The current recruitment of junior doctors from India appears incongruous given the Coalition Government's plans to cap non-EU immigrants, apply transitional controls for all new EU members in future, and introduce more stringent controls for highly skilled migrants. Yet present preoccupations about immigration take no account of the impact of such measures on public services such as the National Health Service (NHS) which has a long history of reliance on overseas health workers. Since the 1930s, successive governments have resolved staffing crises through recruiting workers from overseas. The NHS currently employs around 30 per cent of nurses and doctors from black and minority ethnic (BME*) groups with approximately 30 per cent of doctors and 40 per cent of nurses born outside the UK. The low awareness of the historical importance of overseas recruitment to the NHS has artificially constrained immigration debates. It has also contributed to the failure to tackle the discrimination experienced by these workers in training and career opportunities. BME clinicians are over-represented in the lower grades of the professions, under-represented in senior managerial positions, and work in the less popular areas; fewer than 10 per cent of NHS senior managers and only 1 per cent of NHS chief executives have a minority ethnic background.
Putting history to the forefront requires addressing deep-seated and difficult questions around immigration and the NHS that have never been tackled by policy makers. Health worker shortages have been a perennial problem for a number of interrelated reasons including difficulties around nurse recruitment and retention, the reluctance of UK-trained doctors to take up posts in unpopular locations and specialties, and the challenges of balancing the production of doctors and nurses with NHS staffing needs against the unpredictable forces of immigration and emigration. The difficulties look set to continue given the international shortages of health workers which are anticipated to reach 53,000 in the UK, 40,000 in Australia, and 275,000 in the US over the coming year.
Staffing crises in British hospitals had been identified long before the establishment of the NHS in 1948 and concern over nurse shortages had been the subject of numerous government inquiries which blamed low recruitment on inadequate training, poor pay, and the marriage bar. During the Second World War, hospital domestic and nursing work was regarded as vital to the war effort and attracted a large number of women into national service. But staffing the new NHS was compromised by the national post-war labour shortage. The unprecedented increases in the medical and nursing workforce over the first decade of the NHS exacerbated the problem. Between 1949 and 1958 the medical workforce increased by 30 per cent in England and 50 per cent in Scotland; the nursing and midwifery workforce increased by 26 per cent across Britain. The most severe shortages were in unpopular areas of nursing such as hospitals for the chronically sick, mental hospitals and in geriatric nursing.
As early as 1949 the Ministries of Health and Labour, in conjunction with the Colonial Office, the General Nursing Council and the Royal College of Nursing launched campaigns to recruit hospital staff directly from the Caribbean. Recruitment was aimed at three main categories of worker: hospital auxiliary staff, nurses or trainee nurses, and domestic workers. Senior NHS staff from Britain travelled to the Caribbean to recruit, and vacancies were often published in local papers. In 1949, the Barbados Beacon advertised for nursing auxiliaries to work in hospitals across Britain; applicants were to be aged between 18 and 30, literate, and willing to commit to a three-year contract. By 1955 there were official nursing recruitment programmes across 16 British colonies and former colonies. Over the next two decades, the British colonies and former colonies provided a constant supply of cheap labour to meet staffing shortages in the NHS, and the number of women from the African Caribbean entering Britain to work in the NHS grew steadily until the early 1970s. By the end of 1965, there were 3,000-5,000 Jamaican nurses working in British hospitals, many of them concentrated in London and the Midlands. It has been estimated that by 1972, 10,566 students had been recruited from abroad, and that by 1977 overseas recruits represented 12 per cent of the student nurse and midwife population in Britain, of which 66 per cent came from the Caribbean.
