Overseas-born doctor migration 1962-66.

Abstract

In March 1968 the (then) Ministry of Health22 Now the Department of Health and Social Security. published a study of medical migration into and out of Great Britain (England, Scotland, and Wales) which covered the years 1962 to 1964, with an addendum for the year 1964–65 (Ash and Mitchell, 1968). Detailed description of the methodology employed is contained within that study. The basic data were drawn from an index containing, among other things not relevant here, the names, country of birth, country of qualification, age, and occupation of all provisionally or fully registered civilian doctors known to be in Great Britain at 30 September of each year. Thus, doctors in the armed forces and 1,000 to 1,500 temporarily registered overseas-born practitioners are not included in the index. Each year, as of 30 September, the index is brought up to date and all doctors who have left or entered Great Britain are recorded according to the country they had come from or the one to which they had gone. Certain short-term movements such as holidays, visits, and movements into or out of Britain within any one 30 September to 30 September period are excluded. Foreign-born graduates of British medical schools do not appear as part of inflows to the index but do appear as part of the stock of foreign doctors in the country, as well as in outflow data should they leave Britain. In reckoning the period of time such doctors have been in Britain no account is taken of the years spent before qualifying as a doctor, or, more strictly, since entering the index. In spite of numerous difficulties, the Ministry has been able to improve its methods for tracing the movements of those entering, leaving, or remaining in the index. At times, however, it is not possible to ascertain that a doctor has left Britain until a year or two after the fact; entering doctors, however, are more easily accounted for. Greater gaps exist in the occupational information available; these data are brought up to date each year in keeping with National Health Service, British Medical Association, and other records. As longer time series are becoming available, some of the problems arising out of the remaining data gaps are being obviated. It should be emphasized that some margins of error undoubtedly exist in the material which follows. This is particularly important in the case of some doctors who may have left Britain in 1966 but will not definitely be known to have done so until the 1968 or even 1969 index is compiled; however, the Ministry has made every effort to update and obtain correct information, even if at a later date. For example, a certain number of doctors with unknown occupations at September 1964 are shown in Ministry data to have actually migrated in 1965, although it is fair to assume that the actual year of emigration was earlier; their inclusion in the later year is quite satisfactory for a longer term analysis such as this one. Separate papers have been prepared about the movements of British and Irish doctors into and out of Britain (Gish, 1969a; Gish, 1970; Gish and Wilson, 1970). This paper will concern itself only with medical graduates born outside the British Isles who either were in Great Britain at 30 September 1966 or who entered or left Great Britain between 30 September 1962 and 30 September 1966. Irish-born medical graduates are excluded from this analysis because traditionally they have been as much part of the British medical scene as British-born graduates. In many respects Irish medicine and Irish medical manpower output have always been adjuncts of British medicine. For purposes of record-keeping medical manpower in Britain is divided into the categories British, Irish, and non-British or Irish (either Commonwealth or foreign). This division is somewhat misleading in that the total stock of doctors in Britain includes an estimated 1,000 to 1,500 Britishers who were born in the former colonies who are not included in the British but in the non-British category.33 This figure was arrived at by counting the number of non-indigenous names included in the computer print-outs which list those doctors coming to Britain from Africa, Asia and the Middle East. The total of such names came to 2,000; of these it was estimated (somewhat arbitrarily) that one-half to two-thirds should properly be considered as being British. Because of the very substantial scale of total medical movements into and out of Britain – about 15,000 doctors between 1962 and 1966 – it was not feasible to attempt to single out those who, although born abroad, were culturally British. Presentation of the data and analyses of the results for such a large and diverse group as is being dealt with here offer numerous problems. It was thought best to present the material in four sections: the first being the stock of foreign-born doctors in Britain at 30 September 1966; the second being the inflow of such doctors between 30 September 1962 and 30 September 1966; the third, the outflow of foreign-born doctors over that same time period; and, lastly, a presentation of the balance of these movements and the relationship of that balance to the stock of foreign-born doctors in the country in 1966. (Note that the term ‘foreign’ will be used here to include all non-British-Isles-born doctors, including those from the Commonwealth). Within each of these sections there are two broad categories into which the foreign-born doctors have been divided. The first is place of birth – that is, either in a developed or a developing country. The second is place of qualification – that is, either in or out of the British Isles.44 Including the Republic of Ireland. Each of these categories has in turn been divided into groups; the six groups making up the developed country category include Canada, Australia, New Zealand, the United States, South Africa, and Europe. The