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ANALYSIS: Graham Winyard Medical immigration: the elephant in the room BMJ 2007; 335: 593-595 [Full text]

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Moving the goalposts during the match. Is this the end of meritocracy?

Jyothis T George   (22 September 2007)

Full House

Jorge Zimbron   (22 September 2007)

Medical Immigration: not a sensitive matter

Sudheer T Lankappa   (23 September 2007)

Look within ourselves.....

Mayank Vashishtha, YO31 8JT   (23 September 2007)

The Real Elephant in the Room

Joydeep Grover   (23 September 2007)

The elephant spotted at last!

Meena Shankar, KT2 7QB   (23 September 2007)

Silver Lining

Andrew Montgomery   (24 September 2007)

The real elephant in the room

Mohammad Farhad Peerally   (24 September 2007)

Certainly no Dumbo

Milan M Thomas   (24 September 2007)

IMGs had illegal rights to compete??

Lena Palaniyappan   (24 September 2007)

Medical Immigration is self limiting

Stephen H Raymond   (24 September 2007)

Wake up please BMA and medical students

edmund willis   (25 September 2007)

Re: Wake up please BMA and medical students

Jay Ilangaratne   (26 September 2007)

Re: Wake up please BMA and medical students

Mayank Vashishtha   (26 September 2007)

I am better than you are

Jayaprakash Ayillath Gosalakkal   (26 September 2007)

Howl!

David R Jarrett   (26 September 2007)

Emigrate to Germany

Andre Lagrange   (26 September 2007)

A few solutions for the immigration issue

Arun Natarajan   (27 September 2007)

Refugee Doctors - The Elephant in the Room - Should Postgraduate training places be reserved for UK Graduates?

Maeve Keaney   (28 September 2007)

We got to find an amicable solution

Umesh Prabhu   (29 September 2007)

Competition is good for patients

Martin Zinkler   (2 October 2007)

Re: We got to find an amicable solution

Jay Ilangaratne   (2 October 2007)

some overseas medical schools are inferior

edmund willis   (10 October 2007)

Re: some overseas medical schools are inferior

anand fernandes   (15 October 2007)

A reasonable concern

Madhukar Kumar   (16 October 2007)

