Pressure on Healthcare, Schools, Roads and Trains

Updated 18 July, 2019


  • There was an average of 2,000 GP registrations per day by those from overseas in 2016/17 (NHS statistics for England, Wales & Northern Ireland).
  • The UK recently saw the first sustained drop in the number of GPs per head of population since the 1960s. Rapid, immigration-driven population growth is a key (yet often ignored) factor in this trend.
  • Despite health tourism costing taxpayers hundreds of millions (if not billions) of pounds per year, the British Medical Association has voted to abandon charging overseas patients for treatment.


  • Immigration-driven population growth adds to pressure on school places and on funding.
  • Thousands of schools England are already full or over-capacity.
  • The Department for Education has forecast a further bulge in pupil numbers. An additional 370,000 school places will needed by 2024.
  • Immigration creates additional pressures connected with pupils whose first language is not English.
  • One expert warned of increasing cultural segregation in schools, ‘increasing the likelihood of children growing up without meeting or better understanding people from different backgrounds’.

Social housing

  • Claims that migrants are less likely to occupy social housing than the UK-born population are highly misleading. ‘Immigration may reduce access to social housing for the UK-born’ (MAC, Sept. 2018).
  • Pressure on social housing is further increased by the selling-off of housing stock by local authorities.

Transport / Environment

  • We are losing more and more of our countryside due to the construction of roads, housing and other facilities needed to accommodate rapid population growth, 80% of which is being driven by immigration.
  • The UK is one of the world’s 10 most gridlocked countries (Inrix)
  • Road congestion in London is worse than in Paris, Rome, Berlin and Madrid, with traffic moving at 3.7mph during evening rush hour.

View of the public

  • 60% of voters believe the high level of immigration is piling too much pressure on public services – Ipsos MORI, 2016.
  • They are right. Immigration to the UK has resulted in a considerable cost to the taxpayer of about £18m a day in 1995-2011. Research by Migration Watch UK found that immigration represented a net fiscal cost of £13 billion in 2014/15.

Pressure on healthcare, schools, roads and trains – full briefing

1. Between 2001 and 2016, the UK population rose by a total of 6.6 million. More than 80% of this increase was the result of immigration (see our paper). Rapid population growth will continue to have a significant impact on public service provision, from the queue for social housing (see our separate overview on housing), to hospital, maternity and GP services as well as education, the environment and transport.

2. Many of the public have paid into these services for their entire working lives and do not approve of the huge strains that mass immigration is adding each and every year. Three-quarters (75%) of people think that immigration adds to the pressure on services (and three in five say the impact is too much).

Impact on the National Health Service

3. The NHS is affected in a range of ways by immigration-driven population growth. The Royal College of Physicians has described the NHS as ‘overstretched’. The NHS Five Year Forward Plan said in 2016: “These pressures result from a growing and ageing population placing ever greater demands on a system already under huge strain.”

4. While most migrants to the UK are of working age on arrival and therefore likely to be healthier than the UK average (which includes the elderly), immigration does place certain demands on the health service.

5. Many non-UK healthcare workers play a vital role in the NHS. Yet immigration also means there are many more people in the country each year for the NHS to care for. New residents will of course sign up with their local GP and, in areas where immigration is high, this can lead to longer waiting times for GP appointments and treatments.

6. In 2016/2017 there were 730,000 new registrations with GPs by those from overseas in England, Wales and Northern Ireland – that is an average of 2,000 new GP registrations by migrants per day. Nearly half of the annual total (347,000) were in London and the South-East (ONS). (It should be noted, however, that these statistics should be treated with caution because migrants who moved between homes in the UK may have been double counted. The figures may also include some of those who were here short-term).

Figure 1: New GP registrations by migrants in England

7. A study by the Nuffield Trust said the drop in GP numbers from 65 per every 100,000 UK residents in 2014 to 60 in 2018, marked the first sustained fall in this figure since the 1960s. The General Medical Council has said the rising population is contributing to workplace pressures on GPs. Population growth is a key element of the discussion of the growing strains on the NHS, and on GP surgeries, that is often (and increasingly) ignored in the media and other commentators.

