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

An efficient, productive NHS?

One of the most long-standing public policy discussions about the National Health Service revolves around efficiency: its efficiency as a health system and the efficiency of its employees. As early as 1951 officials at the Ministry of Health began assuming the service was over-staffed, circulating a memorandum that year instructing Regional Health Boards to reduce headcount by five per cent across the board.  That circular, like many later efforts to cut staff costs, demanded health service managers obtain savings by improving the staff productivity without affecting care, effectively asking them to do more with less.

Such exhortations no doubt sound familiar to present day NHS staff, many of whom will have worked through several rounds of cost-cutting, all aimed at increasing productivity and reducing headcount, usually accompanied by soothing words about not harming “frontline” services.

Since the 1950s the NHS has seen various schemes of this type. The premise behind the 1962 Hospital Plan, introduced by Enoch Powell then reinforced by the 1964 Wilson Government, was that spending on new buildings and new equipment to modernise the NHS would be accompanied by better working practices and staffing reductions. Freed from inefficient old hospitals, all categories of NHS staff would be empowered to shed wasteful habits and old-fashioned ways of doing things.

Hoped for improvements were not to be left to chance. The Health Ministry’s Advisory Council for Management Efficiency hired hundreds of efficiency experts to conduct “organisation and method” studies at dozens of hospitals, examining how workers were managed. These ran parallel to “work study” programmes, where hospital workers were watched and timed during their shifts in the hope of uncovering promising areas for improving productivity.

These programmes were not uncontroversial. Acknowledging that absolute efficiency had the clear potential to adversely affect the quality of care, nurses and doctors were largely excluded from their purview. Work study was overwhelmingly targeted at support staff, particularly laundry, catering, cleaning and portering staff, under assumption that their effort could easily be intensified without cutting the clinical attention paid to the sick.

By the mid-1960s, NHS work study operatives had generated studies claiming huge reductions in these categories of staff, sometimes as much as 25 per cent, could be obtained, if new working practices were extended across the NHS.

The mechanism through which this was to be achieved was “productivity bargaining”. Trendy in management science circles in the 1960s, “productivity bargaining” expanded across British industry as a solution to low productivity and increasing numbers of strikes. Firms looked to negotiate bonuses with their workers in exchange for the adoption of new, more efficient, working methods. NHS managers and health workers’ trade unions reached a general agreement to implement bonus schemes in 1967, with the unions hoping that cash incentives would improve their members abysmally low pay. The usual caveat applied from the Ministry of Health that bonus schemes were not to be ‘injurious to the well-being of the sick’.

Progress thereafter was impossibly slow, with just 3 per cent of support staff enrolled in any bonus scheme at all by 1971. As it turned out neither managers nor workers felt that “productivity bargaining” offered them much. Desperate to achieve some kind of improvement in this area, the government’s National Board on Prices and Incomes (NBPI) recommended that hospitals implement interim schemes, where workers were offered bonuses simply for agreeing to reductions in staff numbers, echoing the crude memorandums of the 1950s.

Why were these schemes such failures? At the time, ministry officials suggested bureaucratic inertia was largely to blame. Managers were stuck in their ways and resistant to new ideas. Evaluating the failure in 1971, the NBPI Report blamed hospital administrators and heads of departments for not being ‘alive to the need to keep bonus schemes once introduced under control’. They argued ‘any incentive payment scheme decays in time unless constant attention is paid to its working’.

In their frustration, the NBPI’s investigators revealed why the outcomes of these “productivity and efficiency” programme has historically been so poor. The NHS, for all its varied practices and results, was (and is) a cheap health service and much of its workforce went above and beyond their stated work norms precisely because of their moral investment in work. Extra productivity could only be extracted by continuous management effort to win more intense effort from staff who were already stretched by the NHS’ enormous demands. Health care was labour intensive service work, the efficiency of which was difficult to measure and compare, and even more difficult to make more productive. Moreover, the distinction between “frontline staff” and every other kind of health worker was built on the fiction that support staff were somehow less vital to quality care.

