CHAPTER 4

INTERNAL COLONIALISM - I
BLACK HEALTH WORKERS IN BRITAIN

The exploitation of black health workers in the British National Health Service (NHS)

THE NATIONAL HEALTH SERVICE

The futility of, and huge loss of life in, the First World War, followed by the class confrontations of the twenties and the recession in the thirties, led to a crisis of confidence in the British Establishment in the years leading up to the Second World War. Harold MacMillan wrote: “(After 1931) It had become evident that the structure of capitalist society, in its old form had broken down, not only in Britain but all over Europe and even in the United States. The whole system had to be re-assessed” (3).

The British Government needed to convince the working class that after the war things were going to be different in Britain and that, therefore, there was something worth fighting for. The promise of the creation of the welfare state as envisaged in the Beveridge Report of 1942 was an important aspect of the state’s plan to recruit, and help maintain, mass working class support for the war effort. Free medical care in a National Health Service was to be an important priority for the welfare state.

Some of the long drawn out negotiations between representatives of the medical profession and the government is not available for examination, but a little is known of the Brown plan of March 1943 (4). Here, civil servants, with experience in local authority medical services, proposed a unified health service, incorporating the voluntary hospitals, based on a system of regional units and in conjunction with local government. General practitioners were to be full-time salaried employees. There was widespread opposition to this plan from all sections of the profession with the exception of the Socialist Medical Association. The plan was regarded by the doctors as a threat to their autonomy and freedom of action, but what they were really anxious to preserve was their privileged position in British society and their dominance over all things relating to health and sickness.

The government, on the other hand, sought to obtain the consent of the profession as a whole by playing to sectional interests within the profession and by a policy of ‘divide-and-rule’. The hospital consultants, the elite of the profession, finally agreed to accept part-time or full-time salaried status in exchange for the right to private practice (in the case of part-time contract holders), a say in appointments and promotions and control over the secret merit awards system.

In the circumstances, it was difficult for the general practitioners to press for strong commercial demands and they thus lost the right to sell the goodwill of a practice. The third branch of the medical profession, the medical officers of health, worked in the field of preventive medicine and were isolated from the other two. Lacking high status and prestige, they had little bargaining power in their negotiations with the government over conditions of service in the proposed health service.

In the end, the National Health Service maintained the divisions and hierarchical structures in the profession that developed in the nineteenth century and itself emerged as a tripartite structure. The profession extracted the right to provide medical care, in certain circumstances, on a fee-for-service basis and private practice could continue, in addition, in both primary and specialist care. In the NHS, the general practitioner became less dependent upon his patients and arranged his work schedule to his own advantage. Hospital consultant private practice has expanded. The wealthy appreciate the facilities that go with private rooms and can quite often avoid long hospital waiting lists via a visit to a consultant’s private consulting rooms. Private practice benefits the wealthy and their medical attendants. It brings no benefits to the NHS; on the other hand, private patients may receive preferential treatment at the expense of non-paying clients. Private patients may, however, let the government off the hook; if private practice was abolished, this group, because of their privileged position in society, may become most vocal in their demands for an improved health service all round.

Apologists for Nye Bevan, the Minister of Health who supervised the negotiations with the medical profession maintain that the compromises made in 1946 were a necessary precondition to enlisting the co-operation of the medical establishment without which the NHS could not, allegedly, have been brought into existence. This, doubtless, played no small part in the reproduction, within the National Health Service, of the class structure. and hierarchies of British society together with their functional determinants. The hospital consultant and the general practitioner represent the upper and upper middle classes respectively, within the medical profession, and their median earnings reflect this. Much below them comes the lower middle class in the health sector, the nurses, the various therapists, technologists and technicians, who are primarily female and comprise 30% of the labour force in the health service. Below this group is the working class in the health sector who comprise 54% of the labour force in the health service and are predominantly female (84%) with an over-representation of blacks (5).

As Simpson(6) and Robson(7) maintain, the class structure in the NHS labour force has not changed since its inception and that, moreover, the British system of education perpetuates the class system and replicates social roles.

PROMINENT PRE-N.H.S BLACK HEALTH WORKERS

MARY SEACOLE

One of Britain’s most distinguished black health workers was Mrs Mary Seacole; her treatment at the hands of the British Establishment was a foretaste of what was to befall post World War II black health workers in Britain’s newly founded National Health Service. Much of the detail that is available about the life and work of Mary Seacole comes from her fascinating autobiography written when she retired to England after the Crimean War.

Mary Seacole was born Mary Jane Grant in Kingston, Jamaica, in 1805,(8) (two years before the abolition of the Slave Trade), the daughter of a free black woman and doctress, who also ran a boarding house and hotel; her father was a Scottish army officer. Freed blacks were hemmed in by repressive and discriminatory legislation as a result of which most lived in poverty and in constant fear of repeat enslavements Emancipation did not come till 1833 and even this was followed by a period of enforced apprenticeship.

The West Indian plantocracy headed a hierarchical society based on the lightness of one’s skin and maintained political hegemony in the years leading up to Emancipation by pitting mulatto against black, and free black against slave. In the period immediately following the spectacular achievement of Haitian independence in 1803, the home governemnt in London feared that blacks elsewhere, fired by the Haitian example, might follow suit, and spark off insurrections. Troops were moved to the West Indies and Kingston became a garrison town. It was not uncommon for army officers to seek medical attention and convalesce at well-known hotels (9).

Mary’s mother whose expertise was acknowledged throughout the island, used her skills to help the many who stayed at the hotel. It was not unknown for British officers of high rank to be cared for in this manner by Creole women doctors. Mary’s mother had studied the medical arts that had been brought over from Africa by the slaves and combined them with traditional island medicine. She also studied the healing arts of men trained in Europe.

It was Mary’s childhood ambition tobeanurse and follow in her mother’s footsteps. Practising on her pets, she became so proficient that she was permitted to attend patients at the age of 12. In her youth, she paid two visits to England. Returning home, she spent more time learning all she could about Creole medical art. On November 10, 1836, Mary married a certain Edwin Horatio Seacole and established a store at Black River, Jamaica. In the circumstances, Mary had the opportunity to study and incorporate into her own practice a comprehensive set of therapies which she put to good use when she took over the hotel on the death of her mother, itself occurring shortly after her own husband’s death.

Always eager for knowledge, Mary learned much from the various military surgeons attached to the British forces of the Kingston garrison; there were few officers of the 97th. Regiment to whom she was not known before she joined them in the Crimea. She used her skills to heal persons of all ranks and classes at her hotel in Jamaica, as well as during her travels in Central America. Her first official duties were undertaken in Jamaica in 1853 when she was summoned by the military authorities to supervise the management of an outbreak of yellow fever on the military base at Up-Park Camp. From this she went on to volunteer her services to the Army in the Crimea the following year.

When Mary learnt that the regiments that she had known in Jamaica had been sent to the Crimean War, she decided to follow them and travelled first to England. On her arrival in England, in the autumn of 1854, Mary Seacole spent many days at the Nurses’ Recruiting Office in Belgravia. Thinking that her experience caring for the sufferers of cholera, diarrhoea and dysentery, which diseases also appeared to be the most prevalent of maladies in the Crimea, would be useful to the soldiers out there, Mary applied, albeit unsuccessfully, for the post of a hospital nurse, first, to the War Office, then to the wife of the Secretary of War, and, finally, to the Crimean Fund. Failing to catch the attention of any of the authorities, she laid in a stock of medical supplies and home comforts and set sail for the Crimea with a male relative, a Mr Day. It was probably unlikely that there were many white women who were possessed of Mary Seacole’s skills and experience.

At Scutari, in the Crimea, Mary was recognized and welcomed by many a soldier that she had nursed at the Up-Park Camp. On her way to Balaclava, Mrs Seacole spent a night at the base hospital in Scutari and met Florence Nightingale, but was never requested to help in the nursing of the wounded, although Miss Nightingale had been aware of Mrs Seacole’s skills and experience.

