March 10, 2025 - 5:15pm
One claim frequently made about Britain’s immigration system is that current levels must continue because the NHS, or the care system, would otherwise cease functioning. Last month, John Harris wrote in the Guardian: “Without hundreds of thousands of people who have come to the UK from abroad, the most basic aspects of how we look after old, infirm and ill people would simply collapse.” This argument, however, ignores both current policy and history, and is usually presented without taking into account the record levels of immigration in recent years. As an argument, it is also highly parochial: those who make it never think to compare Britain with our closest neighbours and ask why we are so much more reliant on this form of immigration than they are.
The NHS is indeed highly dependent on immigration. As of September 2024, 36% of its 156,000 hospital doctors and 30% of its 400,000 nurses were non-UK nationals. The UK’s high rate of foreign medical staff is hardly a new trend, but neither is it a constant law of nature divorced from political decisions. The figures from recent years have been unprecedented, with a slower level of change until 2020 before an accelerated rise once the Conservative government introduced the Health and Care visa in August 2020. This is when the “Boriswave” really came into effect.
The change in adult social care is even more marked. The balance between British, EU and non-EU staff had been relatively static until 2022/23, at which point it started to shift strongly towards non-EU workers due to the addition of care workers and home carers to the Health and Care visa in February 2022. Importing foreign healthcare workers is a growing trend globally, but why is Britain so much more extreme than other European countries?
| The proportion of adult social care workers with non-EU nationality doubled from 2021/2 to 2023/4 |
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OECD statistics for 2024 show that Britain, along with Ireland, is a massive outlier in the percentage of foreign-trained doctors and nurses. Norway, Sweden and Switzerland appear to be outliers too, but their situation is not really comparable. In Norway and Sweden, large numbers of foreign-trained medical staff are native students who studied for their medical qualifications abroad before returning home, while in Switzerland nearly all the foreign-trained doctors and nurses come from neighbouring countries. Other European countries range from having half the British rate of foreign doctors and nurses (e.g. Germany) or down to a third or less (e.g. France, Italy and Denmark).
What’s behind this disparity? We often hear of the large numbers of British and Irish doctors moving abroad, requiring replacements from other countries, but the numbers are not as great as are often suggested. Britain trains around 9,500 graduate doctors per year, of which in 2022 1,403 left to practise abroad (around 15%), while data from 2012-17 indicates that 43% of those who do work abroad later return, generally within three years. This indicates that less than 10% of British graduate doctors are lost to other countries over the long term.
Doctors leaving for abroad therefore cannot fully explain the high rates of foreign-trained doctors in Britain and Ireland. Given that comparable European countries like France can run a superior health service with far lower rates of foreign workers, the way we do things is evidently not the only choice available. Neither is it the case that Britain gets its healthcare on the cheap by importing lower-paid medical staff. Looking at the percentage of GDP that different countries spend on healthcare, Britain — though paying slightly less than Germany or France — spends more than most comparable European countries.
International comparisons for care workers are harder to find, though even in the pre-Boriswave days of 2019, Britain was one of the few European countries — along with Luxembourg, Malta, Ireland and Austria — where the share of migrants among care workers exceeded 10%.
Given these international comparisons, it seems likely that Britain simply can recruit from abroad due to the international availability of English-speaking workers, not that it must to the extent it does presently. Policy changes can still make a difference, though. Last spring, the Conservative government belatedly restricted the ability of Health and Care visa holders to bring dependants. This change, coupled with increased Home Office scrutiny, led to an 81% decrease in visas granted to main applicants in 2024 compared to the previous year. While the NHS and the care system aren’t functioning well, neither are they “collapsing” any more than they were in 2023.
These are not easy issues to solve: increasing reliance on foreign workers for health and care work is rooted in ageing populations, as well as resulting workforce and financial constraints. It is an increasing trend worldwide; but as with many aspects of immigration, Britain is an extreme case and has handled it especially poorly in recent years. In this context, lazy claims of inevitable collapse simply don’t stand up to scrutiny.
Will Solfiac is a London-based writer focusing on subjects including the politics and history of immigration. He can be found on Substack.
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SubscribeIf you want to know what is wrong with the NHS, it is “free at the point of delivery.”
If you want to know what is wrong with house prices, it is low and zero down payments for mortgages.
Remember, politicians and bureaucrats know nothing.
And Lord Salisbury said “never trust experts.”
Any service which is apparently free (such as our NHS) is open to abuse. There should be some kind of entry fee to all healthcare service – I bet demand would then fall off to a manageable level. Experience in the EU shows that this practice is not uncommon.
And the NI contribution has always served to finance both NHS and state pensions. This funding model is harmful and ludicrous, since it is impossible for the voter to know how these NI contributions are being spent
It is expensive to train medical students. Training too few doctors – and shipping the balance in from abroad – ensured a higher margin for universities, greater bargaining power for the medical profession, and (in the short term) lower costs for the Exchequer. Universities benefited on the double by churning out cheaper-to-deliver Arts courses at similar fees, while selling off a significant proportion of what medical school places they did have to rich non-EU nationals. This was always a stupid, as well as a cynical, policy, but it has been made more damaging by immigration-fueled demographic growth, an aging population, the Working Hours Directive, and a higher proportion of female doctors seeking work-life balance.
