The GMC is reviewing the way it tests doctors from overseas but not EU countries who want to register in the UK.
The regulator will review the Professional and Linguistic Assessments Board (PLAB) test, which doctors qualified outside of the UK and EU currently have to undergo before they join the UK medical register.
Read more at GP.
Doctors’ leaders have urged the European Commission to update laws allowing doctors to work anywhere in Europe to protect patients.
The BMA told the EC that existing rules covering the free movement of medical professionals are no longer fit for purpose.
The EC is considering revisions to its directive on the mutual recognition of professional qualifications. Under the directive, European Economic Area medical qualifications are valid across Europe, and EEA doctors can seek work in any country in the area.
The BMA submission says: “It is essential that EEA doctors who exercise their right to free movement are able to demonstrate regularly to the host competent authority that they are fully qualified and fit to practise.”
The following is a summary of the BMA’s response:
1. Simplification
It is vital that any simplification of the directive on the mutual recognition of professional qualifications does not dilute the checks and balances that enable authorities to regulate doctors effectively and to ensure patient safety.
2. Code of conduct
Some of the provisions in the code of conduct produced by the European Commission in April 2010 need clarification. Most notably, the code prevents authorities from requiring original and officially translated copies of documents and from requiring applicants to verify their identity.
3. Partial access
Under no circumstances must ‘partial access’ to the medical profession be granted to a doctor whose training or qualifications do not merit full recognition.
4. Mobility for graduates
The scope of the directive should not be extended to include professionals who hold a diploma but have yet to complete a remunerated traineeship of supervised practice.
European medical graduates can apply to enter the UK Foundation Programme without discrimination under law. The FY1 is currently oversubscribed. The BMA believes professional registration should take place in the country in which the doctor completed their medical qualification before they can have this qualification recognised by another member state.
5. Professional card
The introduction of a professional card has been proposed as a tool for facilitating the free movement of doctors.
The BMA argues that the Internal Market Information System (IMI) should be strengthened and made compulsory instead of introducing a card, thus allowing authorities to exchange regulatory data on doctors.
6. Temporary and occasional practice
Standard fitness to practise checks cannot be made on EEA doctors who apply to work on a ‘temporary and occasional basis’ in the UK. This must not be seen as an easier route to enter the UK medical system.
The BMA questions whether temporary or occasional services that are provided online should be exempt from an annual declaration. Regulatory requirements should apply to both electronic and non electronic healthcare.
7. Minimum training requirements
A decision to allow a European doctor to enter the UK should not be based on the length of time individuals have trained for. It should be based on the skills they have acquired. Authorities must be able to satisfy themselves that that a doctor possesses all of the necessary clinical skills in order to undertake their job successfully.
8. CPD
The current directive does not allow authorities to satisfy themselves that a doctor has kept their skills and competences up to date in the years following their qualification.
There should be a way for verifying the CPD status of applicants and, if necessary, impose additional requirements before a doctor can take employment.
9. Proactive alert mechanism
The directive should be revised to introduce a legal duty on all medical regulators to share registration and fitness to practise information proactively with other regulators in Europe. This would act as an alert system. The IMI system must be made compulsory for EU authorities.
10. Language testing
There remains confusion, particularly in the UK, as to the extent to which authorities can verify the language abilities of EEA doctors.
It is essential that doctors are able to communicate appropriately with their patients and colleagues and that the regulatory authorities are able to assess the fitness to practise of each doctor in their jurisdiction.
It is currently the responsibility of employers. Some believe the dilemma of whether the regulator can verify the language skills of a European doctor lies at UK national level.
It is believed that the UK Medical Act 1983 ‘gold plated’ the 2005/36 directive and thus prevents the UK authority from language testing doctor where a concern over their ability is raised.
It is believe that by amending the Medical Act 1983 some degree of informal language testing would be permitted.
Further investigations need to take place at national level to verify this - the BMA encourages the government to address this issue as a matter of urgency.
Global politics are well beyond my understanding. Two facts are clear however - Spain continues to suffer from a major economic crisis and our government is useless.
