International Recruitment Toolkit

About this toolkit

This toolkit is for colleagues involved in leading and delivering international recruitment in the NHS. It aims to encourage and enable good practices and processes for the recruitment of all occupational groups. You can use this resource to plan your approach to overseas recruitment activity for the first time, or to review the quality and efficiency of your existing practices and processes. 

It is for line managers and employers and should be used alongside the International Retention Toolkit to support your overall approach to recruiting and retaining international and domestic staff. 

The toolkit has taken into consideration the NHS Long Term Workforce plan which was published in June 2023. It sets out how the NHS will address existing and future workforce challenges by recruiting and retaining thousands more staff over a 15-year period, and working in new ways to improve staff experience and patient care. The deliverables are train, retain and reform to support organisations who are actively recruiting from overseas and acknowledges the need to do this ethically. 

It is important to ensure that your processes for overseas recruitment are effective and ethical, and that where possible, you work with partners, either across an integrated care system or regional footprint, to benefit from economies of scale. 

This toolkit prompts you to think about how you can make a collaborative approach effective, as well as signposting to sources of advice and guidance on the practicalities of conducting successful international recruitment, and sharing tips and good practice examples from other NHS organisations. 

This resource has been commissioned by the Department of Health and Social Care and produced by NHS Employers in collaboration with NHS England. We would like to give special thanks to the reference groups of employers, staff and stakeholders and the many other contributors from across the sector involved in developing this resource.

Don’t forget the person behind the process

Getting the process right and following all immigration and professional registration requirements is essential, but don’t lose sight of the person behind the process. Your international staff will require a great deal of personal and professional support to get settled into a new country and to adjust to the cultural and working differences of the NHS. 

If you are to attract and retain staff from overseas you will need a comprehensive plan for induction, pastoral and professional support. Embracing a cross-cultural team with different leadership styles allows for a diverse workforce.

National context

Overseas staff make a significant contribution to the care of patients in the NHS. 

The system benefits greatly from their expertise and the new knowledge and skills they bring. In return, they must have access to support and development opportunities to enable them to progress their careers, either within the NHS or in their home countries, if they choose to return.

It is important to think about clear and transparent career progression pathways from day one, as many overseas staff will join the NHS with a wealth of experience from their home countries. If progression routes are not clear or accessible, overseas staff may look for opportunities elsewhere.

Routes into the NHS will change in line with the Long Term Workforce Plan through the development of apprenticeships and reform of medical education and training. The plan also aims to deliver productivity improvements through making the most effective use of emerging technologies such as artificial intelligence. 

As employers focus on growing and sustaining ethical recruitment pipelines for internationally recruited staff, it is equally important that we retain as much of this workforce as possible. The Nursing and Midwifery Council’s (NMC) data report for 2024–2025 shows that 39.1% of new joiners were educated outside of the UK, this is down from 49.4% reported in the 2023-2024 data report. A UK systematic review suggests international nurses face challenges in integrating into their roles when recruited to work in the UK. These challenges are not exclusive to your international nurses and may be experienced by other international staff groups in your workforce.

Working as a system

International recruitment across the NHS will require organisations to refocus efforts to ensure that processes are effective. 

Working as a system means working in collaboration across organisational boundaries towards a shared goal that cannot be achieved by working in isolation. The focus is no longer on operating as sole organisations. 

Systems must be enablers for the NHS organisations within them, making sure good practice is shared, facilitating lead recruiter models and collaborating to ensure all recruitment policies and processes are aligned, including administration, onboarding and pastoral support. 

Working collaboratively has many benefits for all involved. For example, it removes internal competition for overseas recruitment, enables those new to international recruitment to learn from the challenges and solutions from others, and streamlines resources and processes required for international recruitment. 

Where and how do you start?

There are no right answers about where to start and there is no single way to do it. 

Working in systems is mainly about building relationships and encouraging dialogue. You need to find ways, with all your partners, to coordinate the overseas recruitment process, or elements of the process, in order to scale it up and share the resource and cost burden. 

There are likely to be multiple perspectives, with multiple objectives that may be unclear and even conflicting, making the prospect of working with partners feel challenging. But be encouraged by the fact that all your partner organisations will already have a shared understanding of the workforce supply pressures and a general agreement about the need for improvements. This is a great starting point. It just needs one part of your system to raise the issue and to start engaging with others. 

Collaborative recruitment could take many forms. It could mean working with other NHS trusts, with integrated care systems (ICS), or with local community groups in areas such as developing a strong pastoral care offer. The main goal of working as a system is to learn from and work with others to share learning and scale up services to better support the journey for overseas recruits. 

There are also many different areas where collaboration is possible. Systems can work together on advertisements, interviewing, OSCE preparation, pastoral care, professional development and any other topic covered in this toolkit. The important thing to keep in mind is there is no one way collaboration should happen and will vary depending on local needs and resources available.

What needs to happen?

The shift towards a collaborative approach to international recruitment will need a different way of working, and changes in mindset and behaviour from all organisations involved.

Before participating in a system approach it is important to consider what your organisation is looking for in a collaboration. Determine the level of commitment required, your capacity to act in new ways and assess your organisation’s internal tolerances for collaboration and risk.

Also, find out what good practice is already happening. This toolkit will help you to discover some of the excellent examples of good practice in the NHS so you can build on what works well. 

Lead recruiter checklist

National and regional support

NHS England has regional workforce and OD teams that are responsible for supporting and developing people practices across their regions, to make the NHS a great place to work. They take a holistic view of the local NHS workforce, ensuring that enough numbers of appropriately skilled and qualified people are secured through all supply routes, across all professions and at all levels. 

These regional teams should be your first point of call. They will support organisations and systems to deliver good practice in international recruitment, and this support will cover the range of essentials outlined in this toolkit. 

At a national level, NHS England has established a central international recruitment team to support systems and regions to implement international recruitment NHS England will also continue to lead on developing strong educational partnerships focused on the healthcare workforce, in conjunction with central government, to continue building the NHS’s global reputation as a centre of excellence in healthcare education and training.

Future aspirations

Progress continues to be made to support the recruitment of overseas candidates in the areas of mental health, community, midwifery and allied health professionals (AHPs). This quick guide aims to improve the understanding of organisations and recruiting managers in the recruitment of international AHPs through highlighting the differences in process and registration, and recognising the specific challenges faced. 

NHS England is running a national programme aimed to support NHS trusts that are keen to start or expand their AHP international recruitment offer.

The AHP IR Community of Practice meets bi-monthly and offers an open forum to discuss ongoing recruitment of international AHPs. 

Find out more about how to recruit overseas AHPs.  

Good practice: collaboration in action

Where to start

As a starting point, your existing organisational workforce data will help to show what is happening with your workforce supply, for example vacancies and high workforce turnover. From this data you will be able to identify areas where international recruitment could be used to fill workforce gaps. Areas with the largest vacancy rates are likely to greatly benefit from international recruitment. Also, consider the workforce needs of your local health system. By reaching out to partners in an integrated care system or regional footprint there will be opportunities to start a discussion about the system requirements for coordinated recruitment processes, to reduce the resource and cost burden of the activity.

Numbers and skills needed

With a robust and well-rounded workforce supply plan you will be best placed to identify the number of staff you require from overseas and to secure the necessary investment. Engaging with clinical or ward managers early in the international recruitment planning process is essential, so everyone internally has the same expectations about the numbers and skills required. 

If you are looking to recruit a large volume of staff from overseas, it is important to plan how you might phase this into cohorts. Consider the facilities and resources you have available to help you plan. What is the capacity of your training room? What resource do you have in your educational team? Are you limited by the available accommodation? These are all important considerations to help you plan your approach. 

There is increased competition within the UK and around the world for health care professionals. With more trusts looking to international recruitment, candidates are often applying to multiple job postings or are members of multiple recruitment agencies. Final joiner numbers should therefore only be considered at the point of issuing the Certificate of Sponsorship.

Timescales

International recruitment campaigns are not a quick fix. Most success comes when it is given sustained focus by the organisation. The Health and Care Visa enables the fast-tracking of visa applications (decided within three weeks, and sometimes sooner if an individual chooses to attend an appointment either in or outside of the UK). However this is only one step of the process. It can take anywhere between six and 12 months for individual staff to start work with you after you’ve made the decision to undertake campaign activity, and sometimes longer for them to gain professional registration and fulfil the potential of the role. 

Work out your deadlines during the planning stage but be prepared to be flexible as it will most likely take longer to find and recruit candidates overseas. 

Delivery model

When planning how you will coordinate your international recruitment activity, there are some options to consider.

Can you collaborate?

Where possible organisations should be working in partnership. There are lots of advantages, including streamlining processes, reducing competition, and sharing expertise, as well as spreading the resource and cost burden of international recruitment. 

By reaching out to partners, either across an integrated care system, regional footprint or just with a neighbouring organisation, there will be opportunities to coordinate the international recruitment process, or elements of the process. 

See the Working as a System section for ideas about how you can make a collaborative approach effective.

Will you use a recruitment agency?

