There were around 750,000 nurses registered in the UK in August 2023. Around half (374,000) were directly employed by the NHS in England in the hospital and community sector (providing 331,000 full-time equivalent posts). Others worked in primary care, social care or the private sector, or in non-nursing jobs or other parts of the UK. Almost 1 in 4 of those on the register (180,000) trained outside the UK. In 2022/23, half of all the new nurses registered in the UK had been trained in other countries – almost 25,000 in total, the highest level since records began.

There have been widespread nurse shortages in the NHS, with 42,000 vacancies – or around 1 in 9 posts – unfilled in September 2023. The scale of these shortfalls, and the 3-to-4-year lead time and costs of training new nurses in the UK, has made recruiting nurses from abroad an explicit policy priority in recent years. The NHS Chief Nursing Officer reported in December 2023 that nearly all (93%) of the government’s target of ‘50,000 more nurses’ had been achieved through international recruitment. 1 in 3 nurses in the NHS in England trained abroad. 

The UK’s increasing reliance on international nurses has been well documented. The NHS Long Term Workforce Plan (LTWP) aims to grow the NHS nurse workforce by significantly increasing the supply of UK-trained nurses and is committed to markedly reducing reliance on international recruitment.

The global labour market for nurses is becoming increasingly competitive. However, the rise in active international nurse recruitment by other high-income countries, and the extent to which this may be causing the UK to lose nurses through international outflow has received virtually no attention. Even if the aims of the LTWP are realised, the UK will still have to compete to attract international nurses and retain both UK and internationally trained nurses already working in the NHS to maintain staffing levels. 

To assess this potential international outflow, we examined the intent of UK-based nurses to register to practise in other countries. We analysed data held by the Nursing and Midwifery Council (NMC) on applications for Certificates of Current Professional Status (CCPSs). A CCPS is issued to any UK-based nurse who applies to be registered in another country to verify that the applying nurse is on the UK register and therefore eligible to practice. We assessed trends in CCPS application numbers and the pattern of applied-for destination countries for the years 2018/19 to 2022/23, and put this analysis in the broader context of the entire population of nurses on the UK register.

This is the first work in recent years to analyse potential nurse outflow from the UK. The main limitation of the data is that they record applications for CCPSs, which signal interest in moving, but do not show how serious or whether followed through.   

We focused on two main indicators of potential outflow. The first is the total number of CCPS applicants in each NMC financial year (April to March). This gives a reasonable estimate of the maximum number who may leave the UK to practise in another country. 

The second indicator is a proxy for the likelihood of a nurse on the NMC register applying for a CCPS at different time periods. (This is calculated as number of CCPS applicants in a given group (for example, overseas trained) in a year as a percentage of those on the register in that group at the end of that year. This will likely be a slight underestimate of the application rate, as numbers on the register are growing over time.) This allowed us to compare the likelihood of a nurse applying for a CCPS over time and by different characteristics. 

Figure 1 shows the number of CCPS applicants between 2018/19 and 2022/23 categorised by the three geographic regions of training used by the NMC: UK trained, EU trained (in EU and European Economic Area (EEA) countries) and OS trained (in overseas, non-EU/EEA and non-UK countries). 

In the period from 2018/19 to 2020/21, CCPS applicant numbers grew slowly, at an average of 10% per year. The number then grew rapidly, increasing by nearly one-half from 2020/21 to 2021/22 before more than doubling the following year, reaching around 12,400 in 2022/23. This represents about 2% of nurses on the NMC register. 

Figure 1 also highlights that nearly all of the recent rise in CCPS applicants is accounted for by OS-trained nurses. In 2018/19, there were three times more UK-trained applicants than OS-trained applicants, but by 2021/22 the numbers were roughly the same. In 2022/23, just 1 year later, OS-trained nurses made up almost three-quarters of all CCPS applicants. This was despite UK-trained applicants also increasing by a third in that year. The number of EU/EEA-trained applicants remained low throughout the period. The rest of our analysis therefore focuses only on UK- and OS-trained nurses. 