8. As a result of growing strains, a 2017 survey found that one in three GPs planned to close surgeries to new patients. A poll revealed that a third of Britons struggle to get through to surgeries on the phone to make a booking.

Health tourism

9. Non-EU migrants have to pay between £300 and £400 per year for UK healthcare at the time of their visa and immigration applications. Dependants usually need to pay the same amount. In 2015/16, the health surcharge raised £164 million and it has been estimated that the surcharge will bring in £1.7 billion between 2015 and 2025.

10. When we refer to health tourism we are not talking about emergency treatment. This is, as it should be, free on the NHS, to whoever needs it and wherever they come from. Health tourists are those who target the NHS because they will often get better treatment for an existing condition than at home and/or so they can get it for free.

11. The cost of treatment for those who travelled to England to receive urgent care, along with visitors who were described as ‘taking advantage’ of the system, was estimated at £100m-£300m in 2012/13. Even if the cost of health tourism was just 0.3 per cent of the NHS budget, consultant surgeon Professor J. Meirion Thomas notes that this would be enough to pay for thousands more doctors and nurses in our overstretched health service. However, Prof. Thomas suggests the problem is far worse: “Health tourism costs the NHS in the region of £2 billion.” In his view, health tourism ‘costs countless lives and is undermining the whole NHS’.

12. In 2017, a health tourist racked up the UK's biggest-ever unpaid NHS bill after leaving a Manchester hospital with a debt of more than £530,000. The House of Commons Public Accounts Committee found that year that the UK is among the worst countries in Europe at extracting payments from foreign patients. The National Audit Office (NAO) has also criticised the NHS for inefficiency in collecting debts from non-EEA visitors.

13. In April 2017, the government implemented a rule that means that overseas patients can be refused operations unless they cover their costs in advance. This is sensible but needs to be effectively enforced. It is crucial that the NHS and the next PM gets a grip on recovering such costs. Polling suggests that 74% of the public support increased charges for visitors from outside the UK to help fund the NHS. Despite this, the British Medical Association voted in June 2019 to abandon the policy of charging overseas patients for treatment.

14. Visitors from the EU are mostly covered for treatment by the European Health Insurance Card (EHIC) system under which the NHS charges their home country for treatment under reciprocal arrangements. However, the NAO has also criticised the NHS for not being rigorous enough in checking the status of visiting patients from other European countries.

15. If the UK leaves the EU with no deal, your EHIC will no longer be valid. However, the government is "seeking agreements with countries on health care arrangements for UK nationals" (see report).

The NHS and staff from overseas

16. Reliance on overseas-trained medical staff has allowed the NHS to get away with a long-term failure to plan for the training of the medical staff we need. A report by NHS Providers has found that the NHS imports significantly more doctors and nurses than Germany, France, Spain, Canada, the US, Sweden and the Netherlands (see Figure 2 below). Even medical industry groups have said the focus needs to be on reducing reliance on migrant workers and developing the homegrown healthcare workforce.

Figure 2: % of doctors who were foreign-trained, OECD Health Statistics – 2013

17. There is no shortage of young UK people aspiring to train in medicine. Similarly, in the words of former chair of the Migration Advisory Committee, “There is no good reason why the supply of nurses cannot be sourced domestically.” What is needed is much greater investment in training and better planning by the government to ensure the proper up-skilling our own young people. Greater efforts should also be made to retain existing staff through better pay and conditions.

18. Indeed, there is no shortage of young UK people aspiring to train in medicine. The annual number of applications to UK medical schools is 70,000-85,000 for approximately 7,000 places. In June 2015, Dr Peter Carter, head of the Royal College of Nursing, said: “You have virtually every NHS trust... recruiting overseas. It is ludicrous, hugely expensive, and labour intensive. The root cause is not training and retaining enough UK nurses.”