What I find harder to understand are the offers of help that Europe is providing us with. A few days ago, Mrs Merkel offered jobs for up to half a million highly qualified Spanish workers. How kind! Germany is hoping to get an extra large bunch of medical specialists, nurses and engineers.
She will not, however, be offering any of our several hundred thousand illegal immigrants or construction workers or cleaners a job. Mrs Merkel is after our ‘best people’, the highly trained, the ones that have been expensive to produce. It would be laughable if it wasn’t tragic.
The funny thing is that there aren’t many jobless docs these days, the times back in the 1980s and 1990s when you kicked over a stone to find ten doctors underneath are long gone. However, our working conditions are not good. I’m not particularly talking about salaries - while the income is at the bottom end of old European countries it’s still fairly decent. Doctors’ working conditions, in terms of secure contracts, are a disaster; people in their late forties have to pass bureaucratic exams in order to secure their positions and avoid having to move towns. It’s pathetic.
Our health system is used to an excess of doctors and as a professional group we are treated with contempt. There is little pride after years of being simply grateful for having a job.
The numbers of doctors moving out of Spain are difficult to calculate. People leave quietly, independently; they don’t leave a trace or enter any database. However, our Organización Medica Colegial gathers that almost 1,200 doctors moved out in 2010, 56% more than the previous year.
Back in the 1960’s and even 1970’s many thousands of unskilled Spanish workers moved to Germany to make a living, mostly waiters and hotel keepers, the benefits were equal for both countries. The situation is hardly the same in 2011, the way I see it Spain is struggling to take off from a deep recession and Germany is taking advantage of it. Despicable.
Patient care will be compromised by new measures preventing hard-pressed trusts from recruiting experienced doctors from overseas, the Royal College of Physicians has warned.
Following the immigration cap for skilled workers entering the UK, trusts had to use the Medical Training Initiative to employ overseas doctors. The MTI allows non-EU doctors to practise in the UK for a maximum of 24 months before returning home.
But now the MTI is under threat. Later this year the Home Office intends to cut net migration and reduce the maximum length of stay for doctors on the MTI to 12 months. Such a short stay would remove any training incentives for non-EU doctors and make it even more difficult for NHS trusts to recruit experienced overseas medical graduates.
The RCP said that, while it supports a fully home-grown healthcare system, there is currently a need for trusts to recruit from overseas and it is vital for patient care that hospitals can employ experienced non-EU doctors.
President of the RCP, Sir Richard Thompson, said: “Through the MTI, NHS trusts not only contribute to the training of doctors in developing countries, but also experienced medical graduates on the scheme help to ensure hospitals in England are adequately staffed.”
The MTI scheme has been criticised in the past for not enabling enough doctors to enter the country and for being bureaucratic.
Matthew Foster, head of international affairs at the RCP said: “Reducing the time limit of the tier 5 MTI will result in an inflexible system and international doctors and health leaders overseas will lose interest. They will go elsewhere and it will be the UK’s loss.
“The current arrangements ensure that the UK continues to maintain clinical links around the world, and support the World Health Organisation’s code of practice on international recruitment of health personnel.”
Professor Rezvi Sheriff, director of the Postgraduate Institute of Medicine, Colombo, Sri Lanka, said: “Training time in the UK is of great importance to Sri Lankan doctors and the continuing development of our health system. After so many changes to UK immigration regulations in recent years, restricting the Tier 5 medical training initiative to 12 months will force our doctors to shift their focus away from the UK.”
Tier 1 and Tier 2 visas were capped; the former allows highly skilled migrants to apply for permission to work or train in the UK without a job offer; the latter allows UK employers to recruit workers from outside the UK and European Economic Area to fill vacancies which have undergone the resident labour market test.
The MTI scheme falls under Tier 5, which allows overseas nationals to participate in government authorised exchanges. The scheme provided 250 two-year placements for doctors from developing countries in 2008 and was expanded by several hundred more by the previous government.
Read the WHO’s code of practice on international recruitment of health personnel.
A shortage of junior doctors to start work in hospitals this August is forcing the NHS to try to recruit from India, the BBC has learned.
Tighter immigration rules introduced in recent years meant many overseas medics left Britain and returned home.
