Written evidence submitted by the British Medical Association (RTS4689)

About the BMA

The British Medical Association (BMA) is the trade union and professional association for doctors and medical students in the UK. We ensure that doctors and medical students have the resources and support to fight for improvements in the workplace and in medical practice for the benefit of ourselves, our colleagues, our patients, and a healthier society. We do this through organising to win and campaigning to influence on the matters of importance to the medical profession.

1. Introduction

1.1   The British Medical Association (BMA) welcomes the opportunity to respond to the Home Affairs Committee’s consultation on changes to pathways to settlement (also referred to as indefinite leave to remain (ILR)), particularly in the context of doctors who qualified overseas (international medical graduates (IMGs)) and the wider health and care workforce.

1.2   IMGs comprise approximately 42% of licensed doctors in the UK[1] and are indispensable to the delivery of safe, high-quality healthcare, making their retention and integration essential for workforce sustainability. Many IMGs share the experience of meeting immigration and residency requirements. However, IMGs represent a highly diverse group of doctors, with individual migration timelines ranging from recent arrivals to those who have been in the country for several decades.

1.3   The BMA believes that any extension of the qualifying period for settlement is grossly unfair, particularly to those already in the UK and who arrived with the genuine expectation that they, and their families could obtain settlement within five years.

1.4   This proposal creates significant uncertainty, anxiety and financial strain for doctors and their families, which risks exacerbating existing recruitment and retention challenges in the NHS. This also includes prospective medical students who could be deterred from choosing the UK as a destination to study.

1.5   Clear, fair, and timely pathways to settlement are crucial to retaining the international workforce within the health and care sector.

1.6   Any increase in the qualifying period to settlement would also exacerbate existing issues around GP sponsorship where, in the context of doctor unemployment, newly qualified GPs who are IMGs are having difficulties securing employment with GP practices.

1.7   Longer settlement routes also increase administrative burdens and financial costs for employers, particularly NHS trusts and GP practices, and may reduce the attractiveness of international recruitment for highly skilled professionals. Evidence, including GMC research[2], demonstrates that stricter immigration policies dissuade doctors from migrating to the UK.

1.8   Setting immigration rules solely on economic contributions can lead to migrant exploitation, create unfair and arbitrary systems, and fails to account for the diverse benefits migrants bring to communities, beyond economic outputs. The experiences and value of migrants to the communities in which they live are many and we would question the fairness of any ‘earned settlement’ rules.

1.9   If the Government is to insist on introducing inappropriate and arbitrary ‘earned settlement’ or contribution-based rules, they must explicitly recognise the unique and essential role of those who work in the health and care sector, including that of IMGs, accounting for both their direct patient care and wider contributions to training, public health, and the UK economy.

1.10           The BMA is calling for a blanket exemption for workers in the health and care sector and their dependents from the extended qualifying periods, in addition to clear assurances that any changes will not be applied retrospectively to those already contributing to the health and care sector.

1.11           We note that the Government has now launched its consultation into earned settlement, which proposes retaining the five year process for doctors and nurses, and others on highly skilled visas, but extending the qualifying period to settlement to 15 years potentially for those not on highly skilled visas. This would include many people already working in the health and care sector in ancillary, technical or administrative roles, as well as those at band 3 and 4 roles, such as senior healthcare assistants.

1.12           While we welcome the exception for doctors, we strongly encourage the Government to extend this to the wider health and care workforce, given that the NHS relies on the contribution of all its staff.[3]

1.13           Overall, policies that delay or complicate pathways to settlement risk undermining workforce stability within the health and care sector, the integration of essential migrant professionals, and the UK’s ability to maintain high-quality healthcare services.[4]

2. Potential impact of changes to pathways to settlement 

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

2.2 The BMA strongly opposes proposals to extend the qualifying period for settlement. We are particularly concerned about the impact this would have if it were to apply to international medical graduates (IMGs) who comprise approximately 42% (138,405) of licensed doctors in the UK[5] and are essential to the delivery of safe, high-quality healthcare. Extending the settlement period risks creating uncertainty, anxiety, and financial strain for doctors and their families and should they decide to leave the UK, could exacerbate existing workforce challenges. Worryingly recent GMC data[6] shows that greater numbers of IMGs are already leaving the workforce.

