Immigration, Underinvestment, and the NHS Crisis: A Political Economy of Necessity

The UK’s National Health Service is in the grip of a deep and enduring workforce crisis. As of 2023, over 110,000 vacancies remained unfilled across the system, placing intolerable pressure on existing staff and undermining the quality and continuity of care. But crucially, the narrative that immigration is a political choice — part of a liberal “diversity drive” — misses the economic and structural necessity of migrant labour in an underfunded and de-skilled healthcare system.

This is not about ideology. It’s about survival. International recruitment is structural necessity, not a liberal preference. Roughly one in four NHS workers is now recruited internationally — far higher than the 5–10% long considered ideal for workforce stability. This is not accidental. It reflects a precipitous decline in UK-based health training, with domestic trainees falling from over 70% to below 50% in just over a decade. Much of this can be traced to policy decisions:

The removal of nursing bursaries in 2016, which led to only a fraction of the anticipated increase in training uptake. A collapse in EU recruitment following the Brexit referendum (a 90% drop by 2018). Longstanding pay caps and punitive pension limits which deter training and retention.

These measures were framed as efficiencies — but their result has been to drive reliance on cheaper international labour. Minority ethnic workers are now over-represented in the NHS not due to diversity policy, but due to structural dependency produced by austerity.

The points-based immigration system — often presented as meritocratic — has lowered salary thresholds and removed the immigration health surcharge (IHS) for NHS roles. This is a tacit admission: we need migrant workers more than they need us.

Despite political scapegoating, migrants make a net contribution to the UK economy. A 2019 report found they pay more in taxes than they consume in services — including healthcare. Meanwhile, over 50% of UK-born adults aged 65+ live with two or more chronic conditions. This group — while in obvious need of care — contributes to the overwhelming majority of NHS usage:

40% of hospital admissions

50% of delayed bed discharges

This is the demographic reality: a growing, ageing population born in Britain, dependent on care provided disproportionately by workers born outside it. The truth is that immigration sustains public health infrastructure — it does not strain it.

NHS Trusts saddled with PFI debt continue to require government bailouts. Long-term workforce planning is based on optimistic projections, not material commitments. Training systems rely on a university model that burdens trainees with debt and offers little job security in return.

This is not a failure of planning — it’s a result of ideological commitment to austerity, cost-cutting, and private sector entanglement. The fact that immigrant labour has been essential is a symptom of a failing domestic system, not its cause.

What we need is not tighter borders, nor "smarter" immigration — but a democratic workers’ movement capable of demanding sustained public investment, fair pay, and a return to training systems that treat health workers as people, not units of labour.

Calls for managed immigration within the NHS are meaningless unless accompanied by a political commitment to reinvest in domestic training and dismantle the for-profit logic that has gutted the system. Immigration is not a problem — it is a stopgap made necessary by the systematic withdrawal of state responsibility.

Until we name the real issue — the commodification of care and abandonment of public investment — the NHS will continue to depend on migration to plug holes punched by policy.