PLAB and Clinical Attachments Project Preparation for PLAB and Orientation for Future Working in the NHS for Refugee Doctors
October 2009 - August 2011
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The Refugee Council is a human rights charity, independent of government, which works to ensure that refugees are given the protection they need, that they are treated with respect and understanding, and that they have the same rights, opportunities and responsibilities as other members of our society.
“Now I am productive, contributing to society, working, paying taxes. This [PLAB and Clinical Attachments Project] is a crucial service which makes a huge difference.�
Dr from Somalia, an experienced Senior House Officer, fluent in 4 languages, employed after completing a clinical attachment
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Foreword
London is one of the most ethnically and linguistically diverse cities in the world. The NHS in London serves patients with 270 different nationalities, speaking 300 different languages. In order to best serve this unique city, doctors and other health professionals need to reflect the people they care for, something the NHS has embraced. One third of NHS employees are now from a Black, Minority or Ethnic background, mirroring those who visit hospitals, GP surgeries, dentists and other services in the capital. Within this group of employees, a small percentage, too small for the amount who are qualified, come from a refugee background.
Refugees have been forcibly exiled from their home countries, often to be exiled again from their vocation, such as medicine, with avenues to rebuilding a life difficult to find. Refugees can be anyone, from an unskilled labourer to a prominent heart surgeon, and in fact London is home to significant numbers of doctors forced to flee and start again here. This is not a new phenomenon – refugee doctors have been contributing to the UK medical profession for centuries – from Queen Elizabeth I and her physician who fled persecution by the Portuguese Inquisition, to the many Huguenot doctors who fled religious persecution in France in the 17th Century, to Jewish doctors fleeing the Nazis in World War II, and more recently doctors from such diverse locations as the former Yugoslavia, Sri Lanka and Iraq. Medically qualified refugees are people who want to work and are legally allowed to. They want to regain the career they had before it was taken away by oppression, civil unrest and war. They come with skills, experience and specialisations that could really benefit the NHS workforce, but only a small percentage are actually practising medicine. This important project seeks to address why refugee doctors find it so hard to return to work, and has put in place a successful, cost effective, and, to those it helps, a life changing set of services that benefit everyone involved.
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Introduction To date, there have been over 1200 doctors from a refugee background identified by the British Medical Association (BMA), with over half residing in London. In 2001, The BMA set up a database in partnership with the Refugee Council to gauge the number of refugee doctors and their specialisations. Less than 15% of all registered doctors are currently practising medicine.
Despite all the qualifications, experience and skills, the routes back into practicing medicine can be long and difficult even for someone who was a medical doctor for over 20 years in their home country. The asylum system enforces unemployment, sometimes for significant periods of time. Long term unemployment can lead to a lack of confidence and a level of deskilling, particularly in a field such as medicine. Combined with a lack of work experience and professional references from UK employers, refugee doctors are at a distinct disadvantage when they try to resume their career in the UK.
“It is partly due to the lack of clinical skills, which is difficult when you’ve been here for a while without any contact with patients and you haven’t been practicing as a doctor”. Doctor from Iran, currently on the preparation course for the PLAB 1 test
All doctors who completed their training outside the UK, including refugee doctors, have to pass language and clinical competency tests, and then register with the General Medical Council (GMC) to be considered for employment. Essential to securing a job is also experience from a hospital placement (clinical attachment), which enables doctors to gain an understanding of the NHS system and obtain relevant references. All of these stages require substantial financial support which most cannot afford.
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A standard process of re-qualification includes:
1 IELTS (International English Language Testing System) Test
This test measures the ability to communicate in English across all four language skills; reading, writing, listening and speaking. The GMC requires a minimum score of 7.0 in each module as evidence of proficiency for the purpose of registration. 2 PLAB (Professional and Linguistic Assessment Board) Part 1 Test
PLAB 1 is designed to test doctors’ ability to practice medicine safely in a UK hospital and is set at the level expected at the end of Foundation Year 1. 3 PLAB (Professional and Linguistic Assessment Board) Part 2 Test
PLAB 2 is designed to test a doctors’ ability to practice safely as a senior house officer (SHO) in a first appointment in a UK hospital. It is also set at the level of the end of Foundation Year 1. The test uses an Objective Structured Clinical
Examination (OSCE) format, using clinical scenarios or “stations”, each lasting five minutes, and measuring areas such as physical
examination, history taking, or counselling.
4 GMC (General Medical Council) Registration The purpose of the General Medical Council (GMC) is to protect, promote and maintain the health and safety of the public by ensuring proper standards in the practice of medicine. One way they do this is by keeping an up-to-date register of qualified doctors, and they also aim to ensure that all registered doctors maintain the standards the public and the medical profession expect. The current registration fee is £420.
