"You called and we came"

Windrush and the NHS

By The King's Fund

Content warning: Some historical quotes in this exhibition contain racist language.

22 June 2023 marks 75 years since the HMT Empire Windrush arrived at Tilbury Docks carrying passengers from the Caribbean ready to start a new life here in the UK. Less than a month later, on the 5 July 1948, the National Health Service opened its doors for the first time. Our new exhibition uses interviews with NHS staff past and present to bring to life lesser heard voices and stories from within NHS history. While unfortunately these conversations highlight continued inequalities experienced by ethnic minority staff working in the NHS, it also reflects and celebrates the huge contribution that people from the Windrush generation – those who moved from Commonwealth countries, and primarily from the Caribbean, to live and work the UK between 1948 and 1971 – and their descendants have made to the NHS since its formation in 1948.

The NHS is a cherished institution, one that former Chancellor, Nigel Lawson famously observed was ‘the closest thing the English have to a religion’. It is a source of national pride: more people cite the health service as a source of pride than they do our culture and arts, free media, sports teams and the Royal family.

Recent moves to decolonise the history of Britain have focused on expanding the breadth of stories that we tell about ourselves as a nation, our cultural identity and what it means to be British. If the NHS is symbolic of Britain, it’s also representative of Britain’s social history too. The founding of the NHS in 1948 coincided with the call to British citizens from across the Commonwealth to help rebuild the ‘mother country’.

HMT Empire Windrush arrived at Tilbury Docks on 22 June 1948, carrying people from various Caribbean countries answering this call and looking to settle in the United Kingdom. Passengers – many of whom had served in the British Armed Forces during World War II – were working in professions ranging from mechanics, carpentry, tailoring, engineering, welding and music.

On 5 July 1948, less than a month after the arrival of the Empire Windrush, the NHS was born. It was the first time that all citizens in Britain could access health care, free at the point of use, regardless of their background or income.

Before the NHS was established, people who could afford it could access health care via private practices and independently funded hospitals. The availability of health care varied across the country: many medical professionals, such as doctors, were educated and then practiced in city regions, meaning access to care was limited in rural areas. Charity-led voluntary hospitals provided emergency care to those who couldn’t afford to pay for their own care, but funding was limited.

The disparity in access to health care across Britain was an issue the government continued to face. During World War II, emergency medical services had grown exponentially, and after the war the government believed a more organised way of delivering care was needed to support people who were socially disadvantaged and in need of care. Over the next 75 years, the NHS transformed health care in Britain.

Source Croydon Health Services NHS Trust

In the aftermath of World War II there were labour shortages both in Britain and across Europe, but the creation of the NHS meant there was a need not only for doctors and nurses but for all the other roles required to run a national health service including porters, catering and domestic staff, and administrators and managers, and a major recruitment drive was launched.

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Although many women trained as nurses during World Wars I and II, women with families returned to the home and many unmarried women opted for higher paid opportunities in the Civil Service, teaching or as secretaries (Kramer, 2006). This meant that, even before the NHS was founded, there was a nursing shortage in Britain and in 1948, there were 54,000 vacancies. The lack of interest in nursing as a career was exemplified by a recruitment campaign in Tottenham to fill 737 nursing vacancies that only garnered 17 enquiries.

In response to these workforce shortages, the Ministries of Health and Labour, the Colonial Office, the General Nursing Council and Royal College of Nursing embarked on a concerted recruitment drive across the British colonies, particularly focusing on the Caribbean and specifically aimed at domestic and administrative staff and nurses. NHS managers, hospital matrons and British politicians visited the Caribbean as part of this recruitment drive and by 1955, there were 16 NHS recruitment agencies in the British colonies.

The recruitment campaign was a success; 5,000 Jamaican women were working in British hospitals by 1965 and by 1977, 66 per cent of overseas student nurses and midwives originated from the Caribbean. To this day, the NHS is still reliant on overseas workers to staff the health service with 16.5 per cent of staff reporting a non-British nationality and recent nursing recruitment efforts have been focused on Jamaica.

‘Longer to go up the ladder’: training and career development

To qualify as a nurse now usually requires a university degree, but this is a relatively recent development. Up until 1986, there was a two-tier qualification system for nurses in England, State Registered Nursing (SRN) (or staff nurses) and State Enrolled Nursing (SEN) (also known as pupil nurses). The three-year SRN qualification included training in ward management and leadership development and was generally seen as the attractive option for those who might otherwise have attended university, whereas the two-year SEN qualification was more practical and clinically focused. West Indian nurses were more often than not enrolled on the lower status SEN pathway.

