Select Committee on Health Written Evidence

Memorandum by the British Association of Physicians of Indian Origin (BAPIO) (MMC 55)



  1.1  There is a need for urgent and comprehensive review of workforce estimates which are specific to specialities and regions.

  1.2  Entry of international medical graduates (IMGs) in the future should be regulated by requirements dictated by workforce estimates.

  1.3  All IMGs then working in the UK should be treated solely on merit for job appointments.

  1.4  PLAB part 1 examinations overseas should be reconsidered.

  1.5  Doctors on Highly Skilled Migrant Permit (HSMP) should be treated on par with UK and EU citizens for applications to postgraduate training posts.


  2.1  The British Association of Physicians of Indian Origin (BAPIO) is a voluntary organisation and represents the interests of medical doctors from the Indian sub-continent.

  2.2  BAPIO is grateful to the Health Select Committee for giving us the opportunity to submit evidence to its inquiry into Modernising Medical Careers.

  2.3  The Tooke enquiry into MMC has flagged up lack of recognition of rights of HSMP holders as one of the issues along with MTAS application process as problem areas. This evidence will concentrate mainly on the issue of IMGs including those on HSMP.


  3.1  International Medical Graduates (IMGs), majority of who originate in the Indian subcontinent have historically played a significant role in the provision of healthcare of the British people. This has been especially so in specialities and regions traditionally under subscribed by UK graduates.

  3.2  IMGs have contributed immensely to the success of the NHS. In 2005 27.8% of doctors on the GMC register had qualified outside the EEA. The magnitude of contribution from these doctors was amply highlighted by Professor Aneez Esmail as part of the 2005 William Pickles lecture in the Spring Conference of the Royal College of General Practitioners.[3] The DH document also acknowledges this contribution in service provision as well as professional skills.[4]

  3.3  It is estimated that the cost of training a Medical Graduate in the UK is around £262,000. There are over 40,000 IMGs working for the NHS and this translates into a saving of £10 billion pounds for the British taxpayer. Further any references to the loss to the UK taxpayer if a IMG doctor is appointed to a post instead of a UK graduate are flawed as for every doctor the UK "loses" it gains another it did not pay to train.

  3.4  In April 2006, immigration rules were changed abruptly, without warning and without consultation. These were rushed through Parliament. The rules were applied retrospectively so that all IMGs on permit free training (PFT) had to satisfy a residence labour test to be eligible for postgraduate training posts. The effect of this was a huge economic and emotional trauma to thousands of doctors who suddenly had no choice but to leave the country. We estimate that about 8,000 IMGs had to leave the UK in the aftermath of the new immigration rules.

  3.5  The consequence of the new immigration rules is that the number of IMGs coming to the UK for postgraduate training has been significantly reduced.[5]

  3.6  BAPIO is grateful to all the medical fraternity, politicians and public who supported the IMGs against their obvious unfair treatment.

  3.7  Doctors on Highly Skilled Migrant Permit (HSMP) are those who were already in employment at the time of the new immigration rules. Thus these doctors bring both much needed skills as well as experience of working in the NHS to the British people. They are committed to settle in the United Kingdom and are an important resource for the NHS.

  3.8  The Tooke Report, an independent inquiry into modernising medical careers led by Professor Sir John Tooke, concluded that there must be clear shared principles for postgraduate medical training that emphasise flexibility and an aspiration to excellence.[6] It has always been our contention that principles of merit should be applied and IMGs should be allowed to compete on equal footing for training. This will encourage excellence and the best doctors will be able to progress in their chosen careers. This can only be advantageous in the long run for the NHS and for UK.


  4.1  There has been concern regarding the paucity of training places compared to the number of applicants and it has been implied that this is primarily due to IMG applicants on HSMP. We disagree with this assumption.

  4.2  At the end of round 1 of MTAS 2007 process, HSMP doctors obtained 2,679 of 14,247 appointments (around 18% of all appointments). 10,856 of 14,247 appointments (76%) went to UK graduates, and UK and EU citizens. We expect that the appointment rates for UK/EEA nationals would be even higher at the end of Round 2. The majority of unsuccessful UK candidates would have applied to highly competitive specialties like Surgery and Orthopaedics. We do not have statistics regarding the appointments of HSMP doctors but believe that many of these would be in specialities and locations not preferred by UK graduates and a significant number may have been to FTSTA posts (described as the new lost tribe in the Tooke report as they do not lead to completion of training).

  4.3  It is anticipated that there would be about 8,400 to 8,700 training posts in the coming years. We think it is correct to assume that the current slack of about 1,200 UK graduates and remaining 5,600 HSMP holders will be absorbed slowly into the system in a few years time, with some doctors gravitating towards service and career grade posts.

