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.