Moving the goalposts during the match. Is this the end of meritocracy? 22 September 2007
Jyothis T George, Specialist Registrar, Diabetes and Endocrinology, York Hospital, York, YO31 8HE Send response to journal: Re: Moving the goalposts during the match. Is this the end of meritocracy?	Graham Winyard highlights in his analysis that the rights of overseas doctors already in the system must be safeguarded. It is therefore disappointing when the author goes on to argue that the Highly Skilled Migrant Program(HSMP) should be suspended. Increase in the number of UK graduates as a result of increase in medical school places was entirely predictable. (1) The HSMP programme existed well before turbulence hit the medical unemployment market and offered additional eligibility points for some doctors. Promoted widely across the world (2) with invitations coming from none other than the Prime Minister himself (3), it is hardly surprising that a number of overseas doctors migrated to the UK. Doctors on HSMP scheme had to make a declaration of their intention to make the UK their main home and in return were offered permanent residence in the UK after four years. Part of the attractiveness of the UK as a training destination has been the stated policy of providing equal opportunity for all applicants. It was in open competition with other applicants, overseas doctors obtained training positions. The one-third prevalence of overseas doctors in training positions is reflective and proportional to the number of overseas trained General practitioners and specialists employed by the NHS. (4,5) To victimise a group of young doctors who were invited by the government to move to the UK is unfair. Winyard is rightly concerned about a "betrayal of the legitimate expectations of those who entered UK medical training in recent years." Suspending HSMP program would equate to similar betrayal of legitimate expectations of overseas doctors and the joint House of Commons and Lords Human Rights Committee has characterised such moves as "moving the goalposts during the match" and "unlawful". (6) NHS employers, patients and fellow professionals all want the most- skilled doctors to look after the unwell. The suggestion to exclude "overseas doctors with substantial specialty experience" purely to accommodate the needs of foundation trainees could be seen as protectionism and disregard for meritocracy. The influx of overseas doctors the United Kingdom has already decreased (7) and the primary reason for non- EU doctors to migrate to the UK is post-graduate training. (7) The medical fraternity should avoid being a victim of divisive politics. 1) Department of Health. Medical schools: delivering the doctors of the future. London: DoH, 2004. 2) Department of Health. Special envoy to show the world the best of the NHS. 2002 Feb 27. www.prnewswire.co.uk/cgi/release?id=81207www.prnewswire.co.uk/cgi/release?id=81207 3) Department of Health. Opportunities for doctors in England and Wales. 2003 March 1 www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4086975 4) Country of training and ethnic origin of UK doctors: database and survey studies. BMJ 2004;329:597 (11 September) 5) Department of Health. Staff in the NHS 2003. www.publications.doh.gov.uk/public/nhsstaff2003.pdf (accessed 6 Sep 2004). 6) Tougher migrant rules 'illegal' http://news.bbc.co.uk/1/hi/uk_politics/6937329.stm 7) Non-European Union doctors in the National Health Service: why, when and how do they come to the United Kingdom of Great Britain and Northern Ireland? Human Resources for Health 2007, 5:6 Competing interests: None declared
Full House 22 September 2007
Jorge Zimbron, Academic F2 Institute of Psychiatry at the Maudsley Send response to journal: Re: Full House	Dear Editor, I would like to commend Dr. Graham Winyard on his recent article for reminding us of the issues surrounding medical immigration and the important role they play in the current recruitment situation. I would like to challenge a couple of points, though. He argues that the BMA is being ‘ambiguous’ in criticising both, the MTAS fiasco, and the changes in immigration policy. He implies that it is incongruent to do so, as stopping immigration is necessary for the system to run adequately. Although this is somewhat true, the BMA is not lobbying for the rights of future immigrants, but for the rights of current immigrants who have been unfairly forced into exile by the new immigration rules. They deserve nothing but praise for this. He also mentions that the UK currently has ‘the worst of all worlds’ as it invests in expanding medical schools and still recruits people from overseas, only to fail to give them all a job down the line. But this is actually quite clever. In the end, what you get is a large surplus of intelligent, well-intentioned, overqualified people with no transferable skills, thousands of pounds in debt, desperately seeking for a job in the one company who holds the monopoly for employing their services. It’s the best of all worlds, really, and any company in the private sector would kill for this. The way forward is clear. The house is full, so please shut all the doors. All of them. Not only permit-free training, but HSMPs, PLABs, and all entry to UK medical schools by overseas students aspiring to stay in the UK. The fact that all these structures still offer false hope (and charge heavily for the privilege) is nothing but cruel. But what about those already inside? Would it be too much to let them stay? Even if it means a little more competition? After all, they did help to build the house. Competing interests: Jorge Zimbron is an overseas UK graduate unlikely to be able to apply for specialist training next year.
Medical Immigration: not a sensitive matter 23 September 2007
Sudheer T Lankappa, Clinical Lecturer Longley Centre, Norwood Grange Drive, Sheffield S5 7JT Send response to journal: Re: Medical Immigration: not a sensitive matter	Dear Editor, Once again the current edition of BMJ has highlighted some of the issues surrounding International Medical Graduates (IMG) and Immigration. Parallel to the expansion of medical schools during late 90s General Medical Council changed the examination formant of Professional and Linguistic Assessments Board(PLAB) and increased overseas exam centres. This led to increased number of IMG’s in training grade, who worked on permit-free training visa. However, over the last few years various professional bodies and organisations’ have raised concerns about unemployment in general and also relating to difficulties obtaining job by IMG’s. Sudden changes to immigration rules including the removal of permit free training visa proves that these issues have been addressed, contrary to Mr Winyard’ s statement “immigration is sensitive matter, they remain little discussed". If IMG’s knew about the difficulties before taking PLAB they may have considered other options, like training in their own country or obtaining post in an another country. As the author points out with the current system of recruitment for ST around 29% are IMG’s (with and without HSMP). The employers’ perspectives, such as reasons behind recruiting IMG’s should be looked before considering any changes to current system. PLAB in its current state may not be fulfilling the objective hence some amendments should be considered. As staying in UK for months without job and returning home with more debts is not an affordable exercise. Changes in immigration rules without adequate notice will created uncertainty and may impact professional functioning. Hence any changes should be well informed with adequate time. Competing interests: I am an IMG on HSMP Visa.
