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Rapid Responses: Rapid Responses published:
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Obstructing Partnerships
- Peter MacPherson (24 March 2007)
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Reducing Global Partnerships?
- Hilda Ho (26 March 2007)
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UK doctors and global health
- Malcolm E Molyneux, Kevin Marsh, Nicholas J. White, Jeremy Farrar, Neil French, Nick Day, Sarah Rowland-Jones. (27 March 2007)
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Flexibility in MMC vital for overseas experience
- Elinor M Moore (28 March 2007)
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Facilitating Clinical Research Abroad
- Geoffrey Pasvol, Peter Winstanley, David Mabey, Brian Angus, David Lalloo (29 March 2007)
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Revalidation and MMC: effects on volunteering overseas
- prudence m hamade, London EC1 N8QX (30 March 2007)
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MMC is already discouraging UK doctors from working abroad
- Catherine H Roberts (30 March 2007)
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Exchange with the developing world is vital
- Claire A L Davies (30 March 2007)
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Global Health: Disincentives to Research Mobility
- Colin Blakemore, John Bell (30 March 2007)
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Making MMC more flexible for international health
- Darshan Sudarshi (31 March 2007)
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Global Health Partnerships
- Ed Cooper (1 April 2007)
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A global health system which concentrates on a few and neglects the billions of people who carry on the largest burden of disease
- M Justin S Zaman (4 April 2007)
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Global Health Partnerships and THET
- Stephen Tomlinson (5 April 2007)
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International health graduates are a vital resource for the UK and the developing world
- John S Yudkin (6 April 2007)
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Promote the Crisp report and global health partnerships to avoid isolation.
- Christopher P Conlon (8 April 2007)
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A threat to all overseas links
- Nick J Beeching, Harriet C Hughes, Nashaba S Matin, Lionel K Tan (14 April 2007)
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Global Health Partnerships
- James A G Whitworth, Mark Walport (20 April 2007)
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MMC will hurt Britain's standing in the medical world
- Alastair McGregor (9 May 2007)
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Peter MacPherson, SHO Community Child Health Royal Alexandra Hospital for Sick Children, Brighton, BN1 3JN
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Despite the positive recognition of the work undertaken by British doctors in international health, barriers are being raised to make it increasingly difficult to offer much needed care and training to those most in need in the developing world. Having completed a Masters in International Public Health, I am going to work in South Africa as a HIV/AIDS medical officer in a rural hospital. However, I have concerns regarding the infexiblity of the current postgraduate medical training system. There is little way to ensure my experience will recognised or accredited and even less assurance that I will be able to re-enter the UK training system under Modernising Medical Careers should I decide to return to the NHS. Even more worrisome, the MMC restructuring means that we are limiting the ability of health professionals from developing countries to bring their own expertise to the UK and for them to return with enhanced training in fields and specialities not available at home. I would recommend that PMEBT undertake an urgent review of the training accreditation for doctors practicing within the field of International Health, both for those from the UK and those wishing to train further in the UK. Otherwise, we may shortly find that the UK government's aspirations to assist in the highest quality humanitarian care and international development is severely limited. Competing interests: None declared |
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Hilda Ho, specialist registrar Murray Royal Hospital, PH2 7BH
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Many medics aspire to work in the developing world with the intention of doing good; sharing our skills and knowledge,whilst adding considerable variety to our career and personal experience. The Department of Health White Paper published last month has made recommendations for the revalidation of doctors, which appear focussed on re-validation within the NHS. This is clearly appropriate as the paper seeks to address fitness to practice within the UK. The guidelines include re-licensure which would be subject to renewal every five years. Doctors who work overseas (are retired or taking a career break) will be able to maintain registration with the GMC, but have no legal right to practice in the UK. Individual doctors will need to discuss with the GMC whether they need a license or will be able to meet the requirements of revalidation in order to retain it. The appraisal process for re-licensing would include feedback from the doctor's medical director and GMC affiliate, annual appraisal and