Many organisations choose to contract with a recruitment service provider to help with their international campaign activity. There are many benefits to using the services of an expert, particularly if your organisation has not done international recruitment before. You will need to factor in the additional fees for that service and make sure you are clear about each other’s responsibilities in the process for the working relationship to be successful. 

You should also check that the provider you contract with is on the Ethical Recruiters List every time you use their services. 

The Workforce Alliance and Health Trust Europe frameworks

The Workforce Alliance framework for international recruitment service providers and the Health Trust Europe (HTE) framework are available. These frameworks will ensure trusts can be confident that they are procuring international recruitment providers that are recruiting and supplying ethically. 

It contains a clearly defined fee structure, to support trusts in understanding what fees will be applicable, and what services are included, with no hidden fees. The framework agreement uses the NHS Standard Form Terms and Conditions, so you know terms will be fair to both the supplier and your trust. 

Since suppliers have been tested by the NHS Workforce Alliance, you can be assured that the appointed suppliers have the capability to provide the services you need. 

You can find more information about frameworks in this toolkit and on the NHS Employers framework webpage.

PEOPLE RESOURCE AND COST

Your chosen delivery model will have implications for the resource and funding necessary to carry out international recruitment. All models have a cost and it will be important to assess whether, for example, a small value external contract requires additional internal resource, and any differences in expected time to hire. Working in partnership where possible means that you can benefit from scale, resources can be shared, and costs spread.

Project team

In the planning stage it is important to consider the people resource you’ll need to coordinate activity from within the organisation. This will include recruitment and administration, HR professional support, clinical, educational and pastoral support and any contract management. 

Existing staff with lived experience of relocating to the UK from overseas often have a unique understanding of the support overseas recruits may need to adapt to the cultural and working differences of the NHS. They can also play an important role in your project team and with the development of retention strategies. 

International recruitment is most successful when there is investment in teams to recruit, train and support overseas staff. Consideration must also be given to the longer-term resource needed to provide professional and pastoral support, as not doing so will inevitably impact on your ability to retain your international staff. The management of ongoing immigration sponsorship requirements, including visa renewals and right to work checks, is also important to factor into longer-term resource.

Upfront costs

The upfront costs of recruiting from overseas are significant, and this can sometimes be a barrier. However, the return on investment (ROI) in the longer term means that it is a cheaper alternative to temporary agency costs. Your executive board will be looking for evidence of the ROI when you are seeking approval, and it is advisable that an element of international recruitment budget supports retention.

There are also process costs to the candidate such as language testing and any professional registration requirements. 

These costs to the candidate are often provided by the organisation because recruits coming from less economically developed countries would struggle to pay them. 

The costs are sometimes paid as a loan to the candidate to be repaid through their salary, however this is a local policy decision.

Section 12 of the NHS Terms and Conditions of Service Handbook outlines terms of contractual continuity of service. Employers have discretion to take into account any period or periods of employment with employers outside the NHS, where these are judged to be relevant to NHS employment.

The exercise of discretion in paragraph 12.2 is a local matter. However, it is important that any decision is made in a fair, transparent and non-discriminatory way. An employer should be able to demonstrate that it has given due consideration to any equivalent service in another country and that such consideration was part of the process in deciding whether or not to award additional annual leave in each case, as set out under Section 12.2 of the NHS Terms and Conditions of Service Handbook.

Good practice example: financial relocation package

The below examples of financial relocation packages will help you put together a plan for your own organisation’s relocation package. You are encouraged to consider all the elements that will maximise your chances of attracting staff and helping their transition to the UK. These arrangements should apply to all occupational groups.

Contractual repayment clauses

Because the resource and costs associated with international recruitment are significant, it is not unusual for an organisation to insert a repayment clause in contracts of employment, to recover upfront costs if the international recruit leaves employment within a given period. 

Individual trusts can decide on the terms and conditions of employment contracts and on some occasions will claim back costs where needed, including travel and accommodation, in line with that agreement. 

The UK Code of Practice for International Recruitment stipulates that health and social care employers and contracting bodies must provide candidates with the exact terms of the contract under which they will be working and any element which may differ pre- and post-professional registration such as salary, and any incentives and reclaim of advances must be clearly explained in writing. 

NHS Employers has developed repayment clause guidance to support employers with reclaiming expenses from overseas recruits who chooses to leave the organisation. The guidance outlines how to deal with these situations fairly and with a maximum figure to reclaim if the organisation chooses to have a repayment clause. 

The Department of Health and Social Care guidance on applying for health and social care jobs in the UK from abroad must be made available to a candidate at the earliest opportunity.

PASTORAL AND PROFESSIONAL SUPPORT

To be successful at attracting and retaining staff from overseas you will need to form a comprehensive plan for induction, pastoral and professional support. As their employer, you might be the only link to their new country of residence until they become more established, so it’s important that enough resource and preparation is put into the pastoral and professional support your overseas staff will need. 

Trusts should engage with overseas recruits early and often. This includes maintaining contact after a job offer is made but before they arrive to the UK. This could include virtual meetings and introductions with the line manager and other key colleagues they will be working with. 

If you help your overseas staff settle in and establish themselves in the country, they’ll be far more likely to stay.

Recruit to retain

The first six months in a new role typically influences whether a recruit stays for the long term, making induction and early pastoral and professional support crucial. Integrating staff into your organisation and setting out what is expected in a clear and consistent way can help the settling-in process. Effective mentoring, understanding career progression at interview stage, professional support and a supportive learning environment will enable recruits to be as productive as possible in their roles. 

See the Supporting international staff section of our Improving staff retention guide and our International retention toolkit. 

Prepare for leavers

While your aim is to ensure your international recruits have the best possible experience and want to stay with your organisation, you must also be prepared for people to leave. 

Some people can’t adjust or settle, they might want to move to another part of the UK or perhaps only had plans to come and work for 12-18 months before returning home. Having good two-way communication channels may encourage staff to be open about their aims to help you with your planning. Leavers can also provide some vital feedback on how things can be improved. Are there mechanisms in place for them to provide feedback in an open and transparent way? 

As an employer, consider having a transitional approach in place where you support potential leavers to move into different roles within the trust and therefore remaining within the organisation.

IMMIGRATION AND PROFESSIONAL REGISTRATION

During the planning stages, familiarise yourself with the immigration rules and the process for overseas recruits to obtain professional registration. There will be associated timescales for both processes to factor into your planning.

Sponsorship responsibilities

On becoming a sponsor, the organisation must fulfil certain duties, such as record keeping and reporting in order to maintain the sponsorship licence. You will need to factor these duties into your resource requirements. 

Information on the sponsorship licence system, can be found on NHS Employers website. NHS Employers also have a quick guide on applying for certificates of sponsorship (CoS).

Read our sponsorship responsibilities webinar Q&A webpage with questions answered by the Home Office, NHS Business Service Authority and NHS Employers on how to maintain sponsorship responsibilities when employing overseas staff. 

View our NHS Employers webinar with Home Office that goes into detail on immigration queries, visas, and sponsorship.

Immigration routes and the new points-based immigration system

Under the points-based system, overseas candidates must pass a points assessment before they are given permission to enter or remain in the UK. Fixed and tradable points are awarded to reflect skill, salary and in some cases if the role is on the immigration salary list.

The Health and Care Visa is a sub-type of the Skilled Worker Visa available for those who are taking on a role in eligible health or social care jobs or who are a qualified doctor, nurse, healthcare professional or adult social care professional. Find out more information about the Health and Care Visa on the NHS Employers website.

Employers should be aware of other immigration routes that provide the right to work without sponsorship, such as the British National (Overseas) Visa and the High Potential Individual (HPI) Visa. A list of other available visa types is available on the NHS Employers website.

Enhancements to the EU Settlement Scheme (EUSS) mean that from September 2023 people with pre-settled status will automatically have their status extended by two years before it expires. From January 2025, the Home Office will automatically convert as many eligible pre-settled status holders as possible to settled status once they are eligible for it (without them needing to make an application).

Skilled refugees recruited in health and social care will continue to be recruited through the Health and Care Visa route of the points-based immigration system, where migrants are required to meet a particular level of skills and experience and employers are given sponsorship duties.

Considerations should be given to the specific pastoral care requirements of refugees and employers should be mindful of their needs.

Where possible trusts should connect with local authorities, including strategic migration partisanships, to understand the support available and reduce duplication.

The NHS Employers pre-employment check standards contain flexibilities that employers may exercise when an applicant is genuinely unable to present the documents as laid out in the standards. These are often applicants that are furthest from the jobs market, for example homeless people, people with learning disabilities, asylum seekers, refugees, and other forcibly displaced people.

Professional registration

Familiarise yourself with the registration process and associated timescales of the relevant professional regulator so you can factor this into your planning.

• General Medical Council (GMC)
• Nursing and Midwifery Council (NMC)
• Health and Care Professions Council (HCPC)
• General Pharmaceutical Council (GPhC)
• General Dental Council (GDC)
• General Optical Council (GOC)
• General Osteopathic Council (GOsC)
• General Chiropractic Council (GCC)

Also consider approaching the regulator early in the recruitment process, particularly if you are looking to recruit high numbers. Early insight on what upcoming registration demand is likely to be will help the regulator to manage capacity.

