J.Meirion Thomas is a former Professor of Surgery and Consultant Surgeon in the NHS.
It is common knowledge that that there is a crisis in general practice. The Department of Health has promised 5,000 extra GPs by 2020. Recruitment is well behind schedule.
The UK has never trained enough doctors to meet the needs of the NHS. Last year, of the 12,771 new doctors registered by the General Medical Council, 44 per cent qualified abroad: 17 per cent from other countries in the European Economic Area, and 27 per cent international medical graduates, who qualified in countries outside the EEA.
For decades, we have imported almost half the doctors we need. The General Medical Council has expressed concern about this “huge and increasing reliance on non-UK graduates”.
Jeremy Hunt has announced that the number of British medical school places will increase by 25 per cent from 2018 so that the UK is “self-sufficient in doctors by 2025”: numerically an impossible goal.
According to the Universities and Colleges Admission Service (UCAS), the annual number of applications to UK medical school fluctuates between 70,000 and 85,000 for approximately 7,000 places. Tens of thousands British students with the required A-level grades are rejected only because of insufficient training slots.
Over and above the 44 per cent of doctors from abroad who obtained GMC registration last year, the Department of Health has had to resort to further active recruitment from abroad in an attempt to avoid a crisis in general practice. In January last year, it announced that 500 doctors for Lincolnshire were to be recruited from Poland, Lithuania, Spain, Romania and Greece, with promises of relocation packages of £90,000 to plug serious gaps in GP services. Successful applicants would undergo a 12-week training programme which would include lessons in the English language and on British culture. In July, NHS England announced a plan to recruit a further 2,000 foreign GPs. How sad for the NHS which the Secretary of State who has described as “the envy of the world”.
What are the rules and regulations which entitle foreign trained doctors to work in UK?
Primary medical qualifications are reciprocally accepted across the EEA, meaning that all non-UK, EEA doctors can register with the GMC without any skill checks. The GMC has to assume that doctors who graduate in the other member states are as well selected, trained and as competent as our own graduates. Of greater concern, English is not the first language of most of these doctors who may not have been taught medicine in English. As we leave the EU, it is essential that non-UK, EEA doctors should pass a competence exam before being allowed to register with the GMC to prove that their skills are equivalent to UK graduates.
Currently there are about 31,000 EU doctors practicing in UK, mostly from Eastern Europe and from countries worst affected by austerity. Few doctors from affluent Western European countries choose to work in the NHS.
Communication skills are essential to practice medicine. Following a battle with the European Commission, the GMC was allowed in June 2014 to enquire about language proficiency, but still no skills testing. Since then, a significant proportion EEA doctors applying for GMC registration have been refused because they could not provide evidence of adequate language proficiency.
The requirements for International Medical Graduates(IMGs) to register with the GMC are different. They need to pass the Professional Linguistics Assessment Board (PLAB) examination, which is intended to test clinical competence, language and communication skills. The standard of clinical skills expected of PLAB applicants is quite modest: it is pitched at the standard that British graduates are meant to have reached within one year of graduation. Regardless of this low expectation, the pass rate for PLAB (2011-2015) was between 35 per cent and 69 per cent and some candidates took the exam more than four times, by which time their clinical experience and maturity should have far exceeded the standard at which the exam was pitched. Yet many were failing.
Despite this attempt to maintain standards and patient safety in the NHS, when PLAB graduates subsequently took the two most common postgraduate exams: MRCP (Member of Royal College of Physicians) and MRCGP (Member of Royal College of General Practitioners), PLAB graduates were proven to have significantly lower knowledge, skills and consequently pass rate, compared to UK graduates. The authors of an article published in the British Medical Journal concluded that raising the PLAB pass rate “considerably” would achieve equivalent results in these two postgraduate examinations but “would inevitably reduce the pass rate, with implications for workforce planning”. In other words, the NHS workforce can only be maintained by importing some inferior graduates from outside the EEA. No similar information is available for EEA graduates.
While these may be accurate conclusions, it must also be said that many international graduates will have achieved the highest marks in PLAB and also the best possible results in their postgraduate examinations. Furthermore, some or most foreign trained doctors working in the NHS (both EEA and IMG) are amongst the best and most able of their kind. Some of our specialist hospitals have been able to make stellar consultant appointments from abroad. However, it is equally true that many doctors relocating to the UK are economic migrants, migrating because working conditions, salaries and pensions are better here than anything they could ever achieve in their own countries.
Meanwhile, many of our brightest young British doctors are abandoning the NHS for medical careers abroad or using their medical qualification as a springboard to other professions or careers. For example, the Royal College of Emergency Medicine, representing doctors in a major shortage specialty, has reported that 600 consultant and trainee A&E doctors have moved abroad over five years.
Currently 4,881 UK trained doctors are registered to work in Australia; 2,459 in United States and 497 in New Zealand.
For me, the most alarming recent statistic is that in 2016, only 52 per cent of the 7,168 British qualified doctors who completed their two-year (compulsory) foundation training programme after graduation chose to progress to specialist training either in general or hospital practice, down from 71 per cent in 2011.
Is this a consequence of the recent junior doctor strike, which alienated and disincentivised a whole generation of doctors? Hunt had wrongly blamed 11,000 “unnecessary” weekend deaths on junior doctor weekend rostering. The strike will be his legacy.
There is a global market ready to attract the best doctors. Education and universities in the UK are among the best in the world. Only the brightest and the best can secure a place in our medical schools. Currently and alarmingly, as the revolving door of medical excellence rotates, the UK is a net loser of the best doctors. We must train and retain our own.