Training permits deter high-flyers Article from Hospital Doctor The Government may have shot itself squarely in the foot by rushing through its ruling on work permit requirements for non-EU medical graduates who want to train in the UK. The move is widely regarded as a panic reflex, triggered by the prospect of national headlines screaming: 'Jobless doctors!' And there are strong fears that the Government has failed to consider the side-effects of its hastily administered preventive potion. The human cost to international medical graduates (IMGs) is prominent in many doctors' thoughts. But the profession's leaders also warn of gaps in training schemes, causing chaos for rotas already battling with the EU Working Time Directive. They predict reduced competition for posts and hence a fall-off in the quality of recruits. And they are dismayed that a New Labour knee-jerk reaction could inflict irreparable damage on the powerful and mutually beneficial relationship that the profession has established with India and other Asian nations. Nationality figures for SHOs in England were last reported in 2004 and relate to 2002, when IMGs accounted for 33 per cent of a total of 5,518. Service contribution The scale of their service contribution varies hugely from one specialty to another. For example, in obstetrics and gynaecology, more than 70 per cent of SHOs and more than half of SpRs are IMGs. Some will have rights of residency, perhaps through marriage to a UK national, but the Royal College of Obstetricians and Gynaecologists (RCOG) believes that at least half of its current trainees now come under the aegis of the new regulations. Mr Richard Warren, RCOG honorary secretary, says recruitment to the specialty is increasing, but there will still be training vacancies this summer. And he fears that potential IMG applicants will be deterred by the new bureaucracy and simply take their much-needed expertise elsewhere. The caveat allowing trusts to appoint IMGs if they can't otherwise fill posts does little to sweeten the pill. 'The process is cumbersome and difficult for all concerned,' says Mr Warren, a consultant at Norfolk and Norwich Hospital. 'Trusts will have to go through an initial selection process looking at UK and EU applicants. Then they will face a second round to fill up the remaining gaps with IMGs - if they apply.' He points out that doctors outside the UK will have the trouble and expense of travelling here to be interviewed - with no confidence that they will get a job at the end of it. Those already here may have to go home, then return for their interviews. 'We have already had letters from potential recruits who say they are not going to bother - they will go to the US instead. And that will be a loss to service in UK hospitals.' Psychiatry foresees a similar debacle. Clinical tutors have informed the Royal College of Psychiatrists that between half and two-thirds of trainees are IMGs. The college's dean Prof Dinesh Bhugra predicts that learning disability and psychiatry services for the elderly will be hardest hit. He says: 'That is bad news for the UK and for countries where these subspecialties do not exist without trainees coming here to get the necessary experience.' Like many of his colleagues, Prof Bhugra is dismayed by the abrupt implementation of the work permit requirement. He says: 'I know of a trainee who received a letter in the morning saying he had passed his Part 1 exam, and was phoned by his trust at lunchtime the same day to be informed he had to leave. Why on earth could this ruling not have been phased in gradually?' Now excluded He is also seriously worried about service quality. 'I know at least four schemes that usually expect about 400 applicants every time they advertise ten or so vacancies,' he says. 'More than 300 of those are typically post-PLAB IMGs who are now excluded from the word go. So, instead of being able to choose the very best from a large pool of candidates, we are now being told by the Government how to short-list the applications.' Similar concerns have been voiced in paediatrics. Dr Nadeem Moghal, a consultant paediatric nephrologist in Newcastle, has already felt how hard the new ruling bites. Where he used to receive more than 300 applications for each new SHO rotation, this year adverts for nine posts attracted just 11 candidates, two of whom dropped out. 'So the selection process has been taken away from me,' he says. 'I can no longer appoint candidates on merit.' To add insult to injury, one of the nine new SHOs dropped out post-selection, leaving the rotation undermanned and with no back-up list of former applicants to resort to. He understands why the trust has taken such a firm line against considering IMGs. 'It applied the law as it was stated and removed candidates who were no longer eligible,' he says. 'To do otherwise would have exposed the trust to the risk of a fine of £5,000 per IMG appointed.' He also understands why the Government has fallen for the temptation of regulating the NHS jobs market. 