Health Care Workforce Immigration to the UK After Its European Union Membership Referendum

Tarun Ramesh; Alison Leary; Fang Zhang; Hao Yu

doi:10.1001/jamahealthforum.2026.2868

. 2026 Aug 21;7(8):e262868. doi: 10.1001/jamahealthforum.2026.2868

Health Care Workforce Immigration to the UK After Its European Union Membership Referendum

Tarun Ramesh ^1,², Alison Leary ^3,⁴, Fang Zhang ², Hao Yu ^2,^✉

¹Department of Medicine, Massachusetts General Hospital, Boston

²Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts

³Healthcare and Workforce Modelling, London South Bank University, UK

⁴World Health Organization, Europe Human Resources for Health Group, Geneva, Switzerland

Accepted for Publication: June 17, 2026.

Published: August 21, 2026. doi:10.1001/jamahealthforum.2026.2868

Open Access: This is an open access article distributed under the terms of the CC-BY-NC-ND License, which does not permit alteration or commercial use, including those for text and data mining, AI training, and similar technologies. © 2026 Ramesh T et al. JAMA Health Forum.

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Corresponding Author: Hao Yu, PhD, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Landmark Center, 401 Park Dr, Ste 401 East, Boston, MA 02215 (hao_yu@hphci.harvard.edu).

Author Contributions: Dr Ramesh had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Ramesh, Yu.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Ramesh, Leary.

Critical review of the manuscript for important intellectual content: Leary, Zhang, Yu.

Statistical analysis: Ramesh, Leary, Zhang.

Obtained funding: Yu.

Administrative, technical, or material support: Leary, Yu.

Supervision: Yu.

Conflict of Interest Disclosures: Dr Zhang reported research consulting to Pfizer, Harvard Pilgrim Health Care Institute, and GlaxoSmithKline outside the submitted work. Dr Yu reported grants from the National Institute of Mental Health (R01MH132551) and the National Institute of Mental Health (R01MH132128) outside the submitted work. No other disclosures were reported.

Funding/Support: This study was supported by the US National Institute on Minority Health and Health Disparities (R01MD013736), the US National Institute on Alcohol Abuse and Alcoholism (R01AA031588), and the US National Institute of Nursing Research (R01NR020859).

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the US National Institutes of Health, Massachusetts General Hospital, Harvard Medical School, Harvard Pilgrim Health Care Institute, London South Bank University, or the World Health Organization Europe Human Resources for Health Group.

Data Sharing Statement: See Supplement 2.

Additional Contributions: The authors gratefully acknowledge Gerald Gloom (Institute of Development Studies, UK) and Stephen Peckham (University of Kent, UK) for their valuable comments and suggestions on earlier drafts of this article; they were not compensated.

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Corresponding author.

PMCID: PMC13499005 PMID: 42627655

Key Points

Question

Was the UK European Union (EU) membership referendum (Brexit referendum) associated with changes to the immigration of internationally trained physicians and nurses to the UK and National Health Service (NHS) workforce vacancies?

Findings

In this cross-sectional study with an interrupted time-series analysis, including 418 962 physicians and 358 122 nurses who emigrated to an Organization for Economic Cooperation and Development member country, the Brexit referendum was associated with immediate reductions in physician and nurse immigration from the EU and subsequent increases in non-EU physicians and nurses. In addition, the Brexit referendum was associated with increases in NHS physician vacancies.

Meaning

These findings suggest that uncertainty related to immigration policy can alter health care workforce composition, and substitution through non-EU recruitment may not fully offset workforce shortages, which may have implications for health system capacity and global health equity.

Abstract

Importance

The UK relies heavily on internationally trained physicians and nurses. The 2016 UK European Union (EU) membership referendum (Brexit referendum) introduced uncertainty regarding future migration policy, with unclear implications for health care workforce supply and National Health Service (NHS) staffing.

Objective

To evaluate changes in immigration of internationally trained physicians and nurses to the UK after the Brexit referendum and to assess associated changes in NHS vacancies.

Design, Setting, and Participants

A controlled interrupted time-series study was conducted to assess changes in physician and nurse immigration to the UK after the 2016 Brexit referendum, using annual data for 2008 through 2019 from the Organization for Economic Cooperation and Development (OECD) with 32 high-income OECD countries as the control group; an interrupted time-series study was undertaken to estimate changes in NHS England vacancies due to the Brexit referendum, using monthly vacancy data from April 2015 to December 2019. Data were analyzed from January 2024 to June 2025.

Exposures

2016 Brexit referendum.

Main Outcomes and Measures

Annual inflow of EU-origin, non–EU-origin, and total physicians and nurses to the UK; monthly NHS England physician and nursing vacancies.