Mary set up her ‘British Hotel’ near Balaclava, where she provided good nourishing food, accomodation and medicines. She also carried provisions, medicines and bandages to the wounded in the field, and was soon recognised and welcomed by all, including the Commander-in-Chief, Lord Rokeby, and, especially, by the army medical officers who valued her skills and assistance in the field. The ‘Times’ correspondent, William H. Russell, whose revelations about the mismanagement of the War shocked England, paid Mary the following tribute: “I have seen her go down under fire with her little store of creature comforts for our wounded men; and a more tender or skilful hand about a wound or a broken limb could not be found among our best surgeons. I saw her at the assaults on the Redan, at the Battle of Tchernaya, at the fall of Sebastopol, laden with wine, bandages and food for the wounded or the prisoners. Her hands, too, performed the last offices for some of our noblest slain” (10).

When the war ended in 1856, Mary returned to England. She was bankrupt, but some of those of wealth and of high rank that she had helped in the Crimea came to her aid with donations and charity performances. Mrs Seacole died of a stroke in 1881 and is buried in the Catholic cemetry at Kensal Rise, London. At her death, she was reasonably well-off. She was soon completely forgotten in Britain, though not in Jamaica.

When Mrs Seacole’s grave was identified in the early 1970s, the gravestones were slowly disintegrating. They were restored by the combined activities of the Lignum Vitae Club (an association of Jamaican women in London) and the British Commonwealth Nurses War Memorial Fund. The reconsecration ceremony, on November 20, 1973, was attended by representatives of the Nurses’ Association of Jamaica and the High Commissioner for Jamaica in London. The Nurses’ Association of Jamaica have renamed their headquarters ‘Mary Seacole House’.

Mary Seacole’s life spanned the first threequarters of the nineteenth century.

Following Emancipation, the black community in Britain that had existed, without interruption, since the first Elizabethan era, was disintegrating. Living in abject poverty, they were largely excluded from the system of Poor Relief. Instead they received charity on an ad hoc basis from the Committee for the Relief of the Black Poor and had been, themselves, under strong pressure from even their ‘friends’ in the British Establishment to leave Britain and emigrate to Sierra Leone. This was the period when Imperial territorial acquisition was in full swing and various theories of racism were being promulgated by the social anthropologists, the sociobiologists and the social Darwinists.

The ordinary people of Britain were being brainwashed, with these theories, to accept the justification for racial domination, colonialism and the extraction of the natural resources and wealth of other nations, supposedly for the good of civilization and the benefit of all people. Against this social background, the respected and kindly figure of a mulatto woman, skilled in the arts of healing and caring and who had brought so much joy into the lives of all manner of persons from the Caribbean to the Crimea, could only have acted to banish the many obscene, racist ideas then being floated abroad in British society.

DR H. A. MOODY

Harold Arundel Moody was born in Kingston, Jamaica on October 8, 1882, the eldest child in a strict Congregationalist family. His father was a retail chemist (11). His mother was denied a scholastic education(12) but had ambitions for her son. Moody came to London to study medicine at King’s College, and King’s College Hospital. He experienced the racism, that was to dog him for years afterwards, almost from the moment he stepped onto the platform at Paddington station in September 1904.

Moody became an accomplished public speaker and was elected President of King’s College Christian Union. At the completion of his pre-clinical studies, he went on to clinical studies at King’s College Hospital. Here he had to put up with the racism of his fellow medical students, an aspect of peer culture. This was so acute that many black students applied for, and were given, leave of absence so that they could pursue parts of their clinical course elsewhere.

Moody decided to stick it out through to the finish, and ended up with the Warneford Prize and Medal and the Barry Prize in 1906, the Leathes_/ Prize in 1907, and, finally, the Tanner Prize in Obstetrics, and the Todd Medal and Prize in Clinical Medicine in 1910. He received the qualifying diplomas, MRCS, LRCP, in 1910-1911 and the University of London qualifying degree, MBBS, in 1912. In 1919, he received the coveted postgraduate degree of M.D. from the University of London. In 1925, he contributed a paper, as a Fellow of the Royal Society of Medicine, to the Society’s journal (13). However, after qualifying in 1910 with several prizes under his belt, Moody was refused a house doctor appointment, because the matron objected to having a coloured doctor at the hospital, and was later unsuccessful in his application for the post of medical officer with the Camberwell Poor Law Board of Guardians. In 1913, he started his own practice in Peckham, married the sweetheart of his student days and raised four children. He became a successful practitioner and was later elected to the chair of the board of directors of the Church Missionary Society and to the post of president of the London Christian Endeavour Federation. In 1931, he helped found the League of Coloured Peoples. Dr Harold Moody died in 1947. (14)

THE EXPLOITATION OF BLACK HEALTH WORKERS IN THE BRITISH NATIONAL HEALTH SERVICE

At a time when the National Health Service (NHS) is under threat from a monetarist government and the rallying cry from the left is “Save the NHS”, it will be hard to accept that this caring institution, until recently the largest single employer in the European Economic Community, has, in fact, been a major oppressor, in Britain, of black people, both as workers and as consumers. No one level of black workers in the NHS has been spared this exploitation; from doctors to migrant domestics, blacks have been discriminated against in innumerable ways. However, it is the racism suffered by doctors that has, for obvious reasons, been documented in the greatest detail, and been given the widest publicity.

The National Health Service is heavily dependent on overseas workers at all levels and is, in fact, one of Britain’s largest employers of migrant labour. Some 33% of all doctors and 20% of student nurses working in Britain in the early 1980s were born abroad. Although no national figures are available for the other sectors of the labour force in the NHS, one survey of an acute non-teaching hospital in London showed that 80% of ancillary workers were from abroad (15).

OVERSEAS DOCTORS

The recruitment of overseas doctors, in considerable numbers, for service in the NHS, began in the early fifties. The promise of the founding fathers of the NHS that treatment, at the point of delivery, would be free to all, required, for its implementation, a massive expansion of health services throughout the country. From the aspect of medical staffing, this would have required a large increase in the number of doctors, both in the hospital service as well as in general practice, who possessed the requisite qualifications to accept appropriate clinical responsibility. It was unlikely, and indeed undesirable, that this number could or should have come from British medical schools.

The dilemma facing the state was the problem of how to maintain, undiluted, the privileges and financial position of Britain’s senior hospital dcotors and, at the same time, staff the hospital services and the underserviced inner city areas with qualified hospital doctors and general practitioners, respectively. The problem was how to maintain the pyramidal structure of hospital medical employment and yet prevent the build-up of pressure on the apex of the pyramid from the lower orders. The only way in which the pre-eminence and permanence of the apex of the pyramid could have been maintained was by transferring the upward pressure from the lower levels into a horizontal pressure, i.e. out of the pyramid.

The sub-consultant (i.e. the sub-apical) grades in the hospitals’ section of the NHS were, therefore, made temporary and short term so that at the end of a six month or one year contract, for example, the (black) doctor was obliged to move on to a different NHS region whilst another (black) doctor took his place from yet another region of the NHS. And so what was, in fact, an NHS game of musical chairs was made possible by reserve army of labour, a group of black doctors characterized by enforced mobility (16).

To legitimise this exploitation, and in order to entice black doctors into dead-end jobs, the various Royal Colleges, which lay down guide-lines in regard to higher training for doctors as well as set the examinations which future specialists have to pass, gave recognition to many junior posts in small suburban and outlying hospitals, which recognition classed these jobs as training posts even though they have a full (100%) service component and no training facilities and are, in fact, jobs where the junior staff worked with minimal supervision. These posts are filled by black doctors who are then disallowed from continuing with their careers in the NHS for the specious reason that they have worked in these nonacademic institutions. Racism has placed them in a Catch-22 situation and prevents them from entering academic institutions except for a few posts in the Cinderella specialities, reference to which will be made later.

As Sivanandan(17) and Gorz(18) state, the reserve army of black labour was of great benefit to Britain. The black worker had cost Britain nothing. He had been reared and raised, fed, clothed and housed, till he had come of working age, in his home country. Gorz calculated the saving to Britain of a ready made (non-professional) migrant worker to be between £8,000 and £16,000. Moreover, the fact that the migrant worker came initially as single person meant that there was a further saving to Britain, in that there was minimal call on the health, welfare, housing, educational and infrastructural services. In the National Health Service, the introduction of a reserve army of black doctors to cater for the service needs of the NHS, as opposed to its research and training components, helped to cushion a privileged profession, and especially its consultant elite, from the cataclysmic changes in health care delivery that followed in the wake of the foundation of a nationalised health care delivery system that was free at the point of delivery.

