How to pay for the National / International Health Service?

John Narayan

Neoliberal Britain is in trouble. Faced with the legacy of underinvestment and wage freezes after a decade of austerity and the inflation driven current cost of living crisis, workers across Britain’s quasi-public sector have embarked on industrial action not seen for forty years – with more workers prepared to act collectively and, importantly, with the public largely supporting such action.

Central to this return of class politics has been the context of the National Health Service (NHS) – which has seen the public move from clapping NHS workers during Covid to clapping NHS workers on picket lines during strikes. In reaction to a decade of relative underfunding, declining pay and a system at breaking point, nurses, junior doctors and ambulance staff have embarked on historical waves of strike action.

Writing about the Royal College of Nursing embarking on strike action in December 2022, the economist James Meadway made a sensible argument that, given its aging population and Covid induced backlogs, the UK couldn’t afford not to pay nurses properly if it wanted an NHS that functions. Given the figures of settling the dispute with nurses ranging from £2.6-10 billion, Meadway proposed two ways forwards.

1) an expansion of borrowing that would see all taxpayers foot the bill with the premise of growing the economy

2) equalising the rate of capital gains tax with income tax to raise around £16 billion as a possible solution to the impasse over pay and working conditions for nurses.

These debates are crucial as they rightfully put into focus the pay and working conditions of key workers within society – and set out a relationship between taxpayer, service user and workers within the NHS that maps onto broader debates about taxation and income and wealth inequality in British society.

Yet, what I want to suggest in this piece is that simply seeing the current confrontation of NHS workers with their state employers over pay and conditions as a national debate about funding and taxation obscures how such a national service has been and continues to be paid for, at least in part, by others far beyond Britain.

In our 2020-piece Brexit as heredity redux: imperialism, biomedicine and the NHS in Britain, my co-authors and I reflected on the role of the NHS in the Brexit debates – both on and beyond the now infamous red bus and its £350 million promise for the NHS. Part of our argument was that ideas for Brexit often racialised the idea of the welfare state and its constituent parts, such as the NHS. These debates delimited those deserving or non-deserving of treatment whilst whitewashing how the history of empire was key to the NHS and erasing the NHS’s current forms of imperialist extraction of human capital from nations in the Global South.

There is a global shortage of healthcare workers. The World Health Organisation (WHO) estimates a projected shortfall of 10 million health workers by 2030, mostly in low- and lower-middle income countries. Britain’s links to its former empire and its status as a ‘developed economy’ allows the NHS to extract migrant labour to mitigate the lack of investment and planning to produce its own healthcare workers.

For example, 7 of the top 12 suppliers of foreign doctors for the NHS in England are former British colonies or protectorates such as India, Pakistan, Egypt, Nigeria, Ireland, Sudan and Sri Lanka. This is also apparent across nursing where India, Ireland, Zimbabwe, Nigeria and Ghana make up 5 of the top 12 suppliers of foreign nurses.

Such ‘brain drain’ from the Global South leads to a significant inability of poorer countries to provide their own domestic healthcare and reinforces exploitative economic relations between richer and poorer countries. In effect, this creates an imperialist set of relations where poorer countries in the Global South subsidise richer countries in the Global North –  and health systems like the NHS – by paying for the education and training of their immigrant healthcare professionals often at the detriment of their own health systems.

A good example of this was Sierra Leone, one of the world’s poorest countries. At the height of the Ebola crisis in Sierra Leone (2013–2015), which was hastened by the country’s lack of trained staff, the NHS employed 27 doctors and 103 nurses trained in Sierra Leone. This amounted to around 20% and 10% of the number of the doctors and nurses to be found in Sierra Leone itself at the time. This was compounded by the fact that Sierra Leonean trained doctors and nurses employed by the NHS amounted to Sierra Leone providing a financial subsidy to the UK in the region of £14.5–22.4 million.

Outlining the imperial dimensions of NHS recruitment is important to confronting false narratives engendered by Brexit and state racism about who was paying for and who should have access to the NHS. What we showed was that the divide between the NHS, its service users, and taxpayers was not confined to the UK, but opened into wider debates about how the international community – or rather some of the poorest states on the planet – were partly paying for and subsiding our most quintessential ‘British’ state institution.

Since Covid-19, and the unfolding of Brexit’s impacts on the labour market and immigration, the conditions that engender such an imperial transfer of human capital and subsidy to the NHS and Britain have deepened. There has been an acceleration of international health worker recruitment since the pandemic and increased movement of health care workers from poorer to richer countries as workers seek better renumeration and working conditions.