The GMBs policy of restricting the number of training places in order to maintain high downstream salary levels doesn’t help. Ditto rhe Royal College of Nursing.
There are a significant pool of potential doctors and nurses who are both academically able and keen to join the workforce but being forced into other disciplines due to the lack of training places.
Working conditions have a lot to do with it as well. The people with potential to become doctors can choose other careers that are easier.
The imposition of worse working conditions (as well as salary) is facilitated by the use of migrant labour, which is likely cheaper and prepared to accept worse conditions.
So it’s a downward spiral meaning we ‘need’ more migrants every year. But if we’d never started using large numbers of migrants in the first place, we’d have more British-born doctors and more training places.
Of course, this would have cost more. But where did all the money saved go? Houses is my guess – nice for those that owned a house or two in the 90s, but actually a disadvantage for everyone else.
It’s an interesting thought. Everyone wants lower taxes (but good services) – but what if the money saved on taxes simply chases houses and inflates house prices (and rents). And once salaries are sufficient to cover basic needs and some luxuries, isn’t this inevitable?
Something to ponder: what if you could be living in the same house, paying a lower mortgage or rent, enjoying more holidays, with affordable houses for the young, a functioning NHS, great education and no pot holes – if more money had gone on tax and less on blowing up the housing bubble.
if more money had gone on tax and less on blowing up the housing bubble.
Where did the £7-8 trillion inflation of house prices come from if not from the government? It didn’t come from growth, did it? Gordon Brown and his successors quite deliberately used it to buy the votes of the middle class with their own money. Starmer will do it too before long. Just watch.
There are literally 100s of students denied places each year, despite excellent grades. But you think housing is the problem?
An indent means I’m quoting – in this case the person I’m replying to.
This is the nail on the head. It’s been studied by economists and seen as a form of rent seeking behaviour in which supply is artificially restricted. What I find shocking is that the government can do nothing to prevent it – but can only react by importing medical staff from abroad.
Points like this should have been in the article. Thanks.
For years Treasury blocked NHS having a proper medium/long term Workforce strategy because it would require a medium/long term investment linked up commitment in education and training places etc. That has now changed but it can’t deliver instantaneously. It’ll take some years and only if we stay the course.
Social care of course lacks a cross party consensus on future funding and hence staggers around paying peanuts and trying to fill vacancies for what is hard, responsible work.
Like much of our reliance on migrant labour it’s because we want to duck national choices and then leave it to employers to try and do the job asked of them as cheaply as poss.
we want to duck national choices
Like forcing the boomers to pay back some of the unearned property wealth and unfunded pension bunce gifted to them by New Labour, perhaps? There’s enough there to fix all these problems several times over.
Agree with that HB.
However remember that your assets can be reduced all the way down to £14k if you require social care. Now most with sizeable assets don’t live long enough to get down to just the residue £14k, so we either all pay a contribution earlier in life, or Inheritance tax increased.
Your thoughts?
If the National Insurance contributions we’ve been forced to make had been wisely invested instead of squandered on the vote-buying activities and vanity projects of politicians we wouldn’t be having this discussion at all.
Social democracy has failed because the centralisation of power and resources that it creates inevitably leads to bad incentives, corruption and parasitism (ie: Blairism). It needs to be dismantled.
Ducked the question there HB.
If we, for once agree, Boomers pay back some of the unearned property wealth, via what mechanism would you now do that? Your Policy initiative to claw some of it back?
Fact it’s happened then a separate issue, but we are where we are for the moment.
We need to nationalise Council Tax and make it redistributive on a countrywide basis so there is no longer an incentive for Richmond and Hampstead to impose bad policies on Rotherham and Harrogate because they’re not paying for the consequences – only taking the profits. That’s one idea.
It was the employers that wanted an endless supply of cheap overseas labour, relatively low skilled, low wage, part-time service jobs for the past 25 years. The governments were only happy to oblige.
Oh, it was also an ideological position taken by “civil servants” Gus O’Donnell and Jonathan Portes.
Whatever happened in the past, do you now support the investment in training and education needed to wean us off? And do you recognise that may take a while to deliver?
(Doctors, nurses, social care workers aren’t low skill by the way)
Your whole comment is full of fallacies and projection (well, no change there).
I always have supported training ahead of (mass) immigration, for 25 years successive governments have not. Progressives have prioritised mass immigration over just about anything else. So, yes it take a long time to wean us of mass immigration, shame we didn’t start the process 20 years ago but that would have been “racist” (still is apparently).
I didn’t say that doctors, nurses and social workers are low skill, ancillary workers are however.
Low skilled, low paid workers in service industries will work unsociable hours, have little chance of advancement, will be carers themselves and they will struggle to find affordable childcare. More importantly they will likely have much poorer health and will rely heavily on the NHS.
It appears that’s what business wanted, working out well isn’t it.
Progress. That’s good.
