We train fewer doctors per head of population than any other European country. 36% of UK doctors graduated outside the UK, 10% from EU countries, 26% from non-EU countries.1. Most non-EU doctors coming to the UK use either the Tier 2 (skilled worker) visa, or the Tier 5 (Government Authorised Exchange short-term) visa. Visa rules are complex and fast-changing, difficult enough for HR departments to cope with let alone medical graduates. The recent changes in migration, particularly in the Tier 2 visa rules, will have severe repercussions on medical staffing.
Tier 2 visa
Most international graduates come to the UK on a Tier 2 visa. The Home Office puts an annual limit on the total number of Tier 2 visas which is set at 20,700 this year for both medical and non-medical visas. Visas are allocated monthly, but if there are too many applicants a points-based system is used to rank them. Unless applying for shortage specialties (see below), most junior doctors only score 20 points. A squeeze on the number of visas issued and competition for those available meant that in December 2017, the points bar for admission was raised to 55 points. To score 55 points, a doctor needs to earn an unattainable £55,000 (the salary for full-time CT1 post is £36,000, £46,000 for CT3).2 Many trusts have been caught short with doctors unable to obtain visas.3 A Home Office spokesman stated: “We are committed to ensuring that net migration is reduced to sustainable levels and that the jobs of British workers are protected.” 4 The second half of his sentence makes no sense as the Resident Labour Market Test , which hospital HR departments have to apply, prevents Trusts from advertising, let alone appointing, to posts if any British or EU doctor applies.
Restrictions on migration will force Trusts to employ more locums who will be drawn from the already over-stretched resident workforce. The effect will be more gaps on rotas, more stress amongst medical staff and yet more money spent on locums.
International graduates applying for “shortage specialties” are treated differently and automatically score 135 points so are almost guaranteed a visa. It is reassuring that nursing, which is in an even more parlous state than medicine, is recognised as a shortage specialty.
The officially recognised “shortage specialties” in medicine are:5
Clinical Radiology
Emergency Medicine
Old Age Psychiatry
CT3 trainee and ST4 to ST7 trainee in Emergency Medicine
Core trainee in Psychiatry
Non-consultant, non-training, medical Staff Posts in the following specialities:
Emergency Medicine (including specialist doctors working in accident and emergency)
Old Age Psychiatry
Paediatrics.
Although Trusts have come to rely on the Tier 2 visa, there are disadvantages particularly from the graduate’ s point of view. The visa depends on the doctor remaining in a paid post. And while in post they are outside the educational system, with no guarantee of training, supervision or career progression. Many Trusts do offer educational opportunities, but this is not guaranteed with priority often given to home-grown graduates. Furthermore, most graduates on Tier 2 visas are from resource poor countries whose health needs are far greater than the UK’s. The WHO estimate a world shortage of 2 million doctors. We must question whether it is right for the sixth richest nation in the world to be so dependent on international graduates trained at the expense of countries that can ill-afford to train their own doctors let alone ours.
The Tier 5 Medical Training Initiative scheme
The Tier 5 Medical Training Initiative (MTI) scheme is an alternative route for international graduates. The scheme, run principally by the Royal Colleges, offers employment for two years in recognised NHS posts with emphasis on training, mentoring and supervision. While intended for doctors from resource-poor countries the scheme is also used, for example, by dermatologists from Australia, to obtain training in the UK. It is a win-win scheme helping to fill vacant NHS posts as well as offering training to international graduates in a supported environment. Over 600 MTI visas were issued last year.There is again a cap on numbers which, although not yet reached, may prevent the scheme expanding in the future.6
Post-Brexit
The situation for medical migration post Brexit will add further to the woes of medical staffing departments. Currently 10% of doctors and 7% of nurses are from EU countries.1All have been urged to apply for leave to remain and it is likely that this will be granted but new EU nationals wishing to come to the UK will have to battle with the existing Tier 5 and Tier 2 restrictions in the same way non-EU doctors do at present and are equally unlikely to gain admission.