a positive confirmation of the doctor's entitlement to practice. For those on specialist or general practice registers, there is a further requirement for specialist recertification which the Department hopes to coincide with the five-yearly re-licensing cycle. Evidence would be collected in a comprehensive manner from employers, clinical audit, patient feedback, CPD, knowledge and simulator tests, or observation of practice. These proposals are designed for use within the NHS, to regulate doctors' practice within this system. It would make it difficult for doctors to maintain their licences and places on the specialist/GP registers, while working overseas. In developing countries, there may not be the structure in place for the comprehensive appraisal process required. For example, if you were the only UK trained specialist in an area, who would the GMC accept as a suitable appraiser? The health service in an area could be entirely different to the NHS, making it difficult to complete all parts of the professional assessment. Most NHS doctors who work abroad plan to return to work within the NHS. Would several years away make it impossible to return to a post comparable with others who have the same qualifications? Would the overseas experience count against you? Would it be seen as a period when you were essentially 'unappraised'? Some medics working overseas accept low wages, and supplement this with locum work during leave in the UK. Under the current proposals, this may cease to be possible, making it difficult for these doctors to sustain themselves and their families. Will the current proposals discourage doctors from participating in the global exchange of skills and experience that working abroad offers? It would be unfortunate if this were the indirect effect of proposals aimed at improving practice within the UK. It would be helpful if the Department of Health,GMC and Royal Colleges could set-out clear guidance on the revalidation process for those who take a 'break' from working in the NHS. It is essential that there is an acceptance of the flexibility that would be required. Competing interests: None declared |
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Malcolm E Molyneux, Director, Research Programme MLW, Box 30096, Blantyre 3, Malawi, Kevin Marsh, Nicholas J. White, Jeremy Farrar, Neil French, Nick Day, Sarah Rowland-Jones.
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We direct collaborative Programmes of medical research in low or middle-income countries, with support from UK and local institutions. In each site there is a team consisting of a mixture of local and international doctors, scientists and support staff. We aim to use high quality research to contribute to understanding local health problems and to finding ways to address those problems. We provide opportunities for local professionals to work with colleagues from UK and elsewhere, and thereby to gain experience and capacity to address their own problems in their own setting. UK doctors play a vital part in each of these Programmes. They contribute to the work, gain a wider perspective on international health problems, see a large range of disease problems, learn how to be resourceful, and contribute to advances against some of the world’s commonest health problems. We believe that such experience is of great value not only in the host country but for the individuals’ development as future NHS professionals. It is also of vital importance to the kind of international perspective commended in the Crisp Report. Most UK doctors spending a period of time in one of our research Programmes wish to return to a career in UK thereafter. If this re-entry is made difficult or impossible they are unlikely to come abroad in the first place. We believe that the individual, the NHS and the international community would all be impoverished as a result. We observe with great dismay the fact that MMC as currently formulated is likely to make it very difficult for a young doctor to spend a few years, or even one year, working in a developing country. We have each encountered young UK doctors who had hoped to visit our units for a period who have now withdrawn for fear of losing a place in the staffing structure at home. We enthusiastically commend the suggestion that a revised MMC should include mechanisms that not only permit but strongly encourage UK doctors to work in a developing country at some stage during clinical specialist training. This will, we believe, have enormous value for the individual, for the NHS, for global science and for international development. Malcolm Molyneux Director, Malawi-Liverpool Wellcome Trust Clinical Research Programme, College of Medicine, University of Malawi; and Professor, School of Tropical Medicine, University of Liverpool. Kevin Marsh Director Kenya Medical Research Institute ( KEMRI)-Wellcome Trust Programme , Kenya. Nicholas White Chairman; Wellcome Trust South-East Asian Tropical Medicine Research Programmes, and Professor of Tropical Medicine, University of Oxford Jeremy Farrar Director, The Hospital for Tropical Diseases Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Viet Nam Neil French Director, Karonga Preventon Study, Malawi, and London School of Hygiene and Tropical Medicine Nick Day Director, Wellcome Trust – Mahidol University – Oxford Tropical Medicine Research Programme, Bankok, Thailand Sarah Rowland-Jones, Director of Research, MRC Laboratories, the Gambia, and MRC Human Immunology Unit, Weatherall Institute of Molecular Medicine, Oxford OX3 9DS Competing interests: None declared |