19. It is also, frankly, immoral to draw in nurses to the UK - one of the richest countries in the world - from places that may be in much greater need. In 2018, the former mayor of Freetown described a ‘body and brain drain’ from Sierra Leone, noting: “We have only two doctors and 17 nurses for every 100,000 inhabitants.” Investment in quality training is a far better solution than drawing in staff which poorer countries can ill-afford to lose (for more, read our piece).

Impact on schools

20. High immigration increases demand for schools in a number of ways. As the ONS has noted, the impact of children who have recently arrived from abroad is one factor but the main driver is the number of children being born here in the UK, which is also increased by immigration.

21. The ONS has said that, between 2002 and 2013, births to non-UK born women made up 78% of the increase in the number of births.

22. Professor Alan Smithers, director of the Centre for Education and Employment Research at Buckingham University has said local education authorities are under ‘great pressure as there are not enough primaries to cope with the influx of pupils amid immigration and rising birth rates’.

23. The impact of immigration needs to be mapped onto the wider context of projected increases in pupil numbers. Over the past decade (2009-2018), the school system in England took in an extra 670,000 pupils. Sadly, spending per pupil in England fallen by 8% in real terms since 2009/10 (Full Fact) – something that would not have occurred to the same extent if pupil numbers had not risen by as much as they have.

24. The secondary school population is projected to increase by more than 400,000 by 2027, in part due to the baby boom that has been fuelled by high immigration (see figure 3 below). An estimated 87,000 places are needed in advance of 2021/22. One in six children missed out on their chosen secondary school for autumn 2018 (the Good Schools Guide).

Figure 3: Projected number of pupils in state-funded secondary schools in England. Dept for Education National Pupil Projections.

25. Primary school pupil numbers will remain stable beyond 2020/21 but an estimated 79,000 extra places will be needed. Nearly a quarter (23%) of English primary schools are full or over-subscribed. Despite this, there is expected to be a shortfall of 10,000 primary school places across England this year - 2019/20.

26. In some places, especially where schools are already full or oversubscribed, high immigration is one of the key factors creating strains, most keenly in England – which is the destination of nearly 90% of immigrants to the UK.

27. In March 2019, for example, it was reported that immigration was among a number of reasons for ‘unprecedented demand’ on Middlesbrough schools which had left pupils without places (other factors include school place provision and changing patterns of demand). Pressures are also particularly acute in a number of London boroughs.

28. A number of studies have summarised the additional demands on schools arising from the needs of some migrant pupils. They point to requirements ‘leading to higher costs of education provision, including: translation and interpretation services, numeracy and literacy of young children who have not received formal education, understanding of cultural differences by staff, and a lack of records and assessment’.

29. Research by M Moskal (2016) noted that classroom teachers and those specifically appointed as language assistants expressed concerns about the lack of appropriate training. The study concluded that ‘language may constitute a barrier to the equitable benefits of education’. There is certainly a cost involved for the taxpayer. A parliamentary answer in 2016 revealed that £267 million was allocated to schools in 2015/16 to support children for whom English was an additional language.

30. According to Professor Smithers, director of the Centre for Education and Employment Research at Buckingham University, ‘increased numbers and the extra demands on teachers to assimilate children whose first language isn't English will be likely to have an adverse effect [on educational outcomes] rather than bring about an improvement’.

31. The Migration Advisory Committee found ‘no evidence that migration has reduced parental choice in schools or the educational attainment of UK-born children’ (September 2018 report). However, research by the Northern Irish government stated in 2018 that the number of pupils with a lesser grasp of English who are unable to participate fully in classes was on the rise. Separately, a study by the Scottish Government noted: ‘Schools receiving the highest number of migrant children are in some of the most deprived areas’.

32. This, along with other trends may have exacerbated problems of community cohesion that are being ingrained at the very start of children’s lives. For example, Home Secretary Sajid Javid was reported in 2018 as pointing to a ‘segregation problem’ in which 60% of ethnic minority pupils go to schools where ethnic minority pupils are in the majority.

