Introduction: an ongoing dependency
The NHS has drawn on the labour of significant numbers of migrant doctors since its inception in 1948. As is often the case with migrants working in other parts of the economy, they have tended to be concentrated in roles unpopular with the indigenous population. Medical migration to the UK is linked to a flight of graduates trained in British Universities from particular types of care and care settings. This in turn raises fundamental questions about the ethos of the medical profession in the UK and its compatibility with the aims of the National Health Service to provide universal access to healthcare free at the point of delivery. In policy terms, the implications are twofold. There is a need on one hand for a greater recognition of the NHS’s dependency on migrant doctors and a concerted effort to ensure their skills are put to best use. Addressing the reluctance of UK trained doctors to engage with populations such as the elderly and the less affluent, and medical conditions such as mental health disorders, should also be a priority for policy makers.
The NHS medical workforce has always been cosmopolitan. Thousands of refugee doctors from Central Europe came to the UK in the 1930s and 1940s. In the early years of the NHS, many of them worked alongside doctors from various parts of the world including South Asia, the Middle East, Africa, Australia, New Zealand and North America. In 1957, a government-appointed committee looking at the medical workforce estimated that around 12% of doctors working in the UK in the mid-1950s had qualified overseas.
In addition to the migration of doctors from outside the British Isles, there has also been a long tradition of movement of doctors from the Republic of Ireland. In the 1950s, an estimated 120 doctors a year relocated from Eire to the UK and over 2,000 Irish doctors were working as GPs in the NHS in the mid-1960s. By then, the principal flow of doctors was from the Indian subcontinent. Doctors from India, Pakistan, Bangladesh and Sri Lanka numbered around 10,000 in the late 1970s. As early as 1964, four out of ten junior hospital posts in England and Wales were filled by overseas doctors - many of them South Asian. More recently, the UK has become increasingly reliant doctors trained in other EU countries. In 2010, there were 3,432 German doctors and just under 2,000 Polish doctors registered with the General Medical Council (GMC). Long established links remain however important: in the same year, 25,000 Indian doctors and 4,000 Irish doctors were registered in the UK. The NHS’s dependency on migrant doctors remains a central characteristic of the British healthcare system: 37% of doctors registered in the UK in 2012 had qualified overseas. This represents a total of 92,628 medical professionals - which is roughly equivalent to the entire population of the city of Bath.
The uneven deployment of migrant doctors
These doctors have not been evenly distributed throughout the British healthcare system. One of the first researchers to work on medical migration in the NHS, the health policy expert Oscar Gish, noted in the 1960s that ‘The contribution of overseas-born medical graduates to the various medical specialties varies inversely with the attractiveness to British graduates of particular specialties’. Migrant doctors have tended to be disproportionately represented in junior roles, unpopular geographical areas, less prestigious fields of medicine, and positions involving unsociable hours. They have not simply complemented the medical workforce and been seamlessly integrated into the body of doctors working in the NHS. They have taken on roles that are shunned by many local medics.
This is partly to do with professional hierarchies within medical culture. In broad terms, diseases and specialties that involve time-limited and complex interventions in the upper part of the body and dealing with younger patients are afforded a higher status than those that involve chronic conditions and older patients. The prestige of specific medical roles appears to be tied in to perceptions of the difficulty involved in acquiring the necessary skills and the immediate effect of the intervention of the doctor. Neurosurgery and cardiology are thus considered prestigious. Psychiatry, geriatrics and general practice have a lower status.
However, the nature of the deployment of migrant doctors in the NHS can only be fully understood with reference to other factors such as professional rank and geographical location. Lifestyle factors such as being able to access deputising services for out-of-hours general practice provision (historically problematic in less affluent areas) rather than having to work weekends and nights also played a role in the make-up of the NHS doctor workforce. Doctors are middle-class professionals and as such tend to favour areas with social and cultural amenities (e.g. schools or leisure facilities) that they deem suitable for themselves and their families.
Greater numbers of migrant doctors have tended to be found for instance in less affluent areas such as South Wales and the Midlands and North of England. When low professional status, undesirable geographical location, unsocial work patterns and lack of seniority were combined, concentrations of medical migrants reached extreme levels. By the early 1990s around 16% of GPs working in the UK had been trained in the Indian subcontinent. This percentage varied however from over 50% in the deprived Greater London borough of Barking and Havering to less than 2% in prosperous rural parts of the country such as Dorset and Somerset. In 1978, over half of Senior House Officer and Registrar roles in the NHS were filled by doctors from outside of the UK, as opposed to 16% of Consultant posts. In 1975, in England and Wales, over 60% of junior posts in the field of mental illness and over 80% in geriatrics were filled by doctors born outside of the UK as opposed to 32% in neurology and 28% in cardiology. In 1972, over 80% of Senior House Officers in the Manchester Regional Hospital Board’s area were from overseas.
