Here to be and to bloom: a medical student’s forced migration

8th February 20263rd March 2025 by meyg

An image of Ayman Faroug, a medical student at the University of El Fashir until 2024.

Here to be and to bloom: a medical student’s forced migration

By Ayman Faroug – MONDAY 3 MARCH 2025

Ayman Faroug was a medical student at the University of El Fashir until 2024. He had to leave in the middle of his studies. He is now seeking asylum in the UK, where he aims to complete his qualifications. A huge thank you to Faroug, who took the time to write this blog for us.

In the fall of 2010, my whole life trajectory had changed. I witnessed a horrible motorcycle accident of one of my neighbours, who had just died in front of my very own eyes. His accident was so horrific that his head had fluid leakage, which I learned so many years later in the future is termed grey matter. On that day, I felt so bad that I was incapable of helping him, and from that moment I took it upon myself to help the ill ones. You might be wondering why I am telling you such an anecdote. Just for you to have a crystal-clear idea of where I came from and where I am heading.

From a third-year medical student on the verge of starting his clinical rotations to an asylum seeker in the United Kingdom who is trying to make his way to becoming a doctor, what a turn of events.

I had just come home from El Fashir to be in the warmth of my family, and for a few peaceful days, I enjoyed everlasting tranquillity with my mom and my sisters. Just when I thought I was in heaven, with a snap of fingers, a war ensued. Since the 15th of April, the journey of illuminating fear and restlessness was ignited.

I thought I was going to die. As you are in a moment where a rifle is pressed against your head, you start to think of life and the meaning behind it. You can imagine what it’s like to be surrounded by people who are stripped of any morality, and inhumane violence is running deep in their veins. I was praying to God to make it alive; then I knew how precious living is.

I made it out alive, but I never survived humiliation, beating, verbal abuse, and a threat of six-feet-deep burial. I thought of going out there and doing some Die Hard and John Wick stuff, but reality begged the differ.

With a heart full of despair and agony, I had to leave everything behind, and by everything, I mean everything. 22 years of full-lived life just like that, from my family and long-honestly-built friendships, milestones of 15 years of education that was to be crowned with MBBS in Medicine and Surgery.

I have been through a lot of death threats, forced labour, and many other horrible incidents. I left Sudan not knowing where to go, but I ended up going to Libya, Tunisia, alongside the unforgettable 25-hour sail with a small boat to Italy. Along the way, I have witnessed, seen, and lived meanings that were once just words, such as, but not limited to honesty, manhood, divine intervention, betrayal, adventure, friendship, generosity, altruism…

I have been with people who cheated death not only once or twice but so many times. I fire-side-chatted people who Andy Dufresned themselves from Libyan jails. I slept under bridges, walked from Italy to France. Nothing was as survival of the Mediterranean Sea waves that echoed death.

The epiphany of me being in the UK is as surreal as ever, yet real. There is no shortage of moments when I felt devastated, worthless, uncertain, unwanted, and lost. If it wasn’t for Horsforth Town of Sanctuary, I know I would still be in a spiral of self-abuse. They are very compassionate, caring, loving, and supportive by helping asylum seekers and refugees and bridging the gap between us and the local community. They are the embodiment of sanctuary.

They have inspired and ignited a torch of hope in me to make my hopes and aspirations come to fruition. Hence, I have taken some practical steps in trying to get a Statement of Comparability and establishment of lines of communication to land an offer from Medical Schools. Wish and pray for me, for life taught me to never go to a war without enough ammunition: a neurosurgeon in the making.

We are here to be and to bloom.

Fear of referral: Fitness to practise and its implications on safety of migrant healthcare professionals in the UK

8th February 20265th February 2025 by meyg

Fear of referral: Fitness to practise and its implications on safety of migrant healthcare professionals in the UK

WEDNESDAY 5 FEBRUARY 2025

By Amrita Limbu, Postdoctoral Research Fellow, School of Law, University of Leeds

2023 saw more doctors with overseas primary medical qualifications join the UK workforce than those graduating from the UK medical schools.[i] While international professionals have been integral to the National Health Service (NHS) since its establishment over 75 years ago, this marks the first time that they outnumber the UK-trained graduates. In this blog, I provide an overview of how this growing number of overseas-trained healthcare professionals experience a key regulatory mechanism to protect the public – fitness to practise.

Fitness to practise refers to the process regulatory bodies like the General Medical Council (GMC) or the Nursing and Midwifery Council (NMC) use to set professional standards and take action when individuals deviate from these standards. It can be done by addressing complaints related to misconduct, competence, criminal convictions, health conditions, and knowledge of English.[ii]

In the UK, a disproportionately higher number of overseas-trained and black and ethnic minority doctors and nurses are referred to fitness to practise.

For instance, non-UK doctors are 2.5 times more likely than UK graduates to be referred to the GMC by their employers.[iii]
Additionally, of the more serious fitness to practise referrals that the GMC forwards to the Medical Practitioners Tribunal Service, 60% involved international medical graduates compared to 40% for UK graduates.[iv]
As discussed below, these disparities in referrals significantly shape how our research participants experience the fitness to practise mechanism. Existing literature highlights these disparities primarily through analysis of the referrals, outcomes, or cases, while recent research has begun to shed light on the detrimental mental health impacts of the fitness to practise procedure on healthcare professionals.[v]

In our Arts and Humanities Research Council-funded project Making it to the Registers, many overseas-trained nurses and doctors we interviewed found the regulatory mechanism of fitness to practise overwhelming, even when they had not been referred. A doctor with primary qualification from India explained, “fitness to practise is a very scary term”, describing it as “anxiety-inducing”.[vi] Similarly, a nurse trained in Nigeria noted, “honestly, I don’t know how it works, and I hope I don’t get to find that out – where my fitness to practise would be questioned”. The professionals frequently expressed concerns about the fairness of the system, citing disparities in referrals and irregularities in decisions. They pointed to recent cases where minor issues led to severe outcomes, while more serious cases received lenient sanctions.

Beyond fairness, these concerns reflect broader issues that affect migrant professionals’ sense of safety and wellbeing. Investigations by regulatory bodies raise questions about whether practitioners are “fit” to practise, alongside questions on their competence and safety for the patients. Depending on the outcome, they may be cleared without sanction, issued a caution or conditions of practice, or, in more serious cases, face suspension or removal from the registers.[vii] But prior to the outcome, they endure a lengthy period of uncertainty and are often presumed guilty if a fitness to practise concern is raised.[viii] The process can take up to 2-3 years, during which some may face suspension or unemployment, leading to significant financial burden and distressing mental health effects, especially for those with families to support.

For migrant professionals, losing their jobs or falling below a specific income threshold can have implications on their and their dependents’ visa and immigration status, affecting their ability to remain in the UK. As migrants, many are constrained by immigration-related policies such as “No Recourse to Public Funds”, which restrict access to the welfare system for certain migrants, even in critical situations.[ix]

In addition to experiencing long-term trauma, stress and anxiety, studies also report that migrant professionals feel discriminated against by their employers during the process.[x] This often reflects a workplace culture of bullying and discrimination, where ethnicity and place of primary qualification can influence how employers handle cases.[xi]

In response to the insecurity caused by the fitness to practise mechanism, many healthcare professionals we interviewed maintain dual registration with their home country nursing or medical boards, as “backup” or “insurance” measures.[xii] This safeguard measure allows them to resume practice without undergoing a re-registration procedure, which can sometimes involve an examination, should they face a fitness to practise referral or need to return to their home country.