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Elinor M Moore, SpR Infectious Diseases Northwick Park Hospital, London, HA1 3UJ
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I would like to support Whitty et al in their call for flexibility within MMC in order that UK trained doctors can experience working overseas for short periods. I am a Specialist Registrar in Infectious diseases and have spent two stints abroad which have helped me greatly in my professional development. The first overseas experience was at SHO level when I worked for 'Medicins Sans Frontiers' in Southern Sudan, and then subsequently at Registar level when I worked in Malawi as a lecturer in the College of Medicine. The experience I gained from both of these jobs has certainly helped me to become a better doctor in the UK, gaining many transferable skills that are difficult to obtain in the UK system. I meet so many medical students and young doctors who are itching to get similar overseas experience and it will be a great sadness if they are unable to do this within the new MMC system. Competing interests: None declared |
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Geoffrey Pasvol, Professor of Infection & Tropical Medicine Lister Unit Imperial College London, Northwick Park Hospital, HA1 3UJ, Peter Winstanley, David Mabey, Brian Angus, David Lalloo
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As representatives of our respective institutions in the United Kingdom that conduct research into tropical medicine and international health and which support UK clinicians who work overseas, we would like to endorse the editorial of Whitty, Doull and Nadjm (BMJ/24 MARCH/ 2007/VOLUME 334/pp595-6). We agree wholeheartedly that proposed changes to training and validation jeopardise the UK’s support of health care in developing countries. Some of our most talented doctors, scientists and research workers have worked abroad in resource-poor countries, making considerable contributions in both research and clinical practice. The NHS has also benefited when such individuals return to the UK, a point acknowledged by the Crisp report. We see an increasing number of young talented clinicians who express their desire to undertake such work. However, we are concerned that potential processes of revalidation and particularly, the beleaguered and inflexible programme of Modernising Medical Careers (MMC) make it difficult for doctors in training to work in resource poor settings, thus threatening these areas of international health in which the UK has, and continues to play, a leading role. We believe that research and collaborative work with institutions abroad can only enrich and improve the health of the poorest and most disadvantaged in resource-poor countries. We must ensure that the restraints of bureaucracy, increasingly imposed on the practice of medicine in the UK, do not hamper these efforts. Geoffrey Pasvol Peter Winstanley David Mabey Brian Angus David Lalloo Competing interests: None declared |
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prudence m hamade, leader international malaria working group MSF UK offices 67-74 Saffron Hill, London EC1 N8QX
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Dear Sir MSF UK (Medecins Sans Frontieres) sends an average of 75 doctors from the UK per year to medical field projects. This includes surgeons and anaesthetists as well as more generally trained doctors. MSF UK's HR department has been in contact with the GMC to try to resolve the problems related to revalidation and the new specialist training programmes but with little success so far in resolving the restraints raised by the new arrangements. Doctors gain immensely both in clinical skills, technical and operational research as well as life skills by a period spent abroad but most want to resume careers in the UK. This is becoming increasingly difficult and indeed in view of the new MMC arrangements almost impossible for doctors to leave the UK before the full specialist training has been fulfilled. The government has paid lip service to encouraging doctors to work in the developing world while making it virtually impossible to do so. MSF UK relies on volunteers who often work for between 6 months and two or three years in the field. We will be unable to continue sending UK based doctors and our work will have to rely on volunteers from other countries. This will be a severe loss both for the UK medical profession and for MSF as a whole. The government, the GMC and the BMA needs to take urgent action in this matter. Jean Michel Piedagnel Catherine Galliano Dr. Manica Balsegaram Dr. Prudence Hamade Dr Tom Ellman Medical Competing interests: None declared |
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Catherine H Roberts, SpR Microbiology and Infectious Diseases Hammersmith Hospital, Du Cane Rd, London, W12 0HS