Unsurprisingly in this context, more recently, out-of-hours (i.e. evenings, nights and weekends) GP services have offered opportunities for migrant doctors in the UK. The vast majority of GP surgeries chose to opt out of being responsible for providing out-of-hours cover in 2004 when a new GP contract was introduced. This has led to significant numbers of overseas doctors being employed to work in this area. The media headlines about doctors commuting from Central Europe to the UK and the death in 2009 of a patient treated by Daniel Ubani (a Nigerian-born doctor living in Germany who was working his first out-of-hours shift) have detracted attention from a wider story of dependency on incomers to provide this type of service. The GMC’s State of medical education and practice in the UK reports for 2011 and 2013 provide additional evidence that historical patterns of deployment of migrant doctors are being replicated in the 21st century. The proportion of doctors trained overseas working in the East of England and the West Midlands is 47% and 39% respectively, compared to 24% in the South Central and Wessex region and 18% in the Southwest. Moreover, doctors trained outside the UK, the EEA and Switzerland are over-represented in fields such as psychiatry and obstetrics and gynaecology.
The ‘dirty work’ of medicine and the flight from care
The concept of ‘dirty work’ provides a useful framework when it comes to understanding why migrant doctors have clustered in certain areas. As the sociologist Everett Hughes noted:
Every occupation is not one but several activities; some of them are the ‘dirty work’ of that trade. It may be simply physically disgusting. It may be a symbol of degradation, something that wounds one’s dignity. Finally, it may be dirty work in that it in some way goes counter to the more heroic of our moral conceptions.
Migrant doctors have historically done the ‘dirty work’ of British medicine and performed tasks that are seen as unheroic. The history of medical migration in the NHS cannot be understood solely in terms of doctors coming to the UK and filling gaps in the labour market where they naturally occurred due to staff shortages. These shortages are not solely down to the shortcomings of workforce planning and a lack of medics graduating from UK medical schools. Substantial numbers of UK-trained doctors have over the years chosen to leave the UK rather than take on the roles that successive generations of medical migrants have built careers around.
In the early to mid-1960s, when the UK was acquiring a substantial population of doctors from the Indian subcontinent, the net migration of doctors trained overseas to the UK was of around 500 a year. The net emigration of British doctors (Irish - born doctors were included in these calculations at the time) was of just under 400 a year. Even allowing for the fact that some of the latter group of doctors will have been from the Republic of Ireland, it is clear that the UK’s dependency on medical migrants would have been substantially reduced if it had succeeded in retaining these graduates. Studies conducted in the 1960s showed that doctors who migrated were those who had not been successful in obtaining prestigious posts in hospitals. The most popular destinations at the time were Canada, the USA, Australia and New Zealand. It seems reasonable to hypothesise that the doctors who left for these countries could easily have taken on the opportunities in inner city general practice, psychiatry or geriatrics that were available to migrants.
Medical graduates find themselves on an international job market and can therefore make career choices based on their social and professional aspirations which often do not coincide with the needs of the UK’s healthcare system. The UK continues to recruit overseas doctors, and many UK-trained doctors continue to leave the country. There are no official figures tracking the latter movement but 4,741 UK - trained doctors applied for a Certificate of Good Standing from the General Medical Council in 2013. This document is needed to undertake clinical work in other countries and therefore provides a good indication of how many doctors are giving serious thought to moving overseas. Significant numbers are following through on these intentions: in New Zealand alone, 469 UK-trained doctors were added to the medical register in 2013. Doctors trained in the UK are leaving and opportunities are being taken up by doctors trained overseas who are prepared to work unsocial hours, have careers in less popular specialties or live in parts of the UK such as the Midlands. The migration of UK trained doctors is no doubt partially the product of individual choices that result from personal desires or frustrations. It is however undoubtedly amplified by a flight from particular types of care: generations of UK graduates have preferred to seek out opportunities overseas rather than take on the unpopular jobs that migrant doctors have done.