Look within ourselves..... 23 September 2007
Mayank Vashishtha, Specialty Registrar, Surgery Yorkshire Deanery, YO31 8JT Send response to journal: Re: Look within ourselves.....	Its a great relief to see the discussion on medical immigration out in the open finally. As an International Medical Graduate(IMG), I had been waiting for this since March 2006. Ever since the 2006 changes, medical staffings across the UK have made assumptions and their own conclusions and applied immigration rules to recruitment, sometimes unfairly until the national recruitment in 2007. For my British colleagues who may not be fully aware of the UK immigration rules, lets have a look at some of the basic doctors' related immigration policy changes in UK before being judgemental about who to blame for 2007 fiasco: 1) Till March 7,2006, non-EEA doctors in UK posgraduate training were on permit free training (PFT) which gave them equal standing to UK/EEA candidates in job interviews. Please note that this was irrespective of the duration of leave to remain (visa expiry)on their passports. 2)On March 7, 2006, The (department of health)DoH ended PFT with immediate effect and no prior notice. This meant IMGs would need a work permit to take up training posts which meant that they have to pass the " RESIDENT LABOUR MARKET TEST (RLMT)" before they were appointed. However, in the press release on this date, the DoH mentioned the Doctors on the HSMP could take up any job on offer, without having to go through the RLMT. (The RLMT means that it has to be proved by the employer that a non- EEA person is being appointed to a post as there is no suitable candidate from within the EEA to fill the vacancy) 3)In the Explanatory Memorandum HC 1702 (http://www.ind.homeoffice.gov.uk/lawandpolicy/immigrationrules/explanatorymemohc1702) of the immigration rules, it is clearly mentioned that applicants succesful in obtaining entry on the Highly Skilled Migrant Programme (HSMP) are "given free access to the UK labour market" and that the scheme is a route to settlement in UK. Free access to the UK labour market means exemption from RLMT, hence equal footing with UK/EEA applicants. 4) The HSMP is granted initially for 2 years and extended for another 3 years subject at the end of which one can apply for permanent residence in the UK (indefinite leave to remain and work in UK) 5) There is no mention to discriminate in the immigration rules on the basis of the duration of leave to remain in the country as this would invalidate the essence of the HSMP i.e. if non-EEA HSMP holders are discriminated in job opportunities as they do not have the leave to remain for full duration of the training programme, this means that their access to UK job market is restricted (which should be unrestricted or free access for HSMP holders). 6) The DoH got entangled in a mess created by itself when it ended PFT and failed to notice in the first instance in March 2006 the rights of doctors on HSMP and again when it further amended ruled for 2007 recruitment to prevent HSMP holders from competing for training jobs (by inserting the clause about leave to remain and trying to restrict the access of job market for HSMP holders) 7) Judicial intervention resulted in the HSMP holders being treated with the dignity they deserve and be considered on merit in 2007 recruitment. 8) Of note is the fact that HSMP is not occupation specific i.e. HSMP holders can be doctors, engineers, software professionals or anyone as long as they qualify for the scheme. In the new points based system of immigration, HSMP corresponds to Tier-1 of the immigration category in its essence. Also of note is the fact that persons on dependent visa of an HSMP holder (eg. spouse) enjoy the same working rights in UK as the HSMP holder. Discussion: 1)Its a legitimate expectation of anyone on HSMP to have free access to UK job market: this right has been tried to be curbed by the DoH. This has lead to resentment in this group and some even feel like being treated as illegal immigrants. 2) To gain entry on the HSMP, one has to sign a declaration that "I intend to make UK my main home". Signing this involves not only making a commitment to this country, but also leaving behind one's establishments and rejecting other opportunities in the home country or elsewhere in the world to make UK one's home. Making an intercontinental move involves re- establishing family life in a new country (UK) and getting one's children into schools etc. 3) If the UK has respect for EU laws (which have been quoted time and again in the article to club together UK & EU graduates into one category), why does it not respect its own laws and the promises it made to highly qualified people supposed to be the world's best and selected after careful scrutiny for entry into the HSMP??? The non-EEA doctors seem to have to prove themselves again at every step (which helps them get better each time). Being on the HSMP is not enough it seems, this group constantly finds its rights curbed, itself being blamed for training of the MTAS fiasco. 4) The UK at this time is debating on how to integrate immigrants into society. However, its current treatment of the most skilled of legal immigrants who are likely in future to lead their individual communities and mould their opinions in this country doesn't reflect this intention. My unreserved opinion on job opportunities for 2008 and beyond: 1) In near future, strict steps should be taken to ensure equal standing of those IMGs whose are on HSMP already within the NHS training system(employed or unemployed) with the UK/EEA candidates as this is only fair and legitimate and will in long term have the positive effect of a better amalgamated society. This will increase the competition, but is a just way to take things forward. At the same time, entry of new non-EEA doctors in UK should stop although exceptions to this will be new non-EEA doctors who marry a doctor on HSMP and come to UK- I believe this group should have equal rights as their spouses. 2)At the same time, an IELTS (International English Language Testing System) score of 7/9 which is a minimum for a non-EEA doctor to work in UK should be made mandatory for EEA doctors as well as its only fair and important for patient care. 3)In the long term, UK graduates should have priority over anyone else (including EEA and non-EEA doctors) for training jobs. It is important to make policy changes to this effect because as long as doctors training post come under the "employment category", employment laws shall apply to them which gives both HSMP and EEA doctors an equal footing with UK graduates. However, if these posts are considered as "training category", and even then UK and EEA are considered as one group having priority over non-EEA, this would smell strongly of racism and would be highly unfair. To conclude, although past behaviour is a strong indicator of future behaviour, I hope the DoH would not repeat what it did in March 2006 and Feb 2007 by treating non-EEA highly skilled professionals as trash. Competing interests: An International Medical Graduate from India training in the UK, successful in 2007 recruitment round 1 and on the HSMP immigration category
