MPs demand end to repayment clauses in contracts of overseas health workers


The NHS must halt the use of “repayment clauses” in contracts for international healthcare workers, MPs have said.

Members of the Commons health and social care committee came to this finding after an Observer investigation in March revealed how some workers were being forced to pay thousands of pounds if they wish to quit their jobs before their agreed contract ends. Widely used in both the private health and social care sector and in the NHS, the clauses are designed to help with retention of workers and recouping costs associated with overseas recruitment.

In extreme cases, workers have been tied to their roles for up to five years and told they face fees as steep as £14,000 if they want to leave or return home early. Some remain trapped in their jobs in conditions that human rights lawyers and unions have likened to debt bondage.

A report by the select committee, chaired by Conservative MP Jeremy Hunt, the former health secretary, said the use of repayment clauses was “part of a wider picture of worsening exploitation of international workers”. It said the NHS must review its recruitment processes to ensure that “no international health and care staff are being subject to punitive repayment clauses in their contracts”.

The report, published last week, went on: “Those who are subject to repayment clauses must be released from them, and future NHS contracts must not contain repayment clauses.”

It also pointed to an increased risk of modern slavery, adding that labour enforcement bodies must work with councils, employers and recruitment agencies to tackle exploitation.

The recommendations come amid a rise in cases of suspected modern slavery in the health and social care sector. The Care Quality Commission has recorded 16 cases in 2022 so far – more than double the figure for the whole of 2021, when seven cases were identified, and about five times the figure for 2020.

The Department of Health said it would shortly be publishing updated guidance on the use of repayment clauses and took “any reports of unsafe and illegal employment practices” in the health and care sector “very seriously”.

An NHS England spokesperson said the health service was committed to ensuring all international healthcare staff were “supported to thrive”, adding that it was exploring whether further guidance was needed with partners “across government and the health system”.

Repayment clauses are contract terms that stipulate workers will need to pay money if they leave their job within a certain period.

Jeremy Hunt, the health committee chair, said the issue should be a ‘top priority for the new prime minister’. Photograph: Hollie Adams/Getty Images

Practice varies by employer, but the clauses often cover hiring expenses such as flights to the UK, visas and the fee for taking language and competency exams. Some also include the costs of mandatory training, which workers hired in the UK are not routinely required to pay. Often, the breakdown of fees is unclear.

Workers affected by repayment terms have been pushed into debt or locked into long-term payment agreements to cover the fees. Others become trapped in their jobs despite illness or poor working conditions because they are unable to repay.

The select committee report cited the Observer’s investigation as well as evidence from NHS managers, unions and others across the sector.

Gamu Nyasoro, clinical skills and simulation manager at Kettering General Hospital NHS foundation trust, said in her evidence that she knew of cases where workers wanted to return home but could not “because they have been given exploiting contracts that you cannot leave until you pay them something like £10,000”.

The trade union Unison said the clauses were used to “exploit migrant workers and to intimidate them into staying with poor employers”.

Clauses penalising workers for leaving their jobs have previously been found to be unlawful. In 2019, an employment tribunal ruled that an Indian nurse had been subject to an “unenforceable penalty clause” after the care home she worked for deducted £2,000 from her wages for “training costs” when she left before the end of her two-year contract.

The recommendation for the clauses to be scrapped in the NHS came as part of a report into wider workforce issues in the health and social care sector, which identified a critical shortage of more than 50,000 nurses in the NHS, with 490,000 extra jobs in social care likely to be needed over the next decade.

Hunt, the committee chair, said tackling the crisis must be a “top priority for the new prime minister”. The government is expected to provide a full response to the report within two months.