BMJ  2007;335:591 (22 September), doi:10.1136/bmj.39302.403021.94

Feature

Head to head

Should postgraduate training places be reserved for UK graduates? No

University Hospitals, Coventry and Warwickshire NHS Trust, Coventry CV2 2DX

After many young doctors failed to get NHS jobs this summer, Edward Byrne argues that training posts should go to UK graduates. But Edwin Borman believes restricting access would damage the profession

Rumblings of revolution can be heard within the medical profession. What with relentless reforms to the health service, threats to our professionalism, the chaos of the medical training application service (MTAS), and a very real risk of doctors being unemployed, the forces of "blame someone," "get rid of all of them," and "I want the best for me and my own" have been let loose.

But that does not justify shutting the door on our colleagues who have come from abroad to work and train beside us in the United Kingdom. Just the opposite; when we prepare to "staff" the barricades, it is worth remembering that "United we stand, divided we fall."

For most of the lifespan of the NHS, the UK has had an implicit policy to rely on international medical graduates to "top-up" the number of UK graduates. Such a system is cheaper (doctors coming from abroad bring their qualifications to the UK for free), it is more amenable to changing needs (recruitment of trained doctors within a year, rather than having to wait for them to graduate), and it provides for a sharing of experience and the development of healthcare links in a world where disease is globalised and medicine needs to be. The current medical workforce figures confirm this: 36% of doctors registered to practise in the NHS qualified abroad.¹

Freedom of movement

For many years, therefore, the UK has benefited from freely accepting doctors from abroad. Freedom also applies, and always should apply, to the migration of doctors,² whether the reason is to escape from tyranny, to get a better life, or to have access to specific training. And it is with freedom that doctors choose, from among many countries, to come to the UK to advance their medical career.

That decision carries responsibilities. A doctor who chooses to migrate to the UK accepts both the risks and the potential benefits; however, in a society based on fairness, it should also provide a right to be treated fairly. That right should encompass detailed and easily obtainable information on career prospects, reasonable notice of changes to immigration rules, and fair access to the posts that they had been told were available.

Populations also have rights: to health and healthcare workers.³ It is to the UK's credit that it has led the way internationally in recognising that some countries need their own doctors more than the UK does. The NHS's ethical recruitment policy does not allow doctors to be actively recruited from developing countries.⁴ But this cannot be used as an excuse to limit the rights of individuals to migrate.

Equal opportunities

The UK, and in particular the NHS, also has an admirable, though not perfect, record in providing equal opportunity, determined only on the basis of eligibility and merit. While politicians seem to be shying away from the word "multiculturalism," all who work in the NHS accept that we do so on an equal basis with colleagues from many faiths, cultures, and countries.⁵

That is not to say that there are no problems; there is ample evidence of unfair discrimination in the NHS, as there is of vigorous efforts to eradicate such unacceptable behaviour.⁶ The crucial point is that, perhaps more than in any other aspect of life in the UK, the principle of equality is embedded in our function. The NHS, as the largest single employer in the UK, sets an example for others to follow.

Hence, it is to the credit of the medical profession that during the current crisis—even when jobs for UK graduates might have been safeguarded—all eligible applicants have been treated equally and posts have been allocated according to merit. This shows a level of solidarity that is characteristic of the best of the medical profession.

This sense of fraternity extends more widely than doctors from abroad working in the UK. The NHS also leads the world in encouraging links with practices and hospitals in developing countries. This initiative recently was given a further boost by Lord Crisp,⁷ but success and the benefits—that flow in both directions—are dependent on links that almost always are based on personal ties of colleagues who have worked together.

The good name of the medical profession in the UK has already been damaged by the government without notice introducing changes to the immigration rules. It would be a tragedy for the profession itself to sully its reputation by abandoning the principle of solidarity that goes back as far as the Hippocratic oath.

If you are looking for somewhere to allocate blame for the chaos that is MTAS, I suggest that you consider where it was decided that medical staffing no longer needed to be planned for centrally, and that training numbers should be limited to numbers that do not reflect the projected future need for consultants and general practice principals.

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Competing interests: Edwin Borman is chairman of the BMA's international committee. He trained in South Africa. The views expressed here are his own.

References

1. General Medical Council. Registration statistics. London: GMC, 2007.
2. United Nations. Article 13. Universal declaration of human rights (1948). www.un.org/Overview/rights.html
3. United Nations. Article 25. Universal declaration of human rights (1948).www.un.org/Overview/rights.html
4. Department of Health, Code of practice for the international recruitment of healthcare professionals. London: DoH, 2004.
5. General Medical Council. Good medical practice. London: GMC, 2006.
6. Coker N, ed. Racism in medicine. London: Kings Fund, 2001.
7. Crisp N. Global health partnerships. London: Department for International Development, 2007. www.dfid.gov.uk/pubs/files/ghp.pdf

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