By the late 1980s, the NHS again faced serious problems in the retention and recruitment of nursing staff, much as it had done in 1948. The problem now involved chronic shortages of both trainees and qualified nurses. Nursing's popularity as a career choice among school leavers had declined markedly. Changing social expectations and financial constraints meant that young people were now seeking better-paid job opportunities in other sectors of the economy. The abolition of work permits for overseas nurses in 1983 added to the difficulties. Meanwhile, an estimated 30,000 nurses were leaving the NHS every year; their departure blamed on long-standing problems associated with low salary levels and the pressures of the job. By 1998, there were reports that the shortages in newly qualified nurses were approximating 8,000 a year. Problems intensified with the expansion of the NHS in 2000 which created additional demand for nurses that were met by recruiting workers from India.
The shortage of doctors in the UK was well-established by the 1960s especially in unpopular locations such as single-handed general practices in deprived urban areas and remote rural locations, and in hospital specialties like mental health and care of the elderly. In 1944, the Goodenough Committee had recommended expanding medical schools to relieve shortages but the 1957 Willink Committee decided that student numbers should be cut because of the risk of overproduction. Taking into account the minimum five year period of training, the Committee concluded that reducing medical student intake by 10 per cent between 1961 and 1975 would keep numbers in balance. Since 1939 student numbers had increased by more than a third and even before the Committee's recommendations were made public some medical schools had begun to reduce their student intakes. Yet, within months of the report's publication, it became evident that in fact a shortage of medical personnel was imminent.
In retrospect it is clear that the Willink Committee's estimates failed to anticipate the need for extra doctors to improve future health services and to meet the requirements of a growing population. These underestimates drove the first mass wave of medical recruitment from India, Pakistan, Bangladesh and Sri Lanka and by 1960, between 30 and 40 per cent of all junior doctors in the NHS were from these countries. In 1961, Lord Cohen of Birkenhead told the House of Lords: 'The Health Service would have collapsed if it had not been for the enormous influx from junior doctors from such countries as India and Pakistan'. The emigration of these doctors built on Britain's historical links with its ex-colonial territories, especially India. As a direct result of colonial rule, by the time of Indian Independence in 1947 Indian medical schools and hospital administration ran along the lines of the British model. Medical education and training were delivered in English, and geared towards meeting the requirements of the General Medical Council. This ensured that Indian-trained doctors would be able to work in Britain, and encouraged overseas medical graduates to come and gain further training and experience that they would then take home. Emigration of large numbers of UK-trained doctors to work mainly in the United States and Canada, because of the relatively poor pay and conditions of the NHS, compounded the shortages. By the late 1960s, Henry Miller, Professor of Neurology at Newcastle University and chairman of the British Medical Association's Committee for Planning, estimated that the annual emigration of British trained doctors amounted to between 30 and 50 per cent of the annual number of medical graduates.
In 1963 the Conservative Health Minister, Enoch Powell, who later led the call for stricter controls on immigration, launched a campaign to recruit trained doctors from overseas to fill the manpower shortages caused by NHS expansion. Some 18,000 of them were recruited from India and Pakistan. Powell praised these doctors, who he said, 'provide a useful and substantial reinforcement of the staffing of our hospitals and who are an advertisement to the world of British medicine and British hospitals.' Many of those recruited had several years of experience in their home countries and arrived to gain further medical experience, training, or qualification. In 1968, the recruitment of overseas doctors was fuelled again by the predictions of further medical shortages by the Todd Committee, which recommended expanding medical schools. By 1971, 31 per cent of all doctors working in the NHS in England were born and qualified overseas. Overseas doctors remained central to NHS staffing throughout the last decades of the twentieth century, filling vacancies in locations and specialties that were unpopular with UK trained doctors. In 1997, 44 per cent of 7,229 newly registered doctors (under full registration) had received their initial medical education overseas.