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Modernising Medical Careers was set up in response to concerns that training doctors for a specified period of time wouldn't necessarily result in appropriate and thorough training. As such, competancy based training was introduced. This method of assessment creates a list of tick box competancies considered essential in a good doctor. However, this is a crude tool and does not allow assessment of how well a doctor is able to perform their duties. I was fortunate to take 6 months out of an SHO rotation to work as a clinician in a refugee camp on the Thai-Myanmar border. The time I spent in Thailand has been invaluable to my practice in the UK. I honed my clinical examination as there was a severely limited laboratory and radiology service. I learnt the meaning of being critically ill as there wasn't a handy Intensive Care Unit to back me up. Indeed, I learnt how by doing the basics well, it is possible to manage severe conditions with simple therapy. Most of all, I matured as a doctor. These are things that cannot be assessed by proforma competancies. I think it would be a shame, not only for individuals, but for the NHS and other countries, if doctors were prevented from working abroad in the future. Personally, I had hoped to work in Tanzania this year, but the lengthy and complicated application process through MMC has kept me in the UK. So, the effects are already being felt. Competing interests: None declared |
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Claire A L Davies, GP/travel health E8 4QJ
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The proposals on MMC and revalidation are disastrous for those who wish to work overseas. Many doctors wish to give up their time to work in developing countries. It is common for doctors to give up years to work on a volunteer wage for the experience and reward that comes from working in areas with very poor resources. The new regulations and career structure have completely ignored this aspect of clinical practice in the aim of mass producing a single brand of doctor who has no idea how any other health system works outside of the NHS. I find it difficult to see who exactly will benefit from this. Many resource-poor places have come to rely on a steady stream of volunteer doctors who come through well known and highly respected organisations like MSF, Merlin and VSO. In addition, many long term links have flourished between hospitals here and overseas. Doctors in developing countries are often isolated and lack support for their professional development. Such links have been invaluable in allowing them to continue working in these places where poverty is rife and drugs and equipment are rare. Many UK doctors who go overseas will wish to return to the NHS at some point. Those behind MMC and revalidation need to create mechanisms that allow doctors to continue humanitarian work without being forced to abandon their career in the UK. Competing interests: None declared |
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Colin Blakemore, Chief Executive Medical Research Council SG13 8AN, John Bell
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Your editorial Global health partnerships (BMJ 2007; 334:595-596 (4 March 2007)) highlights the valuable contribution that UK clinicians working in low-income countries can make to the health of the world’s poorest people. You rightly emphasise that high-level goodwill needs to be backed by practical support.
The Medical Research Council and The Wellcome Trust make a significant, long term commitment to research and capacity building in Africa and to follow-through into innovation in health policy and practice. But the job is obviously not finished. Nor will it be twenty years hence. In the context of MRC’s ongoing review of its strategy for research in Africa, voices from UK and African alike are calling for new kinds of equitable, sustainable partnership and for greater promotion of African research leadership. Such modern partnerships depend on easy mobility for talented and committed scientists and clinicians - to and from Africa. You are right to be concerned about disincentives to this essential mobility. In relation to revalidation, MRC with the Academy of Medical Sciences and Council of the Heads of Medical Schools responded jointly to the recent report by the Chief Medical Officer (England) Good Doctors, Safer Patients. The response included a call that overseas work be given full recognition in doctors’ appraisal and revalidation. Modernising medical careers (MMC) is a landmark for clinical research. The MRC and AMS share the MMC’s aim to ensure that academic competencies are more fully taken into account than appears to be the case at present, and to offer trainees a flexible training pathway. In addition, we strongly suggest that the MMC should encourage young UK doctors to spend time working in a developing country at some stage prior to or during their clinical specialist training, and the MMC should ensure that their re-entry into the UK’s training programme is not disadvantaged in any way. We continue to support greater access to UK research training for talented scientists and clinicians from low income countries, not least because of the insights they give UK science and the opportunities they generate for long-term international partnerships. It would be regrettable for the UK to lose such experience. And for the international community to be deprived of clinical, academic and teaching resources would be a travesty. All parts of the system must engage in the ambitious vision set out by Lord Crisp and the Chief Medical Officer and, before them, by the Prime Minister’s international Commission for Africa. Colin Blakemore FRS (Chief Executive, Medical Research Council) John Bell PMedSc (President, Academy of Medical Sciences) Competing interests: None declared |
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Darshan Sudarshi, Academic F2 Royal Surrey County Hospital, Brighton, UK (BN2 5BE)