Our study’s focus on migrant healthcare professionals reveals their insecurity with the risk of referrals as well as the absence of mechanisms to ensure their safety as practitioners. Fitness to practise aim at patient safety − to ensure that the practitioner is safe for the patient. Doctors and nurses in our study acknowledged this but also highlighted critical gaps in their own safety. As a doctor trained in Pakistan stated, “when we talk about the word safety, we rarely ever think about our safety as healthcare professionals.”[xiii]

Regulatory focus on ensuring patient safety often overlooks the intertwined needs of the healthcare practitioners. While concerns about practitioners’ safety may seem beyond the regulators’ scope, a nurse trained in Greece rightly pointed out, “if you ignore your staff, we’re going to have no one to look after the patients.”[xiv] Patient safety and practitioners’ safety are interconnected issues, as our research participants emphasise, and patient safety cannot be achieved if professionals themselves do not feel safe and lack legal security.

Further, for many overseas-trained professionals joining the UK workforce, fitness to practise is often an unfamiliar regulatory system, with no experience with a similar mechanism in their previous workplace overseas. They must navigate not only a new country but also diverse cultures and workplace environment. Often, referrals arise from differing interpretations of cultural competence rather than clinical competence.[xv] With growing number of overseas healthcare professionals, regulators like the GMC and the NMC recognise the need to incorporate training and support for the non-UK trained professionals as part of their workforce planning and to maintain professional standards.[xvi] It is also crucial that their experiences with fitness to practise are prioritised in regulatory discussions to ensure both patient safety and practitioner wellbeing. Our study highlights how the fear of referrals creates an insecure environment for migrant healthcare professionals, who often lack confidence in their career stability, ability to remain in the UK, and most importantly, their safety as professionals. Ensuring the welfare of these professionals is crucial not only for their wellbeing but also for maintaining high standards of patient care.

[i] GMC (2024) The state of medical education and practice in the UK: Workforce report 2024. London: General Medical Council (GMC).

[ii] PSA (2022) What is Fitness to Practise? 14 July, Professional Standards Authority, https://www.professionalstandards.org.uk/news-and-updates/news/what-fitness-practise, accessed 31 October 2024

[iii] Atewologun and Kline with Ochieng (2019) Fair to refer? Reducing Disproportionality in Fitness to Practise Concerns Reported to the GMC. General Medical Council; Also see Jalal, Mustafa et al (2019) Overseas doctors of the NHS: migration, transition, challenges and towards resolution. Future Healthcare Journal 6(1): 76–81.

[iv] MPTS (2024) Medical Practitioners Tribunal Service: Report to Parliament 2023. Manchester: Medical Practitioners Tribunal Service. The MPTS conducts hearings independent of the GMC, making decisions including on whether to restrict, suspend, or revoke a doctor’s registration.

[v] Adhiyaman, Vedamurthy et al (2023) What are the precise reasons for the disparity in referrals to fitness to practise between international and UK medical graduates? Medico-Legal Journal 91(4) 198–203; Ceylan, Simsek and Bennett, Megan (2024) Understanding the impact of regulatory investigations by the GMC and GDC. Medical Protection Society. PSA Research Conference: Witness to Harm, 17th October.

[vi] Healthcare professional interview 27

[vii] PSA (2022) What is Fitness to Practise? 14 July, Professional Standards Authority, https://www.professionalstandards.org.uk/news-and-blog/blog/detail/blog/2022/07/14/what-is-fitness-to-practise

[viii] Healthcare professional interview 9; Also see Webster, Eve (2024) Nurse cleared of baby kidnap plot says life ruined. BBC, 05 September, https://www.bbc.co.uk/news/articles/c2l1y1k087vo

[ix] Limbu, Evans, and Giralt (2024) Impact of COVID-19 on migrant families in the UK. Policy Brief. University of Reading and University of Leeds.

[x] ORS (2022) An exploration of the experiences of ethnic minority practitioners and International Medical Graduates of the management of concerns about their medical practice. Swansea: Opinion Research Service (ORS).

[xi] ORS (2022) An exploration of the experiences of ethnic minority practitioners and International Medical Graduates of the management of concerns about their medical practice. Swansea: Opinion Research Service (ORS); Also see NHS Resolution (2023) Being fair 2. London: NHS Resolution.

[xii] Limbu, Amrita (2024) Uncertainty and insecurity of mobile lives: Migrant nurses in the UK NHS and the renewal and maintenance of professional registration in the home country.

[xiii] Healthcare professional interview 10

[xiv] Healthcare professional interview 19

[xv] Stakeholder interviews 2, 12, 13

[xvi] GMC (2024) The state of medical education and practice in the UK: Workforce report 2024. London: General Medical Council.

The Challenges of Active Recruitment Policies for the Moroccan Healthcare System

8th February 20262nd September 2024 by meyg

The Challenges of Active Recruitment Policies for the Moroccan Healthcare System

MONDAY 2 SEPTEMBER 2024

By Finola Durnin-Duffy, Laidlaw Undergraduate Leadership and Research Scholar, University of Leeds

I spent last year in Morocco studying Arabic and while I was there, I became interested in the healthcare system. I heard a lot of anecdotes of people taking German classes in order to move to Germany, specifically to work as nurses. This got me thinking about the migration of healthcare workers, and the effect that active recruitment has on developing countries such as Morocco. In recent years the Moroccan healthcare system has undergone many changes, new policies and funding systems have been implemented with the aim to improve overall access to healthcare and the health of Moroccans. There is a focus on those disproportionately affected by health challenges such as living in rural areas and being vulnerable to poverty due to low income. Additionally, Morocco must balance maintaining its healthcare workforce while competing with higher paying opportunities available in countries such as Germany. It is important to consider the severity of the obstacles that are currently facing Morocco’s healthcare system, in order to understand the impact caused by active recruitment of healthcare professionals from Germany and other European countries.

The issues that all Moroccans face in relation to healthcare disproportionately affect those living in rural areas. In 2006 only 16% of Moroccans were covered by health insurance – with this rate being even lower in rural areas (Boutayeb, A. 2006). Additionally, access to healthcare is affected by the quality of infrastructure. The disparity between urban and rural areas was highlighted most recently in 2023 when the Marrakech-Safi earthquake devastated numerous rural towns as well as damaging parts of the historic Medina in Marrakech. The city was not as badly affected as the surrounding towns partly due to its distance from the epicentre but also due to the fact that most buildings in the centre met modern building standards, which is not the case for the buildings in the affected settlements like the town of Tafeghaghte (Rafferty, J.P. 2023). The areas most affected by the earthquake were located in the hills where the roads are considered poor quality. The earthquake rendered many of the roads impassable during the critical period when many were in need of relief and aid. This undoubtedly contributed to the number of fatalities; reportedly even up to 5 days after the earthquake some survivors had still not been reached with the necessary relief supplies such as food, water and tents (Rafferty, J.P. 2023).

The Moroccan government was criticised for its handling of the situation after the earthquake, adding to the claims that poor governance is an issue that still needs to be addressed within the Moroccan health care system (Mahdaoui, M. and Kissani, N. 2023).

Furthermore, there is a lack of healthcare professionals working in rural areas, with over 80% of them practising in cities, despite the fact that the majority of the population resides in rural areas (Zahouani, C. et al. 2022). Arguably this is due to the fact that rural areas in Morocco are not attractive in terms of professional development.

