Medical Migration and the NHS

This is the third piece in the ‘Moving People’ feature, which explores the ways in which people on the move are labelled, remembered, and constrained. The series offers a historical understanding of present-day structures of asylum and immigration.

The British National Health Service (NHS) has struggled with staffing virtually since its inception and has long relied on migrant medical labour to plaster over shortages. At present, the staffing crisis is particularly acute with a decade of austerity, resulting in cuts to funding and wages in real terms, damaging staff retention and contributing to an estimated shortfall of some 84,000 employees – with approximately 1 in 10 nursing posts lying vacant. Overseas recruitment remains the favoured strategy for addressing shortages, with healthcare thinktank, The King’s Fund, recommending that an additional 5,000 international nurses be recruited over the next three years. However, in light of the formal shift to a post-Brexit “points-based” immigration system, ushered in this past January, relying on an ability to recruit internationally appears naïve. Whilst the Home Office has insisted that medical migrants will not be hampered by the new restrictions – through the creation of special “health and care worker” visas – we can take lessons from history here. This is not the first time that a restrictive migration regime has sought to navigate the NHS’s structural dependence on migrant labour.

British migration controls began creeping in with the 1905 Aliens Act, but initially only targeted ‘alien’ citizens, that is, those not from the British Empire. It wasn’t until the 1962 that former imperial subjects – now Commonwealth subjects – were affected, with the first Commonwealth Immigrants Act. The Act responded directly to increasing concerns about the levels of specifically non-white migration from the so-called ‘New Commonwealth’, with migrants from India, Pakistan and the West Indies, frequently singled out in debates surrounding the legislation. Further demonstrating the racial motivations of the act, consistent attempts were made to exclude white citizens from the Old Commonwealth – i.e. Australia, Canada and New Zealand – from the new restrictions. Once passed, the Commonwealth Immigrants Act put arrivals from the New Commonwealth on similar footing to alien labour migrants by introducing a three-tiered voucher system relying on employment and employability-based criteria for entry. Category A was for those holding job offers, category B for those holding specific skills, and a limited number of category C vouchers were allocated by lottery. Though category C allowed a certain number of Commonwealth citizens an unrestricted right of entry to the UK, in practise, very few of these vouchers were issued, and in 1965 they were done away with entirely.

The 1962 Act did not immediately threaten the inward migration of NHS workers, since these groups easily qualified for category A and B vouchers. The problems began with a 1965 White Paper on “Immigration from the Commonwealth”, which introduced an overall ceiling on the total number of vouchers to be issued per year and was initially capped at 7,500. The cap created scarcity within the voucher system and pitted government ministries against each other, since each sought to secure enough vouchers for their own shortage occupations. The Ministry of Education wanted to secure priority for teachers, the Ministry of Technology for ‘scientists’ and ‘technologists’, the Ministry of Health (MOH) for doctors, nurses, and so on.  All lobbied the Ministry of Labour (MOL), who oversaw voucher issue.

The MOH began to frantically monitor the number of vouchers issued to all professions, to ensure no group was being granted priority above medical professionals – doctors in particular. The new cap had transformed voucher issue into a zero-sum game. More vouchers for one group meant less for another. A handwritten MOH memo from June 10^th, 1965, lists the number of vouchers issued to teachers, nurses, doctors, dentists, scientists, technologists and ‘others’ (figure 1, above). Even though doctors received far more vouchers than any other category, the authors remained concerned that:

“the number of scientists and technologists appears to be growing rapidly (& will be squeezing out others)”.

The MOH then began lobbying for NHS workers to be granted overall priority with the Minister for Health, Kenneth Robinson, appealing directly to the Minister of Labour, Ray Gunter in October, 1965. Robinson urged Gunter to consider “priority for doctors, dentists and nurses over other classes at present equally eligible”.

These lobbying efforts intensified in 1966, when it appeared that the number of vouchers issued to doctors had fallen sharply in the first year of the cap, prompting the MOH to go over the MOL’s head and appeal directly to the official Commonwealth Immigration Committee, writing:

“[Since] The current shortage of doctors in this country is acute […] any hindrance to the inflow of doctors from other countries is a cause of grave concern to the Health Departments, and, if it became widely known, could be a matter for considerable public criticism.”

