Chalk up another win for UK Plc and our world-class service economy: according to new research from the Health Foundation, one of our major exports (medical professionals) is on the upswing. Not only do we furnish expensively-trained home-grown doctors and nurses to countries such as Australia and the United States, but we are now re-exporting immigrant labour too:
‘The number of UK-registered nurses moving to other countries doubled in just one year between 2021-22 and 2022-23 to a record 12,400 and has soared fourfold since before the coronavirus pandemic.’
‘Seven out of 10 of those leaving last year – 8,680 – qualified as a nurse somewhere other than the UK or EU, often in India or the Philippines.’
This development should not come as a surprise. The factors driving it are exactly the same as for native-born workers: there is strong demand in other countries for medical labour, and workers in this sector are increasingly mobile – especially those who have already uprooted themselves once to come to Britain in the first place.
It’s also yet another startling indicator of the United Kingdom’s changing position in the world economy. Where the aforementioned Anglosphere nations remain the apex consumers, as we might expect of first-world economies, in healthcare, Britain is shifting into an orbital position that services those economies.
Worse still, this is at our expense. Contra my flippant introduction, and unlike an actual export industry, there is no benefit to the British economy or people in having medical staff poached like this.
For domestically-trained staff, it means we miss out on the bulk of the potential return on investment for their very expensive, and heavily subsidised training. For immigrant workers, the price of becoming a ‘stepping-stone’ is that we will increasingly struggle to replace that lost investment even with imported labour, becoming instead a training ground for younger workers of intermediate skill and experience.
This should set alarm bells ringing in Whitehall. To date, the complacent view of many policymakers (including the Treasury) is that however much the public might grumble, we will always be able to meet the needs of the Exchequer and our public services with sufficient levels of mass immigration; however sketchy our economy gets, there will always be parts of the world much poorer than us.
Yet the Health Foundation report raises the bleak possibility of the UK becoming a country that simultaneously depends on the mass import of labour and then re-exports a growing share of the most skilled and productive workers, whilst retaining those unwilling or unable to further relocate to more competitive (and more selective) economies.
How did we get here? The obvious answer is NHS pay; medical staff can earn substantially better salaries in Australia, New Zealand, and the United States, and the benefits are compounded by a lower cost of living (most obviously, escaping our housing crisis).
Parts of the Left will argue that this is simply fresh evidence that the Health Service needs to be ‘properly funded’. But taxes are at historic highs, and it’s telling that Labour is refusing to sign up to any major cash injection for the NHS. Other countries that spend a higher proportion of GDP on healthcare have mixed systems that incentivise personal spending and use it to cross-subsidise public provision; in Britain, most private health spending (of which there is plenty) circulates in a parallel and largely separate system.
The other obvious culprit is once again our self-indulgent fixation on standards at the expense of supply. As I have written elsewhere, the NHS is dependent on immigrant labour in no small part because the supply of domestic medical staff is extremely restricted, and it is so because training them is extremely expensive and the state picks up most of the tab.
Obviously, to a great extent the need for training is an unavoidable fact – few people would knowingly roll the dice on a cheap but ill-trained doctor. But in other areas, such as nursing, it is an entirely self-inflicted wound: senior nurses continue to write scathingly about the Thatcher Government’s decision to bow to pressure from unions and make theirs a degree profession:
‘But the national training was lost when nursing leaders persuaded the reluctant Thatcher government to move nurse education into higher education. They were motivated by a desire to increase the status of the profession – not to improve patient care. This was calculated by the National Audit Office in 1992 as £580m for extra staff to do work previously done by students (now supernumerary) and £207m to support colleges introducing the new system.’
Previously, new recruits joined the NHS at the bottom and provided plentiful labour whilst getting on-the-job training. That work still needs doing, but must now be performed by a new class of paid menial staff; trainee nurses, meanwhile, must now complete a three-year academic qualification before they can get an NHS training placement.
Even to the extent that such training must be paid for, however, it is remarkable how badly we go about it. Despite each being the recipient of enormous public subsidy, medical graduates are given free rein to bank the benefits of their degree as a private good, either by taking up work in the private sector or going overseas. (However, it must be noted that the state isn’t entirely to blame, after all, medical unions have historically voted to restrict numbers of medical students).
The obvious case for state subsidy of medical training is that those who benefit deliver return on that investment by labouring for the public benefit. In our current setup, that largely means the NHS. Yet there is no effort to make the investment contingent on the payoff – graduates who take themselves overseas don’t even have to pay back their student loans, which themselves are only a small part of the total public investment their degree represents.
In that context, it isn’t surprising that the Government is chary about the number of medical places it lays on, preferring instead to make up the shortfall by importing staff from overseas.
But this only compounds the broader problem in higher education of capped fees making domestic students a loss-making proposition. In keeping with the finishing-school phenomenon the Health Foundation identifies amongst working professionals, British applicants are increasingly finding themselves locked out of British medical schools, which prefer to cater to much more lucrative overseas students.
All of this is yet more evidence that the head-in-the-sand attitude of British policymakers – primarily that any and all problems, from regulatory fetishism to the birthrate, can be palliated with sufficient transfusions of immigration – is running out of road. There is not, in fact, a viable long-term alternative for recruiting, training and retaining this country’s own workers, and doing the hard work of building systems and services which make that possible.
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