This phenomenon is exacerbated in rural areas, where there is a lower proportion of healthcare professionals. There remains a significant unreliability in the delivery of medications, as well as a lack of technical equipment, both of which compromise the quality of medical care that can be delivered (Zahouani, C. 2022). As a training or newly qualified doctor, the concept of treating patients without the appropriate equipment or medicine is unappealing and would likely lead to most cases from rural centres being transferred to urban centres. Furthermore, many Moroccan doctors choose to specialise, potentially due to the higher wages, and this training must take place in the properly-equipped and educational urban centres. Overall, the working conditions in rural centres are poor due to the existing lack of staff, appropriate equipment, medicines and facilities. Poverty in these areas (Boutayeb, A. 2006) may contribute to increased rates of disease meaning that doctors in rural centres will face bigger challenges in regards to treating patients and professional development. These factors mean young doctors are unlikely to choose these areas as their place of work.

In addition, many Moroccan healthcare professionals complete their training in Morocco, free of charge, only then to migrate abroad (Zbiri, S. 2024), particularly to Europe, in order to obtain a higher salary (Idrissi, B.I. et al. 2023). According to the Statista Research Department (2024), there was 7.2 doctors per 10,000 people in Morocco in 2019 compared to the average of 2.9 doctors per 1,000 people as calculated by the BMA (British Medical Association, 2021). The efforts of the Moroccan government to improve these ratios risk being thwarted by the emigration of qualified doctors and nurses.

Germany has previously been criticised for its active recruitment of healthcare workers, particularly from across the Balkans. Health officials in countries such as Bosnia have expressed concerns that there would be a severe lack of trained medical staff in the near future (Reuters, 2017). According to the Agency for Labour and Employment, in 2016, 10,000 Bosnians applied for work permits in Germany. According to Reuters, nurses at this time were paid between 250-400 euros per month in Bosnia and Serbia, compared to a starting salary of 1,500 euros in Germany. This wage gap begins to explain the number of healthcare professionals who responded to Germany’s 2016 call for foreign workers. Germany aimed to fill gaps in its labour markets by adjusting the visa process for foreign workers.

Despite criticism, Germany has continued to adapt its policy in order to facilitate the registration of international health workers. The skilled worker immigration law Fachkräfteeinwanderungsgesetz approved in July 2023 allows international workers fitting certain criteria to travel to Germany in search of work. This law makes it easier for those with experience or a degree in a skilled profession to settle in Germany (International Health Policies, 2023). Nurses and those with some nursing experiences are able to search for employment in Germany. Germany voluntarily adheres to the WHO Global Code of Practise on the International Recruitment of Health Personnel, which aims to ensure the strengthening of health systems by discouraging the recruitment of health workers from the 57 ‘red-listed countries’. Therefore, when German government officials visited Ghana, one of the red-listed countries, certain news agencies speculated that they were considering healthcare recruitment from Ghana. Germany is not the only country that has to be mindful of recruitment from red listed countries. In 2023 the independent Migration Advisory Committee (MAC) released its annual report stating that roughly 35% of doctors and 20% of nurses recruited to the UK are from ‘red list’ countries such as Bangladesh, Pakistan, Nigeria, Zimbabwe, and Ghana. The report stated it is possible that ‘social media algorithms’ are encouraging workers from red listed countries to migrate to the UK.

There is a lack of statistical data and few studies addressing the issue of Moroccan healthcare workers emigrating to Europe. It is apparent that there are many national causes that motivate healthcare professionals from low- and middle-income countries, such as Morocco, to relocate to European countries like Germany. While Morocco has made policy changes that stipulate that qualified health professionals must stay in Morocco to work for a set period past qualifying, it is still experiencing high levels of emigration of healthcare professionals (Sylla, A. et al.). Morocco is not on the WHO ‘red-list’ which emphasis even further the impact that active recruitment has on all countries, even those not considered high risk. These observations highlight the importance of ethical recruitment in all cases and adherence to the WHO code. The question for Morocco, like many other developing countries, is how to balance the right of an individual to move freely and the needs of the national healthcare system in which they are investing.

Bibliography

Anon. www.make-it-in-germany.com. (n.d.). Working, studying, Living in Germany. [online] Available at: https://www.make-it-in-germany.com/en/.

Boutayeb, A. 2006. Social Inequalities and Health Inequity in Morocco. International Journal for Equity in Health. 5(1).

Idrissi, B.I., Kawkaba, S. and Taya, H. 2023. L’intention Migratoire Des Professionnels De La Santé Publique Au Maroc : Résultats D’une Enquête. International Journal of Accounting, Finance, Auditing, Management and Economics. 4(3-2), pp.121–142.

Mahdaoui, M. and Kissani, N. 2023. Morocco’s Healthcare System: Achievements, Challenges, and Perspectives. Cureus. 15(6), p.e41143.

Rafferty, J.P. 2023. Morocco Earthquake of 2023 | Description, Geology, Deaths, & Facts | Britannica. www.britannica.com. [Online]. Available from: https://www.britannica.com/event/Morocco-earthquake-of-2023.

Sax dos Santos Gomes, L. 2023. Is the recruitment of foreign trained health professionals the solution to Germany’s health care crisis? International Health Policies. [Online]. August 3rd. [Accessed 01 August 2024]

Sito-Sucic, D. 2017. Nurses, doctors leave Balkans to work in Germany. Reuters. [Online]. 9 March. [Accessed 01 August 2024] Available from: https://www.reuters.com/article/business/healthcare-pharmaceuticals/nurses-doctors-leave-balkans-to-work-in-germany-idUSKBN16G18W/

Statista Research Department. https://www.statista.com/statistics/1266549/number-of-doctors-and-paramedics-per-10000-inhabitants-in-morocco/#:~:text=Number%20of%20doctors%20and%20paramedics%20per%2010%2C000%20inhabitants%20in%20Morocco%202019&text=As%20of%202019%2C%20there%20were,doctors%20in%20the%20same%20year.

Sylla, A., El Ouadih, S., Barknan, K., Hassoune, S. and Nani, S. (2021). Migration intention of final year medical students. European Journal of Public Health, [online] 31(Supplement_3). doi:https://doi.org/10.1093/eurpub/ckab165.448.

ZAHOUANI Chadia, ANNAJI Hassane and Ahmed, O. 2022. Rural Development Strategies and Retention of Health Care Personnel in Rural and Landlocked Health Facilities in Morocco: Inventory. Zenodo (CERN European Organization for Nuclear Research). 3(14).

Zbiri, S. 2023. The Right to Health in Morocco [Online]. [Accessed 16 May 2024]. Available from: https://annd.org/uploads/publications/Right_to_health_in_Morocco_Key_issues_and_challenges_Saad_Zbiri_PhD_En.pdf.

Uncertainty and insecurity of mobile lives: Migrant nurses in the UK NHS and the renewal and maintenance of professional registration in the home country

8th February 202611th April 2024 by meyg

Uncertainty and insecurity of mobile lives: Migrant nurses in the UK NHS and the renewal and maintenance of professional registration in the home country

THURSDAY 11 APRIL 2024

By Amrita Limbu, Postdoctoral Research Fellow, School of Law, University of Leeds

Yuna, a nurse from Asia has lived and worked in the UK for more than 15 years but has continuously renewed her nursing registration in her home country for 20 years now.[i] For her, maintaining the nursing registration back home is a ‘backup’ option if she has to go back home to take care of her ageing parents.

Health professionals who relocate to the UK often leave behind nuclear or extended family members in their home country or in a third country. And the need to return for visits, or caring responsibilities as Yuna mentioned, or family reunion is indeed real, especially in an environment of increasingly tightening of borders and restrictions on family migration and family reunion.[ii]

Recently, in April 2024, the UK government increased the minimum income requirement for migrants to bring partners or spouses from £18,600 to £29,000, which is set to further increase to £38,700 by early 2025.[iii] International students and those on social care visas are now altogether prevented from bringing dependants and families from 2024.[iv] These new policies make bringing partners, spouses, or family more difficult and are set to separate more lives and families. In light of these policy shifts, the renewal of registration back home offers a tangible solution, providing a form of insurance for healthcare professionals to imagine a life and career in their home country if need to return arises.

