NHS Employers responds to HCPC English language proficiency consultation

Q1: Do you agree with the proposal to remove self-declaration of English language proficiency as an option for international applicants to join the register?

NHS Employers agrees with the proposal to remove self-declaration of English language proficiency. The employers we have engaged with unanimously agree with this proposal. We believe doing so will improve patient safety, employer confidence, and act as a step to bring English language testing in line with other regulators such as the NMC and GMC.

However, any new proposals should promote English language is tested by default. By testing by default we mean that either the candidates have an external assessment of their English language proficiency by a testing provider in the UK (OET, IELTS, or TOEFL) or they can prove that an assessment was undertaken as part of their registration in their country of qualification.

If not, there is a risk that self-declaration can effectively still occur, which will impact the robustness of the system. For example, if a qualifying countries list is implemented without a high level of evidence of demonstrable skill in clinical practice, this could put employers at risk of employing a candidate who claims to have the required English languages skills but cannot effectively demonstrate in practice.

Q2: To what extent do you agree or disagree that this proposal (qualifying countries list where English is the primary spoken language) would enable international applicants to:

1. Show that they are proficient enough in English to practise safely and effectively? Neither 
2. Feel confident in their own English proficiency? Neither 
3. Easily join the register? Neither 

Q3: Would a 75 per cent English speaking population be an appropriate test for qualifying countries to be on our list (where their primary qualification is gained)?

While NHS Employers generally agrees with this proposal, more details are needed on the methodology for creating and maintain a qualifying countries list. It is mentioned that the 75 per cent English speaking metric is aligned to that of the NMC’s qualifying countries list but is a different methodology to that of the GMC and the UK government. Any list would need to have very clear parameters on how qualifying countries are determined, and how this differs to other similar lists.

In addition, since the list is based on where the applicant gained their qualifications, it would be important to consider an appropriate timescale for when the qualification was awarded. Employers have expressed concerns that a qualification may have been taught and awarded in English 10 years ago but, the candidate may not have practiced in English since that time. It is also important that evidence that the qualification was taught and examined solely in English is made an essential requirement.

Employers agree that if a qualifying countries list is generated, it should be tied to where they gained their qualification and not country of residence, citizenship, or birth. Employers will still need to follow and adhere to the Code of Practice for International Recruitment which manages recruitment to health and social care roles to the UK based on residency.

However, we have collected mixed responses from employers. Some employers do not agree that having the qualifying country list linked to purely where qualifications were gained would be sufficient to demonstrate language proficiency. Employers would prefer having this list tied to clinical practice in addition to where candidates gained their qualifications. If this is purely based on education, some employers feel this is effectively replacing the self-declaration route and not promoting a testing by default system, meaning their English language skills are externally assessed by either a UK test provider or as part of their registration in their country of qualification. Employers have been clear that a testing by default system would build in more confidence and robustness.

In a recent study of an English language programme in India, participants who undertook a baseline screening test had higher pass rates compared to those that provided examination transcripts for a recognised English language examination undertaken in the previous 2 years.

We acknowledge that this is a similar system to other regulators (such as the NMC and GMC). Therefore, we would encourage HCPC to speak with the other regulators to see how a qualifying countries list operates in practice, how to mitigate any risks present and to commit to have one agreed approach across all regulators.

Q4: Separately to considering where qualifications are gained, should we accept evidence of work experience in a listed country where English is spoken by a majority as their first language?

NHS Employers recognises that this approach is consistent with other regulators such as the NMC and GMC. However, employers remain sceptical of this approach and would prefer a testing by default system, meaning their English language skills are externally assessed by either a UK test provider or as part of their registration in their country of qualification.

HCPC may benefit from discussing how this works in practice with other regulators. Employers would need to see evidence that the work experience was undertaken in the 75 per cent of the country that does speak English. There is a risk that the work experience would be within the 25 per cent of the country that does not speak English; HCPC as a regulator will need to be clear with employers about how this risk is managed.

Employers would feel more comfortable if candidates were required to pass a recognised English language test as part of their role outside of the UK. This would provide a level of additional assurance, still promote a testing by default approach, and remove subjective decision making.

Q5: Separately to considering where qualifications are gained, should we accept evidence of work experience in the UK if this has been supervised by a registered health and social care professional? Please explain your answer.

There is a very mixed response from employers on this proposal.

Last year, the NMC introduced a supporting information for employers (SIFE) process for those who have UK work experience in a non-registered health or social care setting. This works in two scenarios: one where a candidate narrowly missed passing an OET or IELTS test, and one based on being trained in English but in a country where English is not the majority spoken language. This process is organisationally led (meaning there is limited guidance from the regulator) and employers may but are not required to do so if they do not feel confident in the candidate’s English language skills or their ability to assess such skills.

In the scenario where a candidate narrowly misses passing an English language test, employers are supportive of this process. They are finding it easy to navigate, supportive, and have confidence in the system. Many have used this route to build their talent pipelines.

However, there is a much more mixed view when it comes to the non-testing route. Some employers are supportive of this route if the candidates are supervised by a UK registered professional and there is clear accountability and sign off process. Other employers are much less confident, more apprehensive and would prefer a testing by default system. They feel their managers would not be confident in assessing someone's English language abilities, as is the case with the NMC SIFE process.

