Intended for healthcare professionals

Feature NHS at 70

Where are UK trained doctors? The migrant care law and its implications for the NHS–an essay by Julian M Simpson

BMJ 2018; 361 doi: https://doi.org/10.1136/bmj.k2336 (Published 31 May 2018) Cite this as: BMJ 2018;361:k2336
  1. Julian M Simpson, writer, Lancaster, UK
  1. simpsonjm{at}icloud.com

Locally trained doctors tend not to want to work in areas of high deprivation and need, and we continue to rely on foreign trained doctors to fill massive gaps. Medicine should acknowledge this historical trend and tackle the dysfunction arising from its contemporary manifestations, writes Julian M Simpson

When I started researching my recent book,1 and speaking to members of the first generation of South Asian GPs to work in the NHS, I was struck that I kept returning to parts of the UK that for the first four decades of the NHS were predominantly industrial and working class. The people I was interviewing had mostly had careers in inner cities and industrial areas. I met them at their homes and practices in the former coalfields of South Wales, Fife, and Yorkshire, and in the urban areas that made up Britain’s industrial heartlands: Glasgow, the Midlands, Manchester, and the East End of London.

This was no coincidence. Medical migration from the former British empire in South Asia was a fundamental aspect of the working class experience of healthcare in Britain in the period I researched (from the 1940s to the 1980s) and beyond. By the end of the 1980s, although about 16% of GPs in England and Wales were from South Asia, their distribution was hugely uneven.

In fact, there was a stark divide. Few South Asian doctors practised in areas that were generally more middle class and rural. In Somerset or Cornwall or the Isles of Scilly, for instance, less than 1% of doctors in 1992 had qualified in South Asia. GPs from the Indian subcontinent were largely catering to the residents of generally working class and industrial areas. In some parts of England, such as Walsall in the Midlands and Barking and Havering in Greater London, they accounted for more than half of the GP population. In cities like Birmingham, Manchester, and Liverpool, about a third of GPs had trained in South Asia.2

“All the doctors looked like Dr Salam”

A research participant recalled that one of his young patients in south Wales, on being admitted to hospital, was surprised to be treated by white doctors as “he thought all the doctors look like Dr Salam.” This is all the more important because of the central role that general practice gradually took on in the NHS, with care increasingly delivered in community settings, and GPs acting as gatekeepers to secondary care. In effect, South Asian GPs were the first point of contact with the NHS for millions of patients. This is why I chose to call my book Migrant Architects of the NHS.

The core principle of the NHS is that it provides care without charge at the point of delivery. This means that, at least in theory, social and financial status should not affect patients’ ability to access care. But of course, to deliver on this promise, you need enough doctors to provide care. It was South Asian doctors who made it possible for the NHS to develop as a system built around primary care and who helped staff the surgeries providing care for patients who historically had struggled to afford to see a doctor. They should be seen as architects of the NHS in the same way that Aneurin Bevan and William Beveridge are.

Nature of “doctor shortages”

The usual narrative in relation to medical migration is that the work of doctors like these helps to compensate for doctor shortages. But what does this expression mean? The huge variations in the proportion of South Asian doctors in the GP population indicate a wider issue. They helped staff general practice, which was at the time seen as an unpopular career option by many UK graduates. And the doctor shortages were also specific to particular geographical areas. The problem was not so much a shortage of doctors in the UK as a shortage of doctors willing to take on particular roles.

During the same period, as thousands of South Asian medical graduates settled in Britain, thousands of their British trained counterparts chose to pursue careers in places like Australia, New Zealand, South Africa, the US, and Canada rather than take up the positions that South Asian doctors did.

Essentially, the history of general practice in the first 40 years of the NHS is also the history of a lack of alignment between the aims and needs of the NHS and the social and professional aspirations of doctors trained in British medical schools.

British general practice today continues to be shaped by these dynamics: much of the GP workforce comprises non-UK-qualified GPs who work longer hours and serve a larger number of patients in deprived areas.3 This has wider implications for medicine and healthcare. This phenomenon is not confined to the UK; nor is it exclusive to general practice.