eight groups making up the developing country category include the Indian Sub-Continent (Ceylon, India, and Pakistan), Other Asia (excluding Middle Eastern countries), Nigeria, East Africa (Kenya, Uganda, and Tanzania), Other Africa (excluding North Africa), Middle East and North Africa, West Indies, and Latin America55 After having gone through the computer analysis, it became evident that it might have been more useful to have kept separate the three countries making up the Indian Sub-Continent category. However, the advantages to be gained by redoing the analysis were not sufficient to justify the additional resources involved. . The motives which move doctors to go from one country to another are complex and there are dangers attached rigidly to ascribing causes or in overly stressing different reasons for different groups. Further complications arise from the fact that the initial move to another country, the length of time stayed in that country, and the point at which it is decided to move out of it are separate decisions influenced by different factors. It is clear, in this respect, that doctors qualified in the British Isles will have a different viewpoint from, and will be in a different position to, those qualified elsewhere. It is equally clear that having come from either a developed or developing country is of critical importance to the entire matter. The 16 Tables and three Figures which follow encompass a huge quantity of data. It would be both pointless and excessively tedious to describe each Table in great detail in the accompanying text. Commentary has therefore been kept down to that which appeared to be a necessary minimum. All the analyses refer to Great Britain and exclude foreign-born doctors in the other parts of the United Kingdom and in the Republic of Ireland. From Table 1 it can be seen that there were over 14,500 foreign-born doctors in Britain in 1966. They represented about one-fifth of all doctors in the country. Of these doctors 35% were born in a developed country, 60% in a developing one, and the place of birth of 5% was not known. (The 671 whose place of birth was not known will be excluded from certain of the analyses which follow.) The largest number of doctors came from the Indian Sub-Continent, which provided 44% of all the foreign-born doctors and almost three-quarters of those coming from less developed countries. The second largest group of doctors were European-born. This group made up half the doctors from the developed countries and constituted almost one-fifth of the total of all foreign-born doctors. The combined total from the Old Dominions amounted to a little less than of Europe. Of all the foreign-born doctors 43% had qualified in the British Isles, 54% had qualified in their own country/group, and only 3% had qualified elsewhere. (For ease of presentation, in the balance of discussion, ‘country’ will also stand for country groups – for example, East Africa.) Except for doctors from the Indian Sub-Continent, Australia, and New Zealand, a majority of the others had qualified in the British Isles. In the case of doctors from the Indian Sub-Continent almost four-fifths had qualified at home. The only group which contained a sizeable number who had qualified ‘elsewhere’ was East Africa. This would be explained largely by the fact that many doctors of Asian origin are included in this group; to a certain extent this would also be true of the category ‘Other Asia’. Figure 1 illustrates the size of the four basic categories of foreign-born medical graduates resident in Britain in 1966. Percentage distribution of all foreign-born doctors in Britain: 30 September 1966. White=born in developed country; qualified outside British Isles. Black=born in developed country; qualified in British Isles. Hatched=born in developing country; qualified outside British Isles. Cross-hatched=born in developing country; qualified in British Isles. Table 2 groups by age foreign-born doctors according to the type of country they were born in and according to whether or not they had qualified in the British Isles (all but 6% of those qualified outside the British Isles had done so within their own country). As with a number of other Tables which follow, it was not thought necessary to break the data down to specific countries because qualified of the relatively small diversity which exists between them, beyond that which is already shown in the Tables as presented. In other cases, where particular countries do differ noticeably, that fact is mentioned in the discussion. From the Table it can be seen that half the foreign-born doctors were under the age of 30, one-third were between 30 and 40, and only 16% were more than 40. There is considerable difference between the ages of those born in developed and developing countries; 90% of those from developing countries were less than 40 (54% were less than 30) as compared with only 72% of those from developed countries (of whom 41% were less than 30). Place of qualification had little influence upon the age distribution of those doctors born in developed countries, their numbers declined regularly with increasing age, whether they had qualified within or without the British Isles. By contrast, the age distribution of doctors from developing countries was heavily weighted in favour of the youngest age groups, and this imbalance was most marked for those who had qualified outside the British Isles. Fig. 2 shows the age structure of doctors from each of four selected countries. The structure of the European group is of interest in that only 39% are under the age of 30, and the proportion in the age group 40 to 49 is even greater than in the 30 to 39 group. These figures reflect European events of the 1930s and 1940s which led to the displacement of large numbers of people, many of whom came to Britain. In some cases the European doctors of that period included in our data were