Migration Watch UK
7 April, 2023
1. Medicine is amongst the UK’s most popular higher education course categories attracting tens of thousands of applicants every year who compete for 7,000 limited places in England and around 1,900 places in the rest of the UK.
2. However, the number of places has not kept up with the increasing demand for doctors within the NHS. As a result, the government have stepped up recruitment of doctors from abroad which has led to a significant increase in the proportion of overseas-trained doctors working for the NHS.
3. This briefing will consider: the number of UK and foreign medicine graduates; what impact this has on the NHS; and what can be done to increase the number of UK-trained doctors and reduce the increasing reliance on recruitment from overseas.
4. Between 2016 and 2022, an average of 37 per cent of Hospital and Community Health Services (HCHS[2]) doctors have come from overseas each year. In 2021 and 2022, this figure rose to 44 per cent.
Table 1: HCHS doctors by nationality joining the NHS, year ending December 2020-2022, year ending June 2016-2019[3]
| 2016 | 2017 | 2018 | 2019 | 2020 | 2021 | 2022 | |
|---|---|---|---|---|---|---|---|
| All nationalities | 17,950 | 19,164 | 19,524 | 21,670 | 23,657 | 23,652 | 26,321 |
| UK | 11,875 | 12,351 | 12,312 | 12,873 | 14,290 | 13,176 | 13,516 |
| Non-UK total | 5,327 | 6,072 | 6,222 | 8,125 | 8,810 | 9,903 | 12,148 |
| Of which: EU/EEA | 2,212 | 2,252 | 2,036 | 2,113 | 2,077 | 1,940 | 1,955 |
| Of which: rest of World | 3,115 | 3,820 | 4,186 | 6,012 | 6,733 | 7,963 | 10,193 |
| Proportion of non-UK joiners of the total (%) | 30 | 32 | 32 | 37 | 37 | 42 | 46 |
5. This increase in overseas doctors joining the NHS was clearly deliberate. Skilled workers, including doctors from outside the EU/EEA, used to be capped at 20,700 per year. In 2018, however, following lobbying from various groups, including former Health and Social Care Secretary Jeremy Hunt and former Home Secretary Sajid Javid[4], doctors were removed from the work permit cap of that time.[5] Since then the number of doctors coming from outside the UK or EU/EEA has increased by 143 per cent, from 4,186 in 2018 to June to 10,193 in 2022 to December.
6. An alternative set of figures, however, indicates the proportion of new doctors who trained overseas is higher still. Looking at the number of first registration doctor applications granted by the General Medical Council in 2022, for instance, shows that 63 per cent of applications to register were granted to individuals who gained their Primary Medical Qualification outside of the United Kingdom.[6] Unlike NHS joining figures as detailed in Table 1, this includes local General Practitioners (GPs), doctors working for private healthcare companies and those potentially not currently practicing at all. It will also involve UK nationals who gained their accreditation abroad.
7. Comparison of the number of overseas doctors recruited each year (see Figure 1 below) alongside the number of students enrolling onto medical training shows that in almost any given year a higher number of overseas doctors are being recruited than UK students are being accepted for training. Although not strictly comparable, due to student data being for the year ending August while the recruitment data is for the year ending June, this is nonetheless highly indicative of the trend of overseas recruitment outstripping domestic education.
Figure 1: Comparison of UK-domiciled medical students enrolled[7] in English medical schools and overseas HCHS doctors joining the NHS in England, 2016-2022.[8]
8. The growing tendency to recruit overseas largely stems from a failure both to train a sufficient number of doctors in the UK and to anticipate the increased demand resulting from a burgeoning population driven by immigration. According to the British Medical Association (BMA) the UK is short of 46,300 doctors in England alone.[9] Other analyses have identified a need for between 5,000 and 11,000 extra medical trainees per year to close the shortfall.[10],[11]
Figure 2: Outcomes for UK-based applicants of medicine courses 2019-2022 - UCAS[12]
9. Notwithstanding the greater need, large numbers of would-be medical students are being turned away every year from medical courses for which they may be qualified, yet for whom limited capacity allows no space. In 2022, there were 19,235 UK applicants to study general medicine, a 25 per cent increase on 2020. Of these, 9,050 were accepted onto courses while 10,185 were turned away.
10. This has seen the acceptance rate plunge from 63 to 47 per cent in the space of just two years.
11. The high rejection rate is the result of the funding cap on government-funded medical training places which, in 2017, the government said cost £165,000 each (excluding student loans).[13] The official position is that numbers are capped to maintain high standards within funding constraints.[14] This policy leaves high numbers of students without a place at a medical school. As Consultant Surgeon J Meirion Thomas has said: “Tens of thousands of students with the required A-level grades and aptitude have failed to gain entry to our medical schools because places are strictly limited by cost.”[15]
12. One Member of Parliament, Anthony Browne MP, recently remarked that the majority of Bulgarian-trained doctors in Britain are not actually Bulgarian, but British graduates who had no option but to get training abroad thanks to the low training capacity.[16]
13. Table 2 below shows the total number of medical and dental students enrolled by domicile over the past decade. It shows how gradually the number of students paying ‘Home’ fees (including EU students prior to 2017-18), who are subsidised by the government, have increased very slowly over time with a temporary uplift from 2020-21 to 2021-22. It also indicates the upper limit of how many medical students can be trained in current facilities. Figure 2 below, displays the total of students paying Home fees.
