BMJ  2006;332 (22 April), doi:10.1136/bmj.332.7547.0-f

Editor's choice

A very British muddle

The latest row in Britain's NHS is about overseas doctors. The Department of Health last month announced that international medical graduates (from outside the European Union) in training posts will now need a work permit before taking such posts. This puts them in the same position as most non-EU nationals seeking to work in the UK, but doctors in training had until now been exempt.

Not surprisingly, this has caused anger among overseas graduates currently in training (15 April, p 913; bmj.com/cgi/eletters/332/7544/744-a), who now see only uncertainty when their current post comes to an end. As Lynn Eaton explains on p 932, the new rule seems to have come about because the NHS has moved from shortage to surplus. Once short of doctors and desperate to recruit from outside the UK, the NHS now may have enough applicants from among UK and European graduates; indeed, last summer the BMA complained that UK medical graduates couldn't get jobs, though, as Eaton says, no one actually knows how many remained unemployed.

Lurching from shortage to surplus and back has been characteristic of Britain's centralised medical workforce planning over the years. So, to an inept command and control regime, add in a layer of European Union law (which means that EU medical graduates are treated the same as UK graduates), and a laissez-faire attitude to the qualifying exam for foreign graduates, PLAB, and the scene is set for bewilderment, unhappiness, and bitterness.

The bitterness, expressed by Surinder Sareen in his letter home (p 955), is caused partly by expectations raised in people who pass the PLAB exam. The UK's General Medical Council (which runs the exam but has no control over jobs) has increased the number of opportunities to take the exam, even though the jobs available for international medical graduates have probably not increased much. Individual overseas doctors feel stuck in the middle—relied on (Career Focus p 152) but unwanted.

Career Focus (http://careerfocus.bmjjournals.com), in its continuing series on what British doctors can do overseas, reminds us that most countries present some barriers to doctors other than their own (pp 155, 160) and also offers insights on hours worked. For junior doctors these are much longer in the US (p 155) and Australia (p 158)—and even France, where the European Working Time Directive is, says Jessica Wilson, "completely ignored" (p 162).

Something else that seems ignored by British politicians busily promoting patient choice is the fact that patients already have lots of choice, argues Philip Steer (p 981). He reflects on the choices women exercise about their obstetric care and on how he treads the line between respecting their views, not colluding with inappropriate choices, and factoring in resources, sometimes resorting to tossing a coin—which shocks the students. He also has advice on how to respond to the question: "But what would you do, doctor?" See if you agree with him.

Jane Smith, deputy editor

(jsmith{at}bmj.com)


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