UK Border Agency (UKBA) consultation: Employment-related settlement, Tier 5 and overseas domestic workers
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UK Border Agency (UKBA) consultation: Employment- related settlement, Tier 5 and overseas domestic workers Royal College of Physicians response 8 August 2011 The Royal College of Physicians (RCP) plays a leading role in the delivery of high quality patient care by setting standards of medical practice and promoting clinical excellence. We provide physicians in the United Kingdom and overseas with education, training and support throughout their careers. As an independent body representing over 25,000 fellows and members worldwide, we advise and work with government, the public, patients and other professions to improve health and healthcare. For more information please contact: Morgan Bailey, international and MTI coordinator (morgan.bailey@rcplondon.ac.uk; 020 3075 1342) Naa Noi, International Medical Graduate manager (naa.noi@rcplondon.ac.uk; 020 3075 1304)
1. Introduction The Royal College of Physicians (RCP) welcomes the opportunity to respond to the UK Border Agency (UKBA) consultation on employment-related settlement, Tier 5 and overseas domestic workers. The RCP is directly involved in the Medical Training Initiative (MTI), which operates under the Tier 5 (Temporary Worker) Government Authorised Exchange (GAE) programme. The Department of Health (DH) set up the MTI scheme in 2009 in order to allow small numbers of experienced international medical graduates (IMGs) to enter the UK to take up paid training fellowships in NHS trusts for up to two years before returning to their home country1. The scheme, which supports the UK’s international development objectives, is beneficial to the NHS, to individual applicants and to their country of origin. In 2010, the MTI placed 220 international medical graduates in NHS hospitals throughout the UK2. The RCP has worked constructively over the last 15 months with the UKBA, DH, the Academy of Medical Royal Colleges (AoMRC) and NHS employing organisations to ensure the scheme operates efficiently and effectively, and complies with UKBA requirements. We remain committed to the scheme and are concerned that proposal to reduce the maximum period of leave for Tier 5 temporary workers on GAE programmes from 24 to 12 months severely threatens the viability of the MTI scheme. Reducing the MTI visa to below 24 months would prevent graduates from obtaining the necessary experience to progress in their home country and would not allow time for them to acquire the skills and competencies they are seeking in the NHS. Gaps in service caused by doctors volunteering overseas would no longer be filled by highly motivated MTI graduates with proven language and competency skills. International links established over decades could be threatened, and with it our ability to help satisfy the UK’s international objectives, including the Millennium Developmental Goals. The RCP’s response to the consultation is restricted to issues that relate to the Medical Training Initiative (MTI) and covers questions 21, 22, 23 and 24. 2. Consultation response Question 21: Should those who enter on the temporary worker route be restricted to a maximum of 12 months leave to reinforce the temporary nature of the route? No. Question 22: If you have answered ‘no’ to question 21 please explain why. The Medical Training Initiative (MTI), which operates under Tier 5 (Temporary Worker) Government Authorised Exchange (GAE) programme, allows a small numbers of experienced international medical graduates (IMGs) to enter the UK so they can benefit from training and development in the NHS before returning to their home country3. 1 Academy of Medical Royal Colleges, 2010, Medical Training Initiative Guide, p.2, http://www.aomrc.org.uk/medical-training-initiative.html 2 Figures from data collection by the Academy of Medical Royal Colleges 3 Academy of Medical Royal Colleges, 2010, Medical Training Initiative Guide, p.2, http://www.aomrc.org.uk/medical-training-initiative.html UKBA consultation: Employment-related settlement, Tier 5 and overseas domestic workers – Royal College of Physicians response, 8 August 2011 © Royal College of Physicians 2011 2
In 2010, the MTI placed 220 international medical graduates in NHS hospitals throughout the UK4, and the
scheme is capped at an annual maximum of 750. As the UKBA consultation papers indicate, in 2010, a
total of 15,260 Tier 5 (temporary worker) visas were issued, including 3,235 for the Government
Authorised Exchange (GAE) programme as a whole5. The MTI scheme accounts for 1.4% of total Tier 5
(temporary worker) visas granted. The impact of MTI on overall levels of immigration to the UK is
therefore negligible.
The RCP strongly believes that the duration of the visa available to those on the Medical Training Initiative
should not be reduced to 12 months, but should remain at 24 months. A reduction of the visa duration to
12 months would prevent graduates from obtaining the experience needed to progress in their own
country, and make the scheme less attractive for hospitals in the UK. Hospitals often require a three-
month probationary period, which leaves only nine months hands-on training which for most will not be
enough to acquire the medical experience they are seeking, nor time to develop related skills such as
learning to teach, management and research. This would put the continuation of the scheme, and the
benefits it delivers, at risk.
