Intended for healthcare professionals


The Medical Training Initiative scheme

BMJ 2010; 340 doi: (Published 21 April 2010) Cite this as: BMJ 2010;340:c1838
  1. Peter Trewby, consultant physician
  1. 1Darlington Memorial Hospital, Darlington
  1. peter.trewby{at}


Peter Trewby argues that the Medical Training Initiative is a positive way forward for international medical graduates and the NHS

By 2006, the growing influx of international medical graduates had led to widespread unemployment and dissatisfaction among international graduates and was threatening the very career structure of graduates from the United Kingdom. The government responded by withdrawing the permit-free visa status previously enjoyed by international medical graduates.1 The flow halted, but there were predictable downsides. In the short term, many international medical graduates already in the UK had to return home. In the longer term, educational links that had been fostered since the beginning of the NHS were threatened.2

In response, the Department of Health and the UK Borders Agency established the Medical Training Initiative (MTI) visa category, now under Tier 5 of the points based immigration system.3 The visa allows doctors to come to the UK to share “knowledge, experience and best practice.”4 It differs in two critical ways from the permit-free visa status: firstly, it is a training visa; and secondly, it is limited to two years and so is not a route to settlement. A steady stream of international medical graduates have availed themselves of the scheme, the majority on royal college sponsorship schemes often funded by their home country.

A new initiative called the MTI scheme and based on the MTI visa was announced in February 2009.5 This is an exciting scheme with potential to benefit international medical graduates, the countries that trained them, and the NHS. For these graduates, the scheme provides training and experience in the NHS for two years before they return to their home country. For trusts and deaneries, extra doctors are provided to contribute to ward, on-call, and clinic duties.4

Trusts and deaneries must first identify suitable posts. These might be funded core training or specialist training posts (specialty training year 3 and above) that are surplus to predicted requirements and already recognised for training. They could be funded posts that are difficult to fill or trust posts, or new posts could be created specifically for MTI graduates. All posts must be recognised as having sufficient educational merit and be recognised by the postgraduate dean and the appropriate royal college. The funding and drive for new posts will come from savings on locums, which are in short supply and of variable quality.

The MTI scheme is a flexible scheme. Job descriptions can reflect this and thus can be at core training or specialty training level, but all jobs must offer the teaching and appraisal opportunities enjoyed by UK graduates. Most graduates will be new to UK medicine, so schemes must include a period of monitored clinical supervision and attendance at an overseas doctors induction course.6

Quality in education and quality in recruitment are factors critical for the success of the scheme. The first requires the post to be recognised as a training post of at least equal standing to UK training posts and for the job description to be factually correct. Quality in recruitment requires careful assessment of the graduate before appointment. Recruitment has been delegated to the royal colleges, described as “guardians of the scheme” by NHS Employers.4

Overseas institutions with links to royal colleges that have already expressed their enthusiasm for the scheme will first put forward suitable candidates. Those shortlisted will be interviewed in their home country by overseas and UK doctors using established techniques to assess communication and knowledge skills. Once the scheme is established, video conferencing may supersede the gold standard of face to face interviewing.

Some trusts and deaneries already interview overseas and can and should continue to do so, using the colleges to sponsor the candidate through General Medical Council recognition when needed. However, some admit doctors under tier 2 (work permit) visas. This is not ideal for the graduate, as security is only for the duration of the post and there is no assurance of the post’s quality; also, there is no return for the country that trained them.

The scheme is in evolution and there will be difficulties. Delay from recruitment to starting UK ward work may typically be three months. The scheme is not a quick fix for short term vacancies; it is for the long haul. Some doctors may see the scheme as a route to settlement; it is not. Some may have expectations of training that cannot be delivered. Honesty in the job descriptions is all important, with night and weekend duties and the balance of general medical and specialist duties clearly defined from the start. Some may feel the scheme will interfere with UK graduates’ training. There is a danger of this especially in craft specialties, but extra doctors on wards and on rotas will enable more time for all doctors to attend teaching and training sessions.

Overseas doctors have enriched the culture of the NHS since its inception, and for many the skills acquired in the UK have benefited patients back home. Some doctors have been exploited and memories of recent unemployment among international medical graduates have tarnished the reputation of UK medicine overseas. The MTI scheme represents a way forward to redress this. It is a middle way, aiming to give training and experience to international medical graduates and to benefit the NHS. It is a scheme that has much to commend it, building on one of the UK’s key international development goals: to add to the knowledge of the wider global workforce.7


  • Competing interests: PT is associate international director at the Royal College of Physicians (London) with responsibilities for international medical graduates.


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