They had me measured for a green uniform and I saw one or two nurses in purple uniform. So when I went back I asked my Jamaican friend ‘what is the green uniform?’ She said, ‘We are pupil nurses, a lower grade of nurses, stupid nurses’ and I went back to the matron and I said to her I was accepted for student nurse training and not pupil nurse training. I had to do the pupil nurse training, otherwise they would send me back to Grenada.
Joyce Bleasdille-Lumsden, former nurse (Kramer 2006)

Often, the differences between the two different training pathways weren’t explained to West Indian nurses and when trainees qualified for enrolment on the higher status SRN pathway, they were denied entry. Not only was the SEN qualification lower status than the SRN pathway but it provided less opportunity and was less transferrable.

Their training is often no use to them outside Britain and returning to their home countries often means the end of their careers as nurses. Back home the conditions often just do not exist for them to go on as nurses. In Guyana, for example, there are no mental hospitals...In various countries from which nurses are recruited (for example the Philippines and Singapore), the SEN qualification is not recognised, a fact the British authorities are well aware of.
(Wilson 1978)

Nursing recruits from the West Indies also found themselves dispatched to unpopular and unprestigious specialties that British nurses avoided, such as psychiatric nursing or working with people with learning disabilities, sometimes referred to as the ‘Cinderella areas of the NHS, with low status and scarce resources.’ (Pearson 1987).

Even once qualified, the challenges for West Indian staff didn’t stop. It was not uncommon for Windrush staff to find that opportunities for development and career progression were placed out of reach, not only at an institutional level but also at a systemic level:

I used to do what I called the watching game. I would watch and see what training was available, who was going for it and how often. I used to challenge the situation. I would say nurse A and B and whatever, she’s had x amount of training, I haven’t been on one. This training is available and I am interested, here is my application and that’s how you got on these things in those day. You had to fight for them.
_{Louise Garvey}_{, former nurse (Kramer 2006)}

I wanted to be trained as a health visitor and [was told] ‘health visiting wasn’t for black girls’. I decided I was going to prove her wrong. It seemed as if I was in a catch-22 because I was now still on a student visa and I asked her to revoke my visa and she wouldn’t revoke my visa unless I stayed at the hospital as a midwife...I decided the only way I could get myself out of this trap was if I were to buy property...so I saw a maisonette and it was going for £9,500 at the time...I went to the GLC (Greater London Council) to the housing department and told them I wanted a 100 per cent mortgage. The person laughed at me...I wrote directly to the director of housing at the GLC. I said I was a midwife and that I had aspirations to go on and do my health visiting training but more importantly in the here and now I am giving very valued service. I walked out of that office with a 100 per cent mortgage...So I left midwifery and...was sponsored for health visiting training.
_{Neslyn Watson-Druée OBE}_{, former nurse and former Chair of NHS Kingston (Kramer 2006)}

In the early 1980s, The King’s Fund began to turn its attention to questions around race and the health care workforce. Unequal access to health care and discrimination in employment opportunities within the NHS were particularly high on the agenda.

The King’s Fund responded directly to requests from people working across the health care system who were experiencing these issues firsthand. In some cases, simply providing a space to meet was what was needed: newly appointed NHS race liaison workers began meeting at The King’s Fund development centre.

At this time, The King’s Fund was still a grant-giving organisation and it began to identify projects in this area. One notable project was the Equal Opportunities Task Force. Funded by the Department of Health, the taskforce met at The King’s Fund. It was instrumental in supporting the NHS to develop and implement policies aimed at tackling racial discrimination in the health service. The taskforce aimed to change employment practices and increase training opportunities for staff from Black and ethnic minority backgrounds. It focused on three areas of concern: the under-representation of staff from Black and ethnic minority backgrounds at senior management level; the lack of employment opportunities available to medical staff from Black and ethnic minority backgrounds in hospitals; and the racial discrimination experienced by nursing and midwifery staff at all levels.

The taskforce celebrated some success publishing guidance and best practice that was distributed across the NHS. It employed eight new equal opportunities advisers, and by 1990 this number had grown to around 30. These advisers supported health authorities to plan and implement equal opportunities strategies within their services.

