The impact of international recruitment of nurses on health systems has been a recurring theme in recent years, rarely out of the headlines.

In this article, we examine how the UK is “located” in the global context, both in terms of inward recruitment and outflows of nurses to other countries. This is critical to shaping long-term national nurse workforce strategy and policies in England.

“Every nurse leaving the UK may add to the replacement challenge”

Looking first at international inflow of nurses to the UK, we show how the UK has relied on international nurses since 1990.

A nurse cannot practice in the UK without being registered with the Nursing and Midwifery Council (NMC), so NMC register data is a useful proxy measure for new international nurses becoming eligible to practice in the UK.

Fig 1 shows numbers of new NMC registrants trained in the UK have remained relatively stable, increasing somewhat in the last decade, whereas numbers of non-UK trained registrants have fluctuated markedly since 1990-91.

Prior to 2022-23, the largest wave of UK registrants was in the 2001-02, when around 16,000 non-UK nurses registered each year and accounted for 53% of all new registrants.

In 2023-24, there were around 29,600 non-UK registrants, or about half of all new NMC registrants. It has been reported that 93% of the last government’s 50,000 NHS England nurse growth target was met by international nurses.

The Philippines and India have been the main “source” countries for UK recruitment in recent years, notably the latter – 8% of all NMC registrants currently on the UK register were from India as of September 2024.

However, there has also been a growth in nurses coming from “red list” countries, designated by the World Health Organization as being vulnerable to losing scarce health professionals, such as Ghana and Nigeria.

The 2023, England’s NHS Long Term Workforce Plan made ambitious commitments to increase domestic training, and to reduce reliance on international recruitment. Yet, trends in applications to nurse training in England have fallen since.

This suggests only a huge investment in training capacity and in improving retention would make the commitment to greater domestic self-sufficiency a realistic target in the revision of the workforce strategy.

Outflow of nurses from the UK has received less attention, but is becoming more prominent. Available data suggests that more UK registered nurses are giving serious consideration to leaving the UK in recent years.

The NMC records every application for a certificate of current professional status (CCPS) made by a UK-registered nurse to have their registration confirmed by a counterpart council in another country.

Turning to potential outflow, Fig 2 shows a marked upward trend in overall CCPS applications since the peak of the Covid-19 pandemic in 2020-2021, and an increase on the concentration across destination countries.

Recent data shows this trend is continuing with nearly 25,000 CCPS applications in 2023-24, up nearly 60% on the year before.

Just three countries – the US, New Zealand and Australia account for nearly 90% of all 2023-24 CCPS applications by UK registered nurses, up from under 65% pre-pandemic.

Two of these countries – Australia and the US are towards the top of the international potential earnings “league table” for hospital nurses, as compiled by the OECD, while New Zealand, is a “stepping stone” country.

Many nurses who wish to move to and work in Australia tend to first apply for registration in New Zealand because it is generally easier to then move to Australia via a mutual recognition agreement.

New Zealand, a country the size of Scotland, reported more than 6,000 UK-registered nurses registering in 2023-24, more than twice the number of new domestic nurse registrants (Miller, 2024).

In 2022-23, almost 8,000 nurses were reported as moving from New Zealand to Australia, and only around 200 in the other direction[ii].

Analysis of CCPS data also highlights that the UK is becoming a “stepping stone” country for international nurses (Fig 3).

In 2023-24, nearly three in four CCPS applications from international nurses were from nurses registered in the UK in the last three years. Many of these are nurses trained in India, Nigeria or in the Philippines.

The latter notably apply for CCPS for the US and New Zealand, while nurses trained in India have a broader focus, with many also considering Australia or New Zealand.

The 2023 NHS Long Term Workforce Plan has not been fully implemented, and is reportedly to be revised later this year to support the Labour government’s new NHS 10-year plan.

Our analysis highlights that any reduction in international nurse recruitment will be from a historically high level. Further, the 2023 plan made no separate assessment of the impact of international nurse outflows.

This increasingly appears to be a glaring analytical gap which needs to be filled, given the marked upward rise in number of nurses thinking about leaving the UK.

Every nurse leaving may add to the replacement challenge. A crude measure of the “in” and “out” flows is shown in Fig 4, which highlights growing “flows” in both directions, but relatively larger growth in outflow, as measured by recent CCPS applications.

The UK has been a very prominent international recruiter of nurses in recent years. It has achieved recent domestic staffing growth in large part by targeting other countries.

It is now apparent that more UK registered nurses are thinking about moving, driven by thoughts of better pay and prospects.

The UK has assumed that being globally connected has been about tapping into other countries for recruitment of their nurses, forgetting that these flows can be in the reverse direction.

Professor James Buchan is senior fellow, Laurie Rachet-Jacquet is economist and Elaine Kelly is assistant director; all at the Health Foundation