But the exodus, added to new European regulations limiting the hours of doctors, caused unfilled vacancies.
The Welsh Deanery is one of four medical training schools across the UK which has been recruiting in India over this year.
The other deaneries involved cover the Severn area, the West Midlands and Northern Ireland. In total, they plan to take more than 100 junior doctors over to the NHS.
The deaneries are looking to recruit in areas such as paediatrics, obstetrics, gynaecology, anaesthesia, as well as accident and emergency.
Read more at BBC Health.
The Prime Minister has announced that fewer doctors will be recruited from overseas.
Eleven consultant specialties are to be removed from the shortage occupation list that identifies gaps in the English labour market, making it harder to recruit doctors from outside the European Economic Area (EEA).
Specialties that will no longer be on the list include paediatrics, dermatology, immunology, plastic surgery, intensive care and renal medicine.
Doctors’ representatives warned it would reduce the NHS’s ability to recruit flexibly.
Dr Ramesh Mehta, president of BAPIO, said: “Mr Brown’s statement seems to be more for political consumption than being realistic.
“The NHS has not yet recovered from the immigration rules fiasco of 2006 - it wouldn’t be surprising if the rules are reversed quickly when the recruitment crisis gets worse.”
In his first major speech on migration in nearly two years, Gordon Brown agreed the Migration Advisory Committee’s (MAC) plans to reduce the number of posts on the shortage occupation list.
Seen as a response to the rise in anti-immigration sentiment, the Prime Minister said he wanted “rising levels of skills, wages and employment” for British residents.
Terry John, chair of the BMA’s international committee, said: “The immigration system must be responsive to the needs of the NHS, and flexible enough to recruit overseas doctors where they are needed. There are still hospitals that are unable to fill junior doctor and consultant vacancies.
“It is therefore important that changes to immigration rules do not damage our ability to recruit the doctors we need to staff our NHS.”
In Scotland, the MAC rejected evidence from Scottish ministers seeking to retain biochemistry, ophthalmology, oral surgery and ENT on the list of consultant shortages. Only consultant radiologists remain on the shortage list.
In England, the only training grade added was ST4 level in paediatrics. Dr Mary McGraw, vice president of training at the Royal College of Paediatrics and Child Health, welcomed the move. “There is a big crisis at that level. It’s when female trainees go on maternity leave, start working part-time and gaps are created.”
Trusts will have to prove they can’t recruit from the EEA before looking further afield for doctors in specialties not on the list.
Consultant specialities remaining on the list include audiological medicine, GUM, haematology, microbiology and virology, neurology, nuclear medicine, O&G, occupational medicine and paediatric surgery. In psychiatry, the disciplines of forensic, general, old age and learning disabilities are also included.
Just last week Hospital Dr reported on record numbers of junior doctor vacancies following WTD implementation.
And, in September, we reported on how the bureaucracy surround the Medical Training Initiative was delaying the recruitment of overseas doctors and causing service chaos.
Read a BMA blog on the issue.
Read the full list of shortage occupations in the Tier 2 category.
Last week saw Gordon Brown get tough on immigration.
In the Daily Mail, we heard that the government was cracking down on immigration starting with a curb on doctors. Self sufficiency should be the goal of workforce planning, but are we really there yet?
My previous blog on rota gaps highlighted the problems many junior doctors have working on understaffed rotas and the fact, which even the Department of Health acknowledges, that part of the rota gaps problem is due to a previous crackdown on immigration.
Predicting the numbers needed to staff the NHS is complicated and whilst we may have competition for jobs in some parts of the country, other parts may have problems recruiting the doctors they need to deliver services to patients.
Earlier last week I was talking on BBC Radio Cumbria about the North Cumbria University Hospitals NHS Trust. This trust is recruiting junior doctors and consultants from India because they can’t find home grown candidates, which clearly illustrates the problem with a heavy handed approach to immigration. My worry is that this will affect the quality of care patients in the NHS are getting and the amount of training that junior doctors are exposed to - leaving them ill-equipped to be the consultants of tomorrow.
Of course, as with most government announcements, there seems to be very little policy behind the rhetoric but in his effort to sound tough on immigration Gordon Brown must not ignore the fact we need a flexible system that does not leave the NHS short of doctors.
