Memorandum by the British Medical Association
The British Medical Association is an independent
trade union and voluntary professional association which represents
doctors from all branches of medicine throughout the UK. It has
a total membership of over 139,000.
Which occupations in your sector has the
highest shares of migrants and why? To what extent do you think
the employment of migrants is a reflection of pressures to minimise
labour costs? Is there a difference in this context between privately
and publicly funded health care jobs?
1. In relation to the medical profession, it
has long been considered that a disproportionate number of Staff
and Associate Specialist (SAS) posts, that do not contain postgraduate
training, are filled by migrant doctors (see Appendix 1 for further
information on SAS doctors). This is often because UK doctors
do not wish to join these grades as they believe they have been
given a commitment to be trained to consultant level. Trusts have
created Trust Grade posts, to fill service gaps, which have non-standard
terms and conditions of service. Doctors employed in these posts
are not protected by national terms and conditions of service
and may be employed on poorer terms. Such posts are often filled
by migrant workers.
2. Given the existence of national terms
and conditions for the majority of medical posts in the NHS there
is little correlation between recruiting migrant workers and the
reduction in associated labour costs. By virtue of being international
medical graduates, the UK will not have paid for their undergraduate
medical education, a saving of £250,000 per doctor.
3. There has been a lag period for the involvement
of migrant doctors at senior levels in the private medical sector;
this has been due to a relative delay in achieving consultant
status. Migrant doctors who have not yet specialised have been
recruited by the private sector to work in non-training service
posts. The BMA is also concerned that private sector providers
might choose to employ GPs from abroad in order to minimise their
costs and perhaps achieve a competitive advantage when pricing
their services. The BMA would be concerned if these doctors were
exploited for this purpose or employed on inferior terms and conditions.
Can immigration only be a short-term solution
to domestic shortages? What is the long-term solution and how
can it be achieved, and when? How does the British Medical Association
view the role of migrant workers in meeting labour demand in the
long-term?
4. Immigration is not only a short-term
solution to domestic shortages. The history of the NHS proves
the efficacy of migration as a long-term solution for a country
that has an implicit policy not to graduate sufficient doctors
to meet its healthcare needs.
5. In the past UK medical schools have not
produced enough graduates to fill all medical staffing vacancies
in the NHS, including training posts, hence the need to recruit
migrant doctors. The government's recently stated aim is for the
NHS to become more self-sufficient. As a means of achieving this,
medical school places have expanded and a number of new medical
schools have been created meaning that reliance on migrant doctors
will decrease.
6. As a result of the increase in UK medical
graduates, there is now an oversupply of doctors seeking postgraduate
training posts in the UK. There are still shortages in service
grade and consultant posts. The Work Permits (UK) shortage occupations
list[1],
issued on 23 July 2007, included salaried GPs and nearly 50 specialties
at consultant level, including anaesthetics, dermatology, neurology,
paediatrics, and trauma and orthopaedic surgery. The relevance
of the shortage occupation list is that when employers apply for
a work permit for a potential employee they do not need to satisfy
the resident labour market test showing that there was no suitable
resident worker before being granted a work permit.
7. The BMA believes that migrant workers
will be required for some decades to come. The BMA's workforce
modelling suggests that over the period to 2030, the demand for
doctors will be met with current planned medical school intake
and levels of overall immigration into the training grades. This
is dependant on the assumption that doctors in the training grades
progress to consultant levels and GP posts, and have the flexibility
to move between training and non-training SAS grade posts as required
to stabilise demand and supply.
It has been reported that some British medical
graduates have difficulties getting further training posts in
the UK. How do you think this relates to immigration and the employment
of migrant doctors in the UK?
8. The UK has a long history of using migrant
staff, and particularly so in the medical workforce. It is estimated
that a third of the NHS medical workforce are international medical
graduates, ie they qualified outside the European Economic Area
(EEA). Historically, this group of migrants has been welcomed
to the UK and their valuable contributions have been recognised.
Following the recent restructuring of medical training in the
UK, it has become apparent that there are far more doctors (UK,
EEA and migrant) wishing to undertake postgraduate training posts
in the UK than there are posts available. Given the policy of
open competition for medical training posts—a position that
the BMA supports—this has resulted in some UK medical graduates
being unable to secure run-through postgraduate training posts.
9. The BMA maintains that doctors subject
to the immigration rules, who are currently in the UK, have a
valid expectation to train or work in the NHS and should be treated
equally with UK and EEA nationals and other resident workers.
