Get back to where you once belonged: responses to South Asian doctors in the National Health Service, c.1960–80
By Andrew Hull and Sanjoy Bhattacharya
Nowhere, perhaps, can history speak to policy more clearly than on the issue of overseas qualified doctors in the NHS. A xenophobic attitude towards immigration was the hatred that dare not speak its name in the recent British general election, as the reception of Gordon Brown’s unfortunate comments that became known as ‘bigotgate’ showed all too clearly.
This time around it is immigrants from new (eastern) European Union states who are arousing in some British citizens irrational terrors about the ‘other’ in our midst. A particular focal point for such fears now is European doctors working in the NHS; the reputations of the many, to whom we owe the continued operation of the NHS, have been sacrificed to the few unfortunate cases where terrible errors have been made (e.g. 2008’s David Gray/Dr Daniel Urbani case). A moral panic has ensued, spawning headlines such as “Foreign doctors’ poor English is killing patients, say MPs: tighter controls on GPs from overseas ‘must be introduced immediately to save lives’”.
It is ironic that South Asian doctors, the previous focus of the overseas doctor panic, still have to take the PLAB English language test to practise, while European doctors have not since the 1983 Medical Act. Moreover, South Asian doctors have also been subjected to the stringent new points-based immigration system. This is highly reminiscent of the way that overseas qualified doctors (OQDs) were treated 30–40 years ago: a heavy-handed type of control, characterised by historians as also highly politicised and infused with the casual racism that still permeates British society, that Dr Surendra Kumar, then Chairman of the Overseas Doctors Association, warned against in October 2001: “We must not repeat what happened in the 1960s and 1970s when doctors from the Indian subcontinent were encouraged to come here and then found themselves mishandled and discriminated against. They were moved from pillar to post and many ended up being pushed into the less attractive specialisations or given GP posts in inner-city areas.”
Our ongoing research has already revealed much of this unpalatable story. By the early 1960s, OQDs from the Indian subcontinent (ISC) were coming to the UK in increasing numbers for training, clinical experience and qualifications, and to secure better wages. Wartime mistakes with medical school quotas had delivered an acute shortage of home-produced medical graduates, which was filled by temporarily opening the gates (embodied in the 1962 Immigration Act) to OQDs. These incoming doctors found that, up to about 1969, jobs, although often in less desirable areas and specialties and at a junior level, were plentiful. Of the 3800 increase in UK hospital staff between 1960 and 1967, 3000 were born overseas; by the mid-1960s, OQDs (mostly from the ISC) made up 40 per cent of NHS junior staff. However, once British-born doctor numbers began to rise again, the numbers of OQDs allowed in was reduced, and those remaining found it harder and harder to get posts that British doctors wanted; hence many highly qualified people who had planned on consultant careers ended up as inner-city GPs.
In 1962, as his Hospital Plan dramatically expanded NHS staffing needs, Enoch Powell, Secretary of State for Health, appealed for help from ISC doctors to bridge the skills gap caused by the 1957 Willink Report’s gross underestimations of home demand for UK-produced doctors. George Godber became Chief Medical Officer in 1962 and immediately raised medical school intakes, but this would not mean more new doctors until five years later. Powell thus welcomed South Asian doctors as temporary educational migrants: after in-post postgraduate training and Royal College Fellowship examinations, they would go home, to be replaced by a new cohort. Temporary staff shortages would be covered with no sacrifice of higher posts to OQDs – a win-win situation, as the UK could rightly claim to be fulfilling post-colonial obligations, while not contributing to ISC brain drain, and at the same time getting cheap labour for the most onerous NHS junior grades. As more home-produced doctors came back on stream, the flow of ISC doctors would gradually be turned off. At the same time, efforts were also made to ensure that the OQDs remained in junior positions and did not get into permanent career-grade jobs.
The increasing short-term importance of OQDs to the NHS led, in the 1960s and 1970s, to the evolution of complex administrative mechanisms for processing and approving potential NHS junior employees from the Commonwealth. This caused the Ministry of Health to introduce a more formal ‘Clinical Attachment Scheme’ in 1966 (made compulsory in 1969). This was intended to assess the OQDs’ clinical competence and their skill in the English language, as well as to find them a suitable NHS position post-assessment.
But there was a critical tension at the heart of the British government’s response. Departments concerned with immigration (the Home Office and the Department of Labour) wished to restrict numbers, as did the Cabinet, bowing to popular perceptions of over-immigration and subsequent racial tension. The Ministry of Health wished only to keep the NHS fully staffed. But the Cabinet also had other considerations, shared by the Overseas Development Ministry. The ISC was not only a major market for British capital goods (including arms) but also a potential bulwark and ally against Soviet expansionism in the region. India, in particular, it was felt, had to be kept on side and thus it was important not to appear to be stealing doctors from a developing former colony. India was by the mid-1960s experiencing an acute shortage of medical personnel, especially in government medical service positions, and it had begun to try to stop its doctors from entering a heated international medical marketplace. The UK government, thus, had to walk a tightrope between its own immediate health and social needs and its wider economic and diplomatic interests. This resulted in a series of contradictory impulses. For instance, the government provided funding to Indian projects aimed at creating postgraduate medical training institutes, while continuing to employ the ISC medical personnel the NHS needed. At another level, some government departments appeared to argue that the discriminatory treatment directed at Indian practitioners in the UK medical job market aimed to redress the shortage of medical professionals in the ISC by forcing postgraduates to return to their home countries.
By 1969, with rising home production of doctors, the profession’s own attitudes towards OQDs were hardening. The British Medical Association and junior hospital doctors were strongly lobbying for language testing for immigrant doctors to be included in the new Medical Act. Department of Health and Social Security literature sent abroad to inform potential immigrants about procedures echoed such concerns and for the first time spelt out standards of English required, making it clear that the best jobs would go to those with the best language skills. However, it was not now just a case of having good command of the written and spoken language: “facility in colloquial English and knowledge of the intonation and rhythms of everyday speech in Britain” were also demanded.
Surendra Kumar’s hope of learning lessons from this shabby treatment of OQDs in the 1960s was dashed when in March 2006 the government succeeded in overcoming a final legal challenge to its Highly Skilled Migrant Programme. Now any junior doctor trained in a non-EU state (again) needed a permit and any NHS Trust wishing to employ non-EU medical staff had to prove there was no home-grown or EU-qualified doctor able to fill the post before it could appoint an OQD. This left about 16 000 working NHS doctors, mostly from the ISC, suspended from work and in limbo. One committed suicide, stressed by the debts he had run up while not able to work, waiting for his employment status to be confirmed. The Department of Health commented in a February 2007 statement (which carried strong echoes of the 1960s): “It has become clear that, due to the changing labour market, the category in the immigration rules for doctors and dentists that allowed permit-free training has led to the displacement of UK graduates, and there has been a growing consensus that changing the rules is the right thing to do.”
We know that history never repeats itself; there are no direct lessons, but there are lessons about the mechanics of power – what Bloch called the “science of change” and Hamlin the “realm of motives, strategies, interests, ideologies and power”. In this realm we can clearly see the parallels between 1962, 2006 and 2010, and that the study of history can speak to the fundamental morality of our policy as well as to its efficiency and effectiveness.
Dr Andrew Hull is a Lecturer in the History of Medicine at Swansea University. Dr Sanjoy Bhattacharya is a Reader in History at the University of York.