On Saturday 5 July  the UK will celebrate the establishment of the NHS, arguably one of the greatest British achievements of the post-war years. Politicians, the media, and of course, the health services are celebrating this landmark achievement, reflecting on the history of the NHS and also looking forward to the challenges facing this very British institution.
The NHS was the brain child of Aneurin Bevan and drew upon his experience of the medical aid scheme offered in Tredegar in South Wales by the major employer in the town, the Tredegar Iron and Coal Company. Bevan became minister for healthcare and housing under Clement Attlee’s post-war government and used this opportunity to radically restructure medical care, ensuring that it was free at the point of delivery for all citizens, irrespective of their ability to pay. It has become one of the hallmarks of British identity, summoning up what the then Chancellor of the Exchequer Gordon Brown referred to on January 14, 2006 in his speech to the Fabian Society as 'one of the great British institutions – what 90 per cent of British people think portrays a positive symbol of the real Britain – founded on the core value of fairness that all should have access to health care founded on need not ability to pay.’
Since the inception of the National Health Service, migrant doctors have been seen as an integral but devalued part of the health workforce. These doctors were necessary for its operation, providing a mobile army of labour in the lower rungs of a pyramidal medical hierarchy, ensuring that UK doctors at the apex did not have to compete too much for pickings from the much diminished private sector. Overseas qualified doctors were provided training in the health service in return for meeting the health service requirements of the population. They were, however, systematically disadvantaged in terms of access to jobs, career mobility, the places where they found employment and the specialties they could occupy. They have come to be called ‘sepoys’ and ‘indentured labour’ pinpointing the situations of trained migrant doctors and the organization employing them. Disproportionately represented in training posts and in non-career grade posts they have, however, been a backbone for the development of this very British institution. Thus, in 2003, only 17 per cent of South-Asian doctors were consultants compared with 42 per cent of white doctors, which provides some evidence that migrant doctors from South-Asia continued into the present century to find their careers limited by the hierarchical nature of the NHS.
But one of the specialties where they have found a home and established a niche is geriatric medicine, a specialty that too was born in 1948. Marjory Warren, often considered the “mother of geriatrics” established the first geriatric unit in the UK, where older patients were admitted, rehabilitated and sent home. This was an innovation in elderly care at that time. Before the establishment of the NHS doctors had provided free medical service to support the charity hospitals but had earned substantial incomes, on the whole, through private practice. After the establishment of the NHS and the amalgamation of most existing hospitals, including the workhouses, into the national provision, doctors’ salaries were paid for out of the national taxation system and there was some resistance to taking over the regular care of elderly frail people. Geriatrics became associated with the wider disdain given to its clientele, older people. As such it became a ‘Cinderella specialty’, a disregarded area of healthcare serving the needs of one of the least regarded groups of patients. However, the work of a few pioneers such as Marjory Warren, slowly changed the nature of healthcare for old people with the development of acute care for older people and its own subspecialisms. It began to offer a career trajectory and eventually became what it is today, the second largest specialty with just under 900 consultants in hospitals. As we enter an ageing society, this development of geriatrics within the NHS is set to continue.
In part responding to the dire medical neglect of older people within the NHS hospital system and in part to government and management pressure to improve bed occupancy figures, geriatric medicine grew rapidly, to large extent depending on recruits from overseas for its expansion. But this 'Cinderella specialty' status also gave room for overseas trained doctors who found their own opportunities for career growth to find a home. They too became pioneers in this discipline, shaping the nature of geriatric care today. It came to be a field where South Asians could find jobs so that 22 per cent of all geriatric consultants appointed between 1964 and 2001 were non-white and had trained outside the UK, compared to 14.1 per cent of all consultants in the NHS.
These doctors felt drawn to the UK, rather than the USA, because in South Asia they were already part of a socio-cognitive community for whom markers of participation in the UK labour market were central to notions of career progression. Migration to the UK for the purpose of training, gaining membership of prestigious UK Royal Colleges (MRCP etc) has long been embedded in South Asian doctors’ professional cultures.
For many doctors, their lecturers in medical school had undergone some form of training in the UK and that upgrading and validating skills through training at one of the UK royal colleges was seen as crucial to being recognized as a good doctor. Thus, the doctors’ mobility was already embedded in a network of professional development which valued temporary movement to the UK. Moreover, at least in medicine, the power of empire continued to be forceful as medical practice and qualifications were very much influenced by regulating bodies and by professional organizations, located in the metropolis. Doctors were thus already in some ways part of a professional community where migration to the UK was seen as part of career progression.
As the country is poised to celebrate, and rightly, the establishment of one of the most remarkable institutions of twentieth century UK, it is also worth remembering and commemorating the twists of history that led to the development of geriatrics and the role of overseas qualified doctors therein.
For details of a project exploring the experiences of South Asian geriatricians, visit Overeseas-trained doctors and the development of geriatric medicine.