Select Committee on Health Written Evidence

Supplementary memorandum by the British Medical Association (MMC 35A)


  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.


  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.


  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.


  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.


  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.


  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.


  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.


  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 hospitals—an 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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