Windrush and the NHS, by the Numbers 2: Where we are today.

Today, the NHS continues to be one of the most diverse workforces in the world as well as one of the largest. In 2018, General Practices in England employed 44,847 doctors, 23,756 nurses, and a further 118,946 other workers. The percentage of overseas-qualified GPs employed varied from a low of 2.3% in the Vale of York to a high of 66.1% in Thurrock, just east of Greater London. Across the UK, 17.86% of GPs were educated outside of the UK and EEA, and 4.08 were trained elsewhere in Europe. (Look at the NHS Digital, General Practice Dashboard for even more) Meanwhile in the hospital and community health services, of 1.2 million staff, 12.7% (144,000 workers) reported a foreign nationality. Some 63,000 of these came from the EU, while another 49,000 were Asian nationals. Looking at London alone, 11.3% of staff were from the EU.

This diversity intensifies when we look into the hospital. Across our project, we have found that hospitals are the sites most strongly associated with the NHS in cultural terms (even though most NHS funded medical care is delivered elsewhere). When we asked people to tell us about ‘their NHS’ the stories we heard were, by and large, hospital stories, and in our ‘Big Draw’ at University Hospitals Coventry and Warwickshire, we found that this association was true even for young children (kids do also like an ambulance and air ambulance!). Since the 1960s, theatrical, cinematic, and televisual representations of the NHS have also focused mainly on hospital medicine, at least until the recent advent of shows like ‘GPs beyond Closed Doors’.  And newspapers tend to illustrate their articles about the NHS with… you guessed it: pictures of NHS hospitals and those who work in them!

So what SHOULD we be seeing in all these pictures of NHS hospitals? Well, in 2018, 37% of hospital doctors gained their primary medical qualification outside the UK, 20% in Asia and 9% in the EU. Approximately 7% of nurses reported an EU nationality, while 6% reported Asian nationalities and 2.4% were of African nationalities. This is equally true for clinical support staff. While a large majority of workers in this group are British, 4.9% are of Asian or African nationality, and 4.1% come from the EU. Today, the numbers tell us that 0.15% of nurses in the NHS are Jamaican nationals – they represent a new generation of Caribbean men and women supporting our health and our NHS. (Have a look at the excellent House of Commons Library Briefing Paper 7783 for more details!)

And alongside these new Jamaican health workers, the effects of the Windrush Generation still endure and still powerfully shape the NHS workforce, as ‘Here to Stay’ demonstrates! Men and women of Jamaican and other Caribbean heritage, and from BAME communities still contribute disproportionately to the nursing workforce of the NHS. When you read their stories (all here in our ‘Here to Stay’ gallery), you can see how many of them come from families with rich and deep NHS connections.

But we don’t see this super-diversity in all the ways that we should. While images of the NHS have become much more inclusive than they were in the past, those ‘powerful portraits’ that I talked about earlier in our Windrush Season are still going to be White for some time to come. At its very top levels, the NHS is still a white man’s world, despite efforts to change. Among non-medical staff (and remember, 9 out of 10 people working for the NHS fit into this broad category, while only 1 in 10 perform medical roles) 93.6% of the top brass are White. The non-medical workforce of the NHS is 82.5% White, but the figures still show us a level of distortion. In the medical workforce, which is almost equally distributed between White and other ethnicities (57.1% White, 38.7% BAME, 4.1% other and 0.1% unknown) the distinction is stark and a bit shocking: White doctors dominate the consultant posts, holding 61.4% of them, while doctors from non-Asian ethnic minority communities are over-represented in the most junior grades and under-represented at senior ones. (You can look into all these figures and many more here!)

Interestingly, there is no equivalent breakdown for nurses and midwives, but the Royal College of Nursing in London did some very revealing research of its own in 2018. In London, the majority of all nursing staff in London NHS Trusts have BAME background ( 27,982 nurses reported a BAME background compared to 24,847 nurses identifying as White). Yet despite being the only UK region with a majority BAME nursing workforce, London performed worst in terms of meeting race equality targets. And its most elite hospitals were also its least diverse, suggesting that the BAME nurses who are the backbone of nursing care across the capital faced barriers to employment in its flagship services. The Workforce Race Equality Standard (WRES) team have also studied the nursing workforce. Across the UK some 1 in every 5 nurses and midwives are from BAME backgrounds — 23.1% of all nurses in the NHS! But they are underrepresented across all the upper pay bands, and only 8 Directors of Nursing in the UK are from BAME backgrounds (only 3.4%), despite this group’s disproportional contribution to the workforce).

Changing the faces on NHS (and gallery!) walls won’t solve the complex structural issues that underpin the slow rise of BAME workers to the most senior leadership roles in the NHS. But celebrating the long and continuing history of BAME contributions to the National Health Service  — before, during, and after the Windrush years –may help us to think more, and more productively about what we should be doing next to ensure that the NHS we see and benefit from is also the NHS we imagine, represent and remember.