Results

The analysis included 418 962 physicians and 358 122 nurses who emigrated to an OECD country from 2008 to 2019. In 2016, the Brexit referendum was associated with immediate reductions of 825 EU physicians (95% CI, −983 to −668) and 2771 EU nurses (95% CI, −2952 to −2590) relative to prereferendum trends. Non-EU immigration also fell in 2016 (−416 physicians [95% CI, −746 to −83]; −2912 nurses [95% CI, −3463 to −2362]) but increased significantly thereafter from 2017 to 2019 (added 3110 physicians per year [95% CI, 2745 to 3474] and 1437 nurses [95% CI, 1036 to 1838]). Overall, total physician inflow rose, while total nurse inflow declined. NHS England physician vacancies increased by 383 posts (95% CI, 88 to 679) immediately after the referendum; nursing vacancies showed no significant changes.

Conclusions and Relevance

In this cross-sectional study, the Brexit referendum’s policy uncertainty produced a sustained decline in EU-origin health care worker immigration, partially offset by recruitment from non-EU countries. This substitution did not prevent increases in physician vacancies and persistent nursing shortfalls, underscoring the sensitivity of health workforce supply to migration policy. Policymakers considering similar restrictions should account for anticipatory effects, substitution dynamics, and potential consequences for global health equity.

This cross-sectional study assesses the association between the 2016 UK European Union membership referendum (Brexit) and changes in immigration of internationally trained physicians and nurses to the UK to fill vacancies in the National Health Service.

Introduction

International health care workers play an important role in the UK, which has among the lowest number of physicians per capita in Europe.¹ In 2026, more than 153 000 of 422 000 physicians (36%) in the UK had graduated from medical schools outside the country, in addition to more than 38 000 of 422000 (9%) from the European Union (EU).² Historically, the UK’s membership in the EU has allowed for largely unrestricted migration between the UK and other EU member countries. As a result, the National Health Service (NHS) had benefited from the health care workforce from the EU, and previous studies have highlighted the dependence of the NHS on internationally trained physicians.^2,3 However, that dependence may change.

In June 2016, the UK voted to withdraw from the EU (hereafter, Brexit referendum), triggering a process culminating in the formal exit from the EU in January 2020. The 2016 Brexit referendum introduced policy uncertainty and raised concerns about new restrictions on migration from the EU.⁴

Previous research has examined the effects of the Brexit referendum on general immigration, finding reductions in EU-origin immigration with heterogeneous effects depending on reasons for migration (ie, education, work, leisure).⁵ However, there is a lack of empirical evidence about how anticipation of Brexit affected immigration of health care workers and NHS workforce shortages, despite calls from the UK government to better describe workforce trends.^6,7,8,9 This study aims to fill this gap by exploiting the Brexit referendum as a natural experiment to study how the policy uncertainty associated with Brexit affected immigration of physicians and registered nurses (hereafter, nurses) to the UK, and whether there were changes in NHS vacancies due to the anticipated restrictions from the Brexit referendum.

Methods

The institutional review board of the Harvard Pilgrim Health Care Institute deemed this study to be exempt because it used only publicly available without personal identifiers and did not involve human participants; informed consent was also waived for this reason. We followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.

Data Source

In this repeated cross-sectional study, we used 2008 to 2019 annual data from the Organization for Economic Cooperation and Development (OECD). The OECD collects information regarding physician and nurse immigrants.¹⁰ As the largest publicly available database of health care workforce migration, the OECD data have previously been used to identify trends in internationally trained health care worker inflow to OECD countries.^11,12

Primary and Secondary Outcomes

We studied 6 primary outcomes using the annual OECD data: EU origin physician inflow to the UK, non−EU origin physician inflow to the UK, overall physician inflow to the UK, EU origin nurse inflow to the UK, non-EU origin nurse inflow to the UK, and overall nurse inflow to the UK. Then, we used monthly data from NHS England from April 2015 to December 2019 to study 2 secondary outcomes: medical and physician staff vacancies and nursing vacancies.

For both primary and secondary outcomes, we restricted the study period to before 2020 for 3 main reasons. First, formal withdrawal from the EU began in January 2020; since then, the UK has experienced changes in health care demand associated with the COVID-19 pandemic. Additionally, the UK introduced a fast-track visa for health care workers in 2020, likely affecting health workforce immigration.¹³ Due to these overlapping forces after the UK withdrawal, it would be difficult to disentangle the effects from one another, especially considering the annual nature of most of the data. Second, the OECD data on health care workforce migration were not available after 2022. Third, because prior analyses have focused on immigration changes before the UK’s formal withdrawal in 2020, using a similar study period before the formal withdrawal allowed us to compare our findings with those reported by prior studies.