The benefits - domestically and internationally, to individual doctors and to health services - are wide-
ranging. The MTI scheme:
• Supports the UK’s international development objectives by sharing knowledge that will enable
health workers from developing countries to improve healthcare on their return home;
• Contributes to the UK government’s investment in strengthening health systems in the
developing world by giving international medical graduates time-limited experience in the UK.
For some countries, such as Sudan, the lack of capacity to train doctors beyond basic specialty
level means 24 months training outside Sudan is essential for doctors wishing to progress to
consultant level;
• Enhances the UK’s reputation and promotes UK education, services and trade in the health
sector by building a network of doctors around the world with a direct relationship with the UK;
• Provides UK hospitals with high-quality, motivated international medical graduates, who help
resolve some capacity issues and takes service pressure off domestic trainees, allowing time for
graduates to study and reflect.
Further detail of the benefits of the MTI scheme is provided below, together with an overview of the
safeguards built into the scheme.
Contribution to international development
The MTI benefits circular migration of health workers from developing countries, such as Sudan, Sri Lanka,
Oman, Pakistan, India, Malaysia, and Botswana, to the UK and back home, thus helping health systems in
the developing world.
The RCP deals with medical institutions in Sudan, Pakistan, India, Botswana and Sri Lanka all of whom
sponsor doctors to come to the UK under the MTI scheme. Sri Lanka’s Post graduate Medical Institute has
produced over 5,000 specialists since its foundation, the majority coming to the UK for their 24 months’
work-based training and experience. If the MTI visa is cut from 24 months to 12 months, Sri Lanka, along
with other international institutions with which the RCP has health links, are likely to send their trainees
elsewhere to gain experience.
The MTI scheme provides international medical graduates with the opportunity to progress in their
career, develop their expertise, access a high-quality structured training programme, and to practice in a
4
Figures from data collection by the Academy of Medical Royal Colleges
5
UKBA, Employment-related settlement, Tier 5 and overseas domestic workers: A consultation. June 2011
UKBA consultation: Employment-related settlement, Tier 5 and overseas domestic workers – Royal College of
Physicians response, 8 August 2011 © Royal College of Physicians 2011 3well-resourced environment. The MTI is now the only route available for international medical graduates to obtain time-limited experience in the UK, often needed to allow them to progress to consultant level in their home country. In Sudan, for example, the lack of capacity to train doctors beyond basic specialty level means those who wish to progress in their career are required to spend 24 months training outside Sudan. Historical links have resulted in the majority of Sudanese trainees coming to the UK for specialty training. The MTI also supports the UK’s international development objectives through the sharing of knowledge and best practice that will enable health workers from developing countries to improve healthcare on their return home. By only accepting those who have posts waiting for them on their return home, and by ensuring as far as possible that that this is the graduate’s intention, we ensure the MTI scheme contributes to the UK government’s investment in strengthening health systems in the developing world. If the visa duration is reduced, the UK stands to lose many of the health links that have been built up over decades and which in turn have facilitated the UK’s contribution to global health. Doctor’s view IMGs promoted by their home country to receive training in the UK under the MTI scheme have proved the brightest and the best of all IMGs with whom I have worked. However it can still take up to 6 months for them to fully acclimatise to UK medicine. This probationary period used to be provided by clinical attachment posts but now has to be taken as part of the MTI scheme. It is only in their second year that the graduates start to develop skills and build the networks which will benefit them, the NHS and their home country on their return home. Reducing the scheme to a frantic 12 months rush would destroy the benefit of the scheme for IMGs, and the NHS, and could discredit the UK as a country for training IMGs in the future. Dr Peter Trewby, Consultant Physician, Darlington. Associate International Advisor, Royal College of Physicians Though I have just been accepted on the most recent round of the MTI [March 2011], if the visa is reduced to 12 months, then I won’t come. In Sudan, if you want to register as a specialist with the Sudan Medical Council, then you need to have gained at least 24 months of sub-specialty training which is difficult to obtain in Sudan. Dr Rihan Elhassan, MRCP London and accepted on to the MTI in March 2011 from Sudan Contribution to the NHS and the UK Although the primary purpose of the MTI scheme is to provide training opportunity for international medical graduates, there are considerable mutual benefits for the NHS. The RCP actively supports a domestically sustainable healthcare system – we set standards of medical practice, promote clinical excellence, provide physicians in the UK and overseas with education, training and support throughout their careers. However, there is a need for trusts to recruit from overseas to make use of spare training and service capacity, which can save hospitals money on locum fees. International medical graduates provide hospitals with high-quality, reliable and safe service to patients. They enrich the NHS with their skills and enthusiasm and have become essential members of the UK’s medical workforce. The MTI scheme is designed to make use of this spare training and service capacity. By taking some of the service pressure off domestic trainees, international medical graduates facilitate the training of all by allowing time for graduates to study and reflect. UKBA consultation: Employment-related settlement, Tier 5 and overseas domestic workers – Royal College of Physicians response, 8 August 2011 © Royal College of Physicians 2011 4
Some of this capacity deficit arises from junior doctors taking time out to work overseas. In 2010, 463 UK
trainees took time out of programme to volunteer overseas and these numbers are set to grow. During
the same period, the MTI placed 220 international medical graduates in NHS hospitals throughout the
UK6. The MTI scheme represents a true graduate exchange scheme enabling UK graduates to work and
volunteer overseas at the same time as offering international graduates experience in the UK enabling
them to benefit their home country when they return.