Portraits and Power

Portraits and Power

What do you see, in your mind’s eye, when you hear the word ‘doctor’? And ‘nurse’? Until very recently indeed, the most common answer to these questions would have been ‘An older white man’ and ‘a white woman’. Even today, research suggests that we commonly expect the members of many high status professions — including doctors, surgeons, and scientists, as well as university professors — to be both male and white. In professions like nursing and teaching, which are socially valued and associated with virtues like care and compassion (but often not well paid), Europeans and North Americans still often picture and represent white faces, though this time those faces are female.

If you look at our galleries here on the People’s History of the NHS, you will start to see why these impressions and stereotypes have lingered. Until very recently, despite the efforts of innovative shows like Emergency Ward 10 (which included a Black nurse by 1959, and a Black female surgeon — AND an interracial kiss — as early as 1964), mainstream sources of information have often whitewashed our images of the NHS. Until the 1980s and 1990s, representations of NHS staff (and even patients) produced by NHS and government institutions for public consumption most often showed individuals of European heritage. Whether explaining mass miniature radiography, depicting nurse training, or illustrating ultrasound scanning), the ‘humans of the NHS’ were portrayed unthinkingly as White.

Coverage in British newspapers was no different; a survey of major papers from across the political spectrum (the Times, The Guardian/Observer, and the Daily Mail) showed that photographs of nurses and images of nursing almost always featured only White women, even though BAME nurses were at the heart of NHS hospital care from the 1950s onwards. Only in articles that specifically discussed ‘race relations’ or ‘immigration’ were BAME nurses and doctors routinely visible. This is not because photos of Black, Asian and Mixed heritage nurses were not readily available. These lovely photos (from 1958 and 1967) kindly shared with the People’s History of the NHS by the Friends of Savernake Hospital, celebrate the diversity of their NHS workforce as well as the Christmas holidays. And by the 1970s and 1980s, photos of union meetings too routinely portray an NHS workforce made up of workers from all nations and ethnic backgrounds.

And still today, if you walk down the hallways and through the boardrooms of British hospitals, medical schools, universities, and professional associations, you will be strolling beneath the gaze of a seemingly endless series of old white men in impressive suits and formal postures. The ‘great and the good’ loom large –often literally – in these settings, and prominently if silently tell a story about the institution’s identity and history. Here at Warwick, for example, a quick look at institutional portraits in the wonderful University art collection reveals a sea of white Vice Chancellors, honorees and benefactors. They look down at us, and sometimes even each other. The only portrait that includes a Black man figures him in the background, literally in the shadow of the portrait’s subject, Lord Scarman (author of the Scarman Report on the 1981 Brixton uprising). They represent a matter of fact about the University: like most, if not all British universities, its appointed leaders have thus far come primarily from one demographic group. Only one portrait, that of Sir Shridath Ramphal, a former Commonwealth Secretary General who held the ceremonial role of Chancellor at Warwick from 1989-2002, challenges this monochromatic vision.

But when an institution’s visual history –its own celebrations of its past — only includes one kind of face, what does it say to those who are not shown? Are their contributions, perhaps, not seen? And what does it say in particular about an institution like the NHS that so obviously includes and absolutely relies on people from every background? The staff of the NHS, like its patients, have never been monolithically White. In fact, both in the past and today, the NHS has long been one of Britain’s most diverse organisations. The portraits in the Here to Stay exhibition coming to Warwick’s brand-new Oculus building from June 15th 2019 – large, formal, and beautifully composed by the artist – begin to bridge this gap between NHS image and NHS realities. They also hang permanently at Sandwell Hospital, and remind us that here in the Midlands, as well as across the NHS, leadership, compassion and inspiration come from BAME NHS staff at every level. This is the National Health Service’s rich Windrush heritage. In a linked exhibition at the Modern Records Centre, we have also curated a display of documents showing the heritage that Windrush and Britain’s BAME communities have built for all of us, at home, at work, and in the arts.

Read more: If you want to know more about the visual stereotypes that shape our expectations about doctors, nurses and other professional groups, here are a few places to start:

Roberta Bivins, Picturing Race in the British National Health Service, 1948-1988, Twentieth Century British History, Volume 28, Issue 1, March 2017, Pages 83–109, https://doi.org/10.1093/tcbh/hww059

Marci D. Cottingham, Austin H. Johnson, and Rebecca J. Erickson. “‘I Can Never Be Too Comfortable’: Race, Gender, and Emotion at the Hospital Bedside.” Qualitative Health Research 28, no. 1 (January 2018): 145–58. doi:10.1177/1049732317737980.

