On Saturday 5 July the UK will celebrate the establishment of the NHS, arguably one of the greatest British achievements of the post-war years. Politicians, the media, and of course, the health services are celebrating this landmark achievement, reflecting on the history of the NHS and also looking forward to the challenges facing this very British institution.

The NHS was the brain child of Aneurin Bevan and drew upon his experience of the medical aid scheme offered in Tredegar in South Wales by the major employer in the town, the Tredegar Iron and Coal Company. Bevan became minister for healthcare and housing under Clement Attlee’s post-war government and used this opportunity to radically restructure medical care, ensuring that it was free at the point of delivery for all citizens, irrespective of their ability to pay. It has become one of the hallmarks of British identity, summoning up what the then Chancellor of the Exchequer Gordon Brown referred to on January 14, 2006 in his speech to the Fabian Society as 'one of the great British institutions – what 90 per cent of British people think portrays a positive symbol of the real Britain – founded on the core value of fairness that all should have access to health care founded on need not ability to pay.’

Aneurin Bevan.
[image © copyright BBC]

Since the inception of the National Health Service, migrant doctors have been seen as an integral but devalued part of the health workforce. These doctors were necessary for its operation, providing a mobile army of labour in the lower rungs of a pyramidal medical hierarchy, ensuring that UK doctors at the apex did not have to compete too much for pickings from the much diminished private sector. Overseas qualified doctors were provided training in the health service in return for meeting the health service requirements of the population. They were, however, systematically disadvantaged in terms of access to jobs, career mobility, the places where they found employment and the specialties they could occupy. They have come to be called ‘sepoys’ and ‘indentured labour’ pinpointing the situations of trained migrant doctors and the organization employing them. Disproportionately represented in training posts and in non-career grade posts they have, however, been a backbone for the development of this very British institution. Thus, in 2003, only 17 per cent of South-Asian doctors were consultants compared with 42 per cent of white doctors, which provides some evidence that migrant doctors from South-Asia continued into the present century to find their careers limited by the hierarchical nature of the NHS.

But one of the specialties where they have found a home and established a niche is geriatric medicine, a specialty that too was born in 1948. Marjory Warren, often considered the “mother of geriatrics” established the first geriatric unit in the UK, where older patients were admitted, rehabilitated and sent home. This was an innovation in elderly care at that time. Before the establishment of the NHS doctors had provided free medical service to support the charity hospitals but had earned substantial incomes, on the whole, through private practice. After the establishment of the NHS and the amalgamation of most existing hospitals, including the workhouses, into the national provision, doctors’ salaries were paid for out of the national taxation system and there was some resistance to taking over the regular care of elderly frail people. Geriatrics became associated with the wider disdain given to its clientele, older people. As such it became a ‘Cinderella specialty’, a disregarded area of healthcare serving the needs of one of the least regarded groups of patients. However, the work of a few pioneers such as Marjory Warren, slowly changed the nature of healthcare for old people with the development of acute care for older people and its own subspecialisms. It began to offer a career trajectory and eventually became what it is today, the second largest specialty with just under 900 consultants in hospitals. As we enter an ageing society, this development of geriatrics within the NHS is set to continue.

Silhouette of elderly man in wheelchair.
[image © copyright BBC]

In part responding to the dire medical neglect of older people within the NHS hospital system and in part to government and management pressure to improve bed occupancy figures, geriatric medicine grew rapidly, to large extent depending on recruits from overseas for its expansion. But this 'Cinderella specialty' status also gave room for overseas trained doctors who found their own opportunities for career growth to find a home. They too became pioneers in this discipline, shaping the nature of geriatric care today. It came to be a field where South Asians could find jobs so that 22 per cent of all geriatric consultants appointed between 1964 and 2001 were non-white and had trained outside the UK, compared to 14.1 per cent of all consultants in the NHS.