Yuna is among the cohort of overseas trained health professionals who shared their experiences of professional registration in the UK as part of the ongoing study Making it to the Registers. She is also among the several healthcare professionals who continue to renew and maintain their nursing registration in their country of origin. For other nurses with foreign qualifications, maintenance of their professional registration back home was also their insurance if things did not work out for them here in the UK. Often noted were insecurities if they are ‘referred’ − a process whereby a healthcare professional can be referred to the regulatory bodies such as the General Medical Council (GMC) or Nursing and Midwifery Council (NMC) for fitness to practise concerns, or asked to produce a valid registration as part of an inquiry, or even sent back home.[v] Renewing their professional registration back home thus provides assurance that they can produce the necessary document if and when needed. More importantly, it enables them to continue practicing their profession in their home country or in the country they received their training, should they need to return. Without it, they risk having to undergo the registration exam procedures again.[vi] In this blog, I touch upon these intersecting themes of insecurity, family and kinship, and immigration policies in the renewal of the NHS nurses’ professional registration in their home country.

In general, fitness to practice referrals are higher against overseas trained healthcare professionals. Referrals received by the medical regulatory body GMC indicate that overseas trained doctors experience referral rate 2.5 times higher than the UK trained doctors, while Black, Asian and Minority Ethnic doctors face double the referrals compared to their White counterparts.[vii] A study in the United States also suggest similar disproportionate trend of ‘overpolicing’ of Black residents in medical education − where they are faced with higher rates of disciplinary interventions as well as dismissal from their programs compared to White residents.[viii]

The process and requirement to renew professional registration vary depending on the profession, country of origin or country they received their training. For instance, some countries mandate only the payment of registration fees and evidence of ongoing nursing practice, while others may additionally require completion of an online training / course as evidence of continuing professional development. Certain countries only permit renewal if the professional is practicing in the same country, while others have no renewal requirements. Nonetheless, the nurses’ interest to maintain professional registration of their home country, along with our study’s preliminary findings, raises crucial questions surrounding career stability and a sense of security experienced by the overseas healthcare professionals within the NHS. This urgency and significance of the matter is further accentuated by the increasing number of migrant nurses recruited in the NHS from across Asia, Europe, and Africa. Statistics from June 2023 reveal that 73 per cent nurses and health visitors in the NHS in England are non-British nationals.[ix]

Historical examples of dismissal of foreign healthcare professionals serve as reminders that these concerns of security and stability harboured by overseas-trained health professionals are indeed valid. Archival research conducted for the project Making it to the Registers reveal instances during the Second World War when refugee healthcare professionals who fled Nazi persecution were allowed to work to make up for the shortage of local doctors and nurses but were later dismissed for concerns of security. The ban on permitting foreign doctors to practice was later lifted, albeit with the condition that they would be immediately removed from hospital employment in the event of invasion or serious military situation.[x] The ban on foreign nurses was implemented for longer as nurses were perceived to pose a higher risk due to their proximity to patients.[xi] While this is an extreme example, one of national security during a war, it nonetheless sheds light on the temporality, inherent insecurity, and inequality that migrants face when compared to the nationals.

Examples also illustrate the tightening of borders and imposition of restrictions on immigration rights in response to fluctuation in demand for foreign labour. For instance, official documents obtained from our project partner BAPIO, who have been supporting international doctors and nurses for the last 25 years, reveal that during the mid-1980s, policy conversations centred around concerns of unrestricted immigration. Until then, foreign doctors and dentists were permitted to undertake postgraduate training and professional employment without a work permit if they were registered with the GMC or the dental regulatory body the General Dental Council (GDC). However, immigration regulations from 1 April 1985 mandated the requirement of a work permit for professional employment, and from 7 March 2006, the permit-free training for foreign doctors and dentists was abolished altogether. These policy shifts coincided with the surplus of British trained medical graduates and the UK’s growing preference for doctors and dentists from the European Union (EU), and therefore mainly affected the health professionals from outside the EU.

Historically, governments have needed to justify permitting foreign professionals to work based on a shortage of domestic or local workforce. This not only attests to the volatility of the migration policies that regulate the entry of foreign health professionals,[xii] but further justifies the concerns of maintaining nursing or medical registration in their home country. As immigration policies and regulations governing foreign healthcare professionals evolve in response to the labour market needs, the uncertainty and transience of mobile lives persist, sometimes even after individuals attain settled status or citizenship. It is unfortunate that foreign healthcare professionals in the NHS feel the need to adopt safeguard measures against career insecurities by continuing to maintain their professional registration in their home countries, but this is likely to become increasingly pertinent for migrants desiring family reunion, especially considering the recent immigration policies that raise the minimum income requirement for family reunion or impose restrictions on family migration altogether. Nevertheless, return is a complicated decision involving not only the individual migrant’s personal considerations but also the future of the children, partner, and other family members. It should not be seen as an alternative to career stability, security, family reunification, or essential flexibility of cross-border mobility.

[i] Health professional interview 22

[ii] Also, health professional interview 19

[iii] McKinney and Gower (2024) Changes to legal migration rules for family and work visas in 2024. House of Commons Library. Link to the research briefings

[iv] Policies in place since 01 January 2024 for international students and from 11 April 2024 for those on social care visa. GOV.UK (2024) Tough government action on student visas comes into effect, Link to the news story

[v] Health professional interview 25

[vi] Health professional interview 15

[vii] Atewologun and Kline with Ochieng (2019) Fair to refer? Reducing Disproportionality in Fitness to Practise Concerns Reported to the GMC. General Medical Council.

[viii] Joshua et al (2023) Dismantling the Overpolicing of Black Residents. The New England Journal of Medicine 389(14): 1258-1261.

[ix] Baker, Carl (2023) NHS staff from overseas: statistics. House of Commons.

[x] The National Archive HO 213/1749

[xi] The National Archive HO 213/2008

[xii] Spiliopoulos and Timmons (2022) Migrant NHS nurses as ‘tolerated’ citizens in post-Brexit Britain. The Sociological Review 71(1): 183-200.

[i] GMC (2024) The state of medical education and practice in the UK: Workforce report 2024. London: General Medical Council (GMC).

[ii] PSA (2022) What is Fitness to Practise? 14 July, Professional Standards Authority, https://www.professionalstandards.org.uk/news-and-updates/news/what-fitness-practise, accessed 31 October 2024

[vi] Healthcare professional interview 27

[vii] PSA (2022) What is Fitness to Practise? 14 July, Professional Standards Authority, https://www.professionalstandards.org.uk/news-and-blog/blog/detail/blog/2022/07/14/what-is-fitness-to-practise

[viii] Healthcare professional interview 9; Also see Webster, Eve (2024) Nurse cleared of baby kidnap plot says life ruined. BBC, 05 September, https://www.bbc.co.uk/news/articles/c2l1y1k087vo

[ix] Limbu, Evans, and Giralt (2024) Impact of COVID-19 on migrant families in the UK. Policy Brief. University of Reading and University of Leeds.

[xii] Limbu, Amrita (2024) Uncertainty and insecurity of mobile lives: Migrant nurses in the UK NHS and the renewal and maintenance of professional registration in the home country.

[xiii] Healthcare professional interview 10

[xiv] Healthcare professional interview 19

[xv] Stakeholder interviews 2, 12, 13

[xvi] GMC (2024) The state of medical education and practice in the UK: Workforce report 2024. London: General Medical Council.

The international regulation of healthcare workers?