Jane Turner, Vivienne Tippett, and Beverley Raphael. “Women in Medicine — Socialization, Stereotypes and Self Perceptions.” Australian & New Zealand Journal of Psychiatry 28, no. 1 (March 1994): 129–35. doi:10.3109/00048679409075854.

https://www.nursingtimes.net/roles/nurse-educators/the-image-of-nursing-how-to-combat-negative-stereotypes/5018581.article

And for an antidote to monochromatic visions of medical professionals, see:

https://www.instagram.com/melaninmedics/?hl=en

Windrush Season, Week One: The Windrush Generation and the NHS

Page from the HMT Empire Windrush, titled 'Names and Descriptions of BRITISH passengers'. The passengers on the list include nurses from Jamaica, scholars from Burma, plumbers from Bermuda and many others. Note that ALL were included in the category of 'British', as subjects of the Empire.
Page from the Empire Windrush passenger lists 1948 (The National Archives, BT 26/237)

Next month, on the 22nd of June, Britain will celebrate Windrush Day. Windrush Day is new:  the British government instituted it only last year, on the 70th anniversary of the arrival of the demobbed troop ship HMT Empire Windrush at Tilbury Docks in 1948 — and only partly coincidentally, in the 70th anniversary year of the NHS.

From that ship disembarked some 1,029 passengers, two of whom had stowed away. You may have seen reports that 492 ‘West Indians’ arrived on the Empire Windrush; in fact, a total of 802 passengers came from somewhere in the Caribbean. Photographs reveal that the great diversity of the Caribbean region was well-represented on Windrush: we see amongst the crowds on deck faces reflecting African, Asian, European, South American, and mixed heritage. 539 passengers reported that they previously resided in Jamaica, 139 had previously lived in Bermuda, while others came from Trinidad, British Guiana and other Caribbean islands. 119 listed England as their last country of residence, and 66 passengers on the Empire Windrush were Poles displaced to Mexico during WWII. Dozens of the Caribbean men had served in the RAF. Other Caribbean passengers listed occupations ranging from ‘household domestic’ (96 – the largest group, including many women) to ‘mechanic’ (85, the second largest group), ‘scholar’ (18), ‘civil servant’ and ‘boxer’ (3); the ship transported a single hatter, judge, and potter, and two piano repairers. 274 fell into other smaller occupational categories. A bare majority of the Caribbean passengers who reported a specific destination knew they were heading for London. As British subjects, all entered the country legally, as they were entitled to do by the British Nationality Act of 1948.

The ‘empire’ in Empire Windrush, is important – though it certainly does not feature very often in the official annual celebratory narrative of events! Britain was still a major imperial power in 1948, with colonies around the world but especially in the Caribbean, Africa, the Pacific region, and Southeast Asia. India and Pakistan had only become independent in 1947, while Sri Lanka and Myanmar gained their independence just months before the Empire Windrush landed its passengers on English soil. Forty-six formal colonies remained, and the sun still never set on the British empire.

And a rebuilding Britain, with its newly expansive Welfare State, had perhaps never in peace-time needed the people it had colonised more. In particular, the new National Health Service that would open its doors on the 5th of July 1948 depended on migrant workers from its very first day. Doctors, nurses, builders, carpenters, cleaners, cooks, clerical staff and porters from the colonies and Commonwealth were absolutely essential if the State was to fulfil the promise made to the British people: that everyone in Britain, regardless of their ability to pay, would have universal access to all necessary medical care free at the point of need.

It is this significant contribution that we here at the People’s History of the NHS will be celebrating between now and the 22nd of June. Every week, we will post five portraits and life-stories shared as part of Inès Elsa Dalal’s ‘Here to Stay’ exhibition, commissioned by the Sandwell and West Birmingham Hospitals NHS Trust. Every week, we will accompany these amazing images and accounts with a blog addressing the history and heritage of Windrush for the National Health Service. And on the 15th of June, we will open to the public two physical exhibitions celebrating Windrush right here on the University of Warwick campus. Put the date in your diaries, and we will tell you more as we go along!

Sources:

You can read a summary of the passengers’ details here: https://www.bbc.co.uk/news/uk-43808007, or view the original passenger lists yourself in person at the National Archives (https://discovery.nationalarchives.gov.uk/details/r/C9152210) or search them on Ancestry.

The National Archives also has a variety of materials on Windrush available digitally: for instance, you can look at Prime Minster Clement Attlee’s response to concerned Parliamentarians  here: https://www.nationalarchives.gov.uk/education/resources/attlees-britain/empire-windrush-2/

If you are interested in learning more about the Polish passengers, you can start here: https://www.britishfuture.org/articles/windrush-poles/ or here

https://www.theguardian.com/uk-news/2018/jun/22/the-other-windrush-generation-poles-reunited-after-fleeing-soviet-camps