Written evidence submitted by NHS Employers (RTS4240)

NHS Employers, part of the NHS Confederation, is the employers’ organisation for the NHS in England. We support workforce leaders and represent employers to develop a sustainable workforce and to be the best employers they can be.

We work closely with employers to understand the issues of importance to them, using this intelligence to provide a collective employer voice to inform and shape policy decision-making around education, training, skills, and workforce planning. We also support employers in implementing policies to enhance workforce supply, staff experience, and retention.

We convene several networks of employers actively engaged in supporting the development of the future NHS workforce, including in relation to international recruitment.

Executive Summary

This submission outlines the implications of proposed changes to UK visa settlement routes, distinguishing between two groups:

• Individuals currently in the UK working in health or social care who hold a Health and Care, Skilled Worker visa or have another time limited visa which enables them to work in the sector.
• Individuals who will arrive after the changes come into effect.

For existing visa holders, maintaining the current five-year route to Indefinite Leave to Remain (ILR) is essential. Many individuals and families have made life-changing decisions based on the rules and policy set out at the time.

Retrospective application of extended settlement timelines would create significant human, social, and financial impacts, including increased costs for health and social care organisations in an already challenging financial landscape. The Home Secretary’s “fairer pathway to settlement” statement made on 20th November 2025 proposed moving toward longer standard settlement routes[1], creating uncertainty for those currently on a five-year pathway and reinforcing the need for firm transitional protections. Our members are clear that they need to retain the talented people who are already in our teams, wherever in the world they have come from, to offer care to our patients.

For future applicants, NHS Employers supports a fast-tracked settlement route-of under 10 years-for those sponsored by NHS or care organisations. This should apply across both clinical health and care roles (such as those on a Health and Care Visa) and key support functions such as digital, finance, estates, and administration (such as those on a general Skilled Worker Visa). Parity between NHS and care sector workers is crucial, as shortages in social care directly and negatively impact NHS service delivery and the overall experience the patient has of health or care. To respond to the new 12-week statutory consultation launched on 20 November 2025 on ‘Earned Settlement’[2], we will be undertaking extensive engagement with NHS employers to provide a full response to the Home Office on behalf of the NHS in England.

Potential Impact of Changes to Pathways to Settlement

What evidence is there on the effect that pathways to settlement have on immigration and rates of settlement?

1. Recent changes in immigration policy have already impacted the health and care workforce negatively. Between 1 April 2024 and 31 March 2025, 5,276 international nurses and midwives left the register, a 33.3% increase compared with the previous year[3]. This demonstrates that internationally educated professionals depend on immigration pathways, and uncertainty can accelerate attrition of staff.
2. The Health and Care Professions Council (HCPC) has found that while most health and care professions are growing, retention remains a challenge. Within four years, 10% of all new registrants across 15 health and care professions left the register. Importantly, this rises to 30% for international route registrants, compared with only 5% for UK route registrants[4].
3. Care workers, Graduate Visa holders and roles on the Immigration Salary List and Temporary Shortage List, already have restrictions on bringing dependants as part of their visa, which limits attractiveness of coming to work in the UK for certain professions and those with families.
4. Any future changes to immigration legislation, including international leave to remain (ILR), must support internationally educated health and care professionals and encourage them to remain and build careers in the UK. The Home Secretary’s statement outlined an “earned settlement” model that may include higher English requirements and evidence of continuous National Insurance contributions[5]. The government has indicated that new health and care overseas workers should have a route to ILR shorter than 10 years[6], reflecting their significant contribution to the UK workforce and society, which NHS Employers supports and awaits the detail of.
5. The Secretary of State for Health and Social Care has called for more domestic recruitment to reduce reliance on overseas and agency staff.[7] NHS Employers welcomed this but stressed that recruitment must be matched with investment in training, retention, and better working conditions to build a sustainable workforce. This also requires a change in legislation to ensure that NHS organisations are not discriminating against non-UK workers if the government wants to prioritise domestic recruitment.

What is the likely impact of longer routes to settlement on businesses and employers, including international recruitment of higher-skilled workers?

6. Extending settlement from 5 to 10 years would place a substantial financial burden on the NHS. This aligns with the longer baseline settlement route referenced in the Home Secretary’s statement in November 2025[8]. Sponsorship periods would double and combined with increases in the Immigration Skills Charge (32%), visa fees, and Certificates of Sponsorship, costs for recruiting internationally trained staff would more than double.
7. These costs would exacerbate pressures on NHS employers who have already invested heavily in international recruitment. Many staff recruited through initiatives such as the drive to increase the nursing workforce by 50,000 under the last government[9] are currently extending their visas and increased financial and administrative burdens could deter organisations from recruiting overseas. 93%[10] of the 50,000 target was achieved through international recruitment, which means tens of thousands of overseas trained staff and their families could be impacted by these changes, in just one staff group alone.
8. The NHS is already under increased financial strain with system deficits rising from £517 million in 2022/23 to £1.4 billion in 2023/24 while being asked to deliver efficiency savings of 5 to 11 percent, the toughest in years[11]. The Department of Health and Social Care’s budget is set to grow from £202 billion in 2025/26 to £232 billion in 2028/29, a real terms increase of about 2.7 percent per year[12], but this modest uplift is being eroded by inflation, rising workforce costs including ongoing industrial action, and growing patient need, leaving many NHS leaders warning that additional funding will be needed to maintain services.
9. If settlement changes were applied retrospectively, staff already in the UK on sponsored visas would face uncertainty and would likely perceive the rules as unfairly shifting mid-journey. Although the Home Secretary has stated that “transitional arrangements” will be introduced, the details are not yet clear. Lack of clarity could drive skilled professionals to leave the NHS or choose other countries with more predictable settlement routes. A loss of colleagues would create staffing pressures and vacancies, with any domestic recruitment plan some years off in terms of producing additional graduates to fill these vacant roles.

