As the United Kingdom faces an era of NHS staff shortages in the fallout from the Brexit vote and clampdowns on immigration, Douglas Haynes’ volume on the regulation of overseas practitioners offers a timely reminder that Britain has long pitted its medical needs against its protectionist instincts. Covering the period between 1850 and 1980, Fit to Practice examines the global influence of British medicine by charting the thorny negotiations that allowed British practitioners to work abroad, and their overseas counterparts to train in Britain. This sprawling topic is made manageable by a focus on the actions of the General Council of Medical Education and Registration of the United Kingdom (GMC). While the GMC was a neutral organisation charged with ‘protecting the public’ by maintaining a register of licensed practitioners, this task was often burdened by political expectations and professional pressures. As a result, Haynes shows how the GMC acted as a gatekeeper to ‘British medicine’ by preserving its largely white, male character – even when selectively permitting foreign and female doctors to cross the threshold.
The first half of Fit to Practice charts the spread of British medicine from the passage of the 1858 Medical Act to the domestic medical crisis precipitated by the Second World War. Haynes shows how the concept of ‘reciprocity’ developed to allow the surplus of British doctors to access local medical markets across the British Empire, with entry onto the British medical register offered to colonial doctors in exchange. For several decades, this offered a form of comparative equality, as doctors were free to practise across national borders – extending into countries such as Japan and Italy as diplomatic alliances were forged. Yet, benefits were only extended to those who held degrees from recognised medical schools and societies, and so long as such institutions held up barriers against women and minorities, so long were they excluded from the arrangement. Indeed, by ensuring that only those medical schools which promoted British medicine abroad – generally through the employment of white British men – the GMC ensured that reciprocity posed little threat to the domestic medical establishment. This system came under strain, however, as several dominions objected to their markets being opened to unwanted outside competition. Britain, too, saw the advantages of limiting access to their register, particularly when managing the flow of foreign doctors in and out of the country during the two world wars. Rather than widening the reach of reciprocity, temporary registration became the tool of choice to prevent refugee doctors from settling in the country. In these opening chapters, Haynes lucidly describes how the British medical community kept their professional interests at the forefront of international practice agreements.
The second half of the book surveys the decades following the Second World War, showing how the independence of India and Pakistan was accompanied by increased restrictions being placed on their doctors practising in Britain. As Haynes argues, concerns about language competency became a proxy for racialised hostilities towards non-white medical personnel, and double standards began to develop in Britain’s attitude towards doctors from more and less ‘desirable’ partner nations. As the cash-strapped GMC became more dependent on support from the medical establishment, they steadily adopted a system where overseas doctors were subjected to high fees, limited registration periods, close supervision and a rigorous admission test to ensure they would remain subordinate to local practitioners. While the GMC continued to recognise the qualifications of most Commonwealth-trained doctors, the emancipation of India’s medical schools from British dominance meant that their standards were increasingly suspect. Haynes thus shows that the preservation of ‘British medicine’ was reflected in the barriers placed on Indian doctors despite a clear need for their labour. Protecting the ‘credibility’ of the NHS provided a cover for creating a two-tiered system of practice that effectively discriminated against overseas doctors, rendering their positions unstable and futures insecure. While reciprocity was only brought to a formal end with the passage of the 1978 Medical Act, its original egalitarian principles had long been corroded by professional and racial anxieties.
Haynes effectively argues that the medical register became instrumental in protecting and promoting a homogeneous vision of British medicine – both by exporting its exponents around the world and by providing access to Britain’s medical market only to those who practised in its image. While the first half of the book reveals a great deal about how other countries interacted with a system designed to privilege British interests, by its close the focus is squarely on the GMC’s efforts to juggle competing interests in its regulation of overseas medical practitioners. This emphasis undoubtedly adheres to Haynes’ introductory description of Fit to Practice as an institutional history of the GMC. Yet, the more insular focus of the second half occasionally raises questions that a broader approach might have addressed. It is not clear, for instance, how the South Asian medical community responded to criticisms of their competence, nor what character an emerging ‘Indian medicine’ was assuming as Britain’s influence waned. Despite the title, ‘practice’ itself receives little attention. If the hegemonic control of white, male elites imbued medicine with any distinct attributes, they are not highlighted. Equally, while race plays a role in the debates over linguistic fluency, gender ceases to be discussed in the later chapters, despite the growing number of women entering the profession. This strand could have enhanced the book’s broader arguments about hierarchies and discrimination within British medicine. Finally, case studies might have helped to give voice to those affected by the policies whose genesis Haynes so carefully reconstructs. Fit to Practice ultimately emerges as a useful guide for considering how the British medical register became a portal for spreading a particular brand of medicine across the world, and for safeguarding it from outside influence. For those wondering what obstacles have prevented Britain from resolving its domestic medical needs with foreign labour, it reminds us not to underestimate the role of bureaucratic tools wielded by small, tractable agencies.