Since the nineteenth century and before, Britain has had a long history of immigration and racial tensions have arisen from groups such as the Irish and East European Jews settling in the country. However, post-war mass migration changed the UK's ethnic landscape in an unprecedented way and successive governments sought to allay public anxiety by introducing tighter controls around immigration. By the 1960s, the 1948 Nationality Act, which had granted British citizenship to citizens of British colonies and former British colonies, was under attack. In 1962, the then Conservative Government introduced the Commonwealth Immigrants Bill, restricting the admission of Commonwealth settlers to those who had been issued with employment vouchers. In the eighteen-months before the Act was passed, many new arrivals came to Britain. This large influx stoked popular fears of uncontrolled immigration, which sustained calls for increased controls. In 1968, a new Labour Government introduced a second Commonwealth Immigrants Act, which distinguished between British passport holders, with the right to live in Britain, and those without. The law was rushed through with the primary purpose of restricting the entry into Britain of Kenyan Asians, driven out by the 'Africanisation' policies of the Kenyan government. As British passport holders, Kenyan Asians had had, up to this point, unconditional right of entry. While this new piece of legislation applied to all Commonwealth countries, including Australia, New Zealand, and Canada, it was more unlikely that people from the New Commonwealth would qualify as patrials, thereby creating a division between white and black Commonwealth citizens.
Exceptions to immigration controls were made for essential and well-qualified staff, hence both nurses and doctors were exempt from the immigration controls imposed in the 1960s. In general, the men and women who came to work in the NHS were welcomed throughout this period of political agitation. Their professional status distinguished them from the mass of migrants, most of whom were classified as unskilled. In spite of his later vocal opposition to black and Asian immigration in general, Health Minister Enoch Powell championed the recruitment of overseas nurses in the early 1960s. As historian of the NHS, Charles Webster suggests, this apparent anomaly was perhaps because the immigration of nurses not only 'provided a plentiful supply of cheap labour, reduced wastage, and undermined the shortage argument' but also 'strengthened his hand in pressing for a strong line against the nurses' pay claim, which itself was his chief weapon in his wider campaign to induce colleagues to adopt a more aggressive approach to the control of public sector pay.' Immigrant nurses were therefore an expedient means of providing political leverage.
The situation had altered by the 1970s. Immigration laws undermined the employment rights of overseas nurses. The automatic right of entry to prospective nurses from the Commonwealth was withdrawn with the passing of the 1971 Immigration Act. Later, in 1983, work permits for nurses were also abolished prohibiting further entry of overseas nurses to train in Britain. A report for the Commission of Racial Equality, published that same year, found a higher proportion of trained overseas-born nurses, than overseas-born nurses in training. It also stated that less than 9 per cent of nurses employed by the NHS were born in developing countries. Despite attempts to improve recruitment within the UK, the shortage of qualified nursing staff continued, and was approximating 8,000 a year by 1998. The subsequent expansion of the NHS under New Labour created a need to rapidly increase the nursing workforce but while the number of British training places was increased, this did not solve the immediate demand for workforce growth. International recruitment became one of the government's key strategies in tackling the chronic shortage of qualified nurses, this time with a focus on recruiting already trained nurses and midwives from overseas, rather than training them in the UK. In 2002-03 more than half of the nurses newly registered with the Nursing and Midwifery Council had trained outside Britain. Unlike for overseas nurses, the tightening of immigration controls in the 1970s and 1980s had not significantly reduced the numbers of overseas doctors coming to Britain, while the output of UK medical schools continued to fall short of the NHS' manpower needs. The flow of overseas doctors into and out of the UK is not monitored, but estimates from the early 1980s suggest that around a third of the yearly influx of overseas doctors returned to their home country. In 1985 the work permit scheme was eventually extended to include doctors. An official 'loophole' was created however which meant that overseas doctors could continue to seek postgraduate training in Britain for a four year permit-free period, extendable for a further year after approval from the postgraduate dean. In 1997, this permit-free period of postgraduate training was extended to six years.