I’m not sure 20years, but depends on industry. I suspect we’ll always need some given declining birth rate, but we agree could and should be much less. But that’s down to us to vote for those who don’t just amplify the rage about it but actually have a coherent plan to reduce the reliance.
Yes. Absolutely.
Mass immigration enriches the middle class by pauperising blue collar people. The ‘ideology’ is just false consciousness at work – no-one, and certainly not anyone like O’Donnell or Portes wants to admit, even to themselves, that their motive is essentially greed.
O’Donnell and Portes saw mass immigration as a tool towards utilitarianism, where in fact like you say, it had the opposite effect by enriching the middle classes and pauperising blue collar workers, creating “neo feudalism”.
Out of interest were those two ever in power?
That’s the thing JW…. they weren’t! Civil Servants do not come up with ideological policy. O’Donnell thought it was his duty to undertake utilitarianism. Shame he never had electoral consent.
Yes – and they still are.
Yes, the arguments are paper-thin—rely entirely on invoking the spectre of “racism.”
There’s no need for mass immigration for anything to function. Take food—I love Mexican and Japanese, yet we have hardly any Mexican or Japanese immigrants. So you don’t need open borders for ‘multiculturalism’.
As for the NHS, it’s a circular s**t spiral. Mass immigration creates the need for even more mass immigration to service the last wave. Worse, in the rush to fill roles, standards collapse. Vetting is non-existent, and enforcing standards is considered “racist”—people with dodgy or outright bogus qualifications get in. The results are obvious.
As for care homes—a dystopian hellscape for old European natives.
Good article . Couple of additional points – these healthcare staff put huge upward pressure in rent in towns and cities all over UK and ireland. Where i live ( ireland) rents are unaffordable for many . Healthcare workers have good pay ( out of taxation, borrowing) and often secure employment. As tenants they are ideal. But it is another way for landlords to shaft ordinary workers. This is a point i want to make while noting the hard work of migrants in hospitals. The upshot is enrichment of landlords at the expense of workers and is unspoken about.
Another point is Boris Johnson is again shown to be a pure globalist.
Research the tsunami of robotics that is about to be thrown at social care. Even in the Isle of Man we now offer robot dogs for dementia sufferers to good effect. New solutions to old problens will make a mockery if mass immigration. However, the liabilities of the past 15 years of low skilled arrivals will remain.
When a robot can wipe someone’s backside when they have dementia we’re in business SG?
I suspect you’re are not v conversant with the sort of tasks looking after elderly patients really involves. It’ll remain largely labour intensive.
As a former associate dean of postgraduate medical education I can state authoritatively that the reason for lack of medical manpower is positive discrimination.
In 1998 a decision was taken not to select white males from British schools to train as doctors. It was thought selecting female candidates and those from ethnic minorities would provide balance. Unfortunately, the NHS and general practice in particular , has always relied on white males motivated to work long hours and develop businesses. What we have now is an excess of people who expect family friendly hours and no commitment to management. There are of course some excellent senior clinicians from all backgrounds, but they are a minority.
Rather than assessing enthusiasm and commitment the profession were ordered to appoint on woke criteria alone.
So we have a mess. Clinicians overwhelmed by the workload because they have not been taught to manage a business and prioritise demand. What is needed is a total rethink about selection for medical school and for careers thereafter, unencumbered by woke prejudice.
There is no proof that women are more empathetic or that doctors from ethnic minorities deal better with people from their background. On both these counts there is rank prejudice against white males.
It is time this country appointed people in all walks of life on ability, rather than any faulty preconceptions.
Dr John OrchardFRCGP
The UK has lagged behind its European peers for decades when it comes to healthcare spending, just because we very recently brought it closer to parity doesn’t undo years of underspending.
We could recruit from home but we all know it’s cheaper to do so from abroad. Politicians favour this route because they know full well that high taxes are more likely to lose an election than broken promises on immigration. (although we may be reaching a point where this could flip)
If we want a healthcare system comparable with the continent, and lower rates of migration, we are going to have to be willing to pay for it but good luck getting that manifesto past the public.
We pay more than Italy, Spain, Netherlands and Denmark. Italy only hires Italians. I cant speak for the other countries.
There seemed to be a key point missing from this article. If we don’t have to import health and care staff, but we simply can, then why have we? Why have we chosen that policy route when other countries have not?
And is anybody checking that all those who entered with a Health and Care visa are still working in health and care?
Both our British children (doctor consultant 38; dentist 36) emigrated to Australia after their experiences working for the NHS. In Australia, they are paid overtime for every hour or part thereof of overtime they may be asked to undertake. In the NHS they were expected to work for long extra hours many a day and received zero pay or thanks for their efforts. The doctor/patient ratios in Australia are far better – ditto nurses. They work in modern, well-equipped facilities – and don’t have to pay for car parking! If they are on night call in hospital they are accommodated in decent rooms and given proper food. None of the above happened to them in the NHS. On top of all that, they were subjected to insulting and demeaning DEI requirements imposed by overpaid managerialists.
Who can blame them for going? UK has lost many such fantastic young medics. It’s obvious why.