In general, doctors consider complex short term interventions, involving younger patients and the upper part of the body, more prestigious than work focused on chronic conditions and older patients.4 Lower status roles in locations viewed as less glamorous have provided career opportunities for incomers, who lack local networks and have historically been subject to discrimination. Over half the doctors who had become NHS consultants in learning disability between 1964 and 1991, for instance, were non-white and trained abroad. For cardiothoracic surgery it was 6.5%.5

No go areas

Similar processes occur in other countries. Overseas trained doctors are crucial to provision in remote and rural settings in Australia and in care for Aboriginal patients.6 Abraham Verghese, in his account of his time as a hospital doctor in the US Appalachians, a postindustrial landscape comparable to the Welsh valleys, recounts that there were so many doctors in one hospital with the common Indian surname Patel that they became known by their specialty–“pulmonary Patel” or “gastroenterology Patel.” 7

The Italian doctor and writer Carlo Levi called his memoir of life in exile in southern Italy under Mussolini Christ Stopped at Eboli, suggesting local people felt they were on the margins of mainstream society, seen as less than human, with the town of Eboli like a border post.8 Levi was asked to help in an emergency because he was medically trained:

“They had learned of my arrival at the town hall and had heard that I was a doctor. I told them that I was a doctor, to be sure, but I had not practised for many years, that there must be a doctor on call in the village and that for this reason I must refuse them. They answered that there was no doctor and that their friend was dying.”

Clearly, doctors also stopped at Eboli in Italy in the early 20th century. They have since continued to avoid certain types of work with particular sections of the patient population, and migrant doctors have often filled the resulting gap. In fact, these patterns are so common that Cuba has developed a countermodel, with its doctors providing care to less affluent and marginalised populations around the world in areas where, to quote the title of a book on the subject, No Doctor Has Gone Before.9

In practice, this means that the highest need and vulnerable populations—poor, elderly, disabled, and mentally ill patients—are more likely to be cared for by migrant practitioners.

Forty seven years ago, Julian Tudor Hart formulated the inverse care law, which says that the availability of medical care tends to vary inversely with the need of the population served.10 It has an additional dimension: the proportion of locally trained doctors tends also to vary inversely with the need of the population served.

Dysfunction in current healthcare policy

The question of why that continues to be the case, and how to adjust the running of healthcare systems to reflect these facts, should be a central concern for policy makers. It has profound, but largely unacknowledged, implications for the way medical systems are run.

History should help us understand one of the paradoxes at the heart of this problem: training more doctors is not alone an adequate response to “doctor shortages.” Once doctors have qualified they are in an international jobs market. If nothing is done to tackle the fact that British doctors have tended to migrate rather than take jobs that they deem undesirable, the government’s aim to achieve medical self sufficiency by producing more medical graduates will most likely mainly serve to boost the healthcare systems of other countries in years to come.

Reducing dependency on medical migrants requires measures such as changing the recruitment processes and culture of British medical schools. They should look at the diversity of their recruitment on a range of criteria—not simply gender and ethnicity but also social background. A recent report by the UK government’s Social Mobility Commission found that professions such as medicine “remain dominated by the privileged.”11 This surely perpetuates the historical flight from working class areas.

Radical change is needed to change doctors’ perceptions of some specialties to boost recruitment to them. For instance, admitting students to university exclusively to study psychiatry, geriatric medicine, genitourinary medicine, or general practice rather than allowing a student body to form that develops aspirations that tend to see such options as second best. A training system that produces graduates who disproportionately aspire to work in middle class areas or take on roles that are perceived as heroic can only be described as dysfunctional. That is unless the medical profession thinks it appropriate not to train enough physicians willing to cater for all conditions and all sections of the population.

Racism and discrimination in medicine

Until radical cultural shift occurs, modern healthcare systems will remain reliant on migrant doctors. There should therefore be greater recognition of the specific work medical migrants tend to do and reflection on what support they require. This should include measures to tackle the racism and discrimination in medicine that shapes doctors’ career paths (not least when it comes to their concentration in particular specialties and geographical areas) and affects their ability to realise their full potential as professionals.

We also need to develop greater understanding of migrant doctors as vectors of culture and professional practices. This is about linguistic skills that can benefit patients (when doctors speak the same language as migrant or ethnic minority patients), approaches to care that the host healthcare system might learn from (currently, the burden tends to be on migrants to adapt), and, say, how imported religious beliefs or social attitudes might shape patient care, for better or for worse.12 Paradoxically, we have little understanding of the effect of medical migration, even though it is a key aspect of modern healthcare.

Biography

Julian M Simpson has published widely on the history of the migration of doctors. He is the author of Migrant Architects of the NHS: South Asian Doctors and the Reinvention of British General Practice (1940s-1980s) (Manchester University Press, 2018). He holds degrees from the Institut d’Etudes Politiques de Paris and the Ecole Supérieure de Journalisme de Lille as well as an MA from the University of Northumbria and a PhD from the University of Manchester, where he worked as a researcher in the faculty of medicine between 2008 and 2017. He is a member of the committee of the Oral History Society.

Footnotes

  • Competing interests: I have read and understood BMJ policy on declaration of interests and declare that I have none.

  • Provenance and peer review: Commissioned; not externally peer reviewed.

  • For more on the NHS at 70 see https://www.bmj.com/nhs-at-70

References

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