When Laura Sanchez was offered a job as a nurse in the NHS, it sounded like the opportunity of a lifetime.
At home in the Philippines, she had seen Facebook ads similar to those on the site today, promising “an attractive relocation package” and inviting her to “Start your UK dream!”
Bosses from an NHS trust in the south-east had even flown to the city near her village to interview candidates in person, desperate to fill empty posts on their wards.
With eight years’ experience, she was a perfect fit. Hours after her interview she was offered a job. “I was very excited,” said the 34-year-old, whose name has been changed. “My friends in other trusts had beautiful jobs and were enjoying it.”
At first, things went smoothly: the work was hard but she was saving enough money to send a small amount to her elderly parents, who had remortgaged their land to put her through nursing college.
Then, in April 2020, everything changed. While working 12-hour shifts on a critical care ward at the height of the first lockdown, without full PPE or regular testing, Sanchez caught Covid. The virus left her fatigued and struggling for breath, but mentally it was even worse.
She returned to the ward but found herself anxious and panicky to the point that she was signed off by her GP. “I kept on crying and crying. I was terrified of the number of deaths,” she said. “Some of the nurses who died in the NHS were my friends.”
In September 2020, just under a year after she arrived, Sanchez made the difficult decision to go home. But when she broke the news to her manager, she was told it was not that simple. She had a two-year contract. To leave early would cost her £6,000.
Sanchez is one of thousands of international nurses subject to repayment clauses in the UK.
To help plug a critical national staffing shortage, with as many as 400 NHS workers leaving every week, the UK is recruiting a historically high number of nurses from overseas.
In the 12 months to the end of September 2021, there were more than 7,000 arrivals from India and 5,000 from the Philippines, data from the Nursing and Midwifery Council suggest – part of more than 125,000 international nurses currently registered. There are plans to boost that number: the government has pledged to add 50,000 nurses for the NHS alone by 2025, with thousands more needed in social care.
Aside from the exams and approvals they need to work in the UK, overseas nurses are ready to go. It costs employers about £10,000 to £12,000 per recruit up front – but saves them as much as £18,500 in agency fees in the first year alone. In some cases, trusts can be paid up to £7,000 by NHS England for each overseas nurse they recruit.
Yet unlike their UK colleagues, those who leave before their contract ends can find themselves footing a hefty bill, an Observer investigation has found – even in cases of bullying, discrimination, ill health and family emergencies.
The repayment clauses – which typically last three years and can cover everything from flights and visas to initial accommodation and training – are widespread in the NHS and private sector, although terms differ and not all employers use them.
One that does, University Hospital Southampton NHS Foundation Trust, cited as an example of good practice in an NHS Employers’ recruitment toolkit, charges Filipino nurses £5,000 if they wish to leave in the first year, falling to £2,500 after a year.
The trust says hiring a nurse from overseas costs about £11,000, “which may include language, theory and practical exams, flights, work visas and accommodation”, and that it uses two-year repayment clauses to “protect that investment”.
Sharp BH Global, an agency that recruits in the Philippines for Leeds Teaching Hospitals NHS Trust, uses “contractual measures” to ensure “nurses honour their commitment” as part of its “Nurses Ready to Roll” programme.
“This contractually binding agreement requires them to honour the full employment contracts otherwise they face financial penalties,” its website says.
In the private sector, the fees are often higher. One care provider with more than 10 homes in the UK is charging migrant workers £7,000 if they try to leave their role within a year, falling to 50% of the “expenses” – £3,500 – if they leave at any point before three years.
In a case identified by Unison, a nurse who was recruited from Zimbabwe in August 2020 to help with the Covid-19 response says she tried to leave after her employer refused to increase her annual salary from £15,000 to £16,000 following her probation period, as agreed. She had been offered a job at an NHS trust, but when she asked for a reference, the employer refused and told her she would have to pay £10,850.
In the worst cases, workers can be locked into their jobs for five years and face charges of up to £14,000 if they try to leave early.
In Sanchez’s case, she had signed an agreement before she started, but the amount – equal to about three months’ pay – had never been specified. With pressure from a union and charity, the trust eventually backed down – but not before saying that unless she paid she would not be able to work in the UK again. “To me, it’s not fair,” she said. “We work hard and I had been sick. I don’t think they should have been asking for any repayment after a year, especially when I got my illness while working at the trust.”
While the clauses are not always enforced, they act as a powerful deterrent, said Susan Cueva of Kanlungan, a charity for Filipino migrants. Some workers stay put in spite of workplace or other issues, fearing that if they leave they will be unable to pay. She likened them to a form of bondage. “You can’t leave unless you pay, and if you leave you have to pay,” she said.
“Lawyers would argue that they signed the contracts and therefore they’re bound by them. They’ll say, ‘They have a choice, they don’t have to sign it,’ ” she said.
But in some cases, workers are shown different contracts from the ones they sign when they arrive, or are only shown the contract when they get to the UK. Others may not fully understand the implications of the repayment terms, because they plan to stay in the UK for good – or have already spent thousands saving to come in the first place. “To go back would mean losing all the money they’ve spent at their end trying to get the job. So they take their chances,” she said.
Ads targeted at international candidates on Facebook paint a sunny picture of life in the UK. But on YouTube, dozens of nurses are speaking up about the harsher reality – from challenges involving bringing family members to live with them to visa problems and costs of living.
There is a subgenre of videos dedicated to repayment clauses. “If you have that clause, start saving now in case you need to leave,” one vlogger advises. “It is your sanity. It is your life. It is your mental health,” another says. “What if you die there before you finish your three-year contract? If you’re not happy in your job?” she trails off. “I knew I had to leave.”