8th February 202615th March 2024 by meyg

The international regulation of healthcare workers?

FRIDAY 15 MARCH 2024

By Priyasha Saksena

Our AHRC project examines the experiences of overseas-trained healthcare workers in navigating the system of professional regulation in the United Kingdom. The focus is deliberately national rather than international given that the historical development of statutory regulators such as the General Medical Council (GMC) was a consequence of nineteenth-century political struggles over the type of individuals who were entitled to call themselves medical practitioners.[1] This is not to say, however, that proposals for professional regulation exist only in the realm of the national; I examine one suggestion for internationalization in this post.

In October 1945, Dr Leopold Neumann, the chair of the Association of Refugee Doctors and Dentists Without Registration in South Africa, wrote to the British Foreign Office, enclosing a memorandum on the plight of refugee medical professionals.[2] There is little information available about Dr Neumann but it is likely that he was one of the many European refugees who had fled the rise of the Nazi regime and found their way to Johannesburg. Once in South Africa, he realized that he was unable to practise medicine given his continental European education and training, which remained unrecognized.[3] He argued that these restrictions were “illogical” given the “scarcity of qualified doctors” and the fact that “in America, England, France, Germany, Russia and in various other countries, medical training is more or less standard.”[4] The main problem, in his view, was that most countries had not entered into reciprocity agreements to mutually recognize educational qualifications and training, requiring refugee doctors to requalify, something that many of them were unable to do on account of “advanced age as well as for financial and other reasons.”[5] Dr Neumann, therefore, proposed “an international agreement … whereby reciprocity of registration is granted to medical doctors who have obtained a degree at a recognised training centre.”[6] This proposal was timely, given the reinvigorated efforts for the establishment of international institutions at the time: for instance, the United Nations was officially founded on 24 October 1945 and there was a simultaneous push for the creation of the World Health Organization, which ultimately came into existence on 7 April 1948. British Foreign Office officials, therefore, considered Dr Neumann’s proposal to be “a good one fundamentally” but were only willing to flag it to the Ministry of Health as being “of possible interest in connexion with the forthcoming Health Organization.”[7]

Although Dr Neumann’s proposal for reciprocal recognition of qualifications (and thereby the ability to practise medicine) at an international level was soon forgotten, there have been such efforts at a regional level. Perhaps the most successful has been the attempt by the European Union (EU) to require member states to implement means to mutually recognize education and training arrangements in order to facilitate the free movement of professional (not only healthcare) workers.[8] Specifically for doctors, nurses, midwives, and dentists, there is an EU-wide system of automatic recognition of professional qualifications.[9] Some regulators continue to extend such recognition even after the United Kingdom’s exit from the EU; the GMC, for instance, has a list of “relevant European qualifications” that are recognized for full registration although there may be practical constraints on the ease of such recognition.[10] Other regional blocs (such as Mercosur and ASEAN) have also made attempts to pursue automatic recognition of qualifications, with varying degrees of success.[11] The efforts have been met with both praise and pushback. As Julia Evetts notes, “[t]he professions are not passive in these internationalization processes” since they “are themselves internationalizing” with the establishment of “international professional federations” that are “made up of representatives from national professional bodies” and “are meeting to negotiate the profession’s response both to EU directives and to wider global processes of internationalization, such as regional and global trade agreements.”[12] Examples of international professional associations in the healthcare space include the World Medical Association, the International Council of Nurses, and the FDI World Dental Federation. The idea of professional regulation remaining intricately linked with the nation-state has, therefore, been challenged in recent years, with the boundaries between national, regional, and international regulation being a matter of political struggle (involving a range of actors including professional associations and regulators) rather than of legal necessity.

[1] For more details on the context in which the General Medical Council was established, see M. J. D. Roberts, “The Politics of Professionalization: MPs, Medical Men, and the 1858 Medical Act,” Medical History 53, no. 1 (2009): 37–56; and Douglas Haynes, Fit to Practice: Empire, Race, Gender, and the Making of British Medicine, 1850-1980 (Rochester, NY: University of Rochester Press, 2017), 9–35

[2] Letter from Leopold Neumann to the Foreign Office, 1 October 1945, TNA/FO/371/51250.

[3] For the limitations imposed on refugee doctors from practising in dominions such as South Africa and Australia, see Haynes, Fit to Practice, 88.

[4] Memorandum enclosed in Letter from Leopold Neumann to the Foreign Office, 1 October 1945, TNA/FO/371/51250.

[5] Ibid.

[6] Ibid.

[7] Note by [?], 15 November 1945, TNA/FO/371/51250.

[8] For details of the move from national to regional regulation and the reaction of professional associations, see Julia Evetts, “Professionalism Beyond the Nation-State: International Systems of Professional Regulation in Europe,” International Journal of Sociology and Social Policy 18, no. 11/12 (1998): 47–64.

[9] Directive 2005/36/EC of the European Parliament and of the Council of 7 September 2005 on the recognition of professional qualifications.

[10] “European Economic Area country qualifications,” General Medical Council, https://www.gmc-uk.org/registration-and-licensing/join-the-register/eea-countries.

[11] Rupa Chanda, Regional Harmonization Processes of Health Professional Regulation: Status, Challenges, and Policy Directions (Draft Evidence Brief No. 7 Prepared for the Second Review of Relevance and Effectiveness of the WHO Global Code of Practice on the International Recruitment of Health Personnel), https://www.who.int/docs/default-source/health-workforce/eag2/2nd-review-of-code-relevance-and-effectiveness-evidence-brief-7-regional-harmonization-processes.pdf?sfvrsn=c5e18644_2.

[12] Julia Evetts, “New Directions in State and International Professional Occupations: Discretionary Decision-Making and Acquired Regulation,” Work, Employment and Society 16, no. 2 (2002): 341–353, 348.

Turning the tables on the language skills of overseas trained doctors? A prompt from the British Medical Journal

8th February 20263rd January 2024 by meyg

Fear of referral: Fitness to practise and its implications on safety of migrant healthcare professionals in the UK

WEDNESDAY 1 MAY 2024

By Marie-Andrée Jacob

During our AHRC project we have noted the emphasis placed on a stringent testing of English language skills for the internationally trained doctors and nurses who hope to join the registers and work in Britain. In this blog, I raise a few questions related to language expectations from migrant and refugee health care professionals, and from UK trained healthcare professionals. As it often does, here comparison helps identifying the background assumptions of a context different from our own, and sheds light on our unexamined assumptions.

Increased levels of immigration in the UK means that the healthcare sector ought to be able to meet the needs of changing demographics. For instance, cultural competence and increased diversity in the healthcare workforce[i] are shown to contribute to improve access to services and satisfaction for immigrant patients.[ii] Research on ‘language concordance’ between doctors and patients demonstrates how it improves doctor-patient encounters and maximises health outputs.[iii] This data supports a better understand of how internationally trained doctors and nurses enrich NHS service provision.

Often, the scrutiny over English language proficiency of overseas-trained professionals, whilst justifiable, emphasises the limits of overseas trained professionals. In turn their widespread bilingualism and multilingualism, often remain unnoticed, or undervalued language skills. Given changing demographics, these language skills could be valorised as comparative advantages surpassing those of unilingual English-speaking healthcare professionals trained in the UK. As part of its regulatory remit to offer safer care for all, could the government mandate British medical schools to offer language provision and certify trainee doctors’ bilingual language skills. This change to the curriculum could assist British-trained doctors in keeping up with internationally trained doctors’ language skills. In the United States, an increasing number of medical schools offer Spanish language as part of medical education to meet the changing needs of patients.[iv]

A recent paper in the British Medical Journal on language in healthcare provides food for thought.[v] It explores the experiences of non-Arab healthcare practitioners caring for Arab patients in the United Arab Emirates. The paper is based on in-depth interviews with foreign healthcare professionals not fluent in Arabic working in the UEA. The research was conducted in English, indicating that the participants were English-speaking. The paper provokes a few elements of comparison between the integration of foreign doctors moving to and working in a place where the language of work is not their first language, in UAE and Britain respectively. It also elicits comparisons between different experiences of caring for patients with whom they do not share a language.