already medical school graduates upon arrival in Britain, while others first entered medical school after arrival in this country. Age distribution of selected groups of foreign-born doctors in Britain: 30 September 1966. The age structure of Australian doctors resident in Britain is closer to that of their colleagues from developing countries than from Europe, although certain similarities to the latter group do exist. This particular age structure reflects the continued movement into Britain of young Australian medical graduates, as well as being indicative of a certain degree of permanent settlement – as shown by the numbers in the older age groups. Just over 90% of those born in India, Pakistan, or Ceylon are less than 40 years of age – 56% are less than 30; and an even higher percentage of those from East Africa fell into these age groups. It was to be expected that the East Africans would be even younger than those from the Indian Sub-Continent because 65% of the former group were graduates of medical schools in the British Isles, many of them fairly recently, as compared with only 22% of the latter. Tables 3, 3a, and 4 provide information about the occupations held by foreign-born doctors in Britain. The first two Tables use the grades recorded in the Department of Health index and the last introduces the concept of ‘established members of the profession’: these are defined as general practitioners, those employed in the senior hospital grades, by local authorities and universities, and in ‘other’ medical employment. It may be assumed that most doctors recorded as having unknown occupations or as not being in the profession had been working as junior hospital doctors, or else had been engaged in areas which did not require clinical work – for example, full-time educational courses. From the Tables we can see that one-seventh of the foreign-born doctors held senior hospital posts (including senior registrars), another one-seventh were general practitioners, and an additional one-tenth held what might be considered to be other permanent medical posts. The majority of the doctors held either junior hospital posts or were classified in such a way as to indicate that they were part of a large pool who were moving into and out of such posts. This tendency was much more marked for those coming from developing countries than from developed countries. Of the doctors born in developing countries up to 30% were holding permanent posts (as defined), while for those from developed countries the comparable figure was almost double (55%). Place of qualification seemed to be a more important variable than place of birth in this regard, in that those born in developing countries who were qualified in the British Isles had an occupational pattern that was more similar to that of those born in developed countries, although substantial differences still remained. Thus, 60% of the developed country doctors who were British Isles qualified held established posts; while for those qualified elsewhere the comparable figure was 51%. For doctors born in less developed countries who were British Isles qualified the figure was 44%, and for those who had not qualified in Britain or Ireland the figure was only 20%. From the information contained in Tables 3 and 3a it is difficult to determine if a special ‘screening’ process exists through which foreign-born doctors must pass. The data are very strongly influenced by age distributions, and it would be expected that the limited professional experience of many doctors from countries with younger age distributions would hinder their progress out of the junior hospital grades. Those qualified outside the British Isles would also initially lack the experience of British medical practice necessary for work outside supervised hospital employment. However, comparisons between the age structure of foreign-born doctors (Table 2) and their occupational distribution (Table 3a) suggests that the latter has been effected by more than the age factor; the occupational differences among the four background groups under consideration are greater than is the age spread among these groups. Table 4 presents information on the distribution of doctors between established and non-established posts for each of the four background groups under consideration, according to time of entry into Britain, thus removing the effect of age and raising the new question of whether career opportunities have changed over the years. Of the doctors who had entered Britain before 1952 only 5% fewer of those born in less developed countries and qualified in the British Isles were in established posts than those in other categories. This is a small variation compared with those between the same groups in Table 3a. The 1952–55 entrants showed only a 1% difference between the proportions from developed and developing countries who were in established employment. In effect, very similar proportions of the doctors making up the four background groups, who had entered Britain more than 10 years before 1966, had achieved established posts by 1966. However, among the post-1956 arrivals there are substantial differences. Of the doctors born in developed countries 60% held established posts as compared with only 37% of those born in developing countries; although those born in a less developed country who had qualified in the British Isles stood, at 46%, somewhere between their compatriots who had qualified at home and those born in developed countries, in terms of job ‘success’. In this respect, for those born in developed countries, it seemed not to matter whether they had qualified in the British Isles or abroad. Any evaluation of the career achievement of foreign-born doctors, particularly those from less developed countries, leads to numerous complexities. An apparently low ‘success’ rate may be due to a preference for an early return home after a stay in