House of Lords Economic Affairs Select Committee Inquiry into the economic impact of immigration
Response from the BMA
December 2007
The British Medical Association is an independent trade union and voluntary professional association which represents doctors from all branches of medicine throughout the UK. It has a total membership of over 139,000.
Which occupations in your sector has the highest shares of migrants and why? To what extent do you think the employment of migrants is a reflection of pressures to minimise labour costs? Is there a difference in this context between privately and publicly funded health care jobs?
1. In relation to the medical profession, it has long been considered that a disproportionate number of Staff and Associate Specialist (SAS) posts, that do not contain postgraduate training, are filled by migrant doctors (see http://www.bma.org.uk/ap.nsf/Content/hiddenheroes for further information on SAS doctors). This is often because UK doctors do not wish to join these grades as they believe they have been given a commitment to be trained to consultant level. Trusts have created Trust Grade posts, to fill service gaps, which have non-standard terms and conditions of service. Doctors employed in these posts are not protected by national terms and conditions of service and may be employed on poorer terms. Such posts are often filled by migrant workers.
2. Given the existence of national terms and conditions for the majority of medical posts in the NHS there is little correlation between recruiting migrant workers and the reduction in associated labour costs. By virtue of being international medical graduates, the UK will not have paid for their undergraduate medical education, a saving of £250,000 per doctor.
3. There has been a lag period for the involvement of migrant doctors at senior levels in the private medical sector; this has been due to a relative delay in achieving consultant status. Migrant doctors who have not yet specialised have been recruited by the private sector to work in non-training service posts. The BMA is also concerned that private sector providers might choose to employ GPs from abroad in order to minimise their costs and perhaps achieve a competitive advantage when pricing their services. The BMA would be concerned if these doctors were exploited for this purpose or employed on inferior terms and conditions.
Can immigration only be a short-term solution to domestic shortages? What is the long-term solution and how can it be achieved, and when? How does the British Medical Association view the role of migrant workers in meeting labour demand in the long-term?
4. Immigration is not only a short-term solution to domestic shortages. The history of the NHS proves the efficacy of migration as a long-term solution for a country that has an implicit policy not to graduate sufficient doctors to meet its healthcare needs.
5. In the past UK medical schools have not produced enough graduates to fill all medical staffing vacancies in the NHS, including training posts, hence the need to recruit migrant doctors. The government’s recently stated aim is for the NHS to become more self-sufficient. As a means of achieving this, medical school places have expanded and a number of new medical schools have been created meaning that reliance on migrant doctors will decrease.
6. As a result of the increase in UK medical graduates, there is now an oversupply of doctors seeking postgraduate training posts in the UK. There are still shortages in service grade and consultant posts. The Work Permits (UK) shortage occupations list,(reference 1) issued on 23 July 2007, included salaried GPs and nearly 50 specialties at consultant level, including anaesthetics, dermatology, neurology, paediatrics, and trauma and orthopaedic surgery. The relevance of the shortage occupation list is that when employers apply for a work permit for a potential employee they do not need to satisfy the resident labour market test showing that there was no suitable resident worker before being granted a work permit.
7. The BMA believes that migrant workers will be required for some decades to come. The BMA’s workforce modelling suggests that over the period to 2030, the demand for doctors will be met with current planned medical school intake and levels of overall immigration into the training grades. This is dependant on the assumption that doctors in the training grades progress to consultant levels and GP posts, and have the flexibility to move between training and non-training SAS grade posts as required to stabilise demand and supply.
It has been reported that some British medical graduates have difficulties getting further training posts in the UK. How do you think this relates to immigration and the employment of migrant doctors in the UK?
