Intended for healthcare professionals


Medical training initiative

BMJ 2009; 338 doi: (Published 04 April 2009) Cite this as: BMJ 2009;338:b1250
  1. Swayamjyoti Ray, teaching and research fellow, Department of Surgery,
  2. Chandra M Kumar, professor, Department of Anaesthesia
  1. 1James Cook University Hospital, Middlesbrough
  1. drsray{at}


Swayamjyoti Ray, chairman of the Junior Doctors Forum of the British International Doctors’ Association, and Chandra Kumar explain the new employment scheme for international medical graduates

Historically, there has been a shortage of doctors in the National Health Service since its formation, for which it has relied heavily on international medical graduates (IMGs).1 These graduates may have emigrated in pursuit of medical excellence or seeking financial gain.2 Some may have come as asylum seekers.

Without doubt, IMGs have given good service to this country. It is fair to say that they have contributed immensely to the development and progress of the NHS since its formation more than 60 years ago.2 Many have risen to positions of seniority and eminence within the profession. Some, however, have been “side tracked” into less desirable specialties and non-career grade positions.3 Furthermore, at times they are faced with difficult working conditions. As far back as 1961, Lord Taylor, himself a doctor, addressed the House of Lords and said, “They are here to provide pairs of hands in the rottenest, worst hospitals in the country because there is nobody else to do it.”1

As with any other organisation, the NHS has variations in demand and supply. An increase in UK medical graduates from 3700 in 1997 to 6200 in 20064 (with an estimated 8000 graduates by 20125) and a further influx of European Union doctors67 has led to severe unemployment among IMGs in recent years. It is estimated that, on average, an IMG has to wait 16 months and make 500 applications before securing a job.28 This message has reached far and wide, and there has been a drastic drop in applications for the Professional and Linguistic Assessments Board (PLAB) examination.9

Simultaneously, in March 2006 the Department of Health abolished permit-free training and the overseas doctors training scheme visas to prevent more IMGs entering the United Kingdom.9 Those IMGs already in the UK had to convert their visas to highly skilled migrant programme (HSMP) visas.10 The government also retrospectively introduced regulations to restrict IMGs with HSMP visas (limited leave to remain in the UK) from applying for training posts in the NHS.11 However, in April 2008 the House of Lords upheld the hard fought challenge to these regulations by the British Association of Physicians of Indian Origin, but the ruling applied only to those doctors who were granted HSMP visas before February 2008. As a result, IMGs whose HSMP visa was issued after February 2008 were not eligible for appointment to any training posts if any graduates from the UK or European Economic Area or international graduates with limited leave to remain (HSMP visa issued before February 2008) applied to those posts.

The training and work experience scheme

With the potential enforcement this year of the European Working Time Directive to 48 hours a week, it is inevitable that there will be a need for more doctors.5 Probably for this reason, the Home Office and the Department of Health have introduced the medical training initiative (MTI) as a part of the training and work experience scheme.12 The scheme operates under tier 5 of the points based system for UK immigration13 and allows IMGs from outside the European Economic Area to undertake work based training for a professional or specialist qualification or a limited period of work experience, provided that it does not affect an existing training scheme.

The MTI covers all schemes, including existing arrangements sponsored or administered by the medical royal colleges and similar organisations (such as the Commonwealth Scholarship Commission), for the training of overseas medical professionals, doctors, or dentists.

Eligibility criteria for the MTI12

  • Must be aged between 24 and 54 years

  • Should be proficient in English, with a satisfactory International English Language Testing System examination score

  • Must undergo initial check with the General Medical Council to verify previous professional qualifications for registration purpose

  • Must have a confirmed job offer from the employer

  • A minimum training period of six months and a maximum of 24 months are permitted

  • At the end of the maximum training period, individuals must leave the UK and return overseas to put into practice the training they have received in the UK.

Suitable jobs or posts for MTI

  • Fixed term appointment (type II, specialist registrars)

  • Locum appointment for training

  • Clinical fellow

  • Research fellow

  • International fellow/scholarships (commonwealth or overseas government or others)

The MTI category does not allow IMGs to take up supplementary employment.

Sponsors of IMGs

Sponsors have to be approved by the GMC. They could be a

  • Royal medical college

  • Postgraduate dean

  • NHS trust or UK consultant.

