Supplementary memorandum by the British
Medical Association (MMC 35A)
MODERNISING MEDICAL CAREERS
Thank you for allowing us the opportunity last
December to appear as witnesses for the Committee's inquiry into
Modernising Medical Careers. We are grateful to be able to use
this opportunity to provide the Committee with further information
following the evidence session.
INTERNATIONAL MEDICAL
GRADUATES
A key part of our evidence session centred on
discussion about international medical graduates (IMGs). We mentioned
that the BMA believes that, despite competition for jobs in 2008
being extremely high, discriminating against overseas doctors,
who have been encouraged to come to the UK to train and to whom
a commitment has already been given, is wrong and is verging on
being immoral. It is the view of the BMA that these doctors are
being unfairly targeted as a consequence of the UK's own failures
of workforce planning, and that the position of these doctors
should have been considered at the same time that the Government
was increasing medical student places with the intention of rendering
the UK self-sufficient in doctors.
We believe that the term International Medical
Graduates (IMGs) is being used inconsistently by different organisations
and will lead to misunderstandings. For example, the General Medical
Council defines IMGs as "nationals from countries outside
the UK/EEA" whereas the term should refer only to an individual's
place of qualification rather than reflecting their immigration
status.
The BMA considers that a more appropriate term
would be "doctors subject to the immigration rules".
Whilst a significant number of IMGs will be subject to the immigration
rules, there are some who are not. It is wrong to suggest that
an individual's place of qualification should determine their
right to work in the UK. Some IMGs are British/EEA nationals,
hold indefinite leave to remain, or have permission to work without
requiring a work permit, meaning that legally they must be considered
on an equal footing with UK/EEA nationals who are UK medical graduates.
The BMA has repeatedly requested the Government to accept their
responsibility to highlight the vastly reduced training and employment
opportunities available to international doctors, and to discourage
future migration to the UK. For such doctors, the Government must
ensure that information about the true situation of medical employment
in the UK is disseminated as widely as possible.
At our oral evidence session, Stephen Hesford
MP asked what proportion of the BMA's membership was made up of
IMGs. This data is not accurately collected in the form requested
but we would estimate that nearly 20% of the BMA's total membership
might be considered within the very generalised grouping of IMGs.[1]
The NHS owes an incalculable debt to international
medical graduates. In the past, the UK has failed to train sufficient
numbers of doctors and without medical immigration the health
service would have failed years ago. Because of this, the Government
has encouraged and even cajoled doctors to come to the UK from
abroad on the understanding that they could expect to train and
work here. The Government's belated attempts to change the rules,
effectively retrospectively, after these doctors have committed
themselves to the NHS and the UK, is unacceptable.
NEW IMMIGRATION
RULES
As you will be aware, the Home Office announced
changes to the immigration rules on 6 February which were later
discussed at your evidence session with ministers and officials
on 18 February. Several questions were asked and it was stated
that these changes would not affect those doctors currently in
the UK who are subject to the immigration rules or applying for
specialty training posts in this year's recruitment drive. However,
if the House of Lords decides that the original guidance released
by the Department of Health was lawful, that would affect the
rights of those currently holding an HSMP visa and would therefore
impact on their chances of attaining a post by August 2008. This
would make the introduction date for the immigration rule changes
of 29 February irrelevant. Irrespective of the House of Lords'
decision, there are currently doctors going through this application
process who were not aware of the rule change when applying for
HSMP. These individuals may have intended to apply to specialty
training in the future recruitment rounds taking place later in
2008 and will now face restrictions in doing so should the Department
of Health's guidance be introduced.
Furthermore, there may also be doctors who had
not yet applied for HSMP before the immigration rule changes were
announced in February but who intended to apply for the second
round of recruitment for specialty training in 2008. These doctors
will no longer be able to access training posts under the new
immigration rules unless there is no suitable UK/EEA candidate
for the post.
The BMA has received verbal assurances from
the Department of Health that those doctors who are currently
studying in UK universities with the expectation of continuing
their studies and training in the UK will be exempt from the immigration
rule restrictions and will be able to complete all of their postgraduate
medical training in the UK. We would welcome further written clarification
on how this will be achieved and the procedures that graduates
of UK medical schools will need to go through to continue their
postgraduate medical training in the UK. In addition, further
guidance is sought from the Department of Health for those renewing
their HSMP visas and those applying for HSMP prior to 6 February
2008.
The BMA's policy on doctors subject to the immigration
rules is already well established and consistent. All doctors
who have entered the UK with a valid expectation to train or provide
a service, and who do not require a work permit, should be eligible
to apply for all posts on an equal footing with UK and EEA applicants.
The BMA condemns the ongoing uncertainties for existing HSMP holders
particularly the Department of Health's policy of announcing that
existing HSMP will not be restricted in their access to postgraduate
medical training whilst continuing with their attempts to introduce
further restrictions for existing HSMP holders subject to the
House of Lords ruling. This is merely adding to the significant
uncertainties already being felt by this group of doctors.
PENINSULA DEANERY
MTAS EVALUATION
The Chief Medical Officer at his oral evidence
with the Committee on 15 November 2007 referred to evaluation
from Peninsula Deanery which appeared to support the view that
the MTAS process was not flawed. We would disagree with Peninsula's
evaluation, as it only evaluated the internal consistency of how
the questions and interviews were marked, not whether the best
candidates were selected using appropriate questions. To give
an illustration, the evaluation could have given the same findings
if candidates had by accident been asked questions about their
horticultural knowledge. The evaluation could then have found
that horticultural scores distinguished candidates from one another,
and the score at shortlisting was mildly predictive of how much
you knew about plants at interview. But none of this would have
selected the people who would be good doctors.