To give an idea of the scale of applicant numbers, OS-trained applicants in 2022/23 (8,900) were equivalent to 7% of all OS-trained, NMC-registered nurses (around 135,000); in comparison, UK-trained CCPS applicants (3,000) amounted to less than 1% of UK-trained nurses on the NMC register (570,000). This suggests a much higher relative level of interest in CCPS applications from nurses who were not trained in the UK compared with those who were.

Figure 2 shows the annual number of OS-trained CCPS applicants as well as the number of OS-trained nurses joining the register for the first time. These measures are not directly comparable but further demonstrate the scale of applicant numbers and illustrate the dynamic nature of the UK nursing labour market. The number of new OS-trained registrants to the UK register was twice as large in 2022/23 as in 2019/20 (inflow), while over the same period, the number of OS-trained registrants applying for a CCPS grew more than 11 times (potential outflow).

The NMC data provide some individual nurse characteristics. We focused on the patterns of applicants by their length of time on the NMC register and country of training. These data can contribute to a better understanding of the profile and patterns of nurses considering leaving the UK. 

Time since initial registration

Figure 3 presents the number of OS-trained applicants in 2018/19 and 2022/23 as a percentage of OS-trained nurses on the NMC register at the end of that year, split by length of time on the register. This enabled us to compare a measure of how likely OS nurses were to apply for a CCPS both by time registered and across years. 

Figure 3 shows that there was a marked increase in the likelihood an OS nurse making a CCPS application between 2022/23 and 2018/19, regardless of how long they had been registered. The most marked increase was for those with the least time on the UK register. In 2022/23, OS-trained applicant numbers were equivalent to 1 in 9 of those who had been on the register for less than 1 year and 1 in 8 of those registered for 1 to 3 years. 

Country of training

Nurses trained in India and the Philippines accounted for almost 4 in 5 (almost 7,000) of all OS-trained CCPS applicants in 2022/23, and over half of all applicants. India and the Philippines were also the two main source countries of OS-trained nurses who joined the register over the period we studied, with numbers increasing sharply over time. Between April 2018 and April 2023, the total number of NMC registrants trained in India more than doubled to close to 50,000, and those trained in the Philippines increased by around two-thirds to over 45,000. However, most of the increase in CCPS applicant numbers from these countries is because nurses are now more likely to apply. For example, in 2018/19, 1 in 120 Indian-trained nurses on the NMC register applied for a CCPS. By 2022/23, this increased to 1 in 10. 

To determine which countries CCPS applicants applied to, we analysed information on destination countries, allowing multiple applications if they were to separate countries. For example, if a nurse put in one application for New Zealand and one to Australia in a single financial year, we included both destinations, whereas two applications to Australia in one financial year would only have been counted once. Applicant numbers to each country are therefore a reasonable maximum for the number of nurses these countries might receive from the UK register in that year. 

In 2022/23, more than 4 in 5 CCPS applications were to just three high-income anglophone destinations: US, Australia and New Zealand. Applicant numbers to these three countries are presented in Figure 4. 

In each year between 2018/19 and 2021/22, applications for New Zealand and Australia accounted for almost two-thirds of all applications. This changed in 2022/23: the US became the most popular destination, with applicant numbers increasing 10-fold in a year. Almost half of OS-trained CCPS applicants for the US had trained in India. Another fifth originally trained in the Philippines. 

CCPS data enable an assessment of trends and patterns in the number of UK-registered nurses with an interest in practising in potential destination countries, but they do not record why nurses are applying. As such, any assessment of the likely ‘push and pull’ factors influencing individual nurses’ decisions is limited, but some labour market and policy changes can be identified. 

One central factor is the actual and relative earnings a nurse can anticipate in different countries. This can be either a push or pull factor in the nurse’s decision to stay in the UK or move internationally, and a determiner of where to move. A ‘push’ factor that may make a nurse consider leaving the UK is the real-terms fall in basic earnings for nurses in the UK over the past decade, lowering their standard of living. In recent years, this has been acutely worsened by the cost of living crisis. A ‘pull’ factor attracting UK-registered nurses to other countries may be the markedly higher average earnings for hospital nurses: the most recent OECD data indicate that a hospital nurse in the UK reported annual earnings of around USD$46,000 (adjusted for purchasing power parity) – substantially less than in Australia (USD$71,000), New Zealand (USD$57,000) and the US (USD$84,900). 

