fees.
The individual who is successfully recruited to a position in the UK is not usually expected to pay the cost of their flight to the UK. This cost is normally met by the employing organisation, but again this is at the employer’s discretion.
The NHS Employers website is accessible to all and social care organisations will be able to read about the code, access FAQs etc.
Social care employers can contact Skills for Care who can then raise it with the team at NHS Employers.
Yes, every time you work with a recruitment organisation you should check the Ethical Recruiters List to make sure they remain on the list. This is because we update the list regularly, and organisations can be removed if they have been found to breach the Code of Practice, no longer recruit internationally, or have dissolved.