However, the final report of the taskforce project revealed limited success, noting that there were many more issues that needed attention. It concluded, ‘Real and consistent progress[...] will only be achieved when action to ensure equal opportunities becomes a formal and routine part of the duties and responsibilities of all health service managers.’

‘Limited success’ is an apt assessment when looking at the opportunities for career progression for staff from Black and ethnic minority backgrounds in the NHS today. The latest NHS race equality benchmarking data finds that white staff are 1.12 times more likely to have access to additional training than colleagues from an ethnic minority background. In our own research, we have heard from staff from ethnic minority backgrounds who describe their experience of being bypassed for career development, a lack of support from managers and requests for progression opportunities being blocked. For Angela, a Black Caribbean woman who has worked in the NHS for more than two decades, this has been her experience: ‘I’ve got people who are managing me who are racist,’ she says. ‘My manager… holds me back, stops me getting opportunities that [are given] to my white counterparts who… [are] may be not as experienced as me.’

Michile’s observation about the glacial pace of change in the NHS is echoed in the data, with only 45 per cent of ethnic minority staff feeling that their trust provides equal opportunities for career progression and promotion, in comparison to 59 per cent of white staff. This belief is also reflected in the data on representation in the NHS. While the NHS has one of the most ethnically diverse workforces in the public sector, this diversity doesn’t stretch all the way to the top of the ‘snowy white peaks’ which in turn reinforces the lack of progression: ‘[I] don’t see anybody of my kind there [on the board], it’s just all white faces. So they don’t fully understand, I don’t think they understand the difficulties that BME [Black and minority ethnic] people go through, you know, which is slightly different to our white colleagues.’

‘How come England did not know me?’: discrimination and acceptance

Britain’s call for Commonwealth citizens to come to help rebuild the ‘mother country’ after World War II brought those seeking new and brighter opportunities to Britain, often a place that they already considered ‘home’. West Indian people held British passports, English was their lingua franca, school education was modelled on the British system and cricket was a shared national past-time. So, it came as a culture shock to Caribbean migrants to find that their presence in and labour for Britain, while actively sought, was not always welcomed. As Gilbert, one of the protagonists in Andrea Levy’s Small island puts it, ‘How come England did not know me?’ In an article in The Yorkshire Post in 2019, Nettie White recounts arriving in England in 1958 and moving to Leeds to become a nurse. She recalls some of the racist comments she received while caring for patients in hospital.

Some people would say things like ‘don’t put your dirty hands on me’ but it didn’t bother me. I’m tough and I wouldn’t take any nonsense from anyone.

West Indian staff used various different strategies including humour, grace and compassion to deal with discriminatory comments from patients.

Someone once asked me if we had to wear clothes in Jamaica and I said ‘not at all...it’s too hot to wear clothes. All we do is sit under the tree all day. His fish and chips nearly choked him.

^{Nettie White}^{, former nurse and founding member of the Leeds Jamaica Society}

Black people, we were treated differently … but we didn’t worry because we know what we wanted to achieve and what we had to do and we did it, and we did it by making jokes with each other and laughing and doing our work properly.

^{Brie and Georgiana}^{, former nurses}

I was making and helping someone pass the teas out and this man said, ‘You have to watch these darkies you know, they’ll steal the milk out of your coffee.’ I froze, I was glad my father was not around to hear. In our district stealing is considered a disgrace. I felt really cold. I withdrew within myself from these people if this is how they would think. Years later I realised that man was very insecure, nobody had asked him anything, he needed to be noticed. What I found then and compared it, the people who are most ignorant are the ones who have never been abroad.

^{Sherlene Rudder MBE}^{, former nurse and co-founder of the Sickle Cell Society UK (Kramer 2006)}

This hostile reception to West Indian staff in the NHS mirrored the broader response that people in the Windrush generation received on their arrival in Britain.

The infamous ‘No Irish, no Blacks and no dogs’ signs have become emblematic of the wave of xenophobic sentiment that arose in response to the influx of people who came to answer Britain’s call for workers. The response also resulted in the ‘colour bar’, an informal discriminatory practice of the time whereby people of colour were denied jobs, housing and services or spaces, such as pubs, had segregated access. This hostile environment extended beyond individuals and communities, all the way through to the national political landscape. Two days after the Windrush docked in Tilbury, a group of 11 Labour MPs wrote to Prime Minister Clement Attlee claiming that ‘An influx of coloured people domiciled here is likely to impair the harmony, strength and cohesion of our public and social life and to cause discord and unhappiness among all concerned.’