ETHICAL PRACTICES

During the planning stages, familiarise yourself with the World Health Organization Code of Practice on ethical international recruitment, available on the NHS Employers website. The latest update of the Code of Practice was published in March 2025. You can use the quick guide  to understand what the Code of Practice means for employers, organisations, collaborations and candidates. 

Planning and managing recruitment in an ethical way should be a priority for all organisations, because it is the right thing to do and because failure to do so is likely to impact on the reputation of the organisation and the NHS as an employer.

Red and amber list countries

There are countries where you cannot undertake direct and targeted recruitment. This is because these countries are receiving government aid and the UK has made a commitment to support their developing health needs. There is nothing to prevent an individual from anywhere in the world applying for work in the NHS if they choose to do so, but employers and agencies must not proactively target these developing countries. 

There are rare exceptions to this where government authorised exchange schemes may bring across staff from countries on the red or amber list, such as the Medical Training Initiative (MTI). This scheme is designed to allow a small number of doctors to enter the UK from overseas for a maximum of 24 months so that they can benefit from training and development in NHS services before returning to their home countries. This is primarily for the benefit of doctors from red or amber list countries.

Best practice benchmarks

Using recruitment agencies, organisations, or collaborations

If you choose to use a recruitment service provider, choose one on an approved framework. This will give you reassurance that recruiting processes adhere to all legal requirements and that you are getting the best value from a service. You should also check that the service provider you contract with is on the Code of Practice for International Recruitment, so you know its recruiting processes are ethical. 

A list of providers that have declared they comply with the ethical code requirements is available on the NHS Employers website. Please check the Ethical Recruiters List every time you work with a recruitment organisation to make sure they remain on the list. 

We also encourage employers to share with us any information relating to agencies who appear to be recruiting unethically or contravening the Code of Practice.

Research the target country

Find out if you need to take any additional steps to recruit an individual from the country you have decided to target, so you can factor this into your planning. 

If you are working with a service provider or as part of a national recruitment programme they will be able to advise, but it is important to ask. It may be helpful talking to other organisations with experience of recruiting from that country, and the relevant embassy in the UK will also be a helpful source of advice and guidance. 

You can also speak to those different nationalities in your existing workforce to gain knowledge on educational pathways and demand for NHS employment in certain countries.

EVALUATION PLANNING

During the planning stage of your international recruitment activity you will want to consider how you are going to evaluate the success of the process and impact of the activity. Continual improvement of any process requires ongoing evaluation and it is worthwhile building this into your recruitment activity from the beginning, considering what elements you want to regularly measure and how this can help improve your future activity.

Why evaluate?

Evaluating your international recruitment activity will help you to: 

• demonstrate the value of international recruitment 
• adjust your processes to ensure quality and efficiency 
• identify and replicate good practice 
• celebrate and share successes. 

You should identify evaluation tasks at the outset and build them into your recruitment planning. There are many information sources for evaluation to consider: 

• workforce data, eg retention figures, pre-employment drop outs, OSCE pass rates, agency spend etc 
• website and social media statistics 
• e-surveys 
• telephone discussions/interviews 
• informal feedback – have a system to record it 
• stay and exit interviews 
• at-event and post-event feedback 
• workshop-type discussion or focus group with staff.

BUILDING A BUSINESS CASE

The upfront cost of recruiting from overseas is significant, and this can be a barrier. However, the return on investment in the longer term means that it is a cheaper alternative to temporary agency costs. Your finance executives will be looking for evidence of this when you are seeking approval for your international recruitment activity.

Based on research from the Nuffield Trust, it takes between six months and two and a half years to see return on investment for an international nurse. Upfront recruitment costs need to be considered in the context of national funding opportunities and the longer-term or alternative routes to increase nurse numbers.

What to include

Your business case must be robust. It needs to clearly state your supply issues, your overall workforce supply plan and how you anticipate international recruitment supporting it.

MARKETING YOUR ORGANISATION

Marketing your organisation to generate interest from potential candidates must be a priority in the early preparation for international recruitment and should become an ongoing activity. Recruitment is not only about filling a vacant position(s) but about building a brand and reputation for your organisation.

Attracting staff in a competitive environment can feel challenging. The NHS Employers Inspire, attract and recruit toolkit contains ideas about a range of attraction methods, with resources and good practice examples for your domestic and international recruitment activity.

Word of mouth is a particularly valuable promotional channel among overseas communities, so ensure your existing staff have a great recruitment and employment experience and encourage them to spread the word about your organisation and the NHS. 

This is a great opportunity to discuss with your existing international recruits why they chose to move to the UK and how their expectations have measured up against the reality. Being able to share positive experiences and case studies will be a powerful marketing tool for your trust.

Employer of choice

To attract talented candidates from overseas, you need to be able to separate your organisation and region from the rest, and separate NHS employment from health systems in competing countries. Jobseekers are no different to any other consumer, they are looking for the best deal. This means different things for different people, so it is important to think about your audience and what will be a priority for candidates coming from overseas.

From a good reputation and culture, a strong pastoral and professional support package, to communicating your relocation package, individuals need to understand what is available to them both within the organisation and in the local area. But make sure you give candidates realistic expectations of the role and the location to reduce the likelihood of them leaving the organisation in the first few months.

ENGAGING EXISTING STAFF

Engage with your current staff early to build support for the recruitment activity. Integration between existing staff and new overseas recruits is strongest when you involve your existing staff as much as possible from the start of the process. When your new recruits arrive, a social event can be a nice way to help your existing staff and new recruits to get to know each other.

It is important that you help existing staff to understand the need for international recruitment and support them through the changes that might be needed to their working environment and ways of working, particularly if your organisation is recruiting from overseas for the first time.

USING A RECRUITMENT AGENCY OR SERVICE

If you choose to use a recruitment service provider to help with your international campaign activity, your early preparation will involve procurement and contracting.

There are benefits to using the services of an expert, particularly if your organisation has not done international recruitment before. You will need to factor in the additional fees for the service and make sure you are clear about each other’s responsibilities in the process for the working relationship to be successful.

Contracting

The number of people you are looking to recruit will determine the procurement or tendering exercise you will need to go through. Whatever the number, you will need to draw up a clear specification and have up-to-date job descriptions. Most organisations that use recruitment services agree a fixed rate for each person that is successfully recruited. The costs can vary depending on volume and the services you require.

Ethical practices

If you decide to use the services of a recruitment service provider, choose one on an approved framework. This will give you reassurance that their recruiting processes adhere to all legal requirements and that you are getting the best value from their service. 

You should also check that the provider you contract with is on the Ethical Recruiters List every time you use their services. NHS Employers updates the Ethical Recruiters List regularly and this is so you know their recruiting processes are ethical. 

A list of service providers who have declared they comply with the ethical code requirements is available on the NHS Employers website.

The revised Code of Practice was released in March 2025. You can use the quick guide to understand what the Code of Practice means for employers, agencies, organisations, collaborations, and candidates.

Best practice benchmarks

These best practice benchmarks will help to ensure you build an effective working relationship with your chosen service provider.

Have a dedicated contact at your organisation who can liaise with the service provider and your recruiting managers, and schedule regular management meetings to review progress against your contract arrangements. Having a detailed project plan may help with this. 

Choose a provider on an approved framework. This will give you reassurance that their recruiting processes adhere to all legal requirements and that you are getting the best value from their service. 

At the start of each recruitment process check that your provider of choice is still on the Ethical Recruiters List.

Have clear arrangements in place about what the service provider’s responsibilities are for employment screening. 

Your contract agreement should outline:

• the types and levels of checks required for different posts 
• that the service provider will be liable if it is discovered that any staff have 
• not been adequately screened 
• that you retain the right to audit the service provider’s screening process at any time.

Decide if you might want the service provider to undertake the initial sift of candidate applications. You may also want them to ask potential candidates to undertake a range of tests or activities to assess values and competence. 

Don’t get caught out by judgement calls. If you want the service provider to make judgements about the candidate’s suitability during screening checks, you should ensure that such judgements follow agreed decision-making guidelines. 

Fair and just contractual practices must be observed by recruiters, contracting bodies and employers in the employment of international health and care personnel. 

As part of your agreement, be clear about who will be liaising with the new recruits between the offer of employment and their relocation. 

Include a contractual statement in the service agreement about the point of payment. For example, you might want to stipulate that the service provider will not receive payment for their services until staff arrive in the UK. 

Ask the service provider to provide you with references from other organisations they have worked with and from candidates they have deployed. Follow these up directly to find out what their experience has been.

INTERVIEW AND SELECTION

International recruitment, like domestic recruitment, needs to centre around a positive candidate experience. It needs to be an engaging process and one which motivates candidates to continue with their application, especially because the process of UK immigration and registration can take time. You want to avoid candidates dropping out of the process or accepting a job offer from another organisation. 