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The IELTS and PLAB qualifications and GMC registration are formal requirements to recognise all overseas trained doctors, including refugee doctors, as eligible to practice in the UK. However, understanding the NHS system, its culture, ethos and practice are of equal importance in determining a successful candidate. While not obligatory, the two project services detailed below are vital to ensuring success for refugee doctors: 5 Clinical attachments
Clinical attachments provide doctors with invaluable UK experience and the opportunity to gain a UK reference, both of which are critical when applying for jobs. A clinical attachment is a period of time (1-3 months) when a doctor is attached to a clinical unit, with a named supervisor, learning about the legal, ethical and cultural context of medical practice through observing hospital teams in their day-to day activities. Unfortunately, clinical attachments are scarce, difficult to access and there is usually a charge involved. 6 Pre-employment support
Finally, creating a professional CV, filling in job applications and attending job interviews is another major challenge for refugee doctors seeking employment. The recruitment model in the UK can be significantly different for many and doctors may need a considerable amount of support to develop the necessary skills and confidence sufficient to compete on an equal level with other medical graduates.
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About the project
We have put together a package of core services relevant to all refugee doctors trying to get into work. The PLAB and Clinical Attachments Project has become a focal point for doctors from the refugee communities residing in London. It stands out for its distinctive holistic approach: providing guidance and practical support, building well established links with the three NHS Trusts in London providing specially designed clinical attachments, and a strong, effective partnership with relevant organisations. The project supports refugee doctors to re-qualify to ensure they meet UK standards. It aims to help refugee doctors to overcome barriers they are encountering and help them to achieve their goal of becoming a doctor within the in the NHS with a good understanding of safety and working practices. The project reflects over a decade of staff experience in providing Information, Advice and Guidance (IAG) to refugee health professionals. The project is funded by NHS London and began in October 2009. The initial 12 month contract was later extended to the end of August 2011. We proposed to help 26 refugee doctors access clinical attachments, with 24 progressing into employment. These targets are on track to be achieved, or even surpassed, within the scheduled time.
“I attended the PLAB course ….. and I found it very helpful. Most of the refugee doctors have similar educational backgrounds and they have difficulty with pre-GMC registration….This project is the only one which welcomes health care professionals without obstruction and provides central support. However, the clinical attachment provided by [the project] is a crucial advantage. It is a necessity for all doctors to refresh the memory and build their confidence.” General Practitioner and Medical Researcher from Iran, currently preparing for the PLAB 1 test
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Our Services
• Face-to-face initial advice and guidance on resuming a medical career • Referrals to suitable providers for work shops and trainings
• Free 12 week preparation courses for PLAB tests (Part 1 & 2) delivered by highly qualified NHS clinicians
• A meeting place for peer-to-peer and group support with access to IT facilities • Free 10 week access to the Skills Lab for a supervised practice on the manikins and medical equipment simulating the PLAB 2 test • Referrals to 10 week long, structured clinical attachments under the supervision of a dedicated Consultant • Free language and communication skills sessions designed around medical case scenarios • Financial support to cover travel expenses while attending courses and clinical attachments • Help with job search – mock job interviews
• Continued support while settling into employment
“This organisation can guide them (refugee doctors), support them financially and provide them with practical support like attending preparation courses and many other facilities. Therefore, I strongly advise all refugee doctors to register themselves with this organisation and gain beneficial help and support.” Doctor from Afghanistan, 19 years of experience in Surgery and research work in Anaesthesia, on a clinical attachment at Newham Hospital
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All clinical attachments are organised in the partnership with the Newham University Hospital NHS Trust, the Whips Cross University Hospital NHS Trust and the West Middlesex University Hospital NHS Trust.
“I spent more than two months calling all the hospitals found on the internet (Wikipedia) but none of them could give me the opportunity to do my clinical attachment.Luckily, a friend informed me that [the project] helps refugee doctors. After being in touch with them they managed to secure a place at hospital where I will do an attachment and the same time this opens up again all kind of opportunities for my future career.�
Doctor from Burundi, worked in Rwanda, holds a Master Degree in Human Biology, currently on a clinical attachment at Newham Hospital Our service is supplemented by specific assistance offered by further partners when appropriate and dependant on individual needs. The Refugee Advice and Guidance Unit (RAGU) at London Metropolitan University provide career guidance, and Southwark College provide preparation courses for the IELTS test.
Finally, the London Deanery plays a crucial role in helping doctors resume their medical career. It runs the National Clinical Apprenticeship Scheme for Refugee Doctors (CAPS), endorsed by the UK Foundation Program Office, which offers medical work placements of 6 months in the NHS, as well as intensive education and generic skills training. Doctors who successfully complete the scheme are recognized as suitable for competing for Foundation Posts.