Statistical Analysis

For our primary analysis of the annual inflow of physicians and nurses, we used a controlled interrupted time-series (CITS) approach to conduct a retrospective analysis of 3 time periods. We identified 2008 to 2015 as the pre-Brexit referendum period, 2016 as the immediate Brexit referendum change, and 2017 to 2019 as the post-Brexit referendum period. This approach has been used in previous studies evaluating health workforce policies.^14,15 A quasi-experimental study design, CITS analysis identified similar treatment effects as difference-in-differences methods.¹⁶ We selected the CITS approach for our primary analysis due to divergence in the pretrends between the UK (treated) and our control countries, which violated the parallel trends assumption required by the difference-in-differences method. Through this CITS approach, we estimated the slope change between the postperiod relative to the preperiod trend, accounting for the change during the year of the Brexit referendum (ie, the level change). The level change accounts for immediate disruptions associated with the intervention (ie, the Brexit referendum), assuming that the preperiod trend would extend into the postperiod in the absence of the intervention.¹⁷ Thus, we specified 3 coefficients per outcome: the pre−Brexit referendum coefficient refers to the slope during the preperiod; the Brexit referendum coefficient refers to the level change in the intervention year of 2016; and the post-Brexit referendum coefficient refers to the slope change in the postperiod relative to the preperiod adjusted for the level change. We estimated linear models to compare the UK with a control group of 32 OECD countries that had data available for the entire study period (eAppendix in Supplement 1 provides a complete list of the control countries). We included the following covariates to account for changes in health care demand and supply at the country-year level: mortality per 100 000, percentage of individuals in good health, health care expenditure as a percentage of gross domestic product (GDP), GDP per capita, percentage insured, population, and the number of physicians or nurses per 100 000—all of these variables were from the World Bank.¹⁸ Standard errors were clustered at the country level.

We conducted a series of sensitivity analysis that included control countries that were members of both the EU and OECD, estimating unadjusted models, omitting covariates with concern for endogeneity (ie, mortality rates, percentage good health), using only preperiod averaged covariates, and using a lagged GDP term (eTables 1-11, 13, and 14 in Supplement 1). A synthetic control method was also used as an alternate specification, where each country was weighted based on their preperiod predictors of the outcome (eTable 12 in Supplement 1).

Additionally, to better understand changes by origin country, the relative changes between 2015 (ie, the year before the Brexit referendum) and 2019 (ie, the end of this study’s post-Brexit period) in the annual inflow of physicians and nurses were mapped. Origin countries with 10 or fewer physicians or nurses were excluded from the maps to limit outlier effects.

To analyze our secondary outcomes (ie, NHS England vacancies), we restricted the study period to between April 2015 and December 2019 because the NHS vacancy data were not available until April 2015.¹⁹ We used an interrupted time-series approach with linear models to estimate changes in vacancies due to the Brexit referendum. We defined April 2015 to May 2016 as the preperiod, June 2016 to December 2016 as the Brexit referendum period (ie, level change), and January 2017 to December 2019 as the postperiod. We controlled for the following covariates: number of physician and nurse graduates in the UK, physician and nurse full-time equivalents, total physician and nurse inflow, and mortality per 100 000. All tests were 2-sided with an α level of .05 and were conducted in Stata, version 18.0 (StataCorp), from January 2024 to June 2025.

Results

The study analysis included 418 962 physicians and 358 122 nurses who emigrated to an OECD country from 2008 to 2019. We did not collect individual-level demographic data (eg, age). Among physicians of EU origin (hereafter, EU physicians), the annual inflow to the UK had increased before the Brexit referendum but decreased by the beginning of 2015, and since then, it has remained substantially low, compared with the unadjusted estimated trend (Figure 1A). The annual inflow of physicians from other regions (hereafter, non-EU physicians) to the UK changed slightly before the Brexit referendum but grew substantially after the referendum, from 7863 in 2015 to 19 647 in 2019, more than doubling during the period and outstripping the unadjusted estimated trend (Figure 1B). The total physician immigration patterns were similar to those of the non-EU physicians (Figure 1C). The annual inflow of nurses of EU origin (hereafter, EU nurses) to the UK increased in the period before the referendum, from 1556 in 2008 to 8980 in 2015. After the referendum (early 2016), there was a sharp decline in the annual inflow of EU nurses, decreasing to 818 by 2019, a 91% reduction since 2015 (Figure 2A). Annual inflow of nurses from other regions (hereafter, non-EU nurses)to the UK increased from 3904 in 2008 to 12 926 in 2016; however, there was a decrease in the annual inflow between 2016 and 2017 (Figure 2B). This resulted in 6817 fewer nurses emigrating to the UK in 2017 compared to 2016. Then, the annual nurse inflow increased after 2017, reaching 20 764 in 2019, similar to the pre-Brexit referendum inflow but lower than the unadjusted estimated trend. Total nurses’ inflow increased prior to the Brexit referendum and then decreased during the remainder of the study period (Figure 2C).