'It is very keen to avoid having unemployed UK doctors,' he says. 'But the solution it has come up with is just a political kneejerk, with no real consultation. 'Market forces mean you regulate an economy at your peril. Our Government would do well to look at the US, where they tightened up the visa regulations after 9/11, then loosened them when the medical and research institutions realised they were no longer getting the best candidates.' Dr Moghal predicts particularly hard times for subspecialties that are less popular with UK graduates. 'I have had two truly excellent registrars in my department who are going to become tertiary specialists in paediatric nephrology,' he says. 'Under the new ruling, they wouldn't be in the system. I get very little interest from UK candidates because they are becoming more concerned with life quality. Coming into my department demands hard work and a lot of on-call, typically one in three or four.' Dr Moghal is confident that the Government will revise the ruling once it recognises the effect on service delivery. But the damage will already be done, he warns. 'IMGs who would once have come here are already going to New Zealand, Australia, Canada and the US - places that welcome them,' he says. 'And our relationship with their universities will be eroded.' He has little enthusiasm for the promise of EU graduates coming to the UK to plug the recruitment gaps. Better chance 'We are in the position where an applicant from Europe who can barely speak English has a far better chance than a doctor from Bangalore who speaks excellent English,' he says. 'Where's the sense in that?' The British Association of Physicians of Indian Origin (BAPIO) points out that EU graduates do not have to undergo a language exam before applying for UK posts, whereas candidates from Asia must pass the Professional and Linguistic Assessment Board (PLAB) test. BAPIO president Dr Ramesh Mehta says the language issue has already produced some bizarre scenarios. 'I know of one doctor from eastern Europe who brought an interpreter to the job interview,' he says. He urges trusts to protect themselves by making sure fluency in English is part of the job description for SHO posts. Lure back He agrees with other commentators that, once Asian doctors lose the culture of coming to the UK, they will prove difficult to lure back. 'Also,' he says, 'the Indian economy is growing very fast. In 20 years, we may find we need them more than they need us. It is extremely shortsighted, in this increasingly globalised world, to shrink back inside the borders of Europe.' Dr Peter Trewby, who leads on IMG issues at the Royal College of Physicians, believes there is a strong risk that the work permit ruling will backfire, with dire consequences for the UK graduates it was designed to protect. 'Doctors from many EU countries know they will be paid more in the UK and have better working conditions,' he says. 'Now they don't face competition from non-European candidates, they may come here in large numbers. And that won't help UK graduates, which was the purpose of the whole exercise.' He, too, is concerned that valuable, longstanding relationships between the UK and Asian countries will be undermined. 'And,' he notes, 'this is at a time when we face many unknowns in medical workforce planning, with women accounting for over 50 per cent of graduates, more men seeking part-time or flexible work, the effects of the Working Time Directive and changes to the way trusts deliver services.' He concludes: 'Quite simply, we are going to need more doctors.' Diary of a disaster in disrupting doctors' training Summer 2005: The Home Office conducts a 16-week consultation on immigration, but doctors' leaders say they were not informed that its remit would extend to doctors in training. 7 March 2006: The DoH announces that, as of April 2006, all doctors from outside the EU will need a work permit to train in the UK, and trusts wanting to recruit non-EU graduates will have to demonstrate they have no appropriate home-grown candidates. 21 March: More than 600 doctors attend a peaceful demonstration in London to protest the ruling (pictured below). 18 April: The BMA and the British Association of Physicians of Indian Origin (BAPIO) issue a joint statement condemning the Government's decision to rush through the new visa requirements. 19 April: Labour MP Austin Mitchell tables an Early Day Motion in the House of Commons about the treatment of trainee doctors from Commonwealth countries. 21 April: BAPIO hands a petition to the DoH containing more than 6,500 signatures, asking for a review of the regulations, including arrangements for overseas doctors already in the UK. 23 May: BAPIO issues two weeks' notice to the DoH and the Home Office of its intention to seek a judicial review. 6 June: BAPIO instructs Rabinder Singh QC to proceed with the judicial review.