The Real Elephant in the Room 23 September 2007
Joydeep Grover, Senior Registrar, Emergency Medicine, Severn Bristol Childrens' Hospital, BS2 8BJ Send response to journal: Re: The Real Elephant in the Room	I am surprised at the conclusions the author has drawn from the data available to him. Firstly he has absolved MTAS of misgivings. MTAS had many failings: it was too straight jacketed, gave precedence to a tick box approach, had questions raised about it's scoring mechanism, was not validated or trialled, and largely proceeded without any consultation with interested parties. There were many flaws and these were clearly mentioned in the judgment of the judicial review brought in by Remedy UK. The judge, Hon. Mr. Justice Goldring, on giving his decision stated that "the premature introduction of MTAS has had disastrous consequences." Many junior doctors had "an entirely justifiable sense of grievance" and he raised the spectre of thousands of disappointed young doctors heading for employment tribunals. (1) Secondly he has roundly blamed 'immigration' for the current status. Sadly it is not immigration to blame, but abject failure of workforce planning. He correctly states that training numbers in UK medical schools were increased in the late nineties. He also correctly states that overseas doctors were encouraged to bolster the NHS with up to 30% of junior doctors being from overseas. This immigration happened at the behest of the government which was very keen on 'improving' medical care and 'modernising' the NHS and was definitely playing catch up by addressing obvious workforce shortfalls. By 2003 it was clear that supply was outstripping demand, and many overseas doctors had difficulty finding work in the NHS. However by 2006 there was already a significant number of overseas doctors who had been employed in the NHS for several years, and who had already made or were in the process of making UK as their main home. Many of these were forced to uproot and return when PFT (Permit Free Training) was abolished, again without any consultation with affected or interested parties. When the DoH realised the possibility of HSMP holders being able to compete for training posts, this was subverted in a variety of ways viz: requirement of time unlimited visas and visas obtained before a particular date. Both these government actions were challenged by BAPIO in it's own judicial review appeal and this led to a compromise situation where some HSMP holders were allowed to compete for training posts. The case is still sub-judice pending an appeal. His data shows that the proportion of overseas graduates in training reduced from 42% to 29% post MTAS and at the same time the proportion of UK graduates in training rose from 58% to 69%. This can be attributed to the success of the measures that the DoH applied on overseas doctors, though as stated above, these were more underhanded in nature. It is obvious that the government failed to plan on the number of doctors it needed on many occasions. Firstly in the workforce review in 1997 (2), then by not limiting the influx of overseas doctors from 2003 to 2006, and finally by planning the MMC reforms without taking heed of ground realities. (3) The victims are all doctors, whether UK or overseas trained. He fails to suggest any concrete suggestions for improvement. Stopping HSMP will be grossly unfair and unjust. Creating more training jobs will only defer unemployment by a few years, producing a cohort of trained specialist doctors with grim prospects of finding jobs in the NHS. It is time to bite the bullet and realise that close to 30% of current junior doctors in UK will remain out of training mainly because of poor workforce planning and even more unjustly due to the flawed MTAS. Furthermore the doctors currently in training will find it grim going when they arrive towards the end of their specialty training when it may turn out that the promised consultant expansion fails to materialise. We must make the NHS independent of the government direction and stop playing it's politics. Otherwise in a few years we will then look back at 2006, the woeful workforce planning, and play the game of blaming immigration, royal colleges, PMETB, BMA and suggest divisive theories instead of looking at the real elephant in the room, an interfering, compulsive, self serving and reactionary government playing political games. (1)Case no. CO/3360/2007, Royal Courts of Justice, Strand, London. 22/05/2007 (2)Medical Workforce Standing Advisory Committee. Planning the medical workforce: third report. London: DoH, 1997. (3)MMC: mass medical culling [editorial]. Lancet 2007;369:879 Competing interests: International Medical Graduate
The elephant spotted at last! 23 September 2007
Meena Shankar, Consultant obstetrician and gynaecologist Kingston Hospital, KT2 7QB Send response to journal: Re: The elephant spotted at last!	Nothing could be closer to the truth than Graham Winyard's analysis of the current medical graduate unemployment crisis. I am pleased that the BMJ has published this article as I believe medical immigration is a matter of extreme importance that has to addressed urgently for the professional well being of both UK and international medical graduates. It is unfair that a country like UK which has a system of well founded medical schools forces its graduates (after long and intense training) to compete with graduates from the rest of the world and face unemployment. As mentioned by Graham Winyard in the nineties more than a third of the training grade medical workforce comprised of overseas doctors, but they were the filling the shortfall that existed then. Medical school numbers were increased, understandably, to create self- sufficiency but immigration laws were were put in place too late to avoid the increased supply over demand that has now resulted. Conflicting immigration laws prevent UK graduates from getting a preferance in appointments for training post and it should be the obligation of the system to give them that preferance. I am an immigrant doctor who came to this country, by choice, during the shortall years and I for one would have felt cheated if I had faced a similar situation when I finished medical school in my country of birth and undergraduate education. Competing interests: None declared
Silver Lining 24 September 2007