Life in Britain for people in the the Windrush generation was one of struggle, with racism woven into the fabric of their everyday experience. Baroness Floella Benjamin has described her childhood as an everyday battle: ‘I left the safety, comfort and security of my loving home knowing I would have to face insults and abuse, from adults and children alike, as I walked the streets.’

For staff from ethnic minority backgrounds in today’s NHS, the picture remains stubbornly similar. When asked to describe the lived experience of being a person with an ethnic minority background in the NHS, the same themes of discrimination and exclusion are still present.

There was actually a Sister, a Black Sister, who was in an office with some of the senior people and they were talking in a corner, two white Sisters, and they said, ‘Oh, have you heard about that BAME network group? What do I need to do? Do I need to Black up to get on that?’ And in front of a Sister who was Black, actually talking and saying that.
_{Interviewee from}_{Workforce race inequalities and inclusion in NHS providers}

[I’m part of] a group of Black cyclists who raise funds [for charities] and create awareness. The BBC saw us at an event and they wanted to film us… and we did an interview. I was in the kitchen [at work] and [somebody said], ‘I’m sure I saw you on the TV the other day.’ Now there was [another] guy [who] must have been listening to this and he turned around and he said, ‘What was that? Crimewatch UK?’ Later on, I asked some of the secretaries, ‘Who’s that guy there?’ [They replied,] ‘That was a consultant.’ So what chance do we have in a diverse country, diverse community, when you’ve got a consultant, a white consultant, actually making comments like that?
_{Interviewee from}_{Workforce race inequalities and inclusion in NHS providers}

For early Caribbean migrants, fortunately discrimination and ignorance weren’t the whole picture when it came to interactions with patients. There were many who appreciated the care that the staff provided, regardless of their race or background.

[I remember] being invited into homes and primarily patients’ relatives’ homes. I remember patients used to say things about me and relatives used to invite me home and I would be invited out for tea and so on.
_{Neslyn Watson-Druée OBE, former nurse and former Chair of NHS Kingston (Kramer 2006)}

It wasn’t only in the patient and staff relationship where connection and acceptance was found, there were also colleagues who made their West Indian counterparts feel valued, welcome and looked after.

We met a lot of good people along the way. The matron at the hospital where I worked took two or three of us under her wing, she wanted to make sure we were all right. She would always look out for us.
_{Betsy Johnson, nurse and founding member of the Leeds Jamaica Society}

Unfortunately, this wasn’t always the case and discrimination from colleagues wasn’t uncommon. This ranged from being underestimated and undervalued by colleagues and being given undesirable shifts and responsibilities, all the way to overt racist abuse.

When I was in the ward, doctors and visitors would walk past me looking for a white face. They’d approach a porter, an ancillary, even a patient. ‘Who’s in charge?’ they’d ask. ‘Where’s sister?’
_{Anonymous midwife (Hicks 1982)}

For some, the continuous drip of racism, microaggressions (subtle or unintentional discrimination as a result of systemic racism) and overt discrimination has left them with bitter disappointment and anger.

The whole thing was set up with the idea of exploitation and if the British don’t choose to remember anything else they owe us, they could at least thank us for their wonderful NHS.
_{Teresa Jerome, senior nurse (Alibhai 1988)}

This calling out of the exploitative nature of the recruitment of staff from the West Indies to grow the NHS from its infancy is mirrored in David Lammy’s observation that the Windrush generation ‘were British subjects not because they came to Britain, but because Britain came to them, took their ancestors across the Atlantic, colonised them, sold them into slavery, profited from their labour and made them British subjects.’

In recent years, the Windrush scandal – the wrongful detention, denial of legal rights and deportation of people from the Windrush generation – has shown the long shadow that is cast by British colonial rule. Despite the huge cultural, economic and societal contribution of the Windrush generation and their descendants, feelings of cultural estrangement and exclusion persists.

My life isn’t fulfilled in England: it’s wasted. What do you call me? I’ve been here since I was 18, I can’t call myself Barbadian. I’ve given the best years of my life to this country. I feel I should be entitled to call England my home.
_{Anonymous Windrush Generation nurse (Hicks 1982)}

We have staff that call it the plantation coming to work, so there’s some very deep-rooted stuff happening in the organisation… I think as the Black staff are generally [employed in] lower bands and the managers are all white, so it becomes like a slave–master type situation… There’s a lot of hurt and pain in that to say that you’re coming to the plantation but I know exactly why they’re saying it… you know, that constant reinforcement of ‘We’re here and you’re there, we progress, you don’t.’