Interviewing has evolved over the years and employers are using a variety of methods to make the process quicker, easier, more accessible and more varied, all of which enhance the candidate experience. Consider if you want to ask candidates to undertake tests or activities that are both values and competence related as part of the selection process. Effective recruitment decisions are more likely when a range of selection methods are used in addition to interview questions. For example, evidence about a person’s suitability for a role can also be gathered from skills testing, a written exercise or work-based scenarios.

Advertisements

It is important to consider the way job advertisements are structured, the information they include, where and how they are advertised.

Job advertisements need to be inclusive and include information on recruiting manager details, state that international applications are welcome, how candidates could liaise with regularity bodies such as the Nursing and Midwifery Council (NMC), and information on visa related requirements. 

These details are especially important to include for direct applications from the list of red and amber list countries on the Code of Practice.

The list doesn’t prevent individual health and social care personnel from independently applying to health and social care employers for employment in the UK, of their own accord and without being targeted by a third party, such as a recruitment agency or employer.

Technology vs face-to-face

To manage the international recruitment interview process in a resourceful way, some organisations are choosing to carry out video interviews using technology such as MS Teams or FaceTime. In some cases, pre-recorded interview questions are used, which allow individuals to be interviewed at a time that suits them.

Other organisations prefer to send a team of experienced recruiters and clinical staff to conduct the selection process face-to-face in the candidate’s home country. This can demonstrate your dedication to the process, help to build connection with candidates and to help them feel more comfortable about your organisation. However, this is a decision for you to make locally, having weighed up the pros and cons.

Values-based recruitment

Values-based recruitment (VBR) is an approach to help attract and select future staff whose personal values and behaviours align with the NHS values outlined in the NHS Constitution. Assessing values across different cultures should form an important part of the selection process for international recruitment.

LANGUAGE ASSESSMENTS

Employing organisations are responsible for ensuring that everyone involved in the delivery of services has the required level of English language competence to enable them to communicate effectively with patients and colleagues.

Identifying English language competency prior to offering an appointment helps to ensure protection for patients, employing organisations, and employees. 

While English language competence testing does not establish an individual’s aptitude for effective communication, it can help to provide a useful tool to build on. 

When appointing individuals who are already registered with a professional regulatory body, you can usually be assured that they will have the minimum standard of communication set by that body. Each of the professional regulators has guidance on the way applicants can demonstrate language competency when registering with them. 

However, when carrying out overseas recruitment activity you will likely be making the selection decision subject to a candidate obtaining professional registration. 

English language tests can sometimes be a tricky hurdle for overseas recruits during the registration process. Some organisations will choose to make it a requirement for overseas candidates to have passed their English tests prior to the interview, so they have assurance that passing the test will not be a problem later in the registration process. Other organisations choose not to make it a requirement and will offer language support to prepare for the individual for the test. This approach produces a much larger pool of candidates, however it is a decision to consider locally.

Achieving the required level

The required level of language proficiency across all professions is high, and candidates may need significant support to reach the expected International English Language Testing System (IELTS) or Occupational English Test (OET) level.

Options for support

Language competency

When appointing individuals who are registered with a professional regulatory body, employers can, in most cases, be assured that the individuals will have acquired the minimum standards set by that body. This will include their required level of English competency for their profession, where this is appropriate. This assurance should be obtained by undertaking the necessary checks with the relevant professional regulatory body as outlined in the NHS Employment Check Standards.

While this gives a certain level of assurance for registered healthcare workers from outside the UK, employers still have a duty to assure themselves that all individuals have the appropriate level of English competency to carry out the specific role they are being appointed to do. This duty is further reinforced by Part 7 of the Immigration Act, which stipulates employers must ensure that everyone involved in the delivery of NHS services has the required level of English language competency to deliver safe patient care. 

Under normal circumstances, any measure of language competency should be assessed through the individual’s application or as part of the interview process. Where seeking assurance as part of the individual’s application, any assessment will need to consider any evidence provided by the applicant to demonstrate that they:

• have passed an English language competency test 
• hold a degree or relevant qualification that was taught in English by a recognised institution abroad
• have lived in a multi-lingual household where a relative or carer used English as their primary form of communication 
• are a national from a majority English speaking country
• have worked in an organisation/institution where English was their primary language 
• have pursued part of their education in the UK.

The person specification and selection process

Under the NHS Employment Check Standards employers are required to seek the necessary assurance of any qualifications that are relevant to the role being appointed to. 

In accordance with good recruitment practise, the inclusion of any language competency requirements should be made clear in the person specification for the role being appointed to. As alluded to earlier, individuals can demonstrate their level of language competency in a variety of ways, therefore the person specification should reflect what equivalent assessment can be accepted where individuals have not carried out an appropriate test. 

If requiring individuals to undergo a language competency assessment as part of the recruitment process, employers must ensure that all job applicants are treated in the same way at each stage of the recruitment process, to ensure they remain compliant with anti-discrimination laws.

English language test results

If a candidate provides evidence of an English language competency test, it is advised you use the available online systems provided by the relevant accredited body to verify the results. IELTS results can be verified by registering for their free online checking system. OET results can be verified via a similar system but the individual must give the prospective employer permission to verify the results through their OET account. The employer must also be registered to access the OET results verification portal. More information on professional employment checks is available on the NHS Employers website.

Seeking assurance of compliance

EEA nationals (including Swiss nationals and individuals with European Community rights)

Following the end of the European Union transition period on 31 December 2020, the Department of Health and Social Care has been working with professional regulatory bodies to review registration arrangements for applications from holders of EEA qualifications. 

In 2023, the Secretary of State undertook a review of the standstill regulations. On 29 June 2023, a report was published confirming the decision to retain them.

Under a separate agreement that came into force on 1 December 2023, regulators are now required to put processes in place to recognise comparable professional qualifications obtained in Norway, Iceland and Liechtenstein. Regulators must also have processes in place to recognise comparable Swiss qualifications following a further agreement that came into force on 1st January 2025.

EEA and Swiss qualified healthcare professionals will be able to continue to register with the relevant professional regulator, without the need to sit additional professional exams, mitigating delays to registration and employment in the NHS. More information on this is available on the GOV.UK website. 

POST SELECTION AND PRE-EMPLOYMENT

Depending on what you have agreed to provide for your new recruits for their relocation, there may be tasks for the coordinator at this point such as flights, accommodation, pulling together welcome packs and confirming arrangements for induction.

Maintaining contact

During the period between offer of employment and relocation to the UK, it is important that you maintain regular contact with your new recruits. You should make every effort to reduce the risk of a candidate dropping out of the process or accepting a job offer from another organisation.

Technology, like Microsoft Teams and FaceTime along with social media platforms, make it much easier to stay in touch. You can use these communication channels to give regular updates, send tips and advice for relocation, share photos and news about your organisation and local area, start discussion groups and invite questions from your new recruits. 

Information on maintaining contact is available in the international retention toolkit in the section: creating strong foundations.

Progressing regulatory and immigration processes

Make clear what is expected of candidates throughout the process. Your new recruits will be responsible for progressing the UK regulatory and immigration processes. Continue to communicate with them, make sure they are clear about the process and motivate them at appropriate stages so you can avoid unnecessary delays. 

Each of the professional regulators have guidance that you can use to explain the process to your recruits.

• General Medical Council (GMC)
• Nursing and Midwifery Council (NMC)
• Health and Care Professions Council (HCPC)
• General Pharmaceutical Council (GPhC)
• General Dental Council (GDC)
• General Optical Council (GOC)
• General Osteopathic Council (GOsC)
• General Chiropractic Council (GCC)

Employment checks

The NHS pre-employment checks standards will also be an essential part of the process at this point. NHS Employers provides practical information, toolkits and resources to support you with these checks. 

Pay particular attention to the application process for criminal records checks or Certificates of Good Character for someone from overseas. For advice on who can apply, how to apply and contact details for criminal record checks overseas, see Home Office guidance. 

The NHS Counter Fraud Authority (NHSCFA) is a special health authority tasked to lead the fight against fraud, bribery and corruption in the NHS. 

They are independent from other NHS bodies, report directly to the Department of Health and Social Care, and can be contacted at any time to report cases of potential fraud.

WELCOME AND INDUCTION

Given the value of staff from overseas and the high costs of running a recruitment campaign and relocation, a successful induction process and ongoing pastoral and professional support is of the utmost importance.

As their employer or lead recruiter, you will likely be the only link to the UK until they become more established, so it’s important you help your recruits settle in and establish themselves, they’ll be far more likely to stay.

As part of the employees induction, the international recruits should have their probation policy outlined to them as part of their on boarding when joining the trust. This should include how long the probation period is and what it entails. The probation period and policy should be the same for both international and domestic staff.

Designing an induction programme

Your organisation and those that you work with will already have a well-established corporate induction programme, but it is worth considering what additional support or information might be beneficial for your overseas staff. For example, introducing a programme of social adaptation will help your overseas staff to learn about the NHS and the cultural and working differences. A programme like this will also enhance English language levels, particularly on areas such as typical ward dialect and phrases.