The threat of ‘public criticism’ directly contradicted the MOH’s own public messaging on medical migration at the time, which consistently downplayed the reliance of the NHS on migrant labour. In 1962, a draft response by the MOH for parliamentary questions was edited down from the statement that Commonwealth migrants “undoubtedly [make] a valuable contribution to the running of the hospitals” to the statement that they “make a contribution to the staffing of the hospitals”. In October of 1965, in an interview for The Guardian, the MOH attempted to dismiss concerns about the impact of the new migration cap on NHS staffing, stating they did not expect it to cut “down the number of doctors and qualified nurses coming from the Commonwealth”. The response made no mention that the MOH was feverishly tracking the number of vouchers issued to Commonwealth doctors on a monthly, and in some cases, weekly basis.

Nowhere is the MOH’s acute awareness of the NHS’s reliance on migrant labour more clearly demonstrated than in their approach to foreign policy. In March 1966, the MOH had become concerned that the Indian government was about to impose restrictions on the emigration of doctors. This would have been catastrophic for NHS staffing, for Indian doctors were by far the largest migrant doctor group. In retaliation, the MOH suggested flooding the system with vouchers to Indian doctors, hoping that the more vouchers were issued, the more doctors were likely to be able to evade these restrictions. These measures would have directly undermined other branches of the British government, specifically, the Commonwealth Relations Office (CRO), who were taking great pains to reassure the Indian government that the UK was not interested in siphoning off their medical labour. The CRO sought assuage India’s fears by portraying Indian doctors working in the NHS primarily as students, who would eventually return to the motherland. The MOH’s desperation to secure NHS staffing levels through Indian migration would have directly undermined this rosy view of medical migration as a mutually beneficial training scheme.

In the end these measures were not implemented since the number of Commonwealth doctors arriving appeared to level out. However, even though the new cap did not cause the number of arrivals to fluctuate significantly, waiting lists for vouchers skyrocketed. Both the MOH and the MOL recognised the negative impact these prolonged wait lists were having on the quality of doctors arriving, speculating that higher quality candidates with relevant experience and more advanced degrees would be deterred. In a letter from November 26^th 1966, a MOL official writes that

“I am quite prepared to admit we do not necessarily get the best doctors by this [voucher] method”.

The UK migration regime of the 1960s sets several important examples for our post-Brexit dilemma. Firstly, it shows that overall migration caps will affect medical migration even if these migrants are eligible for entry and are granted priority, as was the case for Commonwealth doctors in the 60s. At present, the Conservative Party has stated that healthcare workers will be exempt from Tier 2 visa caps however, this says nothing about whether they will be counted in overall migration numbers. If they are, then healthcare workers are not exempt from the proposed cap on overall migration. We can thus expect similar hostilities to arise between government ministries who will seek to ensure that their departments get a bigger slice of the migration pie. Global Talent Visas will provide a second route for the entry of “highly-skilled workers” however, the government has already stated that these visas will be capped and so they pose the exact same problems as the Tier 2 route.

It was also recognised as early as 1966 that the obstacles created by a restrictive immigration system made the UK a less attractive destination for highly-skilled migrants, and likely lowered the calibre of arrivals. This directly contradicts the Conservatives’ repeated claims, that the end of free movement will help Britain attract the “best and brightest”. Most crucially, this example highlights the fallacy of attempting to distinguish between “good” and “bad” immigrants. It should be emphasised that at the same time as  government ministries were scrambling to secure entry for groups with specific skillsets – read: “good” migrants – political discourse at large was busy likening these populations to a literal disease. In the 1960s, South Asian migrants in particular, were continuously associated with tuberculosis, smallpox, and rickets. Thus the very same groups which were recruited to provide healing hands to the nation, were also being framed as the source of its infection. The hostility fomented towards South Asians at large, directly fed into the logic underpinning increasing migration restrictions, and thus obstructed the entry of so-called “good” migrants. This government has failed to learn the lessons history has to offer. If you sow the seeds of vitriol and intolerance, try as you might, you cannot separate the “good” from the “bad” migrants, you cannot separate the wheat from the chaff.

Acknowledgements: I am particularly grateful for the support given by the Leverhulme Trust in this line of research.