2.3 Evidence indicates that clear, fair settlement pathways are a key factor in retention of international professionals. GMC research[7] from 2023, shows that among doctors who qualified outside the EEA, 28% cited visa requirements as a systemic reason for considering leaving the UK. This provides clear evidence that barriers to settlement, visa requirements and uncertainty over immigration status contribute to workforce attrition and risking undermining long-term recruitment. This should also be considered in the context that England has fewer doctors per capita than other comparable countries[8].

2.4 The proposal to increase the qualifying period to settlement will also exacerbate existing issues around GP sponsorship where, in the context of doctor unemployment, newly qualified IMGs are having difficulties securing employment with GP practices partly due to the lack of GP practices who hold sponsorship licences. Any extension of the time needed for newly qualified GPs to be eligible for settlement will only exacerbate these problems and may present a real risk of these doctors moving out of general practice or leaving the UK altogether. A recent survey of GP registrars by the BMA and RCGP revealed over 71% of respondents (372) found getting a job which sponsors a visa either “difficult” or “very difficult”. This figure was even greater (82%) among the GP registrars less than 4 months from CCT (i.e. before becoming a fully qualified GP). Alongside RCGP, we have called for a permanent, sustainable solution to the issue, which might include:

• An accelerated route to indefinite leave to remain after three years; or  
• Umbrella sponsorship, with an overarching organisation acting as a sponsor for two years post-Certificate of Completion of Training (CCT). 

2.5 Any extension to the settlement period could deter future IMGs from choosing to work in the UK and may prompt those already in the system to leave.

2.6 We therefore welcome that the Government’s consultation proposes that the five-year qualifying period is maintained for doctors. It is essential that the Government ensures this exemption is made. However, the NHS relies on the contribution of all its staff, and we are concerned that, under the current plans, people who have been working in the NHS in other roles, including in ancillary, technical and administrative roles, could face a 15-year route to settlement. We would urge the Government to include all workers in the health and care sector, whom we depend on for a functioning health and care system, in this exemption.

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

3.1 It is important to recognise that the NHS depends on a supply of senior doctors, who are already fully trained to take up consultant or specialist roles, coming from overseas to work in the UK. The immigration system should reflect this dependence and thus include these senior doctors in the exemptions to ensure sufficient numbers of this critical workforce.

3.2 Longer settlement routes increase administrative burdens and costs for employers, who must maintain visa sponsorship for extended periods. This includes having to adhere to monitoring and reporting obligations. This will place additional strain on HR departments and exacerbate staffing shortages, particularly in primary care, where GP practices already face challenges in sponsoring doctors. International recruitment of highly skilled professionals, including doctors, is likely to become less attractive if settlement timelines are extended, undermining workforce sustainability in the health and care sector.

3.3 The costs currently incurred by employers such as NHS Trusts and GP practices, include the Immigration Skills Charge – paid each time they employ a sponsored worker. The Government intend to increase this fee on the 16 December 2025, by 32% to £1,320 per person – for small sponsors, such as GP practices, the rate will rise from £364 to £480. The increase in the charge will add financial strain on employers which are already facing budget challenges, and this could impact their ability to recruit and retain overseas healthcare workers, including IMGs. This would be in addition to the recent increase in national insurance contributions, which is already placing additional financial pressure on practices. 

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

4.1 Longer routes and stricter requirements for settlement will have a significant impact on migrant households already in the UK, both financially and on a personal level.

4.2 In terms of a financial and economic impact, the extended reliance on visa sponsorship will increase direct costs for doctors and their families, including visa fees and immigration-related legal and administrative expenses.

4.3 The majority of doctors are employed on a health and care visa (a lower cost visa reflecting the UK’s effort to attract and retain healthcare professionals). However, for a five-year visa, this still results in considerable expense, for example:

• Each applicant will pay £590 for a visa, and for a family of four, this totals £2360. If the qualifying period for ILR is extended beyond the existing five years, this will need to be paid twice.

Once an applicant has met the qualifying time for settlement, there are further costs:

• Applying for indefinite leave to remain is £3,029, which for a family of four means a payment of £12,116.
• The cost of applying for British citizenship is £1,735 for adults and £1,214 for children, which includes the citizenship ceremony fee. For adults, additional costs for the "Life in the UK" test and an English language test may apply. 

