Writing migrants back into NHS history: addressing a ‘collective amnesia’ and its policy implications

‘One of the nurses went into a family one night and there was a very obstreperous man and he said “We'll have none of them Irish and none of them blacks in here” so she said “Fine, no problems. I shall leave now but there won't be anybody back because we are all them Irish or them blacks.”’ Clodagh, health visitor¹

Introduction: the silences of NHS history

The National Health Service (NHS) has used migrant workers from its inception. As early as 1957, the Willink Committee on medical manpower found that 12% of doctors in a random sample taken from the Medical Directories of 1953 and 1955 were mainly overseas-trained.² The majority of these doctors had entered Britain during or after World War II, suggesting that many of them would have been Jewish and Central European refugees from Nazi-dominated Europe. Later, migration from the Indian subcontinent became a key dimension of the recruitment of doctors in Britain. At the end of the 1970s, the Royal Commission on the NHS estimated that between 18,000–20,000 registered doctors in the UK were born outside the UK, with half of these being from India or Pakistan.³ In the 1950s and 1960s, large numbers of Irish and Caribbean nurses were essential to the expansion of NHS services, a pattern that was replicated in the early 2000s when nurses from Africa, India and the Philippines came to the UK.⁴ A 2005 report found that in 2003, 29.4% of NHS doctors were foreign-born and that 43.5% of nurses recruited to the NHS after 1999 were born outside the UK.⁵

In spite of this long history of substantial migration into the NHS, little effort has been made to understand the ways in which it has influenced the development of healthcare in the UK. The popular perception of the NHS as a ‘typically British’ institution (in a restrictive white sense rather than in an inclusive sense) tends to prevail in public perceptions of the organization and in its self-image. Of the 19 photos used by the BBC's online archive to illustrate the development of the NHS up to the 1970s, not one shows a black or Asian person.⁶ The ‘historical timeline’ on the NHS website makes no reference to immigration.⁷ Political and organizational histories of the NHS pay scant attention to migrants. A word search for ‘immigration’ in Rivett's online National Health Service History yields little more than the occasional passing reference to overseas doctors.⁸ Nor can much be found in Webster's two tomes on the health services since the war.⁹

Where there is a focus on migrant health professionals in the NHS, the themes most widely covered are the experiences of individual groups of migrants and discrimination. This includes the dearth of opportunities for overseas doctors,¹⁰ the lack of recognition of the skills and experience of migrant nurses,¹¹ exploration of how Irish nurses construct identity,¹² reflections on the experiences of Black and Minority Ethnic NHS employees in the North West of England¹³ and a vast literature on racism grounded in empirical evidence¹⁴ as well as theoretical analysis.¹⁵

These studies have generated a wealth of useful data but three fundamental issues require further examination. First, there is a basic need to document and recognize the scale of the dependency of the NHS on immigration. Second, to what extent were migrants facilitators of development and/or agents of change within the NHS? Third, can a better understanding of this history inform policy?

Recognizing that migration has underpinned the NHS

Historians of immigration have since the end of the last century been arguing for an enhanced appreciation of how migrants have contributed to shaping European nation states – their role has been marginalized and sometimes denied through a process that Gérard Noiriel calls ‘amnésie collective’ (‘collective amnesia’).¹⁶ As Leo Lucassen has noted ‘Ellis Islands’ – spaces that recognize the scale and impact of immigration are absent from the European landscape and immigration does not form part of the collective memory of Europeans who remain attached to the concept of a homogenous and stable population.¹⁷ This perhaps helps to explain the ‘collective amnesia’ of NHS histories when it comes to immigration. A systematic evaluation of the extent to which the NHS has depended on migrants incorporating available figures for different professions and at different points in time would provide a first step towards their reintegration into the history of the NHS. It is important in this context to emphasize that the relationship between the NHS and migrants has been one of dependency – it could not have existed in the form that it took without overseas employees. That the NHS was by the mid-1960s fundamentally reliant on overseas doctors rather than simply benefiting from the additional manpower they provided can be ascertained by the concern expressed by a Ministry of Health official at the potential consequences of conflict between India and Pakistan:

‘At yesterday's TUC debate, Dr Elliott of the MPU is reported as saying that the NHS was in danger of collapsing, possibly within the next few months, because of diminishing manpower. The war between India and Pakistan might result in the recall to India and Pakistan of doctors from British hospitals which could therefore face paralysis within weeks … The same unpleasant thought had occurred to us and we have been considering what we can do.’¹⁸

