Our forever failing NHS

Is it a good idea to rely on foreign recruits to staff your military? 

The instinctive answer, to anyone with any sense, is no. A cursory look at the historical record of nations that have relied on foreign soldiers tells you to trust your gut; Rome provides the clearest warning. As civic duty withered, the legions were filled with foreign foederati, armed communities settled inside the state rather than citizens defending it. The Roman provincials, wrote Gibbon:

… congratulated their masters on the powerful accession of subjects and soldiers; but they forgot to observe that multitudes of secret enemies, insolent from favour, or desperate from oppression, were introduced into the heart of the empire.

Carthage made the same error commercially, outsourcing war to mercenaries who promptly turned on the city when the money ran out. The Abbasids imported Turkish soldiers to escape internal weakness, only to discover that a state dependent on outsiders for force soon becomes dependent on them for permission to rule. The Ottomans’ Janissaries followed the same trajectory: effective, entrenched, then politically obstructive, requiring violent abolition. Different civilisations, same outcome: once a people surrender their swords, they eventually surrender the state. 

The Armed Forces are unusual amongst our public services in not already relying on Human Quantitative Easing to keep it afloat. Even so, the Armed Forces are not entirely exempt, having long supplemented domestic recruitment with foreign “warrior races” — the Gurkhas — and Commonwealth soldiers, especially from Nigeria and Fiji.

There are plans to expand this, however, and in doing so loosen the ties of our soldiers to our nation. Despite the terrible record of the “Wallacewave”, the refugees settled under the Afghan resettlement programme, campaigners are urging the UK government to allow Afghan special forces veterans who resettled in the UK after the Taliban takeover to join the Army. These campaigners, who include former security minister Tom Tugendhat, argue that strict citizenship rules — which mean ex-Afghan fighters cannot join until they have been in the UK long enough to naturalise — are wasting a pool of highly skilled, loyal recruits. The Ministry of Defence says Afghan exiles can apply for military roles once they become citizens and meet standard criteria.

Aside from the added danger of access to military hardware, reliance on foreign labour is endemic within our public services. Prisons are increasingly reliant on West African recruits, many of whom can barely speak English — and accidental reseals have spiked 128 per cent since last year. Education is likewise being outsourced to the lowest bidder, as teachers from abroad can be paid less than domestic recruits and a given a resettlement bonus when joining — whilst domestic recruits receive nothing.

Perhaps as damaging a policy as staffing our military with foreign recruits is staffing our health service with them.

It is a well-worn pro-immigration trope that the NHS would collapse without immigration (which is why we are so fortunate so many Channel migrants say they want to become doctors) and it is true that the workforce does include many foreign recruits. The Telegraph recently reported that “Britain relies on twice as many foreign doctors as most Western countries”. The UK is an international outlier of staggering proportions. An OECD study found that 38.3 per cent of Britain’s doctors were trained overseas in 2023, nearly twice the international average of 19.6 per cent. GMC figures show the share has since risen to 42 per cent, compared with just 15 per cent in Germany and just 11 per cent in France.

Britain now imports over 20,000 foreign-trained doctors each year while its own graduates are squeezed out of training and career pathways. This is not accidental. In October 2019, medical practitioners were added to the Shortage Occupation List, exempting the profession from the Resident Labour Market Test. Hospitals were no longer required to offer roles to UK citizens first, or to demonstrate that no suitably qualified British doctor was available, before recruiting from abroad. The result has been predictable: intensified competition, displaced domestic graduates, and a workforce increasingly sustained by importation rather than training.

But when it comes to staff, quantity and quality are two very different things. A recent report noted that foreign-trained doctors are sometimes viewed by colleagues as holding “not as good medical qualifications”. Their perceptions are backed up by the evidence; research suggests that half of foreign doctors are not fit to practise in the UK, and a disproportionate number of internationally-trained doctors are being reported for bad conduct.

The NHS recognises this as a weakness. In its Long Term Workforce Plan, it warns that reliance on foreign-trained staff leaves the service dangerously exposed to “future global shocks and fluctuations in international workforce supply”. Yet it simultaneously acknowledges that the habit cannot be broken without serious expansion and investment in domestic training — a commitment successive governments have been unwilling to make. There has been no serious or significant commitment to meet it’s targets, even after Wes Streeting last year condemned the NHS for leaning too heavily on foreign-trained staff and pulling “the immigration lever” too readily.

With an ageing population, our need for doctors is only set to increase. Yet without increases in domestic training capacity — a decision that requires major investments of both political and financial capital — and a re-prioritisation in favour of British trained doctors, we are only setting ourselves down the path of even greater reliance on sub-standard doctors. Perhaps we, like the Romans, will become a historical warning for others.