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Like many other F2 doctors wanting to gain overseas experience I have received conflicting messages from MMC, “we really encourage you to gain overseas experience, but don’t go this year- stay in the system”... Therefore it was really encouraging to read the editorial by Whitty et al. Apart from the wonderful personal experience and transferable skills, there is the crucial humanitarian argument for UK doctors to become involved in this field. Strong interest already exists – through thriving organisations such as medsin (www.medsin.org) and alma-mata (www.almamata.net), medical students and junior doctors actively give up their free time to learn about international health – but there is a urgent need for scope in the new postgraduate curriculum. MMC can adapt and be more flexible in several ways: 1. Short-term 4 month (F2 level) a. Academic F2 programmes overseas - fantastic opportunity to learn about international health research and with potentially little impact on service delivery in the UK b. F2 programmes in International Health- 2 programmes already exist in London. A proposed third one was recently withdrawn due to lack of funding [1]. These need to be expanded and continued to specialist level. 2. Medium term 1 year> (ST level) There is great potential for young doctors to gain the necessary MMC competencies and more abroad at many of the tropical medicine centres- thus counting for one of their specialist training years. These are some simple ideas to show how the system can be more flexible. There needs to be a more systematic process of ensuring that young doctors continue to gain overseas experience, if we are to fulfil the objectives set out by Lord Crisp’s report [2]. 1. Nicholson et al. BMJ Careers 2007; 334: 23-25 2. Crisp Report 2007 Competing interests: None declared |
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Ed Cooper, Retired paediatrician London N4
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The Rapid Responses of 30th March produced something special under Global Health Partnerships: a letter from the seriously great and good - Chief Executive of the Medical Research Council and President of the Academy of Medical Sciences, followed by three letters from coalface workers showing the disastrous effects of Modernising Medical Careers as they are experiencing it. In the first letter Blakemore and Bell call for mobility between Britain and the rest of the world for clinicians while maintaining their career security, and they cite other calls for the same thing from other great and good people. The trouble is that in a giant organisation like the NHS "calling for" counts for nothing, even if the call comes from the Prime Minister or the Chief Medical Officer. Middle managers, that is nearly all of us, spend our days trying to discover what we are being directed to do (it is usually far from clear) and then trying to do it, usually with sufficient general awareness to know that this contradicts something else that we are being directed to do. A "call for" is not for the urgent to-do tray. MMC has arisen from a "call for", or consultation document, A Health Service of All the Talents, published in 2000, that I thought at the time was rather good. That call has now been translated, doubtless via almost uncountable directives through chains of middle managers, into the horror of MMC, 2007. The flexibility of the original call is now a depressing rigidity, and mediocrity is the ruling standard throughout. The Chief Executive of the NHS will just have to follow the call of his predecessor, Lord Crisp, and direct - I say direct - that time spent overseas is always to be counted as a strong asset in promotion or entry to further training, and that any NHS trust that has not made an effort to link with an institution overseas is going to have to explain itself to him. Competing interests: None declared |
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M Justin S Zaman, Research Fellow in Epidemiology and Honorary Specialist Registrar in Cardiology University College London
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This is an excellent piece on an important topic. As a cardiologist who aspires to be involved in reducing the global burden of cardiovascular diseases, I have had to become an academic to achieve these goals. 80 percent of deaths from cardiovascular disease worldwide and 87 percent of related disability currently occur in low-income and middle-income countries. As Dr C.L. Onen from Botswana wrote in Clinical Medicine, April 2004, ‘The world can ill-afford a global health system which, without parallel in history, concentrates on a few and neglects billions of people who carry on the largest burden of disease’. As one of the old ‘NTN’ generation, I found it difficult to combine international health and UK medicine 5 years ago and – laudable as some aspects of MMC are – see how it has rendered it even more difficult to combine such aspirations. Exchanges of health professionals can bring much needed expertise to poor communities and help improve access to appropriate health care. I aim to forge partnerships with researchers abroad to raise global awareness about health burdens and exchange knowledge and skills with them, in genuine partnership rather than benign paternalism. I hope to work in international cardiovascular epidemiology, especially in low-cost, high- yield diagnostic/management strategies. This I hope will not only be of benefit to those nations but also to my future NHS practice as a UK cardiologist. NHS/academia should support such aspirations in a reverse brain-drain ideology. Exposure to resource-poor health services abroad would provide relevant experience to aspiring NHS consultant interested in evidence-based health policy in the context of cost-effectiveness. We can ourselves in the developed world learn a great deal from less developed countries providing effective health care for a fraction of the cost. I think this type of thinking is of importance in a world in which we are beginning to appreciate the cons of technology and where we are all becoming more ever more connected across the globe in the face of increasing inequality. Competing interests: None declared |