Three-panel line charts of physician inflow to the UK, 2008 to 2019, by origin. Three panels labeled A, B, and C, arranged with panel A across the upper left and panels B and C along the bottom row. All panels use a horizontal axis labeled Year with ticks from 2008 through 2019. All panels use a vertical axis labeled Physicians who emigrated, No. Panel A title: EU physician inflow to the UK. Vertical axis ranges from 0 to 3500. A dark teal line with circular markers labeled Observed varies from about 2100 in 2008 to about 3300 in 2014, then drops to about 2100 in 2015 and remains near 2000 to 2400 through 2019. A magenta line with circular markers labeled Control countries (mean) remains near 300 to 450 across years. An orange solid line labeled Fitted pretrend UK rises from about 2450 in 2008 to about 3000 at 2016. An orange dotted line labeled Predicted based on pretrend UK continues upward after 2016 to about 3200 by 2019. A vertical light blue band centered at 2016 with blue text above reading Brexit referendum passed. Panel B title: Non-EU physician inflow to the UK. Vertical axis ranges from 0 to 25000. Dark teal Observed values are about 8000 to 9000 from 2008 to 2016, then increase to about 10500 in 2017, about 14500 in 2018, and about 20000 in 2019. Magenta Control countries (mean) values are near 1200 to 1800, with a slight dip around 2013 to 2015 and higher values near 2016 to 2019. The same vertical light blue band at 2016 and the same blue text appear. Panel C title: Physician inflow to the UK. Vertical axis ranges from 0 to 25000. Dark teal Observed values are about 10000 to 12000 from 2008 to 2016, then rise to about 12500 in 2017, about 16500 in 2018, and about 22000 in 2019. Magenta Control countries (mean) values are near 900 to 1200 across years. An orange solid line labeled Fitted pretrend UK is near 10500 in 2008 and rises gradually to about 11200 at 2016; an orange dotted continuation labeled Predicted based on pretrend UK extends to about 11600 by 2019. The vertical light blue band at 2016 and the blue text Brexit referendum passed are repeated. — Unadjusted predicted lines were extrapolated from before to after the Brexit referendum for EU physicians, physicians from countries in other regions (non-EU), and all physicians. Control countries (mean) shows the mean inflow to the control group of 32 countries in the Organization for Economic Cooperation and Development from the same countries of origin.

Three-panel line graphs of nurse inflow to the UK by year, 2008 to 2019. Three panels labeled A, B, and C, arranged with A at upper left, B at lower left, and C at lower right. Each panel contains a time series line chart with a light blue vertical band centered on year 2016 and the blue text Brexit referendum passed above the plotting area. Each panel uses a black line with dark teal circular markers labeled Observed near the upper mid area, and a magenta line with magenta circular markers labeled Control countries mean near the lower portion. An orange solid line labeled Fitted pretrend UK runs upward across the pre-2016 years, and an orange dotted line labeled Predicted based on pretrend UK continues upward after 2016; the legend for the orange lines appears in panel A at upper right. Panel A title at top left: EU nurse inflow to the UK. Horizontal axis labeled Year with ticks from 2008 through 2019. Vertical axis labeled Nurses who emigrated, No., ranging from 0 to 14000. Observed values rise from about 1500 in 2008 to about 9000 in 2015, then about 7800 in 2016, then drop to about 800 in 2017 and remain near 800 to 900 through 2019. Control mean in panel A stays near 300 to 500 across all years. Panel B title: Non-EU nurse inflow to the UK. Vertical axis labeled Nurses who emigrated, No., ranging from 0 to 25000. Observed values are about 4000 in 2008, about 2500 in 2009, then increase to about 5500 to 6500 during 2011 to 2013, about 8000 in 2014, about 12500 in 2015, about 13000 in 2016, drop to about 6000 in 2017, then rise to about 11000 in 2018 and about 21000 in 2019. Control mean in panel B declines from roughly 2500 in 2008 to near 1000 to 1500 by 2011 and remains near that level through 2019. Panel C title: Nurses inflow to the UK. Vertical axis labeled Nurses who emigrated, No., ranging from 0 to 30000. Observed values are about 5500 in 2008, about 4200 in 2009, about 6200 in 2010, about 8500 to 9000 in 2011 to 2012, about 11000 in 2013, about 15000 in 2014, about 21500 in 2015, about 21000 in 2016, drop to about 7000 in 2017, then about 12000 in 2018 and about 21500 in 2019. Control mean in panel C decreases from about 3000 in 2008 to about 1200 to 1600 from 2011 onward. — Unadjusted predicted lines were extrapolated from before to after the Brexit referendum for EU nurses, nurses from countries in other regions (non-EU), and all nurses. Control countries (mean) shows the mean inflow to the control group of 32 countries in the Organization for Economic Cooperation and Development from the same countries of origin.

