Student Visas - Home Affairs Committee Contents

Written evidence submitted by the British Medical Association (BMA) (SV53)


1.  The British Medical Association (BMA) is an independent trade union and voluntary professional association which represents doctors from all branches of medicine throughout the UK. It has a membership of over 141,000 doctors.

2.  This response sets out points that the BMA would like to bring to the attention of the Home Affairs Committee in relation to the inquiry into the impact of proposed restrictions on tier 4 migration:

  • The BMA is concerned that closure of the Tier 1 Post Study Work Route will result in the NHS losing out on the benefits from its significant financial investment in doctors' training and that NHS service delivery will be compromised due to a shortfall of specialty trainees.
  • Non-EEA students studying for medical degrees at UK universities have made a significant financial commitment with the reasonable expectation of embarking upon specialty training. It would be morally unjust to remove this option whilst they are partway through their training by closing the Tier 1 Post Study Work Route.
  • Removing the opportunity to progress to specialty training may well force prospective international students to undertake medical studies in countries other than the UK. The BMA is concerned that the reduction in the funding stream that international students provide to UK medical schools could be a serious to blow to the future provision of medical education.
  • Clinical placements are of vital importance in providing medical students with the skills to graduate and enter the Foundation Programme. The BMA has serious concerns about the government's proposals to change the ratio of study-work on courses including work placements from 50:50 to 66:33 and the potentially detrimental impact upon the quality of medical training in the UK.


3.  One factor which should be taken into account when considering whether to close the Tier 1 Post Study Work Route is the investment made in doctors who have studied in the UK as international students. It costs in the region of £250,000 to train a newly qualified doctor in the UK and in addition to this the NHS makes a significant investment in terms of the salary paid to those who undertake the Foundation Programme.[86]

4.  According to the Medical Schools Council there are 3,000 non-EEA students studying clinical medicine in the UK. Attrition rates for students graduating from UK medical schools are extremely low and the vast majority of UK medical graduates proceed onto the Foundation Programme. Following completion of the Foundation Programme, they have the opportunity to apply for specialty training, If they are successful in securing a specialty training post, they would then transfer to the Tier 1 Post Study Work Route in order to take up their duties.

5.  Given that the 3,000 non-EEA students referred to above have already been included in UK medical workforce planning, closure of the Post Study Work Route has the potential to undermine the provision of healthcare in the UK, even taking account of the scope for variation in medical workforce needs between devolved nations.

6.  There is a real risk that some of the most competent and talented UK-trained doctors applying for specialty training will be lost to the NHS. The NHS could potentially lose out on some of the benefit of the investment made annually in Foundation Programme salaries (£39 million[87] at present)

7.  Non-EEA students make up to 7.5% of those studying in programmes in clinical medicine at UK universities. Their tuition fees amount to more than £100 million annually. Such students make significant contributions to their local economies through living and accommodation expenses. It should also be recognised that these students have made these commitments with the wholly reasonable expectation of embarking upon specialty training. The BMA strongly feels that to remove this option whilst they are half-way through their training would be completely wrong and morally unjust.

8.  The Medical Schools Council, in previous submissions to the UKBA, has highlighted that Transparent Approach to Costing (TRAC) methodology demonstrates that overseas students are a very profitable aspect of business for higher education institutions and help support teaching and research in other parts of institutions. Despite the recent increase in university tuition fees for UK nationals, the BMA is concerned that any reduction in the funding stream that international students provide to UK medical schools could have serious knock-on effects to both the provision of undergraduate medical training and to higher educational institutions in general. Prospective international students may well select other destinations to undertake their medical studies due to the limited opportunities now afforded to them in the UK beyond the Foundation Programme. The resulting decline in international medical students in the UK would mean a sharply reduced income for individual medical schools through the loss of the significant fees paid by this group of students (between £25,000 and £35,000 per year depending on the medical school).


9.  Currently, medical degrees in the UK consist of an average of two years of pre-clinical training in an academic setting and three years of clinical training at a teaching hospital. There is considerable variation in the way in which medical schools integrate these two elements in their curricula. Courses also differ between schools, some emphasising problem-based learning, others favouring lecture-based teaching.

10.  Clinical placements are vital for providing medical students with the requisite skills to graduate and enter the Foundation Programme. It is through these placements that students have the opportunity to interact with patients from a range of social, cultural, and ethnic backgrounds and with a range of illnesses or conditions. They also provide experiential learning in specialties such as medicine, obstetrics and gynaecology, paediatrics, surgery, psychiatry and general practice. The placements are designed to reflect the changing patterns of healthcare and provide experience in a variety of environments including hospitals, general practices and community medical services.

11.  In the final year, the student must use practical and clinical skills, preparing for their eventual responsibilities as an F1 doctor. These include making recommendations for the prescription of drugs and managing acutely ill patients under the supervision of a qualified doctor. A student will assist a junior doctor and, under supervision, undertake most of the duties of an F1 doctor. There is also a "shadowing" period, allowing them to become familiar with the facilities available, the working environment, the working patterns expected of them, and to get to know their colleagues.

12.  The BMA is therefore extremely concerned about the proposal to raise the minimum ratio of study to work from 50:50 to 66:33 and the potentially detrimental impact upon the quality of medical training in the UK. Whilst we recognise that the thinking behind it is to deter migrants seeking an easy route into employment, we would also point out that clinical  placements are unpaid and are an educational component of the medical degree.

13.  The BMA also notes that the consultation does not clarify if the study-work ratio would be applied to the whole course or individual years. This has major significance for medical training; the clinical experience described above takes place in years four and five.

14.  Paragraph 7.4 of the UK Border Agency consultation document, The Student Immigration System, provides for an exemption from the 66:33 ratio, where there is a statutory requirement that the placement should not exceed one-third of the total length of the course. Whilst clinical training in the UK is not covered by such a requirement, it is governed by European law. European Directive 2005/36/EC allows European Union (EU) nationals who hold an EU PMQ or specialist qualification to practise as doctors anywhere in the EU. Article 24 of the Directive states that the period of basic medical training must be at least six years of study or 5,500 hours of theoretical and practical training provided by, or under the supervision of, a university. From the introduction of the licence to practise, "basic medical training" is the period leading up to full registration with a licence to practise.

15.  The EU Directive 2005/36/EC also states that basic medical training must provide assurance that individuals acquire the following knowledge and skills:

  • "Adequate knowledge of the sciences on which medicine is based and a good understanding of the scientific methods including the principles of measuring biological functions, the evaluation of scientifically established facts and the analysis of data."
  • "Sufficient understanding of the structure, functions and behaviour of healthy and sick persons, as well as relations between the state of health and physical and social surroundings of the human being."
  • "Adequate knowledge of clinical disciplines and practices, providing him with a coherent picture of mental and physical diseases, of medicine from the points of view of prophylaxis, diagnosis and therapy and of human reproduction."
  • "Suitable clinical experience in hospitals under appropriate supervision."


16.  The BMA is concerned that the proposed changes to tier 4, in conjunction with the changes to tier 1, will have an adverse impact on non-EEA students studying for a medical degree in the UK as well as workforce planning provision and NHS service delivery.

January 2011

86   The Foundation Programme is a two-year postgraduate training programme, the first year of which is compulsory in order to gain full registration with the General Medical Council. Back

87   Figure based on the 2009 calculation that trainees are paid an average of £74,200 over the two-year Foundation Programme multiplied by 525, the number of non-EEA doctors entering the Foundation Programme each year. Back

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Prepared 25 March 2011