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Journal of Health Policy & Opinions
A Historical Look at Indian Healthcare Professionals in the NHS
Balmukund Bhala 1, Aruna Bhala 2, Neeraj Bhala 3
1 Consultant Anaesthetist, Wellingborough
2 Community Paediatrician, Northampton General Hospital
3 Consultant Gastroenterologist, Queen Elizabeth Hospital, University of Birmingham NHS
Foundation Trust, Birmingham
Key words
NHS, Indian, Healthcare professionals, contribution
cite as: Bhala B, Bhala A & Bhala N. A Historical look at Indian healthcare professionals in the
Doctors and nurses from the Indian subcontinent have been working in the UK healthcare
sector for over a 100 years. Initially only open to Europeans, Indians were allowed to enter
the Indian Medical Service (IMS) in 1855, although the requisite was that they had to sit exams
based in London and had to be registered with the General Medical Council (GMC). At the
time there were many schools training Indian doctors, but only as licentiates. In relation to
medical education, through pressure applied by the IMS, indigenous courses for the training
of Indian doctors were abolished and several medical colleges, modelled along western
pedagogic styles, were established. The staff of all these colleges were appointed from the
IMS and their methods of instruction were virtually indistinguishable from those practised in
England and Scotland. Indian degrees were recognised in 1892 by the GMC and this
recognition persisted until 1975, with a short interlude in the mid-1930s when there was a
dispute between the GMC and the Government of India about the quality of Indian medical
education. 1
However, the development of medical practice in India did not follow the pattern that should
integrate indigenous practice with ‘western medicine’ and they should not be over reliant on
medically trained professionals, relying instead on medical assistants and health workers who
did not have to undertake a full-fledged medical training. The emigration of Indian doctors,
the failure to produce a coherent medical policy, and the absence of public-health medicine
and health facilities in rural areas meant that Indian degrees were quite suitable for working
in England, but probably totally irrelevant for working to the benefit of the vast majority of
the Indian population. 1 It is estimated that by 1945 there were ‘no less’ than 1000 sian
doctors throughout Britain, 200 of them in London alone and most of them working in primary
care. In 1960, Enoch Powell, Health Secretary took the lead to change the immigration policy
in order to meet the workforce demands of the NHS. Improved immigration policy helped,
amongst others, Indian doctors and nurses to study further and progress to more secure jobs.
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In the 60s and 70s, many internationally recruited healthcare workers faced open racism and
discrimination often leading to repetitive failures in examinations and stunted career
progression͘ TV comedy series ‘The Indian Doctor’ portrayed the challenges faced by Indian
healthcare professionals working in remote communities 3 . It is also true that many doctors
were also probably influenced by the ‘Gandhian philosophy’ of service to the benefit of
humanity without personal rewards. This is perhaps why many doctors also ended up in
deprived areas and became involved in local politics. At the end of the 1970s, the Royal
Commission on the NHS 2 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. A 2005 report
found that in 2003, 29% of NHS doctors were foreign-born and that 44% of nurses recruited
to the NHS after 1999, were born outside the UK.
s the gaps existed in unpopular areas or ‘hard to fill’ specialities, they were allowed to work
in inner cities or remote areas as well as district general hospitals. There was already an
official acknowledgement of the roles that these overseas doctors were playing. In a debate
in the House of Lords in 1961, Lord Cohen of Birkenhead commented on the fact that:
‘The Health Service would have collapsed if it had not been for the enormous influx from junior
doctors from such countries as India and Pakistan.’ 4
Lord Taylor of Harlow in the same debate said:
‘They are here to provide pairs of hands in the rottenest, worst hospitals in the country because
there is nobody else to do it.’
Although it is useful to understand immigration from the point of view of the state, it is also
important to acknowledge that, much like the late 19th and early 20th century, because of
the links that have already been described, many overseas qualified doctors had a personal
desire to come to England to improve their clinical training, to work in the great institution of
the NHS, and to pick up skills that they would then take home. Many of course chose to
immigrate permanently, but the most common reason for coming was to obtain skills and
then go back. Even to this day the premium of British experience continues to play well
particularly in the private medical sector in many Commonwealth countries. But what was
clear from the outset was that both the jobs and the experience available to this influx of
immigrant doctors were going to be severely restricted. Over half of migrant doctors were
disappointed with their experience of working and studying in this country. 5 So they ended
up being tied to the UK and the NHS, because returning without fulfilling their aspirations was
not an option.
The experience of the International Medical Graduates (IMGs) and nurses included themes
such as, the devaluation, self-blame, discrimination/lack of equal opportunity, invisibility,
experiencing fear and tolerated such behaviour for fear of being thrown out with their
families. As the primary motivation was to provide an excellent service to their patients rather
than seek recognition or fame, the contribution of many doctors and nurses of Indian origin
were forgotten and lost in the NHS. Frustrations grew and interviews revealed some common
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themes for dissatisfaction such as; feeling devalued and deskilled and perceptions of racial
discrimination, not feeling personally or professionally valued and unmet expectations. 6,7
Migrant doctors were more likely to become GPs against their inclination, and more likely to
be practising in a speciality that was not their first choice. They were also more likely to feel
that they had progressed more slowly in terms of postgraduate training and experience.