There is a further way in which Britain benefits from the employment of overseas doctors. Some of these doctors return to practise in their own countries and so take with them the practice of Western medicine and the demand for the technical infrastructure that goes with it. The continuing cultural penetration and domination by British medicine results in an important and growing market for British technical equipment and for the products of British pharmaceutical companies. As David Ennals, the former Secretary of State for Social Services acknowledged: “We have exporting potential which I am doing the best I can to help mobilise. One way of encouraging exports is to train people here, where they will become accustomed to using some of the best products we are making and which can be used abroad” (19).

The earliest black doctors to work in the NHS soon came face to face with the racism of their colleagues, and especially of their senior colleagues, a problem that began to spill over into the correspondence columns of the ‘British Medical Journal’ at the beginning of the sixties. Although the then editor of the journal closed the correspondence on racial “prejudice” and discrimination in the NHS in the early sixties, the subject continued to crop up at professional meetings and in medical writings.

The recruitment of the Third World medical reserve army of labour continued, even under Enoch Powell, Minister of Health in the Conservative Government of the early sixties. After working in the NHS for a few years and after acquiring such skills as they had managed to perfect, black doctors were told by their consultants and senior colleagues that their services were no longer needed in the NHS. Furthermore, they were told that they were highly unlikely to succeed in the competition for the posts leading up to a consultancy. A consultancy is also a post that carries with it security of tenure till retirement.

Black doctors were then “advised” that the options open to them were:-firstly, a return to their country of origin; secondly, re-emigration to the United States, one of the old (white) Dominions in the Commonwealth, or an oil-rich state; or, finally, a change of speciality, say, to one of the NHS’s Cinderella departments, such as geriatrics, psychiatry or mental handicap (and even then with no promise of promotion according to merit), or, more usually, into general practice in an underserviced inner city area; in all these NHS areas of work, they were unlikely to meet up, at least until the deepening recession, with competition from white British or white Commonwealth doctors. Although the reason often given for the failure of a black doctor to slot into a higher training grade is that he is not qualified enough, the reason given for not permitting him to continue in his current temporary training grade is that he is too highly qualified. The black doctor thus finds himself in a veritable no-win situation.

Complaints about racism in the NHS continued to be voiced, and, in 1976, the Community Relations Commission, the statutory body set up under the Race Relations Act 1968 and the predecessor of the Commission for Racial Equality, produced the first major report on doctors from overseas. The Commission found that overseas doctors were over-represented in the lower grades and under-represented at the higher levels of the service; that overseas doctors were over-represented in the least popular specialities, which specialities were also the ones where a few of them were permitted to reach higher level jobs; that overseas doctors were less represented in pleasant rural areas; and, finally, that overseas doctors were underrepresented in teaching hospitals and academic units.(20)

The Community Relations Comission recommended that “overseas doctors should be both represented and consulted on all issues and decisions which concern their employment, training and career prospects in Britain. It is impractical, as well as inequitable, for a group of doctors who provide one-third of the country’s hospital service and 18% of general practitioners to be denied consultation on changes which closely affect them, and representation on bodies which make decisions about their conditions”. The Commission went on to “recommend that the position of overseas doctors in the promotion structure and their access to specialist training should be examined in more detail. Opportunities should be available, when required, for existing doctors to take advantage of the improved training systems already recommended for overseas doctors entering the country”.

It is part of the modus operandi of British capitalism that complaints and grievances in regard to privilege, inequality (especially those associated with race and class), exploitation and corruption, all essential ingredients in a capitalist democracy, should be defused by commissions, enquiries, reports and recommendations, without altering, even by one iota, the basic fabric of the political structure. And so none of these recommendations was ever implemented, in a meaningful way, as they were fundamentally incompatible with exploitation and the drive for profit.

With the onset of the latest world capitalist crisis, the need for the services of the reserve army of medical labour decreased. This was accompanied by the termination, by the General Medical Council in London, of the status of recognition, previously granted to the major medical schools on the Indian subcontinent, which recognition entitled their graduates, in theory at least, to practise medicine, whilst in the United Kingdom, on an equal footing with the graduates of British medical schools. This was followed in 1978 by the provisions relating to the registration of overseas qualified medical practitioners in Sections 17-29 of the Medical Act of 1978. These granted, after an exam held in Britain, limited registration, (for a period of 5 years), to work under supervision in the hospital service (generally in the Cinderella departments), to graduates from the non-white Commonwealth.

There were a few exceptions to these rules: graduates of certain recognised institutions in Hong Kong, the West Indies, Singapore and Malaysia were exempt. Graduates from all the old white (Commonwealth) Dominions were, of course, exempt. Before they were granted limited registration, the non-white overseas graduates had to pass tests in English and professional competence, conducted, on behalf of the General Medical Council, by the Professional and Linguistic Assessment Board (PLAB). At the end of the five year period of limited registration, these doctors could apply for full registration, which, however would only be granted at the discretion of the General Medical Council (GMC).

The GMC’s explanatory note LR 2 states: “In exercising its discretion in such cases, the Council will have regard to the knowledge and skill which the doctor has shown while holding appointments under limited registration, and to the experience which he has acquired. A high standard of practice will be needed in order to qualify for full registration, under these provisions, and an applicant must satisfy the Council that he is of good character”.

In practice, the overseas doctor is channelled into working without supervision in second rate hospitals,themselves without facilities for training or teaching. And so the doctor works in circumstances which are hardly conducive to attaining the standards required by the GMC for full registration. The discretionary powers of the Council in this respect and the ‘good character’ provisions in the requirements act as a powerful deterrent to any thoughts of militancy.

The first batch of overseas doctors to apply for limited registration under the new provisions were granted this in February 1979. By the middle of 1983, there were growing fears that a considerable number of Asian doctors would not remain registered after February 1984 when the five-year period of limited registration, of those who were the first to be registered under the 1978 Act, came to an end. These fears were based on the fact that the majority of these doctors were working in purely service jobs in the run down hospitals which are the medical ghettos of the NHS, and could not have reached the ‘high standard of practice’ required for full registration. Deregistration would have meant the loss of their work permits and the threat of possible deportation (21).

By the middle of 1983, attempts were already being organised to defend any doctor facing repatriation, but the General Medical Council and the medical hierarchy, already facing militancy from other black doctors, decided otherwise. Very few doctors lost their registration and the threat never materialised. The Medical Act of 1978, which has been described as a slaver’s charter(22) and which, incidentally, was enacted under a Labour Government, (responsible also for the ‘virginity tests’ on Asian women arriving at HEATHROW-London airport and for the notorious Parliamentary Green Paper that paved the way for the racist Immigration and Nationality Act of 1981), legitimised the underclass status of black doctors in the health service, increased their vulnerability and exacerbated their feelings of powerlessness. While much ink was spilt, in the Act, on how black doctors were to be controlled during their stay in this country, precious little was said on how these doctors were to be protected from exploitation, even though by 1978, the contents of the Report on overseas doctors by the Community Relations Commission, were widely known.

THE REPORT OF THE POLICY STUDIES INSTITUTE (PSI)

The next major report, with a liberal perspective, to come out, on overseas doctors in the NHS, was that put out by the Policy Studies Institute, in 1980 (23). This concluded that the NHS had relied, and continues to rely, on a floating population of overseas doctors, whose very presence is utilized to sustain the hierarchical medical structures in the service. Although there are large numbers of overseas hospital doctors in each of the NHS regions, the overseas general practitioner tends to be found in those parts of the inner-city areas which have large black populations. In the hospital service, again, overseas doctors are to be found predominantly in the lower or junior grades, especially in the unpopular specialities such as geriatrics, psychiatry and anaesthetics, and they are under-represented in the popular specialities such as general medicine and general surgery. Overseas-qualified general practitioners tend to have a postgraduate qualification related to a hospital medical speciality for the reason that they initially aspired to a senior post in hospital medicine, but then found their promotion and advancement blocked.

