The UK dream – From oasis to mirage The General Medical Council, the regulatory body for Doctors in United Kingdom (equivalent of Medical Council of India) has revealed a couple of weeks ago that the maximum number of doctors sacked in the United Kingdom over the past five years is from India. Over the past five years, one out of every 250 doctors of Indian origin was sacked. The report also says that doctors trained in India but working in the UK are four times more likely to be sacked. Since 2009, 117 doctors trained in India and Pakistan had been debarred from practising in Britain. India tops the sacking list, followed by Pakistan, Egypt and Nigeria. The tradition of training in the United Kingdom (UK) is long established and has made significant contribution to the Health Services of both Britain and India. However, institutional racism within the National Health Service has been demoralising many International Medical Graduates (IMGs) working in the UK. According to Statistics from General Medical Council of United Kingdom, out of the 260, 000 doctors working in the UK, some 68, 000 are foreign qualified doctors, comprising of 26% of UK’s National Health Service Workforce. The vast majority of IMGs are from the Indian Subcontinent. It is well documented fact that without contribution from India, which provides highest number of professionally qualified clinical staff, doctors and Consultants after Britain, many NHS services would struggle to provide effective care to their patients. Furthermore, the British Association of Physicians of Indian Origin (BAPIO), the single largest Organisation that represents the interests of IMGs in the UK announced that International Medical Graduates (IMGs) are 16 times more likely to fail the examinations in the UK than their white counterparts despite having successfully completed the same stringent training programme, smacks of the heights of racism in the National Health Service (NHS) of UK. In fact, The British Association of Physicians of Indian Origin (BAPIO) and has brought a judicial review in March 2014 against the Royal College of General Practitioners (RCGP) and General Medical Council (GMC) over claims that the college's membership exam (MRCGP) discriminates against minority ethnic candidates. Doctors must pass the MRCGP exam to practice as general physicians in the UK. Although BAPIO did not win the case, the Honourable judge Mr Mitting while delivering his judgment a few weeks ago in London warned the RCGP that “it must change its assessment process after acknowledging that ethnic minority medical graduates were put at a disadvantage by the current assessment”. “Endless amount of research has been commissioned to date with no solutions or action points, it has taken a court case to effect action”. “RCGP should now take action, including by selecting more representative examiners and role-players for the assessment”. The judge further commented "If it does not act and its failure to act is the subject of a further challenge in the future, it may well be that it will be held to have breached its duty". What is clear is that now the RCGP has a legal duty to find a solution to the problem. The Court case was indeed a landmark and a moral victory for BAPIO & IMGs working in the UK.
FACTS & REALITIES RELATING TO IMGs IN THE UK Higher Specialist training in the UK is popular amongst IMGs because it is perceived to be good and well thought of abroad. Currently, IMGs make up about 26% of the NHS workforce. Why do International Medical Graduates (IMGs) go to the UK? • • •
To acquire qualifications, which have International reputation. To obtain training at the world’s best Centres of excellence Settle down in the UK (not all, but the vast majority)
Over the past two decades, there has been an exponential increase in IMGs going to the UK. This slowed significantly down after 2006. There has been a significant increase in newly qualified doctors graduating from UK medical schools, the numbers of which has doubled since 1998. The students from the European Union (EU) graduating from UK Medical schools, and equally, graduates who have qualified in the EU outside Britain entering the UK for better training opportunities has also increased. Since March 2006, the number of IMGs struggling to obtain postgraduate training in the UK has spiralled out of control, the main reasons being fundamental changes introduced to postgraduate training and a major shift in immigration policy for IMGs There has been a sudden, unexpected, and radical shift in the immigration policy for IMGs in the UK. The British Government announced the new immigration ruling in March 2006 without discussing this issue with any organisation representing the interests of IMGs. It came into effect a mere one month later in April 2006. This legislation effectively ended ‘equal opportunities’ for doctors from the Indian subcontinent and those from outside the EU. After April 2006, all doctors who wish to work in the UK from outside the EU are now required to have a work permit. The move means that any NHS Trust in the UK wishing to employ a doctor from outside the EU will have to prove that a doctor who has graduated in the UK cannot fill the vacant post, ending the current permit free training arrangement for IMGs. The chorus of disapproval and protest from all sections of the medical profession including Royal Colleges, British Medical Association and Overseas Doctors Associations in the UK did not deter the British Government from implementing the legislation. It is estimated that some 15,000 IMGs, mostly from the Indian Subcontinent, have been affected as a result of this rushed legislation. This knee jerk leg isolation has traumatised the UK’s IMG community, causing enormous anguish to thousands of doctors and their families, and making their futures uncertain. As the doctors who have been affected did not have financial, moral, or psychological support to withstand this crisis, most have already gone back to their home countries. In a country where there are one million patients waiting for inpatient treatment and two million waiting for their first outpatient appointment, it is an irony that there are so many IMGs had to return to India.
