Select Committee on Health Written Evidence

Supplementary memorandum by Professor Dame Carol Black (MMC 56A)


  The position of international medical graduates eligible for training in the UK.

  This submission draws closely on the response of the Academy of Medical Royal Colleges to the Department of Health Discussion Document on proposals for managing applications from medical graduates from outside the European Economic Area (October 2007).


  1.  For many years the NHS has depended on international medical graduates to help provide its services. They have made essential contributions, particularly in general practice, obstetrics and gynaecology, paediatrics and psychiatry. Indeed there is no area of the NHS in which they have not had and continue to have a distinctive part in maintaining and enhancing the quality of practice and service. However, as a consequence of other changes our dependency on recruitment of doctors from abroad has lessened, and this must be recognised.

  2.  There are unacceptable tensions between the way in which the policy of greater self-sufficiency has been implemented alongside immigration policies that allow continuing open competition for entry into postgraduate and specialty medical training programmes.

  3.  Clearly there is a duty to support UK graduates from our medical schools. If the UK is to achieve self-sufficiency by continuing to attract able young UK nationals into UK medical schools and, in turn, the NHS, there must be good prospects of completing training after graduation. Significant denial of training opportunities for UK medical graduates, and subsequent unemployment, would be a waste of major investment in talented people who have already undergone highly competitive selection.

  4.  At the same time we should also have proper regard to the reasonable expectations and claims of doctors from abroad, the contributions they make to medicine and the service in the UK, and the skills many are able to take back to their own countries. Moreover, medical graduates from outside the European Economic Area include doctors from countries with whom UK medicine has forged strong and greatly valued bonds over many years. The Colleges are doing their utmost to maintain those bonds and urge government and the NHS to assist them in doing so.

  5.  It is scarcely necessary to say that steps towards restoring the reduced training prospects of UK graduates must include a way of defining candidature for training posts that ensures continuing high quality, is just, wise and proportionate to the problem, and is legal. The challenge is to find imaginative solutions that marry these responsibilities. Unsurprisingly, there is some divergence of views among the Colleges; but all see the need for compromise of some degree in finding solutions to this problem of the Government's making.

  6.  The UK has a high international reputation for postgraduate medical education, using that standing to benefit countries with less developed training programmes. We have urged Government to take the necessary steps to safeguard that high reputation. For example, the Academy of Medical Royal Colleges has recommended that the Health Departments create a limited number of training places for young doctors from developing countries, with the requirement that they return home at the end of their training. This would demonstrate commitment to an ethical approach to international recruitment. The Academy would also like to see exchanges of doctors at the higher end of their training, where doctors on the threshold of their specialist careers are enabled both to give and receive new experiences and skills that can benefit the service in their home countries. We also believe it is important to develop medical training initiatives that will encourage and allow overseas doctors to come over for periods of focused training of high quality, and to take these skills back to their home countries.

  7.  We recall that most international medical graduates come to the UK in search of specific training needs and yet spend time in junior training posts providing service without having their educational needs met. In the Academy's view the UK has a responsibility to continue to provide these doctors with training in specific specialised areas, enabling many to return home with improved clinical skills and the ability to improve health care in their own countries.

  8.  The Academy also feels that it is important that medical graduates from outside the European Economic Area should be able to come to the UK for defined periods of training, in College approved posts, perhaps in rotation with a UK trainee going abroad on a planned exchange scheme. This would have major benefits for both the doctors involved and the countries they serve.


  9.  It is also clear that the design and implementation of MMC have served to stifle career and service enhancing opportunities, both in the UK and abroad, and the Academy strongly supports the more flexible approach to specialist training and employment envisaged by the Tooke Inquiry. Overall the Academy believes there is a case for looking more widely, to providing new opportunities in specific training, individual career development and service needs in different countries.


  10.  The Academy has drawn attention to the problems of specialties that have depended on recruitment of trainees from other countries to fill vacancies. Although it is to be expected that with current pressures the requirement to recruit from international medical graduates will lessen with time, the Academy recognises the challenges that a number of specialties face.


  11.  There is a common view that guidance surrounding eligibility to work needs to be made substantially clearer. Several years ago the Colleges drew attention to the growing problems facing international medical graduates wishing to work in the UK. They were skilled practitioners, some with considerable experience from overseas, but they lacked full and current advice on the UK job market and therefore their decision to come to the UK was often uninformed. Even then the available number of UK junior posts (both training and non-training posts) was far below the number of international medical graduates applying for them, and consequently there was high unemployment.

  12.  Potential applicants for all posts need to be told of work permit restrictions at and prior to the point of application. It will require careful management of the expectations of international medical graduates, including those in the UK and in no post, or in a temporary post, and doctors outside the country. One problem with introduction of the previous policy was that doctors who had come in good faith to seek postgraduate medical training in the UK had no adequate forewarning. Recruitment drives overseas have also caused damage. The International Fellowship Programme, aimed at recruiting overseas qualified specialists into consultant posts in shortage specialties, led many medical graduates from outside the EEA to believe that there were widespread shortages in medicine in the UK, a mistaken belief that to some extent prevails.

  13.  The Highly Skilled Migrant Permit (HSMP) is a particular issue, providing a route for significant numbers from outside the EEA to compete for entry into postgraduate and specialty medical training programmes. Applicants for an HSMP need specific guidance about a wide range of matters including availability of training posts, professional registration and equivalence or not of qualifications. There are concerns, for instance, over doctors who have worked in service posts for two to three years to whom retrospective application of changed policy might be seen as unfair.

  14.  In view of the numbers, and the tensions referred to in points 2 and 3 above, it may be desirable to investigate tightening the criteria for award of an HSMP. This will require care and sensitivity, in view of the differences between specialties in the need for international medical graduates to provide service—an across-the-board redefinition of "highly skilled migrant" may be difficult to achieve.

  15.  A further point is that it might become necessary in future to make it clear at entry to UK medical school of non EEA people that there is no guaranteed specialist training.

January 2008

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