Doctors without borders: let foreign medics in!

Last week, the image of Britain’s National Health Service (NHS) as a fertile training ground for doctors from around the world received another blow. The Department of Health (DoH) closed post-graduate training positions to non-EU doctors. It’s a two-pronged attack. Firstly, the Home Office has announced that non-EU doctors or international medical graduates (IMGs) will not be eligible for the highly skilled migrant programme (HSMP). Secondly, the DoH proposes that those already working here with HSMP status will only be allowed to take such jobs if no UK or EU doctor is available (this advice is currently subject to appeal in the House of Lords).

UK health secretary Alan Johnson claims, disingenuously, that the new measures will not end the recruitment of overseas doctors to the NHS: ‘These new rules only apply to training places in the UK. International doctors will still be able to come and work in the NHS in thousands of other non-training posts and will still be able to fill training places in shortage specialties.’ In other words, migrant doctors will be used, as ever, to plug gaps in the NHS. But whereas in the past those who were sufficiently determined, talented and hard-working did manage to obtain training positions and build successful careers, these doctors will now have no hope of career progression. They will be banished to the sidelines, with no hope of getting back on the pitch.

There are two sorts of posts for junior doctors in the UK. Training jobs are approved and monitored by the Royal Colleges and deaneries; employers are obliged to give doctors access to study leave, courses and supervised learning opportunities. In non-training posts, doctors have no such rights and in most cases are not allowed to sit the Royal College examinations required for further career progression. These are effectively dead-end jobs.

IMGs have ended up as the scapegoats for a spectacular failure of workforce planning by the government in recent years. Post-graduate medical training in the UK was reduced to a shambles in 2007. The government tried to push through a new system with minimal consultation with doctors, in an attempt to streamline (that is, shorten and debase) the process of producing new consultants. Instead of two tiers of training, firstly at senior house officer level, then specialist registrar, there was to be one specialist training ‘run-through grade’.

However, the government somehow forgot to think through a plan for doctors who were still in the old training scheme, and who could not all be shoehorned into the new one. And these doctors were very angry: having already been appointed to competitive training posts at senior house officer level, they were now forced to apply again. To add insult to injury, the new jobs were assigned through the infamous Medical Training Application System (MTAS): online, insecure and based on obscure and banal short-listing criteria. Conventional measures of commitment to a specialty, such as postgraduate qualifications, research and publications, were jettisoned for what seemed like a creative writing competition. Here’s a sample question from the psychiatry application form: ‘Describe a recent example in clinical psychiatry of when your ability to communicate made a fundamental difference for a patient. What were the skills that you demonstrated and how did they affect the outcome for that patient? How did you learn that your intervention had been helpful?’

Hundreds of doctors did not secure a job, and many others were informed of their new place of work at the last minute, leaving them only weeks to move to the other end of the country, and often splitting up families and couples.

Doctors protested in the streets and the chair of the British Medical Association (BMA) resigned. In frustration at the BMA’s inactivity, new pressure groups, Remedy UK and Mums for Medics, were set up. And unfortunately, some of that very legitimate anger has turned against a traditional scapegoat – foreigners in our midst, taking our jobs. This idea has been encouraged by the government, despite a lack of evidence that IMGs have been given jobs ahead of UK graduates. Among an embittered and disillusioned profession, the idea has become acceptable that clamping down on IMGs will make all our problems go away.

In response to the new proposals, BMA chair Hamish Meldrum repeated the idea, now commonplace, that freedom of movement for international doctors should be restricted: ‘Taxpayers have made a major investment in the careers of UK doctors, and it makes sense to manage the numbers of international doctors coming to work in the NHS in future.’ Perhaps more surprisingly, the British Association of Physicians of Indian Origin (BAPIO), who fought the DoH’s removal of permit-free training last year, has also accepted this concept. BAPIO president Dr Ramesh Mehta said: ‘This should have happened four years ago. We don’t have enough training posts and our UK doctors should have opportunities.’

The idea that doctors from the developing world have been coming here and taking our jobs is laughable. In the past few years, expanding UK medical schools have churned out thousands of new doctors. This has meant IMGs face harder and harder competition. Many of them move here to take the General Medical Council’s (GMC) language and clinical skills exams, then live in poverty, applying for literally hundreds of clinical attachments (unpaid observing posts) before being allowed to register with the GMC and compete for real jobs. And, when in competition with UK doctors for posts, IMGs face huge disadvantages; imagine answering the above application question if you’ve never worked in the NHS and English is not your first language. Similar problems apply to any interview process. Even without deliberate discrimination, it is inevitable that experience in the NHS will to some extent weigh the process in favour of British doctors. But historically, the best and brightest (and to some extent, luckiest) of IMGs have been able to make it and the NHS has benefited enormously from their contribution.

Like other countries, we should continue to have robust requirements that doctors from abroad demonstrate a required level of knowledge and competence to work in our system. (Ironically, for EU doctors, mostly coming from very different training systems, no such testing is required.) But in the long run, the NHS and its patients can only benefit from a culture where doctors from elsewhere are welcomed, encouraged and trained.

Consultant anaesthetist Edwin Borman (a South African graduate trained and working in the UK) described the positive, democratising nature of medical immigration in a recent article: ‘While politicians seem to be shying away from the word “multiculturalism,” all who work in the NHS accept that we do so on an equal basis with colleagues from many faiths, cultures, and countries… Perhaps more than in any other aspect of life in the UK, the principle of equality is embedded in our function.’ (1)

The medical profession must not allow itself to be bought off by Johnson’s cheap political manoeuvres. If there are not enough training posts for British doctors, we need to demand that the DoH funds more of them. This could only be a good thing for clinical standards in the UK, allowing us to nurture and take advantage of the talents of the best doctors from around the world.

Dr Liz Frayn qualified at the University of Glasgow Medical School and has practiced in England and Australia.

(1) Should postgraduate training places be reserved for UK graduates? No, Edwin Borman, British Medical Journal, 22 September 2007