Lets Rethink HealthCare: Doctors, Demand, and the Cost of Not Planning.

At some point in almost every conversation about the NHS, we end up here:

“Surely the problem is obvious — we just don’t train enough doctors.”

And we’re not wrong.

But the moment we start pulling on that thread properly, we realise it’s tied into almost everything else we’ve already talked about: fragmented responsibility, short political time horizons, quick fixes that look cheap, and a habit of acting surprised by outcomes that were visible years — often decades — in advance.

So let’s slow this down and actually walk it through together.

Demand didn’t suddenly explode

Let’s start by clearing away a myth.

The pressure on the NHS didn’t arrive out of nowhere.

Demand has been rising steadily due to:

an ageing population
more people living longer with chronic disease
expanded diagnostics and treatment expectations
seven-day services
increased regulatory and administrative load per clinician

None of this was unforeseeable. None of it was sudden. And none of it required particularly heroic modelling to anticipate.

It was all visible in demographic data, epidemiology, workforce surveys and international comparisons long before it became a crisis.

The problem was never prediction.

It was acting early enough in a system where training a doctor takes 10–15 years, not one spending review.

So why didn’t we just train more doctors?

This is where the conversation usually gets more complicated than we expect.

Because the honest answer isn’t “because no one thought of it”.

It’s because no single organisation actually owns the problem.

Who decides how many doctors qualify each year?

Most of us assume there must be a body somewhere with a dial marked “number of doctors”.

There isn’t.

Instead, there’s a chain:

the Treasury decides how much money exists at all
the Department of Health decides how much of that goes into training
NHS England funds postgraduate training posts
universities can only train as many students as they’re funded for
the regulator sets standards and licenses doctors — but does not set numbers
the doctors’ union represents its members — but cannot create places or fund them

So when we ask “why didn’t they train more doctors?”, the awkward answer is:

There is no single ‘they’. Responsibility is fragmented, and authority ultimately sits with government funding decisions.

If that feels familiar, it should. It’s the same structural pattern we’ve already seen elsewhere in the NHS.

Didn’t anyone warn about this?

Yes. Repeatedly.

Professional bodies, colleges and workforce analysts warned — publicly and often — that:

the UK had fewer doctors per head than comparable countries
training numbers weren’t keeping pace with demand
reliance on overseas recruitment was growing
and this wasn’t a sustainable long-term position

What they couldn’t do was fix it themselves.

They don’t control medical school places. They don’t fund training posts. They don’t set the budget.

This wasn’t silence.

It was a system where warnings fell into the gaps between institutions.

So how did the NHS cope?

By pulling the fastest lever available.

International recruitment.

And to be absolutely clear — this isn’t a criticism of overseas doctors. They are skilled, committed, and they’ve kept the NHS functioning.

But from a system perspective, how we rely on something matters.

Overseas doctors: not a moral issue, an economic one

Today, roughly 40% of doctors licensed in the UK trained overseas — about double the proportion seen in comparable countries.

That creates a resilience issue we don’t often talk about, because it’s easy to misread.

So we need to be precise.

People who expect to settle long-term in a country tend to:

buy homes
spend locally
raise families
invest in pensions
anchor economically

People who expect to return home — or who face uncertainty about long-term residence — tend to:

remit income overseas
save aggressively rather than spend
delay or avoid housing investment
minimise discretionary consumption

Neither behaviour is “wrong”.

But they have very different economic effects.

Let’s do the back-of-a-fag-packet maths

We’ll keep this deliberately conservative.

We know that around 40% of doctors are overseas-trained, and that not all of them are equally mobile.

So let’s assume — cautiously — that only half of overseas-trained doctors are still in a phase where a meaningful share of income is being remitted or saved to leave.

That’s 20% of the total doctor workforce.

Using current figures, that’s roughly 65,000 doctors.

Now take a deliberately low salary assumption — the basic pay of a newly qualified doctor — even though many earn more.

Call it around £36,000 a year.

That gives a total pay pool of about £2.4 billion per year.

How much of that leaves the UK?

There’s no NHS-specific remittance dataset for doctors, so we don’t pretend there is.

We do ranges.

If that group remits or saves for exit:

10% of pay → about £240m a year
20% of pay → about £480m a year
30% of pay → about £720m a year

That money is not spent in the UK economy.

Not circulating through housing, childcare, cafés, trades, or services.

And then there’s the multiplier

Money spent locally tends to be spent again.