Over the past two decades, many overseas doctors who went to the UK with the intention of obtaining structured surgical training, have unfortunately taken up Non Consultant Career Grade (NCCG) jobs. As such, there is no hope of any career progression in this grade and doctors in this grade would always work under the supervision of a consultant. It is estimated that nearly 70% of doctors taking up NCCG Posts are overseas qualified and nearly all of them have been unsuccessful in obtaining a structured training leading to a Consultant Post in the UK. It is disheartening to note that there has been a dramatic and alarming (600%) increase in NCCG posts in the UK since 1996. Several IMGs with Postgraduate qualifications from India have changed their Specialty interests just to be able to secure a job and earn a living in the UK. The number of IMGs qualifying as General Practitioners has increased by 50% - with overseas applicants up by three fold. Having obtained both Higher Surgical Training in General Surgery and Subspecialty training in Oncoplastic Breast Surgery at some of the world’s best Centres of excellence in the UK, I have seen institutional racism at close quarters. I have learnt by experience that no matter what, IMGs have to be many times better and talented when compared to local UK graduates to get placements for competitive jobs in mainstream popular Medical and Surgical Specialties and subspecialties. To give an example, there were only nine places across the UK for the most prestigious National Subspecialty Training Programme in Oncoplastic Breast Surgery when I had applied. I was the only Indian to have been selected for that year. All other eight placements went to UK trained doctors. That in itself speaks volumes of Institutional racism in action. During that time – late 1990s, Institutional racism was always brushed under the carpet and many IMGs suffered silently. With the emergence of strong Organisations that represent IMGs in the UK like British International Doctors Association (BIDA) and British Association of Physicians of Indian Origin(BAPIO), the spotlight on the issue of racial discrimination in the National Health Service has been brought into sharp focus. How to minimise Institutional racism in the National Health Service? 1. Work hard. Stay focussed. One has to be much better than the local citizen to achieve success in a foreign country. No point sulking that you are as good as a local & yet have not been offered the job 2. Do not be subservient. Stand up for your knowledge and ability. There are laws to protect overseas qualified professionals (Equal opportunities) 3. Associate with an Indian community aboard. It gives lot of emotional and psychological comfort. 4. Finally, enjoy your stay aboard. Imbibe the good qualities of the Nation and people abroad & ignore the bad aspects. Obtain experience at aspects of your profession that you may not be exposed to at Home in India
My advice to prospective UK Trainees •
Obtain Basic & Higher Specialist training in recognised Centres in India.
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For those pursuing Surgical training, pass MRCS (Membership of Royal College of Surgeons) examination in India. Now with Exit FRCS (Fellowship of Royal College of Surgeons) examinations also being rolled out outside of UK since 2012, there is no need for doctors to go to the UK to obtain FRCS. FRCS can now be taken in an overseas location (Dubai/Sri Lanka). The Exit FRCS examination is also likely to be held in India in not too distant a Future. Similarly, MRCP examinations can also be taken in India without the need to work in the U.
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In the current scenario of intense racism and poor training opportunities in the UK for overseas qualified doctors, it is advisable not to rush to the UK to pursue Higher Specialist Training.
CONCLUSION Despite the yeomen contribution made by IMgs in the UK to the National Health Service for several decades, Institutional racism and discrimination against them persists right from getting a Training Post and to even after becoming a Consultant. Sadly, the British Government has not take into consideration the enormous contribution made by IMGs to the NHS before announcing the new legislation in 2006. This has had a dreadful impact on thousands of doctors already in the UK looking for equal opportunity in hope of finding a training placement. It has also shattered the hopes of many prospective trainees from overseas. Is there light at the end of the tunnel? The answer lies in the title of the article. For the foreseeable future, IMGs must stop chasing the oasis as it has become a mirage.
Dr. P. Raghu Ram MS, FRCS (Edin), FRCS (Eng), FRCS (Glasg), FRCS (Irel) CEO & Director , Ushalakshmi Breast Cancer Foundation www.ubf.org.in Director & Consultant Oncoplastic Breast Surgeon KIMS-USHALAKSHMI Centre for Breast Diseases www.breastcancerindia.org Former Member, National Executive Committee British International Doctors Association (BIDA), UK