Britain. Opposed to this is the possibility that people return home only reluctantly after having failed to achieve a desired posting, and that only the ‘successes’ remain to be counted 10 years later. Both approaches seem relevant, although the more pessimistic idea of a time threshold, after which career success becomes increasingly difficult, would be more in keeping with present interpretations of the position of all junior hospital doctors in Britain. It is also reasonable to expect that doctors trained in the British Isles, or in countries more like Britain – say, Australia – would achieve a permanent post in British medicine more quickly than others. Table 5 and Fig. 3 show the periods at which the stock of foreign-born doctors first entered medical employment in Britain. Of the total number of doctors represented, a little over one-fifth arrived before 1952, one-third between 1952 and 1962, and the balance of 44% between 1962 and 1966. Figure 3 illustrates the importance of recently entered doctors from the less developed countries, who were also qualified abroad, to medical care in Britain. This group made up over a quarter of the total number of foreign-born doctors working in Britain in 1966. Year of entry of all foreign-born doctors in Britain: 30 September 1966. The area of each circle is correlated with the relative size of each group. The big proportion of doctors born in developed countries who had entered before 1952 are evidence of the large group of political refugees from the second world war still working in Britain today. In addition, a considerable number of the doctors born in developed countries had entered between 1952 and 1955. Of the doctors who had entered before 1955 almost two-thirds had qualified in the British Isles. Three-quarters of the British Isles qualified doctors who had entered in the five years before 1966 came from developing countries: although two-fifths of all those trained in the British Isles came from developed countries, under a quarter of them had graduated in that five-year period. This can be explained by a shift in the number of places in British medical schools available for those from developed countries to those born in developing countries. It is unlikely that doctors who entered Britain before 1952 will leave the country in any large number. Table 4 shows that a high proportion of this group are in established posts: and they are now older than 40. Almost two-thirds of these doctors were born in developed countries, many being the political refugees referred to earlier. Most of the entrants of that period who were born in developing countries were qualified, as would be expected, in the British Isles. This raises the question of how many of this sizeable group were from the colonial families of British stock referred to earlier. It seems probable that many such people would have stayed on in Britain after qualification as a consequence of the movement of most British colonies towards independence. The stock of foreign-born doctors in Britain at any given time will be determined by the composition of the flows entering and leaving the country. Thus, examination of these flows will indicate existing trends in the changing composition of the stock of these doctors. As pointed out earlier, the Department of Health index does not contain inflow information about foreign-born graduates of British medical schools who enter into medical employment in this country directly after qualification. A separate exercise was conducted in order to obtain these data. As the exercise was based on a survey which did not have a complete return (23 out of 26 medical schools responded) it must be treated with some caution (Gish, 1971). Over the four-year period 1962–66 almost 6,000 foreign-born doctors entered Great Britain. In addition there were almost 800 foreign-born graduates of British medical schools, of whom virtually all would have entered into initial employment in Britain. It may be that some of these 800 graduates may have both left and re-entered the country over the four-year span and so would appear in the Department of Health inflow data. This gross inflow of almost 7,000 foreign-born graduates may be compared with an output of 6,522 British medical students over the same four-year period. From Table 6 we see that of the total number of entrants of the period three-quarters had come from developing countries, primarily the Indian Sub-Continent. The only developed country contributing a substantial number of medical graduates was Australia (a number almost equivalent to the total Australian stock in Britain in 1966), although relative to medical school output in those countries the numbers coming from New Zealand and South Africa may have been as great or even greater. It should be noted here (again) that graduates of European medical schools are unable to attain initial registration with the General Medical Council except on a temporary basis and so would mostly be excluded from our figures. Those European-born graduates who are shown as having entered Britain between 1962 and 1966 would be either graduates of British medical schools re-entering the country, or graduates of other schools which qualify for registration in Britain (virtually all of them in the Commonwealth). Except for those from Asia, there were as many developing country graduates from British medical schools as there were entrants from those countries. Table 7 shows the countries from which the foreign-born doctors entered Britain. About three-quarters of the total entered directly from their country of birth (84% if unknowns are excluded). The outstanding exception was the European group, whose members entered Britain primarily from developed countries other than their own. In the developing country group over 90% of those from the Indian Sub-Continent entered Britain directly from their own country, while for the others in this