Even a modest local multiplier of 1.3–1.7 gives us:

£240m leakage → £300–£400m of lost domestic demand
£720m leakage → close to £1.2bn of lost demand

So the order of magnitude of the economic impact sits somewhere between:

£300 million and £1.2 billion per year

That range matters, because it sets the scale for what comes next.

So what would it actually cost to train enough doctors?

Before jumping to conclusions, we need to do this properly.

Training more doctors isn’t a one-off bill. It’s a pipeline cost, spread over many years, that only reaches full scale once the system is running steadily.

So let’s break it down.

How many more doctors do we need just to keep up?

Most credible workforce models point to a shortfall that requires around 4,000–5,000 additional UK-trained doctors per year, on top of current output, just to:

stabilise staffing
reduce rota gaps
and meet predictable future demand

That’s not about perfection.

It’s about not permanently running the system on the edge.

What does it cost to train a doctor?

Training a doctor isn’t just tuition fees.

It includes:

medical school teaching
clinical placements
supervision
foundation training
specialty or GP training
and the opportunity cost of senior staff time

When all of that’s added up, most estimates land around:

£200,000–£250,000 per doctor, spread over many years

What does that look like at scale?

If we take:

4,000–5,000 extra doctors per year, and
£200k–£250k per doctor, amortised across the training pipeline

Then once the system is fully ramped, the steady-state annual cost lands at roughly:

£1–1.5 billion per year

Not a spike. A plateau.

That’s the cost of stopping things getting worse.

But that still leaves the built-in deficit

Here’s the step we haven’t been honest about until now.

Everything above only deals with current and future demand.

It quietly assumes that today’s workforce mix is fine.

It isn’t.

Right now, around 40% of doctors trained overseas. That isn’t a short-term fix — it’s the accumulated result of decades of under-training domestically.

If we only train enough doctors to meet new demand, we lock that dependency in permanently.

We stabilise a fragile equilibrium — we don’t fix it.

What does “reducing reliance” actually mean?

This doesn’t mean cutting off overseas recruitment or asking anyone to leave.

It means changing the balance gradually, so overseas recruitment becomes:

a supplement
a resilience buffer
not the load-bearing structure

Comparable countries typically sit closer to 20–25% internationally trained doctors.

If we aimed for something similar over time, that implies an excess dependence of roughly 50,000–70,000 doctors.

We don’t fix that overnight.

But we do need a plan to shrink it deliberately.

What would a realistic repair plan look like?

Not a shock. A glide path.

Suppose we said that over 20–25 years, we want to reduce overseas reliance by half.

That means training an additional:

2,000–3,000 UK-trained doctors per year, on top of what’s needed to meet new demand.

So now the real target becomes:

6,000–8,000 extra UK-trained doctors per year, sustained over decades.

That’s the difference between stabilising the system and repairing it.

One more thing we should be clear about

At this point, it’s worth spelling something out explicitly — because it often gets muddled.

This isn’t about a lack of willingness.

It’s not that UK citizens don’t want to be doctors.

It’s that they aren’t given enough training places to become them.

Every year, large numbers of well-qualified UK applicants are turned away from medical school, not because they wouldn’t make good doctors, but because the system has capped places for decades.

So when we talk about “reducing reliance on overseas doctors”, what we’re really talking about is replacing unmet demand with domestic opportunity.

Let’s put some numbers on that.

How many additional UK doctors does the plan actually create?

From earlier, we said a serious repair plan looks like:

6,000–8,000 additional UK-trained doctors per year
- 4,000–5,000 to meet rising demand
- 2,000–3,000 to unwind the inherited deficit

Those are net additions, sustained over time.

Over a 20–25 year horizon, that translates into:

120,000–200,000 additional UK-trained doctors in the workforce
(allowing for retirements and normal churn)

In other words:

Well over a hundred thousand additional UK citizens, in skilled, well-paid, socially useful jobs — who currently never get the chance.

And that’s before we count:

nurses
allied health professionals
educators
supervisors
and the wider employment supported by training infrastructure

So this isn’t just a healthcare fix.

It’s a long-term employment and skills policy that we’ve been quietly not running for decades.

Why this matters politically as well as economically

Once we see it this way, another misconception falls apart.

We’re often told shortages exist because “people don’t want these jobs anymore”.

But medicine remains hugely oversubscribed.

The bottleneck isn’t motivation.

It’s training capacity.

So when we import labour to fill gaps created by our own caps, we’re not correcting a labour shortage — we’re working around a policy choice.

