We are grateful to the Committee for giving us an opportunity to offer evidence to the Enquiry—Workforce needs and planning for the health service.

  Since the announcement of New Work Permit Regulations by the Department of Health on 7 March 2006, we have been inundated with messages from International Medical Graduates whose careers have suddenly become uncertain. We therefore have focused our evidence within that specific parameter with some key recommendations.

  Our initial feedback suggests that there is an over whelming support for the principals of the new point system for controlling worker migration proposed by the Home Office as a means of meeting the needs of the UK's job market in general.

  Please let me assure your members that it has been always our intention to co-operate with Government Departments and other professional bodies to find practical resolution to difficulties through consultations and negotiations.

  On behalf of BAPIO I am submitting our evidence in the attached document for the Health Select Committee.

1.  BACKGROUND

  The British Association of Physicians of Indian Origin [BAPIO] is a voluntary organisation established in 1998 and launched by a Minister of State for Health. It aims are: to realise the potential of its members in achieving clinical excellence, assist members in improving their career prospects, to monitor and highlight the difficulties faced by doctors coming from the Indian sub-continent and to support them and to promote professional links with the Indian subcontinent.

(a)  With seven regional divisions BAPIO provides a regional perspective on national issues affecting over 25,000 doctors from the Indian subcontinent who work in the United Kingdom. Its members include doctors trained overseas and in the UK. It has established close working relationships with institutions such as the Royal Colleges, the General Medical Council and British Medical Association, including the Department of Health to highlight issues affecting doctors from the Indian subcontinent.

(b)  BAPIO organises conferences, seminars and training events to improve clinical skills and understanding of the NHS and life in the United Kingdom for migrant doctors. It is also involved in the consultation processes more generally related to the health sector.

2.  AIMS OF THIS SUBMISSION

(a)  To inform on the input of international medical graduates (IMGs) into the service needs of the NHS.

(b)  To inform on the contribution of the NHS to the training of IMGs and their subsequent.

(c)  Contribution to the health services of their home countries.

(d)  To inform on the advantages of employing IMGs in the health sector.

(e)  To inform on the implications of Modernising Medical Careers (MMC) to IMGs.

(f)  To inform on implications of European Work Time Directive (EWTD) on IMGs.

(g)  To inform on implications of new immigration ruling (effective 3 April 2006) on IMGs.

3.  INTERNATIONAL MEDICAL GRADUATES AND THE HEALTH SECTOR

(a)  There is a long history over many decades of doctors completing their primary training in the Indian subcontinent and then coming to the UK for higher specialist training. These doctors have filled a lacuna in the service needs of the health care sector for a long period of time when the UK was simply not training enough doctors to meet the service needs in the primary care sector and in hospitals.

(b)  It is estimated that there are about 81,000 doctors currently working in the hospital sector in the UK. Of these around 50,000 are UK trained and 31,000 have obtained their primary training overseas, mostly from the Indian Subcontinent. Around half of these international doctors are working as junior doctors. There may be an additional 5,000 doctors who have passed the PLAB entrance examination and are currently unemployed. (ref DH )

(c)  Workforce needs assessment has been lacking in the health sector; however the ready availability of IMGs has reduced the impact of poor workforce planning. This has been especially important as there is the expected pyramid in the system with not all junior trainees assured of consultant positions at the end of their training. However this has not caused significant difficulties as many IMG doctors have been happy to move back to their home countries on completion of training and others have accepted non-consultant career grade positions in the UK.

(d)  All this is set to change because of three separate issues:

1.  The introduction of the Modernising Medical Careers programme.

2.  The implementation of EWTD especially from 2009 when junior doctors will be allowed to work only 48 hours per week.

3.  A new immigration ruling, which was introduced in April 2006 with no prior consultation with any of the stakeholders.

4.  MMC AND THE IMGS

(a)  The Modernising Medical Careers programme went live from August 2005. The first stage of this programme was the introduction of a Foundation programme after completion of medical school.