Countries with the largest relative increase between 2015 and 2019 in the annual number of physicians migrating to the UK were Egypt (588%, an increase of 191 to 1314), Malta (521%, 38 to 236), Nigeria (478%, 233 to 1347), and Sudan (494%, 82 to 487), respectively (Figure 3A). Countries with the largest relative decrease in the annual number of physicians immigrating to the UK were Austria (−52%, from 33 to 16), Italy (−34%, from 328 to 215), Latvia (−33%, from 24 to 16), and France (−27%, from 48 to 35), respectively—all are EU countries. Similar trends were identified among nurse migration patterns (Figure 3B).

Two-panel world choropleths of physician and nurse inflow change to the UK. Two stacked world map panels with country borders and panel labels at the upper left of each map. Panel A title text at top left: Physician inflow to the UK. Countries are shaded with a blue gradient; many countries appear pale blue, while several are darker blue, and some countries are light gray. A horizontal color bar legend sits in the lower left of panel A, transitioning from very light blue to dark blue, labeled Change from 2015, percent. The numeric endpoints printed under the bar read minus 75 at the left and 900 at the right. Panel B title text at top left: Nurse inflow to the UK. Countries are shaded with an orange gradient; many countries appear pale orange, several are darker orange, and many countries are light gray. A horizontal color bar legend sits in the lower left of panel B, transitioning from very light orange to dark orange, labeled Change from 2015, percent. The numeric endpoints printed under the bar read minus 100 at the left and 1558 at the right. In both panels, the United Kingdom is visible in northwestern Europe with surrounding European countries outlined; no point markers, arrows, or callouts appear, and there are no axis lines beyond the two color legends.

Our CITS models confirmed the unadjusted results of reductions in health care workers immigrating to the UK from the EU. As shown in Table 1, EU physicians immigrating to the UK decreased significantly in 2016 (coefficient, −825.3; 95% CI, −667.8 to −982.9) relative to the prereferendum trend. The annual inflow of EU physicians increased slightly in the postreferendum period, by 69 physicians per year (coefficient, 69.3; 95% CI, 0.37 to 138.29). In comparison, the Brexit referendum was immediately associated with 415 fewer non-EU physicians immigrating to the UK (coefficient, −416.3; 95% CI, −82.9 to −749.7) relative to the preperiod trend. However, that was followed by a significant increase of 3109 non-EU physicians per year in the postreferendum period from 2017 to 2019 (coefficient, 3109.7; 95% CI, 2745.3 to 3474.2). The trend of the total number of physicians was similar to the non-EU physician trend.

Table 1. Controlled Interrupted Time-Series Models of Change in Annual Physician and Nurse Inflow to the UK by Area of Origin (European Union [EU] or Beyond EU [non-EU]), by Brexit Time Period .

Change by period and profession	EU origin		Non-EU origin		Total
Change by period and profession	Coefficient (95% CI)	P value	Coefficient (95% CI)	P value	Coefficient (95% CI)	P value
Physicians
Pre-Brexit (baseline trend)	49.81 (20.49 to 79.12)	.002	136.48 (54.59 to 218.37)	.002	93.67 (51.63 to 135.71)	<.001
Brexit (level change)	−825.34 (−982.88 to −667.79)	<.001	−416.29 (−749.67 to −82.90)	.02	−640.26 (−818.78 to −461.75)	<.001
Post-Brexit (slope change)	69.33 (0.37 to 138.29)	.05	3109.74 (2745.27 to 3474.21)	<.001	1588.62 (1402.31 to 1774.93)	<.001
Nurses
Pre-Brexit (baseline trend)	1021.03 (958.18 to 1083.88)	<.001	1245.82 (1079.72 to 1411.92)	<.001	1136.88 (1045.91 to 1227.84)	<.001
Brexit (level change)	−2771.28 (−2952.26 to −2590.31)	<.001	−2912.33 (−2361.61 to −3463.06)	<.001	−2859.76 (−3173.81 to −2545.72)	<.001
Post-Brexit (slope change)	−3094.34 (−3207.38 to −2981.30)	<.001	1437.45 (1036.41 to 1838.48)	<.001	−824.97 (−1023.91 to −626.03)	<.001