The first noticeable aspect is the terminology used by the authors to describe the participants. The paper does not refer to them as ‘migrant,’ but as ‘expats.’ Both terms evoke being engaged in temporarily labour migration. Yet ‘migrant’ is usually a term reserved for non-white, non-Western migrating to work temporarily, whilst expats, with its more business and ‘professional’ connotations, is a term rather used to describe white, Western people migrating to work temporarily.[vi]

The authors criticise the idea that healthcare providers ‘can learn as they work when working with patients from other cultures.’ They argue that in spite this widespread assumption, expat doctors should ideally obtain formal language training in Arabic before caring for Arabic speaking patients. What we read between the lines here is that ‘learning as you work’ is a possible and accepted option for non-Arabic fluent doctors moving to work in the UAE. We could discuss the pros and cons of such a practice, and the authors do so briefly. However, the surprising comparative point here is this: the notion that refugee and migrant internationally trained doctors could join the UK register and start practicing in the NHS on the basis on their medical expertise, and ‘learn as they work,’ is completely out of line with reality. Migrant and refugee doctors, regardless of the level of specialty, skills, and the years of experience they acquired outside Britain, do not have the option to care for patients whilst ‘learning the language as they work.’ Their listening, reading, written, and spoken English is tested before they can begin to work. This is to ensure patient safety. As Al-Yateem and his co-authors explain, there are indeed legal and other risks of misunderstanding and misdiagnosis associated with ‘learning as they work’ approach. And yet, would that be so unconceivable to allow more flexibility around English language skills? Indeed, prior to Brexit, EU medical graduates did not require to pass English tests, and the hiring employer had latitude. Since Brexit EU medical graduates have lost that privileged position vis-à-vis non-EU medical graduates, but we can also ask questions about who can be seen as deserving the benefits of flexibility, and who is seen as needing scrutiny.

The data of the BMJ paper also shows that in the UAE, Arabic-fluent patients respond well when spoken to in broken Arabic,[vii] that patients appreciate the efforts of doctors who try and engage them in their language, that they use humour and laughter to encourage them, and that overall, communication builds on more than language. Reflecting on this with a comparative outlook, I ask myself whether British, English-speaking patients would offer similar positive responses to an overseas-trained medical doctor who would provide them with expert care in broken, or less than perfect English.

The ‘expat’ non-fluent in Arabic doctors who took part in the research on which the BMJ paper is based, shared with the researchers their experience of working in a foreign language environment. Once again, the research findings bring out surprise: participants explained that they should be ‘pro-active in learning basic medical terms in Arabic.’ More tellingly, ‘participants in the study recommended using professional medical interpreters to overcome language barriers in the healthcare context.” Perhaps such self-confidence should not surprise, coming from Western, non-Arabic fluent, English-speaking doctors working in Arab settings. The contrast with the attitude of non-British doctors trained overseas, which we interviewed as part of our research project, is striking. After having conducted more than thirty interviews with participants and having analysed secondary literature on overseas trained doctors and nurses wishing to work or currently working in Britain, my colleagues and I have not encountered a level of self-confidence and self-importance resembling that of the BMJ paper participants. Not a single participant has expressed the idea that a medical translator could be a solution at hand to translate what they have to say to English-speaking patients. Regardless of key issue of healthcare funding in British and UAE systems, there is a clear difference in attitudes, which rehearses the hegemony of English language across healthcare contexts.

The BMJ paper’s conclusion wraps things up nicely: “learning basic medical terms in patients’ native language offers an innovative and effective solution to address the language barrier issue and improve healthcare services for Arab patients.”[viii] Sounds relatively straightforward. For several reasons, it is unlikely that British medical registration of internationally trained medical graduates will move in that direction. But still, could some lessons be learned from this example; could we envisage a more open and grateful attitude towards international healthcare providers who migrate to Britain, equipped to provide healthcare to British patients?

After all, although they may be necessary, English language skills are not sufficient. ‘The ability to speak English does not make one a good doctor,’ and many British-trained doctors with excellent English struggle to communicate well with patients.[ix]

[i] Andrea Baumann, Mary Crea-Arsenio and Valentina Antonpillai, ‘Global Migration and Key Issues in Workforce Integration of Skilled Health Workers’ in Margaret Walton-Roberts, eds, Global Migration, Gender, and Health Professional Credentials: Transnational Value Transfers and Losses, University of Toronto Press, 2022, 95-109 at 96.

[ii] Id.

[iii] Naomi Cano-Ibáñez et al. Physician–Patient Language Discordance and Poor Health Outcomes: A Systematic Scoping Review Front Public Health. 2021; 9: 629041, Published online 2021 Mar 19. doi: 10.3389/fpubh.2021.629041; Julian Simpson, Migrant Architects of the NHS. South Asian doctors and the reinvention of British general practice (1940s-1980s), University of Manchester Press, 2018.

[iv] Rose Molina and Jennifer Kasper, ‘The power of language-concordant care: a call to action for medical schools’ (2019) 6: 19 (1) BMC Medical Education 378, doi: 10.1186/s12909-019-1807-4

[v] Nabeel Al-Yateem et al, ‘Quality and safety issue: language barriers in healthcare, a qualitative study of non-Arab healthcare practitioners caring for Arabic patients in the UAE’ British Medical Journal 22 December 2023 https://doi.org/10.1136/bmjopen-2023-076326

[vi] Sarah Kunz, Expatriate: Following a Migration Category, Manchester University Press, 2023; Amanda Klekowski von Koppenfels, ‘What’s the difference between a migrant and an expat? The Conversation, 20 December 2016. A similar distinction can be drawn between mobility and migration. Expats or ‘mobile professionals’ rarely depend on immigration decisions, and if they do not achieve their goals, often have the choice of returning home or moving somewhere else; however highly skilled migrants do not have access to that same mobility. See: Agnieszka Weinar and Amanda Klelowski von Koppenfels, Highly skilled migration: between settlement and mobility, Springer 2020; Agnieszka Weinar, European citizenship, and identity outside of the European Union. London/New York: Routledge, 2019.

[vii] “However, at times the use of broken Arabic was considered helpful, especially when words/phrases were correct. Participants noted that many patients and their families appeared to be more comfortable with this form of communication and were receptive of the messages.

Many of them will be surprised when I say it in Arabic words; they will like it and laugh, and they look more engaged, even with the simple words that I use. (P13), Ibid

[viii] Ibid.

[ix] Interview with Dr Selladurai Shanmugadasan, Audrey Gillan, ‘Knowing English does not make you a good doctor’ The Guardian, 2 September 2000.

Gender, Migration, and Medical Registration in the UK

8th February 20265th December 2023 by meyg

Gender, Migration, and Medical Registration in the UK

TUESDAY 5 DECEMBER 2023

By Amrita Limbu, Postdoctoral Research Fellow, School of Law, University of Leeds

Sociologist Margaret Stacey, in her study of the General Medical Council (GMC) Regulating British Medicine referred to medicine as ‘a man’s profession’. Stacey also served as a lay member of the GMC from 1976 to 1984. As the regulatory body of the medical profession, the GMC maintains the UK medical register exercising control of who gets to be on the register. Inclusion to the medical register provides medical practitioners the license to practice medicine, and for the GMC, the register is a way to ensure patients safety by maintaining the professional standards of the practitioners’ knowledge, skills, qualifications, and experience. Historical examination of medical registration in the UK reveals that women faced significant barriers in gaining access to the medical register. Prior to 1860s, women were not permitted to attend medical schools or take licensing examinations.