International recruits may be with the NHS for short period or for their whole career. It is important to showcase the variety of benefits they receive for working in the NHS, such as the NHS Pension Scheme. The scheme is one of the most generous in the UK and supports staff to have a good standard of living in their retirement. You can find out more on our NHS Pension Scheme web pages. Individuals can still claim their pension benefits if they live abroad in retirement.

Also consider incorporating the induction support available from professional regulators, professional associations and trade unions such as the Royal College of Nursing (RCN), British Medical Association (BMA), UNISON and Occupational English Test (OET).

The General Medical Council (GMC) runs a free workshop for overseas-trained doctors designed to help them settle into medical careers in the UK. 

The King’s Fund hosts a free, short course to learn about the history of the NHS and how it all works and fits together. 

The BMA has a guide to working in the UK for internationally trained doctors, including information about how the NHS works. 

OET has the success stories resource to help new recruits overcome common communication challenges.

PASTORAL SUPPORT

Consider the human factors that personally affect individuals during the first few months and beyond of living and working in the UK. Organisations with the best retention rates are those that have invested in dedicated people resource to provide essential pastoral support. 

Your overseas staff will need bank accounts, National Insurance numbers, somewhere to live, access to shopping, public transport and other amenities. Helping them with these arrangements will make a big difference to how well they ease into life in the UK. Introducing some coordinated social activities can also prove very helpful in encouraging integration into teams.

Pastoral support arrangements can at times require 24/7 support from the trust, and be available in case of situations such as flight delays or cancellations. 

This should be considered in team planning and pastoral care requirements.

Getting the basics right

PROFESSIONAL SUPPORT

When your overseas recruits arrive, your initial focus will be on providing professional specific training and education and supporting them to adjust to new systems and ways of working. Be mindful that you may need to adapt your training if they are unfamiliar with technical language or equipment that they will be using.

Understanding the NHS – educational resources

International recruits are likely to have come from very different healthcare systems and may have little understanding of how the NHS works. Sharing material to help them understand its history and make-up is an important part of adjusting to new systems and ways of working. The King’s Fund runs a free, short course to learn about the NHS.

Longer term, your overseas recruits should have access to the same learning and development opportunities and support for career progression as your UK workforce. Professional support is important across an employee’s whole career and should be based on each individual’s preferences and career aspirations. As part of this process they should be offered an annual personal development review and a personal development plan should be agreed.

It is important to support international recruits to save for their future and their retirement. The NHS Pension Scheme is one of the most comprehensive and generous in the UK and offers many additional benefits that may be attractive to international recruits, such as life assurance and ill health benefits. Individuals can still claim their pension benefits if they choose to live abroad in retirement.

Also consider signposting staff to support available from the relevant professional regulators, professional associations and trade unions, such as the RCN, BMA and UNISON.

International recruits will need to know what fraud is, how to avoid it and what they can do if they get targeted. 

Think about having some top tips to share with your recruits. Fraud incidents should be reported to the police and the fraud prevention team. There is also information on the take five stop fraud website.

Freedom to Speak Up

NHS England aims to ensure everyone working within the NHS feels safe and confident to speak up and encourage NHS leaders to take the opportunity to learn and improve from those who speak up. 

The National Gurdian’s Speak up review of overseas trained workers stated that speaking up is hindered by fears of retaliation, including potential dismissal and jeopardising career progression, exacerbated by the link between visas and employment. Adaptation struggles, including communication difficulties, further impact confidence in speaking up.

While many internationally recruited workers share some of these barriers with their UK-trained colleagues, their unique circumstances intensify these challenges.

It is important to make your internationally recruited staff aware of who are Freedom to Speak Up Guardians within your organisation. Freedom to Speak Up Guardians are designated individuals within NHS organisations who support staff in raising concerns about patient safety, workplace issues, or any other matters that may hinder their ability to perform their jobs effectively. They provide a confidential and safe channel for employees to speak up when they feel unable to do so through traditional routes.

The NHS Employers website has a number of resources for employers regarding Freedom to Speak Up, such as  guidance for managers and employer actions. 

Part of the NHS equality, diversity, and inclusion improvement plan is to implement a comprehensive induction, onboarding and development programme for internationally recruited staff.

The International Retention Toolkit includes information on making new recruits feel welcome. This includes information on preceptorship, buddying, induction and integration.

Pastoral checklist

Prior to arrival

• Welcome letter. 
• Information pack, ie what to bring, clothing needed, adaptors, local area. 
• Details about accommodation (subsidised or otherwise). 
• Pre-employment arrangements; occupational health appointment, uniform / badge orders.

Arrival

• Meeting recruits at the airport. 
• Welcome pack including essential groceries, bedding, kettle, etc. 
• Information pack ie local area, utility companies, doctors, dentists, emergency contacts. 
• Connecting recruits with local communities and existing staff networks i.e. WhatsApp groups. 
• Greeting lunch / welcome dinner with previously recruited international recruits, ward managers and other clinical staff. 
• Facilitating recruits to open a bank account, such as pre-booking their bank appointment. 
• Support for registering with a GP 
• Information on local transport options 
• Permit from the post office, if the individual does not have an e-Visa. 
• Tour of the local town, including a visit to the supermarket, places of worship, bank, post office and attractions etc. 
• Salary advance.

Induction and beyond

• Corporate and social induction, including additional support for overseas recruits. 
• Ensure they are aware of the benefits of joining the NHS Pension scheme, including flexible retirement and death in service. 
• Supported learning about UK and NHS culture and values. 
• Professional specific training and education eg OSCE programme. 
• Buddying and peer support arrangements, preferably with previously recruited overseas nurses. 
• Ongoing professional development, career planning. 
• Preceptorship or equivalent arrangements. 
• Introduction to health and wellbeing offers provided by the trust. 
• OSCE test date and travel organised.

RECRUITING TO RETAIN

The first six months in a new role typically influences whether a recruit stays for the long term, making induction, early pastoral and professional support crucial. Integrating staff into your organisation and setting out what is expected in a clear and consistent way can help the settling-in process. Effective mentoring, professional support and a supportive learning environment will enable them to be as productive as possible in their roles.

International retention checklist

Career pathways for all staff should be as rewarding as possible. Below is a checklist to ensure your offer to overseas staff is as fulfilling as possible.

• Review recruitment and onboarding offers for standardisation and transparency. 
• Ensure policies respond to any form of inappropriate or discriminatory behaviour for all staff and services users. 
• Provide means such as culturally competent leadership training to ensure all managers and mentors feel equipped to compassionately support international staff with their unique personal and professional learning needs. 
• Implement ways to find out individual staff’s motivation for migration and why they have chosen to work in the NHS. Support them to actualise this to improve job satisfaction and fulfilment. 
• Compassionate and inclusive pastoral support at organisational level should be a priority - recognising the unique learner status of overseas staff alongside acknowledging the invaluable positive contributions made are determinants of successful integration and acculturation. 
• The power of communities and cultural networks are fundamental to successful migration, and therefore the personal and professional lives of our international colleagues both inside and outside of work. 
• Provide support with local language idiosyncrasies promotes a sense of belonging. 
• Career progression, such as recruiting into relevant specialisms, should be prioritised and included in career discussions and as part of appraisal reviews.

During the planning stage of your international recruitment activity you will need to consider how you are going to evaluate the success of the process, the collaboration if you worked with partners and the impact of the activity. Being clear about what you want to achieve and making time to regularly review your activities will help you to assess how successful it is and whether changes need to be made. 

Your evaluation plan should be created at the outset of the international recruitment activity, setting out clear recruitment objectives and targets and considering all the evaluation methods available to you.

What is your data telling you?

Once you have gathered your data and evidence, you can explore what it tells you about the success of your international recruitment activity in meeting its objectives. 

As a starting point, your organisational workforce data will help to show what is happening with your international recruitment process. For example, high attrition at pre-employment stage. Have you looked at previous recruitment exercises and taken feedback into account? Of those interviewed and made appointable, how many took up the post? How long did the process take and, if they didn’t end up starting in the role, do you know why? A review of this can help you identify any areas for improvement and prevent this pre-employment attrition in the future.

UK PROFESSIONAL REGISTRATION

The Nursing and Midwifery Council (NMC) overseas registration process application and streamlining requirements is fully online.

Applicants create an NMC online account that will stay with them throughout their registration with the NMC. They will use the account to submit their registration application, upload copies of evidence required and pay relevant fees. They are also able to track the progress of their application through their account.

Once in receipt of a completed eligibility application, the NMC will confirm eligibility with the applicant’s regulator (and where necessary their training institute) and they will be invited to take the two-part test of competence process and submit their full registration application. 

Detailed information about the overseas registration process can be found on the NMC website.

What is the test of competence?

The test of competence is a test against the NMC’s proficiency standards and has two parts.

The computer-based test (CBT) is a multiple-choice examination that assesses theoretical knowledge and is accessible around the world for applicants to access in their home countries administered by Pearson Vue. In the new test of competence, the CBT will be split into two parts (part A focusing on numeracy, and part B on theory).