Andrew Montgomery, locum New South Wales, Australia Send response to journal: Re: Silver Lining	I find the position in the UK utterly bizarre. New Zealand and Australia face a severe shortage of doctors willing to work in prinary care and emergency medicine. I am unsure as to the position with regard to "specialist" training posts - but do know, for example, that it is difficult to find specialists in O&G and Psychiatry. I also know that the Australasian basic medical training is of the highest standard in the world and that there is endless highly paid and interesting work "down under" in the aforementioned disciplines. Australia and New Zealand both enjoy a better climate and lifestyle than the UK. Any UK doctor who feels short changed will be welcome down here with open arms. Few would regret the move. Competing interests: None declared
The real elephant in the room 24 September 2007
Mohammad Farhad Peerally, 4th year Medical Student University of Sheffield Send response to journal: Re: The real elephant in the room	While Mr Winyard has successfully given us a very explicit view of the situation of postgraduate medical training in the UK, one area he has missed is that of non-EU UK medical graduates. These students make up about 15 % of the medical undergraduate population and UK medical schools depend on their financial backing to survive. Each student would have forked out a minimum of £80,000 by year 5 of their course, excluding costs of living - and they chose Britain knowing the rules when they started medical school - which would have allowed them fair access to postgraduate training. Now since April 2006, with the abolition of permit-free training, these students, who many are in 5-10 times more debt than local students are left in limbo with a strong feeling of breach of moral contract. What I fail to understand even more is the fact that these non-EU british medical school students are included in all the figures used by the Department of Health/Foreign office when accounting for UK graduates and yet judged as "international medical graduates" when applying for jobs. What the tax-payer should also know is that inspite of international students paying a minimum of £80,000 for his training, it costs about £250,000 to the tax-payers to train every single one of them. If priority is to be given to UK graduates in the allocation of postgraduate training posts, it only make sense that all UK graduates are accounted for - including non-EU UK graduates who after 7 years of training in the UK, inspite of the colour of their passport, consider the UK as their home. Competing interests: I am an international medical student in a British medical school.
Certainly no Dumbo 24 September 2007
Milan M Thomas, Urology FTSTA 2 Queen Elizabeth Hospital, Woolwich, SE18 4QH Send response to journal: Re: Certainly no Dumbo	Dumbo used his big ears to fly. Unfortunately the “big elephant in the room” in Graham Winyard’s refreshingly poignant analysis regarding the impact of migrant doctors on unemployment for UK medical graduates[1] will not take off easily unless there is serious open discussion. Many UK graduates, like myself are now tending to the wounds inflicted by the implementation of MMC, which, as Parashkev Nachev exemplified[2], was merely a poorly construed whim made by the Department of Health2. With specialty recruitment set to get harder for applicants in August 2008[3], we are all facing even greater uncertainty, which is having a negative impact on current training and work. I believe this country’s huge investment into training doctors is being wasted in putting UK juniors in service jobs whilst oversees doctors are still eligible to take up training posts. Should it now be appropriate to limit round 1 applications to those trained in the UK alone? Furthermore, during this year’s recruitment, overseas graduates increased their chances of success by applying to a lower specialty training level even with years of experience, which was not recognised by the Colleges. This was much more pronounced in the, practically based, surgical specialties. We still await full clarification of 2008 recruitment plans. Now is the time to clarify what all junior doctors currently working in this country should expect in the impending months. To avoid this would allow the same last-minute decisions that plagued the continuously evolving 2007 recuitment process and the huge life-changing plans that both UK and overseas doctors had to make in literally days. Milan Thomas FTSTA urology, Queen Elizabeth Hospital, Woolwich, SE18 4QH milanthomas@nhs.net 1. Winyard G. Medical Immigration: the elephant in the room. BMJ 2007; 335:593-595 (22 September) 2. Nachev P. MTAS or a tale of evidence heedless medicine. BMJ 2007; 335: 615 (22 September) 3. Munn F. Juniors face harder contest for training posts next year. BMA News (22 September, 2007) Competing interests: None declared
IMGs had illegal rights to compete?? 24 September 2007
Lena Palaniyappan, ST3 RVI, Newcastle, NE1 4LP Send response to journal: Re: IMGs had illegal rights to compete??	Quoting Winyard "There were broadly sufficient posts to accommodate UK applicants, together with those from the rest of the European Economic Area (who have clear legal rights to compete for posts on equal terms under European law)," Did IMGs apply through MTAS illegally?? or did IMGs have unclear legal rights? ? can you clarify this - Author & Editors? Competing interests: IMG
Medical Immigration is self limiting 24 September 2007
Stephen H Raymond, Staff Specialist in O&G Royal Hobart Hospital, Hobart, Tasmania Send response to journal: Re: Medical Immigration is self limiting	If the availability of posts in the UK goes down, or even if it is perceived that it has gone down, those doctors considering leaving their home countries for the UK will realise that there is a poorer chance of obtaining a post than there was, and make other choices. In other words it will soon become general knowledge that it is no longer as good an option to go to Britain as it once was. There will then be a reduction in overseas doctors applications. Whether ultimately this will solve the problem remains to be seen. Competing interests: None declared
Wake up please BMA and medical students 25 September 2007
edmund willis, GP Brigg n lincs 53 bridge street brigg north lincs dn20 0rg Send response to journal: Re: Wake up please BMA and medical students	Graham Winyards article sets out clearly the crisis facing young doctors today, as a result of the governments incomprehensible failure to restrict immigration of doctors from poor countries who are being drained of their medical expertise. He also makes it very clear that rising numbers of medical graduates will make the crisis dramatically worse in the very near future. I am part of an expensive sophisticated system of medical student education - which takes great pains to ensure that our graduates are very well trained and very good at communicating with patients. We are now working in the knowledge that many of our students will be unable to acheive a career in medicine, the jobs having been taken by overseas graduates who have qualified from much more primitive systems of medical education. Unless the medical schools and the BMA act now - to make the government stop the highly skilled migrant programme, and restrict (like france and germany) the immigration of EU doctors - many of whom have poor language skills and a medical education with little patient contact. Competing interests: teacher at hull york medical school