Migrant doctors: ‘saviours’ and ‘pariahs’
Awareness of this historical context should lead to a more balanced appraisal of the role of migrant doctors in the UK and, in policy terms, to less focus on controlling access to the medical labour market and expressing concern about the skills of overseas doctors. Throughout the history of the NHS, migrant doctors have both offered a solution to recruitment problems and been seen as a problem to be dealt with. As the sociologists Christopher Kyriakides and Satnam Virdee put it, they are in effect both ‘saviours’ and ‘pariahs’ in the NHS. Refugee doctors who came to the UK in the 1930s and 1950s faced an array of obstacles when it came to entering the labour market. The increased dependency of the NHS on South Asian doctors from the 1950s led to criticisms of the competency of migrant doctors in the media and by the medical profession. This eventually led to a policy response. In the 1970s the General Medical Council (GMC) withdrew its recognition of degrees from medical schools in Pakistan, Sri Lanka and India and professional and linguistic aptitude tests were introduced. Krishna Korlipara, a GP in Bolton and one of the first generation of South Asian doctors to work in the NHS, wrote at the time of the criticisms of migrant doctors: To benefit from their presence and at the same time accuse them of being dangerous to the community is like inviting a man for a meal and stabbing him at the table.
The relationship between Britain and its medical migrants continues to be dysfunctional. The controversy surrounding the Daniel Ubani case in particular led to concerns being voiced about the abilities of non-UK trained doctors. The GMC has been given increased powers to evaluate English language proficiency. However, no British employer is under an obligation to give work to a doctor with poor English language skills. If hospitals, GP surgeries and other providers of healthcare employ people who are incompetent, the reasons for this should be addressed. Immigration policies introduced in 2010 make it more difficult for doctors who are not EEA nationals to get visas to work in the UK. Migrant doctors have always represented an essential resource for the UK healthcare system. They will continue to play a central role in the delivery of healthcare for the foreseeable future. In this context, it is paradoxical that recent policy efforts have aimed to limit migration, including the migration of doctors, and made it harder for international medical graduates to work in the UK.
Conclusion: supporting migrant doctors, challenging the culture of British medicine
Historically, medical migration has enabled the UK to bridge the gap between the needs of the British healthcare system and the aspirations of UK-trained doctors. Given that history shows the extreme dependency of the UK’s healthcare system on migrants to deliver essential healthcare, policy makers should seek to encourage doctors to come to the UK and make greater efforts to provide them with support. For example, this could take the form of intensive language classes; advice on how medicine is practiced in the UK and building a career in the NHS, or developing mentoring programmes and support networks. Much more could be done to treat migrant doctors as a valuable and essential resource. Doctors trained in the global South are used to making optimal use of limited funds. They also have insights into different cultures. As well as asking them to adapt to the UK system policy makers should reflect on how they might be able to help improve it. Explicit recognition that the UK is not self-sufficient in medical labour and therefore needs to attract international medical graduates and make use of their skills would be a welcome development.
Policy makers should also address the causes of the exodus of British doctors. Whilst the ethics of countries such as the UK importing healthcare workers from the global South has been debated in some detail, the failure of UK medical schools to train sufficient numbers of staff happy to work in certain disciplines or geographical areas and to provide services at unsociable hours has been the focus of much less attention. The education and training of doctors involves considerable investment from the British state and it would seem appropriate to ensure that it is closely aligned with the needs of patients. This calls for a reflection on the nature of the education that doctors receive, a challenge to existing medical culture and/or the adoption of strategies to recruit and retain the type of student who may be more likely to undertake work that has traditionally been seen as ‘dirty’. Possible ways forward could involve, for instance, the payment of tuition fees in exchange for following particular career paths (e.g. working in psychiatry or inner-city general practice), the recruitment of more students from different social backgrounds or with ambitions to train in particular branches of medicine and the more systematic use of training programmes to expose doctors to types of work that they may not otherwise have considered as offering viable career options.
Initiatives to improve access to care in rural areas of South Africa have for instance included paying tuition fees for aspirant doctors who serve particular populations when they graduate. South African provinces have also offered scholarships to black and disadvantaged high school graduates for medical training in Cuba. In exchange, they agree to practice in the public sector for a period equivalent to the duration of their training. In Japan, a home prefecture scheme was successful in addressing doctor shortages by recruiting medical graduates from rural areas to work there. A more radical approach to aligning healthcare needs with the supply of doctors has been adopted in Cuba and Venezuela where large numbers of doctors who receive salaries that are low by the standards of the global North frequently work with deprived populations both domestically and overseas.
These examples show that flight from care, although an international phenomenon, is avoidable. Addressing it would however involve engineering a fundamental shift in the culture of British medicine and British medical education. Until that takes place, the UK will remain dependent on migrant doctors. It should acknowledge this fact and make the most of the essential labour they provide.
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