Would-be NHS staff from overseas will shortly find it easier to secure permission to work in the UK. Doctors and nurses from the European Economic Area, who have helped to meet staff shortages in recent decades, may no longer have the right to do so. Parvati Raghuram (Open University) looks at how the NHS has depended on foreign workers since its creation.

The claim that the NHS would get an additional £350m per week if the UK quit the EU was arguably one of the most persuasive slogans of the Brexit campaign. The National Health Service has been one of the prides of the postwar social architecture and has come to be closely tied to British identity. Skilfully linking the NHS with Britishness was thus a winning strategy for Leave campaigners.

Commonwealth countries and the (Inter)National Health Service

Migrant doctors from Europe, especially Jews who moved due to rising anti-Semitism in parts of Europe, had always formed a part of the medical profession in the UK. However, after the establishment of the NHS in 1948, many of the early flows were from the British Commonwealth countries. Training and work were inextricably intertwined through immigration regulations and the architecture of the health service, ensuring a steady supply of doctors (Table 1).

Thus. the National Health Service has always been an international health service. It has been populated by large numbers of migrant doctors who not only served the NHS but also constituted it, innovating and establishing it through specialist services in remote locations all over the UK. From the 1960s onwards a number of legislative changes were made to attract migrant doctors, who would come to populate the lower and middle parts of the pyramidal medical hierarchy. They did not contribute to a pre-existing NHS; rather they made the health service what it is today.

Table 1: Immigration rules affecting Commonwealth migrant doctors

Year Regulation 1962 Voucher system introduced 1971 Vouchers abolished; work permit system introduced 1985 Four-year permit-free training scheme introduced 1997 Nature of training available to non-EU migrants altered. Training typically takes five years, but all training posts had shorter stay periods 2006 Non-EU migration virtually closed

The NHS and the EEA

Since the early 2000s there has been a shift towards recruitment from within the European Economic Area (Table 2). Freedom of movement within Europe led to an increase in the pool of migrant doctors, and in 2006 a dramatic shift took place – a virtual end to the migration of doctors who are third country nationals, i.e. those whose primary medical qualifications were obtained outside the EEA.

Immigration and EU workers: timeline

Free movement until World War 1

1957: Reintroduction of freedom of mobility of workers through the Treaty of Rome

1973: UK joined European Community

1992: Freedom of mobility of citizens – Maastricht Treaty

2004 onwards: Expansion of the EU (ten countries joined in 2004; 2 in 2007; and 1 in 2013)

Migration regulations only tell half of the story. Professional workers like doctors can practice in the UK after registering and obtaining the appropriate licence. Under EU law doctors within the EEA cannot be discriminated against, but in June 2014 a new English language test was introduced for hose trying to obtain the licence to practice in the UK. This led to a reduction in the numbers of doctors obtaining a licence, compared to those who registered.

Table 2: Number of registered & licensed doctors in the UK by primary country of qualification

PMQ country of origin 2010 2011 2012 2013 2014 2015 2016 2017 Austria 35 38 20 37 28 19 19 16 Belgium 43 36 36 22 37 31 35 45 Bulgaria 166 139 129 94 89 20 32 33 Croatia 1 2 3 23 110 24 23 25 Czech Republic 116 141 128 124 102 60 80 103 Denmark 30 20 17 16 25 7 14 7 Estonia 13 7 10 9 12 4 5 10 Finland 13 7 10 9 12 4 5 10 France 41 51 50 72 72 15 29 21 Germany 195 153 129 138 135 57 80 70 Greece 282 365 524 465 406 123 171 169 Hungary 207 186 175 125 89 44 57 63 Iceland 5 5 1 5 1 2 1 1 Ireland 129 145 137 170 174 242 244 241 Italy 370 386 425 610 744 124 137 137 Latvia 59 25 26 22 18 14 11 21 Lithuania 71 45 38 38 44 8 13 26 Malta 20 23 42 39 40 24 48 62 Netherlands 43 57 86 106 114 72 98 72 Norway 3 6 3 5 12 3 3 2 Poland 158 113 137 163 173 82 95 123 Portugal 48 64 92 82 104 47 30 54 Romania 677 449 288 276 263 108 170 164 Slovakia 40 40 49 44 57 17 28 29 Slovenia 7 3 17 10 15 3 6 11 Spain 124 159 264 323 247 49 67 65 Sweden 21 25 22 21 22 11 23 15 Switzerland 29 27 37 37 28 10 17 28

And back again to the Commonwealth?

Ten years later the tables turned as the UK voted to leave the EU. This led to large drops in the number of some health professionals such as nurses, although the full effects are yet to be documented across the sector. Growing staff shortages in some parts of the health sector are causing concern that the EEA will no longer serve the health workforce requirements of an ageing and rising population and its attendant demands for health care.

Although some areas such as emergency medicine, paediatrics and psychiatry have almost always been on the list of shortage specialties, and are allowed to recruit internationally, shortages are now more widespread. Moreover, the cap on Tier 2 visas (previously the Work Permit category) from outside the EEA to a maximum of around 20,000 per year across all the professions – alongside the demand from some other sectors such as IT for these visas – meant that many areas of the health service remain understaffed. NHS bosses have claimed that this significantly affects their ability to deliver healthcare safely and have pressed for the removal of the cap. The Home Secretary has now capitulated to these demands. What is clear is that the NHS, as ever, struggles to remain national.

Yet this internationalism of the NHS is only one exemplar of the UK’s position within a world of connections – with Europe and with other countries, including the Commonwealth. Only when the power and necessity of these connections – and their role in making the UK what it is today – is recognised will anti-immigration arguments and sentiments about Europeans and non-Europeans alike be challenged.

This post represents the views of the author and not those of the Brexit blog, nor the LSE.

Parvati Raghuram is Professor of Geography and Migration at the Open University.