The BMA has repeatedly drawn attention to the government's responsibility
to highlight the decreasing opportunities available to international
doctors prior to them coming to the UK. The recent change in
immigration law[2]
has affected many doctors; it was appalling that the government
"offered no opportunity for organisations representing affected
doctors to communicate their views about the changes, and failed
to comply with its duty to examine the race relations issues involved",
as stated in the High Court ruling on 9 February 2007.
10. The change in this law caused extensive
confusion for doctors subject to the immigration rules applying
through the Medical Training Application Service (MTAS) and, despite
requests from the BMA, clear guidance for this group of applicants
was not forthcoming until very late in the day. The guidance was
open to interpretation by individual Postgraduate Deaneries. The
current proposals to clarify Department of Health guidance, published
on 8 October 2007, Modernising Medical Careers (MMC) England
Recruitment to foundation and specialty training—Proposals
for managing applications from medical graduates from outside
the European Economic Area was given a 10 working day response
time in consultation. This was unacceptably short; such compressed
deadlines suggest that the Department of Health has not learnt
from the experiences of the last two years.
11. Migration of doctors from the EEA has
also contributed to the over-supply of medical professionals into
postgraduate training posts, something which has not been accounted
for or assessed in workforce planning. Migrant staff competing
for training posts may have had more experience than UK trained
junior doctors having worked in their country of origin before
coming to the UK, and may therefore be recruited above UK medical
graduates/trained doctors. Some international doctors target posts
that are least attractive to UK doctors believing that this will
increase their chances of successfully securing employment. Morale
among doctors in training is also low following the failure of
the application system in 2007 and the introduction of the new
Modernising Medical Careers training system. This group believe
that they have been given a commitment to be trained to consultant
level and achieve their Certificate of Completion of Training
(CCT).
12. BMA policy and a survey of its members
supports the organisation's position of a fair deal for international
doctors and international medical students who qualify in the
UK. 54.4% of respondents stated that international medical graduates
should not be prevented from competing for training posts. This
should be applicable only to those already working within the
NHS. This position was also stated by the BMA in its response
to the recent DH in discussion paper Modernising Medical Careers
(MMC) England Recruitment to foundation and specialty training—Proposals
for managing applications from medical graduates from outside
the European Economic Area.
13. The BMA does not believe that the immigration
of qualified doctors should be stemmed. For doctors considering
future migration to the UK, the government must ensure that information
about the true situation of medical employment in the UK must
be disseminated as widely as possible. The government must additionally
be mindful of the potential consequences should the UK once again
require the services of overseas doctors to staff the NHS in the
future. Alienating this group will not encourage them to migrate
here in the future, which the BMA anticipates will be necessary.
Reform of the UK immigration system is making
it more difficult for employers in the health and care sectors
to recruit workers from outside the EU. How far do you think it
will be possible to meet demand for migrant labour in your respective
sectors with workers from within the enlarged EU?
14. In addition to benefiting from free
movement between member states in relation to taking up employment,
EEA qualified doctors have a more straightforward route to registration
than doctors who have graduated outside the EEA. Under Directive
2005/36/EC on the Recognition of Professional Qualifications doctors
are entitled to full registration in any EEA member state if they
fulfill both of the following criteria:
— they are citizens of an EEA member
state; and
— they have completed primary medical
training in an EEA member state and hold a recognised qualification.
15. There are restrictions in place on Bulgarian
and Romanian nationals which can restrict their right to take
up employment. The General Medical Council (GMC), which registers
doctors, is treating doctors who have graduated from medical school
in Bulgaria or Romania, differently by not granting them automatic
recognition whilst the GMC awaits further detailed information
from the appropriate authorities in these countries.
16. It is difficult to anticipate the future
demand for doctors; this is acknowledged in the Department of
Health's admission that workforce planning has been poor to date
and exact training numbers are not known. As of 2005, the number
of specialist registrars (those nearing the end of training) was
18,000, with an additional 26,000 in lower training grades. These
numbers include over 18,000 doctors who gained their qualification
outside of the EEA. As previously stated, the BMA's workforce
modelling suggests that over the period to 2030, the demand for
doctors into training posts will be met by a combination of the
current planned medical intake and levels of overall immigration.
17. Some doctors undertake postgraduate
medical training outside the formal training grades in the UK
and return to their country of origin. If this practice continues
it would mean that the NHS would still be reliant on medical staff
from outside the EEA at more senior levels.
18. It is important to consider the position
of refugee doctors in relation to meeting workforce needs. This
group of ready trained professionals are already in the UK and
should be given every opportunity to practise their profession
in the country that has granted them asylum. Not doing so would
result in them being left to deskill. Many refugee doctors have
successfully secured employment in the NHS. Supporting this group
to resume their careers in the UK would reduce, but not eliminate,
the NHS' reliance on migrant workers.