What is the likely impact of longer routes and stricter requirements for settlement on migrant households already in the UK?

• the financial and economic impact, including access to benefits; and  

• the personal and social impact.

10. Longer routes to settlement could place families and employers under financial strain, with additional costs for visa renewals, dependants, and the Immigration Health Surcharge, making the NHS a much less attractive option for clinical professionals who operate in a global market and who we want to retain.
11. The social and personal impacts would also be significant. Many people already in the UK have made life-changing decisions, including relocating families, buying homes, or enrolling children in schools, based on a five-year route. Changing the rules mid-journey risks undermining trust, negatively impacting integration into UK society by making people feel unwelcome. We can also confidently predict an increase in numbers of people leaving the UK for more favourable destinations, which are in competition for healthcare professionals. The GMC data published in November 2025 shows an increase in the number of internationally educated doctors leaving the UK over the last year which could be a result of current policy changes and the negative narrative.[13]
12. Delays in settlement may reduce the UK’s attractiveness as a workplace for international recruits, leading to vacancies in both health and care sectors and creating knock-on effects for NHS service delivery, including the government’s headline pledge to reduce waiting lists over the course of the parliament.
13. Over recent months, there has also been an increase in racist abuse against NHS staff. The NHS Confederation has publicly condemned this abuse, recognising that it affects staff wellbeing and retention[14]. Protecting settlement pathways and creating a supportive environment is essential to retain a workforce that is over 200 nationalities strong and makes up approximately 21% of the NHS workforce[15].The new earned-settlement requirements - higher English levels, NI contribution evidence, good-conduct checks, and debt requirements - may create added pressure for households already experiencing instability[16].

What potential effect could changes to eligibility for settlement have on integration?

14. NHS staff are central to UK society, with over 1.5 million employees[17] contributing to healthcare, tax revenues, and community integration. Fit for the Future: The 10 Year Health Plan for England[18] aims for 10% of the NHS workforce to be internationally educated employees. Delays in settlement or stricter requirements could undermine the sense of these employees belonging and delay integration.

15. Retention toolkits developed by NHS Employers provide guidance for line managers and organisations to retain staff[19], including internationally recruited staff[20]. However, policies that reduce certainty about settlement may make it harder for staff to feel welcome, increasing the likelihood they will leave and impacting future retention levels, as well as impacting wider NHS staff morale, which is already low as shown in the recent NHS Staff Survey 2025, where over 40% of staff reported work-related stress and fewer than a third felt their pay was fair[21].

How should “long-term contribution” to the UK be defined and quantified when considering pathways to settlement?

• social and community contributions; and 

• fiscal and economic contributions. 

16. Long-term contribution should consider both economic and social impact. This includes sustained employment, income tax contributions, public service, and positive participation in communities.

17. The NHS’s role as an anchor institution is not only national but deeply local, with direct impact on communities. NHS organisations are often the largest local employers, providing stable jobs and apprenticeships that support social mobility and local growth. Their procurement choices can strengthen local supply chains, with evidence showing that directing spend to local businesses helps retain wealth in communities and fosters inclusive growth. Estates and infrastructure projects also contribute to regeneration, creating spaces that benefit both patients and residents. This means NHS policy decisions on workforce, procurement, and estates have ripple effects that shape community resilience, economic opportunity, and wellbeing. Recognising the NHS’s anchor role highlights how health policy is inseparable from wider community development and tackling inequalities.
18. The government has suggested a shorter route for “high-skilled, high-contributing individuals” such as nurses, doctors, engineers, and AI leaders[22]. NHS Employers believes this principle should apply across the health and care sector, including support roles, as all sponsored employees make a measurable and significant social and community contribution, primarily through their employment in public service contributing directly or indirectly to the health and wellbeing of citizens.
19. The Migration Advisory Committee (MAC) Stage 1 report into the Temporary Shortage List (TSL) did not make recommendations on settlement rights, sponsorship models, fees, or cap mechanisms[23], which means there is lack of transparency and the sector is left with significant uncertainty.
20. Any framework should be realistic. For example, expecting a Band 5 nurse to volunteer additional hours to reduce time to settlement, while working shifts, supporting families, and maintaining rest for safe patient care, is not feasible. Core work already constitutes a significant public contribution.

What exemptions should there be to the new rules?

21. NHS Employers will be constructively engaging with the live consultation on settlement routes, which we acknowledge asks for views on the instances where a shorter route to settlement may be applicable. As part of this inquiry and the government consultation, we will be advocating against any retrospective application of the new rules.

22. The Home Secretary’s commitment to transitional arrangements must provide absolute assurance that individuals already in the UK on Health and Care or Skilled Worker visas prior to the changes will continue to benefit from the existing five‑year pathway to Indefinite Leave to Remain. Changing the rules mid-course would compromise retention, integration and trust, risking the departure of highly skilled staff and further undermining morale.
23. Individuals currently employed within the NHS and care organisations, whether in clinical, support, digital, finance or administrative roles, should continue to benefit from a shorter route to settlement. Ideally limited to under ten years, this pathway must reflect the essential contributions these workers make to public health and social care.
24. Together, these exemptions would protect current staff, recognise their contribution, bolster morale, and ensure the UK remains an attractive destination for international healthcare professionals. In turn, this would ensure the NHS can meet the health needs of an ageing population where increasing numbers of people like with more than one complex condition.

Dec 2025