(b)  F1 is open only to UK graduates and titrated to the output of medical schools in the UK. It is expected that the number of F2 posts would be about 15% greater than the F1 posts and these would then be available for European graduates and IMG doctors. At the end of the F2 year these doctors can apply for a seamless five year programme leading to certification of specialist training. (Ref: http://www.mmc.nhs.uk/pages/home)

(c)  The IMGs will be at a disadvantage for application for these posts as foundation year competencies will be expected for selection. The intake of the medical schools is expected to rise to up to 8,000 per year over the next two years. This will mean there would be 8,000 new doctors coming out of medical schools every year from 2012 or so;—this figure currently stands at over 6,000. (Ref DH)

(d)  The MMC will put the IMGs at a competitive disadvantage and it is likely that fewer IMGs are likely to obtain and complete training and this is therefore likely to discourage influx of IMGs into the UK.

(e)  The large number of UK graduates will expect to be accommodated in consultant or GP positions at the end of the training and it is concerning that a recent report raised worries that there will be inadequate positions for all these UK graduates (Ref: Prof Nick Bosanquet's report on Reforms).

5.  EWTD 2009 AND IMGS

(a)  The EWTD in 2009 will mean that there will be a need for a larger number of junior doctors to run a compliant rota. Figures have varied from eight to 11 doctors on each tier. It is unlikely that the increased medical output from UK medical schools would be adequate by 2009 to meet up to this need and therefore there is likely to be dependence on European graduates or IMGs to fill the service needs in the NHS. However the impact of the MMC and the new immigration ruling (see below) may be that there is less interest amongst IMGs to come to the UK as there is a high risk that the training they obtain will be patchy in the climate of discriminatory short listing for jobs.

6.  NEW IMMIGRATION RULING—APRIL 2006

(a)   Background

  1.  Permit free training was the mechanism that over the last three decades allowed doctors from outside the United Kingdom to work and train in the UK. This ensured there was equal opportunity for doctors who were not UK citizens to obtain appointments based on merit. Thousands of international medical graduates have come to the UK and have served the NHS well and also obtained excellent quality training which many have taken back to their home countries. Others have completed their training and chosen to continue in career grade appointments here and have given their skills and expertise to the British health service.

(b)   The New ruling

  1.  The Department of Health declared on 7 March 2006 that a decision has been made to end permit free training. This effectively ended equal opportunity for international medical graduates as they would only be able to obtain an appointment if the NHS Hospital Trust could prove that they could not fill the post by a suitable candidate who was a UK or EU citizen.

  2.  The New Rules have been announced without appropriate consultations with the organisations such as BAPIO as well as BMA and the Royal Colleges.

  3.  There is no evidence available in pubic that the Department of Health had undertaken comprehensive Race Equality Impact Assessments in line with the requirements of the Race Equality Scheme.

(c)   Effects of the new ruling

  1.  The new ruling would have devastating consequences for IMGs already in the UK. To worsen matters, the ruling has been interpreted in a variety of ways by various medical personnel departments.

  2.  Many IMGs who had been short listed and called for an interview suddenly received a phone call informing them that they had been removed from the shortlist. Some IMGs who had arrived at the examination hall for the GPVTS test were offered an opportunity to not sit the exam but simply leave as they were told that they would no longer be considered for the posts.

  3.  Advertisements for jobs often carry a warning that those who are no UK or EU citizens will not be considered and therefore need not apply. Those IMGs who do not obtain a job at a particular point in time would have to leave the UK immediately and have to apply for jobs from their home countries.

  4.  The rules also appear to suggest that IMGs can no longer move from a visitor's visa to a work permit visa or vice versa without returning to their home countries.

  5.  MGs who have already been in the UK for many years and in training will not be treated differently from those who are not yet in the UK. Some of these very experienced doctors may have to leave the UK because they have not been able to obtain a job because of this ruling. This will lead to abrupt end to their training and also a serious loss to the NHS health care system. Additionally trainees from countries like Sri Lanka and Pakistan often have to complete some period of training outside their home countries before they can take up consultant position in their own country.