What, if any, changes to UK immigration policy
would you like to see?
19. The BMA recommends the following policy
changes:
— The BMA supports a policy of self-sufficiency
and is encouraged that the Department of Health's aim is for the
NHS to become more self-sufficient and less dependant on the migration
of healthcare professionals from outside the EEA. It is now moving
in this direction for medical personnel.
— Effective workforce planning is needed,
where workforce patterns are based on need and not artificially
restricted on the grounds of affordability. It is also essential
to take into account current and planned medical school intake,
coupled with future migration and immigration.
— The BMA recognises the extremely
valuable contribution that migrant workers make to the NHS medical
workforce and would welcome government policy acknowledging the
same.
— The BMA calls for the government
to clarify its immigration policy. The immigration rules for postgraduate
doctors in training were amended in April 2006 with serious consequences
for many migrant doctors. Since this time there has been a lack
of clarity about how doctors in certain immigration categories,
including the Highly Skilled Migrant Programme, should be considered
during recruitment processes. It is vital that absolute clarity
of the employment and immigration rules and how they affect migrant
doctors is provided as soon as possible and is disseminated widely.
— According to an estimate by the World
Health Organisation there is currently a global shortage of approximately
4.3 million health workers. Developing countries are among the
most affected. In 2005, the BMA called for collaboration between
developed and developing nations to address this crisis. In 2005
the BMA organised an international conference on the global health
workforce. This resulted in a call to action on the healthcare
skills drain which is included in Appendix 2. The government,
in recognising that individuals have the right to migrate, must
balance this right with the rights of home country populations
to have access to healthcare professionals. We therefore welcome
recommendations 11, 12 and 13 made by Lord Crisp in his report,
"Global Health Partnerships: the UK contribution to health
in developing countries"[3]
and we urge the Government to implement them. The recommendations
are included in Appendix 3.
— It is essential that for any future
changes of government policy which will affect migrant doctors
there is adequate time for consultation of all appropriate parties.
What are your views on the new points-based system
for managing migration to the UK?
20. The National Health Service (NHS) has
a multi-national workforce and there are many doctors working
in the UK who are subject to the immigration rules. In July 2005
the Home Office issued a consultation Selective Admission:
Making migration work for Britain which introduced the concept
of a points-based immigration system for the first time. The BMA
submitted a detailed response (see Appendix 4).
21. Responses to this consultation formed
the detailed command paper for a points-based system which was
published in March 2006 as A points-based system: Making migration
work for Britain. This document sought to simplify the existing
system of over 80 routes of entry into the UK by proposing a new
five-tier system of immigration.
22. The BMA, in its response to the 2005
consultation document, did not support a managed migration system
which focused primarily on economic benefits to the UK. Rather
it recognised the multi-national workforce from which the NHS
benefits, including the teaching and training delivered by international
doctors. It stated that whilst the government must ensure that
it complies with ethical recruitment policies, it must also recognise
that some doctors from developing countries wish to come to the
UK for specific training and then return to their home country
to put these skills into practice. The BMA recognises the importance
of this, and in particular, of doctors receiving training in specialties/procedures
that are not available in their home countries. We recognise that
a balance is needed between the excellent service migrant doctors
provide to the NHS, ensuring fair and equal opportunities in the
NHS and the long-term effects on damage to healthcare services
in the developing world.
23. As regards the points-based system,
on the whole the BMA welcomed the simplification of the immigration
system, but urged the need for joined-up government thinking when
implementing any new system, in order to ensure that the unique
nature of the postgraduate medical training system is fully considered
when introducing any new immigration categories that will affect
the medical workforce.
24. Doctors will fall primarily within Tiers
1 and 2 of the new points-based system. Tier 1 is set to be introduced
in the first quarter of 2008. We urge the Home Office to take
into account the need for a period of transition, with a specific
date from which only the new system would be in operation, and
widespread advance publicity about the changing system to ensure
individuals are adequately informed. This is even more important
given the past 18 months and the changes that have been made to
the immigration rules, which have had serious consequences for
doctors in training in the UK, and led to extreme confusion and
discontent.
25. The BMA calls for doctors already in
the UK with a valid expectation to train or work in the NHS to
be treated on an equal footing with UK and EEA nationals.
November 2007
1 www.bia.homeoffice.gov.uk/6353/11406/49552/Shortage_List_23_July_20071.pdf Back
2
Since 3 April 2006, non-EEA or non-resident doctors are no longer
eligible for the postgraduate doctor and dentist and trusts will
need to apply for a work permit before employing such a candidate
and demonstrate that there are no suitable resident workers to
take up the post in their stead. Back
3
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_065374 Back
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