These doctors felt drawn to the UK, rather than the USA, because in South Asia they were already part of a socio-cognitive community for whom markers of participation in the UK labour market were central to notions of career progression. Migration to the UK for the purpose of training, gaining membership of prestigious UK Royal Colleges (MRCP etc) has long been embedded in South Asian doctors’ professional cultures.

For many doctors, their lecturers in medical school had undergone some form of training in the UK and that upgrading and validating skills through training at one of the UK royal colleges was seen as crucial to being recognized as a good doctor. Thus, the doctors’ mobility was already embedded in a network of professional development which valued temporary movement to the UK. Moreover, at least in medicine, the power of empire continued to be forceful as medical practice and qualifications were very much influenced by regulating bodies and by professional organizations, located in the metropolis. Doctors were thus already in some ways part of a professional community where migration to the UK was seen as part of career progression.

As the country is poised to celebrate, and rightly, the establishment of one of the most remarkable institutions of twentieth century UK, it is also worth remembering and commemorating the twists of history that led to the development of geriatrics and the role of overseas qualified doctors therein.

For details of a project exploring the experiences of South Asian geriatricians, visit Overeseas-trained doctors and the development of geriatric medicine.

Take it further

Read more about the birth of the Welfare State

Explore the NHS with Open2

The NHS governance project

About the author

Parvati Raghuram is Lecturer in Geography at the Open University. Her research interests focus on the ways in which the mobility, of individuals, goods and of ideas is reshaping the world.

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A two hour drive and a 40 minute boat ride along the Ganges north of Calcutta is Green Island. As the name suggests this is an island where the original vegetation that once covered the Ganges Delta remains relatively undisturbed.  I say relatively because while human disturbance is limited, every year when monsoon storms and high tides swell the river level Green Island is flooded, sometimes to a depth a little over a meter.

Studying this type of vegetation is crucial to my work as it represents exactly the kind of plant community that has the potential to be preserved in the fossil record. As the floodwaters scour the leaf litter from the soil surface, and the island margins are eaten away by erosion, leaves are washed into the river where they may be deposited in muds and silts and eventually fossilised. We see many such deposits in the rock record from which we deduce information on past vegetation and climate.

I was in the company of Professor Subir Bera from Calcutta University and his wife who had organised the day. We had special police permission to visit and collect on the island and even had a police escort. On the boat with us were several people from the nearby village who had (as we discovered later) prepared a wonderful lunch of fish and meat curries, rice and fruit, all served on banana leaves.

As the open wooden boat neared the island we could see whole trees, still with green leaves, that had recently fallen in to the water as the riverbanks were eroded. Caught in the branches of one such tree was the body of a goat. Now for most this might seem gruesome but for me it was fascinating because it was another example of taphonomic processes – taphonomy is the study of fossilisation.

As the Ganges undercuts the edges of Green Island whole trees fall into the river - perhaps on their way to being fossilised.
[Photo © copyright Bob Spicer]

Green Island is a little over a kilometre in length and a few hundred metres wide. Here we collected the populations of leaves from 56 different species of trees shrubs and vines. After pressing, drying and mathematically scoring them CLAMP analysis positioned the Green Island vegetation near the Kerala sites we had previously analysed, but in an area of the three-dimensional plot that indicated they were from a slightly cooler site.

Because Green Island is on a flat delta plain I could use meteorological data in the form of a grid in which observations from individual meteorological stations can be interpolated (mathematically extrapolated) for sites such as Green Island that does not have its own measurements.

CLAMP showing the positions of modern forests determined by their leaf architecture.

The plot above shows the positions of the Indian forests that I have analysed so far. In this plot each ball represents a forest. Green Island is Labelled “Green” and the other labelled balls are forests in Kerala. The positions of balls are determined by the numerical score that describes leaf architecture for at least twenty species of woody trees, shrubs and vines from each forest.

Balls that plot close together indicate forests with similar leaf architectures, while that that plot far apart are very different. The balls are colour coded such that blue represents cool climates and red ones hot climates. Orange, green and light blue indicate forests growing in intermediate climates. It is easy to see that the Indian forests (coded maroon) all lie in the warm end of the plot.