  6.  Under the new regulations the NHS Trusts as employers will have to support a new culture of recruitment practices based on "nationality" rather than "merit".

  7.  This ruling will prevent this and damage the close relationships that exist between UK and the Commonwealth doctor communities.

7.  BAPIO POSITION

(a)  BAPIO unequivocally believes the retrospective application of this ruling is wrong. It also believes that this ruling was brought about without any consultation and in an abrupt fashion with no concern for the welfare of the IMG community who for many decades have been the backbone of the NHS.

(b)  BAPIO believes that there is a need to manage workforce requirements better and to protect the interests of the UK trained graduates. However this must not happen with complete disregard to the effect on IMGs. IMGs already in the UK have committed huge amounts of time, money and effort to come to UK, sit necessary exams and apply for jobs, work hard and make career progress. They did this on the premise of equal opportunity and it is wrong to change the rules of the game midway.

(c)  BAPIO believes that this ruling will have significant detrimental effect on the morale of the IMGs working in the UK and this may affect the health care they deliver. It may also lead to loss of trust with many IMGs leaving the UK at a time when home grown graduate numbers are still not adequate to meet all service needs.

(d)  BAPIO believes the way forward is by having clearly declared annual quotas for IMGs which are applied in a prospective manner. This will discourage excess influx of IMGs and prevent recurrence of the current problem of estimated 5,000 unemployed IMGs in the United Kingdom. Those IMGs who have entered the UK must be treated equally to UK and EU citizens and merit must continue to be the sole criteria for career progress.

(e)  This is in the best interests of the IMGs, the NHS and the British people.

8.  BAPIO ISSUED FOLLOWING JOINT STATEMENT ALONG WITH THE JUNIOR DOCTORS COMMITTEE OF THE BMA

(a)  BAPIO and JDC call for the following transitional arrangements to be made for non-EEA residents already in the UK training or seeking training posts.

(b)  Those who have not completed the PLAB II examination should be given up to 18 months in which to do so and in which to seek employment in a training post which will then be subject to permit-free status for its duration.

(c)  Those who have passed PLAB II but are as yet unemployed should be granted up to two years from the date they passed the exam to find a training post that will attract permit-free status for its duration.

(d)  Those doctors currently on SHO training programmes should be given leave to enable them to compete equally alongside EEA-residents for new MMC specialist training programmes in August 2007.

(e)  Those doctors currently on SpR training programmes should be allowed to complete their postgraduate training to CCT with permit-free status.

(f)  Clarification of how the changes will affect those currently undertaking research in the UK.

(g)  Those doctors who are currently in non-training posts as a transient measure whilst waiting for training posts, should be allowed leave to enable them to apply for training posts.

(h)  The status of HSMP visa holders is unclear especially from the Deaneries' point of view. These doctors should be treated on par with UK/EEA doctors when they apply for training posts irrespective of the duration of the HSMP (Home Office has stated that this should be so)

(i)  Overseas doctors graduating from UK medical schools.

  1.  We call for overseas doctors graduating from UK medical schools to be allowed to complete their postgraduate training in the UK under permit-free status. In most cases, doctors having to return to their home countries after completing the foundation programme will not be in a good position to continue their training or careers and will have to start at the beginning of their home systems. This does not create any advantage or incentive for overseas students to study at UK universities, who would have taken this very expensive option with the hope of completing their post graduate training in the UK

  2.  Overseas students currently studying in or about to graduate from UK universities will also have an expectation of completing their training in the UK as these regulations were not inplace when they commenced their medical education in the UK. The new ruling comes too late for them to do anything about it.

9.  GENERAL

  Finally, BAPIO regrets that despite having excellent working relationship with the Department of Health, letters on this issue were not replied to so far. Since the announcement of the new regulations BAPIO was inundated with inquiries from aoctors who were anxious about their career and uncertainty about their future. Over 600 doctors a petition signed by over 6,500 doctors expressing their concerns was presented at the reception Department of Health on 21 April 2006.

Dr Ramesh Mehta

President, BAPIO

May 2006