Uncertainty and insecurity of mobile lives: Migrant nurses in the UK NHS and the renewal and maintenance of professional registration in the home country

By Amrita Limbu, Postdoctoral Research Fellow, School of Law, University of Leeds

Yuna, a nurse from Asia has lived and worked in the UK for more than 15 years but has continuously renewed her nursing registration in her home country for 20 years now.[i] For her, maintaining the nursing registration back home is a ‘backup’ option if she has to go back home to take care of her ageing parents.

Health professionals who relocate to the UK often leave behind nuclear or extended family members in their home country or in a third country. And the need to return for visits, or caring responsibilities as Yuna mentioned, or family reunion is indeed real, especially in an environment of increasingly tightening of borders and restrictions on family migration and family reunion.[ii]

Recently, in April 2024, the UK government increased the minimum income requirement for migrants to bring partners or spouses from £18,600 to £29,000, which is set to further increase to £38,700 by early 2025.[iii] International students and those on social care visas are now altogether prevented from bringing dependants and families from 2024.[iv] These new policies make bringing partners, spouses, or family more difficult and are set to separate more lives and families. In light of these policy shifts, the renewal of registration back home offers a tangible solution, providing a form of insurance for healthcare professionals to imagine a life and career in their home country if need to return arises.

Yuna is among the cohort of overseas trained health professionals who shared their experiences of professional registration in the UK as part of the ongoing study Making it to the Registers. She is also among the several healthcare professionals who continue to renew and maintain their nursing registration in their country of origin. For other nurses with foreign qualifications, maintenance of their professional registration back home was also their insurance if things did not work out for them here in the UK. Often noted were insecurities if they are ‘referred’ − a process whereby a healthcare professional can be referred to the regulatory bodies such as the General Medical Council (GMC) or Nursing and Midwifery Council (NMC) for fitness to practise concerns, or asked to produce a valid registration as part of an inquiry, or even sent back home.[v] Renewing their professional registration back home thus provides assurance that they can produce the necessary document if and when needed. More importantly, it enables them to continue practicing their profession in their home country or in the country they received their training, should they need to return. Without it, they risk having to undergo the registration exam procedures again.[vi] In this blog, I touch upon these intersecting themes of insecurity, family and kinship, and immigration policies in the renewal of the NHS nurses’ professional registration in their home country.

In general, fitness to practice referrals are higher against overseas trained healthcare professionals. Referrals received by the medical regulatory body GMC indicate that overseas trained doctors experience referral rate 2.5 times higher than the UK trained doctors, while Black, Asian and Minority Ethnic doctors face double the referrals compared to their White counterparts.[vii] A study in the United States also suggest similar disproportionate trend of ‘overpolicing’ of Black residents in medical education − where they are faced with higher rates of disciplinary interventions as well as dismissal from their programs compared to White residents.[viii]

The process and requirement to renew professional registration vary depending on the profession, country of origin or country they received their training. For instance, some countries mandate only the payment of registration fees and evidence of ongoing nursing practice, while others may additionally require completion of an online training / course as evidence of continuing professional development. Certain countries only permit renewal if the professional is practicing in the same country, while others have no renewal requirements. Nonetheless, the nurses’ interest to maintain professional registration of their home country, along with our study’s preliminary findings, raises crucial questions surrounding career stability and a sense of security experienced by the overseas healthcare professionals within the NHS. This urgency and significance of the matter is further accentuated by the increasing number of migrant nurses recruited in the NHS from across Asia, Europe, and Africa. Statistics from June 2023 reveal that 73 per cent nurses and health visitors in the NHS in England are non-British nationals.[ix]

Historical examples of dismissal of foreign healthcare professionals serve as reminders that these concerns of security and stability harboured by overseas-trained health professionals are indeed valid. Archival research conducted for the project Making it to the Registers reveal instances during the Second World War when refugee healthcare professionals who fled Nazi persecution were allowed to work to make up for the shortage of local doctors and nurses but were later dismissed for concerns of security. The ban on permitting foreign doctors to practice was later lifted, albeit with the condition that they would be immediately removed from hospital employment in the event of invasion or serious military situation.[x] The ban on foreign nurses was implemented for longer as nurses were perceived to pose a higher risk due to their proximity to patients.[xi] While this is an extreme example, one of national security during a war, it nonetheless sheds light on the temporality, inherent insecurity, and inequality that migrants face when compared to the nationals.

Examples also illustrate the tightening of borders and imposition of restrictions on immigration rights in response to fluctuation in demand for foreign labour. For instance, official documents obtained from our project partner BAPIO, who have been supporting international doctors and nurses for the last 25 years, reveal that during the mid-1980s, policy conversations centred around concerns of unrestricted immigration. Until then, foreign doctors and dentists were permitted to undertake postgraduate training and professional employment without a work permit if they were registered with the GMC or the dental regulatory body the General Dental Council (GDC). However, immigration regulations from 1 April 1985 mandated the requirement of a work permit for professional employment, and from 7 March 2006, the permit-free training for foreign doctors and dentists was abolished altogether. These policy shifts coincided with the surplus of British trained medical graduates and the UK’s growing preference for doctors and dentists from the European Union (EU), and therefore mainly affected the health professionals from outside the EU.

Historically, governments have needed to justify permitting foreign professionals to work based on a shortage of domestic or local workforce. This not only attests to the volatility of the migration policies that regulate the entry of foreign health professionals,[xii] but further justifies the concerns of maintaining nursing or medical registration in their home country. As immigration policies and regulations governing foreign healthcare professionals evolve in response to the labour market needs, the uncertainty and transience of mobile lives persist, sometimes even after individuals attain settled status or citizenship. It is unfortunate that foreign healthcare professionals in the NHS feel the need to adopt safeguard measures against career insecurities by continuing to maintain their professional registration in their home countries, but this is likely to become increasingly pertinent for migrants desiring family reunion, especially considering the recent immigration policies that raise the minimum income requirement for family reunion or impose restrictions on family migration altogether. Nevertheless, return is a complicated decision involving not only the individual migrant’s personal considerations but also the future of the children, partner, and other family members. It should not be seen as an alternative to career stability, security, family reunification, or essential flexibility of cross-border mobility.

[i] Health professional interview 22

[ii] Also, health professional interview 19

[iii] McKinney and Gower (2024) Changes to legal migration rules for family and work visas in 2024. House of Commons Library. https://commonslibrary.parliament.uk/research-briefings/cbp-9920/?ref=publicsquare.uk

[iv] Policies in place since 01 January 2024 for international students and from 11 April 2024 for those on social care visa. GOV.UK (2024) Tough government action on student visas comes into effect, https://www.gov.uk/government/news/tough-government-action-on-student-visas-comes-into-effect

[v] Health professional interview 25

[vi] Health professional interview 15

[vii] Atewologun and Kline with Ochieng (2019) Fair to refer? Reducing Disproportionality in Fitness to Practise Concerns Reported to the GMC. General Medical Council.

[viii] Joshua et al (2023) Dismantling the Overpolicing of Black Residents. The New England Journal of Medicine 389(14): 1258-1261.

[ix] Baker, Carl (2023) NHS staff from overseas: statistics. House of Commons.

[x] The National Archive HO 213/1749

[xi] The National Archive HO 213/2008

[xii] Spiliopoulos and Timmons (2022) Migrant NHS nurses as ‘tolerated’ citizens in post-Brexit Britain. The Sociological Review 71(1): 183-200.