33. Worryingly, the government’s former integration czar Dame Louise Casey noted in a 2016 report that the school age population is even more segregated when compared to residential patterns of living and that this ‘increases the likelihood of children growing up without meeting or better understanding people from different backgrounds’.

34. Ofsted has also ‘raised concerns about the well-being of children in segregated, supplementary and unregistered, illegal faith schools’. The government should take these concerns very seriously.

Impact on Roads, Transport and other Infrastructure

35. More people also means more crowding on the public transport network, which, especially in London and the South East, is already extremely busy. The number of passengers on the London Underground rose from 800 million a year in 2002 to 1.3 billion a year in 2016. In the space of a month in 2017, 109 million journeys were made. A senior manager has warned that overcrowding was threatening to make parts of the network “inoperable” by 2031.

36. The net addition of the population equivalent to a small city every year from overseas cannot but worsen congestion on the roads. The traffic data company Inrix said in 2018 that the UK has been named among the ten most gridlocked countries in the world. As Inrix noted: “The cost of this congestion is staggering, stripping the economy of billions.”

37. While some suggest that the solution this is simply to build more roads, it is far preferable to preserve our irreplaceable countryside for future generations by reducing the rate of population growth through a cut in immigration levels.

38. Immigration places pressure on UK water supplies. It is estimated that in 25 years time another 850 million litres of water will be needed every day in England, that is equivalent to the amount of water in 340 Olympic sized swimming pools. The Royal Geographical Society ranked the South East of England 161st out of 180 areas globally on its ability to deliver sufficient water to residents.

Impact on social housing

39. It has been estimated that that over 90% of immigrants in the UK are in households that are not excluded from social housing on the basis of their immigration status. The MAC noted in September 2018 that ‘immigration will naturally increase the demand for social housing [which, in certain circumstances] could reduce the access to social housing for the UK-born’ (p.95 of the 2018 MAC report). For more, see our housing brief.

40. In many areas there is a lengthy waiting list for social housing and thus social housing is not immediately accessible to recent migrants. As a result, pressure on social housing lags considerably behind migrant inflows. However, the proportion of migrant-headed households occupying social housing is now greater than the proportion of households headed by a UK-born person occupying social housing, with the difference being greater for local authority providers than housing association providers.

41. Pressure on social housing has been further increased as local authorities have sold off stock which has been purchased by private landlords eager to take advantage of the booming demand for rented properties resulting from increased immigration. Three-quarters of the very large increase in renting (of all kinds) in the UK can be attributed to migrant-headed households.

Expansion of Public Services and Infrastructure

42. Proponents of mass immigration often suggest that since migrants pay tax they are contributing towards their share of public services and infrastructure. This ignores the fact that, between 1995 and 2011, immigration overall was a net fiscal cost to the country of between £18m and £25m per day. The requirement to expand public services and infrastructure is largely due to new migrants; if net immigration were zero there would be no need for a major expansion.

Impact on the environment

43. High immigration threatens the UK’s environment and biodiversity. The need to provide ever-growing numbers of homes, roads and public services for a rapidly expanding population adds to pressures on our countryside and the green belt. Polling carried out by the Campaign to Protect Rural England shows that 64% of people agree that green belt land should be protected. Another poll finds that 64% say the population is projected to grow too quickly.

44. However, a large chunk of our countryside has been built upon or set aside for construction due to the need to accommodate rapid population growth:

  • A million new homes that are planned between Oxford and Cambridge are set to cover an area of countryside larger than Birmingham.
  • Plans have been approved to build hundreds of homes every year on the South Downs National Park.
  • More than 38 square miles of green belt land were set aside for construction by local authorities between 2012 and 2018.
  • The year 2017/18 saw the largest release of green belt land to date, with more than 19 square miles of supposedly protected countryside allocated by ten councils for use as building sites (according to the Campaign to Protect Rural England).