When deciding whether to move and where, nurses likely weigh pay along with other push and pull factors. These may include working environment and conditions, staffing levels, career and educational opportunities, the existence of migrant communities from the applicant’s home country, ease of entry into the country (for the applicants as well as any family members) and its geographic location (for example, ease of travel to their home country). The period we considered coincided with the pandemic, and it is unclear the extent to which experiences of working on the front line during COVID-19 led nurses to consider their options. Another recent possible ‘push’ factor was the 2023 nationwide NHS nurse strikes in England, which demonstrated dissatisfaction with pay and working conditions.

Amidst global nurse shortages worsened by the pandemic, several competitor countries have attempted to increase their pull with enabling immigration policies and regulatory procedures. Examples include New Zealand announcing increased investment in and fast-tracked residency for internationally qualified nurses. The US announced accelerated nursing credential verification to more rapidly address visa application backlogs. The Australian government has agreed to implement the recommendations of a 2023 review of international health practitioner regulation aimed at expanding fast-track registration pathways and improved workforce planning. Patterns of nurse outflows can also be associated with changes in general immigration policies. For example, the sudden rise in CCPS applicants to the US in 2022/23 coincided with the ‘rolling over’ of unused visas from the pandemic period, doubling the number of employment-based visas available between 2021/22 and 2022/23. Whether this was a one-off occurrence or the beginning of a trend remains to be seen. 

Our analysis of CCPS applications from 2018/19 to 2022/23 tracked the growing number of UK-registered nurses applying for registration in other countries, particularly Australia, New Zealand and the US. Applicants more than doubled between 2021/22 and 2022/23.

This CCPS-based measure of potential outflow also highlighted that the UK is a ‘stepping-stone’ country for some OS-trained nurses. Two-thirds (63%) of the increase in CCPS applicants in 2022/23 (around 8,300 more nurses) were UK-registered nurses who had first trained overseas. Our analysis also highlights that the relative time these OS-trained applicants spend on the UK register is reducing, suggesting that they are considering moving on to another country more quickly than in the past.   

While the overall number of CCPS applicants remains relatively small compared with the total number on the NMC register, and it may be too early to determine whether the rise in applicants is part of a trend, these patterns have potentially important implications for UK nurse recruitment and retention policies. 

First, there is a relatively higher propensity of OS-trained nurses to apply for possible registration in other countries compared with nurses trained in the UK. This suggests a need to examine in more detail why these nurses may be moving on more rapidly and what can be done to retain them. The estimated upfront cost of recruiting an OS-trained nurse is between £10,000 and £12,000, with additional costs for onboarding. If OS-trained nurses choose to leave the UK after only a few years, there is less time to recoup these costs. 

Second, based on these CCPS-application trends, it must be recognised that the recent policy approach to increase NHS nurse numbers by rapidly ramping up active international recruitment brings with it the risk of increased vulnerability to international outflow. If OS-trained nurses continue to be much more likely to move onto another country than UK-trained nurses, this risk should be factored into overall nurse workforce planning.

The LTWP, which sets out the national policy approach, acknowledges the high level of reliance on international staff and includes the stated objective of explicitly reducing international recruitment over the next 15 years. However, given the recent trend to increase active international recruitment, this will only be achievable with ambitious, funded growth in domestic training places and domestic educational intake. In addition, the LTWP gave no consideration to international outflows as a factor for analysis.

Any increase in the international outflow of nurses will also add to the challenge of training more nurses in the UK. To counter this, we need more effective retention of nurses irrespective of their country of training, but with a targeted focus on the tens of thousands of OS-trained nurses who are so vital to the NHS’s ability to deliver services. This means developing a much better understanding of why nurses are moving internationally, and how we can encourage them to stay.