Several scholars have recounted the narratives of two pioneer women who successfully navigated the UK medical register by exploiting legal loopholes. Elizabeth Blackwell who obtained her medical qualification from America gained entry to the UK register through a special provision that allowed individuals with a foreign or colonial medical degree and already practicing medicine in England prior to the establishment of the medical register under the Medical Act 1858 to register.[i] Elizabeth Garrett Anderson likewise managed to get on to the register by studying privately for the licensing examination and taking the apothecaries examinations. She was refused admission to the medical schools and refused permission to sit for the examinations by London University and the Royal College of Physician and Surgeons.[ii] The Society of Apothecaries’ charter pertained to the sale of drugs, and as there were no legal grounds to prevent women from selling drugs, they were obligated to admit Elizabeth Garrett Anderson in their examination.[iii] The GMC subsequently closed both the entry pathways taken by the two women.

Following the initial struggles, the numbers of women doctors rose gradually: from 2 in 1871 to 25 in 1881 to 100 in 1891.[iv] By the end of the 1990s, around half of all medical students and recent graduates were women.[v] Today, 49% of all licensed doctors are women, and they also make up 57% of doctors in postgraduate specialty training at 57%.[vi]

Despite women’s entry to the register, there remains limited understanding of the gender-specific implications associated with registration. Research indicates persisting disparities extending to career progression, specialty selection, and work patterns. Even today, a higher proportion of women doctors work part-time or less-than-full-time compared to their male counterparts; childcare related reasons being the primary factor influencing this work pattern.[vii] And in specialties with larger proportion of women doctors such as obstetrics and gynaecology with 83% female doctors in 2022, trainees spend more time in the same training level and specialty level.[viii] However, the extent to which gender dynamics impact the registration process for women compared to men, and how these factors subsequently impact the career choices of women doctors and their career progression remains underexplored.

Further, when considering the intersections of gender, registration, and migration, the process of registration for migrant women doctors is likely to be more intricate compared to their UK-trained counterparts. Registration for foreign practitioners entails navigating English language requirements and completing the Professional and Linguistic Assessments Board (PLAB) tests, all within the constraints of immigration regulations. Migration poses challenges of time limitations on most visas, cost of visas and extensions, absence of welfare support that nationals benefit from, limited or absent local support network, all of which further complicate the registration process. Additionally, studies have highlighted how women are more likely to sacrifice careers and skills during a migration process at the privilege of their male partner’s careers. When women negotiate with gender to strategize migration, for instance through marriage, they often end up reproducing relations of subordination, putting a hold to their careers.[ix]

Archival research conducted for our project Making it to the Registers shows that during the 1960s, discussions centered around encouraging the employment of women doctors, especially attracting married women doctors back to the profession through part-time appointments or flexible training schemes, less rigid requirement of experiences and shorter training courses.[x] While the GMC has come a long way in inclusion of women to the register, these examples underscore the potentials of policies in bringing about meaningful changes – changes that can enhance the experiences of migrant and refugee women health practitioners’ entry to the UK medical register.

The Making it to the Registers team includes Marie-Andrée Jacob, Priyasha Saksena, Nasreen Ali, and Amrita Limbu.

[i] Stansfeld, James (1877) Medical Women. The Nineteenth Century: A Monthly Review 1(5): 888-901.

[ii] Haynes, Douglas M. (2017) Fit to Practice: Empire, Race, Gender, and the Making of British Medicine, 1850-1980. Rochester: University of Rochester Press.

[iii] Anderson, E. Garrett (1893) The History of a Movement. Fortnightly Review 53(315): 404-417.

[iv] Stacey, Margaret (1992) Regulating British Medicine: The General Medical Council. Chichester: Wiley.

[v] Stacey, Margaret (1992) Regulating British Medicine: The General Medical Council. Chichester: Wiley.

[vi] GMC (2023) The State of Medical Education and Practice in the UK: Workforce Report 2023. London: General Medical Council.

[vii] GMC (2023) The State of Medical Education and Practice in the UK: Workforce Report 2023. London: General Medical Council.

[viii] GMC (2023) The State of Medical Education and Practice in the UK: Workforce Report 2023. London: General Medical Council.

[ix] Manohar, Namita (2019) Gendered Agency in Skilled Migration: The Case of Indian Women in the United States. Gender and Society 33(6): 935-960.

[x] Wellcome Collection, Employment of Married Women Doctors

Austrian Doctors in the British Caribbean

8th February 20264th September 2023 by meyg

Austrian Doctors in the British Caribbean

MONDAY 4 SEPTEMBER 2023

By Priyasha Saksena

In this post, I examine how the regulatory instrument of registration became a useful mechanism to expand the availability of healthcare personnel in times of “crisis” by examining the recruitment of European doctors by the governments of British colonies in the Caribbean.

The British medical register was, as Douglas Haynes notes, a “gateway to the empire” as imperial service was linked to the possession of a British medical qualification.[1] Although this requirement enabled the creation of a largely homogenous profession, it also created a recruitment crisis. Scholars have noted that staffing the Colonial Medical Service (CMS) was a struggle on account of low pay and the perception of a lack of prestige. As a result, doctors were often recruited both locally and from other parts of the empire (particularly British India) to fill in the gaps, even though such workers were often relegated to lower positions.[2] Difficulties in recruitment were exacerbated by the outbreak of the Second World War since almost all available personnel were drafted into the military; after the war, most British doctors were absorbed into the newly-established National Health Service in Britain rather than the CMS.[3]

For some British colonies, the solution lay in the recruitment of European doctors, many of whom were struggling to find stable work in post-war Europe. Austria proved to be a particularly fertile ground of recruitment. Although some colonies (such as Jamaica and Trinidad) refused to accept Austrian candidates (claiming to have sufficient local recruits or because of their lack of British qualifications),[4] others were more open, albeit with some restrictions (the Bahamas, for instance, insisted on recruiting doctors “of pure Austrian descent”).[5] After security screenings, many applicants were found to be “undesirable” (because of either Nazi or communist links),[6] but officials ultimately prepared a list of eight candidates who were suitable for colonial service.[7]

Apart from security concerns, doctors with overseas qualifications faced hurdles in practising medicine in the British colonies since colonial governments required medical officers to have a qualification that was “registrable in the United Kingdom.” Between 1945 and 1948, approximately 30 foreign medical officers were appointed to the CMS, the majority of whom were Polish doctors on the temporary register that had been created by the General Medical Council (GMC) to enable qualified overseas-qualified doctors to practise medicine (in limited capacities) in Britain for the duration of the war.[8] Recruiting doctors directly from Austria, however, posed a problem since none of them were on the GMC’s temporary register. Colonial officials instead sought a way out through local legislation. In the Bahamas, authorities relied on a saving clause in existing legislation that permitted registration of foreign doctors “if the Governor in Council may so determine” while in British Guiana, an existing ordinance provided for “temporary registration of any person who is employed or has been selected for employment in Government Medical Service.”[9] Other colonies, however, could not find ways in existing legislation. Therefore, St Lucia and Dominica passed special legislation to enable such recruits to practise.[10] The Leeward Islands amended its Medical Act “to permit state of emergency to be declared to allow registration of medical officers with foreign qualifications.”[11]

A shortage of healthcare workers was, therefore, considered to be a situation that required exceptional measures to be taken. Colonial officials, much like their counterparts in Britain, relied on the flexibility of the term “emergency” to expand the availability of healthcare personnel in the British Caribbean.[12] This long history of reliance on overseas medical labour continues to raise critical questions about ethical and sustainable recruitment in the contemporary world.