That’s an important distinction.

What does that do to the cost?

We already said training costs roughly £200k–£250k per doctor.

Adding another 2,000–3,000 doctors per year increases the steady-state cost by around:

£400m–£750m per year

So the full, long-run investment becomes:

£1.5–2.25 billion per year

Put that in context:

£55–£80 per household per year
£5–£7 per month
roughly ¾–1p on the basic rate of income tax

For a plan that:

reduces churn
increases retention
strengthens supervision
lowers agency spend
and keeps more economic value circulating in the UK

This isn’t spending more forever.

It’s spending now to stop paying forever.

But don’t UK-trained doctors leave as well?

Yes — some do.

The difference is pattern, not purity.

Most UK-trained doctors spend the bulk of their careers working in the UK. A minority go abroad — often for fellowships or short-term work — and many return.

Crucially, when UK-trained doctors leave, they tend to do so later, after years of UK work, tax, and local spending.

That’s very different from a system where a large share of the workforce arrives already intending to be mobile.

So while doctor mobility exists in both directions, the flows are not symmetrical — either in scale or in economic impact.

And yes — training posts are the bottleneck

At this point we usually say:

“Fine — but we can’t just train more doctors if there aren’t the posts.”

That’s true.

The real choke point isn’t just medical school places. It’s postgraduate training posts and the senior capacity to supervise them safely.

But this is also where the virtuous cycle appears:

train more doctors →
more stay →
more become senior clinicians →
more supervision capacity →
more training posts

Right now, we’re stuck in the opposite loop.

And then there’s the private health sector

Private healthcare doesn’t cause this problem — but it amplifies it.

Private providers don’t train doctors. They recruit from the same finite pool.

When supply is tight:

private providers can outbid the NHS for marginal hours
doctors respond rationally with portfolio careers
the NHS experiences hollowing-out rather than clean exits

The NHS carries the cost of training and supervision.
The market extracts capacity once shortages exist.

That asymmetry matters.

“But doesn’t private healthcare take pressure off the NHS?”

Sometimes — at the margins.

But only if there’s spare workforce capacity.

In a constrained system, private provision mostly reallocates staff time rather than creating new care. The pressure doesn’t disappear — it just moves.

So private healthcare isn’t inherently the problem.

Private healthcare in a system that under-trains its workforce is.

One last belt-and-braces question: will this still work in 50 years?

If we’re honest, this is the question that matters most.

The population will keep ageing. The 85+ group will grow fastest. Demand will rise with complexity, not just headcount.

So this only works if we design it as a self-correcting system, not a one-off fix.

That means:

planning to ratios, not headlines
recalibrating every few years
keeping demand-growth and deficit-repair as separate tracks
treating training and supervision as core infrastructure
and not relying on miracle productivity gains

If we do that, overseas recruitment remains a buffer, not a crutch.

And that’s the difference between stability and resilience.

So what’s the real takeaway?

It’s not just that:

“We’re already paying for the shortage.”

It’s this:

We’re paying twice — once for care, and once for our failure to plan — and we’re doing it every year.

A stable NHS doesn’t just meet demand.

It repairs its foundations and carries itself forward, generation by generation.
It needs long-term engineering, not short-term renovation.

Demand didn’t suddenly explode

So why didn’t we just train more doctors?

Who decides how many doctors qualify each year?

Didn’t anyone warn about this?

So how did the NHS cope?

Overseas doctors: not a moral issue, an economic one

Let’s do the back-of-a-fag-packet maths

How much of that leaves the UK?

And then there’s the multiplier

So what would it actually cost to train enough doctors?

How many more doctors do we need just to keep up?

What does it cost to train a doctor?

What does that look like at scale?

But that still leaves the built-in deficit

What does “reducing reliance” actually mean?

What would a realistic repair plan look like?

One more thing we should be clear about

How many additional UK doctors does the plan actually create?

Why this matters politically as well as economically

What does that do to the cost?

But don’t UK-trained doctors leave as well?

And yes — training posts are the bottleneck

And then there’s the private health sector

“But doesn’t private healthcare take pressure off the NHS?”

One last belt-and-braces question: will this still work in 50 years?

So what’s the real takeaway?

Further reading / evidence (for transparency)

Population & ageing

Healthcare demand & demographics

Doctor supply & international comparison

Medical training capacity

Migration & overseas doctors

Remittances & economic flows

Economic methodology

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