Table 2: Total medical students enrolled by fee status and domicile, 2012-2022[17]
| Year | Home students (incl. EU to 2016-17) | Overseas Students | Grand Total | |||||
|---|---|---|---|---|---|---|---|---|
| Total (excl. EU) | England | Northern Ireland | Scotland | Wales | EU | |||
| 2012-13 | 6,470 | 5,420 | 45 | 670 | 335 | 535 | 805 | 7,810 |
| 2013-14 | 6,310 | 5,315 | 35 | 630 | 330 | 535 | 715 | 7,560 |
| 2014-15 | 6,325 | 5,315 | 50 | 625 | 335 | 505 | 810 | 7,640 |
| 2015-16 | 6,250 | 5,170 | 75 | 665 | 340 | 530 | 735 | 7,515 |
| 2016-17 | 6,285 | 5,215 | 50 | 680 | 340 | 565 | 710 | 7,560 |
| 2017-18 | 6,890 | 5,460 | 230 | 825 | 375 | - | 770 | 7,660 |
| 2018-19 | 7,655 | 6,120 | 230 | 920 | 385 | - | 850 | 8,505 |
| 2019-20 | 8,455 | 6,885 | 235 | 955 | 380 | - | 910 | 9,365 |
| 2020-21 | 9,280 | 7,570 | 265 | 1,050 | 400 | - | 1,060 | 10,340 |
| 2021-22 | 9,535 | 7,690 | 350 | 1,085 | 410 | - | 965 | 10,500 |
| 2022-23 | 8,945 | 7,015 | 300 | 1,205 | 425 | - | 875 | 9,820 |
14. Between 2018 and 2020, the cap in England permanently rose by 25 per cent from 6,000 to 7,500.[18] However, this was partly due to a fall in students from Europe after the UK’s departure from the EU (who were previously treated the same as British students). In 2020 and 2021 the cap was temporarily increased further to over 9,000, only to be re-imposed at 7,500 in 2022. Commenting, the then-Education Secretary James Cleverly initially blamed the difficulty of increasing capacity before later admitting that funding was the main issue.[19]
Figure 3: Total no. of UK-domiciled medical students enrolled in English medical schools 2012-23[20]
15. As may be inferred from what happened in 2020-21 and 2021-22 when 800-1,000 more places were funded each year than 2019-20, it turned out that training capacity was actually higher than funding had previously allowed. In 2021-22, for example, the cap on the number of British students was raised and medical schools ran at (what appears to be) capacity. That medical schools were able to take on 1,000 more students without apparent difficulty indicates that real capacity was and is greater than funded capacity. In 2021-22, across the UK, there were a total of 9,535 British students enrolled on medical courses, as well as 965 overseas students. If the cap were to be permanently raised to this level of capacity, that would result in 590 more British students enrolled this year.
16. If, in addition, places allotted to overseas students were allocated instead to British students, that would mean approximately a total of 1,500 more places for ‘Home’ students per year. This is a low-end estimate as there may yet be further unidentified excess capacity, such as at the new Chester University Medical School whose 50-100 places, all designated to overseas students,[21] are not included in Office for Students targets for 2022-23.[22]
17. The same is true for similar new establishments at Worcester and Brunel universities, the latter of which will train over a hundred international medical students.[23] A notable irony exists in the case of Three Counties Medical School at the University of Worcester in having been founded with the explicit intention of addressing local medical needs.[24] Despite this, like many universities they have been strictly ordered by government not to train more/any UK-born medical students.[25]
18. Such an approach would be entirely in line with the consensus reached outside government. Raising the cap and trying to train an adequate number of UK-based doctors is agreed with by the Royal College of Physicians,[26] the British Medical Association[27] and the Migration Advisory Committee,[28] the latter having said: “[We have] consistently emphasised the need to raise British human capital and thereby lessen employer dependence on immigration.”
19. A further policy change that would increase the supply of doctors, thus reducing the need for additional doctors from overseas, would be to end the ‘pension tax trap’ for doctors.[29] At present, because the pensions lifetime allowance has been frozen, many doctors are hitting the annual cap on pension contributions and finding that their tax bill is increased as a result, in some cases to the extent that they are effectively not paid for overtime shifts. This penalises certain levels of work and so has led to doctors working fewer hours or retiring altogether.
20. The government has sought to address this in the Spring Budget, which is scrapping the lifetime allowance, to encourage workers, particularly doctors, to work up to the retirement age.
21. An additional area of contention is whether workforce management is being hampered by the differing work preferences of male and female doctors. The proportion of female doctors to male doctors have reversed in recent decades. For example, just 27 per cent of registered doctors aged over 60 are women, while in the 25-29 age group it is 56 per cent.[30] According to one surgeon, this creates problems in the workforce as female doctors are less likely to specialise and prefer roles with a better work-life balance.[31] Data from the Office for Students shows that 62 per cent of medical students enrolled in 2022-23 are female.[32]
Conclusion19. This paper shows that despite tens of thousands of UK medical applicants being turned away every year and widespread agreement that the UK has a significant doctors’ shortage, Britain has failed to adequately increase funding for medical places. This has left the NHS with little immediate option but to attract doctors from poorer countries with greater health needs. At the same time, harmful taxation policies unintentionally encouraged some doctors to reduce their working hours and others to retire early. By scrapping these tax measures and funding medical training places to capacity, the UK could make significant progress towards addressing the doctors’ shortage.