^{Interviewee from}^{Workforce race inequalities and inclusion in NHS providers}^.

‘A debt of gratitude’: celebrating the Windrush contribution

Despite the barriers faced, there is also great pride in the contribution and the tangible difference that the Windrush generation and its descendants have made to patients’ lives:

We were asked to come here. We came on British passports and we paid our own fares. We took care of sick humans. We helped to make this city great. And we wouldn’t change any of that for the world.
_{Betsy Johnson}_{, nurse and founding member of the Leeds Jamaica Society}

Credits

Our thanks go to Sherill Gregory and Michile Ashling who generously shared their experiences with us for this exhibition. Thank you to the following organisations for their support and helping us shape this exhibition:

The Black Cultural Archives is the home of Black British history and their mission is to collect, preserve and celebrate the histories of people of African and Caribbean descent in the UK and to inspire and give strength to individuals, communities, and society.

The Caribbean & African Health Network (CAHN) is a Black-led organisation set up to address the wider social determinants to eradicate health disparities for Caribbean & African people in the United Kingdom. We work with the Black community and cross-sector organisations to build community resilience, relationships, and a social movement to improve health outcomes for Black people. Their vision is to eradicate health disparities for Caribbean and African people within a generation.

The Caribbean Nurses & Midwives Association (UK) acts as the voice of Caribbean nurses and midwives in driving change towards the improvement of health & social care, education, workforce, and policy development. Their mission is to develop a unique group of professionals with wide range of experience to influence the improvement of healthcare, inequalities of health and practitioners to reach their full potential.

Enfield Local Studies and Archives kindly provided us with many of the historical images featured in this exhibition. Their collection documents the history of the London Borough of Enfield with over 10,000 photographs of the local area dating back to the 1860s, alongside maps, local newspapers and journals, pamphlets and ephemera relating to local societies, schools and organisations.

The Florence Nightingale Foundation (FNF) is a charity which supports nurses and midwives to improve care and save lives. FNF’s main focus is on improving health, clinical outcomes and patient experience, through building nursing and midwifery leadership capacity and capability. It does this by enabling nurses and midwives to access bespoke leadership development opportunities. FNF is committed to providing equity of access to leadership opportunities for nurses and midwives from the global majority. We want to close the gap in career opportunities across health and social care settings. On this 75th Windrush anniversary they are launching their next Windrush leadership programme, funded by NHS England, for nurses and midwives from a global majority background.

The Whittington Health NHS Trust provides hospital and community care services to 500,000 people living in Islington and Haringey as well as other London boroughs including Barnet, Enfield, Camden and Hackney. The video featuring the children of St Anthony’s Catholic Primary School performing Professor Laura Serrant’s poem, ‘You called… we came’ used at the start of this digital exhibition originates from the trust’s 2020 Black History Month celebrations. Following a successful fundraising campaign, a statue dedicated to Windrush and Commonwealth nurses and midwives was unveiled outside the trust in 2021 to celebrate the dedication and key contribution of Caribbean nurses to the formation of the NHS.

Special thanks to Professor Laura Serrant, a multiple award-winning international speaker who focuses on global diversity and inclusion, nurse and professor of community and public health at Manchester Metropolitan University. She has been featured in the HSJ Top 50 Inspirational Women in Healthcare, Black, Asian and Minority Ethnic Pioneers and Clinical Leaders and featured as number eight in the Powerlist UK, a listing of the top 100 most influential Black people in the UK. She is the author of ‘You called…and we came’, the poem that inspired the title of this exhibition as well as featuring in the exhibition. The poem was original written for the Chief Nursing Officer’s Black, Asian and Minority Ethnic Pioneers Advisory group conference for Black History Month 2018, marking the 70th anniversary of the arrival of HMT Empire Windrush. The poem was also chosen to feature on the national Windrush monument in London in 2022.

Project team: Emma Sheffield, Felicia Thomas, Hong-Anh Nguyen, Jordan Reid, Lisa Oxlade, Lynsey Hawker, Megan Price, Nick Willsher, Nikki Smiton.

Video editing: Caleb Mitchell