(You can find my most recent commentaries on the Junior Doctors’ crisis as it unfolds in 2008 by following this link).
The situation of doctors who trained overseas but who are practising here is even grimmer than the situation facing the home-grown variety. If you are new to this debate, you should know that the British Government has decided that we now have more specialist trainees with ambitions to become consultants than there will be consultancy posts in a decade or so’s time, and that the way to tackle this is to cut the number of specialist doctors right now.
We arrived in this position because the European Working Time Directive outlawed the 100+ hour weeks that junior doctors worked at the time. Suddenly there weren’t enough junior doctors, so med-school numbers were ramped up, and the government invited doctors in from overseas on a Highly Skilled Migrants Programme. Now that we have “too many” doctors the government has just pulled the work-permit rug out from underneath their feet. Now, if the government had been honest and said that this position could be changed without consultation and with virtually no notice, then it wouldn’t be so bad. But they weren’t honest about it, as shown by the recent successful Judicial Review and Injunction achieved by the British Association of Physicians of Indian Origin. It seems that they still are not honest: they are still advertising for overseas doctors, and still offering language tests even though they know that they will not be offering visas.
Apart from the legal dubiousness and the total lack of natural justice in this situation, sending our over-seas trained doctors packing is bad for the NHS.
You see, we don’t just need overseas doctors to make up the numbers, we actually need them to improve and strengthen the quality of care provided by the NHS.
In our larger cities, with substantial immigrant populations, there are medical and ethical problems around interpretation. Now overseas doctors are not the answer to this problem, but they do help ameliorate it. The NHS relies on the following kinds of interpretation:
- Official Interpreters – these are invaluable, over-worked and frequently unavailable
- Family members – this is fraught with difficulty, sometimes their grasp of English is poor, sometimes they have their own agenda and don’t translate honestly, sometimes patient confidentiality gets blown out of the water
- Multi-lingual NHS staff – in an area where there is a community from a particular ethnic or linguistic group, it is quite likely that there will be nursing, secretarial, admin or medical staff from the same group
As I said, overseas trained doctors are not the answer to this problem, and it is racist and foolish to assume that a Tamil speaker can help with a Punjabi patient, but a multi-ethnic medical profession is the only appropriate way to provide a care a multi-ethnic patient community.
Developing-world trained doctors reinforce medical techniques and provide reality checks. The more diagnostic technology you have been trained with, the blunter your diagnostic skills become. I heard a tale from the ward-round of a US-trained physician who wanted to order a CT scan of a rather portly gentleman who had been stabbed with a rather short knife. Simply common-sense and basic anatomy told his UK-trained colleagues that, no, there was no chance a vital organ had been nicked. Ha ha. Cute anti-American story there. But a similar under-development of diagnostic skills has happened in the UK.
We sure as hell need the technology, but doctors who trained in harsher economies, who can use the technology but don’t always need it to do their thinking for them, provide our home-grown techno-medics with good solid reality checks. The people who have the greatest skills with – for example – forceps deliveries are doctors who have worked in developing countries.
As a rule of thumb the skills you need in the UK are the skills that UK-trained doctors are given. However, if I was part way through a dangerous labour I would rather have an obstetrician who could choose sensibly between a foreceps delivery and a ceasar and who could identify foetal distress if I’d removed the electronic equipment in a fit of hormonal and pain-racked stroppiness, in preference to one who couldn’t work out what was happening and who would be unsafe with forceps. (Yes, I’d prefer scented candles and a midwife, but sometimes one doesn’t have that option).
If you come to a country knowing that you will have to leave it in three or five or eight years’ time, you will make different life-decisions than if you come to that country believing you can make your life there.
Recently I met a young Indian couple. She was pregnant and, because of the timing of her baby, she cannot apply for the first year of the training posts. She plans to have her baby, locum for a bit, and if her husband gets a job this time around she will step back into the maelstrom this time next year. She wants to be a GP and if she is given the chance she would be the perfect example of how we can provide good medical care in areas with ethnic-minority communities. Her husband wants to stay in hospital medicine. It’s clear that if he does not get a job offer within the next few weeks that he and his wife will have to up-sticks in the summer with a baby just a few weeks old and go on to Australia or back to India.
Now, if they had been warned that they might face this situation do you honestly think they’d have had a baby? They are doctors. They know how contraception works. They had understandably assumed that their skills – needed in July – would still be needed in August.
There was of course the question of whether it was acceptable to siphon doctors out of the developing world. This is yet another place where the dishonest short-termism of the government bites. If the deal was, “come here as ward-fodder for five or so years – you and your family won’t be able to stay, but you will be able to move on or go home with a first-world training in your speciality and five years’ of first-world savings” then fair enough. Everyone knows where they stand, and it is a Win-Win situation or – if you are feeling cynical – at least everyone understands how they are being exploited and by whom. In fact, that is very nearly an ethically responsible way for the government to behave. No surprise that they haven’t done this then.
Instead, from having a reasonably secure future within the NHS, the overseas doctors have gone more or less overnight to being lined up on the metaphorical dockside waiting for the boat home. The government has taken every chance it could to exclude oversees trained doctors from MMC and the MTAS recruitment rounds. According to the various judicial reviews and injections, it has been failing to follow its own procedures by excluding people with inadequate warning. The legal fight put up by the British Association of Physicians of Indian Origin has managed one step forward followed by half a step back every time. As it stands at the moment, those with visas valid until the 1st of August are being included in the MTAS selection process, which must be a bitter comfort given how flawed that process actually is.
What sticks in my throat, as an outsider to the whole debacle, is that the government is getting away with a divide and conquer approach. Young British medics are understandably fearful for their own jobs, and they are torn between personal anguish as their friends colleagues are stitched up beside them and a more personal and increasingly immediate fear for their own future. Pastor Neimueller, anyone? “They came for the overseas trained doctors, and I did not protest because I did not train overseas…” etc.
Not only is the government treating overseas doctors like inconvenient items past their sell-by date, they are destroying the quantity of medical care available to all of us in this country by vastly reducing its quality, in part by reducing the ethnic and national mix of those providing it.
Update: Dr Crippen has blogged twice on the subject: Looking after Johnny Foreigner and The Royal College of Obstetricians and Gynecologists welcomes Johnny Foreigner. I’ve added emphasis to the email Dr Crippen quotes from the President of the Royal College of Obstetricians and Gynecologists which says: “The completed forms have been particularly difficult to assess and score and seem incapable of allowing the identification of the more able doctors. Also they fail to identify UK graduates, which we all thought was the major purpose of MMC.” Quite.
While I am adding links to this post, read some of the responses to article in BMJ Careers about International Medical Graduates career prospects in the UK. And here is a commentary from the excellent Frontpoint Systems on the subject of institionalised prejudice (homophobia as well as sexism and racism) within the NHS. And another comment from Dr Crippen on how overseas trained doctors do the work of consultants but are sidelined into staff grade posts.
Please – I am very aware that my understanding of the plight of overseas-trained doctors here is lacking and that this has more opinion and less fact than my previous commentaries. If you have anecdotes, comments or stories which you wish to add to this debate, do feel free to use the comments thread here.