The BMA’s junior doctors committee is working to ensure that international doctors are able to take up the posts they are offered without being hindered by the red tape that surrounds visa applications. With 2010 around the corner, it’s very much a case of watch this space to see how the immigration changes on top of the European Working Time Directive affect junior doctor recruitment.
Migrant doctors have made a huge contribution to the NHS over the past 60 years and yet it has gone largely unrecognised.
In an attempt to rectify this, researchers at the Open University have carried out 60 interviews with retired and serving overseas-trained doctors from South Asian countries about their experiences of working as geriatricians in the NHS from 1948 to the present day. The interviewees obtained their initial medical qualifications in India, Bangladesh, Sri Lanka, Pakistan and Burma and at the time of the interview ranged in age between 40 and 91.
They all followed a longstanding tradition of migrating from South Asia to the UK. Several had lived and worked in India during the colonial period, with one remarking about his teachers that “most had royal college qualifications”. He explained: “I’m one of the Midnight’s Children - I was born in 1946 just before partition. So, the British influence was very much in the family and it was sort of ingrained. And then when you see your teachers they all had their British degrees behind their names…” (born in Bihar, 1946, arrived in UK in 1972).
From its inception, the NHS depended on recruiting staff from overseas. Immigration legislation in the 1960s and 1970s targeted migrants from the Commonwealth countries. Legislation on racial discrimination in employment, enacted in 1976, and growing concerns about staff shortages in the NHS also influenced doctors’ career opportunities.
Overseas doctors can be seen as a mobile army of labour, particularly in the lower rungs of the medical hierarchy and in the less popular specialties, among which was geriatrics.
A crisis of staffing in the 1960s meant that by 1974 over 60% of consultant geriatric posts were filled by overseas trained graduates. This compared with 3% in general medicine and 9% of all NHS consultants.
This workforce development was not always viewed positively. Professors of geriatric medicine wrote to the Royal Commission on the NHS in 1976 saying: “The present pattern of education of medical students, nurses and other health personnel in Britain does not reflect the needs of this high risk group…so that elderly people have grave difficulties in attaining the healthcare appropriate to their needs…This concentration of overseas graduates in what remains a low status specialty is undesirable on many grounds.”
Contrastingly, many of the doctors interviewed expressed great enthusiasm for the NHS. For some it matched their own value systems: “I had to stay here. And I was never going back. I had a lot to go back to, wealth, position, knowing people. I would have risen there then much better, financially much better…I hope they don’t change it… There is no institution like National Health.” (born in Bombay, 1927, arrived in the UK in 1953).
Many also appreciated differences in the way doctors worked in the NHS: “I had a very good relationship with the ward sister…here we saw nurses more or less as equal and they were not subservient and you asked for their opinion about things that they were good at. You didn’t tell them, you asked them. In the Indian scene…doctors were only for doctoring and so a lot of things, even maintaining notes, we had in our hospital, we had a separate person like a clerk who went round with us and wrote down in the notes, medical notes.” (born in Bangalore, 1945, arrived in the UK in 1973).
Geriatrics was a ‘Cinderella’ specialty. In the early days of the NHS, care of older people with chronic conditions was little more than tending and took place in the back wards of large municipal hospitals, ex-Poor Law infirmaries and cottage hospitals.
Patients might go for years without seeing a doctor and were often confined to bed permanently. The founders of the geriatric specialty attempted to change this situation, in part as a more humane approach to medical care and treatment in later life but also in response to a demand to find ways to release hospital beds for use by other patients.
The specialty’s poor image resulted in marginalised groups of doctors such as GPs, women returners and migrants being recruited.
The South Asian doctors’ accounts provide testimony to the prevailing attitudes of the time towards older patients: “Geriatrics came to occupy as a second class doctors doing second class service for second class clients. I would not accept that. When I first started becoming a consultant I started here. I used to get great wad of letters. ‘Will you kindly see this patient and advise’.