Re: Wake up please BMA and medical students 26 September 2007
Jay Ilangaratne, Founder www.medical-journals.com Send response to journal: Re: Re: Wake up please BMA and medical students	Dr Willis says "We are now working in the knowledge that many of our students will be unable to acheive a career in medicine, the jobs having been taken by overseas graduates who have qualified from much more primitive systems of medical education." However, in this week's Career Focus[1]it is reported that "Despite worries that people who can't secure training posts under the new Modernising Medical Careers programme are going to try their luck overseas, figures from the General Medical Council on how many trainees have successfully been awarded a certificate of good standing (essential if applying for work overseas) show that for the first half of the last three years there's been very little change in the number of applicants".At least such evidence[1] does not support the notion that UK trained graduates would suffer unprecedented unemployment in future years as indicated in the editorial[2] and echoed by Dr Willis. Further, while Dr Willis seem very willing to blame "overseas graduates" for taking the jobs of UK trained graduates,he clearly had failed to provide any hard evidence to support his rather bold assertion.Perhaps, Dr Willis had expressed a personal concern rather than evidence-based facts in this regard. Dr Wilis had also felt apt to describe overseas doctors as a group "qualified from much more primitive systems of medical education".It is regrettable that Dr Willis' remarks give the impression that all overseas qualified doctors emanate from "primitive systems"; I would think, it would be sensible for him to reflect upon his brash statement especially as he claims to be involved in teaching medical students.Based on the said assertion, I wonder whether Dr Willis considers his colleagues at the Hull-York Medical School who have qualified overseas,originate from "primitive systems" of medical education and they too, have "taken" the jobs destined for UK trained graduates? Finally, I hope, the views expressed by Dr Willis are not those of the Hull-York Medical School. References [1] Storm in a tea cup?(http://careerfocus.bmj.com/cgi/content/full/335/7620/104) [2]Graham Winyard Medical immigration: the elephant in the room BMJ 2007; 335: 593-595 Competing interests: None declared
Re: Wake up please BMA and medical students 26 September 2007
Mayank Vashishtha, Specialty Registrar York District Hospital Send response to journal: Re: Re: Wake up please BMA and medical students	Dear Mr Willis I am disappointed by the grim view you take of the standard of medical education in other countries, and I am more surprised by this coming from someone holding an office at a medical school. There is no doubt that the British medical schools produce excellent graduates, but at the same time you need to realise that before they can work in the NHS, IMGs are tested for language skills (IELTS minimum score of 7/9), as well as knowledge and skills (PLAB parts 1 & 2 respectively). On top of this, those who succeed in securing coveted training jobs are the best of IMGs in the UK. Your judgement call generalising quality of training in non british medical school is disaapointing. At the same time, I agree with your suggestion of policy changes to give British graduates priority over EU/Non-EU doctors, however I strongly oppose being unfair to doctor's already on HSMP who have clear rights to free access to UK job market and support their equal standing for all jobs as they have already made a commitment to this country. If the british people's voted government has made a workforce planning mistake, the british people who voted for this government should bear their share of consequences (increased transient competition) with the current in country IMGs rather than culling the non- EU IMG's already here and treating them as a "use & throw" commodity. Competing interests: An IMG on HSMP
I am better than you are 26 September 2007
Jayaprakash Ayillath Gosalakkal, Consultant Paediatric Neurologist UHL Leicester Send response to journal: Re: I am better than you are	I have lived, worked and taught in three continents and several sophisticated systems. I have seen my fellow international medical graduates survive and thrive in the US, Australia, Canada and UK (till recently). I do not know how our education suddenly became less sophisticated. If the country feels it needs to check the quality of those who practise there they can conduct exams in standards which they feel are adequate, In our understanding the medical establishment felt that the PLAB fulfilled this need. If it was not so it should have been amended. To blame those who took and passed this test in good faith is misleading. We have a simple proposition -show us the statistics as to how many International medical graduates were preferred to IMG in any deanery and we will accept your argument. Tell us if the number of positions under MTAS were equal to the number of positions available at PRHO/SHO/SPR grade under the old system. Otherwise we would think the elephant in the room in the form of IMG is just a convenient scapegoat for the indefensible MTAS Competing interests: Proud of my primary medical education
Howl! 26 September 2007
David R Jarrett, consultant physician Queen Alexandra Hospital , portsmouth, PO6 3LY Send response to journal: Re: Howl!	Howl! I have seen the best minds of my generation destroyed by MTAS ( apologies to Allen Ginsberg ). There are further consequences of the MTAS affair beyond medical unemployment. Many trainees have opted for the general practice "default" position for there second round options when not successful in the first round applications. General practice needs commited volunteers not reluctant "also rans". Like many consultants I have been dismayed that many of our most able and motivated young colleagues have been passed over for specialty training whilst others with lesser skills have been successful. It is sad that the traditional nuturing and support of the best trainees is now seen as personal patronage and nepotism. A cynic might believe there is a higher political motive, a baby elephant in the room. Namely medical unemployment will inevitably lead to a driving down of salaries and the acceptance by the profession of greater government control. Competing interests: None declared
Emigrate to Germany 26 September 2007
Andre Lagrange, Consultant Anaesthetist Uppsala University Hospital, Sweden Send response to journal: Re: Emigrate to Germany	Lot´s of jobs available in Germany. So go ahead, learn the language and try something new! Others have done so before. Andre Lagrange (who emigrated twice from Germany and now lives a happy life in Sweden) Competing interests: No competing interests