  4.4  The competition from HSMP holders in the coming years will decrease dramatically. Many doctors on PFT visas and Work Permits (WP) were able to "switch" to HSMP as they had been in the UK at the time of announcement of the new immigration rules. This is no longer the case as PFT has been abolished, and issuance of a WP requires a Resident Market Labour (RLM) test. It is very difficult for a newly arrived IMG to accumulate enough points to apply for HSMP status.

  4.5  The DH occasionally refers to the high attrition rates amongst IMGs but the statistics used are from a time frame when different immigration rules existed. These do not apply to doctors on HSMP.

  4.6  DH suggests that it has reached self sufficiency in medical manpower. However Sir Liam Donaldson has said in his evidence that there is no over supply of doctors and UK will continue to need doctors from overseas. We are in agreement with this assumption.

  4.7  UK continues to need IMGs in under subscribed specialties. Obstetrics & Gynaecology received only 0.5 UK applicants for every post in the current recruitment session. Similar situations exist in the specialties of Psychiatry, Anaesthesia and Paediatrics amongst others.[7]

  4.8  There is however a need for urgent and comprehensive workforce estimations which are specific to specialities and regions. Entry of IMGs in the future may be regulated by requirements dictated by such workforce estimates. All IMGs who will then work in the UK should be treated solely on merit for job appointments. Conduct of PLAB part 1 examinations overseas may need to be reconsidered.

  4.9  We believe there is no reason for British Graduates to fear competition as they are extremely well trained.


  5.1  The Appeal Court has now declared that the DH guidance on excluding HSMP holders from training is illegal. Lord Justice Sedley said "The guidance, in my judgment, directly and intentionally affects immigration law and practice by imposing on the possibility of employment in the public sector a restriction beyond those contained in the Rules."[8]

  5.2  The House of Lords and House of Commons Joint Committee on Human Rights (JCHR) ruled recently against retrospective application of immigration rules as follows: "The Committee concludes that the changes to the HSMP are clearly not compatible with the right to respect for home and family life under Article 8 ECHR and contrary to basic notions of fairness. It recommends that the Immigration Rules should be amended so that the changes apply only prospectively, that is to future applicants to the HSMP, and that those already granted leave to remain under HSMP when the relevant changes took effect should be treated according to the rules which applied before those changes.[9]

  5.3  It further censured the government as follows: "The Committee recommends acceptance by the Government that it does not have unfettered power to make changes to the Immigration Rules which engage Convention rights and would interfere with a right, that such changes should be prospective only, and that changes to the Immigration Rules should always be accompanied by a statement as to their compatibility with the ECHR".[10]

  5.4  There is a strong argument that the Department of Health as one of the largest employers in the world should set a good example and show due regard to the principle of equality of opportunity in recruitment of its work force.

  5.5  We would also like to point out that Mr Justice Stanley Burnton in his judgement on the Judicial Review Action brought by BAPIO commented that the Home Office had failed to undertake the Race Equality Impact assessment in line with the Requirement of the Race Relations legislation. It is unfortunate that a statutory body disregarded their own regulation.

  5.6  We believe that had the DH undertaken expected adequate steps to consult all the stakeholders including IMG organisations prior to issuing guidance on PFT and HSMP, they would have gained the insight to the most likely impact of their proposals and some of the problems of MMC could have been avoided.

  We would like to acknowledge the contribution of Dr Joydeep Grover, Dr Asha Reddy, Dr Vinay Shanthi, Dr Ashok Beckaya, Mr Buddhdev Pandya and Dr Raman Lakshman in the compilation of this document.

Ramesh Mehta


December 2007

Table 1: Reduction in number of doctors taking the PLAB examinations subsequent to new immigration rules introduced in April 2006. Figures Based on verbal communication with GMC

YearNumber of candidates
who passed

YearNumber of candidates
who sat the examination
Number of Candidates
who passed

3   British Journal of General Practice: Asian doctors in the NHS: service and betrayal pp. 827-834(8) Author: Esmail, Aneez Back

4   MMC: Modernising Medical Careers (MMC) England Recruitment to foundation and specialty training-Proposals for managing applications from medical graduates from outside the European Economic Area, Dept of Health, 8 October 2007 Back

5   Verbal communication from GMC-see Table 1 Back

6   Aspiring to Excellence: Independent Inquiry into Modernising Medical Careers, Professor Sir John Tooke Back

7   Fourth Report from the Health Committee, Session 2006-07, Workforce Planning HC 171-II. Back

8   Bapio Action Ltd & Dr Imran Yousaf (on the application of) v Secretary of State for the Home Department & Secretary of State for Health. Back

9   Twentieth Report from the Joint Committee on Human Rights, Session 2006-07, Highly Skilled Migrants: Changes to the Immigration Rules, HL Paper 173/HC 993, paras 27-51 Back

10   HL Paper/HC (2006-07) 173/993, paras 52-56 Back

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