It is also important to remember that if the numbers of migrants working in the NHS have historically been high in absolute terms, overseas personnel have tended to be over-represented in certain geographical areas (largely characterized by isolation and/or deprivation), less desirable roles and/or particular areas of care. The concentration of migrants in specific parts of the health service led to them playing an important part in shaping the development of NHS structures. In the early years of the NHS, the viability of a hospital system based on a small number of consultants and a large number of junior doctors was, for instance, heavily reliant on its migrant workforce. In 1964, over 40% of junior hospital posts in England and Wales were filled by overseas doctors.¹⁹

Migrants and other ‘architects’ of the NHS

Repositioning migrants in mainstream narratives of NHS history and examining to what extent an institution that is central to Britain's identity was shaped by migratory flows would be facilitated by a move beyond a generic focus on ‘Asian doctors’ or ‘Caribbean nurses’ to explore the contributions of a range of groups in specific parts of the health service. Recent work on South Asian doctors has started to engage with these issues. Esmail²⁰ calls for closer attention to be paid to the role of South Asian doctors in the shaping of general practice. Raghuram et al.²¹ examine the relationship between migration from the Indian subcontinent and the development of geriatrics where, as was the case with less popular specialties (psychiatry being another example) a large number of overseas doctors were employed. Their work shows how Asian doctors clustered in the specialty, creating a ‘professional niche’ that provided opportunities within the NHS. One of their participants goes so far as to suggest that ‘without racism there would be no discipline of geriatrics’. Looking at an earlier period and a different group of migrants, Weindling²² has highlighted the numerical importance of medical refugees from Nazism. While his analysis emphasizes the obstacles they faced, including anti-semitism, he also points to the importance of their structural role in providing medical care to continental migrants and notes the contributions of a number of high profile individuals. Hilton²³ makes the latter point eloquently when it comes to the development of psychiatry, reminding us for instance that Joshua Bierer founded the first day hospital in Britain. Similarly, in examining the role of immigration in nursing in Britain, Solano and Rafferty²⁴ argue that there is an unresolved tension in the NHS between government agendas driven by policy concerns over staffing levels and the potential development of a professional ethos that transcends hierarchies based on race, class and gender.

The expansion of such work into other areas of medicine and nursing and to other professions would make an important contribution to the historiography of the NHS. That migrants contributed to shaping healthcare delivery through taking on certain positions in the NHS structures is one dimension of their impact. British healthcare as we know it today is at least in part a product of international population movements and the National Health Service needs to be studied in its international context – skilled migration affects welfare provision, not just wealth creation.²⁵ It is also important to consider the extent to which migrants were in a position to influence the way in which care was delivered and shape policy and practice through individual and collective agency.

An approach derived from social history could prove fruitful here. EP Thompson, in his Making of the English Working Class,²⁶ defined a new agenda for social history with his aim of rescuing ordinary working class lives from the ‘enormous condescension of posterity’. Undertaking a similar task on behalf of migrant healthcare professionals, other NHS employees and the general public would add greatly to our understanding of how the NHS developed. In contrast to the direction in which much social history has headed in recent decades, this would not involve moving away from the field of policy and practice. Using a social history approach in the realm of policy can help establish whether practices and systems with as much validity as those that met with approval from or emerged within the traditional centres of power such as Whitehall or the Royal Colleges were in fact developed elsewhere and to measure the extent to which these centres of power were influenced from the periphery. Rather than being exclusively concentrated on the disempowered, social history methodology can, therefore, be used to question London-centric and political narratives of the development of the NHS. Such approaches have already been used in a number of studies relating to nursing,²⁷ AIDS policy as shaped by activists²⁸ and mental health provision.²⁹ Incorporating such narratives into general histories of the NHS would give us a more holistic understanding of the past and a different perspective on the present. It is in this sense that we would argue for a need to broaden our understanding of who the ‘architects’ of the NHS were. This is obviously not to say that migrants were drawing up plans in Whitehall for the establishment of the NHS. Using the word in the wider sense of ‘any planner or creator’³⁰ enables us to consider the NHS as an evolving organization brought into existence by the actions of thousands of people, many of whom were migrants, rather than as a monolithic structure established by politicians and civil servants in the immediate aftermath of World War II. Approaching the history of the NHS from such an angle could lead to a better understanding of what impact migration might have had on the development of healthcare in Britain. Is the daily practice of psychiatry in Britain influenced by the fact that the specialty employed hundreds of practitioners trained in the Indian subcontinent? To what extent has engagement with ethnic minority patients been shaped by the presence of migrants in the NHS workforce? Our inability to provide detailed answers to such questions is a major gap in our understanding of how the NHS evolved.