“They bloody well didn’t want my advice. They wanted me to remove the body blocking their beds. And I said to myself, I will never become a clinical undertaker. Never. I have learned some medicine and I want to practice it.” (born in Bombay, 1927, arrived in the UK in 1953)
The doctors interviewed found that opportunities for career progression tended to be limited - even today more than twice (42%) as many white as overseas non white (17%) doctors are consultants in the NHS.
Geriatrics did, however, offer a way to progress. Many of those interviewed followed the pioneers in this respect, often taking the advice of senior colleagues as this doctor recalls: “Because my consultant, who was exactly like me…he was a trained cardiologist and then there were openings in geriatrics so he quickly moved into that area and he said if you want to go through the fast track up then this is a less crowded road.” (born in Madras, 1958, arrived in the UK in 1996).
But professional advancement was not always the whole story. Also important was personal achievement for both doctor and patient: “It took me five years but I got him back to work…I’m not joking, I cried that day. I cried that day when that fellow - he was a butcher - I got him back to work.” (born in Kerala, 1941, arrived in the UK in 1968).
The South Asian doctors talked not only of the stigma of working in geriatric medicine but also of personal encounters with discriminatory practices. They tended to focus on three areas where, as outsiders, they experienced discrimination: in getting their first post in the UK; when attempting to get a post as a specialist registrar; and in the allocation of discretionary merit awards and consultant positions.
Some picked out particular instances where interviews were unfairly conducted, promotions denied and work went unrecognised. Opportunities to secure promotion in the more popular specialties were few, even for experienced, well qualified doctors as preference seemed to be automatically given to UK trained doctors.
“Well chances were nil. I mean let us not beat about the bush. In those days if in an interview you found a local graduate you might as well walk off. But you could only get if there were more than one or two, three posts and you were competing amongst yourselves.” (born in Haryana, 1947, arrived in the UK in 1975).
Many found it difficult to secure posts in London and the south east and instead opted to work in more peripheral areas such as the northwest and Wales and in non-teaching hospitals where there was perceived to be less competition from UK graduates.
Those interviewed were nearly all consultants and one way of measuring their success was through the receipt of merit awards. South Asians and geriatricians were far less likely to receive merit awards than white doctors in other specialties.
“I think the main reason, without trying to be critical, is that the geriatricians had a hard, heavy, workload, clinical workload and had little time left to do other extra work, like research, publications and in terms of giving awards these other aspects were given more importance than the guy who was providing sort of a bread and butter service.
“And without trying to be cynical, maybe old schoolboy ties and that sort of thing can play a part. But I better not say anything more than that!” (born in East Bengal 1935, arrived in the UK in 1967).
Developing service provision in hospitals often meant struggling for resources for the care of older people. And South Asian doctors helped develop the idea of age-related admission to a unit which focused exclusively on older patients, with doctors, nurses and medical students trained in old age medicine. Collaborations with GPs, social workers and other professionals were also seen as essential to improving service provision.
While this research examined the challenges of the mid to late twentieth century, many of the issues that the NHS and its doctors face today remain the same.
New immigration rules exclude many non-EU doctors from training in the UK but the introduction of the European Working Time Directive has led to staff shortages, reminiscent of the earlier period. And, of course, providing good care to an ageing population continues to be a pressing issue.
The research makes a case for the need to recognise the achievements of international medical migrants in the past, and suggests they can help the NHS and its patients in the future.
It was led by Professor Joanna Bornat and funded by the Economic and Social Research Council.
Prof Bornat said: “We wanted to record and highlight the huge contribution these doctors have made in shaping medical provision in the UK, and their experiences of working in the NHS, before these first-hand accounts were lost forever.
“Their determination and dedication has meant that the quality of care for our older population has progressed at a truly tremendous rate.”
Find out more about this research.
Strict new immigration rules are creating problems with recruiting junior doctors from overseas and leaving hospitals short of staff.
Gynaecological services at Erne Hospital in Enniskillen, Northern Ireland, were suspended recently because only one of six new junior doctors recruited from the Asian subcontinent was able to start work on time. The doctors have been told it will take at least 9 to 12 weeks for their work permits to be issued.
“It is bureaucracy gone mad,” said Professor Mahen Varma, a cardiologist at the hospital.