Any non-testing system brings in a level of subjective decision making on the part the manager. While there are FAQs on the SIFE process to support employers in developing their SIFE processes, and guidance from the NMC is pending, nothing has been released despite the route being open since September 2022. There are concerns that due to a lack of guidance on how managers can assess a candidate’s English language level, some managers may sign off a candidate without the required skills which ultimately could pose a risk to patient safety.

A lack of published guidance from the regulator has led to an inconsistent approach across employers. The subjective nature of line manager assessment, and the employer-level response to SIFE, has led to confusion among employers and inconsistent approaches to candidates.  

There have also been high levels of reported exploitation when using the SIFE process for UK work experience. Feedback from unions and other representation on the Cavendish Coalition (a group of health and social care organisations united in their commitment to provide the best care to communities, patients and residents), indicates that many overseas recruiters are charging candidates large sums of money for unregulated roles in the UK (for example senior care workers or health care support workers), on the promise that they will acquire registration after 12 months’ time. This is not the case as the SIFE process is an organisational decision, and candidates are often moving to the UK not understanding the full process. Additionally, there are examples in social care where line managers are signing SIFE forms in exchange for a fee.

We understand that the NMC SIFE process is being reviewed at the beginning of 2024, and we would encourage HCPC to engage with the NMC about the outcome of this review of the SIFE process and to ensure that any steps taken to change HCPC processes remain aligned with the direction of travel of the NMC and other regulators.

Employers also feel the reference to work experience in the UK is too vague and should be narrowed, and timelines thoroughly defined.

To explore this is more detail, we suggest that HCPC speak with other regulators to better understand how the use of work experience to support English language proficiency operates in practice.

Q6: Do you agree or disagree with our proposal to expand our list of approved test providers? Please explain your answer.

NHS Employers agrees with the proposal to expand the list of English test providers. This will bring HCPC in line with other regulators and is unanimously supported by the employers we have engaged with.

Q7: In addition to our current approved providers, which test providers should we consider accepting as evidence of English language proficiency?

NHS Employers believes that in addition to the current test providers of IELTS and TOEFL, HCPC should recognise OET. The addition of OET as a provider is unanimously agreed by the employers we have engaged with.

Some employers believe the TOEFL should be removed as a test centre provider. Employers are not seeing a large proportion of candidates using this provider, and it is not recognised by other regulators such as the NMC or GMC.

NHS Employers would be supportive of a SIFE process for candidates who narrowly miss on an English language test after 2-3 attempts, but not for a scenario based on work experience.

Q8: Should our list of approved tests be exhaustive? We would value your view on the combined effect of our proposals.

NHS Employers believes the list of test centre providers should be exhaustive. This ensures the greatest level of clarity for both employers and candidate expectations and enables clear equivalencies to be drawn across suppliers to promote a uniform standard.

This would also support employer’s experiences to sign up to online verification services. Over the course of 2023, there were several cases of English language testing fraud reported to the NMC. By having an exhaustive list of test providers, employers will be able to sign up to a set number of verification services to view and prove candidate test results. This will enable the protection of patients through the safe recruitment of staff.

Q9: Which of these statements would you most agree with?

1. Overall, these proposals provide greater assurance that applicants’ proficiency in English is sufficient for them to practise safely and effectively
2. Overall, these proposals provide the same assurance that applicants’ proficiency in English is sufficient for them to practise safely and effectively 
3. Overall, these proposals provide less assurance that applicants’ proficiency in English is sufficient for them to practise safely and effectively

We agree mostly with the second statement. 

While removing the ability to self-declare and additional test centre provides will increase assurances, other proposals around supporting information from employers for UK work experience could decrease assurances if more details on the process are not made clear. Employers would prefer a testing by default system. If not, they need to be supported and feel confident in their abilities to sign off anyone in terms of their English language skills. 

Q10: In addition to the equality impacts set out in the Equalities Impact Assessment, can you identify any further impacts relating to protected characteristics that we should consider? 

NHS Employers agrees that removing self-declaration would mean more people need to take a test, and that this could impact those with protected characteristics, as identified by HCPC.

However, employers strongly believe that to make the system as robust as possible and remove subjective decision making there should be a testing by default approach. This would promote clearly defined candidate expectations and protect them from exploitation. It would also support employers and protect them from potential claims of discrimination if they do not feel comfortable in assessing a candidates English language based on their work experience.

Q11: Do you have any further comments to make about the proposals and information in the consultation?

As described in this consultation, NHS Employers believe any new proposals should promote a testing by default approach. This would build employer confidence in the system, make it as robust as possible to counteract potential issues relating to fraud. We hope that the steps taken by HCPC will improve the issues identified in this consultation.

We would also recommend that any new proposals be open for a trial period (to be determined). This way the proposals can be assessed once implemented and adjusted if needed. 
    
Some employers are currently experiencing issues whereby candidates do not possess the English language skills they thought upon hiring due to the self-declaration process in current HCPC arrangement. It is very difficult for them to hold simple conversations, which is essential when delivering patient care (for example, in OT professions). This has made managers hesitant to recruit due to communication issues.

We support the HCPC in reviewing their current processes around English language proficiency and addressing the concerns that exist about a process based on self-declaration. We look forward to continuing to engage with HCPC as the review progresses.