The career prospects, in hospital medicine, of a white graduate from one of the old white Commonwealth Dominions, tend to approximate, those of a white British graduate, but what the PSI report failed to investigate, and which is common knowledge within the hospital service, is that the experience of black British graduates (who may also be British citizens), approximates closely to that of a black overseas graduate. British-born black graduates with English-sounding names and English accents (or, at least, accents that sound English over the telephone) are readily invited to job interviews, only to find the interview panel, first startled, then embarrassed, and, finally, reject the black applicants.

Race is the common denominator here, and, it would appear, an important determinant of career prospects. The PSI report also found that the (white) British graduates tended to spend less time in the more junior grades than the oversea graduates; among British hospital doctors aged 35 to 44, say, 71% are consultants compared with only 16% of oversea doctors in this age group. 68% of British qualified hospital doctors with a higher qualification (e.g. M.R.C.P., F.R.C.S., M.R.C.O.G.,) are consultants as compared with 28% of oversea doctors with similar ranking British postgraduate qualifications. Overseas doctors whose English is adequate make less progress in their careers than British doctors of the same age and with broadly similar qualifications. It was felt that this was probably due to the fact that overseas doctors tend to work in non-teaching districts; and, even though their English may be good and they are otherwise suitable, they tend to be excluded from the teaching hospitals. The reason given by British doctors for this state of affairs (but one which is not borne out by the evidence) is that some patients prefer not to be treated by a nonwhite doctor.

The PSI report also found that overseas doctors made five times as many applications for jobs as British-qualified doctors and while it may appear that there was open competition for junior jobs, many such posts were earmarked for certain known candidates. Most doctors believed that overseas doctors do not compete on equal terms with British doctors and many are exploited by being obliged to work in unpopular posts without being able to obtain the training for which they came to the U.K.

The PSI report concluded that the specialities in which ‘Englishness’ and an English cultural affinity are an asset, as in psychiatry and geriatrics, are the very ones which were staffed predominantly by overseas doctors. The report stated that not only was the exploitation of overseas doctors harmful to the overseas doctors themselves, but that this also had harmful effects for the NHS, in that it permitted, by the utilization of a reserve army of black medical labour, an artificial structure to develop in the NHS in which two-thirds of hospital doctors were juniors. In a stable situation, the ratio would have to be reversed, with two-thirds of hospital doctors being consultants and one third juniors. Patients would then receive higher quality care, there would be a more rational organisation of hospital health care delivery and the training of juniors would be better accomplished because of a greater number of consultants.

The PSI report went on to make a number of recommendations on the basis of these conclusions, but, to date, there has been no evidence that either the government or the medical hierarchy has taken them seriously.

Over the years a large number of reports analysing the racism in the employment sector of the National Health Service has been produced by statutory bodies, academic groups and voluntary organisations, but the ruling Establishment has steadfastly refused to take action, and this even when a DHSS directive, on race and employment, to health authorities has been consistently ignored. The reasons for this are discussed towards the end of this chapter.

THE RACE RELATIONS ACT 1976

Race Relations legislation in Britain has been based, broadly speaking, on the earlier American model, with one important exception. The American model permits positive discrimination, i.e. in situations where racial minorities are poorly represented, employers are permitted, even encouraged, to discriminate in favour of these groups in order to attempt to reach a situation where all the racial groups are represented in a workforce in proportion to their numbers in the local community.

In British race relations legislation, positive discrimination is unlawful; instead, there is what is known as ‘positive action’ which, in practice, can mean very little. In theory, it is taken to mean that employers should take all possible steps to encourage racial minorities to go in, for example, for training that will, subsequently, entitle them to apply, on equal terms as whites, for job situations where their own racial groupings are poorly represented. But discrimination in apportioning places in training is itself unlawful (S.4(2)(b) of the Race Relations Act 1976).

As a result, the Race Relations Act, the Commission for Racial Equality and the system of Industrial Tribunals have, over the years, worked or acted in contradictory and bizzare ways. There are, of course, those who will argue that racism and allied exploitations cannot be eradicated under capitalism.

THE DEPARTMENT OF HEALTH AND SOCIAL SECURITY CIRCULAR - HC (78) 36

Following on the enactment of the rather anaemic Race Relations Act in 1976 by a Labour government, the Department of Health and Social Security issued a health circular - HC (78) 36 - to all Regional and Area Health Authorities and Boards of Governors of Special Hospitals for action. This directive gave detailed advice to these bodies on their various responsibilities under the new Race Relations Act and guidance on the implementation and monitoring of employment policies and practices in order to eradicate unlawful discrimination on grounds of race, colour, nationality, ethnic or national origins.

Unlawful discrimination could be either direct (on the grounds just stated), or indirect, as when an unjust or unnecessary stipulation is entered by prospective employers into the qualifications necessary for a job, such that it excluded certain racial groups. Health authorities, their personnel officers and appointment committees, and the Royal Colleges paid scant attention to the Act and the Department of Health and Social Security’s directive, with the result that, when challenged by the author in several Industrial Tribunals throughout the country (24), none had ever even heard of health circular HC (78) 36.

THE COMMISSION FOR RACIAL EQUALITY (CRE)

The statutory body, the Commission for Racial Equality (CRE), was set up by the Race Relations Act 1976 to carry out the duties of :

(a) working towards the elimination of discrimination;
(b) promoting equality of opportunity and good relations between persons of different racial groups generally; and
(c) keeping under review the working of the Act, and, when required by the Secretary of State or when it otherwise thinks it necessary, to draw up and submit to the Secretary of State proposals for amending it (25).

The first investigation by the CRE into employment practices in the NHS was carried out in 1983 (26). The CRE reported that in their talks with health authority personnel, officers and administrators, it was asserted that the presence of black workers proves that there is no discrimination, an attitude that the CRE regarded as misplaced. However, not once in their 20-page report did the CRE refer to the document produced by their predecessors, the Community Relations Council (CRC), although they referred to 15 other reports that had been researching allied problems. A reference to the CRC’s 1976 report would only have had the effect of demonstrating the permanence and inevitability of racism in Britain’s exploitative social system. The CRE report, in its ‘softly, softly’ approach, concluded, though, that the hospital is as “vulnerable” to unlawful racial discrimintion as other employing groups and that discrimination is very frequently the result of “the unthinking operation of a system which discriminates against ethnic minority groups”. The CRE’s findings were not dissimilar to those of the CRC and the Policy Studies’ Institute.

In a report prepared for the Social Science Research Council by the Department of Sociology of the Polytechnic of North London(27), Lesley Doyal et al. concluded that staff from ethnic minority groups, across the board, in the NHS, tend to be congregated in particular types of low grade health work. Although there is considerable pressure on health authorities to take the issue of racism in employment practices seriously, the Report went on, most have not deemed it necessary to tackle the problems of ethnic minority members as either producers or consumers of health care, and this despite the urgings of the Department of Health and Social Security in Health Circular HC (78) 36.

THE RACE RELATIONS CODE OF PRACTICE, prepared by the Commission for Racial Equality, was approved by Parliament in 1983 and came into effect in the spring of 1984 (28). It is 30 pages long and “aims to give practical guidance which will help employers to understand not only the provisions of the Race Relations Act and their implications, but also how best they can implement policies to eliminate racial discrimination and to enhance equality of opportunity. It does not impose any legal obligations.........however.............its provisions are admissible in evidence in any proceedings under the Race Relations Act...........”

In essence, the Code is just so much paper to attempt to detract, not just from the lack of action on the part of statutory bodies towards, but, even more, the active neglect of, their responsibilities under the Act. The Code of Practice is essentially a re-hash of the Race Relations Act, the guide to the Act published by the Home Office and the explanatory documents on the Act published by government departments, such as the Department of Health’s Circular HC (78) 36. Like so many more of the state’s strategies, it is intended to give the illusion that a specific issue is being taken seriously when it is not.