Career breaks
To these woes must be added the number of doctors taking career breaks, particularly after FY2 posts. The UK foundation programme career destinations report 20178 found that 13.8% intended to take a career break following their F2 post. There is a need for more focused work on why graduates are taking career breaks. Reassuringly, GMC figures do show that of those qualifying 3 and 4 years ago, 90% were back in speciality or core training within three years. But will the same apply to the 2017/18 cohort who have been through the trauma of the new contract and the damaging altercation with the Secretary of State over 7-day working? Furthermore, the recent data blunder arising from mis-transcription of interview data will cause many junior doctors to wonder whether the UK medical system has the administrative skills to cope with junior doctor appointments let alone the ability to promote excellence and advance the careers of motivated and able doctors.
Increasing UK medical student places. The only answer
The visa stranglehold and the global shortage of doctors means UK self-sufficiency in medical education is the only answer to the medical staffing problem. Realising this, the government has increased the current 6000 medical students admitted each year is to 7500 starting with 500 extra this September and a further 1000 in 2019/20. Sadly, this will only ease the situation to a small degree partly because the increase is on the background of an extraordinary2% reduction in medical school intake in 2013, this despite the increase in female graduates requiring time off for family reasons, the increasing age and medical dependency of the population and the reduction in working hours associated with the European Working Time Directive. The Secretary of State wishes the UK to be self-sufficient in doctors by the end of the next Parliament7 but the measures he suggests will barely redress the shortage of doctors arising from the 2013 cut in numbers, let alone the year on year increase in the medical demands of the population and the increase in graduates wishing to work part-time for personal reasons.
Conclusion
The increase in the Tier 2 points threshold for international medical graduates, the reduction in EU graduates entering the UK post Brexit, and doctors’ career breaks will place unacceptable strains on medical staffing. The increase in medical school output post 2023, while welcome, is not enough to address historical under-staffing and increasing medical need. A more flexible approach to medical migration and an increase in Tier 5 graduates coming to the UK on two-year limited visas are essential, as is expanding the shortage speciality list for Tier 2 visas. The preoccupation with migration numbers must not trump medical needs nor the aspirations of international graduates. Above all there needs to an unprecedented increase in medical school places. The College of Physicians has called for a doubling in medical school numbers9, essential if we are to put the NHS workforce back on track. Funding will be needed but is it right to use funding from resource-poor countries to train their doctors to treat our patients? In the light of past failures, should we look at an altogether more radical approach to medical training. Could trusts, chronically desperate for medical staff, combine to part-own and fund medical schools, still, under the aegis of the GMC, but outside the heavy-handed and so often wrong central control of resource planning? The money saved on locum costs would go a long way to fund the training of additional students. Until more doctors are trained, we must strive to understand and prevent the haemorrhage of those doctors we have. To this end, politicians and managers must learn to value their staff, this more important than ever in these times of financial restraint and staff shortages.
Peter Trewby
Treasurer, Doctors for the NHS
President Association of North of England Physicians
Past Associate International Director Royal College of Physicians
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- NHS staff from overseas: statistics https://researchbriefings.parliament.uk/ResearchBriefing/ Summary/CBP-7783
- Are junior doctors paid enough to get a UK visa? Https://fullfact.org/health/junior-doctors-visa/
- NHS doctors blocked from coming to work in the UK. https://inews.co.uk/news/health/nhs-doctors-blocked-coming-work-uk/
- Home Office in the Media.https://homeofficemedia.blog.gov.uk/2018/01/17/home-office-in-the-media-17-january-2018/
- Immigration Rules (updated January 2018) https://www.gov.uk/guidance/immigration-rules/immigration-rules-appendix-k-shortage-occupation-list
- Medical Training Initiative http://www.aomrc.org.uk/medical-training-initiative/
- NHS in England to be ‘self-sufficient for doctors by 2025’ says Hunt http://www.publicfinance.co.uk/news/2016/10/nhs-england-be-self-sufficient-doctors-2025-says-hunt
- UK Foundation Programme’s Career Destinations Report 2017www.foundationprogramme. nhs.uk/download.asp?.
- https://www.rcplondon.ac.uk/news/new-medical-school-places-now-we-re-halfway-there
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