Neo-colonialism may not be a word that is part of every-day conversation and neither has it been a term given much consideration by successive UK governments. To say this is unfortunate is an understatement. An understanding of neo-colonialism is essential in understanding how the NHS – and the UK for that matter – has evolved into what it is.
Neo-colonialism can be summarised as a form of control where a powerful country or bloc both influences and benefits from a less powerful country or bloc, without direct political rule, using economic, institutional, cultural or structural mechanisms.
NHS staffing and Britain’s colonial past
So how does this relate to the NHS? Put simply, the UK is the powerful country. It has influenced other, poorer countries by encouraging people to come from them to work in the NHS. As a result, the UK has benefited, by fulfilling the human resource needs of the NHS, up to a point. This has been achieved using all the mechanisms listed above: economic (the prospect of improved pay and conditions), institutional (the NHS), cultural (English is taught in many overseas schools; I taught some bright students in the Sudan who had aspirations to become doctors), and structural (medical training).
While there may no longer be a British Empire, the former colonial power is still exercising that power by creating a voluntary brain drain that the governments of less developed countries (LDCs) have been unable to prevent. The UK government has in turn given little consideration to the impact this brain drain has had on the healthcare systems of LDCs.
The NHS is free for all at the point of use. However, what lies behind this statement is where the true costs and impacts are really felt.
From the early days of the NHS in 1948, it was recognised that there were an insufficient number of medical personnel within the UK to meet the growing demands for its developing services. At the time, the government failed to launch a major drive to encourage UK citizens into the medical profession. Medical school places were only modestly expanded and medicine was considered an elite profession. There was no recruitment campaign to meet the need, and the nursing profession was characterised by long hours, low pay and institutional living, which did not encourage retention.
This prompted the need to meet the demand for trained medical personnel from overseas, which by the mid-1950s had become government policy. Initially, recruitment targeted Ireland, but it soon turned to the Caribbean, India, Pakistan, Bangladesh, Sri Lanka, many African nations and, more recently, the Philippines.
There was no formal assessment of the impact the recruitment of trained medical personnel had on the health services of the countries people were being encouraged to leave. This is now on the agenda of the World Health Organisation.
The impact of NHS recruitment
Ireland
The impact of NHS recruitment on medical services in Ireland was significant and damaging. Ireland effectively subsidised the NHS with its medical workforce for decades and this was felt particularly in rural areas. In some years between the 1950s and 1970s more than half of Irish medical graduates left Ireland, with the majority headed for the UK. This wave of emigrants would have Included my maternal grandfather, Dr Ernest Connell, who left Dublin in the 1940s to establish a medical practice on the South Quay in Great Yarmouth, who served the community and seafarers alike for decades, and left a family legacy of two further generations of medical practitioners. This includes my mother. She worked as a nurse until the effects of constantly having to lift overweight patients onto their beds (bear in mind this was before health and safety concerns) produced a form of repetitive strain injury that severely and permanently distorted her wrist, leaving her with an uncompensated lifetime of pain and successive (some botched) operations, until a diagnosis of rheumatoid arthritis enabled her to receive a disability allowance.
The point is that Ireland bore the cost of training, while the UK gained the workforce.
The Caribbean
The impact across the Caribbean – Jamaica, Barbados, Trinidad and Tobago, Guyana and others – was severe, long-lasting and far more damaging than in Ireland. In many places the emigration of medical personnel hollowed out entire health care systems. Between the 1950s and 1970s, 30-60% of trained nurses left. Some nations had only one medical school, whilst others none. Extraction under unequal conditions – the draw from an impoverished nation to the wealthier UK – was known about but largely ignored. As with my own, many families have stories to tell about their experience of emigration and working in the UK. As one recent academic study puts it: “Caribbean nurses were disadvantaged and continue to be disadvantaged through clear patterns of institutionalized racism, marginalization, discrimination, and devaluing of prior credentialing and knowledge.”
India
India’s experience was similar to the Caribbean’s, albeit on a different scale in terms of population and training facilities. From the early 1950s, the UK became the destination for many Indian-trained doctors. Through the 1960s and 1970s tens of thousands of Indian-trained doctors worked in the NHS (including at the South Quay practice in Great Yarmouth). The loss of doctors hit the poorest states in India the hardest. The Indian government’s investment in training was lost. Extraction under unequal conditions was once again prevalent, with India’s size hiding the harm but not preventing it. A 2017 study puts it this way: “The costs and human capital losses associated with health worker migration are presumed to be significant for India, but have not been fully assessed in terms of overall numerical or policy significance.”
