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How did the UK come to find itself facing a major political crisis with the prospect of expending the forseeable future redefining its relationship with the European Union? One of the key contributing factors is that political leaders allowed the issue of migration, a question of marginal importance to public debates, to become increasingly toxic. The blame for this does not solely reside with the usual suspects, such as UKIP and the British tabloid.  Responsibility is shared with those who refused to recognise that reliance on migrant labour is ultimately a political choice. As such, politicians should be prepared to defend it as a choice. These questions need to be addressed if we are to have an adequate strategy to maintain staffing levels in the UK’s National Health Service post-Brexit.

The UK has for years seen a clash between advocates of two dishonest positions on migration policy. One is characterised by the fear of difference and a longing for an idealised past. The other refuses to acknowledge reliance on migration is, in fact, a societal choice about public policy, rather than a phenomenon over which politicians have little control. This leaves public discussion of migration swaying between, on the one hand, a fearful identity politics and, on the other, a liberal celebration of diversity and the contribution that immigrants make to the UK.

As the UK moved towards its recent general election, advocates of both positions defended their positions.  The Daily Mail raised the spectre of a Labour government under Jeremy Corbyn allowing higher numbers of migrants to enter the country. London’s Evening Standard, now edited by the former Chancellor George Osbourne, shamed the outgoing government by pointing out that although the Tories are committed to drastically reducing migration levels, none of their ministers was prepared to outline which section of the economy would cope with fewer workers.

Of course, one of the sectors that would simply not to be able to function normally without migrant labour is the NHS. Around a third of doctors registered in the UK are from abroad. They number 90,000 – roughly the entire population of Bath. Ten percent of the total NHS medical workforce comes from the European Economic Area. The concerns about migration that were in part responsible for Brexit naturally raise questions about the UK’s ability to provide a functioning health service. Efforts are already underway to encourage greater numbers of doctors to migrate to the UK from India. The NHS, which remains one of the world’s largest employers, is also dependent on migrants in nursing, cleaning, catering and a host of other professions. The British healthcare system offers a perfect example of the tensions between xenophobic instincts and social realities.

It is, however, problematic to assume that because there are skills shortages, the only way to fill them is through migration. Taking this view does not speak to the reasons why the skills shortages arise, and what other policy choices might be made to address them in the medium to long term. In the short term, it may be that the labour of migrants to ensure decent health care provision in Britain. But, in the past, different paths could have been taken. The heavy reliance that the UK places on migrants today does not therefore necessarily need to continue. The policy could be tailored to ensure a better alignment between the training the UK population receives and the needs of the NHS. In fact, the Conservatives have started taking steps to try to address the UK’s medical schools continued failure to provide appropriate graduates. The Health Secretary Jeremy Hunt has announced an increase in the numbers of doctors being trained in the UK with the stated aim to make the country self-sufficient in medical labour within a decade.

This is not, however, the first time a government has thought that it would be able to drive Britain towards medical self-sufficiency quickly. There are quite profound structural reasons as to why this is a difficult thing to do. Medical migrants have historically found themselves confined to the low-status medical specialities and (post-) industrial landscapes. Training a number of doctors that match the number needed in the NHS does not guarantee they will be prepared to take on particular roles.  It does not mean that there would be enough UK-trained doctors willing to provide care for the elderly in Barrow-in-Furness or work as a psychiatrist in Walsall. Getting British-trained doctors to take on these roles is not straightforward.

Doctors, like all professionals, are in an international labour market and historically British graduates have themselves migrated in large numbers to take up opportunities in places such as Canada, the US, Australia, South Africa or New Zealand. They have middle-class aspirations to live and work in major cities, affluent rural areas and close to good social and cultural amenities. Hunt’s demand that medical graduates serve for at least four years in the NHS is the sort of initiative that might break this cycle.  However, questions remain as to how such a policy would be made to work in practice and four years might not be enough to truly embed doctors into the NHS. Other ways of stemming the outward flow of medical graduates might include increasing the social diversity in medical schools and attempting to shift medical culture’s perceptions of certain types of care. Such measures could be deployed alongside schemes helping to pay fees in exchange for students undertaking to practice in hard to staff specialities. Naturally, much of this would require the political will to take on the medical profession.  And such an approach could prove counterproductive at a time when morale is already low in the medical profession, and fewer students are applying to take medical degrees.

It is also important to recognise that many of the roles in the NHS which a generation or two ago offered career paths for working-class people would be difficult to fill without migrants.  Living on a nurse’s or a porter’s salary in London is now a real challenge for anyone wanting to buy a house and bring up a family locally. The presence of migrant workers in the NHS is also ultimately about limiting public expenditure.

In the 1960s, as public hostility towards migration grew, government officials took to  hiding from the public the scale of the movement of overseas doctors needed to sustain the NHS by massaging official figures. This sort of behind the scenes manoeuvring continues to characterise British political debate. Trying to duck the issue has however clearly not worked. Brexit surely signifies that the UK will from now on take sole responsibility for defining its immigration policy. If migrants are in the country to staff the NHS it will ultimately be because they are needed and because this is viewed as being in the national interest. Politicians who believe this should have the courage of their convictions, explain their thinking to the public, and make the case for migration. Alternatively, they need to outline credible plans to align the systems for training professionals to the needs of the NHS and to provide for an increase in expenditure that would make careers in the NHS more attractive (and indeed viable) for people already living in Britain. The latter course of action would involve expending a considerable amount of capital both financially and politically. There are no easy solutions. But continuing to rely on migrants whilst simultaneously denigrating them and constructing them as a problem should not be one of them.

About the Author: Julian M. Simpson is a researcher at the Centre for the History of Science, Technology and Medicine at the University of Manchester. His first book ‘Migrant Architects of the NHS: South Asian doctors and reinvention of British general practice (1940s-1980s) is due to be published next year by Manchester University Press.