Coloniality in the NHS – A Call for Change

With over 1.3 million staff, the National Health Service stands proud, not only as a time-honoured provider of universal healthcare but also as the UK’s biggest employer.

The picture in Sheffield stands prouder still. With a workforce of over 17,000, Sheffield Teaching Hospital Trust is one of the city’s biggest employers, followed by others including Sheffield Children’s Hospital Trust and Sheffield NHS Social Care Foundation Trust, not to mention the city’s GPs and NHS dental practices.

Both universities provide training and research opportunities for a vast array of professions, including doctors, nurses and speech and language therapists. It’s clear the institution of the NHS intricately weaves our health and wellbeing with employment, skills, training and opportunities.

But as with most historic British institutions, coloniality and migrant labour are central to the fabric of the NHS.

Two weeks after the Empire Windrush anchored at Tilbury Docks in Essex, the NHS was formed. Many Windrush passengers worked to build it during its foundational years, as desperately-needed nurses were recruited from Britain’s colonies in the Caribbean. Even Enoch Powell, infamous for his anti-immigration ‘Rivers of Blood’ speech, appealed for help for the NHS from the Commonwealth. In response to this call, more than 18,000 doctors from South Asia came to the UK. Many would stay and many others would follow in their footsteps from all corners of the globe. Today, ethnic minorities make up one in five workers in the NHS.

Undoubtedly the NHS would not have been established as the jewel of British achievements without the hard work and dedication of the first generation of Windrush healthcare professionals and the continued commitment of migrant workers. Yet the NHS today is mired in deep structural racism which is rooted in the surviving traces of colonialism.

Only a small minority of qualified Windrush nurses were accepted onto UK registered nurse training and even fewer were promoted once qualified. This was an experience shared by South Asian doctors. Few gained posts in prestigious institutions like Sheffield Teaching Hospitals or university medical schools – and even fewer were promoted.

This picture remains enduringly bleak across the NHS workforce. Although over 18% of people in non-medical positions are from Black and ethnic minority backgrounds, they occupy only 7% of very senior roles. A similar pattern emerges in medical positions, with senior doctors more likely to be white.

Sheffield fares no better than the national picture. Around 19% of Sheffield’s population is from Black and ethnic minority groups, compared with 13% nationally. Our Pakistani, Caribbean, Indian, Bangladeshi, Somali, Yemeni and Chinese communities, among many others, bring richness to our city. With over 120 languages spoken, Sheffield is one of the most diverse cities in the country.

The NHS workforce in Sheffield does not reflect this diversity. Only 13% of Sheffield’s NHS workforce hail from minority communities and a mere 5% of those professionals occupy senior roles. Mirroring the national picture, workers from minority groups are also less likely to be shortlisted for NHS jobs and have less access to training opportunities.

NHS staff from minority groups are also more likely to experience harassment and bullying from staff and patients, as well as a higher likelihood of being entered into formal disciplinary procedures. Although things are improving in terms of staff recruitment, the outlook once hired is worsening with respect to bullying, harassment and access to training opportunities.

These data do not make a spectacle of a few bad apples. They reflect deep structural problems in our NHS that range from biases in hiring and disciplinary processes to white Euro-centric medical education, migrant charges and even counter-terrorism laws.

The good news is people are calling for change – and this call is slowly turning the tide.

The Change

The immigration health surcharge is a fee that migrants pay to use the NHS. The Covid-19 pandemic brought this migrant contribution to the NHS to the public’s attention, resulting in the dropping of the surcharge for NHS workers.

The 2015 Prevent strategy, meanwhile, places a statutory duty on the staff in NHS trusts and universities to identify patients and colleagues that they believe are at risk of radicalisation. Healthcare professionals are now rightly questioning the place of this Islamophobic policy, which often results in Muslim colleagues being viewed with suspicion.

Galvanised by the Black Lives Matters movement, students in our city recently wrote an open letter to Sheffield Medical School to start a conversation about how the curriculum needs to change to tackle racism in healthcare.

Since 2015, the NHS has mandated the Workforce Race Equality Standard (WRES), which aims to improve equality of access and opportunities for Black and minority ethnic communities. But the change needs to run deeper and faster. Migrant NHS charges still place barriers on access to healthcare for minority communities. By law the Prevent strategy must still be enforced by NHS trusts. Universities barely prioritise the decolonising of the healthcare curricula and the NHS workforce remains largely unrepresentative of the communities it serves.

The NHS and the city of Sheffield do not bear these problems in isolation. They are seen across institutions, towns and cities. But they are strikingly incompatible with the NHS’s founding values. And as the NHS continues to thrive on migrant skills and labour, it’s high time it starts to break down its colonial associations and structures which put those migrants at a constant disadvantage.