Intended for healthcare professionals


Refugee doctors in Britain: a wasted resource

BMJ 1997; 315 doi: (Published 02 August 1997) Cite this as: BMJ 1997;315:264

Helping them would help the health service

  1. Anita Berlin, Senior lecturera,
  2. Paramjit Gill, Senior lecturerb,
  3. John Eversley, Senior research fellowc
  1. a Department of Primary Health Care and General Practice, Imperial College School of Medicine, Norfolk Place, London W2 1PG
  2. b Department of Primary Care and Population Sciences, University College London and Royal Free Hospital Medical School, London N19 5NF
  3. c Public Policy Research Unit, Queen Mary and Westfield College, London E1 4NS

    The exact number of refugee doctors in Britain is not known. Estimates suggest there are at least 200, equivalent to the annual output of a typical medical school. The disproportionate number of doctors among refugees is a phenomenon that has been observed in earlier waves of exiles, notably those fleeing Germany and central Europe in the 1930s. Refugees have made substantial contributions to professional life in Britain, particularly in medicine and science.1 2 The profound and all embracing sense of loss experienced by refugees3 4 is compounded for the many who are professionals, who feel that their skills and knowledge are unused while they must depend on welfare.5 They represent a waste of human potential that deserves greater attention and action from the medical profession.

    To practise in Britain doctors who qualified overseas must first gain limited registration with the General Medical Council (GMC) through one of four routes: sponsorship, membership of a royal college, passing the Professional and Linguistic Assessment Board (PLAB) test organised by the GMC, or “requalification” through the United Examining Board. Sponsorship is open only to those returning to their country of origin, and pass rates for college and board exams are low. Most overseas doctors opt to take the PLAB test. After achieving a good pass in the prerequisite International English Language Testing System (IELTS)6 candidates sit a clinical exam, which, from next year, will include an Objective Structured Clinical and Oral Exam (OSCOE).7

    No one would argue with the need for doctors who qualified overseas to demonstrate that their skills are of a high enough standard to practise in Britain. The profession and the state have invested the GMC with the responsibility of protecting society from deficient doctors.8 Refugees are disadvantaged, however, in comparison with other overseas doctors seeking registration for several reasons: extreme financial hardship (some receive no state benefit since the Asylum Bill 1996); psychological distress associated with loss, persecution, and the ambiguity of their legal status; the cost of exam fees, which is likely to rise with the introduction of the OSCOE; lack of opportunity to prepare for clinical exams, especially because of the haphazard provision of clinical attachments; long waiting lists for retaking the PLAB test; unhelpful feedback after failure; and racism. Given the repeated findings of racial discrimination against Asian graduates from British medical schools,9 10 it seems reasonable to infer that graduates from overseas schools must face even greater discrimination in their search for careers advice, clinical attachments, and, once having secured limited registration, jobs.11

    Over the years several institutions and agencies have developed considerable expertise in helping refugee doctors, notably Southwark College, which helps with preparation for the PLAB test, and the World University Service, which provides careers advice. A few organisations, including the BMA, help selected individuals. Recently a group of academics, teachers in adult education, non-governmental organisations, and refugees met to coordinate activities helping refugee doctors to achieve their maximum potential. A study group, initiated by refugees, has started in east London. At a one day workshop in June organised by the Jewish Council for Racial Equality, delegates proposed that a forum for refugee doctors be set up to represent the doctors and take these activities further.

    Although support and training are available for refugee doctors, these are unstructured, often expensive, and difficult to access. Despite the efforts of a dedicated few, very little help is provided by the medical community and none is funded by the NHS. The BMA has a stated commitment to exposing human rights abuses.12 Paradoxically refugee doctors are often the ongoing victims of such abuses, frequently because they refused to participate in persecution and torture.13

    Workforce predictions indicate that 500 additional new doctors are required annually in Britain,14 each one costing around £200 000 to train.15 For very much less, a package could be developed to integrate more refugee doctors into the workforce (box) and thus satisfy what the United Nations High Commission for Refugees considers one of the three rights of refugees: local integration without dependence on welfare.16 Although safeguards against so called bogus refugees would be needed, overall this could be a “win-win” situation, not only helping to relieve the consequences of human rights abuses but also satisfying Britain's healthcare needs.

    Steps for facilitating integration of refugee doctors into NHS workforce

    • Establish network of clinical attachments through collaboration between the regional postgraduate deaneries, the royal colleges, health authorities, and trusts

    • Ensure appropriate careers advice through colleges and deaneries and non-governmental organisations such as World University Service and the BMA

    • Provide more bursaries for travel and subsistence for clinical attachments and cost of the Professional and Linguistic Assessment Board's (PLAB) test

    • Provide revision courses and “mock” exams for the Objective Structured Clinical and Oral Exam (OSCOE)7

    • Reduce waiting lists to take and retake the PLAB test

    • Provide constructive feedback on areas of deficiency after the PLAB test

    • Review the role and practice of the United Examining Board

    • Continue to expose and challenge racism



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