Pakistan
The impact on Pakistan was even more acute than in India because there were fewer medical schools, a weaker health care infrastructure and far fewer trained medical professionals. Since the 1960s, Pakistan has been one of the major source countries for overseas-trained doctors for the NHS. The impact of this has been to leave whole districts in Pakistan without adequate medical cover, and government investment in training lost.
Bangladesh
The impact on Bangladesh (East Pakistan, before 1971) was also serious and was exacerbated by extreme need and a limited supply of trained medical professionals. Post independence, the NHS was the main destination for junior doctors, mid-wives and nurses. This has left many areas in Bangladesh with no doctor coverage and led to increasing numbers of deaths from preventable conditions. Extraction under unequal conditions, once again, is a pattern that has persisted over the years.
Sri Lanka
In the past, Sri Lanka proved to be an exception to the norm and was impacted far less, as it was able to protect its healthcare system through government policy. The outward migration of doctors was less extensive than in other countries due to the self-protection measures Sri Lanka took: retention policies ensured medical personnel would not be drawn to the NHS.
Sri Lanka may once have had something to teach other LDCs hoping to limit the brain drain. However, recent statistics show this is no longer the case, as significant numbers of Sri Lanka-trained doctors are leaving the country.
Africa
The impact on many African countries has been catastrophic. Medical personnel have been drawn from Nigeria, Ghana, Kenya, Uganda (specifically nurses), Zimbabwe, Zambia, Malawi, Sierra Leone and South Africa.
Between the 1970s and 1980s some countries lost between 30-70% of their trained doctors, with nursing losses even higher. Impacts included empty hospitals, hospitals staffed by nurses alone and long distances for people to have to travel for basic care. Preventable deaths from treatable conditions increased. The UK Government was aware of these consequences, but once again chose to ignore them.
The Philippines
A very different scenario arose in the Philippines: the export of health care workers became a deliberate state strategy, which of course does not lessen the impact on domestic health care. Large scale migration to the NHS commenced in the 1970s and over the 1990s-2000s Filippino nurses were one the largest overseas nursing groups in the NHS.
The impact within the Philippines has left many rural areas chronically understaffed, with hospitals facing retention problems along with high staff turnover. The standard of training (based on the US system) is higher. On arriving in the UK, many nurses are more highly trained than the roles they perform, which benefits the NHS, but undermines the value of the individual.
It is not uncommon to learn of people from the Philippines being duped into paying fees for bogus overseas jobs, which can include being flown to an overseas destination and abandoned because there was no job. (It is sad indeed to learn that since my time there that this type of scamming continues). It was common in the days of the corrupt presidency of Ferdinand Marcos (you may recall his wife Imelda’s love of shoes), something truly abhorrent in a country where the average per capita income today is around $3,500 per annum, a fact that explains in part why the attraction of working overseas is so great.
The loss of healthcare workers – a long-term problem for LDCs
Overseas-trained medical personnel do not often return to their country of origin. Rather, they move on to other countries such as Australia, New Zealand, Canada or the US.
This is therefore a permanent and debilitating drain on the already limited resources of less developed countries and is one reason amongst many that perpetuates global health care inequality.
A study by Health Workers 4All (Collection of Case Studies 2015)- states: “If the situation remains as it is today, one billion people will never see a health worker in their life.” (p.24).
Compensation – and a taste of our own medicine?
Should compensation be paid to the governments of the countries that invested in their healthcare systems for limited return? Let’s remind ourselves of what happened in a different era. On the abolition of slavery, the UK government was lobbied by the powerful slave owners to be compensated for their losses.
There is probably no likelihood that the once ‘Great’ Britain can or ever will repay its debt to those countries that have helped sustain John Bull’s health at the expense of the very many.
Another question: what would happen if the LDCs prevented people emigrating to work in the NHS? There is some evidence they might. As long ago as 2008, a group of researchers from India wrote:
“In light of growing awareness of the adverse impact of physician movement, a few developing countries have asked destination countries to financially compensate the countries of origin for losses.”
As the saying goes, ‘what goes around, comes around’.
After decades of attracting medical staff away from less developed countries – with the impacts on their healthcare systems – a self-inflicted wound is developing in the NHS, a result of the current national mood of myopic nationalism, increased immigration controls, and racism.
Is it any wonder that fewer and fewer people from overseas want to work in the NHS? When John Bull’s arteries clot, he may have a long wait on the stretcher because the doctors and nurses he told to “go home” did just that.
Food for thought when you next need to use the NHS.
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