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Each model included covariates of mortality per 100 000, percentage of individuals in good health, health care expenditure as a percentage of gross domestic product (GDP), GDP per capita, percentage insured, population, and the number of physicians or nurses per 100 000. The baseline trend represents the 2008 to 2015 trend in the pre-Brexit referendum period; the Brexit referendum represents the level change in 2016; the post-Brexit referendum period represents 2017 to 2019. Coefficients represent the annual physician or nurse inflow change relative to the pretrend in the pre-Brexit referendum period.

Table 1 shows that the annual inflow of EU nurses to the UK decreased by 2771 in the immediate Brexit referendum period (coefficient, −2771.3; 95% CI, −2590.3 to −2952.3) relative to the prereferendum trend. During the post-Brexit referendum period, there were 3094 fewer EU nurses immigrating to the UK per year (coefficient, −3094.3; 95% CI, −2981.3 to −3207.4). Among non-EU nurses, the Brexit referendum was associated with 2912 fewer nurses in 2016 immigrating to the UK (coefficient, −2912.3; 95% CI, −2361.6 to −3463.1) relative to the prereferendum trend. This was followed by an increase of 1437 non-EU nurses per year immigrating to the UK (coefficient, 1437.5; 95% CI, 1036.4 to 1838.5) during the postreferendum period. Total nurse immigration had an overall reduction both in 2016 (coefficient, −2859.0; 95% CI, −2545.7 to −3173.8) and during the post-Brexit referendum period (coefficient, −825.0; 95% CI, −626.0 to −1023.9) relative to the prereferendum trend.

Table 2 showed that NHS England physician vacancies increased significantly by 383 in 2016 (coefficient, 383.3; 95% CI, 87.5 to 679.2) relative to the prereferendum period. After the Brexit referendum, there were no significant changes relative to the prereferendum period. In terms of NHS England nursing vacancies, there were no significant changes in either the immediate Brexit referendum or the postreferendum period.

Table 2. Changes in Monthly National Health Service England Vacancies by Clinician Type: Results of Interrupted Time-Series Models.

Change	Physician vacancies		Nurse vacancies
Change	Coefficient (95% CI)	P value	Coefficient (95% CI)	P value
Pre-Brexit referendum (baseline trend)	0.29 (−1.41 to 1.98)	.74	0.875 (−4.19 to 5.95)	.73
The 2016 Brexit referendum (level change)	383.33 (87.50 to 679.16)	.01	526.19 (−302.35 to 1354.73)	.21
Post-Brexit referendum (slope change)	−0.28 (−2.12 to 1.57)	.76	−0.13 (−6.43 to 6.15)	.97

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Each model included covariates of number of physician or nurse graduates in the UK, physician or nurse full-time equivalents, total physician or nurse inflow, and mortality per 100 000. The baseline trend represents the trend in April 2015 to May 2016 in the pre-Brexit referendum period; the 2016 Brexit referendum represents the level change from June 2016 to December 2016; the post-Brexit referendum period represents January 2017 to December 2019. Coefficients represent the monthly change in National Health Service England vacancies relative to the pretrend in the pre-Brexit referendum period.

Our alternate specifications generated similar results to our main results when we included only the control countries that were members of both the EU and the OECD (eTables 4 and 5 in Supplement 1). Results from the synthetic control model were similar to the study’s primary results.

Discussion

This study extends previous research by using quasi-experimental methods to elucidate how the Brexit referendum changed both health workforce immigration to the UK and the NHS England vacancies. We found that the Brexit referendum was associated with a decrease in immigration to the UK from EU countries, regardless of clinician type (physician or nurse). In comparison, physician emigrants to the UK from non-EU countries increased substantially after the referendum. However, the Brexit referendum was associated with differential effects on total immigration by clinician type, with total physicians increasing but total nurses decreasing. We also found an associated increase in NHS England physician vacancies but no change in NHS England nursing vacancies. Overall, our results indicate a changing health care workforce in the UK with implications for health care service quality and quantity due to uncertain migratory policies caused by the Brexit referendum.