8. The UK has a long history of using migrant staff, and particularly so in the medical workforce. It is estimated that a third of the NHS medical workforce are international medical graduates, i.e. they qualified outside the European Economic Area (EEA). Historically, this group of migrants has been welcomed to the UK and their valuable contributions have been recognised. Following the recent restructuring of medical training in the UK, it has become apparent that there are far more doctors (UK, EEA and migrant) wishing to undertake postgraduate training posts in the UK than there are posts available. Given the policy of open competition for medical training posts - a position that the BMA supports - this has resulted in some UK medical graduates being unable to secure run-through postgraduate training posts.
9. The BMA maintains that doctors subject to the immigration rules, who are currently in the UK, have a valid expectation to train or work in the NHS and should be treated equally with UK and EEA nationals and other resident workers. The BMA has repeatedly drawn attention to the government’s responsibility to highlight the decreasing opportunities available to international doctors prior to them coming to the UK. The recent change in immigration law (reference 2) has affected many doctors; it was appalling that the government ‘offered no opportunity for organisations representing affected doctors to communicate their views about the changes, and failed to comply with its duty to examine the race relations issues involved’, as stated in the High Court ruling on 9 February 2007.
10. The change in this law caused extensive confusion for doctors subject to the immigration rules applying through the Medical Training Application Service (MTAS) and, despite requests from the BMA, clear guidance for this group of applicants was not forthcoming until very late in the day. The guidance was open to interpretation by individual Postgraduate Deaneries. The current proposals to clarify Department of Health guidance, published on 8 October 2007, Modernising Medical Careers (MMC) England Recruitment to foundation and specialty training - Proposals for managing applications from medical graduates from outside the European Economic Area was given a 10 working day response time in consultation. This was unacceptably short; such compressed deadlines suggest that the Department of Health has not learnt from the experiences of the last two years.
11.Migration of doctors from the EEA has also contributed to the over-supply of medical professionals into postgraduate training posts, something which has not been accounted for or assessed in workforce planning. Migrant staff competing for training posts may have had more experience than UK trained junior doctors having worked in their country of origin before coming to the UK, and may therefore be recruited above UK medical graduates/trained doctors. Some international doctors target posts that are least attractive to UK doctors believing that this will increase their chances of successfully securing employment. Morale among doctors in training is also low following the failure of the application system in 2007 and the introduction of the new Modernising Medical Careers training system. This group believe that they have been given a commitment to be trained to consultant level and achieve their Certificate of Completion of Training (CCT).
12. BMA policy and a survey of its members supports the organisation’s position of a fair deal for international doctors and international medical students who qualify in the UK. 54.4% of respondents stated that international medical graduates should not be prevented from competing for training posts. This should be applicable only to those already working within the NHS. This position was also stated by the BMA in its response to the recent DH in discussion paper Modernising Medical Careers (MMC) England Recruitment to foundation and specialty training - Proposals for managing applications from medical graduates from outside the European Economic Area.
13. The BMA does not believe that the immigration of qualified doctors should be stemmed. For doctors considering future migration to the UK, the government must ensure that information about the true situation of medical employment in the UK must be disseminated as widely as possible. The government must additionally be mindful of the potential consequences should the UK once again require the services of overseas doctors to staff the NHS in the future. Alienating this group will not encourage them to migrate here in the future, which the BMA anticipates will be necessary.
Reform of the UK immigration system is making it more difficult for employers in the health and care sectors to recruit workers from outside the EU. How far do you think it will be possible to meet demand for migrant labour in your respective sectors with workers from within the enlarged EU?
14. In addition to benefiting from free movement between member states in relation to taking up employment, EEA qualified doctors have a more straightforward route to registration than doctors who have graduated outside the EEA. Under Directive 2005/36/EC on the Recognition of Professional Qualifications doctors are entitled to full registration in any EEA member state if they fulfill both of the following criteria:
- they are citizens of an EEA member state; and
- they have completed primary medical training in an EEA member state and hold a recognised qualification.
