Paying Twice: Migrant workers face NHS bills under crackdown

Thousands of overseas workers in the NHS and social care are being told to pay large medical bills at the same time they face higher visa hurdles, as the government’s immigration crackdown reshapes who can work, stay, and access free care.

From spring and summer 2025, ministers tightened Skilled Worker visa rules, ended new overseas recruitment for most care workers, and raised sponsorship fees, arguing the UK must cut net migration and build a homegrown care workforce. Unions, hospital leaders, and advocacy groups warn the policy mix has triggered “paying twice” scenarios: migrants cover rising immigration costs and then face NHS charges running into the thousands if their status does not give them free care or if their paperwork lapses during job changes.

Policy changes and timing

The Home Office changes—part of a policy reset led by Home Secretary Yvette Cooper—have been fast and far-reaching. Key measures include:

• The general Skilled Worker salary threshold rose from £38,700 to £41,700 in April 2025.
• The skill level moved to RQF 6 (graduate level), removing more than a hundred roles from eligibility.
• The Health and Care Visa retains a lower £25,000 salary floor to keep essential NHS roles open.
• Certificate of Sponsorship fees jumped from £239 to £525, with new rules from 31 December 2024 prohibiting employers from passing sponsorship-related costs onto workers.
• From May 2025, the government ended most new overseas recruitment for frontline care roles (with some exceptions for those already sponsored and compliant).

Ministers say these steps address exploitation in social care and reduce reliance on lower-paid migrant labour. Employers and worker advocates say the timing, combined with higher fees and tighter checks, has hit people already filling essential roles in hospitals and care homes.

How NHS charging interacts with visa status

Under NHS charging regulations, care is free for UK residents and many visa holders. However, billing risks arise in specific situations:

• Migrants between jobs or with visas that do not grant free access can be billed for non-urgent hospital care.
• Visa changes that coincide with surgery dates, maternity visits, or follow-up appointments can trigger surprise invoices.
• Short gaps in sponsorship or unclear status during an employer switch can lead to charges.

Advocacy groups and local caseworkers report bills reaching several thousand pounds—burdensome when workers are already paying for visas, dependant applications, and housing. Often charges are cancelled once status is clarified, but the stress, fear of debt, and administrative time are significant.

“Paying twice” captures the sense of doing everything right—working long shifts, paying visa fees, following rules—then being billed for care when paperwork stalls.

Workforce and provider impacts

Providers report mounting workforce strain as a result of the changes:

• Higher sponsorship and compliance costs lead to frozen posts, slower recruitment, fewer training places, or cuts to international recruitment teams.
• Smaller care providers, already budget-constrained, say audits, legal costs, and higher minimum salaries reduce the number of roles they can offer.
• Some providers are leaning more on temporary staff, which often costs more and reduces continuity of care.
• Health leaders warn that even small reductions in adult social care staff can push patients back onto the NHS, increasing delayed discharges and hospital bed pressures.

Guidance for health sector employers on the change cycle is available via NHS Employers: Home Office Immigration Rules collection.

The most controversial step: ending new overseas recruitment for care workers

• From May 2025, most new overseas care worker applications ceased, affecting around 40,000 overseas care workers in some way.
• Exceptions remain for those already sponsored and in compliant roles; those can later apply for settlement if eligible.
• Officials justify the closure by citing evidence of abuse by rogue providers (illegal fees, coercion) and the need to rebuild a domestic workforce.

Health leaders acknowledge potential long-term quality improvements but warn of immediate staffing gaps that could tip local systems into crisis.

Administrative gaps and real-world examples

Confusion over NHS charges is growing in the margins:

• A nurse whose sponsor changed may face a billing request for follow-up scans if her visa renewal is delayed.
• A care worker switching employer may lose access to free care without realising it until a bill arrives.
• Family dependants with different immigration rights can be unexpectedly charged.

Analysis by VisaVerge.com suggests tighter sponsorship rules and employer cost pressures increase the risk of administrative gaps that trigger NHS charges during job changes. While many cases are resolved, the stress can deter care-seeking and lead to worsened health outcomes.