These included the policy of rotating posts at teaching hospitals. This may also apply to
vocational training schemes. 5 Working at a teaching hospital helped in the fostering of vital
informal networks which could greatly influence a young doctors entry into the key areas of
many specialties. Having trained outside of Britain migrant doctors were more likely not to
have cultivated a reputation in a British teaching hospital from which rotational opportunities
tended to arise.
Despite such negative experiences participants indicated that the experiences gained whilst
working in the NHS were useful. IMGs who wanted to see the NHS and the general working
environment improve, took active parts in meetings of British Medical Council (BMA) and the
GMC. A need was felt to have an Indian associations of doctors in different regions of UK,
hence organisations like Overseas Doctors Association (ODA), Indian Medical Association
(IMA-UK) were conceived. In parallel other organisations sprung up from Hindu International
Medical Mission to Sewa International, BAPIO to Global Association of Physicians of Indian
Origin (GAPIO), as a way to represent the Indian doctors globally.
NHS is celebrated by the politicians and public alike as a great British institution, yet from its
inception it has been crafted and nurtured by the contribution of a significant number of
international medical and nursing graduates. Incorporating narratives from migrant
healthcare workers into general histories of the NHS would give us a more holistic
understanding of the past and a different perspective on the present. It is in this sense that
one would argue for a need to broaden understanding of who the ‘architects’ of the NHS
were. NHS is an evolving organisation brought into existence by the actions of thousands of
people, many of whom were migrants, rather than as a monolithic structure established by
politicians and civil servants in the immediate aftermath of World War II. Approaching the
history of the NHS from such an angle could lead to a better understanding of what impact
migration might have had on the development of healthcare in Britain. Is the daily practice of
psychiatry in Britain influenced by the fact that the specialty employed hundreds of
practitioners trained in the Indian subcontinent? To what extent has engagement with ethnic
minority patients been shaped by the presence of migrants in the NHS workforce? Our
inability to provide detailed answers to such questions is a major gap in our understanding of
how the NHS evolved. 1,9
As NHS enters its seventh decade and a new 10-year strategy is revealed, there needs to be a
greater understanding and acknowledgement of the huge contribution of international
medical and nursing workforce in the shaping of the future of this country. In 2018, as NHS
turned 70, the Royal College of General Practitioners (RCGP) exhibition has attempted to
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highlight the contribution of IMGs (many from the Indian subcontinent) as architects and
lifeblood of NHS and primary care provision in the UK.
We now understand that healthcare migration has mutual benefit to both countries of origin
as well as adopted lands. This is evident in USA, Canada, Africa, Australia and New Zealand
through further emigration/immigration. Medical immigration also expanded beyond
medical world as many doctors brought with them, through their leadership, wider cultural
concepts of spirituality and alternative practices (i.e. acupuncture, yoga, pranayama) to better
health of the nation. Our next steps includes recognising the role of women from within the
UK and amongst migrants, in the NHS. 8 The Interim NHS People Plan needs to understand
the aspirations and well-being for staff across boundaries and find sustainable solutions to
continue to provide for the wide-ranging aspirations of the NHS Long term plan. Political
leaders need to decide on the narrative for educating the public on the contribution of
migrant health workers and crucial role they play in providing excellent care. NHS Employers
and regulatory bodies need to clean up their acts in providing culturally sensitive support,
demonstrate emotional intelligence and provide equal opportunities to reach one’s potential͘
Brexit effect might create more opportunities in near future, if recent visa problems could be
handled properly. The UK, as we know it today, is to a great extent the result of population
movement. Migrants do not just bring a colourful presence, different cultures, music and food
but shape nations by working in industry, public services and becoming involved in civil
society. 10
NHS is a role model for other countries including India are aspiring to. Evidence of that is seen
in some reverse migration to India. Hopefully other countries will benefit from excellent
leadership and patient safety experience in NHS. Our problems of the past are diminishing
but new problems might replace them and we need to identify them so we could tackle them
head on. Organisations such as BAPIO have a huge leadership role to play in the present and
future of the NHS. We would like to remind our readers what Swami Vivekananda advised our
next generations: ‘Not to forget our Indian roots, with our spirituality as the base!’
References
1. Esmail A. Asian doctors in the NHS: service and betrayal. Br J Gen Pract. 2007
Oct;57(543):827-34. PMID: 17925142; PMCID: PMC2151817.
2. Royal Commission on the NHS, Sub-Committee B Overseas Doctors, Note by the
Secretariat (no date). BS 6 /3573, National Archives, Kew.
3. Avatar Productions, Bang Post Production (post-production), Rondo Media. The Indian
Doctor (2010-). Distributors; British Broadcasting Corporation (BBC) (2010) (UK) (TV)
4. Kyriakides C, Virdee S. Migrant labour, racism and the British National Health Service.
Ethn
Health. 2003;8(4):283-305.
5. Smith D. Overseas doctors in the National Health Service. London: Policy Studies Institute;
1980.
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6. Nichols J 1 , Campbell J. The experiences of internationally recruited nurses in the UK
(1995-2007): an integrative review. J Clin Nurs. 2010 Oct;19(19-20):2814-23. doi:
10.1111/j.1365-2702.2009.03119.x.
7. Alexis O 1 , Vydelingum V , Robbins I. Engaging with a new reality: experiences of overseas
minority ethnic nurses in the NHS. J Clin Nurs. 2007 Dec;16(12):2221-8.
8. Fiona Johnson: Diversity within diversity: Nuffield Trust, 2018
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addressing a collective amnesia' and its policy implications. J R Soc Med.
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