The shock announcement that international medical graduates (IMGs) now need a work permit to train or work in the NHS came in March.Years of encouraging doctors to come to the UK were suddenly ended by a statement from Health Minister Lord Warner: doctors will only be recruited to the UK where there is a genuine skills shortage. NHS Trusts will be required to get a work permit for every doctor they wish to employ from outside the European Economic Area (EEA) and will also have to demonstrate that a resident worker could not fill the vacancy.[1] This decision affects not only those who wish to come here to work, but also those who are in the UK now. Despairing doctors who have invested much time, effort and money to further their medical careers in Britain feel badly let down. Many will have to return home at short notice. This sudden change has caused confusion among employers and employees alike.

Background

The NHS has relied on international recruits to maintain adequate staffing levels. As some overseas doctors return to their own countries after training, they have helped fill junior posts without generating too many applicants for consultant posts. Now the system has broken down. SHO posts in Accident and Emergency, for example, have attracted on average 537 applicants over the past 18 months.[2] Some advertisements have resulted in more than 1,000 applications. With next year's medical graduates increasing by 20 percent, high numbers of IMGs passing PLAB (Professional Linguistic Assessment Board) tests, and European Union doctors also seeking work in the UK, action had to be taken.

Previously, overseas doctors and dentists could train in foundation programmes as senior house officers and in specialist registrar grades or their equivalent. For immigration purposes they were considered as being in training, not employment. Now the posts are being regarded as employed positions requiring work permits. The old category of 'postgraduate doctors and dentists'continues but only applies to non-EU nationals who have completed their medical or dental studies in the UK and are allowed two years permitfree training in the foundation programme.

Permission to work

To obtain a work permit an employer must show that a vacancy exists which cannot be filled by a resident worker from the UK or EEA, nor by a UK doctor who is either a refugee or on the Highly Skilled Migrant Programme (HSMP). Doctors with existing leave to remain can stay until that leave expires. Should they be in a post when the leave expires, they will have to apply for a different category of leave to complete the post, probably the work permit category. IMGs in some immigration categories (eg. a dependent of another migrant) may not be able to apply for such a work permit and would have to leave the UK and then make the appropriate application for entry clearance from abroad.

Refugee doctors, along with UK and EEA graduates, will now have less competition when applying for jobs. However, there are concerns that some medical staffing departments think they are only to consider the European applicants, regardless of others'immigration status.We are now left with a situation where a graduate from a substandard Eastern European medical school (who, for political reasons is exempted PLAB and speaks English only as a third language) is to be preferred over a doctor, fluent in English, who trained in a top Indian medical school (based on the British system) and has passed PLAB. It is not surprising that BAPIO (British Association of Physicians of Indian Origin) has initiated legal action against the Department of Health (DoH).[3]

Getting a work permit

To obtain a permit, the employer must pay a £153 fee and submit application form WP1, the candidate's GMC certificate and references, and evidence that the post could not be filled by a resident worker: a copy of the advert; confirmation of where and when it was advertised; details of how many applied and how many were short listed; and an explanation as to why each resident applicant was not appointed. On top of all this, the doctor also needs to be granted leave to remain in the UK.

Betrayal

There is near universal acceptance that UK graduates should have posts available to them. Nevertheless, the unexpected introduction of these regulations without consulting doctors'representatives has angered many. IMGs already here will find it much harder to get a job, especially a highly regarded position. Overseas doctors feel betrayed. They were encouraged to come to the UK but now compete with more UK graduates, thanks to medical school expansion, resulting in unemployment for both groups. Nonetheless, the current remedy is ill thought out. Overseas doctors have expressed distress over the DoH 's insensitivity. Some dread the humiliation of returning home, poorer and jobless.

One physician recalls a recent unpleasant experience when selecting 70 candidates for medical training posts. Four EEA candidates had scored fewer marks than the best 70, but they were above the 'minimum acceptable'. So, the selectors were obliged to displace four IMGs to make way for the EEA candidates.' I cannot recall ever feeling as tainted as I did by this final process.'[5] Jobs are not necessarily being given to the best applicants.

Ways forward

The DoH has failed to collect workforce-planning data that would allow for accurate projections of medical vacancies. In addition there is uncertainty as to the effects on vacancy numbers of Modernising Medical Careers and the phasing out of SHO posts. Numbers of applicants and posts may not match in the coming year or so. What can be done?

• The number of doctors taking the PLAB exams could be limited. This question has already been raised with the GMC.
• IMGs already here could be exempt from the new regulations.
• The BMA has called for better workforce planning and an increase in training grade posts, consultants and GPs.[6]
• Clear guidance is needed regarding the wording of advertisements in order to ensure that they are not discriminatory; for example, stating 'non-EEA nationals or candidates who require a work permit need not apply'should not be acceptable.
• There will be a greater role for organisations like PRIME (Partnership in International Medical Education) to offer teaching in home countries.
• The BMA and the British International Doctors Association advocate an annual international application process with doctors applying for training posts from their home country, and only travelling to the UK once a job offer had been made. Recruitment would thereby be on the basis of workforce demand as in the USA and Australia. Once within the UK, IMGs would then compete with other medical graduates fairly. According to the DoH, such a recruitment process should be in place in the UK by August 2007.[7]

Negotiations are underway and the rules may be modified as a result. It is a pity though that consultation did not take place before Lord Warner's announcement, as this may have averted some of our colleagues' distress.

Love our neighbours

The DoH's change in policy is not in keeping with biblical morality: 'When an alien lives with you in your land, do not ill-treat him. The alien living with you must be treated as one of your native-born'.[8] Nor does it conform to Jesus'command to 'love your neighbour as yourself'.[9] The Good Samaritan cared for aliens, sacrificially giving them time and practical help, despite cultural divisions. The new regulations will help commendably to stem the Developing World brain drain.[10] However, the effect on those caught in the middle - their UK training incomplete and their future uncertain - is to be condemned.