Responses from unions and advocates

UNISON, the UK’s largest union for public service workers, supports action on exploitation but warns:

• Ending overseas recruitment without better pay and conditions will deepen shortages and reduce continuity of care.
• The union calls for removing visa sponsorship from care employers and creating a national framework that protects workers and makes care jobs attractive to UK residents.

UNISON’s public statements and campaigns: Home Office Immigration Rules collection.

Worker advocates propose practical fixes to reduce “paying twice” cases:

• Clear letters from sponsors explaining status during transfers.
• Translated guidance for family dependants.
• Simple checklists at hospital registration.
• Dedicated staff support lines to advise overseas workers on documentation.

Employer responses and financial squeeze

The ban on passing sponsorship costs to workers is beneficial for staff but adds financial pressure on employers:

• Larger NHS trusts say they can absorb the rises; smaller providers report having to downscale recruitment or stop international recruitment entirely.
• Higher Certificate of Sponsorship fees and more stringent audits increase compliance costs.
• Employers are advised to plan visa timelines carefully to avoid contract gaps and to set aside budgets for sponsorship costs.

Practical guidance for employers: Home Office Immigration Rules collection.

Government justification and longer-term reform agenda

The government frames the reset as aiming for:

• Fewer low-paid migration routes.
• Better protection against abuse.
• Investment in UK-based training, career pathways, and fair pay agreements.

An independent commission on adult social care, chaired by Baroness Casey, is working on long-term reforms. The Home Office’s official collection of rules and updates is available at: Home Office Immigration Rules collection.

Practical advice for workers and employers

Workers:
1. Confirm visa conditions before scheduled care.
2. Keep a “status pack” handy: current visa grant, latest Certificate of Sponsorship number, confirmation letter from sponsor, proof of address.
3. Renew visas early and book biometric appointments promptly.
4. If billed, contact the hospital’s overseas visitor team and provide proof of status.

Employers:
– Coordinate start dates with visa grants so staff arrive with full access to care.
– Offer internal briefings to overseas staff on NHS charging rules.
– Consider paying for legal advice, guaranteeing paid time off for visa appointments, and offering wage advances if unexpected charges arise.

Further employer advice: Home Office Immigration Rules collection.

Wider implications and outstanding questions

• The salary uplift to £41,700 and the RQF 6 requirement have narrowed the Skilled Worker route, though the Health and Care Visa remains at £25,000 for essential roles.
• The Certificate of Sponsorship fee increase to £525 and the ban on passing costs to employees shift financial pressure to employers.
• Ending new overseas recruitment for care workers in May 2025 forces a rapid pivot to domestic recruitment before training pipelines are fully ready.

Major outstanding issues:
– Will staffing stabilise quickly enough to avoid harm to services?
– Will promised pay and training reforms reach the frontline in time?
– How will immigration policy be coordinated with workforce planning and transparent timelines for threshold reviews?

Sources and further reading

• Home Office Immigration Rules collection: Home Office Immigration Rules collection
• NHS Employers guidance on immigration rule changes: https://www.nhsemployers.org/articles/immigration-rule-changes-july-2025
• UNISON social care campaign and statements: https://www.unison.org.uk/news/2025/05/reform-of-care-must-be-priority-as-overseas-recruitment-ends

Key takeaways (quick summary)

• Policy changes (2024–25) raise thresholds and fees, and stop most new overseas recruitment for care workers from May 2025.
• Many overseas health and care workers risk being billed for NHS care during visa gaps or status changes—creating the sense of “paying twice.”
• Employers face higher costs and compliance duties; smaller providers are most vulnerable.
• Practical steps—better communication, careful visa planning, and employer support—can reduce harm while longer-term reforms take effect.

Until policy, funding, and workforce planning align, overseas workers in health and care remain central to the system—and vulnerable to charging and administrative gaps that can harm both staff and patients.