In the six months to September 2021 nearly half of people joining the UK nursing register came from abroad: almost 11,000 were trained overseas compared to 13,000 who trained in the UK. 

This number could even exceed 20,000 in this financial year, according to England’s chief nurse, Ruth May. 

Exams and requirements tweaked

However, there are some concerns that standards may be slipping in the rush to recruit more staff. 

Overseas nurses sit a computer based test in their home country before facing a practical exam in the UK. In India, nurses must sit a multiple choice exam which tests professional knowledge, skills and attitude. Candidates can sit the exam as many times as they like, but must wait six months if they fail the test twice. 

This process was made easier in 2019, when the pass score was changed from 90 per cent for critical thinking questions and 60 per cent overall to just 68 per cent overall, with critical thinking questions scrapped.

“The critical thinking questions were comparatively difficult for the nurses to understand. Once the change happened, they were able to easily score without the fears of the critical thinking questions,” said Ajinas AM, Assistant Secretary General, Trained Nurses Association of India.

Meanwhile Filipino nurses can now be hired straight after they have qualified, according to a senior nurse from the country. 

“Before the pandemic, not only UK but for instance also US, or Middle East or Germany, Ireland, they all want at least two years clinical experience from the nurses,” they said.

“But during the pandemic there is no more number of years of experience as long as you are a licensed registered nurse in the Philippines, meaning you have passed the local board examinations here in the country.”

The nurse said that the pass mark for the English language exam had also been lowered from 7.5 to 6.5.

A spokesperson for the Department of Health said: “No changes have been made to the entry criteria for nurses applying from abroad to practise in the UK. Any applicants would still have to meet these robust standards set by the Nursing and Midwifery Council to ensure patients receive the best possible care.”

It has also emerged that the UK government is set to recruit several thousand nurses from Nepal. The details of the deal are still to be fleshed out but according to Dr Thaneshwar Bhusal, a Nepalese government official, the UK has agreed to support the training of Nepalese nurses in return for extra staff. 

“We have agreed in principle that it will be a zero cost process, that the Nepalese individuals selected will not have to pay a single penny. We also do not want our people to stay in the UK for a long time, we are looking at a maximum of five years, we really want our Nepalese nurses to then come back home and work here,” said Dr Bhusal, who added that the deal will likely be signed off in March. 

A spokesperson for the Department of Health said no agreement had been signed. 

‘Supercharged’ international recruitment

It comes amid a backdrop of surging international recruitment for the NHS, according to William Palmer, a senior fellow at the Nuffield Trust health think tank.

“In the first six months of the pandemic there was a very noticeable drop off in overseas recruitment,” he said. “And since then, it’s ramped back up and actually the latest data shows it’s exceeding what it was beforehand.”

The government has actually “supercharged” international recruitment, he added, by handing out grants of £25,000 to £100,000 to trusts to enable them to bring in staff from overseas. 

In December NHS England chief executive Amanda Pritchard wrote to all employers, directing them to “accelerate recruitment plans… and where possible bring forward the arrival of internationally recruited nurses”.

The Nursing and Midwifery Council has also pledged to fast-track the registration process, which currently takes around 60 days. 

Meanwhile, writing in the Telegraph in February, Sajid Javid promised to recruit 10,000 nurses from overseas and 5,000 healthcare support workers by the end of March as part of a “radical” plan to tackle record backlogs built up during the pandemic.

Professor James Buchan, a senior fellow at the Health Foundation, says that although many countries are looking to recruit internationally, the UK is probably the most active at the moment. 

“Several trusts will get together, or work with an agency and essentially go big time, to try and get the numbers up through one channel of recruitment rather than more sporadic, small attempts to fill a few places,” he said. “There are potential economies of scale for the employer.” 

And rhetoric of job adverts focuses on the broader quality of life, not just the position. “Whether you enjoy city living, stunning coastlines or a peaceful countryside setting, Devon offers it all,” a group of trusts in Devon said in an online advertisement. 

Trusts are also offering generous relocation packages including paying fees for registration with the Nursing and Midwifery Council, the first two months accommodation and a welcome pack that includes a mobile phone sim card and food. 

While this may seem costly it is actually cheaper for the NHS to recruit a nurse from overseas than to train one from scratch. Analysis by the Nuffield Trust found that it can cost an NHS trust between £2,000 and £12,000 to recruit a nurse from overseas, while training a nurse from scratch costs around £140,000.

But an investigation by the Observer last week found that some international nurses are being trapped in their jobs by clauses in their contracts that require them to pay up to £14,000 if they want to leave their role within five years, allowing hospital trusts to recoup their costs. 

A ‘critical shortage of staff’ globally

Relying on overseas recruitment is not an issue limited to Britain. The International Council of Nurses (ICN) has warned Covid-19 will exacerbate a global shortfall of nurses, which stood at 5.9 million even before the pandemic, in 2019. 

The organisation’s chief executive, Howard Catton, fears that wealthy countries aggressively recruiting more international medics will only widen the unequal distribution of nurses, leaving lower income countries in the lurch.

“Nursing shortages were endemic before the pandemic, especially in low and middle-income countries,” he told the Telegraph. “Now there is evidence that governments of wealthier nations are turning increasingly to international recruitment to plug the gaps in their nursing workforces.”

For instance in Canada – which has also eased language requirements – Ontario reported that 2,259 internationally trained nurses joined the workforce in the first six months of 2021, more than during the whole of 2020. 

Meanwhile Quebec is reportedly developing “recruitment missions” to high income countries like France and Belgium, but also Brazil, Algeria, Libya, Mauritania, Morocco and Tunisia, to help fill 4,000 vacancies.

Across the border, roughly 1,000 nurses are arriving to work in the United States every month from the Philippines, Caribbean and Africa. 

While countries such as the UK, Canada and US are offering attractive packages, many health workers are also being pushed out of their own countries.