The next report to come out of the Commission for Racial Equality (CRE) on overseas doctors was entitled ‘Overseas Doctors: Experience and Expectations’ and was published in 1987 (29). By this time, much publicity had already been focussed on the racism in the NHS both in employment and in service provision, by black community activists and community organisations. This CRE report was, consequently, low-keyed. No reference was made to that important document, the Department of Health Circular HC (78) 36, probably because not a single health authority in the country had taken any action on it since it was issued 9 years previously in 1978. That this directive is still current was confirmed, in 1985, by a Parliamentary Undersecretary, in the reply to a letter written by Mr Tony Benn, Member of Parliament, on behalf of the author.

Nonetheless, the 1987 CRE report concluded that, whilst almost a third of all hospital doctors in England and Wales were from abroad, they were still concentrated in the lower grades and in the unpopular specialities, notably geriatrics, accident and emergency and psychiatry. They represented less than 19% at the senior grade of Consultant. Overseas doctors had to make more applications for posts than their British counterparts. 31% of all overseas doctors had to make more than 10 applications before they obtained a post; the corresponding figure for white British doctors was 0%. Overseas doctors are over-represented in locum posts, stay in them longer, have fewer prospects of promotion, and change their career options more frequently in order to improve their chances of progress. Three out of ten British-trained, but only one in twelve overseas-trained doctors were in receipt of the lucrative (and secret) merit awards. One in ten of the U.K.-trained consultants but only one in fifty of the overseas-trained consultants had been asked to sit on a merit award committee, Most importantly, the research findings demonstrated that the experiences of black British-born and British-trained doctors approximate those of the overseas-trained doctor, indicating that race is an important determinant of a doctor’s career prospects in the National Health Service.

In this report, the Commission for Racial Equality’s recommendations included the suggestion that the Department of Health and Social Security (DHSS) should collect statistics on doctors in the NHS not only by place of birth but also by ethnic origin. This would help in monitoring the career development of second generation ethnic minority doctors. The DHSS was also urged to issue revised guidelines to Regional and District Health Authorities on the elimination of direct and indirect discrimination and the promotion of equal opportunities in areas where they have specific responsibilities as employers.

There is, of course, no indication that health authorities would treat new directives, on racial matters, from the DHSS any differently from the manner in which they have responded to health circular HC (78) 36. This can be illustrated by the experience of one health authority as recorded in a Health Education Council report (30). In 197677, following on the enactment of the Race Relations Act, a formal equal opportunities statement was adopted by the health authority.

Consequently, in 1981, the personnel officer submitted a report to the District Management Team suggesting a simple ‘head count’ of ethnic minority staff in the various departments of the health authority. This would then have been compared with local employment patterns. Initially rejected by the District Management Team (DMT), the report was re-submitted and accepted in 1982, although, subsequently, shelved. According to the Personnel Officer, this simple and very cost-effective exercise had not been carried out because the Management Team did not see it as a priority issue, and the decision had, therefore, been taken to abandon it. Equal Opportunities had subsequently never been discussed by the health authority, even though the issue had frequently been raised by the local Community Health Council, the NHS’s local, toothless, consumer watch-dog. This has also been the author’s experience as a representative of voluntary organisations on local government and health authority committees. There is nothing like a simple head count to draw attention to the racist nature of health authority employment practices and to the fact that there is something dreadfully wrong.

The Greater London Council’s ( GLC’s) report, ‘Ethnic Minorities and the National Health Service in London’(31) also gives the liberal perspective on race relations in the NHS. It enumerates a number of problems facing London’s racial minorities in their dealings with the health service, both as workers and as consumers, and offers suggestions for improvements using the machinery that is currently available for redress. There is no comment on the rigid resistance to meaningful change on the part of health authorities, even with increasing pressure from the ethnic minority communities since at least the middle seventies.

To bring up to date the continuing struggle of black people to be allowed to participate in their own health care, two further reports (from community organisations) will be summarised. In a 1985 report, i.e. 9 years after the Race Relations Act, 7 years after the DHSS Circular HC (78) 36, and 15 months after the introduction of the CRE’s Race Relations Code of Practice, the London Association of Community Relations Councils (LACRC) concluded that the overall performance of health authorities in London in tackling racial disadvantage and discrimination in employment is desperately poor (32). Not only do most health authorities have a long way to go before they can claim to have a programme that could be effective but their personnel procedures, in fact, make it more difficult for them to eliminate discrimination.

The London Association of Community Relations Councils then goes on to make a series of twenty-one policy recommendations addressed to the Department of Health and Social Security, the Regional Health Authorities, local government, District Health Authorities, health service trade unions, professional associations, community health councils, the National Health Service Training Authority, the Commission for Racial Equality, the National Association of Health Authorities and the King’s Fund Centre, in the pious hope that there is abroad in British society a genuine will to eradicate racism, (which is, after all, historically speaking, a main source of the national wealth) if only there was the wherewithal.

In 1986, LACRC was reconstituted and renamed the Greater London Action for Race Equality (GLARE). Its objective is to work towards the eradication of racism in the Greater London area and it provides a means whereby the twenty-eight community relations councils of London can come together to undertake joint strategic action against racism. In 1987, GLARE produced a progress report, on the development of equal opportunities in employment in London’s health authorities, entitled ‘No alibi, no excuse’ (33). This follow-up report was published 18 months after LACRC’s ‘In a critical condition’. Its assessment was that “...........exhortation and encouragement - not just by a voluntary organisation like GLARE which can easily be ignored, but by the DHSS and its Minister in May 1986-have so far failed to persuade a substantial number of health authorities to take equal opportunities seriously”. Sir Barney Hayhoe, M.P., Minister of Health, addressing a conference of members of London health authorities said, “I know the many pressures on authorities and their senior staff, but these must not be used as an alibi or excuse for inaction on the equal opportunities front” (34).

In its journal ‘Socialism and Health’, the Socialist Health Association stated(35) that the plight of medical staff from the ethnic minorities is a consequence of the elitist and status-conscious nature of the medical hierarchy. It went on: “The veto (against ethnic minority staff) can be exercised at all levels - “....their English is not good enough”; if the qualifications are British, then the required experience will be found lacking; if qualifications and experience are present, then the interviews mysteriously become more of a hurdle. One applicant for a forensic medicine post was asked why he did not go back and work in this speciality in his country. When he replied that no such service existed, it was suggested that a good idea, surely, would be to get one "started up”. However, the Socialist Health Association, which is affiliated to the Labour Party did not comment on the role of representatives from the Labour Party and the trade unions, on health authorities, who collude actively, or by default, with the racism of Britain’s corporate class.

Further evidence of this is found in the report ‘No alibi, no excuse’. Describing its disappointment with the health service trade unions’ lukewarm response to LACRC’s first report(36), the GLARE report went on “..........equal opportunity is still a marginal issue within the health service unions; their commitment shows itself more in statements of principle than in decisive action” (37).

Nor is it just in the area of hospital practice that overseas doctors suffer under institutional racism. Mrs Jean Robinson, a former chair of the Patients’Association, has said that the complaints system of local Family Practitioner Committees is loaded against overseas qualified general practitioners. The decisions of Medical Services Committees demonstrated a bias against overseas doctors that was obvious to the lay person, with the result that patients interested in seeing that justice is done in every case were often angered when white doctors were let off easily (38).

NURSES

The first colonial nurses to be recruited, in recent history, for work in Britain arrived in 1941. In the war years, colonial students, mainly from British West Africa, the West Indies and British Guiana, were accepted for nursing. In 1947, the Colonial Office stated its intention of setting up a Colonial Nursing Service of high standards. The Colonies which were prepared to participate in the training scheme were to set up their own nursing selection committees to recruit nurses for training in Britain. In Britain, the nurses were placed in selected hospitals. In case the British Government’s noble intentions were cynically interpreted, it was specifically stated that these nurses were not to be used to correct the shortage of British nurses. The committee in England responsible for placing these nurses was made up of representatives from the Ministry of Labour and National Service, the Colonial Office and the Nursing Recruitment Centre.