4.4 The financial security associated with obtaining settlement is central to enabling doctors, and other migrants already in the UK, to establish stable lives and feel truly settled and crucially settlement is the pathway to obtaining UK citizenship. Without settlement, it becomes significantly harder to plan in the long-term, including investing in housing or creating stable living circumstances.[9]

4.5 Prolonged or uncertain pathways to settlement risk sending a clear signal that migrants are not welcome to fully establish themselves in the UK, by making the pathway to obtain UK citizenship further out of reach. This can act as a powerful deterrent both to remaining in the country and to the future recruitment of highly skilled professionals, including essential doctors.

4.6 Extended routes to settlement create prolonged uncertainty for migrant families, making it difficult for them to feel fully rooted in the UK. This uncertainty can limit participation in local communities, reduce engagement in social networks, and constrain involvement in civic or community activities—key drivers of integration. For children, family uncertainty can impact educational outcomes, as parents may be hesitant to make long-term decisions about schools, extracurricular activities, or relocation for work. In addition, ‘settled’ children, that is those with indefinite leave to remain are eligible to apply for home fees for university. Those without that status, will be expected to pay international fees which are considerably more. Household stress can also increase, with ongoing visa renewals, administrative burdens, and financial pressures putting strain on family cohesion.

4.7 The constant focus on immigration rules within the UK will likely impact the mental health and wellbeing of those within the migrant community, including IMGs and their families. A significant number of doctors are already unsettled by the rise of anti-migrant rhetoric in the UK and hostile language used by politicians[10] including the proposals in the Immigration White Paper. This leaves them feeling unsettled but also questioning whether it is worth remaining in the UK[11].

4.8 For IMGs, these challenges have direct workforce implications. Doctors already experience high levels of stress and burnout due to the pressures of their work, which can lead to periods of leave and reduced capacity, as well as negatively impacting retention.

4.9 The stress and anxiety associated with uncertainty over long-term immigration status risks exacerbating this. This is particularly concerning given the NHS’s ongoing workforce crisis, its heavy reliance on IMGs and the need for stable staffing to enable effective and sustainable workforce planning. In this way, delayed settlement pathways not only affect migrant families personally but also threaten the sustainability and resilience of the NHS workforce, exacerbating existing recruitment and retention challenges.

5. What potential effect could change to eligibility for settlement have on integration? 

5.1 As already touched on, restricting or extending the path to settlement may reduce integration by creating a prolonged period of conditional residence, during which migrants may feel less secure in participating fully in society. Security of settlement supports social cohesion, long-term community engagement, and professional stability, which are essential for effective workforce integration in the NHS.

6. How the new earned settlement rules could work

6.1 How should “long-term contribution” to the UK be defined and quantified, when considering pathways to settlement? This could include how the following elements should be defined and weighted: 

-          social and community contributions; and 

-          fiscal and economic contributions.  

6.2 Setting immigration rules solely on economic contributions can lead to migrant exploitation, create unfair and arbitrary systems, and fails to account for the diverse benefits migrants bring to communities, beyond economic outputs. The experiences and value of migrants to the communities in which they live are many and we would question the fairness of any ‘earned settlement’ rules.

6.3 That said, if the Home Office is intent on introducing “earned settlement” rules they must explicitly recognise the unique and indispensable contribution that workers in the health and care sector make, particularly IMGs and other healthcare professionals to the UK. Many of these workers cared for patients during the COVID-19 pandemic, and faced significant physical and mental health challenges, including a high risk of infection, developing long COVID, and experiencing burnout from intense work pressure and trauma. Many reported persistent and severe long-term symptoms, impacting their ability to work and their overall quality of life and 49 doctors died after contracting the virus, a high proportion of these were IMGs[12].

6.4 We believe that those who work in the health and care sector should be automatically exempt from any increase in eligibility requirements, for example, we know that doctors make a “real and lasting contribution” to the economy and society and (with others who work within the health and care sector) should be exempt from extended qualifying periods.

6.5 Whilst we welcome that the contribution of doctors has been recognised in the Government consultation on the proposals and the proposal to exempt doctors from the extension, this should be extended to everyone working within the health and care sector, given they automatically contribute economically and socially by working in the NHS, often fulfilling essential roles.

Impact on IMGs specifically

6.6 IMGs deliver direct patient care, providing expert, often life-saving treatment at critical and vulnerable moments in people’s lives. Beyond frontline care, senior doctors play a vital role in mentoring and training junior colleagues, ensuring the next generation of medical professionals is supported and developed.