The WHO Health Workforce Support and Safeguard List identifies 55 countries as ‘vulnerable’ with an insufficient availability of health workers required to achieve the UN Sustainable Development Goal target for universal health coverage (UHC) by 2030. These countries have a health workforce density below the global median: 49 medical doctors, nursing and midwifery personnel per 10,000 people. The WHO recommends that such health systems are strengthened partly through limiting active international recruitment of workers in listed countries by developed healthcare systems.

At home, the NHS has seen an acceleration of international health worker recruitment. Research by the Nuffield Foundation has shown that the decline in EU staff recruitment in the NHS has been compensated by increased recruitment from the rest of the world. Although this hasn’t solved the NHS’s recruitment issues – with many specialist roles remaining unstaffed – there has been a shift in the make-up of the foreign work force of the NHS.

A good example of this has been nursing, which has been subject to the 2019 electoral commitment by the Conservative government to increase the number of nurses by 50,000 (full-time equivalent) by the end of 2023/24. Within nursing, EU and EFTA nurses and health visitors have decreased by 28%, from 38,992 to 28,007 between September 2016 and September 2021, whilst those from the rest of the world have increased from 67,055 to 97,731. To put this into context, a near 11,000 loss in EU nurses, has been accompanied by an increase of around 30,000 nurses from the rest of the world.

The NHS follows The Code of Practice for International Recruitment – which produces a  list of ‘red’ and ‘amber’ countries based on the aforementioned WHO Health Workforce Support and Safeguard List. Yet, due to the engrained flows of people from its former colonies and a decentralised form of recruitment in the NHS the current influx of nurses into NHS has often contravened this system.

The Nuffield Trust reported that in the six months to September 2022, more than 2,200 (20%) of new international nurses came from just two red list countries: Nigeria and Ghana. By the end of 2022 more than 1200 nurses from Ghana joined the UK’s nursing register and in the year to March 2023, the figure for Nigerian nurses has reached nearly from 3,500.

In addition to this, the UK government has developed bilateral agreements with red list countries like Nepal and Ghana that appear to offer a path for the NHS to actively recruit nurses from red listed countries. The latter agreement even appears to include a payment of £1000 per nurse.  What is clear here is that even at it breaking point the NHS continues to be propped up by unequal transfers of labour and capital from the Global South.

The current wave of strike action in the NHS has rightfully questioned neoliberal orthodoxy on the welfare state, income inequality, and issues such as funding and taxation. But the reality of the extraction of human capital into the NHS raises genuine questions about nationally focused tax-based solutions. The need to raise or redistribute tax revenue to alter the working and living conditions of those working in the NHS, such as nurses, should not be questioned or turned back.  

But the idea simply returning more money into a nationally-bound universal health service ideal – tax-funded by and free at the point of delivery for British citizens – fails to adequately deal with questions about global health worker shortages, global health inequalities or the neo-imperial extraction of healthcare workers.

The above is important because as the neoliberal orthodoxy is being questioned in Britain, we should pay attention to the answers being generated. As I have outlined with Ishan Khurana in these pages, even though the neoliberal global economy is in crisis at the international level, and we have seen a return of state and class politics at a national level, without a real understanding of the imperial underpinnings of neoliberalism such endeavours may leave us with a regurgitation of the racialised and securitised contours of social democracy.

For instance, reforming the NHS would entail not only providing just pay and working conditions through taxation for NHS workers or simply rejecting the idea of foreign workers in the NHS in the pursuit of national autarky – but rather should examine issues such as how the border regime and state racism prevents access to those who already pay or work for the NHS; reforming the training of NHS staff within Britain and by default linking this to industrial and higher education policies; and reparative readdress for unaccounted funding by, and the damage wreaked on those living within, the Global South.

In this sense, how can the British taxpayer and the national health service contribute to a wider international health service for the many and not the few? To expand the idea of class this way is thus to examine how the cost of living here impacts the cost of living over there – and to organise to reduce the cost of living everywhere.

John Narayan is a Senior Lecturer in European and International Studies at King’s College London and an anti-racist scholar of globalization and inequality.’ John’s most recent publications have focused on Black Power and the political economy theories generated by groups like The Black Panther Party and Black Power groups based in the UK. His current research centres on anti-racism, abolitionism and IPE, and the political economy of the influential anti-racist scholar Ambalanaver Sivanandan. He is Chair of the Council of the Institute of Race Relations and a member of the Race & Class Editorial Working Committee.

Header Image Credit: NHS Employers


Narayan, John 2023. ‘How to pay for the National / International Health Service?’ Discover Society: New Series 3 (3):