A few solutions for the immigration issue 27 September 2007
Arun Natarajan, SpR (LAT), Cardiology South Tyneside District Hospital Send response to journal: Re: A few solutions for the immigration issue	Let us contemplate on a few ways and means to end this immigration problem then: 1. The Home Office may stop issuing new visas to doctors. No new doctor will then be able to enter and work in the UK. The minus points will be that this may undercut the income of the Home Office, the GMC and Royal Colleges in the longer term. 2. In addition to the above, the Home Office may refuse visa extensions/renewals/to grant PR status for those already in the system. This will hopefully clear the field once and for all, for UK graduates and their European comrades. The major disadvantage of this will be serious shortfalls in the incomes of the aforementioned esteemed institutions. The other disadvantage for the NHS is that trusts (especially non-teaching hospitals) may be left high and dry when looking for doctors for their exclusive service-oriented, non-training posts. Furthermore, this may cause a significant number of specialist trainees, GPs and even consultants to abruptly leave the country as they may be caught having HSMP, PFT or Work Permit types of visas. Needless to say, this may leave gaping holes in the healthcare system across Britain. The trivial matter that doctors already in the system seeking training posts will find their career in shambles, is of course a non-issue. 3. If the above are not immediately feasible because of noisy dissent from overseas doctors, trusts and deaneries have one other way out. They may allow everyone to apply, but offer the choicest positions and the so- called competitive specialities to UK and EU graduates and save the leftovers for the non-EEA hopefuls. I just have this strange feeling that solution #3 is already in play now. Competing interests: I am an IMG
Refugee Doctors - The Elephant in the Room - Should Postgraduate training places be reserved for UK Graduates? 28 September 2007
Maeve Keaney, Consultatnt Medical Microbiologist and Director of Reache Northwest Salford Royal NHS FoundationTrust, Hope Hospital, Stott Lane, Salford, M6 8HD Send response to journal: Re: Refugee Doctors - The Elephant in the Room - Should Postgraduate training places be reserved for UK Graduates?	Refugee doctors are international medical migrants with unique characteristics. They have migrated because of absolute necessity and this has been recognised by the granting of their refugee status. Their requirement for access to training posts and service posts alongside UK and EEA graduates was not considered in the articles published in BMJ of September 2007. Refugee Doctors must not be forgotten or disadvantaged by `the system’ now or in the future. Firstly, the number of refugee doctors applying for training posts small and has very little impact on the overall availability of training posts. Secondly, refugee doctors will live and work in the UK for the rest of their lives. They are here to stay ! Thirdly, refugee doctors are a cost effective and sustained source of doctors. The relatively low cost of adaptation of refugee doctors represents good return on investment. On average it costs £20k and two to three years for refugee doctors to pass the necessary English Language test (IELTS) and PLAB examinations. Policy makers need to recognise the unique circumstances of refugee doctors and recruitment systems must give them the opportunity of progress through fair competition. The NHS workforce should reflect the community it serves. Refugee doctors who contribute to the NHS are often leaders in their community, promoting integration. Their contributions to UK society need to be valued, nurtured and enabled to endure. Maeve Keaney Consultant Microbiologist and Director of Reache Northwest http://reache.wordpress.com Competing interests: Reache is an NHS based organisation assisting refugee and asylum seeker healthcare professionals return to their professional role
We got to find an amicable solution 29 September 2007
Umesh Prabhu, Consultant Paediatrician The Pennine NHS Trust, BL97TA Send response to journal: Re: We got to find an amicable solution	There is a crisis with current situation in the UK regarding available training posts and the number of doctors applying for it. There must be some solution and current situation cannot continue. It is not acceptable to have thousands of young bright doctors with no certainties about their future be it a local graduate or IMG. There would a be few who would argue that in the best interest of patients anyone from anywhere in the world should be allowed to apply for the UK training posts and the best candidate should be selected. I can see the argument but find it difficult to support it. If this is the case then why UK should spend £1.6 Billion each year to train 8000 medical students to make them doctors? Why can't UK import all doctors from abroad and this is just absurd. The best solution for the current crisis is: 1. GMC should stop conducting PLAB examination until the current crisis is over or at least stop conducting them abroad. 2. Change immigration regulation so that local graduates/citizens and those with same rights are given first preference but exempt IMGs who are already in the UK. UK has moral a responsibility to look after the interest of those IMGs who have worked in the NHS and those who have come to UK with the promise of equal opportunity. Immigration regulations should not be applied retrospectively 3. Those overseas medical students studying in UK who are paying huge amount of fees should be allowed to compete along with local graduates/UK citizens and those with similar right of stay. 4. Refugee doctors must be given the right to compete with local graduates/UK citizens and those with similar rights. 5. GMC, Home Office, BMA, Ethnic Minority doctors organisations, CoPMED and MMC should work together to find an amicable solution which is fair to local graduates, EU doctors and fair to IMGs. Competing interests: None declared
Competition is good for patients 2 October 2007
Martin Zinkler, Consultant Psychiatrist Newham Centre for Mental Health, E13 8SP Send response to journal: Re: Competition is good for patients	The temptation to over-regulate medical immigration should be resisted. A certain degree of competition for doctors' jobs in training and beyond is healthy and will help in selecting those doctors who do well with their patients. Being trained in Germany at a time when postgraduate jobs were quite competitive, I found the system showed quickly which doctors did well and which didn't. After all not everyone successful in medical school will make a good doctor, whether it is about confidence, competence, attitude or organisational skills. Doctors who don't do well in clinical practice have a range of other employment possibilities in research, industry, publishing or indeed starting a new career. But to deal effectively with underperforming doctors employers need to be able to quickly fill vacant posts which only works where there is competition for posts. From the individual doctor's perspective it creates an incentive to perform above expectations. The idea that everyone who graduates from medical school should complete specialist or GP training is unique to medicine and perhaps to the clergy. A more competitive system with more incentives to do well on the job can increase quality in clinical practice generally and could reduce the need for complex, expensive and probably ineffective mechanisms to regulate medical practice like the ones suggested by the GMC. Competing interests: None declared
