When the NMC introduced the SIFE pathway in 2023, it was intended to solve a real and pressing problem: internationally educated nurses, many of them highly experienced, were stuck in lower-paid healthcare assistant roles because they couldn’t clear the OET or IELTS hurdle. The idea was straightforward—if an employer could vouch for a nurse’s English in a clinical setting, that evidence could supplement or even replace a formal test score.
Two and a half years on, SIFE has become a significant route onto the register. Between April 2024 and March 2025, 5,316 internationally educated professionals joined the NMC register using SIFE—roughly a quarter of all overseas nurses, nursing associates and midwives who registered during that period. The NMC has reported no fitness to practise concerns linked to English language competency among this group.
So is SIFE working? The answer, as with most things in healthcare workforce planning, is not simple.
For those unfamiliar with the detail, SIFE stands for Supporting Information from Employers. It allows internationally educated applicants to provide employer-based evidence of their English language competence as part of their NMC registration application. Applicants must have been working in a non-registered role in a UK health or social care setting for at least 12 months full-time, with the same employer for that period and the same line manager for at least six months.
There are two main eligibility routes. The first covers applicants who completed their pre-registration training in English but in a country where English is not the majority spoken language. The second is for those who have attempted at least two English language tests and narrowly missed the required score—by no more than 0.5 in IELTS or half a grade in OET—in any one domain.
The sign-off itself must come from a line manager who is an NMC registrant at Band 6 or above, counter-signed by a senior manager at Band 8a or above. It is, in principle, a structured process. But it is also, by design, a subjective one.
The scale of SIFE uptake has been significant. Of the 5,316 professionals who used the pathway in 2024–25, 63% were educated in India, 11% in the Philippines, and 7% in Ghana. These figures reflect familiar patterns in international NHS recruitment, but they also raise a practical question: are line managers across the country equally well equipped to assess English language competence consistently and objectively?
The NMC’s position is reassuring. No fitness to practise cases have been linked to language competency concerns among SIFE registrants. But absence of formal complaints is not the same as absence of concern. Many in the sector will know from experience that language difficulties in clinical settings do not always result in formal reports—they are more likely to surface as miscommunication during handovers, unclear documentation, or patients who feel they haven’t been fully understood.
Feedback from employers is mixed. Some have welcomed the flexibility, particularly those who have invested in supporting overseas staff and feel confident in their ability to assess clinical communication. For these organisations, SIFE makes sense: they have observed their staff working with patients, communicating with colleagues, and handling the day-to-day demands of a healthcare environment in English.
Others are less confident. In its response to the Health and Care Professions Council’s English language proficiency consultation, NHS Employers noted that “any non-testing system brings in a level of subjective decision making on the part of the manager,” and flagged concerns that some managers may sign off candidates without the required skills, “which ultimately could pose a risk to patient safety.” NHS Employers reported that employers represented through the Cavendish Coalition would prefer a system that defaults to formal testing—a view reflecting a broader discomfort with placing a specialist linguistic judgement in the hands of clinical line managers, however experienced.
More troubling are the exploitation risks that have emerged around the pathway. NHS Employers, drawing on feedback from unions and the Cavendish Coalition, reported in its HCPC consultation submission that many overseas recruiters are charging candidates large sums for unregulated UK roles—such as senior care worker or healthcare support worker positions—on the promise that they will qualify for NMC registration after 12 months. This is misleading: SIFE sign-off is an organisational decision, and candidates often arrive in the UK without a full understanding of that. The same submission documented examples in social care where line managers have been signing SIFE forms in exchange for a fee—a practice explicitly prohibited under NMC guidance, which states that “applicants should not be asked for payment or any other additional conditions in exchange for receiving SIFE.” A 2025 Royal College of Nursing survey lends further weight to these concerns, finding that 15% of internationally educated nursing staff paid fees to secure a UK job, with over half of those fees charged illegally by UK-based recruitment agencies. These are precisely the kinds of abuses that undermine a well-intentioned policy.
We should also consider what SIFE means for the professionals using it. Working as a healthcare assistant for 12 months while waiting to register is not without cost. Non-registered roles typically pay 30–40% less than newly registered nursing positions. Applicants must remain with the same employer throughout, limiting their mobility. And there is a real risk that clinical skills can erode when someone is working outside their trained scope of practice for an extended period.
Recent UK immigration policy changes add a further layer of difficulty, with restrictions on family reunification for those in non-registered positions. For many internationally educated nurses, the SIFE route is not a shortcut—it is a long and uncertain path with significant personal and financial costs.
Good luck on your journey to becoming a skilled healthcare communicator!
At SLC, we have worked with NHS Trusts, Health Education England, and international partners on English language training for overseas healthcare professionals for over a decade. We have seen first-hand how targeted, well-structured language preparation transforms both exam outcomes and clinical communication. We have also seen what happens when language support is inadequate or absent.
SIFE was never designed to replace language testing entirely. The NMC is clear that it is supplementary evidence. But in practice, for many applicants, it functions as an alternative—a way to join the register without achieving the required OET or IELTS scores. That distinction matters.
The standard expected is roughly CEFR Level C1: the ability to express oneself fluently and spontaneously, and to use language flexibly and effectively for social, academic, and professional purposes. That is a high bar, and rightly so. Whether a line manager’s sign-off can reliably confirm that level of competence—particularly in a pressured clinical environment—remains an open question.
None of this is to say that SIFE should be scrapped. The problem it was created to address—experienced nurses unable to progress despite years of safe practice in the UK—is real and was causing genuine hardship. But a pathway that relies on employer judgement needs robust, standardised guidance, proper training for those making assessments, and ongoing monitoring that goes beyond the absence of fitness to practise referrals.
For nurses who are considering the SIFE route, it is also worth weighing the alternatives carefully. Passing OET or IELTS provides a guaranteed, universally recognised route to registration—with immediate access to registered roles, higher pay, and greater job flexibility. It also builds the language skills that will serve you throughout your career, not just at the point of registration.
At SLC, we work with nurses at every stage of their journey—from those preparing for their first OET attempt to those who have narrowly missed and need targeted support to close the gap. If you are weighing up SIFE against further test preparation, or if you are an employer looking for guidance on supporting your staff through either route, we are here to help.
Explore SLC’s OET Preparation Courses and IELTS Preparation Courses for healthcare professionals.
For employers seeking advice on SIFE or language training for your international staff, contact us at enquiries@specialistlanguagecourses.com
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