By 1948, nursing selection committees had been set up in Nigeria, Palestine, British Honduras, the Gold Coast, Sierra Leone, British Guiana, the Leeward Islands, Tanganyika, Northern Rhodesia, the Windward Islands, Malta, Cyprus, Trinidad, Jamaica, Gibralter and Mauritius. Moreover, recruitment on an individual basis was also carried out and aliens were recruited as physiotherapists, radiographers, occupationa1 therapists, 1aboratory technicians, pupil midwives, nursing assistants in mental hospitals and nursing orderlies (42). This was necessary in view of Britain’s acute post war labour shortage, and the recruitment of colonial nurses to train (whilst working) in Britain, although ostensibly for the promotion of a high standard colonial nursing service, must be seen in this light. To further offset the acute nursing shortage, the British Government in desperation offered to train, in British hospitals, women from the Baltic Displaced Persons’ Camps in Germany, Italy and Iran (43).

The number of nurse trainees recruited rose considerably in the sixties, peaked around the beginning of the seventies and then tailed off with the deepening recession and the contraction of the British labour market. In the late sixties, a considerable number of nurse trainees were recruited from Malaysia and the Philippines, in addition. In 1977, out of a total of 78,440 students and pupil midwives in England and Wales, 9,202 or 11.7% were born overseas. Of these oversea nurse learners 6,119 or 66.5% of the total came from the Commonwealth countries; 2,028 or 22% from Ireland; and 1,055 or 11% from other foreign countries. Within the group of Commonwealth nurses, the largest single category were the Malaysians (1,934 or 21% of oversea nurse learners), followed by the West Indians (1,366 or 15%), and, finally, the Mauritians (698 or 7.6%). The largest group coming from a non-Commonwealth country were those from the Philippines (359 or 4% of oversea nurse learners) (44).

Oversea nurse learners are more likely to be found in mental or geriatric hospitals and are disproportionately recruited to the less prestigious nursing schools who find it difficult to get British students. A significantly higher proportion of oversea nurse learners are channelled into the less prestigious 2-year State Enrolled Nurse (SEN) training rather than the normal 3-year State Registered Nurse (SRN) training(45), even though the Matrons of British hospitals and their Directors of Nursing Education realise that the SEN training is not recognised in most oversea countries.

In many cases, the nurses were recruited with the promise that they would be permitted to commence their SRN training after their probationary period. Cherrill Hicks(46) wrote that the memories of West Indian nurses who arrived in Britain in the 50’s and 60’s are primarily ones of exploitation and loneliness. Initially promised places on SRN training courses, many nurses were then directed into SEN training courses where, most times, all the pupils were black, although many had their ‘0’ levels. Fully qualified nurses from overseas whose English was of a high standard were told that their qualifications were not recognised and that they would have to retrain in Britain. Furthermore, they were told that as their English, too, was not good enough, they would not be able to take up SRN training. 90% of these nurses, in one instance, were then entered for SEN training no matter how skilled they were. Yet in the day to day running of the ward, these nurses were often expected to act up, often up to the level of ward sister, and to accept responsibility, but without the status or remuneration of a senior nurse (47).

In contrast, English girls who had left school at 15 with no qualifications were being allowed to sit the General Nursing Council (GNC) entry test for SRN training. The attitudes of senior white nurses and their less than even-handed disciplinary procedures were calculated to undermine the self-confidence and self-esteem of black student and pupil nurses.

Oversea learners are still being directed into low status nurse training schemes, even though these qualifications are still not recognised in many overseas countries. In January 1982, there were still 1,004 overseas learners (excluding those from Eire and the EEC) in training. Entry into SRN (RN) courses is made more difficult for oversea learners by the arbitrary manner in which local nursing directors interpret and apply GNC entry requirements and in the manner in which they often vary them from year to year, always to the detriment of the overseas nurse learners.

“The General Nursing Council (GNC) itself, for example, might recognise the Malaysian GCE -but that does not mean that the schools have to.....The schools also use the GNC’s entry test, which was primarily designed for those without ‘0’ levels, on overseas learners with all the requisite qualifications for SRN training..........Overseas learners are still being channelled into certain specialities e.g. geriatrics, psychiatry, and into the less prestigious schools and hospitals which cannot attract British learners. This year (1982) nearly one-third of the total number of overseas learners (1,653 out of a total of 5,105, according to GNC figures) are in psychiatry and mental handicap training” (48).

A Commission for Racial Equality (CRE) survey in 1986 showed an under-representation of ethnic minority students in general nursing training. In Greater London where the ethnic minority population is about 15%, only 1% of trainees at three schools were black. The survey criticised the nursing schools’ recruiting techniques which operated to the detriment of black students, and some of which, at least, are in contravention of the provisions of the 1976 Race Relations Act that relate to word of mouth recruitment and indirect discrimination. The CRE’s survey found that the majority of schools made use of informal methods of recruitment, such as word of mouth advertising and unsolicited letters. The schools also used a variety of academic criteria in determining minimum entrance requirements, which contrasted with the statutory minimum for entry to general nursing training, which is five ‘0’ - levels. Finally, the schools relied on a whole number of subjective criteria, such as ‘imagination’, ‘motivation’, and ‘the ability to integrate without undue difficulty’ (49).

An editorial in the ‘Nursing Times’ in 1984 admitted that racism is rife in the National Health Service, and that, although everyone knows it, few will admit to it. It added that if one is a black nurse, one’s chances of promotion and advancement are considerably less than if one is white.(50)

In fact, the racism that nurse learners experienced in the hospital situation was acute; the students from overseas had to put up not only with the racism of their superiors but also with that of their colleagues of equal rank. One nurse spoke of her fear of bringing her husband into the Nurses’ Home because of this. The effects of the personal racism of the more senior nurses facilitated by the hierarchical nature of the system, which gave superiors enormous power, resulted in the extreme vulnerability and exploitation of nurse learners who depended on the hospital for both their jobs and their homes in Britain. For most of them, without relatives or close friends in Britain, the Nurses’ Home is the only home they have. Something utterly trivial can cause an oversea nurse learner to be labelled a trouble-maker, which would then result in her inability to get a job upon qualifying. (51)

The real fear of victimisation that black nurses feel is not confined to learners. A researcher interviewing black nurses in the West Midlands reported such fears amongst a midwifery sister, a nursing tutor and a health visitor (52). All spoke of discrimination, victimization and exploitation in the ‘Cinderella’ specialities and of racism on the part of managers and, worse still, white colleagues with whom they had worked for years. This report suggested that there is something in the collective nursing psyche, which reinforced by rigid hierarchical structures and professionalism, made it vulnerable to racial prejudice.

In 1984, the report of a workshop, for Community Health Councils and Community Relations Councils, on providing effective health care in a multiracial society, told of a xenophobic retired dean of a British medical school who had recently written anonymously to the ‘British Medical Journal’ (‘BMJ’) in the following vein : “We need to draft a dozen of our best brains to grapple ruthlessly with the problems of career structure and opportunity in medicine for as long as it takes. Otherwise we shall permanently weaken our university faculties of medicine, reduce opportunities of local young men and women and offer patients an increasingly foreign service. Politicians care little for the future, but patients who by and large prefer to have a doctor who shares their own background and attitudes should not stand by.” (53).(54).

The report, from the workshop(53), went on to state that “the views expressed by the anonymous retired senior doctor and the fact that they were reproduced in the ‘BMJ’ highlighted the existence of deep-rooted racist beliefs at senior levels in the health service, and ignored the valuable contribution made by black health workers to the NHS over the last 30 years...............it exposed a fundamental lack of recognition and appreciation of the different needs of black patients.........It was not simply a question of providing special services for black and ethnic minority communities, but a question of raising the standard and delivery of services for everyone through improving the services given to the black and ethnic minority communities”.

The feelings of insecurity amongst overseas nurse learners is compounded by the operations of the 1971 Immigration Act. Under the provisions of this Act, a nurse learner faces deportation when she ceases to be a student. If she has qualified, then she has ceased to be a student, her student’s visa no longer operates, and she has to return to her own country. The only way she could continue to remain in Britain is to go in for postgraduate or specialist nurse training or to obtain a work permit. After her specialist training, a nurse still has to apply for and obtain a work permit and these are becoming increasingly difficult to obtain. The time periods spent in Britain during basic and postgraduate training do not count towards qualification for permanent resident status.