6.7 IMGs also contribute to broader public health and community wellbeing, leading initiatives that improve population health outcomes, as seen during the COVID-19 pandemic, where they were instrumental in vaccination campaigns, critical care responses, and community outreach. These contributions extend beyond the immediate healthcare system and deliver lasting societal value. Any settlement framework that fails to recognise these contributions risks undermining workforce stability, NHS sustainability, and the UK’s ability to respond effectively to future health challenges.

6.8 In addition, they also contribute to the economy through both taxation and their contribution to sustaining critical public services.

6.9 If the Government is to include “long-term contribution” as part of any earned route to settlement, doctors must automatically be considered to make a “real and lasting contribution” to society, given the essential nature of their role and the public service they provide on a daily basis.

7. What exemptions should there be to the new rules?

7.1 Any proposed extension of the qualifying period for settlement is grossly unfair, particularly to those already in the UK and who arrived with the genuine expectation that they, and their families could obtain settlement within five years. However, within these proposals, we would call for a blanket exemption to all those working within the health and care sector and their dependents to the extended period to settlement. 

7.2 We are also calling for reassurance that the rules will not apply retrospectively to people already living and working in the UK. To do so would be to unfairly re-set the bar, would penalise doctors who have already contributed years of service to the NHS and patient care and risks talented, experienced doctors leaving the UK to live elsewhere where visa restrictions are less strict.

8. How have other countries applied contribution-based systems?

8.1 Contribution-based systems in Australia and Canada award expedited settlement to highly skilled migrants who meet criteria for economic and social contribution, including doctors. In Canada, specific measures under the Express Entry system have allowed internationally trained physicians to obtain permanent residence more quickly, including exemptions from certain job‑offer and self‑employment requirements, and dedicated invitation rounds for health workers. In Australia, an “Expedited Specialist Pathway” enables eligible internationally qualified specialists and general practitioners to complete a streamlined registration process, allowing them to practice in areas of workforce shortage more efficiently. While these pathways are targeted rather than universal, they demonstrate international recognition that doctors provide an essential public service, and that immigration and registration systems can and should be adapted to ensure these professionals are supported and retained.

8.2 European countries also present alternative, more accessible routes to settlement or professional mobility which make the UK’s immigration and settlement offer comparatively less attractive. For example, the EU Blue Card Directive facilitates entry, residence and mobility of highly skilled non‑EU nationals across many EU Member States, under more favourable conditions than the Government’s proposals. For example, in Germany, a highly qualified worker can apply for a settlement permit after 27 months of employment if they hold an EU Blue Card and have B1 German language skills.

8.3 If the UK extends the settlement route from five to ten years without a comparable exemption, there is a real risk that doctors faced with longer uncertainty and weaker settlement prospects in the UK will look instead to European alternatives. This directly competes with the NHS’s need to recruit and retain IMGs and underlines why settlement policy must explicitly protect those already working in the UK.

9. Summary

9.1 Extending the settlement period risks undermining NHS recruitment, retention, and workforce stability including into the care sector. Those who work within the sector, including IMGs, are indispensable to the UK, and any settlement policy must reflect their essential role.

9.2 The BMA urges that those who work in the health and care sector, in particular IMGs, be explicitly included in exemptions for those making a “real and lasting contribution” and that transitional arrangements safeguard those already practising in the UK.

9.3 More broadly, it is vital that the Government focus on developing a balanced workforce strategy that combines both domestic training investment with retention and support for international medical talent.

9.4 We are also concerned that the language[13] used by Prime Minister Kier Starmer in unveiling the Immigration White Paper and the language used by the Government and others since, has fuelled racist and xenophobic rhetoric. The use of such language fails to accurately illustrate the essential role of migration to the UK, this includes international workers maintaining the health of patients across the health and care sector.

9.5 The health and care sector in the UK has always been reliant on the commitment and expertise of its international workforce. Figures from NHS England and Skills for Care show that in England, 776,000 workers – around a quarter of the total workforce of just over three million – are non-British nationals.[14] Our health and care sector is built on the hard work and rich diversity of its workforce. We know that the international workforce across the health and care sector, and IMGs who make up 42% of the medical workforce will be all too aware of the heightened anti-migrant rhetoric preceding and following the summer riots in 2024, along with these immigration proposals, and the Government cannot take for granted that they will stay in the UK. There is a risk that they will leave the UK altogether for countries where they will get a warmer reception.