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.

The Windrush Generation and the NHS: By the Numbers

The National Health Service is one of the largest employers in the world, and is the largest employer in Britain itself. It relies on a very wide range of professions and occupations to keep its doors open – from the highly visible doctors and nurses to the often-forgotten or undervalued porters, cleaners, cooks, carpenters, electricians, and managers, among many others. As my colleague Jack Saunders discovered, the figures can be surprising: in 1963, for example, the NHS employed more construction and maintenance staff than hospital doctors (19,552 vs 18,095). And as we know, the NHS has long had a voracious appetite for workers from abroad. This has made it, almost since its inception, one of the most diverse workplaces in the UK. These blogs have reiterated what has become a well-known claim: that migrant workers saved the NHS (and that they still keep it afloat today). But how exactly did they do it, and in what numbers?

Let’s start with a ‘numerical snapshot’ of inward migration to Britain in the early years of the NHS. This was the era of ‘Open Door’ Britain, framed by the British Nationality Act of 1948 which made all ‘British subjects’ into ‘Citizens of the United Kingdom and Colonies’. It is worth noting that this comprised, at least in theory, millions of people: virtually every man, and a much-increased majority of women then alive who had been born or naturalised in the British Isles, Britain’s remaining colonies, protectorates, and the former Dominions of Australia, Canada, Ceylon (Sri Lanka), Newfoundland, New Zealand, India, Pakistan, Southern Rhodesia (Zimbabwe), and the Union of South Africa. Under the 1948 Act, all of them (and the subsequent children of fathers covered by the Act) were entitled to come to the United Kingdom freely, and to take up residence there. However, legislators at the time apparently anticipated little change in established migration patterns, in which there was extensive migration from the British Isles out to the Empire; a free inward flow from the Republic of Ireland and of British subjects from the ‘Old Commonwealth’ (mainly Australia, Canada, and New Zealand); and relatively limited, largely elite, temporary migration to the UK of everyone else.

They were wrong: new transport and communications technologies, lower costs, and the global economic and political turmoil that followed World War Two and decolonization, as well as Europe’s enormous demand for labour both during reconstruction, and with the rise of service-intensive welfare states, prompted significant increases in migration, not least to the UK. The newcomers had no difficulties finding work: of the 233 men who disembarked from the Windrush on 22 June 1948 and travelled on to London, 148 were already in jobs by the 1st of July, with 11 more anticipating immediate placements. By 1958, approximately 125,000 West Indians had come to the UK to work. In the same period, 55,000 migrants arrived from India and Pakistan, many displaced by Partition. These unanticipatedly high numbers would, by 1961, prompt ever tighter immigration restrictions – but notably, such legislation always turned a wary eye towards the needs of the NHS.

As Emma Jones and Stephanie Snow have shown, the new National Health Service was especially greedy for workers to take up the low-paid jobs that local populations rejected once better opportunities were available: porters, cooks, cleaners, and ancillary workers were all in short supply. Nursing shortages, already extensive before 1945, became desperate as the NHS struggled to cope with the enormous backlog of unmet health needs. By 1948, there were 54,000 nursing vacancies, and by 1949 the Ministries of Health and Labour were working actively with the Colonial Office, the Royal College of Nursing and the General Nursing Council to actively recruit Caribbean women. They would fill the yawning gaps in the Service’s nursing, auxiliary and domestic workforces. Their numbers climbed steadily – by late 1965, there were as many as 5000 Jamaican women staffing British hospitals, and by 1977, 12% of all student nurses and midwives in Britain were recruited overseas, with 66% of those from the Caribbean.[1] Numbers for auxiliary and domestic workers are harder to come by, but pictures and stories of NHS hospitals in this period show us that they made essential contributions across the Service, as so many of their descendants do today.

Doctors too were imported from Britain’s diminishing empire and former colonies in large numbers. By 1960, almost 40% of junior doctors in the NHS came from India, Pakistan, Bangladesh and Sri Lanka—countries that, because of the ties of empire, already taught their medical students in English, and indeed, had a significant medical presence in Britain even before the NHS opened its doors. These doctors, like their fellow recruits into nursing, were essential to the survival of the NHS in its first decades. By the 1960s, this was routinely recognised in British politics and culture: ‘without them, the Health Service would have collapsed’ became a truism of the immigration restriction debates of the 1960s and early 1970s. Figures from 1971 suggested that 31% of all NHS doctors in England were born and educated abroad.

Britain’s dependence on a global clinical workforce was reflected in British immigration law. Even Enoch Powell, during his tenure as Health Minister from 1960-1963, actively recruited Caribbean nurses, though their automatic right of entry was removed by the 1971 Immigration Act, and work permits for training nurses were abolished in 1983. These restrictive changes proved to be short-sighted. Strategies to end the UK’s dependence on overseas nurses persistently fell short between the 1970s and 1990s, not least because domestic recruitment was crippled by poor pay and often appalling working condition. New Labour renewed international recruitment in 1998. By 2003, over half of all new nurse recruits had trained abroad. Doctors’ freedom of mobility, meanwhile, continued uninterrupted and almost entirely unrestricted – though so too did the limitations formally and informally placed on them in terms of their access to the most desirable or high-status training posts, specialities, and other professional opportunities.

Next week, in our final Windrush Season blog, we will look at the diversity of the NHS workforce today! And don’t forget to have a look at our beautiful and ever-growing Here to Stay gallery. If you are in the area, you can register HERE to join us at the free Opening event on 15 June 2019, at the University of Warwick campus.

[1] Emma L. Jones and Stephanie J. Snow, Against the Odds: Black and Minority Ethnic Clinicians and Manchester 1948-2009 (Manchester: Manchester NHS Primary Care Trust in association with the Centre for the History of Science Technology and Medicine, 2010), pp.6-19. Do read this lovely book if you have a chance — it has great pictures too! And if you would like to record your NHS story for posterity, try the NHS at 70 Oral History project.