History as a tool of policy

Building on existing critiques of the marginalization of migrants in national historical narratives and using social history as a mechanism for adding to political narratives of NHS history has the potential to reframe our views of the organization and yield valuable policy insights. Reviewing the role that migrants have taken on in providing healthcare for certain sections of the population could lead us to reflect on what importance British society attaches to treating mental health disorders, caring for older people or improving the health outcomes of working class people and racialized groups. What does it say about Britain that there have historically been locations and specialties that were unpopular among British-born professionals? Brian Chikwava's³¹ recent irreverent fictional account of the lives of Zimbabwean migrants in London refers to ‘BBC’ (i.e. British Buttock Cleaner) jobs involving caring for the elderly and infirm being one of the only employment paths open to outsiders – suggesting a long-term trend in delegating to incomers aspects of care considered to be unworthy of the attention of the indigenous population. History can be used in a way not dissimilar to social psychology: it reveals patterns of human behaviour that can then be identified and addressed. Understanding racism as it affected a specific group at a particular moment in time is important. Finding trends that are present in the NHS over a number of years adds another layer of understanding to processes of discrimination. The ways in which migrants have engaged with mainstream professional bodies as well as the NHS and the roles of migrant organizations are also worth exploring: if migrants are able to innovate is full use made of these innovations and are their skills used to best effect? In the same way that examples of good medical practice might be sought overseas, is appropriate use made of the knowledge and expertise of migrant health workers who come to the UK? How have migrants organized themselves in the past to develop networks that provide social and professional support? History can play a part in identifying how this has worked and how it might be best supported in the future.

Tosh's³² argument that a critical recourse to history can enhance our understanding of the present is highly relevant in this instance. He advocates a holistic approach to evidence that unlike say economic or sociological research is not informed by a problem-solving agenda driven by theory but that remains aware of the importance of the ‘unexpected and illuminating’ insights that history can have for the present. This methodology has not so far as we can ascertain been applied to the exploration of issues connected with healthcare provision and diversity. It has the potential to greatly enrich the field.

Conclusion: reframing NHS history, reframing Britishness

The development of alternative histories of the NHS could make an important contribution to the evolution of organizational culture within the NHS. The persistence of racism and discrimination can only be supported by a history that marginalizes the role of ethnic minorities, migrants and other groups. If challenging discrimination in the NHS necessitates engagement with organizational culture as argued by Kalra et al.,³³ an awareness of historical patterns of discrimination and recognition of the fundamental part that ethnic minorities and migrants have played in the history of the NHS would seem to be key components of cultural change. In turn, such an exercise might enable migrants and ethnic minority staff to feel a greater sense of belonging in the NHS. This is surely worth exploring both from an ethical perspective but also as realpolitik in light of the existing problems of recruitment within certain minority groups and given Britain's ongoing need to attract staff in competitive international labour markets. Such an initiative could form part of a wider programme of reflection on the nature of Britishness and the extent to which history in Europe and Britain has tended to downplay the role of migrants in shaping modern societies. If there is to be an informed debate about immigration, an attempt to measure the many ways in which modern Britain is in fact the product of the work of migrants would seem to be a prerequisite to any constructive national conversation on the subject. As Panikos Panayi puts it, immigration is a ‘central factor’ in the evolution of the country.³⁴ From its cosmopolitan London financial world to media magnates such as Maxwell, Murdoch and now Lebedev, from its undocumented cleaners that work in thousands of offices across the UK to the casual labourers that support its agriculture, from its overseas-born Premiership footballers to, dare we whisper it, its royal family with roots on the European continent, the UK as we know it today is to a great extent the result of population movements. Migrants do not just bring a colourful presence, different cultures, music and food. They shape nations by working in industry, public services and becoming involved in civil society. The history of the British National (or should that be International?) Health Service provides us with an excellent illustration of such processes at work.

Footnotes

DECLARATIONS —

Competing interests None declared

Funding Medical Research Council and the University of Manchester

Ethical approval Not applicable

Guarantor JMS

Contributorship This essay emerges from a series of discussions between the four authors on the historical, social and policy context of a research project focusing on the impact of South Asian doctors on the development of general practice in the UK. AE came up with the original idea for the study; VSK suggested extending the scope of thework to encompass wider debates on immigration; successive drafts were written by JMS. AE, VSK and SJS commented on these and discussed them in detail with JMS