If the Tier 5 visa is cut to 12 months, the UK stands to lose not only our health links with these countries,
but also future opportunities for collaboration. Though the UK’s reputation around the world as a centre
of excellence in healthcare is still strong, there is strong competition from the USA, Canada, Australia,
France and Germany in particular. Currently, there exists a network of doctors around the world who
worked or trained in the UK for some of their career. This has enabled the UK to promote our education,
services and trade in the health sector. Reducing the duration of the visa would put the UK’s international
reputation at risk, and doctors from around the world will no longer have a direct relationship with the
UK, resulting in loyalties and partnerships being formed elsewhere.
Doctor’s view
I have long experience of hosting postgraduate students from overseas in Liverpool … In all cases these
graduates have returned to their home countries full of enthusiasm for their specialty. In each case this
has led to continued research and training links, including several joint scientific publications after their
return to their home country. The presence of such trainees on our unit enriches local training for all UK
staff, including nurses and other professions as well as the doctors. It enables us to learn on a day to day
basis about differences between our disease patterns and approach to that overseas, which is vital for
our field.
In addition, these placements have enabled reciprocal training of our own medical trainees overseas,
especially in Colombo. Two of our senior registrars have completed a year or more of training in Sri
Lanka and we expect more to follow. Two of our nurses visited Colombo to see conditions in the hospitals
at first hand, and deliver some local training, and raised funds to enable their nursing Sri Lankan
colleagues to visit our unit. Trainees returning to Colombo and Muscat have continued dialogue with us,
enabling significant formal training links between the Royal College of Physicians of London and
Ministries of Health and sister colleges overseas.
Dr Nick Beeching, clinical director of Infectious Disease Unit, Liverpool
Training time in the UK is of great importance to Sri Lankan doctors and the continuing development of
our health system. After so many changes to UK immigration regulations in recent years, restricting the
Tier 5 medical training initiative to 12 months will force our doctors to shift their focus away from the
UK.
Professor Rezvi Sheriff, Director of the Postgraduate Institute of Medicine, Sri Lanka
Training in Sudan is very basic and not structured. At least 80 per cent of your knowledge and education
comes from your own efforts, unlike the UK where you can get direct teaching and education in a
structured format. Every Sudanese doctor’s main ambition is to train in the UK, and the MTI opened the
gate for us.