The NMC has a hub that contains all the information candidates, recruiters and employers prepare for the ToC such as: 

• candidate handbooks 
• test specifications 
• blueprints 
• practice tests for the new CBTs 
• an OSCE prep resource pack.

Guidance and information booklets are available on the NMC website. This includes CBT and OSCE guides for nurses and midwives, blueprints and specifications.

These pages include detailed booking instructions and course/module information. If an incorrect CBT has been sat, applicants will be required to resit and pass the correct CBT. 

For more information, please visit the NMC’ website.

What is the OSCE?

It is based on UK pre-registration standards. Applicants are required to act out scenarios that nurses or midwives are likely to encounter when assessing, planning, delivering and evaluating care.

Approved OSCE test centres

There are five approved OSCE test centres, providing a choice of six locations to sit the OSCE: Ulster University (Derry), University of Northampton, Oxford Brookes University (Oxford and Swindon) at Northumbria University and The Leeds Teaching Hospitals NHS Trust. Each location offers the OSCE in the different fields of nursing, midwifery and nursing associate.

Language requirements

Applicants who trained outside the UK need to demonstrate that they have the right level of English to be able to deliver safe care. There are three ways they can evidence their language competence:

• An approved English language test.
• Their qualification, if it was taught and examined in English where the programme comprised 50 per cent clinical interaction with patients, families, healthcare professionals and other service users, 75 per cent of which was in English.
• If they have undertaken registered practice for at least 12 months in the last two years in a majority English-speaking country where their language was assessed to gain registration in that country.

To make sure applicants do not fall victim to scams, make sure that applicants only register and pay for OET through the official OET website. If you have seen suspicious activity from organisations pretending to offer OET test services, please report this activity to OET.

Language tests

IELTS (International English Language Testing System) is one of the accepted examinations. This test assesses general language skills and is seen to be more academically focused. 

To register with the NMC via IELTS, the overseas nurse must ensure they achieve the following grades:

• Grade 7.0 or above in speaking, listening and reading.
• Grade 6.5 or above in writing.
• Overall grade of 7.0.
• When combining, 6.5 for listening, reading, and speaking, or 6 for writing.

The OET (Occupational English Test) is an alternative test, which has been accepted by the NMC since 2017. It assesses language skills more specific to healthcare workers, including the ability to communicate effectively in medical scenarios, write a referral letter or understand a patient consultation.

The overseas nurse must ensure they achieve at least a grade B in the reading, listening and speaking sub-tests and at least a grade C+ in the writing sub-test.

Further information about the tests, including costs, remote testing, in-trust testing, sample questions and scoring criteria, can be found on the OET and IELTS websites.

The NMC accepts supporting information from employers when: an individual narrowly misses out on a score in one of the four domains by 0.5 in the IELTS (6 for writing and 6.5 in the other domains) or half a grade in the OET (C / 250 or above in writing and C+ / 300 or above in the other domains); or they were trained and assessed in English in a country where English is not a majority spoken language, and who have been working for at least one year in a non-registered role in a health and social care setting in the UK.

More information on these changes and next steps can be found on the NMC website.

IMMIGRATION REQUIREMENTS

Upon successful completion of the CBT, the sponsoring organisation can assign a certificate of sponsorship (CoS) to the overseas nurse. They can then apply through UK Visas and Immigration (UKVI) for a Health and Care Visa as a skilled migrant worker under the skilled worker route. Overseas nurses have up to 12 weeks from the employment start date noted on their CoS to sit their first OSCE exam and achieve registration within eight months. They can be legally employed as a pre-registration candidate (band 4) during this preparation time.

See Sponsorship guidance for employers and educators for more information about the immigration process and what you need to know about the immigration system.

Employers should be aware of other immigration routes that provide the right to work without sponsorship, such as the British National (Overseas) Visa.

The government announced a series of changes to the immigration system which impact the NHS. An overview of the changes can be viewed on our Impacts of the changes to UK immigration policy page. This includes increasing minimum salary thresholds, changes to rules on salary threshold deductions, and rules on the recruitment of care workers and senior care workers such as restrictions of dependants and working with regional partnerships.

In May 2025, the government published the immigration white paper that outlined changes to the UK immigration which will impact the whole immigration system, including raising the skill level to RQF6 (graduate level) and above. 

Step-by-step process

The diagram below shows a summary of the registration and immigration process for an overseas nurse who is out of country and will be sponsored under Health and Care Visa to work in the UK.

1. OVERSEAS NURSE DEMONSTRATES ENGLISH LANGUAGE PROFICIENCY.

Applicant will take the IELTS or the OET to demonstrate they have the appropriate level of English.

Test can be taken before arriving in the UK.

The NMC requires evidence when the applicant submits their application* (step EIGHT).

2. OVERSEAS NURSE COMPLETES NMC ELIGIBILITY AND QUALIFICATION APPLICATION.

Applicant will create online account and complete eligibility and qualification application.

Evidence of identification and qualification is submitted, and evaluation fee paid (non-refundable).

NMC will confirm eligibility for registration within 14 days of receipt of all information required. 

3. OVERSEAS NURSE TAKES THE COMPUTER-BASED TEST (CBT). 

CBT assures the NMC the applicant has the right knowledge and skills to practise in the UK.

Test is run in a number of overseas locations. It is taken before arriving in the UK. 

Results available 48 hours after taking the test.

4. EMPLOYER BECOMES SPONSOR FOR OVERSEAS NURSE. 

Employer assigns the CoS to the applicant upon passing CBT. 

The sponsorship reference number should be used for the Health and Care Visa application. 

5. OVERSEAS NURSE SUBMITS VISA APPLICATION. 

Applicants will submit their Health and Care Visa application and provide biometric information.

The earliest an applicant can apply for their visa is up to three months before the start date of employment stated on the certificate of sponsorship. 

Decision on visa usually within three weeks. 

6. VISA APPLICATION APPROVED. OVERSEAS NURSE TRAVELS TO UK. 

UKVI approves the Health and Care Visa application.

Biometric Residence Permits (BRPs) have been replaced by eVisas.

Individuals will receive instructions on how to create their UKVI account in their decision letter.

Registration must be achieved within an eight-month timeframe. 

7. OVERSEAS NURSE TAKES OSCE EXAM. 

OSCE will assess applicants clinical knowledge and can only be completed in the UK.

Applicant has up to 12 weeks from employment start date noted on CoS to sit the OSCE exam for first attempt.

Results emailed within five working days from OSCE test date. 

Candidate has three attempts at the OSCE as part of one application, with a minimum of ten days in between each sitting. UKVI approves the Health and Care Visa application.

8. OVERSEAS NURSE COMPLETES NMC REGISTRATION APPLICATION. 

If applicant has passed OSCE they will submit health, character and language evidence and pay registration fee via their online portal.

NMC will aim to assess the application within 30 days and issue registration number (Pin).

Applicants should ensure their PINs are issued as soon as possible to avoid delays in taking up post.

Applicant has gained registration and can work as a registered nurse in the UK.

Employer must tell the UKVI within 10 working days of the individual’s full registration confirmation. 

The process is subject to change and you must refer to the Trained outside the EEA guidance on the NMC website for full, up-to-date details.

RECRUITMENT TIMELINE

If your organisation is new to international recruitment, this suggested recruitment timeline will give you an indication of what is possible in the best-case scenario.

To help the applicants understand the recruitment process, highlight this timeline as part of the application process or include it in the information pack shared at the start of the recruitment process.

If your organisation is already conducting international recruitment, use the timeline as a benchmark. You should consider: Are your processes running ahead or behind of the timeline? Can you identify barriers slowing the process? How can you overcome these barriers?

INTERNATIONAL NURSING RECRUITMENT PASTORAL OFFER SELF-ASSESSMENT

OSCE PREPARATION PROGRAMME

Overseas nurses have up to 12 weeks from the date of employment (as stated on their CoS) to complete the OSCE. Support materials such as mock exams and the assessment criteria are available to candidates through each of the test centres. In the run-up to the examination, candidates must be given support and the opportunity to practice and prepare.

Supervised practice

When designing your OSCE preparation programme, consider if you will include a period of supervised practice in a clinical area during the training period. There are generally two different approaches adopted by organisations: 

1. A bootcamp-style approach, which sees the candidates preparing for the OSCE examination intensively over a shorter period with no clinical practice. 

2. A longer preparation programme, which sees candidates work clinically during the training period, with regular release for OSCE preparation. 

There is no evidence to suggest one approach is more successful than the other.

Resources to help design your programme

NMC nursing exam blueprints - set out the skills and procedures the overseas candidate needs to know and be able to demonstrate.

OSCE train the trainer - training courses are provided by the OSCE test centres. 

Best practice benchmarks

The preparation programme should fully prepare the candidate for the OSCE and for employment as a band 5 registered nurse. 

The preparation programme should combine theory and practice within the classroom environment. Where possible, it should be supported by overseas nurses who have previously been through the OSCE process. 

Ensure candidates have plenty of time to practice their skills prior to taking the OSCE examination. 