group the percentages varied from one-third to two-thirds. It is of interest to note the relatively high proportion of developing country entrants, other than those from the Indian Sub-Continent, who entered Britain from other developed countries. The ages of doctors entering Britain between 1962 and 1966 are shown in Table 8. Almost half were younger than 30, with India, Pakistan, and Ceylon being particularly well represented in this age group, but it is important to see that almost as many doctors were aged between 30 and 40. While proportionately more doctors from developed countries were in the older age ranges, there were in total almost three times as many doctors in the 30 to 40 age group who had come from less developed countries. Those doctors from developing countries other than the Indian Sub-Continent were particularly well represented in the middle age ranges. Table 9 shows that almost 4,000 foreign-born medical graduates left Britain over the four-year period 1962–66, of these, one-third had been born in developed countries and two-thirds in developing countries. Over a quarter of the emigrants had qualified in the British Isles, almost 30% in other developed countries and somewhat under half in developing countries. From Table 10 it can be seen that the emigrants were largely concentrated in the 30 to 40 age group, although almost a fifth were still under the age of 30, and another sixth were over the age of 40. Doctors who had qualified in the British Isles were less concentrated in the 30 to 40 age group and tended to be either younger or older than their colleagues who had qualified elsewhere. Of particular interest are the number of years spent in Britain by the foreign-born doctors leaving the country, as shown in Table 11. Exactly 30% of those qualified in the British Isles and almost half of those qualified elsewhere had spent less than two years in the British Isles, while almost three-quarters of those qualified elsewhere and half of those qualified in the British Isles left within four years. On the other hand, a fifth of those who had qualified in the British Isles did not leave until after having spent at least 10 years in the country.77 The absence of any foreign qualified doctors who had left Britain after 15 years does not appear to be reasonable; however, because of the nature of the data base any such doctors would be included with the 10 to 14 year category. In general the tendency has been for those qualified in Britain to remain longer in the country than for those trained in their home countries. Calculations from Table 12 show that (excluding unknowns) 28% of the doctors leaving Britain did not leave for their country of birth – somewhat over 1,000 doctors in all. The comparable figure for incoming doctors was 26% (Table 7). Only one-tenth of those born in developed countries went to developing areas (120 doctors in all) and only one-eighth of those born in less developed countries left for developed countries (298 doctors in all). The comparable figures for incoming doctors were 5% and 8%. Of those from developed countries only South Africans and Europeans showed any important tendency not to return home; in the case of South Africa almost one-half of the outflow from Britain did not return home, while for Europe the comparable proportion was four-fifths. It should be remembered that only 17% of the European-born doctors entering Britain arrived from their countries of birth (Table 7). For the developing countries the most serious examples of non-return were the Middle East (about one-half of those leaving Britain) and East and Other Africa (about one-third in each case). These figures, however, are reasonably consistent with those for entering doctors from these areas. Almost 600 of the over 1,000 medical graduates who did not return to their own countries went to countries at a level of development similar to their own. Such movements present less difficulty than when non-return leads to movement from a developing to a developed country. It is noteworthy that the 298 doctors from developing countries who left for developed ones were so small in number. However, if the number of (especially) Commonwealth medical graduates who now sit the examination of the American Educational Council for Foreign Medical Graduates (ECFMG), held twice yearly in London and Edinburgh, is any indication then the number of such graduates who leave Britain for another developed country – in this case the United States – may have risen significantly in more recent years. Tables 13 and 14 offer an analysis of the countries to which the foreign-born doctors had gone in relationship to their original place of qualification, and to the period of time which they had spent in Britain. Fewer of those who were British Isles qualified tended to return to their own countries, or to countries at a similar level of development. Almost a quarter of the British Isles qualified graduates, from both developed and developing countries, ‘crossed the line’ to other kinds of countries than their own – that is, developed or developing, as the case may be. For those who had originally qualified elsewhere than the British Isles only 7% and 12% respectively of those from developed and developing countries had ‘crossed the line’. The only developed countries for which ‘line crossing’ was significant were South Africa – at least for those trained in the British Isles – and Europe. Of those from a developing country who had qualified in Britain or Ireland the phenomenon is important for those born in all parts of Asia and the Middle East (a substantial part of those shown as born in East Africa are also of Asian background). The apparent exceptions, to be found in Table 13, to the rule that those who qualify at home tend more to return home, primarily stem from statistical phenomena resulting from some of the very small numbers involved in these cases –