Our findings have several important implications. First, the decreased inflow of both physicians and nurses of EU origin after the referendum was called but prior to the UK’s formal withdrawal points to an anticipation effect of Brexit. Our findings are consistent with those of prior studies regarding the anticipation associated with Brexit,^5,20 which may have occurred through multiple mechanisms, such as immigrants from the EU being uncertain about how the UK migratory policy would affect long-term career prospects, social mobility, and opportunities for them and their families. Historically, the UK has been an attractive destination for health care workers from the EU for 2 main reasons: (1) ease of migration and (2) legal protections for EU citizens afforded by the UK’s EU membership, including access to social security, health care, welfare, public education, and a range of antidiscriminatory protections.^2,5 These incentives allowed the UK to benefit from EU health care labor to mitigate its domestic workforce gaps.²¹ However, the uncertainty regarding the formal terms of Brexit may have led to health care workers in the EU to remain in their home country or immigrate to a different country given their anticipation that previous benefits would be revoked in the UK. Similarly, hospitals and physician practices in the UK may have been less incentivized to hire EU physicians and nurses if they were unsure about how the formal terms of Brexit would affect their ability to retain these physicians and nurses. They may have been unwilling to invest time and capital in recruiting and training EU health care workers who might have to return to their country of origin when the UK withdrawal from the EU became formalized. Our findings that EU physician immigration began to decrease in 2015 are likely associated with the passage of the EU Referendum Act of 2015, findings consistent with those of another study that analyzed EU-origin immigration to the UK.⁵

Beyond the impact on EU health care worker immigration, the Brexit referendum may also have changed how non-EU health care workers perceived immigration to the UK. After the referendum, EU physicians faced a similar burdensome visa process as non-EU physicians. A more equalized immigration field may increase non-EU physician immigration to the UK, leading to unexpected labor workforce substitution of non-EU physicians for EU physicians. Furthermore, the increase in non-EU physician migration exceeded the reduction in EU physician migration, leading to higher total physician migration to the UK in the postreferendum period.

Second, we found that physician inflow from EU countries decreased relative to the pre-Brexit referendum trend and that total physician inflow increased after the Brexit referendum, especially from countries in Africa and Asia, likely exacerbating physician shortage issues in those origin countries. The substitution of EU physicians with those from non-EU countries could impact the NHS workforce. The General Medical Council in the UK has established norms for accepting physician credentials from select EU or European Economic Area countries. Conversely, the UK requires physicians from non-EU countries to repeat clinical training and/or meet more stringent requirements, including English proficiency and other credentialing examinations, which could burden the NHS, delay credentialing processes, and require additional visas. This may be an area where the NHS and professional organizations could support non-EU physicians. We found that the Brexit referendum was associated with an increase in NHS physician vacancies despite the influx of non-EU physicians. This indicates that the rise in non-EU physicians was insufficient to offset the rising demand for health care services facing the NHS.

Furthermore, labor workforce substitution may not be as simple as 1 EU to 1 non-EU physician due to clinical training differences, credentialing challenges, and language barriers. This has implications for workforce distribution and care quality. Non-EU physicians may prioritize practicing in different locations or specialties compared with EU physicians.²² Additionally, previous research has indicated lower test scores among non-EU immigrant physicians compared to EU-trained physicians, but there is insufficient evidence about care quality between these 2 groups in the UK.²³ The substitution may also be complicated by the increasing NHS dependence on non-EU physicians, with subsequent impacts on global medical brain-drain, raising ethical issues of recruiting physicians from countries with physician shortages,²⁴ such as Egypt, Malta, Nigeria, and Sudan, all of which had relatively large increases (although Malta has a modest absolute change) in physicians immigrating to the UK during our study period, some of which (eg, Nigeria) are on the World Health Organization (WHO) designated list of countries with shortages.²⁵ In its newly published 10-year health plan for England, the UK government acknowledged that “it will neither be possible nor ethical to maintain our current levels of international recruitment” and announced an ambitious prospective goal “to reduce international recruitment to less than 10% by 2035.”²⁶ It will be interesting for future research to assess whether that goal is achieved in 10 years. Although prior research indicates that the 2010 WHO Global Code of Practice achieved short-term success in curbing clinical recruitment from shortage countries, the effects have faded over time, raising concerns regarding long-term effectiveness. As the WHO recommends, the UK and other high-income countries should recommit to reducing active recruitment from shortage- and conflict-affected countries, while respecting freedom of international migration.^26,27,28

Third, we found that both the EU nurse and total nurse inflow decreased to the UK after the Brexit referendum. Despite the decreases, NHS nursing vacancies remained stable after the Brexit referendum. This finding could be multifactorial but is likely due to changes in UK policy regarding nursing students. While a 2011 government policy reduced the funded nursing slots due to a perceived oversupply of nurses, a 2017 policy ended the nursing bursary, which was intended to remove restrictions on nursing placements.²⁹ Along with additional funding through NHS for expanding clinical placements, the number of UK-trained nurses could have offset the reduction in total nurse inflow, coupled with a potential decline in UK nurse outflow. The increase in non-EU nurses was likely due to the government commitment to provide England with “50 000 more nurses” in 2019 to be implemented over 5 years, and active recruitment by employers to recruit from non-EU countries to meet that target, including those on the WHO “red list” of at-risk countries.^30,31 In 2023 to 2024, almost half (49.4%) of all new joiners to the Nursing and Midwifery Council register were internationally educated, reflecting a substantial change in the nurse population in the UK. Each of these domestic policy changes makes it difficult to isolate the referendum’s contribution.

