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Society, Politics & Law

International health service: How the NHS has always relied on overseas labour

Updated Wednesday 15th August 2018
This content is a part of our Brexit Hub, and is field under
Topic: Welfare

Potential NHS staff from outside of European Economic Area (EEA) will shortly find it easier to secure permission to work in the UK. Yet doctors and nurses from the EEA may no longer have the right to do so. Dr Parvati Raghuram looks at how the NHS has depended on foreign workers since its creation.

Creative commons image Icon Bradford Timeline on Flickr under Creative Commons BY-NC 4.0 license NHS leaflet from 1948 The claim that the National Health Service (NHS) would get an additional £350m per week if the UK quit the EU was arguably one of the most persuasive slogans of the Brexit campaign. The NHS has been one of the prides of the post-war social architecture and has come to be closely tied to British identity. Skilfully linking the NHS with Britishness was a winning strategy for Leave campaigners.

Commonwealth countries and the (Inter)National Health Service

Migrant doctors from Europe, especially Jews who moved due to rising anti-Semitism in parts of Europe, had always formed a part of the medical profession in the UK. However, after the establishment of the NHS in 1948, many of the early flows were from the British Commonwealth countries. Training and work were inextricably intertwined through immigration regulations and the architecture of the health service, ensuring a steady supply of doctors - as shown in the table below.

The NHS has always been an international health service. It has been populated by large numbers of migrant doctors who not only served the NHS, but also constituted it, innovating and establishing it through specialist services in remote locations all over the UK. From the 1960s onwards, a number of legislative changes were made to attract migrant doctors, who would come to populate the lower and middle parts of the pyramidal medical hierarchy. They did not contribute to a pre-existing NHS; rather they made the health service what it is today.

Immigration rules affecting Commonwealth migrant doctors

Year Regulation
1962 Voucher system introduced
1971 Vouchers abolished; work permit system introduced
1985 Four-year permit-free training scheme introduced
1997 Nature of training available to non-EU migrants altered. Training typically takes five years, but all training posts had shorter stay periods 
2006 Non-EU migration virtually closed 

Immigration and EU workers key dates

Year What happened?
Before 1914 Free movement
1957 Reintroduction of freedom of mobility of workers through the Treaty of Rome
1973 UK joined European Community
1992 Freedom of mobility of citizens - Maastricht Treaty
2004 onwards Expansion of the EU (ten countries joined in 2004; two in 2007; and one in 2013)

The NHS and the EEA

Since the early 2000s, there has been a shift towards recruitment from within the European Economic Area, which is shown in the table below. Freedom of movement within Europe led to an increase in the pool of migrant doctors, and in 2006 a dramatic shift took place - a virtual end to the migration of doctors who are third country nationals, i.e. those whose primary medical qualifications were obtained outside the EEA.

Migration regulations only tell half the story. Professional workers like doctors can practice in the UK after registering and obtaining the appropriate licence. Under EU law, doctors within the EEA cannot be discriminated against, but in June 2014 a new English language test was introduced for those trying to obtain the licence to practice in the UK. This led to a reduction in the numbers of doctors obtaining a licence, compared to those who registered.

Number of registered and licensed doctors in the UK by primary country of qualification

PMQ country of origin 2010 2011 2012 2013 2014 2015 2016 2017
Austria 35 38 20 37 28 19 19 16
Belguim 43 36 36 22 37 31 35 45
Bulgaria 166 139 129 94 89 20 32 33
Croatia 1 2 3 23 110 24 23 25
Czech Republic 116 141 128 124 102 60 80 103
Denmark 30 20 17 16 25 7 14 7
Estonia 13 7 10 9 12 4 5 10
Finland 13 7 10 9 12 4 5 10
France 41 51 50 72 72 15 29 21
Germany 195 138 129 138 135 57 80 70
Greece 282 365 524 465 406 123 171 169
Hungary 207 186 175 125 89 44 57 63
Iceland 5 5 1 5 1 2 1 1
Ireland 129 145 137 170 174 242 244 241
Italy 370 386 425 610 744 124 137 137
Latvia 59 25 26 22 18 14 11 21
Lithuania 71 45 38 38 44 8 13 26
Malta 20 23 42 39 40 24 48 62
Netherlands 43 57 86 106 114 72 98 72
Norway 3 6 3 5 12 3 3 2
Poland 158 113 137 163 173 82 95 123
Portugal 48 64 92 82 104 47 30 54
Romania 677 449 288 276 263 108 170 164
Slovakia 40 40 49 44 57 17 28 29
Slovenia 7 3 17 10 15 3 6 11
Spain 124 159 264 323 247 49 67 65
Sweden 21 25 22 21 22 11 23 15
Switzeland 29 27 37 37 28 10 17 28

And back again to the Commonwealth?

Ten years later the tables turned as the UK voted to leave the EU. This led to large drops in the number of some health professionals such as nurses, although the full effects are yet to be documented across the sector. Growing staff shortages in some parts of the health sector are causing concern that the EEA will no longer serve the health workforce requirements of an ageing and rising population and its attendant demands for health care.

Nurse NHS Creative commons image Icon 12019 on Pixaby.com under Creative-Commons license Although some areas such as emergency medicine, paediatrics and psychiatry have almost always been on the list of shortage specialties and are allowed to recruit internationally, shortages are now more widespread. Moreover, the cap on Tier 2 visas (previously the Work Permit category) from outside the EEA to a maximum of around 20,000 per year across all the professions - alongside the demand from some other sectors such as IT, for these visas meant that many areas of the health service remain understaffed. NHS bosses have claimed that this significantly affects their ability to deliver healthcare safely and have pressed for the removal of the cap. The Home Secretary has now capitulated to these demands. What is clear is that the NHS, as ever, struggles to remain national.

Yet this internationalism of the NHS is only one exemplar of the UK’s position within a world of connections - with Europe and with other countries, including the Commonwealth. Only when the power and necessity of these connections and their role in making the UK what it is today is recognised will anti-immigration arguments and sentiments about Europeans and non-Europeans alike be challenged.

This article was previously published on the LSE Brexit Blog

 

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