Qualified overseas nurses resident in Britain suffer racism also when they work for private nursing agencies or in private hospitals. The agencies are normally only able to offer temporary work either on a long term or, more commonly, on a short term basis. There is no holiday or sick pay and no security of tenure. But black nurses, again, find themselves being offered night shifts in psychiatric or geriatric hospitals, or jobs which are dirty or physically more demanding, which are all the jobs that white nurses would rather not do. There is, further, no seniority pay, only a flat rate irrespective of seniority. This makes it cheaper, sometimes, for an NHS geriatric hospital, for example to employ black agency nurses rather than NHS employed staff.

NURSES - PROMOTION

Torkington(55) explains how the informal systems operating in the NHS work to successfully circumvent even the most plausible equal opportunities policies in the health service. If a sister’s post is coming up for example, in the near future, the Nursing Officer and the Senior Nursing Officer may approach the white staff nurses in advance and prepare them well for the questions that would be asked in the interview. In one instance, a white nurse, who had returned to nursing as a part-timer in a special unit after a spell out of it, was asked by management whether she would like to replace a sister who was retiring in six months’ time. When the part-timer replied in the affirmative, management began to groom her for the post by first offering her full time employment, and then sending her to similar units throughout the country to learn about all aspects of the post. Two months before the post was advertised, she was sent to a special course covering present and future developments in such units.At the interview for the job, her appointment was a ‘fait accompli’. Torkington believes that, even with outside monitors and trade union representatives, the outcome would not have been any different.

THE POLITICS OF NURSING

In recent years, the nursing workforce has become highly stratified and differentiated(56), with the presence of overseas nurses facilitating the creation of a workforce divided along class and racial lines, between career nurses on the one hand and de-skilled ‘practical’ nurses on the other. There is a correlation in nursing between elite positions and (white) race, with ethnic divisions reinforcing the class divisions of the past and West Indians now over-represented in the less qualified SEN and nursing auxiliary categories. Overseas nurses are also over-represented in the staffing of ‘unpopular’ specialities such as geriatrics, psychiatry and mental subnormality, thus further reinforcing the divisions within nursing itself. Moreover, there is now an increasing need for workers in these three specialities and there has been a direct recruitment of overseas nurses into psychiatric hospitals for training (57).

The changing demographic pattern in the British population has meant an increase in the number of patients suffering from chronic mental and physical disabilities, and needing labour intensive care. Nursing of chronic mental and physical illness, however, has been hugely unpopular with British nurses. As nursing, in the way it is currently organised, demands compliance with authority, passivity, and the acceptance of difficult working as well as living conditions, it is not surprising that overseas nurses, who are vulnerable, for a number of reasons, and are easily victimised, are in great demand. As Doyal et al. put it(58): “It is evident then, that not only have overseas nurses facilitated the rationalisation and de-ski11ing of the nursing profession but they have also helped to maintain a particularly oppressive and anachronistic set of social relations”.

NATIONAL HEALTH SERVICE ANCILLARY WORKERS

The ancillary workers collectively form the largest group of workers in the National Health Service. About one in three of all hospital workers are in this category and one working person in every hundred in Britain is employed as a hospital ancillary worker (59). The Department of Health and Social Security (DHSS) classifies personnel in the NHS as professional and technical, administrative and clerical, works and maintenance staff, and, finally, ancillary staff. The ancillary staff include domestics (more than half), catering staff (a little less than a fifth), laundry workers, porters, gardeners and telephonists.

The recruitment of overseas domestic workers for employment in British hospitals began soon after the end of the European War in 1945. Recruitment schemes were organised by the Ministry of Labour and National Service in consultation with the trade unions and employing authorities,and were only to be implemented in areas where no British labour was available. Under these schemes, Belgian women arrived for work, as domestics in London hospitals, in 1945. Owing to a shortage of labour in Belgium itself, however, this scheme soon terminated. Desperate for labour, Britain applied to the Allied Control Commission in Germany for permission to recruit East European women, then in displaced persons’ camps in Germany, for work as domestics in British hospitals. Initially, they were to work in sanatoria and tuberculosis hospitals, but later, if found suitable, they could work in other hospitals and as orderlies or trainee nurses.

Following this, another scheme to recruit ‘European Volunteer Workers' of all nationalities from displaced persons’ camps in Austria and Germany was implemented. These were to work mainly as domestics, but also, to a lesser extent, as hospital and, ward orderlies. Finally, under the North Sea schemes, Germans in the British zone of Germany were similarly recruited.

A survey undertaken by the Association of Hospital Domestic Administrators in 1968 revealed that 11% of domestic staff were from the New Commonwealth. A City University study in 1979 revealed that in two London hospitals 22% of the domestics were West Indian and 19% Filipino. Doyal(60) concluded from the study of a London hospital that the highest concentration of overseas workers in the hospital’s section of the health service was in the ancillary and maintenance category where 78% of all workers had been born abroad. These workers were predominantly female and were concentrated in domestic (84% from overseas) and catering jobs (82% from overseas). The overseas workers tended to be in the lowest grades of unskilled ancillary and maintenance work.

However, in 1979, the issuing of work permits to foreign workers (with the exception of those from EEC countries) was halted. The jobs market was contracting as a result of the recession and, in any case, management were finding it cheaper to replace full-time workers with part-timers. Some foreign ancillary workers were sent back home. Deportations increased after 1973 and peaked in 1980. It was the deportation of Filipino domestics that attracted publicity, as this was accompanied by much harshness on the part of the government, which applied, rigidly, the immigration rules under which the Filipinos were recruited. Their work permits were issued under the following conditions:

1. Domestic workers should be resident and full-time.
2. Permits will only be issued to unmarried men, couples working in a joint post, and to women with no children under the age of 16
3. Intending domestic workers should have had previous experience of the kind of work for which they are entering Britain to undertake.(61)

The first requirement ensured that housing for these workers was not the responsibility of the state. The workers lived in poor conditions and their jobs often did not carry welfare benefits. The second requirement ensured that the state was spared the expense of providing family welfare. After a period of five years, the workers were entitled to call over dependants if they could prove that the dependants were their responsibility. Until 1978, the Filipinos were given permanent residence. Since the recession, the three requirements have been used to deport the Filipino workers. When some workers applied, after five years, to be allowed to bring their families over, they revealed themselves, according to the Home Office, to be illegal immigrants since they had not declared that they had children under the age of 16 when they were granted work permits, thereby obtaining them fraudulently and therefore holding themselves liable to deportation. Such was the twisted logic of the state.

The fact of the matter is that the workers were duped by the unscrupulous recruiting agencies in the Philippines, often with the connivance of the British government and their officials abroad, as the British government was at this time desperate for labour of this kind in the caring agencies of the NHS, and in the money-spinners of the tourist industries, the hotels. The Filipinos’ fellow workers in the unions saw them as competitors in their own struggles for jobs and better wages. When the unions did support the victimised Filipinos, they did so on a one-off basis rather than fight against the institutionalised racism that was oppressing foreign workers, In fact, when the Greater London Council, in preparation for its report on ‘Racism within the Trade Unions’ sent questionnaires to the health service trade unions, only ASTMS and NUPE replied, whilst significantly, COHSE (Confederation of Health Service Employees) declined to do so (62).

The threat of dismissal, followed by automatic deportation to their home countries, keeps these workers in conditions of isolation and alienation. The beneficiaries are the British government which profits from cheap, captive labour and the Philippines government which imposes a tax varying from 30% to 70% on the remittances the workers send home to their families (63).

Doyal et al. are of the opinion that the NHS of the future will continue to be dependent on large numbers of overseas workers to fill both skilled and unskilled jobs. The health service is labour intensive and rationalisation policies are severely limited both by the inherent nature of the labour process and the capital spending cuts entailed by monetarism (64). With the health and emergency services being used increasingly for social control, it is worth noting that the proportion of workers, from the ethnic minorities, in the emergency services viz., the ambulance and fire services, continues to be miniscule. This is greatly disadvantageous to the minority populations during times of civil strife and is evident during the recurring urban uprisings.