Lastly, the asymmetric changes between physician and nurse immigration after the Brexit referendum are notable considering the increases in total physician inflow vs the declines in total nurse inflow. Differences in occupational licensing, stability in domestic nursing workforce, differentials by clinician type between UK and origin countries, and differences in NHS recruitment targeting a specific type of clinician could all be related to this asymmetry. Additional exploration of this relationship is important to better understand clinician immigration implications after the referendum.

Limitations

Limitations of this study include its cross-sectional design and the lack of information regarding physician and nurse characteristics at the individual level. We also did not analyze physician specialties, which could have implications for the maldistribution of certain physician specialties in the UK. Our findings about vacancy changes are limited, since we used only NHS England data, not capturing information on either non-NHS physicians or other areas in the UK. The NHS England preperiod data capture just 14 months, which could affect the model’s reliability—a longer period for baseline trend estimation would strengthen its validity. Given that our study period ended before the COVID-19 pandemic, and it remains important to understand how international health care worker inflow to the UK may have changed further after the nation formally completed its separation from the EU in 2020. Our study focused on the association of the Brexit referendum with health care worker inflow to the UK, not the outflow of health care workers from the country, another important topic for future research.³² Furthermore, while our study shed light on the substitution between EU and non-EU physicians in the UK, future research should evaluate how workforce substitution may affect physician choice of specialty and practice location, patient outcomes, and health care costs in the UK, both qualitatively and quantitatively.

Conclusions

This cross-sectional study found that the Brexit referendum affected health workforce immigration to the UK and NHS vacancies, which was associated with a reduction in immigration of EU health care workers, an increase in non-EU physician immigration, and an increase in NHS England medical vacancies. Along with the rising demand for health care services, the Brexit referendum may have amplified NHS workforce challenges. Our findings confirmed an anticipatory effect of uncertain migration policies caused by the referendum, which had implications extending beyond Brexit. As other countries enter and exit free movement zones, such as the EU, or implement restrictive migratory policies, they should consider both the anticipatory and unanticipated consequences on the health workforce and on patient health outcomes.

Supplement 1.

eAppendix. Control Countries

eTable 1. Changes in Annual Physician Inflow to the UK by Origin: Unadjusted Results of the CITS Models

eTable 2. Changes in Annual Nurse Inflow to the UK by Origin: Unadjusted Results of the CITS Models

eTable 3. Changes in Monthly NHS England Vacancies by Clinician Type: Unadjusted Results of ITS Models

eTable 4. Changes in Annual Physician Inflow to the UK by Origin with only EU Countries as Controls: Results of the CITS Models

eTable 5. Changes in Annual Nurse Inflow to the UK by Origin with only EU Countries as Controls: Results of the CITS models

eTable 6. Changes in Annual Physician Inflow to the UK by Origin: Adjusted Results of the CITS Models Without Mortality or % Good Health

eTable 7. Changes in Annual Nurse Inflow to the UK by Origin: Adjusted Results of the CITS Models Without Mortality or % Good Health

eTable 8. Changes in Annual Physician and Nurse Inflow to the UK: Adjusted Results of the CITS Models With a Lagged GDP per Capita Term

eTable 9: Changes in Annual Total Physician and Nurse Inflow to the UK: Adjusted Results of the CITS Models using only preperiod averaged covariates

eTable 10 Changes in Annual Physician Inflow to the UK: Adjusted Results of the CITS Models With All Covariates

eTable 11. Changes in Annual Nurse Inflow to the UK: Adjusted Results of the CITS Models With All Covariates

eTable 12. Changes in Annual Physician and Nurse Inflow to the UK: Results from a Synthetic Control Method

eTable 13. Changes in Monthly NHS England Physician Vacancies Full ITS Model Estimates

eTable 14. Changes in Monthly NHS England Nurse Vacancies Full ITS Model Estimates

jamahealthforum-e262868-s001.pdf^{(404.6KB, pdf)}

Supplement 2.

Data Sharing Statement

jamahealthforum-e262868-s002.pdf^{(16.9KB, pdf)}

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