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Stephen Tomlinson, Chairman, The Tropical Health and Education Trust (THET) THET, 210 Euston Road, London NW1 2BE
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Response to Editorial of 23 March by Christopher Whitty, Linda Doull and Behzad Madjm The Tropical Health and Education Trust (THET) strongly supports the concerns expressed by Whitty, Doull and Madjm about the importance of freeing up UK doctors from unintended restrictions on their ability to contribute to the Global Health Partnerships advocated by Lord Crisp in his recent report. THET is heavily involved in promoting such Partnerships, aimed at the training and continuing medical education of desperately needed health workers, and the building of long term healthcare capacity, especially in Africa. Unless that training and support for health workers can be delivered, the Millennium Development Goals will not be met. Nor will poorer countries be in a shape to cope with the rising burden of non-communicable diseases and trauma, as well as the great infectious killers. Although many of the health workers needed in the poorest countries are mid-level health officers and nurses, and much of the activity carried out by Health Links can take the form of relatively brief exchange visits, this is simply not enough. We know that doctors have an indispensable role in teaching, training and research, as well as dealing with the most complex clinical cases. In the poorest countries, any coherent health strategy that can offer hope must depend in part on a mixed economy of practical assistance from northern partners. The contributions of UK doctors working for between several months and a few years have been quite frequently the foundations upon which sustainable strategic initiatives have been built. They have also been an important factor in training the young African doctors who would otherwise struggle to move up the career ladder in their own countries. For the UK, the creation of such rich professional opportunities for its doctors has resulted in the acquisition of new clinical, managerial, leadership and cultural skills, and thus benefited not only the doctors themselves, but also the wider NHS. These mutual benefits for those with the greatest needs and those of us in the UK must not be put at risk. Hence, from the perspective of building the capacity to train and teach the health workers on which the future of developing countries rely – a major plank of UK international development policy - the obstacles to which Whitty et al have drawn timely attention must be addressed, as a matter of urgency. Prof. Stephen Tomlinson, CBE, Chairman, Tropical Health and Education Trust (THET). Competing interests: None declared |
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John S Yudkin, Professor of Medicine and former Director, International Health and Medical Education Centre University College London, London N19 5LW
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The discourse over the MTAS debacle is in danger of masking the problems posed by Modernising Medical Careers (MMC) itself for career flexibility. The widespread perception is that the new doctor needs to decide on a career choice during the 2nd Foundation Year, and once on the Specialist Training conveyor belt, is churned out 5 years later as a fully qualified specialist to practise until retirement. As one of my youg colleagues commented, a new meaning for ST depression. But fully qualified is not the same as fully rounded - many of the most interesting and creative and rewarding dctors are those who combine a number of different interests and skills. The system seems to be designed to disadvantage people who want to explore opportunities, or to spend time doing something else, whether a period of research, or working overseas, or even unrelated to medicine. The Intercalated BSc in International Health which started at UCL in 2001 has graduated 91 Alumni, and there are now similar BSc courses at Leeds and Bristol. These have helped generate an army of globally aware young doctors and senior students most of whom are keen to undertake a period of work overseas. Interestingly, a survey by the Alma Mata Network, comprising some 300 such people (www.almamata.net), has found that most of those wanting to work overseas intend to return to the UK, and that, were UK public health training more internationally oriented and flexible, this would be a popular career choice. Thus the fact that MMC has produced a collective paranoia about stepping off the conveyor belt might not only deprive the NHS of all the clinical and cultural skills which a period of overseas work generates, but also, paradoxically, seriously handicap recruitment to a problem specialty. The reports by Lord Crisp (1) and the Chief Medical Officer (2) recognise the importance of the UK and its health service contributing to global development. Yet, whether intended or no, the effects of MMC and MTAS are to pull up the drawbridges and recreate an Island Britain. 1. Crisp N. Global health partnerships: t he UK contribution to health in developing countries. London: Department of Health, 2007. www.dh.gov.uk/assetRoot/04/14/31/75/04143175.pdf 2. Donaldson L. Health is global—proposals for a UK government-wide strategy. London: Department of Health, 2007. Available from www.dh.gov.uk/PublicationsAndStatistics/Publications/ Competing interests: None declared |
