Paper IV: Training the Public Workforce

The state is the largest employer of doctors, nurses, dentists and teachers in Britain, and in each of these professions it has failed to train enough people of its own. It caps the number of British students who may train as doctors, then recruits from abroad to fill the gap. It has paid relocation bonuses to overseas teachers while missing its own targets for training teachers at home. It funds a token expansion of dental training while expanding the routes by which dentists trained abroad may register.

The principle of this paper is simple. A public employer should pay to train its own workforce, as employers do in Germany, and should bear a cost when it recruits from abroad instead, as employers do in Singapore. Training for the public workforce should be funded by the services that rely on it, with a commitment from those it trains to serve for a period in return.

The paper proposes that the NHS meet the cost of training doctors and nurses beyond what the National Skills Account covers, that the cap on medical school places be lifted in line with the needs of the health service, that dental training be expanded with a commitment to NHS practice and that teacher training be funded so that it is cheaper for a school to train a teacher than to recruit one from abroad.

1The problem

The pattern is the same across the public workforce. Training places are rationed to save money in the short term, while the cost of recruiting from abroad falls elsewhere or is not counted at all. Young British people who want to become doctors are turned away while more doctors join the UK workforce from abroad each year than British medical schools train, many of them from countries that can less afford to lose them. The Medical Training (Prioritisation) Act 2026 now gives graduates of British medical schools priority for foundation and specialty training, which makes the expansion of domestic training both more urgent and more effective.

2Principles

The employer pays for the pipeline. A public service that relies on a profession should fund the training of that profession.

Training should be cheaper than importing. The cost of recruiting from abroad should fall on the service that chooses to do so.

Public training brings a public commitment. Those whose training is funded by a public service should work in that service for a period, or repay part of the cost.

Expansion must be matched by training posts. Places at medical school are worthless if there are no posts for graduates to train in afterwards.

3Doctors and nurses

S28Make the NHS responsible for funding the training of doctors and nurses

Make the NHS, which already funds clinical placements, responsible for the tuition of medical and nursing students beyond their National Skills Account entitlement. The entitlement will be applied to tuition first, as on any other route, and the NHS will meet the balance, so that medical and nursing students pay no tuition and carry no graduate contribution. Where a medical course runs beyond the four-year lifetime maximum for loans for living costs set out in the first paper, the NHS will also support students' living costs for the remaining years. With the entitlement applied first, the cost to the NHS at current numbers is around £0.5 billion a year, rising as places expand. It sits with the service that depends on the training and that bears the cost when it falls short.

S29Lift the cap on medical school places

Expand medical school places in line with the needs of the health service, towards the 15,000 places a year envisaged in the NHS Long Term Workforce Plan, with foundation and specialty training posts expanded in step so that every British graduate has a route into practice. Nursing places will be expanded on the same basis, including through nursing degree apprenticeships for those who wish to train while employed.

S30Require a period of NHS service in return for funded training

Require doctors and nurses whose training is funded by the NHS to work in the NHS for a minimum period after qualifying, with the length set to reflect the cost of training. Those who leave the NHS before completing the period will repay a proportion of their training costs, reduced in line with the service they have given.

S31Charge NHS employers for recruiting abroad

Continue to apply the Immigration Skills Charge to NHS employers for every overseas-recruited doctor and nurse, at the higher rates set out in the third paper, with the revenue paid into the budget for training doctors and nurses at home. A trust that recruits abroad rather than training will therefore fund the training of others. Because the charge moves money within the health budget, it changes incentives rather than paying for the expansion, which will be funded explicitly as set out in section 6. The charge will be phased in as domestic supply grows, so that services are not left short of staff during the transition.

4Dentists

S32Expand dental training with a commitment to NHS practice

Fund a substantial expansion of dental school places through the NHS, well beyond the increase from 809 to 859 places planned for 2027-28. Dental students will be funded on the same basis as medical students, with the entitlement applied to tuition first and the NHS meeting the balance and living costs in the years beyond the four-year loan limit. Every dentist whose training is funded in this way will commit to a period of NHS practice after qualifying, with proportional repayment if they move wholly into private practice before completing it.

Most dentists work in practices that combine NHS and private work, so a commitment to NHS practice will work only if NHS dentistry is worth staying in. Expansion of training must be accompanied by reform of the NHS dental contract, which is widely regarded as the main reason dentists reduce or end their NHS work. Without it, more training will produce more private dentists within a few years of qualification.

5Teachers

S33Expand salaried routes into teaching

Expand salaried routes into teaching, including the teacher degree apprenticeship introduced in 2025 and salaried postgraduate training, with trainees' salaries funded nationally rather than from school budgets. A school that hosts a trainee will gain an additional member of staff at no cost, which makes training cheaper for the school than recruiting from abroad. Teaching degrees and apprenticeships will also be open to funding through the National Skills Account like any other route.

S34Direct funding to the schools that train

Give every school and trust a training allocation based on the size of its teaching staff, paid according to the number of trainees it actually hosts. Schools that train will receive their allocation in full, while those that do not will see it used by schools that do. Because schools are already funded by the state, a levy would simply move public money in a circle. A training allocation moves it from schools that rely on others to train to those that do the training.

S35Price the recruitment of teachers from abroad

Apply the higher Immigration Skills Charge set out in the third paper to schools sponsoring overseas teachers, with the revenue paid into the training allocation, so that a school recruiting abroad helps to fund the schools that train. No further relocation payments will be offered to attract teachers from abroad. Increases will be phased by subject as domestic recruitment improves, so that shortage subjects such as physics are not left without teachers during the transition.

S36Replace training bursaries with retention payments

Replace training bursaries, which are paid during training with no requirement to teach afterwards, with retention payments of equivalent value paid after the first, second and third years of teaching in a state school. Money now spent on people who may never teach will instead reward those who stay, addressing the loss of teachers in their early years, which is the other half of the shortage.

A retention payment after the first year of teaching cannot meet a trainee's living costs during training, so the change will be sequenced with the expansion of salaried routes. In each subject, bursaries will be replaced only once salaried places are available on a scale that meets demand. Trainees who choose a fee-based route will be eligible for the loans for living costs set out in the first paper.

6Cost

The cost to the NHS of meeting medical and nursing tuition beyond the entitlement, and living costs in the later years of medical courses, is around £0.5 billion a year at current numbers and will rise as places expand. Expanding places, clinical placements and specialty training posts will require an explicit addition to the NHS training budget, set out in each spending review alongside the expansion it pays for. The teaching measures largely redirect existing spending on bursaries and training, while the national funding of salaried routes will require its own budget as those routes grow. Charges paid by NHS employers and schools for recruiting abroad move money within public spending. They strengthen the incentive to train but are not a source of net funding for the expansion.

7Territorial application

Health and education are devolved, while immigration is reserved. The Medical Training (Prioritisation) Act 2026 already applies across the United Kingdom.

8Legislation and delivery

A country that cannot train its own doctors, nurses and teachers depends on others to provide the services its people rely on most. Public services should train the people who run them.