Informal assessment should take place throughout the preparation programme and a formal mock OSCE should be undertaken at least three weeks before the OSCE date to make sure the candidate is ready for the examination. 

Individual feedback should be provided to candidates to ensure continuous learning. 

Study days should be offered as protected learning time and where candidates are working clinically during the preparation period, this should be incorporated into their shift allocation. 

Ensure the programme helps candidates to build up their confidence and ability to verbalise their knowledge. 

Pastoral support pre-and post-OSCE is essential. Stress levels may run high and candidates may need support to manage nerves or emotions. 

Consider creating a dedicated peer support group for the preparation period. 

It is important to recognise that the candidate is already qualified in their home country, so previous experience and education must be recognised.

ONGOING PROFESSIONAL SUPPORT

The end of OSCE preparation for your overseas nurses is just the beginning of their journey working for your organisation.

Preceptorship

The NMC strongly recommends that all new registrants have a period of preceptorship, including anyone who has entered a new part of the register and those newly admitted to the register having trained overseas. Where an overseas nurse is newly qualified and has no previous clinical experience, or they have not practiced clinically within the previous 12-18 months then, they should be offered a place on your existing preceptorship programme alongside other newly qualified nursing staff. 

You might also consider offering the opportunity for a more bespoke/enhanced version of preceptorship, taking into consideration that some of your overseas nurses may have considerable clinical experience.

Professional development

Your overseas nurses should have access to the same learning and development opportunities and support for career progression as you provide for your UK nursing workforce. Professional support is important across an employee’s whole career and should be based on the individual’s preferences and career aspirations. As part of this process they should be offered an annual personal development review and a personal development plan should be agreed. 

For overseas nurses, as with all nurses, midwives and nursing associates registered with the NMC, professional development includes the requirement to revalidate every three years to be able to maintain their NMC registration.

NHS Pensions

Overseas nurses should also be made aware of the benefits from joining the NHS Pension Scheme such as life assurance and benefits on ill health as well as different retirement options.

International nursing associations

Nurses arriving to the UK from across the globe are faced with the challenge of adapting to working in the NHS and adjusting to a new culture. NHS England have been working with International Nursing associations that provide support to overseas nurses.

The overall aim of the group is to form a collaborative between associations to enhance the pastoral care to overseas trained nurses in England. 

The role of the group is to enhance the overall pastoral support to overseas nurses through sharing of initiatives across the Diaspora associations and bringing together a common offer, with a focus on the group’s key objectives of: 

• health and wellbeing 
• professional support 
• pastoral care to international nurses.

A list of international nursing associations and information how to contact them can be found on the NHS Employers website.

COMMUNITY ROLES

International nurses working in the community require unique support, both for the nurses themselves and the employer teams supporting them.

This section of the toolkit has been designed to specifically support trusts in their recruitment efforts for international nurses in community settings. It should be read in conjunction with the rest of the toolkit and aims to draw attention to the areas that are of specific focus when hiring and onboarding international community nurses. 

This section has been designed with the Queen’s Nursing Institute, NHS England, and a national task and finish group with key stakeholder. This included representation from the national patient and community advocates forum (PCAF).

Challenges in recruiting international community nurses

Not all countries have community nursing roles and most internationally educated nurses do not have a clear understanding of what community roles in the UK look like. This has meant that NHS trusts have found it more difficult to recruit international community nurses than their acute counterparts. As such, NHS trusts have had to be innovative in establishing unique ways to identify potential candidates based on transferable skills and values-based recruitment. 

In addition to marketing your organisation, it is also essential to think of how to market these roles in a creative way to different audiences.

Once international nurses are recruited to work in a community setting, one of the biggest challenges is how they adapt to different ways of working. This would apply to both how the NHS works, and how they adjust to working in the community. Some of the most different ways of working include driving to conduct home visits – as they may arrive to their home visits by different means. We have a driving checklist in the professional support section which has our top tips on supporting international community nurses in learning to drive in the UK.

Myths about community nursing

With international recruitment to community nursing roles being fairly new to the UK, there are many myths about community nursing both from the perspective of recruitment teams and overseas nurses themselves. Below are some myths and their respective truths about recruiting internationally to community roles.

Preparing for recruitment

Marketing community trusts and community roles often can look different than other nursing roles and sectors, due to the lack of similar roles internationally affecting supply. 

While there is generally recognition of global similarities with the delivery of care in hospital settings, many internationally educated professionals will not be familiar with the structure or function of community healthcare in the NHS.

Defining community care, the services undertaken by the organisation, communicating your offer, and the structure of the NHS is crucial to ensuring international arrivals recognise the difference. 

There are many different job roles within community settings. The range of roles and different language used can make it difficult for both trusts and potential candidates to be best matched. Below are some of the different job titles available. Be sure to read the advertisement section for more information.

In partnership with Lincolnshire Partnership Foundation NHS Foundation Trust, Cumbria, Northumberland, Tyne & Wear NHS Foundation Trust and South London and Maudsley NHS Foundation Trust, Just R and CapitalNurse have produced a video on becoming a Mental Health Nurse.

1. District Nurse
2. Community Health Nurse
3. Community Children’s Nurse
4. Public Health Nurse
5. Hospital at Home
6. Hospice Nurses
7. Care Home Nurse
8. Homeless Health Nurse
9. School Nurse
10. Health Visitor
11. General Practice Nurse
12. Mental Health Nurse
13. Learning Disability Nurse

The NHS Futures Platform has a designated section for internationally recruited mental health and learning disability nurses.

Top tips for recruiting international community nurses

Based on learning from community trusts who have started international recruitment, including Kent Community Health NHS Foundation Trust and Sussex Community NHS Foundation Trust, below are some top tips when recruiting overseas nurses to community roles: 

Conduct a skills audit of applicants before recruitment to assess their baseline clinal skills, as well as skills and suitability for other areas, such as driving. 

Create a candidate information pack for prospective applicants setting out the structure of the NHS, opportunities for roles and career progression, dispelling any myths about community working, information on your trust and the local area (see pastoral self-assessment checklist).

Shortlist where possible staff with relevant experience of caring for a patient in a home or clinic, their values, and other transferable skills. 

Be sure to engage existing staff in the onboarding process. They may require additional support to feel confident in welcoming new team members, and this provides an opportunity to address any concerns or questions they may have. 

Be sure to discuss being open and sharing different things about others’ cultures. Engage in discussions and existing staff should be involved in planning cultural awareness events or other materials.

Objective Structured Clinical Examination (OSCE) support

The delivery of OSCE preparation is potentially more complicated for community organisations. Considerations of how to manage the preparation work needs to factor in additional requirements such as:

• ability to travel for training 
• location of new recruits versus the training venue 
• option to outsource.

There is no separate OSCE for community nurses; they must still receive training for potential acute skills and scenarios. This might involve accessing a neighbouring organisation for support and advice and potential collaboration for the community situations.

Tailoring pastoral care

As community nursing involves working with a high degree of autonomy, pastoral care for overseas nurses requires more focus on ensuring that they feel supported and comfortable in visiting patients by themselves. 

The ability to work independently is a key factor when working in the community. Therefore, pastoral care should be tailored to support international nurses with vulnerability, violence, and safety at work. 

When looking at the pastoral self-assessment checklist, particular attention should be paid to nursing associations and local communities, local transport, and a tour of the local area. 

It is also important to reflect the diversity of a community organisation. The changing geography, landscape, patient demographics and population profile across a large area are important considerations to ensure new arrivals expectations are aligned with reality.

There are added complexities when considering accommodation for community trusts as many services are provided within rural settings. Careful consideration needs to be given to the location of any accommodation that’s provided particularly in the context of transportation between home and work which either needs to be within walking distance or on good public transport routes which cover a variety of shift patterns (for example evenings, weekends, and bank holidays).

Community nurse pastoral care checklist

Professional support

Advanced skills can be practiced in the community and nurse led services are always expanding. Generic role profiles are helpful as the UK Visas and Immigration requires a description of duties when issuing Certificates of Sponsorship. This reduces complications if staff move internally between roles. 

It can take up to 12 months for a new member of staff to achieve all competencies required to practice as a Band 5 nurse independently. The education and practice development team should ensure a training needs analysis is completed and a competency profile is developed to support the knowledge and skills acquisition. Prescribing courses and advance practice courses are available to support the development of autonomous practitioners.

One of the biggest challenges for international community nurses is learning how to drive in the UK. Community nurses do home visits, and some areas require nurses who drive as patients’ homes are not near each other. However, countries such as India and the Philippines do not require nurses to learn to drive for work purposes.

