The National Health Service is one of the largest employers in the world, and is the largest employer in Britain itself. It relies on a very wide range of professions and occupations to keep its doors open – from the highly visible doctors and nurses to the often-forgotten or undervalued porters, cleaners, cooks, carpenters, electricians, and managers, among many others. As my colleague Jack Saunders discovered, the figures can be surprising: in 1963, for example, the NHS employed more construction and maintenance staff than hospital doctors (19,552 vs 18,095). And as we know, the NHS has long had a voracious appetite for workers from abroad. This has made it, almost since its inception, one of the most diverse workplaces in the UK. These blogs have reiterated what has become a well-known claim: that migrant workers saved the NHS (and that they still keep it afloat today). But how exactly did they do it, and in what numbers?
Let’s start with a ‘numerical snapshot’ of inward migration to Britain in the early years of the NHS. This was the era of ‘Open Door’ Britain, framed by the British Nationality Act of 1948 which made all ‘British subjects’ into ‘Citizens of the United Kingdom and Colonies’. It is worth noting that this comprised, at least in theory, millions of people: virtually every man, and a much-increased majority of women then alive who had been born or naturalised in the British Isles, Britain’s remaining colonies, protectorates, and the former Dominions of Australia, Canada, Ceylon (Sri Lanka), Newfoundland, New Zealand, India, Pakistan, Southern Rhodesia (Zimbabwe), and the Union of South Africa. Under the 1948 Act, all of them (and the subsequent children of fathers covered by the Act) were entitled to come to the United Kingdom freely, and to take up residence there. However, legislators at the time apparently anticipated little change in established migration patterns, in which there was extensive migration from the British Isles out to the Empire; a free inward flow from the Republic of Ireland and of British subjects from the ‘Old Commonwealth’ (mainly Australia, Canada, and New Zealand); and relatively limited, largely elite, temporary migration to the UK of everyone else.
They were wrong: new transport and communications technologies, lower costs, and the global economic and political turmoil that followed World War Two and decolonization, as well as Europe’s enormous demand for labour both during reconstruction, and with the rise of service-intensive welfare states, prompted significant increases in migration, not least to the UK. The newcomers had no difficulties finding work: of the 233 men who disembarked from the Windrush on 22 June 1948 and travelled on to London, 148 were already in jobs by the 1st of July, with 11 more anticipating immediate placements. By 1958, approximately 125,000 West Indians had come to the UK to work. In the same period, 55,000 migrants arrived from India and Pakistan, many displaced by Partition. These unanticipatedly high numbers would, by 1961, prompt ever tighter immigration restrictions – but notably, such legislation always turned a wary eye towards the needs of the NHS.
As Emma Jones and Stephanie Snow have shown, the new National Health Service was especially greedy for workers to take up the low-paid jobs that local populations rejected once better opportunities were available: porters, cooks, cleaners, and ancillary workers were all in short supply. Nursing shortages, already extensive before 1945, became desperate as the NHS struggled to cope with the enormous backlog of unmet health needs. By 1948, there were 54,000 nursing vacancies, and by 1949 the Ministries of Health and Labour were working actively with the Colonial Office, the Royal College of Nursing and the General Nursing Council to actively recruit Caribbean women. They would fill the yawning gaps in the Service’s nursing, auxiliary and domestic workforces. Their numbers climbed steadily – by late 1965, there were as many as 5000 Jamaican women staffing British hospitals, and by 1977, 12% of all student nurses and midwives in Britain were recruited overseas, with 66% of those from the Caribbean. Numbers for auxiliary and domestic workers are harder to come by, but pictures and stories of NHS hospitals in this period show us that they made essential contributions across the Service, as so many of their descendants do today.
Doctors too were imported from Britain’s diminishing empire and former colonies in large numbers. By 1960, almost 40% of junior doctors in the NHS came from India, Pakistan, Bangladesh and Sri Lanka—countries that, because of the ties of empire, already taught their medical students in English, and indeed, had a significant medical presence in Britain even before the NHS opened its doors. These doctors, like their fellow recruits into nursing, were essential to the survival of the NHS in its first decades. By the 1960s, this was routinely recognised in British politics and culture: ‘without them, the Health Service would have collapsed’ became a truism of the immigration restriction debates of the 1960s and early 1970s. Figures from 1971 suggested that 31% of all NHS doctors in England were born and educated abroad.
Britain’s dependence on a global clinical workforce was reflected in British immigration law. Even Enoch Powell, during his tenure as Health Minister from 1960-1963, actively recruited Caribbean nurses, though their automatic right of entry was removed by the 1971 Immigration Act, and work permits for training nurses were abolished in 1983. These restrictive changes proved to be short-sighted. Strategies to end the UK’s dependence on overseas nurses persistently fell short between the 1970s and 1990s, not least because domestic recruitment was crippled by poor pay and often appalling working condition. New Labour renewed international recruitment in 1998. By 2003, over half of all new nurse recruits had trained abroad. Doctors’ freedom of mobility, meanwhile, continued uninterrupted and almost entirely unrestricted – though so too did the limitations formally and informally placed on them in terms of their access to the most desirable or high-status training posts, specialities, and other professional opportunities.