Re: We got to find an amicable solution 2 October 2007
Jay Ilangaratne, Founder www.medical-journals.com Send response to journal: Re: Re: We got to find an amicable solution	It is suggested by Prabhu that "UK has moral a responsibility to look after the interest of those IMGs who have worked in the NHS and those who have come to UK with the promise of equal opportunity".However, even before the restrictive immigration rules came into force, some IMGs may have suffered in the hands of one NHS Consultant of Indian origin who brazenly stated on an online forum that[1] "Indians can always go back home" and questioned where the local graduates could go while emphasising he would give preference to British graduates at the interview stage.With attitudes like that one wonders as to how the UK could properly discharge any moral obligation(if not a legal one) it has to treat IMGs fairly? References [1]Ilangaratne J. Confession of an Asian consultant. BMJ Rapid Responses 5 Dec 2003.(http://bmj.bmjjournals.com/cgi/eletters/327/7427/0-h) Competing interests: None declared
some overseas medical schools are inferior 10 October 2007
edmund willis, gp and clinical tutor hyms bridge street surgery, brigg, north lincs, dn20 8nt Send response to journal: Re: some overseas medical schools are inferior	As well as having an elephant in the room - we also have some ostriches with their heads stuck firmly in the sand ! -if we dont recognise that some overseas medical schools provide a poor education. Some students hardly see a patient before qualifying. Of course there are also some overseas graduates who can match anyone from the uk. If many uk graduates have to go overseas to find work and the nhs employs doctors who have a less intensive and expensive education, that is overall a poor bargain for the taxpayer. The uncertainty and hopelessness is also terrible for morale among our junior doctors and medical students, and that has a severe effect on patient care. The HSMP must be stopped and something must also be done about EU graduates. In my dreams the GMC might find something useful to do about a real problem. Competing interests: None declared
Re: some overseas medical schools are inferior 15 October 2007
anand fernandes, SpR Public health oxford Send response to journal: Re: Re: some overseas medical schools are inferior	Yes..some overseas medical schools provide poor education as compared to those of the U.K. Does Dr.Willis need reminding then that for an overseas doctor to work in the UK in any shape or form, an exam conducted under the aegis of the GMC (which I presume Dr.Willis pays his subscription to) needs to be taken and passed? This exam incidentally purports to assure the NHS that the candidate is on par with his UK colleagues. And while there are overseas graduates who can match anyone from the UK, there are, interestingly enough, some who will even outperform them! The issue at the current time is how does the UK taxpayer get value for his money. Yes, he pays to get UK graduate doctors through their education in the hope that that graduate then trains in the monopoly employer and proceeds to serve the population's health needs. But does (or has) the UK taxpayer paid for enough doctors (or nurses)to serve the health needs (or demands) of the nation? The answer is NO. It will remain a very vehement NO for a long time to come. The simple reason for that is that not all UK doctors who are offered training posts will work in the NHS. Secondly, not all UK doctors trained in the NHS will chose to serve in the areas of most need. Dr.Willis proposes scrapping the HSMP and 'doing something about EU doctors'. Overseas doctors like UK doctors want access to good training. Create barriers like the ones the DOH and Prof. Winyard propose and you will stop them from competing with the UK's finest for training posts. However, these steps will ensure that your 'service' posts stop getting filled as well because the lure of an attractive salary does not attract the best of the overseas doctor unfortunately (If Mintzberg is to be believed). I suspect your monopoly employer will not take to kindly to that..nor will your MP. Does this scenario sound familiar? We don't have enough doctors who are UK trained, lets get some from overseas. A few years later when the UK has trained what some mandarin has decided is enough doctors, lets boot out all the overseas doctors (who incidentally also paid taxes to pay for UK medical graduate training while having no recourse to state funds in return). Disruption of family life, career, human rights..what's that? I suspect the above is what Dr.Willis proposes. In which case, there's a head that needs dislodging from the sand pretty close to home...especially if he works with colleagues who may have trained overseas. The morale of overseas graduates working in the NHS isn't at its best either. Competing interests: IMG
A reasonable concern 16 October 2007
Madhukar Kumar, Deptt of Psychiatry University of Chicago Hospitals, Chicago, USA 60637 Send response to journal: Re: A reasonable concern	I agree with a lot of things mentioned in the featured article. These pertain mainly to the big mess which the DoH have caused in medical recrutiment in the NHS. I do not, however, agree that there is an issue of missing the obvious i.e. Elephant in the room. In my experience on the NHS, foreign graduates were only recruited when there were no locals willing to take the jobs. This maybe an overgeneralisation, but I am sure that many people share this view.The fact that there has been systematic mismanagement of the NHS at all levels, including the integration of postgraduate medical training , is the main problem.That overseas doctors wish to train in the UK, is not.Dr.Winyards demands to link issues of immigration to medical training worry me.I believe the NHS is probably the worlds best nationalised healthcare delivery system which also provides excellent clinical training to its doctors.However, political interference in the health services and extensive micromanagement are its drawbacks. By arguing that issues like immigration relate to medical training is giving politicians a stronger hand to use the NHS as a political platform.This, in my opinion, is certainly not good for either patients, doctors or the system as a whole. Competing interests: None declared