In this plot the Indian forests have been treated as if they were fossils. They have found their own position with respect to the other sites for which the climate is known. Despite the fact that the Indian sites all plot close to other warm sites they form a group beyond the limits of the existing cloud of sites, and using this calibration all the Indian sites yield a climate prediction that is several degrees colder than that which is observed.

The next stage is to include the Indian observed climate information so that the shape of the plot will change and the ability of the method to give accurate results for fossils that represent ancient forests growing in warm climates does not suffer from the same error of underestimating temperatures.

About the author

Bob Spicer is Professor of Earth Sciences at the Open University. Founding Director of the OU's Centre for Earth, Planetary Space and Astronomical Research (CEPSAR) his interests are broad. However he is most at home when studying how plants can be used to tell us about ancient climates, and how that information can help us plan for managing our planet in the future.

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On April 10 1949 the Cambridge–trained Indian palaeobotanist Birbal Sahni died after a massive heart attack. His death at the early age of 57 came only days after the then Indian Prime Minister Pandit Jawaharlal Nehru had laid the foundation stone of what was later to become known as the Birbal Sahni Institute of Palaeobotany. Each year, on the anniversary of Birbal Sahni’s death, wreaths are laid at the spot in the grounds of the Institute where he was cremated in accordance with Hindu custom. This year I was privileged to take part in this event that was preceded by an ancient ceremony of prayers and purification.

I did not know quite what to expect when I arrived in the main entrance foyer of the Institute because laid out on the floor beneath the soaring curved staircase were mattresses covered in white sheets surrounding a temporary hearth that had been constructed the previous day. Sitting on the sheets, cross-legged were the staff of BSIP and directly next to the hearth were the BSIP Director, his wife, and a Brahmin priest.

The ceremony began with the priest chanting ancient shlokas, rhythmic poetic prayers, in Vedic Sanskrit.  Sanskrit is the oldest continuously spoken language in the world and as early as 1500 BC its structure, as preserved in the oldest Hindu texts known as the Vedas, is so refined that it clearly has a common older source. Sanskrit is the basis of religious texts in Hinduism, Buddhism, Jainism and Sikhism. It is the oldest known member of the Indo-European family of languages.

As the prayers proceeded and incense sticks were ignited, offerings of rose petals, ghee, sugar solution, and rice were prepared. Then small dry branches of mango wood were arranged within the hearth and set alight. As the smoke rose throughout the building and the prayers continued, we all added the offerings of herbs and other aromatic elements to the fire. I have no knowledge of Sanskrit but I can say that the rhythmic sounds of it expertly spoken were incredibly soothing.  

Sanskrit rythmic poetic prayers and perfumed smoke permeate the BSIP building.
[photo © copyright Bob Spicer]

The prayers were ones for the general well-being, not only of the staff and the Institute, but for all humankind and our shared planet. The concept of such a ceremony is one of purification. There are sixteen such ceremonies in the life of a Hindu marking critical stages in the passage through life. What I was witnessing is the last in this succession. The sounds of the prayers and aroma of the perfumed smoke carried to all parts of the building cleansing and purifying. It was a ceremony that brought everyone together in a common purpose.

The ceremony concluded with the priest tying a length of hand-spun thread, dyed yellow with turmeric and red with turmeric mixed with lime, around our wrists, right hand wrists for the men and left hand wrists for the women. This was a symbol of our common purpose and a reminder of what we had participated in. In the past few days as I have been wearing mine, several people not connected with BSIP have asked how I came to have such a symbol. I have been pleased to explain.

About the author

Bob Spicer is Professor of Earth Sciences at the Open University. Founding Director of the OU's Centre for Earth, Planetary Space and Astronomical Research (CEPSAR) his interests are broad. However he is most at home when studying how plants can be used to tell us about ancient climates, and how that information can help us plan for managing our planet in the future.

Subscribe to Bob Spicer's posts