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Project delivery and achievements in the wider NHS context The NHS expects the right accountabilities, continuous improvement and a value demonstration of the investment in education and training. The project fits well into the new NHS framework of 5 main delivery objectives:
Security of supply, having people with the right skills in the right place at the right time
Responsiveness to patient needs and changing service models High quality education and training that supports safe, high quality care and greater flexibility Value for money
Widening participation
The achievements of this project clearly demonstrate in particular value for money and active progression of widening participation.
“I am also thankful to you and your agency who arranged for me to start a Clinical Attachment at West Middlesex University Hospital from Sep to Dec 2010. After this attachment I have been successful in the interview for my present Senior House Officer post in an NHS Hospital.� Doctor from Pakistan, 20 years of practicing medicine in Pakistan and Africa, in employment since February 2011
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Value for money
It costs £250,000 to fully train a UK medical student with training up to the end of the Foundation programme. For less than £170,000 we helped 62 refugee doctors to achieve the following:
18 doctors have now secured employment within the NHS 36 doctors have attend the PLAB preparation courses (These courses have been delivered by the 9 tutors from the NHS)
25 have been supported to gain required qualifications (PLAB 1 exam passed by 13 & PLAB 2 exam passed by 12) 23 doctors have been supported on to structured clinical attachments
In London, 7 NHS hospitals have now employed 15 doctors from this project including: St. Mary’s Hospital, Hillingdon Hospital , Chelsea & Westminster Hospital, Newham Hospital, Whips Cross Hospital and Queen Elizabeth Hospital.
A further 3 NHS hospitals outside London have employed another 3 project beneficiaries; City Hospital in Peterborough, Queen Alexandra Hospital in Portsmouth and Stratford Hospital in Birmingham. These jobs include the following positions: CAPS posts (Clinical Apprenticeship Scheme for refugee doctors: paid work placements of 6 months in the NHS hospitals) Trust grade posts (Senior House Officer)
Training posts (Foundation Year 1 and 2 posts)
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Widening participation
The project supports diversity and equal access to services, training and development opportunities. It is free from discrimination with everyone having fair opportunities to progress. It contributes to the diversity of the NHS workforce reflecting better the communities it serves. The 62 doctors are from 20 different countries, 37 are male and 25 female, ranging in age from 28 to 57.
“It is fantastic to be here and I am quite happy to have met a consultant like Mr Giordano‌ a clinical attachment is essential to get started in the NHS.â€? Doctor from Guinea, on a clinical attachment at Whips Cross Hospital
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The impact of refugee doctors’ presence in hospitals The NHS London serves a diverse population made up of many different groups and communities. Refugee health professionals have an important role to play in ensuring that the health services are responsive and appropriate to the diverse range of communities. Helping refugee doctors to join the NHS workforce will contribute towards achieving better health outcomes for all and reducing the inequalities experienced by some groups.
“The project impacts the organisation’s equality schemes whereby the trust can demonstrate positive action as a continuation of the previous refugee doctor programmes. It also helps the organisation meet its equality duties and ensures that hard to reach groups can access our services”. Kamel Dhokia, HR, West Middlesex University Hospital NHS Trust
“We had to engage our colleagues to supervise doctors on the attachments and the response was positive. We are helping individuals to progress through the system; they will fill the gaps and contribute to the NHS.” Dr Sandy Gupta, Clinical Attachment Lead at Whips Cross University Hospital/the Project Steering Group Chair
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Ways forward This project provides an effective model for getting refugee doctors into appropriate employment. It helps them to re-build career paths which will have a longer term impact on individuals, their families, employers and local communities. The cost incentive in supporting refugee doctors is also compelling, being considerably lower than training UK professionals from scratch. The project has been delivered against a backdrop of significant external and internal changes, including the merger between Refugees into Jobs and Refugee Council. It has not affected the service for clients or the partnership work. The need for our services is evident; referrals through word of mouth, networks and partners continue at a steady level.
“Continue with the current provision and also make sure that ring fenced funding is made available so this service is not lost in the current economic climate.� Kamel Dhokia, HR, West Middlesex Hospital
We are committed to taking forward this specialist provision, building on the experiences of the project, and disseminating good practice. Stable, long term funding would enable us to help more refugee doctors unlock their potential and integrate into the NHS workforce.
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“……the government should encourage such kind of association because it could help many refugee doctors who can not retrieve their career because they either do not have proper information or do not have financial means to undertake all PLAB exams.” Doctor from Burundi
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The Refugee Council 240–250 Ferndale Road London SW9 8BB
Tel: 020 7346 6700 Fax: 020 7346 6701 www.refugeecouncil.org.uk British Refugee Council, (commonly called the Refugee Council) is a company limited by guarantee registered in England and Wales, [No 2727514] and a registered charity, [No 1014576]. VAT reg no: 936 519 988. Registered office: 240-250 Ferndale Road, London SW9 8BB, United Kingdom