One YouTuber, Becca Agyemang, a mother of three from Accra, Ghana, began working as an NHS nurse in the south-east in September 2020. She had paid about 40,000 cedis (roughly £4,000) for her studies. The costs of bringing her to the UK – her conversion exams, visa and flights – were paid by the trust.
After a year, she wanted to leave her role not because of bullying or an emergency, but because she was struggling without a support network around her.
She got an offer from another NHS trust in London, but for leaving before the three-year term was over, she was told she would have to repay recruitment costs of about £3,500. “It was OK because I had saved a bit at that time,” she said, but “it wasn’t easy. They took it from my salary. So you just have to sort yourself out, rent, accommodation.”
But her situation is not as bad as that of some of her friends. “One of my friends was in a care home. She paid more than £5,000 after working more than three years. They still made her pay it all,” she said.
Another nurse, from the Philippines, said she left her job at a care home after being “traumatised” while working there at the height of the pandemic, months after arriving in the UK. “I just didn’t expect it to be that difficult physically and mentally,” the nurse, now working for the NHS in the south-west, said.
She had calculated the costs of her training and relocation to be about £3,000. But the care home said she owed £6,700. “I really wanted to transfer to a better way of living, even though it was very, very costly,” she said. “We’ve given them all our savings just to escape.”
Unions, charities and lawyers – as well as associations representing Filipino and Indian nurses in the UK – are calling for an urgent review of the contract terms, which they say are discriminatory.
The British Indian Nurses Association believes the issue has flown under the radar for so long because migrant nurses – particularly those from India – are unlikely to complain. “For them, this is better than being in India. They don’t realise they are being treated unfairly,” a spokesman said.
Francis Fernando, a community nurse leader in London, said nurses were already paying “exorbitant fees” linked to their visa applications at a time when the NHS was desperate for nurses, on top of the threat of potential repayment costs. “This isn’t encouraging nurses to come here to help with our vacancies,” he said. “We are shooting ourselves in the foot. We have to do better as a society.”
Associations representing care home providers did not respond to requests for comment last week. But Danny Mortimer, chief executive of NHS Employers, which represents NHS trusts, said they valued “the very important contribution” of overseas nurses and recognised that “to help staff make the move from abroad, supporting them with some of the associated costs is also important”.
NHS Employers publishes guidance for organisations to “develop and communicate the financial packages available,” Mortimer said.
He pointed to the government’s code of practice for the international recruitment of health and social care staff in England, which says “no individual should be charged fees to gain employment” – but does not mention repayment clauses.
The Institute for Human Rights and Business (IHRB), said that, as with all jobs, there was a “normal rate of attrition” involved with hiring from overseas that employers had to factor in. “Companies have to accept that as a business cost,” Neill Wilkins, head of the IHRB migrant workers programme said. “The British government’s own modern slavery statement says recruitment costs should be borne not by workers but by employers.”
It is not the first time repayment terms have been in the spotlight.
In 2018, two major outsourcing firms were threatened with legal action by former employees who had been met with demands for up to £20,000 in training costs when they tried to leave within two years.
And in 2019, an employment tribunal sided with an Indian nurse who had £2,000 deducted from her wages by a care home provider, which had claimed it was repayment of a loan to cover her training costs when she left within two years of starting the job.
Employment Judge Christopher Camp said the idea it was a loan was “illusory” and that it was actually an unenforceable penalty clause. The use of the clauses by care providers, he said, was an “increasingly common practice”.
Alex Bernardino, a nurse from the Philippines, is currently locked in a legal battle with his old employer over a £7,000 fee. He had agreed to the care home’s three-year term on arrival in the UK – despite it being different from the contract he had been shown while in the Philippines – because he thought it was the norm and planned to stay for “the longest of times”.
“Maybe I was naive,” said Bernardino, who is not using his real name because of the legal case. “I was just thinking, ‘I’m going to be there for that long anyway.’ I was really excited; I just wanted to be in the UK.”
The reality of his life in the UK turned out to be different from what he imagined. In his first few months, he says he witnessed staff being verbally abusive to elderly residents and “talking down” to them.
After raising concerns, he claims managers did nothing and he was bullied by colleagues. “In the Philippines I was an emergency room nurse,” he said. “But they told me I was not really a nurse and treated me as a janitor, making me clean the floors.”
He was offered a job in the NHS in London, which he accepted. But the care home told him he would have to pay £7,000 – a fee he is currently being pursued for.
If he does end up having to pay the sum, for which he was never given a breakdown, the consequences will be dire. With a wife and young children to support, his family will “have to make sacrifices”.
“I will have to work more; to do overtime to be able to afford everything,” he said. “But if I stayed in that care home I would be very miserable. So it would’ve been worse.”
Parosha Chandran, a barrister who helped draft the UK’s modern slavery laws, and professor of modern slavery law at King’s College London, called for use of the clauses to be urgently reviewed by the government.
She said workers could be put under “huge amounts of pressure by these contract clauses to stay in employment” in conditions akin to debt bondage.
“Like any other worker there might be myriad reasons – personal or professional – that lead them to take a tough decision to leave,” she said. “But unlike healthcare workers not subject to those contracts, there is a sum of money, regarded as a debt, that has to be paid back before the person is free.
“Clearly there has been an entrenchment of conditioning in the minds of migrant workers, and their employers, to think this is acceptable when it is not.”