The sponsor or employer must make a formal job offer with a confirmation of salary. Once an IMG accepts the offer, the employer or sponsor will apply for a work permit.

When an NHS trust or deanery is the employer, a signed and dated letter of sponsorship or endorsement from the appropriate royal college or similar organisation must accompany the work permit application. Employers are responsible for coordinating with the UK Border Agency and ensuring that appropriate documentation is submitted to obtain the work permit. “NHS Professionals will act as ‘national scheme sponsor’ issuing certificates of sponsorship to doctors appointed to posts approved under the MTI by the dean, college, and local employer. The certificate of sponsorship will support application for entry to the UK under tier 5. They will ensure all of the requirements of the scheme have been met before sponsorship is provided and that details are recorded of the employment.”13

Role of deanery

  • Liaises with the royal colleges and NHS trusts and identifies the number of training posts available

  • Ensures that the training within the MTI scheme does not interfere with or compromise the existing training of trainees in recognised posts and programmes

  • Responsible for ensuring that the training is of high quality with appropriate supervision, learning opportunity, and appraisal. The training programme should include trainer accreditation, contact details, timetable, key stages, course or module titles, location(s), and key outputs such as appraisals

  • The deanery must support the work permit application when sent to the Home Office.

Role of royal medical colleges

  • Responsible for approval of training

  • Setting standards of practice for entry into the MTI scheme and identifying potential candidates and maintaining a waiting list

  • May act as sponsor for an MTI applicant’s GMC registration and (from September 2008) licensing as an alternative to taking the PLAB test.13

At present not all medical royal colleges actively advertise the MTI scheme. Colleges that support the MTI scheme include

  • Royal College of Physicians (England)

  • Royal College of Ophthalmologists

  • Royal College of Paediatrics and Child Health

  • Royal College of Obstetricians and Gynaecologists

  • Royal College of Pathologists

  • College of Emergency Medicine.

The Royal College of Anaesthetists and the Royal College of Psychiatrists are considering operating MTI schemes.

Salary and payments arrangement

  • The doctor must be employed for a minimum of 30 hours/week

  • A minimum basic salary must be above the current national minimum wage of ₤13 400 a year for working 48 hours/week and ₤11 128 a year for 40 hours/week13

  • Self funded or honorary posts are not permitted under the MTI scheme.

Immigration issues

The MTI scheme is initially meant for one year and is subject to an extension for another year. However, the total period should not exceed two years. After completing their training programme, IMGs may apply to return to the UK under a different category as long as they have spent more than a year in their home country or overseas.

If there is a need to employ an individual who already has an MTI permit with another employer, a change of employment application will be required. Under the current immigration rules, only those international students studying medicine in the UK can apply to switch into the MTI category without leaving the UK, provided they satisfy the MTI criteria. From September 2006, individuals who are in the UK already undertaking permit-free training may apply to switch into the MTI category. Individuals under the MTI scheme are allowed to bring their dependants to the UK, who will be able to work during the period for which the MTI permit is valid.

To apply for the MTI scheme the MTI1 application form is available on the Home Office website

The scheme is still evolving, and if properly set out it may be beneficial to both the NHS and the IMGs. The medical royal colleges are the official sponsoring body and will act as “gate keepers” to the scheme. The colleges will maintain a waiting list or pool of IMGs for deaneries to access whenever necessary. The colleges will also set the criteria and act as sponsors for GMC registration in line with GMC regulation. It is expected that the colleges will charge a fee to IMGs for assessing and processing their applications. The involvement of the postgraduate deanery may not be essential. The college tutor can authorise jobs, but the dean will have to agree to the job contents and ensure that training is not compromised. The deanery, however, will need to identify the number of training posts available and coordinate between the royal colleges and the NHS.

Unresolved issues

With an evolving scheme, unresolved issues may surface after implementation. The following may be important:

  • Effects of the European Working Time Directive

  • Who will arrange visas?

  • How will the pools of doctors work?

  • Will the candidates be allowed to take examinations?

  • Can the training be structured for five or six years so that it is more beneficial for the doctors and they can complete all parts of their examinations?

  • Difference between training and service

  • Conflicts of interest between the trusts, deaneries, colleges, and IMGs

  • Change of rules on those who are already on the scheme


  • Competing interests: None declared.


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