DISCUSSION

Against the background of racial disadvantage in Britain, which is not unrelated to Britain’s colonial legacy and the differing but ever present degrees of discrimination, disadvantage and exploitation that were evident in Britain’s relations with her colonial possessions, there are two frameworks within which racial problems are defined. One framework focuses on equality of opportunity. This emphasizes the simple act of discrimination as the source of racial disadvantage. If this were true, then a campaign to end discriminatory practices would improve the situation of black people in Britain (65).

A second framework focuses on equality of outcome. This postulates that since racism is deeply entrenched in British society, one should look at the whole pattern of economic outcomes by race and at the rights of blacks to attain equal standing with whites of comparable backgrounds, rather than emphasizing acts of discrimination which may deny blacks equal opportunities.

A third major concern is that the disadvantages of black people (Asians and Afro-Caribbeans) have stubbornly persisted, whereas many other racial groups such as the Jews, before the war, various East European groups, immediately after the war, and the Hungarians, after 1956, have come to Britain in the recent past and have overcome their initial disadvantages, even though they were not English-speaking. There must, therefore, be deep and fundamental causes for the persistence of racial problems in Britain.

PERSPECTIVES ON RACISM

Both conservatives and liberals claim that racism is not a fundamental aspect of capitalism. They claim that racism has little effect on capitalism’s profits. Free competition under capitalism, they would argue, makes racial discrimination unlikely. Since capitalists are only interested in hiring productive workers, they would ignore racism, and with it the luxury of entertaining discriminatory prejudices. In a free market, the pressures of competition will drive out racially discriminatory practices. (66). Conservatives and liberals claim that racism is psychologically or structurally motivated and its perpetuation is effected by factors that reside outwith the economic system, since capitalism mitigates and obviates the effects of racism. They attribute the origins of racism to pre-capitalist cultures and ascribe its persistence to dogged psychological prejudice (67).

Conservatives and liberals tend to see white and black workers crowded into noncompeting groups in a labour market characterized by racial dualism. The reality is that the labour market is divided into two racial compartments, one for the deployment of white labour and one for the deployment of black labour. None are more aware of this than the managerial class of the corporate state. Each sector has its own mechanisms for managing the various aspects of its own part of the labour market.

The black labour force has served the functions of a surplus army of labour to fill the shortages in white labour that occur during periods of expansion of the economy; in periods of recession and a contraction of the economy, this part of the labour force is the first to become redundant. Moreover, a large part of the black labour force is frozen into marginal, low-paying, semi-skilled or unskilled jobs, involving a high risk of occupational hazards, often offering only seasonal employment in a declining part of the market. The incarceration of the black labour force in this manner is maintained by the institutional racism of the racist state when the racist practices and operations of one institution or one part of the corporate class are supported by other institutions and the corporate class as a whole.

Conservatives and liberals take, as given, the preferences of white workers to work with other white workers. They claim that the primary motivating force for discrimination is the preferences of white workers. Capitalists who hire predominantly unskilled labour hire only black workers. As a result, black workers are crowded into low wage, labour-intensive work, whilst whites are in high wage, capital-intensive production. It has also been suggested that the preference of white consumers forces owners to discriminate. Conservatives, furthermore, offer two other victim-blaming theories for the persistence of racism in Western societies. The first is that blacks, as a racial group, have lower I.Q.s than whites. The second is that blacks have failed to take advantage of available opportunities which enabled other ethnic groupings to climb the socio-economic ladder.

Liberals, for their part, avoid victim-blaming. Whilst conservatives tend to oppose statutory initiatives to overcome problems, liberals urge some action towards reducing discrimination in society. Conservatives argue that the government has no right to be dictating racial solutions to free citizens in a democratic society and that compulsory anti-discrimination policies may do more harm than good. Liberals argue that money and effort should be expended into reducing the disadvantage that blacks face in our society. Although they accept that there is a debit side to these measures, liberals, nevertheless, propose that some compulsory programmes are necessary in order, as they put it, to break the vicious cycle of disadvantage, deprivation and despair in which the majority of blacks find themselves in Western societies.

Dr David Owen, the leader of Britain’s Social Democratic Party, gave the liberal view on institutional racism when he said that: “The Commission for Racial Equality has the legislative power to investigate (institutional racism) but somehow the clear moral lead necessary to change attitudes seems to have largely evaporated in the country and, particularly, in the Government” (68).

THE RADICAL PERSPECTIVE. Radicals explore the relationship between capitalism and racism, which they declare is intimate and goes back a few centuries (69). Early capitalists justified their horrendous trade in human cargoes by suggesting that the African and the Indian were somehow less than human. This argument, aided by the missionary factor, was later taken up by colonialists and finely honed to justify colonialism and racialism which themselves were later to give birth to the system of apartheid.

The continuing existence of capitalism, and its international extension, imperialism, have not only exacerbated racial problems in the metropolis, but also actively encouraged them, in order to keep workers vulnerable and divided amongst themselves.

The origins of racism lie within the economic system, and the competition that operates under a free market economy generates conditions favourable to the growth of racism. Capitalism develops unevenly, resulting in differential benefits to communities and to groups within a community. In these times, capital keeps moving in order to find the most fertile conditions, including the cheapest labour, for growth. Capitalists respect their class alliances in the interests of profitability, and would keep workers divided and from emerging as a powerful working class with strong bargaining powers.

Radicals argue that average I.Q.s and failure to take advantage of one’s opportunities are of little significance in determining an individual’s economic success. The labour market has changed so much of late and is so fragmented that the conditions necessary for success on the socio-economic ladder have also changed. The radicals argue that one-off initiatives, either by the state or by industry, to help blacks are unlikely to lead to progress against institutional racism, unless the underlying structural supports, that underpin racism and which are themselves capitalist in origin, are demolished.

The radical’s position can be summed up as follows: since the economic system reinforces racism, it has to be transformed; moreover,its tendency to divide the working class and oppose black to white must be countered by strategies to unite all sections of the working class and thus build up their collective strength.

Any strategy in the NHS that is committed to improving black people’s health must oppose and challenge racism at all social and political levels and eliminate the discrimination which puts the health of black people and of the ethnic minorities at risk. Because few, if any, black people are at senior levels in the NHS, there is no black perspective in management decisions (70). Racial minorities in Britain lack political power and influence. This political poverty is both the cause and consequence of the discrimination that dominates the institutions, traditional ideologies and political life in the United Kingdom (71). To summarize the patterns of medical employment in the National Health Service as they apply to doctors from the racial minorities: Firstly, national minority doctors are employed overwhelmingly in the lowest grades in the service, i.e. house officer grades, and often working very long hours: this has previously been described as an example of vertical racial segregation in the workforce. Secondly, national minority doctors are employed in the ‘Cinderella’ departments, e.g. geriatrics and mental handicap. If the concept of ‘cultural affinity’ is used to discriminate against minority doctors (and this argument is often resorted to by racists on recruitment panels without any justification whatsoever), then one would expect these very specialities to be staffed overwhelmingly with doctors from the majority community. Alas,besides calling for a great deal of patience and dedication, great personal rewards are unlikely to come to doctors working in the ‘Cinderella’ departments. This phenomenon has been described as a horizontal racial segregation of NHS staff.

Thirdly, national minority doctors are largely confined to the less well-paid areas of the health service. Merit awards, especially the more remunerative ones, as well as important and powerful positions on health service and hospital committees go to consultants in general surgery, general medicine, obstetrics and gynaecology who, except for the occasional token Asian or Afro-Caribbean, are white. This has been described as pay-related segregation.

Lastly, there has always been an over-representation of overseas doctors in locum posts. Again, this has been described as an example of tenure-related segregation. (In a further aspect of segregation in British society generally, workers from the racial minorities are over-represented in the voluntary sector as opposed to the (statutory) public sector).........The Commission for Racial Equality has, moreover, consistently failed to view racism as existing at the core of every issue relating to power, economic production, culture and society. Skilled black professionals represent a basic and provocative challenge to the raison d’etre of white racist supr