The output from UK medical schools was increased in 2000 and this brought a change in attitude towards overseas doctors. By 2005 the government feared that the recruitment of overseas doctors would deny employment to a large number of home-grown medical graduates, especially as International Medical Graduates (IMGs), who were often highly skilled, and with several years' experience in their chosen field, remained an attractive prospect for the NHS. In a bid to keep junior posts open for graduates who were British or EEA nationals, in April 2006 the Department of Health retrospectively sought to debar IMGs from applying for training posts in the NHS. Under new rules, hospitals were told they must prove they could not recruit a junior doctor from the UK or the EU before shortlisting candidates from other countries. The British Association of Physicians of Indian Origin (BAPIO) challenged the Government in the High Court, which ruled that the Department of Health's guideline was illegal. The judgement was upheld by the House of Lords in April 2008, but not before thousands of overseas doctors had had their opportunity of permit-free training abruptly withdrawn at great personal and financial costs to themselves and their careers. The long-term implications of this action however were not anticipated so the UK is now once again looking to recruit Indian-trained doctors to fill vacancies in specialties unpopular with UK-trained graduates.
Migrants arriving in the first wave of mass migration endured verbal and physical abuse both within and outside the workplace. White trade unionists resisted the employment of migrants and imposed a quota system. Within the NHS, concern that importing overseas workers was likely to create tensions was recognised in a 1949 Home Office memo:
'it has been found that the susceptibilities of patients tended to set an upper limit on the proportion of coloured workers who could be employed either as nurses or domiciliaries.'
Racism and discrimination have been universal experiences of health workers migrating to the UK especially around training and career progression. Many of the nurses who came to the UK from the Caribbean in the 1950s expected to achieve the internationally-recognised State Registered Nurse qualification (SRN) which would allow them to return home and gain employment. But nursing authorities at that time argued that their racial characteristics limited their intellectual capacities and motivation to achieve that level of training. Thus many overseas nurses were forced or even duped into State Enrolled Nurse (SEN) training rather than the more prestigious and more highly valued SRN qualification. The longer term consequences of this were significant as the SEN was not an internationally-recognised qualification and limited overseas nurses' options for returning home.
The move towards recruiting overseas-trained nurses has not prevented discrimination and exploitation. Overseas-trained nurses are required to complete a programme of supervised practice placement and adaptation, but as the Researching Equal Opportunities for Overseas-trained nurses and other Healthcare Professionals (REOH) Study found, the skills and experiences of these highly trained individuals are not given adequate recognition within the inflexible formal assessment and accreditation system in the UK, leading to under-grading, deskilling, and skills waste. Like nurses, BME doctors have been disadvantaged by the medical profession's internal hierarchies which left them working on the geographical and institutional margins of medicine. As migrants, they experienced difficulties in getting shortlisted for jobs and were more likely to gain posts away from prestigious teaching hospitals and medical schools. Some even had to accept lower remuneration in order to support themselves and their families. Nor were BME doctors trained in the UK exempt from barriers, particularly around selection processes where those responsible for shortlisting candidates frequently excluded individuals on the basis of a foreign surname.
The legacy of discrimination against first generation overseas health workers has had consequences for the recruitment from the second generation. Nurses, especially, do not see nursing or other health service work as a career they would wish for their daughters. And although some of the barriers have been removed since the 1990s with new legislation and workplace regulations, institutional discrimination within the NHS continues to impede many working lives. This has direct implications for the future of the NHS and its status as a world-leading provider of healthcare as it is likely to continue to need to recruit manpower from overseas
Since the 1930s, unplanned shifts in population growths, upturns and downturns in economic conditions, and changing political motivations have created and continue to create contingencies in NHS staffing for which successive governments were and are unprepared. It is clear that any government would find it very difficult to manage health manpower requirements by achieving equilibrium between migration and immigration flows. Shortages of health workers, especially doctors, are difficult to handle because of the lag time between the creation of training places and qualification.