Technically, the sample size appears very small
and may be unrepresentative of much larger Deaneries or more highly
competitive specialties. The evaluation also simply says that
candidates who scored well at shortlisting also scored well at
interview. It does not tell you whether people who scored poorly
at shortlisting (through unfair criteria) would have actually
scored well at interview because they were unable to secure interviews.
Peninsula's evaluation seems to be just a check
of internal consistency, not that the right questions were asked
and the evaluation does not answer the critical question of whether
good candidates were missed.
KNOWLEDGE BASED
TESTING
In the evidence session with COPMeD on 17 January
2008, the BMA's opposition to knowledge based testing was cited
as catalyst for problems with recruitment. The BMA's policy is
based on sound research and concerns were expressed simplistically
at COPMeD's evidence session. It is important to note that, with
the exception of GP recruitment, which itself uses not a knowledge
based test, but an aptitude test, no proposals or pilot studies
of suitable knowledge based testing had been carried out. This
was the reason the BMA's Junior Doctors Committee refused to accept
its introduction at this stage.
ATTEMPTS TO
HALT INTERVIEWS
TAKING PLACE
It was of great concern to hear at various sessions
that a number of witnesses believed the medical profession had
not raised awareness of its concerns. As mentioned at our own
evidence, the BMA repeatedly called for delay both publicly and
in private discussion with the Department of Health, the Royal
Colleges and others. The BMA also wrote a number of occasions
to the then Secretary of State, expressing serious concerns.
MMC PROGRAMME BOARD
We mentioned that we had some concerns about
the MMC Programme Board and its direction of travel for 2008.
The purpose of the Board is to advise ministers on changes needed
both to medical training and the application process for training
programmes in England for 2008 and beyond. Our experience since
our evidence session has been that engagement between the BMA
and other Board stakeholders has resulted in positive development
of strategic thinking. There does remain a tendency for high level
strategy to run away from initial thinking when it comes to practical
implementation eg post CCT fellowships, which seem to have substantially
increased without strategic or workforce planning.
The BMA has stressed that design for the future
needs to be led by the profession but although the Programme Board's
membership draws together stakeholders from the Department of
Health, the NHS and clinicians from the BMA and the royal colleges,
we remain concerned that some of the pitfalls of last year's recruitment
process could be fallen into if the medical profession's voice
is not fully heard.
The Programme Board's remit should focus on
quality and standards, of which detailed, robust workforce planning
is an important part. However, the Board's efforts should not
be subjugated entirely to crisis-management in workforce numbers
decided externally and in isolation. Proper workforce planning
is central to quality and standards and not only about numbers.
Clinicians on the Board feel that their role is to build on the
frameworks outlined by Sir John Tooke to develop excellence in
training and education for the future, and not to simply to endorse
decisions about numbers, crudely based upon what strategic health
authorities are willing to afford.
FINAL TOOKE
REPORT
The BMA views the recommendations contained
in the report as an important package that the medical profession
can move forward with but it is essential for the Government to
play its part in light of the report. While there are some areas
of detail in Sir John Tooke's report that need further, careful
consideration, speedy action on the key recommendations will deliver
better education and training for doctors, and will be beneficial
for the NHS and the public. In response to the report, the BMA
is ready and willing to play a leading role in developing a mechanism
for providing coherent advice on matters affecting the medical
profession.
The Department of Health in England has agreed
to implement many of Tooke's recommendations but delayed making
a decision on several others, including the key recommendation
to create NHS: Medical Education England (NHS: MEE), to oversee
training in England that effectively moves power from the Department
of Health, and puts it back into the hands of the medical profession.
The BMA strongly feels that all the stakeholders who have expertise
to bring to these areas should be part of this body. The evidence
has always shown that excluding any major stakeholders results
in negative outcomes. NHS:MEE must be a body of all the talents.
The creation of NHS: MEE in this way would regain
the faith of doctors and provide a better guarantee of quality
and safety for patients. The medical profession also applauds
Sir John Tooke's recommendation to ring-fence the budget for medical
education and training. The BMA, along with all the other medical
bodies, believes that both of these changes are absolutely essential
if we are to ensure high quality medical training in future. For
several years now, trusts have been raiding funding set aside
for professional education and training to meet deficits. This
funding also pays for medical student placements in hospitalsan
essential element of their education. Failing to protect it risks
the standard of training for many doctors, and ultimately the
future quality of patient care.
The BMA does understand why some of the changes
cannot happen immediately, as it was the rushed implementation
of earlier reforms that caused many of these problems in the first
place. However, the BMA will be closely scrutinising the process
of implementation to ensure that vital action is not delayed,
or lost in bureaucracy. There appears to be a lot of reliance
in the Government's response on the results of the Next Stage
Review of the NHS, the results of which are expected in July.
Whilst the BMA accepts the need for some further consultation
on the implementation of NHS:MEE, we must be assured that the
Government will proceed with this vital development. Without this
the whole confidence of the medical profession, only just being
re-built, will be thrown away.
The Government needs to take action on NHS:
MEE and the protection of funding for education and training.
The BMA is committed to working with others to ensure the effective
and timely delivery of these necessary improvements to medical
training to continue to ensure the highest quality care patients
deserve.
Dr Ian Wilson
Deputy Chairman
Central Consultants and Specialists Committee
Dr Jo Hilborne
Past Chairman
Junior Doctors Committee
13 March 2008
1 The number of IMGs (doctors who qualified outside
the EEA) who are in practice as a percentage of the total number
of members who are in UK practice Back
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