Migrant doctors have made a huge contribution to the NHS over the past 60 years and yet it has gone largely unrecognised.
In an attempt to rectify this, researchers at the Open University have carried out 60 interviews with retired and serving overseas-trained doctors from South Asian countries about their experiences of working as geriatricians in the NHS from 1948 to the present day. The interviewees obtained their initial medical qualifications in India, Bangladesh, Sri Lanka, Pakistan and Burma and at the time of the interview ranged in age between 40 and 91.
They all followed a longstanding tradition of migrating from South Asia to the UK. Several had lived and worked in India during the colonial period, with one remarking about his teachers that “most had royal college qualifications”. He explained: “I’m one of the Midnight’s Children - I was born in 1946 just before partition. So, the British influence was very much in the family and it was sort of ingrained. And then when you see your teachers they all had their British degrees behind their names…” (born in Bihar, 1946, arrived in UK in 1972).
From its inception, the NHS depended on recruiting staff from overseas. Immigration legislation in the 1960s and 1970s targeted migrants from the Commonwealth countries. Legislation on racial discrimination in employment, enacted in 1976, and growing concerns about staff shortages in the NHS also influenced doctors’ career opportunities.
Overseas doctors can be seen as a mobile army of labour, particularly in the lower rungs of the medical hierarchy and in the less popular specialties, among which was geriatrics.
A crisis of staffing in the 1960s meant that by 1974 over 60% of consultant geriatric posts were filled by overseas trained graduates. This compared with 3% in general medicine and 9% of all NHS consultants.
This workforce development was not always viewed positively. Professors of geriatric medicine wrote to the Royal Commission on the NHS in 1976 saying: “The present pattern of education of medical students, nurses and other health personnel in Britain does not reflect the needs of this high risk group…so that elderly people have grave difficulties in attaining the healthcare appropriate to their needs…This concentration of overseas graduates in what remains a low status specialty is undesirable on many grounds.”
Contrastingly, many of the doctors interviewed expressed great enthusiasm for the NHS. For some it matched their own value systems: “I had to stay here. And I was never going back. I had a lot to go back to, wealth, position, knowing people. I would have risen there then much better, financially much better…I hope they don’t change it… There is no institution like National Health.” (born in Bombay, 1927, arrived in the UK in 1953).
Many also appreciated differences in the way doctors worked in the NHS: “I had a very good relationship with the ward sister…here we saw nurses more or less as equal and they were not subservient and you asked for their opinion about things that they were good at. You didn’t tell them, you asked them. In the Indian scene…doctors were only for doctoring and so a lot of things, even maintaining notes, we had in our hospital, we had a separate person like a clerk who went round with us and wrote down in the notes, medical notes.” (born in Bangalore, 1945, arrived in the UK in 1973).
Geriatrics was a ‘Cinderella’ specialty. In the early days of the NHS, care of older people with chronic conditions was little more than tending and took place in the back wards of large municipal hospitals, ex-Poor Law infirmaries and cottage hospitals.
Patients might go for years without seeing a doctor and were often confined to bed permanently. The founders of the geriatric specialty attempted to change this situation, in part as a more humane approach to medical care and treatment in later life but also in response to a demand to find ways to release hospital beds for use by other patients.
The specialty’s poor image resulted in marginalised groups of doctors such as GPs, women returners and migrants being recruited.
The South Asian doctors’ accounts provide testimony to the prevailing attitudes of the time towards older patients: “Geriatrics came to occupy as a second class doctors doing second class service for second class clients. I would not accept that. When I first started becoming a consultant I started here. I used to get great wad of letters. ‘Will you kindly see this patient and advise’.
“They bloody well didn’t want my advice. They wanted me to remove the body blocking their beds. And I said to myself, I will never become a clinical undertaker. Never. I have learned some medicine and I want to practice it.” (born in Bombay, 1927, arrived in the UK in 1953)
The doctors interviewed found that opportunities for career progression tended to be limited - even today more than twice (42%) as many white as overseas non white (17%) doctors are consultants in the NHS.
Geriatrics did, however, offer a way to progress. Many of those interviewed followed the pioneers in this respect, often taking the advice of senior colleagues as this doctor recalls: “Because my consultant, who was exactly like me…he was a trained cardiologist and then there were openings in geriatrics so he quickly moved into that area and he said if you want to go through the fast track up then this is a less crowded road.” (born in Madras, 1958, arrived in the UK in 1996).
But professional advancement was not always the whole story. Also important was personal achievement for both doctor and patient: “It took me five years but I got him back to work…I’m not joking, I cried that day. I cried that day when that fellow - he was a butcher - I got him back to work.” (born in Kerala, 1941, arrived in the UK in 1968).
The South Asian doctors talked not only of the stigma of working in geriatric medicine but also of personal encounters with discriminatory practices. They tended to focus on three areas where, as outsiders, they experienced discrimination: in getting their first post in the UK; when attempting to get a post as a specialist registrar; and in the allocation of discretionary merit awards and consultant positions.
Some picked out particular instances where interviews were unfairly conducted, promotions denied and work went unrecognised. Opportunities to secure promotion in the more popular specialties were few, even for experienced, well qualified doctors as preference seemed to be automatically given to UK trained doctors.
“Well chances were nil. I mean let us not beat about the bush. In those days if in an interview you found a local graduate you might as well walk off. But you could only get if there were more than one or two, three posts and you were competing amongst yourselves.” (born in Haryana, 1947, arrived in the UK in 1975).
Many found it difficult to secure posts in London and the south east and instead opted to work in more peripheral areas such as the northwest and Wales and in non-teaching hospitals where there was perceived to be less competition from UK graduates.
Those interviewed were nearly all consultants and one way of measuring their success was through the receipt of merit awards. South Asians and geriatricians were far less likely to receive merit awards than white doctors in other specialties.
“I think the main reason, without trying to be critical, is that the geriatricians had a hard, heavy, workload, clinical workload and had little time left to do other extra work, like research, publications and in terms of giving awards these other aspects were given more importance than the guy who was providing sort of a bread and butter service.
“And without trying to be cynical, maybe old schoolboy ties and that sort of thing can play a part. But I better not say anything more than that!” (born in East Bengal 1935, arrived in the UK in 1967).
Developing service provision in hospitals often meant struggling for resources for the care of older people. And South Asian doctors helped develop the idea of age-related admission to a unit which focused exclusively on older patients, with doctors, nurses and medical students trained in old age medicine. Collaborations with GPs, social workers and other professionals were also seen as essential to improving service provision.
While this research examined the challenges of the mid to late twentieth century, many of the issues that the NHS and its doctors face today remain the same.
New immigration rules exclude many non-EU doctors from training in the UK but the introduction of the European Working Time Directive has led to staff shortages, reminiscent of the earlier period. And, of course, providing good care to an ageing population continues to be a pressing issue.
The research makes a case for the need to recognise the achievements of international medical migrants in the past, and suggests they can help the NHS and its patients in the future.
It was led by Professor Joanna Bornat and funded by the Economic and Social Research Council.
Prof Bornat said: “We wanted to record and highlight the huge contribution these doctors have made in shaping medical provision in the UK, and their experiences of working in the NHS, before these first-hand accounts were lost forever.
“Their determination and dedication has meant that the quality of care for our older population has progressed at a truly tremendous rate.”
Find out more about this research.