Nevertheless, a lack of longitudinal data to track the migration, immigration, recruitment and retention of health workers has contributed to the difficulties. As has the fact that workforce planning for medicine and for nursing has been treated as two separate enterprises, despite evidence from economic analysts since the 1960s of the inherent problems in this approach. In May 2006, Josie Irwin, Head of Employment Relations for the Royal College of Nursing, summarised the difficulties in oral evidence to the House of Commons' Health Committee. Numbers of nurses, she said, had increased by 85,000 since 1997. However: 'the quality of workforce planning in the UK means that we do not know where all those nurses have gone; we do not know how many of them have stayed in the UK; we do not know how many of them have stayed in the NHS ... we do not know very much about the retirement behaviour of these nurses ... the success of importing new numbers of nurses in the UK is challenged by not knowing enough about them once they have entered the workforce.'
Manpower challenges persist. A 2008 report by the Organisation for Economic Cooperation and Development, The Looming Crisis in the Health Workforce, suggests that the overall pool of potential workers will diminish internationally on account of contractions in younger age cohorts. UK medical and nursing school places have increased significantly over the last 10 years with the aim of developing a sustainable UK-trained workforce. Yet history suggests that the UK's dependence on overseas health workers will continue and may even be exacerbated by the international shortage of health workers.
The Coalition Government's resolve to introduce further curbs on immigration as a response to public concern about the drain of migrants on local resources simply repeats the contradictory patterns of earlier administrations. Putting history to the forefront would help policymakers construct historically-evidenced agendas that could aid health manpower planning and improve equity and opportunity for significant numbers of health workers.
Current debates need to reflect on the impact of tightening immigration controls - including those for highly skilled migrants - on public services, especially the NHS. The forces of migration and emigration are unlikely to weaken given the global nature of the healthcare market, and the NHS will continue to need to recruit staff from overseas. Acknowledging the UK's long reliance on overseas health workers and establishing a system for the collection of longitudinal data to monitor the migration, immigration, recruitment and retention of health workers are achievable short-term policy goals which would help manpower planning enormously. Measures could be put in place to ensure the qualifications and training of highly skilled migrants are recognised within UK systems; and institutional discrimination around training and career opportunities in the NHS needs continuing redress. Addressing the deep-seated problems around nurse recruitment and retention, and the unpopularity of certain medical specialties and locations are much more challenging issues and will require a longer timeframe. History shows that it is in the UK's long-term interests to ensure that future generations of overseas health workers operating in a global market will choose to work in the NHS.
*Technical Note: BME: the predominant term employed throughout this article is 'black and minority ethnic', or BME, to describe all members of minority racial groups. Other terms such as 'black', 'West Indian', 'Caribbean', 'Afro-Caribbean', and 'South Asian' and 'Asian' have been used where appropriate to distinguish between ethnic minority groups. We recognise that the persons to whom the terms are applied do not necessarily define themselves by such terms.
Organisation for Economic Cooperation and Development (2008) The Looming Crisis in the Health Workforce.
Panayi, Panikos (2010) An Immigration History of Britain. Pearson Education. Julian M Simpson, Aneez Esmail, Virinder S Kalra, Stephanie J Snow (2010) 'Writing migrants back into NHS history: addressing a 'collective amnesia' and its policy implications', Journal of the Royal Society of Medicine 103(10): 392-6.
Smith Pam A., Helen Allan, Leroi W Henry, John A Larsen, and Maureen M. Mackintosh (2006) 'Valuing and Recognising the Talents of a Diverse Healthcare Workforce', Report from the REOH Study: Researching Equal Opportunities for Overseas-trained Nurses and Other Healthcare Professionals. European Institute of Health and Medical Sciences, University of Surrey, the Open University and the Royal College of Nursing.
Stephanie Snow and Emma Jones are Wellcome Research Associates in the Centre for the History of Science, Technology & Medicine, University of Manchester. firstname.lastname@example.org; email@example.com. This paper is based on their new book, Against the Odds: Black, Minority and Ethnic Clinicians and Manchester, 1948-2009, published by Carnegie Press, 2010 on behalf of Manchester Primary Care Trust who funded the research.
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