[1] Douglas Haynes, Fit to Practice: Empire, Race, Gender, and the Making of British Medicine, 1850-1980 (Rochester, NY: University of Rochester Press, 2017), 15.

[2] Anna Greenwood, “Introduction: Looking Beyond the State,” in Beyond the State: The Colonial Medical Service in British Africa, ed. Anna Greenwood (Manchester: Manchester University Press, 2016), 1–18.

[3] Florence Ejogha Nkwam, “British Medical and Health Policies in West Africa, c1920-1960” (PhD diss., SOAS University of London, 1988), 165–203.

[4] Telegram from J. Huggins, Governor or Jamaica, to the Secretary of State for the Colonies, 13 December 1948, TNA/CO/877/32/5; and Telegram from J. Shaw, Governor of Trinidad, to the Secretary of State for the Colonies, 19 January 1949, TNA/CO/877/32/5.

[5] Note by A. G. Denton-Thompson, 3 February 1949, TNA/CO/877/32/5.

[6] Note by [?], 28 March 1950, TNA/CO/877/32/5.

[7] Note by R. Reeves, 20 May 1950, TNA/CO/877/32/5.

[8] Memo on recruitment of foreign doctors, 15 October 1948, TNA/CO/877/32/5.

[9] Note by [?], 7 February 1949, TNA/CO/877/32/5.

[10] Telegram from R. D. H. Arundell, Governor of the Windward Islands, to the Secretary of State for the Colonies, 28 December 1948, TNA/CO/877/32/5.

[11] Telegram from Earl Baldwin, Governor of the Leeward Islands, to the Secretary of State for the Colonies, 19 November 1948, TNA/CO/877/32/5.

[12] For more on how the language of “emergency” has shaped the British medical register, see Marie-Andrée Jacob and Priyasha Saksena, “The Changing Natures of the Medical Register: Doctors, Precarity, and Crisis,” Social and Legal Studies (2023), https://doi.org/10.1177/09646639231178878.

Esther Simpson, pioneer and inspiration for Making it to the Registers

8th February 20267th August 2023 by meyg

Esther Simpson, pioneer and inspiration for Making it to the Registers

MONDAY 7 AUGUST 2023

By Marie-Andrée Jacob

In this first blog entry I introduce our 2023-2025 AHRC project Making it to the Registers via a foray into the personal archives of tireless activist Esther Simpson.

4 August 2023

To many residents of Leeds and staff and students at the University of Leeds, Esther Simpson will be known as being a new university teaching building opened in 2022. Cambridge barrister and law reader John Eidinow has recently published her biography: Esther Simpson: The True Story of Her Mission to Save Scholars from Hitler’s Persecution (Robinson publisher, 2023)

Esther Simpson is intimately connected to our AHRC research project Making it to the Registers: Documenting Migrant Carers’ experiences of registration and fitness to practise, which we launched at the Leeds Playhouse on 31 March 2023.

She worked, between 1933 and 1978, as Secretary of the organisation Academic Assistance Council (which then became the Society for the protection of science and learning). In fact, she was much more than the organisation’s secretary: Esther Simpson was a lobbyist, an administrator, negotiator, translator, and interpreter. She worked tirelessly to arrange for grants and opportunities to help find work and relocation plans in Britain and across the Commonwealth for refugee academics who were fleeing Nazi Germany and other persecuting regimes. Over the years she has used her extensive networks to help hundreds of academics. In the words of a journalist interviewing Simpson in 1992, to the Society for the Protection of Science and Learning, ‘the idea was to salvage people and not to let remarkable talents, experience and expertise go to waste.’

In 2023, there is not a week that goes without the media lamenting on the shortage of qualified staff to sustain the NHS. And yet internationally trained healthcare staff, doctors, nurses, and pharmacists arrive here with skills and expertise but find extremely hard to access jobs they are trained to do. Talented, educated people being disabled, and hobbled by various regulatory hurdles. This disconcerting puzzle is at the centre of our project.

The background: who is relied upon in times of emergency?

Our inquiry into the regulatory hurdles faced by internationally trained healthcare workers started in during the 2020 global pandemic. Whilst looking for information about the UK General Medical Council’s response to the pandemic, we came across archivist Courtney Brucato’s blog on the history of the GMC’s responses to doctor shortage in times of crisis. We found out that during World War II, facing an intensified demand for doctors, the General Medical Council (GMC) extended emergency registration to Jewish refugee doctors and overseas- qualified doctors primarily from British colonies.

In 2020, the GMC was facing a similar challenge. Article 2 of the 2020 Coronavirus Act, stipulated for the emergency registration of health care professionals. The GMC and other statutory regulators opened their registers to get more staff to help out. On that occasion, the regulators focused mainly on bringing back retired doctors on to the Medical Register.

Given the history of the GMC policies, we can ask how else could the Register have been opened during the pandemic? In times of need, who is envisaged and trusted to answer the call of duty?

When researching the history of UK medical registration from its inception in 1858, we saw that the definition of who can become and remain and health care professionals is flexible, and that the register can open and tighten depending on circumstances. For example, our research has discovered that the 1960s a perceived ‘oversupply’ of foreign medical graduates led to the termination of reciprocal registration arrangements with Commonwealth countries. The register, as well as the fitness to practice procedures (that relate to the skills, knowledge, health, and character that professionals must satisfy to remain on the register), are highly adaptable to changes of circumstances. This taught us that the medical register is not devoid of political consideration, and is far more complex and richer than being just a bureaucratic tool compiling names of qualified practitioners.

What we are dealing with is a regulatory instrument that is intimately connected to colonial legacies, and responsive to political, public health and economic pressures, including interactions with professional associations, lobby organisations, and trade unions.

We also know that despite the well-researched fear of migrants embedded in the creation and maintenance and delivery of health services, the NHS has been since its inception, and still is, reliant on immigrant labour.

Hence the question: what does it takes to become, and to remain a healthcare professional today?

This is the background question at the heart of Making it to the Registers. Some sub-questions we aim to explore include: How have regulators, historically and in the present day, adapted registration requirements and FtP procedures for emergency conditions? What are the past and present experiences of registration for migrant health workers of these requirements and procedures? What other mechanisms regulate the conduct of future and present professionals broadly speaking, and what sort of exemplars might they offer for the Fitness to Practise model. What is the role of modern registration in maintaining Fitness to Practise, ensuring patient safety and supporting regulatory objectives such as widening participation?

To answer these questions, we need to better understand the impact of registration and Fitness to Practise on broader social, legal, culturally competent ways to acknowledging the contribution of internationally trained carers in the UK. To answer these questions, we will be looking at the history using various archives, including those of the General Medical Council, Nursing and Midwifery Council, British Medical Association, Royal College of Physicians, Royal Society of Medicine, Home Office, Foreign and Commonwealth Office, as well as the archives of our partner organisation British Association of Physicians of Indian Origins, as well less institutional archive collections. To capture contemporary experiences we will interview health care workers, organisations who represent and lobby for them, as well as regulators.

Esther Simpson’s lifelong goal was not to let talent, expertise, and knowledge that we need go to waste. Our initial findings show that people with the expertise that is so sorely needed need to go through such hurdles to make it to the registers and to be recognised as available to contribute to collective efforts, including in times of crisis.

The Making it to the Registers team includes Priyasha Saksena, Nasreen Ali, Amrita Limbu and Marie-Andrée Jacob.