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Christopher P Conlon, Chairman, Joint Colleges Committee on Infection and Tropical Medicine Nuffield Department of Medicine, John Radcliffe Hospital, Oxford, OX3 9DU
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I wholeheartedly support the sentiments expressed in your editorial on Global Health Partnerships and many who have responded to it. There is an extraordinary paradox between the Crisp report and the politically driven changes to the NHS. Doctors still want to come to the UK to undertake postgraduate training and increasingly there is a desire to formalise exchange programmes between UK training centres and institutions in the tropics. The recent changes in immigration law and the arrival of MMC (Modernising Medical Careers)have seriously undermined this and threaten to isolate British medicine. Lack of exchange of trainees is bad for education and training and narrows the perspectives of young physicians. In addition, foreign graduates have contributed greatly to the NHS ever since its inception. Many UK-trained doctors work in the tropics and carry out vital research to benefit directly populations in developing countries. Trainee doctors work in tropical units but most want to return to the UK, often to follow academic careers. MMC not only makes it difficult for trainees to 'step off the treadmill' to gain tropical experience but it is also anti- academic, offering no encouragement for periods of research. More recently the fiasco of MTAS (Medical Training Application Scheme)has not only limited choice for those with an interest in academic medicine and global health but has seriously disadvantaged trainees currently working abroad. The uncertainty of the interview process, late invitations to interview and an interview process spread over many weeks have all made it difficult for those abroad to get to the interviews when offered. Finally, the GMC (General Medical Council)is still not sure how to treat UK doctors working abroad in terms of revalidation. Current suggestions that those working abroad can remain on the register but only be licensed to practice when back in Britain are far from ideal. It is hardly acceptable for a UK doctor on the GMC register to do clinical work abroad when not licensed to practice in the UK. British medicine has to campaign to restore sanity to the current process of change so that global health partnerships can continue to be productive for training, education and research. The recommendations of the Crisp report need to be supported by doctors and politicians. Otherwise we will be irresponsible and isolated. Competing interests: None declared |
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Nick J Beeching, President, British Infection Society Tropical and Infectious Disease Unit, Royal Liverpool University Hospital, Liverpool L7 8XP, Harriet C Hughes, Nashaba S Matin, Lionel K Tan
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The British Infection Society welcomes and endorses the recent editorial by Whitty and colleagues [1]. The ensuing rapid responses, from both trainees and national and international authorities, reflect the anxiety and anger felt at every level of the medical profession about the recent implementation of MMC training reforms and the MTAS process [2]. These concerns apply particularly to those training and practising in the infection specialties, where there has been an increasing trend towards joint training at SpR level in clinical microbiology/virology and infectious diseases. Excellent flexible training schemes, which cross the traditional boundaries between clinical practice and laboratory-based practice, have been carefully nurtured by the relevant Royal College Committees and Specialist Societies. It is paradoxical that the driver for this process has been the need to ensure that the next generation of infection specialists have the broad training which best meets the needs of the Modern NHS – a goal presumably shared by MMC. Sadly the reality of MMC threatens to set this process back by 10 years, by polarizing views about the level of experience and competencies acceptable for entry into training in clinical microbiology or virology, either after F2 or at ST3 level. Many trainees still wish to reach MRCP or similar level before entering pathology training, and this has become difficult. In addition, trainees in infection disciplines often support themselves through relevant training and examinations such as the Diploma in Tropical Medicine and Hygiene by doing locums or other short-term appointments. Such opportunities could be diminished by inflexible application of MMC and MTAS procedures. The tropical medicine training pathway, with infectious diseases, has been preserved with difficulty and the infectious disease curriculum has always allowed for accreditation of short periods of experience abroad. Trainees are often attracted to the infection disciplines by the opportunity to work overseas, returning to the NHS with enhanced clinical skills, a wider view of the world and continuing links with colleagues overseas that are mutually beneficial for both training and clinical