The NHS is traditionally viewed as a typically British institution; a symbol of national identity. It has however always been dependent on a migrant workforce whose role has until recently received little attention from historians. Migrant Architects draws on 45 oral history interviews (40 with South Asian GPs who worked through this period) and extensive archival research to offer a radical reappraisal of how the National Health Service was made. This book is the first history of the first generation of South Asian doctors who became GPs in the National Health Service. Their story is key to understanding the post-war history of British general practice and therefore the development of a British healthcare system where GPs play essential roles in controlling access to hospitals and providing care in community settings. Imperial legacies, professional discrimination and an exodus of British-trained doctors combined to direct a large proportion of migrant doctors towards work as GPs in industrial areas. In some parts of Britain they made up more than half of the GP workforce. This book documents the structural dependency of British general practice on South Asian doctors. It also focuses on the agency of migrant practitioners and their transformative roles in British society and medicine.
Chapter 1 describes the evolution of British general practice between the 1940s and the 1980s, a period during which it took on a role as the ‘cornerstone’ of the NHS. In the years that immediately followed the inception of the NHS in 1948, the field’s status was low and the Collings report of 1950 offered a damning assessment of the care it offered. Gradually however, policy makers placed an increasing focus on the provision of care in community settings rather than the more costly environment of hospitals. In parallel, general practice went through a process of professionalisation and was recognised as a medical specialty. The combined effect of these developments was to consolidate the position of primary care at the heart of the British healthcare system. General practice nevertheless remained a fragmented field, with practitioners enjoying a great deal of professional autonomy. South Asian migrant doctors were key to these developments. General practice remained unpopular with British-trained doctors, so the presence of migrant doctors masked a recruitment crisis which was particularly acute in industrial areas. The fragmented nature of general practice also resulted in them having a significant impact on the nature of care on a day-to-day basis.
Chapter 2 connects the history of the NHS to the history of the British empire and post-war migration. The arrival in Britain of the South Asian medical graduates who became GPs was the product of a very specific post-imperial context that existed in the forty years following the establishment of the NHS. The post-war migration of doctors was not a spontaneous or new phenomenon-it is linked to the long history of British medicine in South Asia and is an amplification of longstanding imperial flows of doctors to Britain. Medicine on the Indian subcontinent had been fundamentally shaped by its imperial past. Conversely, in a growing NHS, their labour offered a solution to the staffing needs of the new organisation, particularly in junior posts, in unpopular specialties and in industrial areas. There was a time lag between the formal end of empire and the dismantling of its legacies such as the freedom of doctors to move to Britain and their ability to gain recognition for their qualifications. This explains how between the 1940s and the 1980s South Asian doctors came to take on such an important role in the British healthcare system.
Chapter 3 shows that a key factor behind the large-scale migration of South Asian doctors to Britain was the lingering effect of what Andrew Porter has called the ‘empire of the mind’. South Asian medical systems functioned along post-imperial lines rather than being radically redefined. British medicine remained a model to be emulated and South Asian medicine continued to situate itself in relation to medicine in Britain. Imperial legacies shaped medicine on the Indian subcontinent and more generally the thought processes of doctors. These after-effects of empire can be detected in doctors’ accounts of their medical training and careers in medicine as well as when they discuss their personal backgrounds and wider exposure to British culture. This context is essential to understanding the post-war movement of South Asian doctors to Britain. Migration thus appears in doctors’ oral history interviews as a ‘natural’ process as one of them put it, rather than a hiatus.
Chapter 4 shows how a discriminatory professional environment limited doctors’ professional options and how their responses to this context contributed to defining the nature of British general practice. The entry of medical migrants into general practice was unplanned both by central government and doctors themselves. Understanding how doctors ended up working as GPs and being overrepresented in industrial parts of Britain involves developing an appreciation of the environment that the NHS provided at the time. Doctors’ decisions to stay in Britain were made in a professional context which was characterised by racism and what Albert Memmi has termed ‘heterophobia’ (i.e. the fear of difference). Being marked as non-white, and more generally as different directed South Asian doctors towards less prestigious roles in medicine, such as being a GP. A second layer of discrimination occurred within general practice, resulting in migrant doctors being disadvantaged when it came to obtaining GP positions in the more desirable areas.
The professional options of South Asian doctors who decided to stay in Britain were limited, notably as a result of racism and heterophobia. The presence of significant numbers of South Asian doctors in general practice in industrial and inner-city areas in nevertheless partly ascribable to their agency: they actively decided to remain in Britain and forge careers as GPs even though this was not the type of work they envisaged doing initially. The entry of a significant number of South Asian doctors into the profession of general practice was not officially orchestrated or even encouraged at a national level by the British government or the leaders of the medical profession. The individual choices to become GPs made by thousands of South Asian doctors had a major structural impact on the development of British primary care. By the early 1990s, around 30% of GPs in major cities such as Birmingham and Manchester had qualified in South Asia and in some parts of the country (for instance Walsall in the Midlands) South-Asian trained doctors made up more than half of the NHS’ GP population.