In South Wales, the Abertawe Bro Morgannwg Trust has recruited nine middle grade doctors from India who are waiting the green light from UK immigration. The trust currently has 73 vacant doctor posts at all grades, according to figures collected by South Wales West Welsh Assembly Member Alun Cairns.
Dr Ramesh Mehta, president of the British Association of Physicians of Indian Origin (BAPIO), said they had heard of similar problems across the UK with the Working Time Directive making the situation even worse.
He said the problems related to bureaucracy created by the new Medical Training Initiative (MTI), launched in February, which allows international medical graduates (IMGs) to work in the UK for two years and then return home.
The immigration process involves paperwork from five organisations - the royal colleges, deaneries, the GMC, NHS Professionals and the Home Office.
BAPIO has proposed that all the paperwork should be coordinated by the royal colleges. It has also asked for IMGS to be allowed to stay for longer than two years because it takes them six months to settle in and that they should be given more training under the scheme.
“The immigration process for IMGs is taking too long while hospitals have acute shortages of doctors. These people in their ivory towers should wake up and let these doctors come here and get on with some good work,” said Dr Mehta.
A Department of Health spokesman said: “We are not aware of any delays caused by immigration, however, we will respond to any issues raised with us.”
He said the royal colleges could never take over the role of UK Border Agency (UKBA) or issue the overseas visas.
But he said the current length of leave for IMGs to stay in the UK and proposals to increase training benefits were currently under discussion.
“The DH continues to work closely with UKBA to ensure the MTI can bring maximum benefit to IMGs and the NHS,” he said.
It’s planned that MTI will provide 750 placements a year for IMGs.
An international doctors’ group is considering providing their own officials for the new revalidation process because they are so concerned about the level of complaints against overseas medics.
The British Association of Physicians of Indian Origin (BAPIO) says they have major concerns about the new system of responsible officers being appointed to relicence doctors because they are likely to be medical directors.
Responsible officers will have the authority to handle complaints locally about the conduct and performance of individual doctors and refer those who fall short of fitness to practise standards to the GMC.
BAPIO is concerned because they claim that most complaints to the GMC about international medical graduates (IMGs) come from professional colleagues and medical directors rather than patients.
A disproportionate number of overseas medics are referred to the GMC following fitness to practise complaints. The GMC has commissioned research to find out why this is occurring.
GMC fitness to practise statistics showed that, in 2008, 44% of initial complaints involving IMGs were classed as serious and led to a full investigation compared to only 29% of referrals for UK graduates.
Dr Ramesh Mehta, president of BAPIO, said “We have been wondering how we can assist IMGS and are actively considering expanding in a major way so that we will be able to provide responsible officers in the same way as other organisations.”
He said they were concerned that research commissioned by the GMC into the over representation of IMGs in fitness to practise proceedings had not yet reported because the problems are so serious.
“The issues are complex. Part of the problem is colleagues’ inability to understand the cultural background of international doctors. Although they speak good English, maybe the way it is spoken or maybe the interpretation by the people they work with could be a problem. Misunderstandings can crop up easily about diversity and there is also no doubt that some doctors still have a problem of racism. So there is no straightforward answer to this.”
He said IMGs also lacked support from potential representative organisations. He said in a recent case a BAPIO member, who was refused support by other groups, took a grievance against a deanery and the Department of Health to an industrial tribunal. Initial advice suggested the doctor should accept financial compensation instead, but BAPIO took on the case and they won at tribunal.
“We know of several other cases like this where things could have been really different. We get at least one or two cases like this a week where the organisations who should have supported the IMGs locally have failed to do so,” said Mehta.
A BMA spokesman said: “This something we are concerned about but it is difficult to speculate about the reasons why more international doctors are referred to the GMC. The statistics are worrying. Whether procedures are more difficult or less sympathetic for these doctors, combative language such as accusing the medical director of racism makes things escalate or whether these doctors don’t have the infrastructure or networks that UK colleagues have needs looking at.
“But we need to see the GMC research before we can make any changes in policy.”
A GMC spokeswoman said the study, commissioned from the Economic and Social Research Council in November 2007, is due to report later this year.