research. Similarly, many others work overseas with humanitarian and other organizations and return to work in a wide variety of medical disciplines in the UK. The introduction of new regulations last year and continued uncertainty about the legal position of overseas applicants for training posts has made it extremely difficult for Britain to fulfil its historical international leadership role in training postgraduate specialists of the future for many countries. We are aware of many excellent doctors who could also have contributed to British practice, as their predecessors have done for decades, and who are already looking to other countries for their training. This will also deprive the UK of links that have been so beneficial for British trainees, at the same time as British trainees are being discouraged from seeking overseas posts. Meanwhile, many British trainees have felt obliged to return prematurely from overseas posts, or have not travelled this year, so that they can be available for whatever weekly decision is made about MMC/MTAS. The British Infection Society strongly supports the efforts of trainees to ensure that applicants for posts are treated in an equitable fashion across the whole of the UK. For the future, we hope that all those implementing MMC, including programme directors, deaneries and schools of medicine, will be empowered to allow flexibility in design and implementation of training programmes at all levels, to allow continued bilateral exchanges of clinical and scientific experience internationally. Without this, we will rapidly lose our international pre-eminence in the field of Tropical Medicine and lose contact professionally with many of our friends and colleagues throughout the world. The suggestion by Cooper to encourage specific links between NHS institutions and overseas locations would help towards this goal [3]. Meanwhile, overseas experience must be recognized at the highest level for the value that it brings to all medical specialties in the NHS. Nick J Beeching President Harriet C Hughes Training grade representative Nashaba S Matin Training grade representative Lionel K Tan Training grade representative British Infection Society www.britishinfectionsociety.org References 1. Whitty CJM, Doull L, Nadjm B. Global health partnerships. BMJ 2007;334:595-6 (24 March) 2. Brown M, Boon N, Brooks N, Brown E, Camm J, Caufield M et al. Modernising Medical Careers, Medical Training Application Service, and the Postgraduate Medical Education and Training Board: time for the emperors to don their clothes. Lancet 2007;369:967-8 (24 March) 3. Cooper E. Global partnership. NHS chief must direct that time overseas is an asset. BMJ 2007;334:761-2 (14 April) Competing interests: None declared |
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James A G Whitworth, Head of International Activities Wellcome Trust, 215 Euston Road, London W1N 2BE, Mark Walport
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The Wellcome Trust is a major funder of biomedical research in developing countries. In 2005 over £100 million was committed to study HIV, malaria, tuberculosis and other neglected diseases. A significant proportion of this funding supports clinical researchers from the UK living and working in developing countries. We share the concerns raised in the editorial by Whitty et al, and in subsequent correspondence from the heads of major UK overseas reasearch programmes, the MRC and Academy of Medical Sciences, the schools of tropical medicine and many individual senior and junior clinicians. Both MMC and accreditation schemes are erecting new barriers that make it increasingly difficult for UK clinicians to undertake the research projects and programmes that are vital to efforts to improve the future health of populations in the developing world. Building flexibility into MMC, accreditation and revalidation processes is essential to maintain this area of current excellence which the UK does so much to assist in improving global health. It would be a retrogressive step to allow these new measures to undermine the work and career progression of dedicated clinical researchers working in the developing world. Competing interests: The authors are employed by the Wellcome Trust which funds UK clinicians to work in developing countries |
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Alastair McGregor, SpR Infectious Diseases Royal Free Hospital
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As Whitty et al indicate, the contribution made by British doctors in research, education and medical aid in the developing world is very considerable. This, combined with a history of foreign doctors working as trainees in the UK, has lead to the creation of extensive and mutually beneficial links between clinicians and researchers in the UK and developing countries. These links extend to some suprising places, as I found when working with an NGO in Myanmar. Even there, in an infamously isolated and deprived setting, doctors were sitting English exams, revising for the PLAB and MRCP and trying to find a way to train for a while in the UK. The Burmese doctors I worked with had their plans summarily cut short when permit free training was suspended. Without a drastic rethink, an inflexible MMC will destroy the ability of junior doctors to spend time abroad and will (already has) prevent foreign doctors from training here. These links are mutually beneficial - it would be a shame to so carelessly ruin them. Competing interests: None declared |
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