“Work study” was by no means the last attempt to extract more effort from the NHS’ workforce; the 1980s saw the introduction of private sector managerialism; and in the 2000s the Blair government developed an obsession with targets and metrics as a motor for modernisation. Since 2012 Strategic Transformation Partnerships mark the latest attempt to extract more work from health workers. Future health planners might do well to acknowledge previous failures to intensify “productivity” and perhaps be a little more sceptical about the likelihood of drastically improving performance.

 

Nurse training over time – a guest blog by John Beales

This is a guest blog kindly written for us by John Beales.  John is a former nurse, and worked in the NHS from 1983 until 2000.  He is now undertaking a Masters degree in History at the University of Bristol.

These two records of the presentation of certificates for the completion of nurse training and badges awarded upon qualification in 1961 and 1987 are separated by more than just time; they subtly reveal the changing nature of nurse training. At the Royal Northern Hospital in London, where my mother trained as a State Registered Nurse, in order to receive a certificate of training and the coveted hospital badge you had to complete a fourth year of ‘training’ by working as a staff nurse at the hospital for a year after qualifying.  The Chief Physician, Chief Surgeon, Hospital Chairman and the Matron signed her certificate of training.  When I qualified as a Registered General Nurse at University College Hospital in London in 1987 you received a hospital badge when you completed the 3 year training, and my certificate was signed by the Director of Nurse Education and the Chief Nurse Advisor; nursing having freed itself from the dominance of Medicine and having established specialist nurse tutor roles.  The signs of the changes are there in the absence of the Matron as the exemplar of authority within nurse training and their replacement with a Director of Nurse Education.  The differences are also there on the covers of the presentation booklets, the ‘University College Hospital School of Nursing’ being dually identified as the ‘Bloomsbury College of Nurse Education.’

But in reality the focus was still on training rather than education. Whilst changes in the role of nurses, the availability of sterile supplies, changes in service provision and technology meant that I did not have to cook patient’s breakfasts, perform the regular ward and theatre cleaning and manual cleaning and sterilising of equipment that were a feature of my mother’s training, my own training was still predominantly practical, focusing on ‘hands-on’ care and skills acquisition: blocks of shift-based clinical placements lasting roughly 8 weeks being interspersed with weeks of classroom teaching. As a student nurse you were part of the workforce, rather than being supernumerary, and I recall plenty of instances where students were left in charge of wards or other clinical areas, this being part of your ‘management training’, as well as a result of expediency if there were instances of staff sickness or errors in shift rota planning. However, my mother and I both recall that our training gave us realistic expectations of the nature and variety of nursing practice and fostered both an esprit de corp and an allegiance to our training hospital: the award, and wearing, of your training hospital badge when you qualified being something to be proud of.

 

 

Nursing degrees were rare when I qualified and the practice-based nature of nurse training meant that most courses lacked wider academic recognition. Change was inevitable due to both the need to ensure that nurses were prepared for the rapid pace of developments in care delivery and the desire for recognition as a profession. Project 2000, introduced in the 1990s, began the move from hospital to university based nurse education. Many commentators have gone on to bemoan this change, blaming it for a perceived loss of ‘compassion’ in nursing and the fostering of unrealistic career expectations. I think that both of these have been overstated. But, an area that seems to have been overlooked is the way in which hospital based training, and the award of your training hospital badge when you qualified fostered a sense of belonging amongst nurses in the NHS, and how that has been diminished since the move to University based education; clinical placements now normally taking place at a variety of different hospitals. In the absence of the award of qualification badges by universities, and a move away from the wearing of them due to concerns about infection control and patient safety, the most common place you find these badges now is on online auction sites. Now retired after a 48 year long career in the NHS my mother still has her training hospital badge. I left the NHS in 2000. Last year I sold mine on e-bay.