Dr Tarig Mahmoud, MRCP London and former MTI trainee from Sudan
6
Figures from data collection by the Academy of Medical Royal Colleges
UKBA consultation: Employment-related settlement, Tier 5 and overseas domestic workers – Royal College of
Physicians response, 8 August 2011 © Royal College of Physicians 2011 5Operation of the MTI and safeguards a. Quality of International Medical Graduates (IMGs) The MTI scheme has robust safeguards to ensure only high quality IMGs are recruited. IMGs on the MTI scheme must demonstrate high-level English language and communication skills in order to be registered with the General Medical Council (GMC). The level is set at a minimum of seven, out of a possible nine, in each category of the International English Language Testing System (IELTS)7. Individuals achieving this level are considered to have the ability to handle ‘complex language well and understand detailed reasoning’.8 For IMGs coming into paid NHS fellowships, the RCP ensures candidates have excellent medical expertise and good communication skills by interviewing them in their home country before they are able to start working in the NHS9. The interviews are conducted by both UK fellows and overseas fellows of the RCP in a UK Core Medical Training (CMT)-style interview assessing communication and clinical skills, as well as the individual’s CV and career ambitions10. Once in the UK, IMGs are required to have an induction period to assimilate into the NHS. They are supervised by a consultant and are subject to the same assessments as their UK counterparts. b. Length of Stay There are robust safeguards to ensure IMGs cannot prolong their stay in the UK. The Tier 5 visa limits an individual’s stay to 24 months. At the end of this period the IMG cannot be employed legally and is required to leave the UK. There is no option for extension or switching of visa categories. Once the IMG returns home, they are not permitted to apply for another Tier 5 visa for five years11. c. Numbers The total number sponsored under GAE route is 3,235, but only 220 of these came through the MTI scheme in the last year, and the MTI visas are capped at 750 per year. If and when this level is reached, the scheme operates on a ‘one out, one in’ basis so this number would be unaffected by the duration of the visa. Compared with the value that IMGs bring to their home countries and the NHS, the impact on UK immigration is negligible and, because of the circular migration implicit in the MTI visa and the restrictions on re-entry, there is no further net effect on UK migration once a steady state is reached and this is regardless of the visa duration. Doctor’s view There are already safeguards in place to ensure doctors benefiting from Tier 5 visas return to their home countries after training in the United Kingdom and, we in the South Sudan, will ensure that this provision is built into the individual trainee contracts. From my point of view this is possibly the best foreign aid (in kind) which the United Kingdom can give to any developing country.12 Dr Eluzai Hakim, RCP International Advisor for South Sudan, Consultant Physician, Isle of Wight 7 The categories include listening, reading, speaking, and writing in English. 8 “My test score”, IELTS, http://www.ielts.org/test_takers_information/getting_my_results/my_test_score.aspx 9 The UK style interviews assess a doctors clinical and communication skills at a core medical training (CMT) level by using scenarios and actors to observe how the doctor reacts in different situations. 10 The interviews are conducted for posts that are salaried. 11 The Academy of Medical Royal College (AoMRC), which is the overarching national sponsor for the MTI, receives written confirmation in the form of a Migrant Exception Report for any doctor that leaves their post prematurely. They would then notify the UKBA immediately and the individual’s visa would be rescinded. The AoMRC also sends out quarterly checks to the Trusts to ensure that all doctors under the MTI are still in post or that we are notified that they have left. This helps to ensure that even if a Trust does not send us the Migrant Exception Report we are still aware of any changes. 12 The Republic of South Sudan will be an independent country on 9 July 2011. The Ministry of Health with South Sudan has directly written into his proposals for postgraduate training the use of the MTI. Dr Hakim is the RCP’s International Advisor for South Sudan as he is a representative of the Diaspora community. UKBA consultation: Employment-related settlement, Tier 5 and overseas domestic workers – Royal College of Physicians response, 8 August 2011 © Royal College of Physicians 2011 6
Question 23: Should the ability to bring dependants in the Tier 5 (temporary worker) category be removed? No. The RCP believes that doctors on the MTI scheme should have the right to bring their dependants, particularly as we support the retention of the 24 month maximum stay. We believe that not allowing those on the MTI scheme to bring their dependents would have a detrimental affect on the viability of the MTI scheme. It would make the scheme unattractive to a potential MTI doctors, and may disproportionately affect and deter applications from certain groups. A period of two years’ separation from one’s family may impact negatively on the doctor’s experience in living and training in the UK, and their decision to participate in the scheme. Question 24: If we were to continue to allow Tier 5 temporary workers to bring their dependants, should those dependants’ right to work be removed? The RCP’s primary concern is that the MTI scheme remains viable, an attractive option for international medical graduates and continues to bring benefit to the NHS, UK plc and global health. However, we appreciate that the issue of dependents’ right to work is complex and any decision made in this area needs to be carefully balanced with domestic concerns, particularly in the current financial climate. As such, we do not offer a firm view on whether dependants’ right to work should be removed. International department Royal College of Physicians 11 St Andrews Place Regent’s Park London NW1 4LE Tel: +44 (0)20 3075 1342 Fax: +44 (0)20 7486 4034 Email: international@rcplondon.ac.uk www.rcplondon.ac.uk UKBA consultation: Employment-related settlement, Tier 5 and overseas domestic workers – Royal College of Physicians response, 8 August 2011 © Royal College of Physicians 2011 7
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