Julian M Simpson

Writing migrants back into NHS history: addressing a 'collective amnesia' and its policy implications.

The National Health Service (NHS) has used migrant workers from its inception. As early as 1957, the Willink Committee on medical manpower found that 12% of doctors in a random sample taken from the Medical Directories of 1953 and 1955 were mainly overseas-trained.2 The majority of these doctors had entered Britain during or after World War II, suggesting that many of them would have been Jewish and Central European refugees from Nazi-dominated Europe. Later, migration from the Indian subcontinent became a key dimension of the recruitment of doctors in Britain. At the end of the 1970s, the Royal Commission on the NHS estimated that between 18,000–20,000 registered doctors in the UK were born outside the UK, with half of these being from India or Pakistan.3 In the 1950s and 1960s, large numbers of Irish and Caribbean nurses were essential to the expansion of NHS services, a pattern that was replicated in the early 2000s when nurses from Africa, India and the Philippines came to the UK.4 A 2005 report found that in 2003, 29.4% of NHS doctors were foreign-born and that 43.5% of nurses recruited to the NHS after 1999 were born outside the UK.5 In spite of this long history of substantial migration into the NHS, little effort has been made to understand the ways in which it has influenced the development of healthcare in the UK. The popular perception of the NHS as a ‘typically British’ institution (in a restrictive white sense rather than in an inclusive sense) tends to prevail in public perceptions of the organization and in its self-image. Of the 19 photos used by the BBCs online archive to illustrate the development of the NHS up to the 1970s, not one shows a black or Asian person.6 The ‘historical timeline’ on the NHS website makes no reference to immigration.7 Political and organizational histories of the NHS pay scant attention to migrants. A word search for ‘immigration’ in Rivetts online National Health Service History yields little more than the occasional passing reference to overseas doctors.8 Nor can much be found in Websters two tomes on the health services since the war.9 Where there is a focus on migrant health professionals in the NHS, the themes most widely covered are the experiences of individual groups of migrants and discrimination. This includes the dearth of opportunities for overseas doctors,10 the lack of recognition of the skills and experience of migrant nurses,11 exploration of how Irish nurses construct identity,12 reflections on the experiences of Black and Minority Ethnic NHS employees in the North West of England13 and a vast literature on racism grounded in empirical evidence14 as well as theoretical analysis.15 These studies have generated a wealth of useful data but three fundamental issues require further examination. First, there is a basic need to document and recognize the scale of the dependency of the NHS on immigration. Second, to what extent were migrants facilitators of development and/or agents of change within the NHS? Third, can a better understanding of this history inform policy?

Access to general practice in England: time for a policy rethink.

Improving access to general practice is one of the current priorities of healthcare policy in England and offering patients timely access is central to this agenda. A £50 million ‘Challenge Fund’ to support pilot initiatives offering GP appointments earlier and later in the day was set up in 2013 and a further £400 million has now been pledged to expand this programme. British Prime Minister David Cameron has promised that patients will be able to see a GP 7 days a week from 8 am to 8 pm and his Health Secretary Jeremy Hunt has outlined plans to recruit an additional 5000 GPs to make this possible.1,2 The Government believes that this policy will reduce admissions to accident and emergency (A&E) services.3 However, its approach is not based on any detailed evidence that there is a strong link between access to general practice and recourse to A&E.4 It also involves privileging a particular dimension of access to general practice over others. This article explores how policy came to be dominated by concerns about speed and convenience, and calls for a wider debate that incorporates other aspects of access. Access to general practice can be described as having three main components:5 If this definition is borne in mind, it would be logical to conclude that policy aimed at improving access would involve addressing these different dimensions of care …

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

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

International medical graduates and quality of care

The care is good, now we must tackle the prejudice

The UK's dysfunctional relationship with medical migrants: the Daniel Ubani case and reform of out-of-hours services

In 2008, a patient died in the UK after being given an excessive dose of diamorphine by an overseas-trained doctor working in out-of-hours (OOH) primary care. This incident led to a debate on the recourse to international medical graduates and on the shortcomings of the OOH system. It is argued here that a historical reflection on the ways in which the NHS uses migrant labour can serve to reframe these discussions. The British Medical Association, the General Medical Council, and the House of Commons Health Committee have emphasised the need for more regulation of overseas graduates. Such arguments fit into a well-established pattern of dependency on and denigration of overseas graduates. They give insufficient weight to the multiple systemic failings identified in reports on OOH provision by the Department of Health and the Care Quality Commission. Medical migrants are often found in under-resourced and unpopular parts of healthcare systems, in the UK and elsewhere. Their presence provides an additional dimension to Julian Tudor Harts inverse care law: the resources are fewer where the need is greatest, and the practitioner dealing with the consequences is more likely to be a migrant. The failings of the UK OOH system need to be understood in this context. Efforts to improve OOH care should be focused on controlling quality rather than the movement of doctors. A wider reflection on the nature of the roles that international medical graduates are asked to play in healthcare systems is also required.

Adding the past to the policy mix: an historical approach to the issue of access to general practice in England

Abstract Historical perspectives can be embedded into policy initiatives through a process of ‘past-proofing’—ensuring new policies take the study of the past into consideration. We describe how this was done in a project looking at patient access to general practice in the NHS. We argue that current preoccupations with timeliness which have led to the marginalisation of other dimensions of access are connected to a broader process of neo-liberal reform since the 1970s. This reflection can support a reframing of the terms of current debates on a major issue in British health care. It has wider implications for the policy relevance of history.

Why We Should Try to Get the Joke: Humor, Laughter, and the History of Healthcare

Abstract This paper advances two central arguments. The first is that focusing on humor and laughter can play a central part in enhancing our understanding of the contemporary history of healthcare. The second is that the value of the meaning contained in humor and laughter has thus far been underestimated in the field of oral history. Our discussion of these issues is grounded in an analysis of oral history testimony and documents gathered in the course of research into the history of the London hospitals, Guy’s and St Thomas’, and of their associated institutions (i.e., medical schools, staff associations, and the like) since the 1970s. Note on Multimedia Content: The online version of this article doi:10.1093/ohr/ohw110 includes audio files that allow readers to listen to some of the printed interview excerpts. In the HTML version, readers may simply click and play; in the PDF version, it is necessary first to download the PDF.