Driving checklist

Driving is a key requirement in community nursing because of the large number of supplies and equipment that are needed when visiting patients. The Queen’s Nursing Institute has support for international nurses to drive in England. When recruiting community nurses internationally, the following areas need to be considered:

• Provide nurses with information on driving in the UK (i.e. how will they obtain a vehicle once in the UK, the steps needed to drive in the UK in the long term, information on the local road system, rules of the road etc). Government sources like driving in the UK are a good source.
• Nurses who are eligible to drive in the UK may benefit from a confidence course to help them familiarise themselves with the UK road network and driving conditions. One such course is the UK Familiarisation Course (some of the things covered include: the law, defensive driving, motorways, dual carriage ways, town driving, country lane driving).
• Depending on the country of origin driving lessons and a test in the UK may still be required even if a licence is held. This government resource can help determine if you can exchange a foreign driver’s licence. 
• Volunteer driver schemes might help internationally education nurses needing to travel while they are working towards their own driving competence.
• Visits could be clustered, for example to large care homes to reduce travel.
• Appointing a driving instructor may be more efficient than financing lessons depending on the number of nurses being recruited and the length of the recruitment campaign.
• Learning to drive takes time – staff who cannot drive may not reach the required standard within the expected time.
• Access to hire/pool cars and NHS lease cars might be an option to help with finding a vehicle in the first few months.

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UK PROFESSIONAL REGISTRATION

The General Medical Council (GMC) sets the standards that international medical graduates (IMGs) must meet in order to register as a doctor in the UK. There are various routes to obtain registration with a licence to practice in the UK. The route that will be applicable will depend on the training and experience of the doctor you are employing. 

There are some postgraduate qualifications acceptable outside the UK for GMC registration, but in most cases, doctors from non-EEA countries also need to pass the Professional and Linguistic Assessments Board (PLAB) test to demonstrate that they have the necessary skills and knowledge to practice medicine in the UK.

Many IMGs also have to show the GMC that they have an adequate standard of English. For most doctors this is demonstrated by obtaining a satisfactory score in the International English Language Testing System (IELTS) or Occupational English Test (OET).

PROFESSIONAL STANDARDS

It can be difficult for doctors new to the UK and the NHS to adjust quickly. It is vital that you put in place adequate support in transitioning to new professional environments and consider the new systems and ways of working that might be required from your overseas recruits.

There are resources to help with this adjustment:

• GMC core guidance, Good Medical Practice, describes what it means to be a good doctor, professional values and behaviours.
• GMC free learning session, Welcome to the UK Practice. This session will help doctors new to practice, or new to the UK to fully understand the ethical issues that will affect them and their patients on a day-to-day basis.
• The NHS GP international induction programme, this provides a supported pathway for overseas qualified GPs to be inducted safely into NHS general practice.
• The BMA gives members access to practical online guidance on all aspects of medical ethics.

What is the PLAB?

The Professional and Linguistic Assessments Board (PLAB) test is the main method used by the GMC to ensure international medical graduates have the necessary knowledge and skills to be granted full registration and a licence to practise in the UK. Doctors wishing to take the PLAB test must have already successfully completed IELTS or OET.

The first part of the PLAB test can be taken at a number of test centres overseas, but the second part must be taken in the UK. Further details about the PLAB test, including dates, test centres and costs, is available on the GMC website.

Candidates must pass both parts of the test within a maximum of four attempts at each. 

Part one - Written knowledge test which is held at various locations around the world. 

Part two - Objective Structured Clinical Examination (OSCE). The OSCE is held at the GMC clinical assessment centre in Manchester.

PLAB preparation programme

Familiarise yourself with the test blueprint, to understand what is expected of doctors to pass the PLAB test and the level and which they are assessed. This will help you if you are supporting candidates to pass through the PLAB route. 

It will also help to be familiar with the test blueprint during the pre-employment stage, to satisfy yourself that doctors who have already passed the PLAB test have the necessary knowledge, skills and experience for the role you are employing them to do. They will be entitled to apply for GMC registration having successfully passed the PLAB test.

Resources to prepare overseas doctors for working in the UK

Good medical practice – guidance and interactive online tool, setting out the professional values and behaviours expected of doctors.

Welcome to the UK practice – free GMC workshop to support overseas doctors adapt to working in a different culture.

Living and working in the UK – guidance and support materials for overseas doctors.

NHS induction programme for IMGs – welcoming and valuing international medical graduates in UK clinical practice.

Also consider signposting staff to support available from the relevant professional regulators, professional associates, royal colleges and trade unions. Consider how working with these groups, such as the Academy of Medical Royal Colleges, can support the IR profess and doctors should they chose to join as members.

Language tests

Applicants will need to achieve the required score in one of the GMC’s accepted language tests, unless one of the following applies:

• the applicant can evidence their primary medical qualification was taught and examined in English and acquired less than two years ago
• the applicant can evidence that they have worked in a medical capacity for the past two years or more in a country where English is the first and native language
• the applicant submits a copy of their UK job offer alongside an English language reference form, signed off by an NHS organisation listed as a designated body. This is unlikely to be accepted if an IELTS or OET test has previously been failed.

Further terms and exemptions apply. Please consult the GMC website for further details.

The IELTS (International English Language Testing System) is one of the accepted tests if the above does not apply. This test assesses general language skills and is generally considered to be more academic.

The overseas doctor must ensure they achieve the following grades:

• grade 7.0 or above in speaking, listening, reading and writing
• overall grade of 7.5.

The OET is another test that can be completed to obtain GMC registration, having been accepted since 2018. It assesses language skills more specific to healthcare workers, including the ability to communicate effectively in medical scenarios, write a referral letter or understand a patient consultation. 

The overseas doctor must ensure they achieve at least a B grade in the writing, reading, listening and speaking sections.

Further information about the tests, including costs, sample questions and scoring criteria, can be found on the OET and IELTS websites.

Immigration requirements

Overseas doctors will need a job offer and Health and Care Visa under the skilled worker route to live and work in the UK.

Overseas doctors can come to the UK on a standard visitor visa in order to take the second part of the PLAB test. The visa will permit them to stay in the UK for a temporary purpose, usually for up to six months. 

The government announced a series of changes to the immigration system which impact the NHS. An overview of the changes can be viewed on our Impacts of the changes to UK immigration policy page. This includes increasing minimum salary thresholds, changes to rules on salary threshold deductions, and rules on the recruitment of care workers and senior care workers such as restrictions of dependants and working with regional partnerships.

In May 2025, the government published the immigration white paper that outlined changes to the UK immigration which will impact the whole immigration system, including raising the skill level to RQF6 (graduate level) and above. 

STEP-BY-STEP PROCESS: REGISTRATION AND IMMIGRATION

The diagram below shows a summary of the registration and immigration process for an overseas doctor who is out of country and will be sponsored under Health and Care Visa to work in the UK.

*This diagram provides a summary of the registration process. The process is subject to change and you can refer to the registration and licensing guidance on the GMC website for full, up-to-date details.

RECRUITMENT TIMELINE

The process of recruiting an overseas doctor, which includes them obtaining a visa and becoming registered with the GMC, can take longer than you might expect. 

For some doctors it can take 18 months from applying to starting in post. Timescales will depend on the stage at which the doctor is in the GMC registration process when you interview them. It is important to consider your timescales and how to pitch your recruitment to attract the right candidates and minimise delays.

PASTORAL AND RELOCATION SUPPORT

Overseas doctors should be supported in the same way you would for all new recruits on arrival when they are new to the UK and the NHS. Your support may include help with organising transport and finding accommodation, schools and other local facilities as well as support with administrative tasks such as setting up bank accounts and mobile phones. See the induction and beyond section for best practice.

If a doctor’s partner wants to pursue their own career in the UK, whether that is in healthcare or in another profession, also consider what support your organisation can offer. For example, supporting them to learn or improve their English and to find suitable work. 

High importance should also be placed on ensuring that ongoing pastoral and professional support networks are in place for doctors transitioning to new social, cultural and professional environments.

The effort put into assisting and integrating overseas doctors and their families will be key to them being able to work at their potential and choosing to stay with your organisation.

Fair to Refer report

Research commissioned by the GMC has found disproportionate referrals of Ethnic Minority doctors to fitness to practise processes. 

The report states this could be driven by:

• poor induction and support in transitioning to new social, cultural and professional environments
• working patterns that leave them isolated and in roles lacking exposure to learning experiences, mentors and resources
• poor feedback from managers who are avoiding difficult conversations, but which could prevent problems later.

PROFESSIONAL DEVELOPMENT

Your overseas doctors should have access to the same learning and development opportunities and support for career progression as you provide for your UK medical workforce. Professional support is important across an employee’s whole career and should be based on the individual’s preferences and career aspirations. As part of this process, they should be offered an annual personal development review based on the GMC’s core guidance, and a personal development plan should be agreed.

For overseas doctors, as with all doctors registered with the GMC, professional development includes the requirement to revalidate every five years to maintain their licence to practise and their registration with the GMC.

Overseas doctors should also be made aware of the benefits from joining the NHS Pension Scheme such as life assurance and benefits on ill health.

Medical Training Initiative

The Medical Training Initiative (MTI) is a scheme that provides an entry route for overseas doctors wishing to train and develop their skills in the NHS before returning to their own country. The scheme allows suitably qualified overseas postgraduate medical specialists to undertake a fixed period of training in the UK, normally within the NHS, before returning to their own healthcare systems.

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