16. It is difficult to anticipate the future demand for doctors; this is acknowledged in the Department of Health’s admission that workforce planning has been poor to date and exact training numbers are not known. As of 2005, the number of specialist registrars (those nearing the end of training) was 18,000, with an additional 26,000 in lower training grades. These numbers include over 18,000 doctors who gained their qualification outside of the EEA. As previously stated, the BMA’s workforce modelling suggests that over the period to 2030, the demand for doctors into training posts will be met by a combination of the current planned medical intake and levels of overall immigration.
17. Some doctors undertake postgraduate medical training outside the formal training grades in the UK and return to their country of origin. If this practice continues it would mean that the NHS would still be reliant on medical staff from outside the EEA at more senior levels.
18. It is important to consider the position of refugee doctors in relation to meeting workforce needs. This group of ready trained professionals are already in the UK and should be given every opportunity to practise their profession in the country that has granted them asylum. Not doing so would result in them being left to deskill. Many refugee doctors have successfully secured employment in the NHS. Supporting this group to resume their careers in the UK would reduce, but not eliminate, the NHS’ reliance on migrant workers.
What, if any, changes to UK immigration policy would you like to see?
19. The BMA recommends the following policy changes:
- The BMA supports a policy of self-sufficiency and is encouraged that the Department of Health’s aim is for the NHS to become more self-sufficient and less dependant on the migration of healthcare professionals from outside the EEA. It is now moving in this direction for medical personnel.
- Effective workforce planning is needed, where workforce patterns are based on need and not artificially restricted on the grounds of affordability. It is also essential to take into account current and planned medical school intake, coupled with future migration and immigration.
- The BMA recognises the extremely valuable contribution that migrant workers make to the NHS medical workforce and would welcome government policy acknowledging the same.
- The BMA calls for the government to clarify its immigration policy. The immigration rules for postgraduate doctors in training were amended in April 2006 with serious consequences for many migrant doctors. Since this time there has been a lack of clarity about how doctors in certain immigration categories, including the Highly Skilled Migrant Programme, should be considered during recruitment processes. It is vital that absolute clarity of the employment and immigration rules and how they affect migrant doctors is provided as soon as possible and is disseminated widely.
- According to an estimate by the World Health Organisation there is currently a global shortage of approximately 4.3 million health workers. Developing countries are among the most affected. In 2005, the BMA called for collaboration between developed and developing nations to address this crisis. In 2005 the BMA organised an international conference on the global health workforce. This resulted in a call to action on the healthcare skills drain which can be viewed at http://www.bma.org.uk/ap.nsf/Content/skillsdrain The government, in recognising that individuals have the right to migrate, must balance this right with the rights of home country populations to have access to healthcare professionals. We therefore welcome recommendations 11, 12 and 13 made by Lord Crisp in his report, "Global Health Partnerships: the UK contribution to health in developing countries" (reference 3)http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_065374 and we urge the Government to implement them. The recommendations can be viewed at http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_065374
- It is essential that for any future changes of government policy which will affect migrant doctors there is adequate time for consultation of all appropriate parties.
20. The National Health Service (NHS) has a multi-national workforce and there are many doctors working in the UK who are subject to the immigration rules. In July 2005 the Home Office issued a consultation Selective Admission: Making migration work for Britain which introduced the concept of a points-based immigration system for the first time. The BMA submitted a response to this consultation.
21. Responses to this consultation formed the detailed command paper for a points-based system which was published in March 2006 as A points-based system: Making migration work for Britain. This document sought to simplify the existing system of over 80 routes of entry into the UK by proposing a new 5-tier system of immigration
22. The BMA, in its response to the 2005 consultation document, did not support a managed migration system which focused primarily on economic benefits to the UK. Rather it recognised the multi-national workforce from which the NHS benefits, including the teaching and training delivered by international doctors. It stated that whilst the government must ensure that it complies with ethical recruitment policies, it must also recognise that some doctors from developing countries wish to come to the UK for specific training and then return to their home country to put these skills into practice. The BMA recognises the importance of this, and in particular, of doctors receiving training in specialties/procedures that are not available in their home countries. We recognise that a balance is needed between the excellent service migrant doctors provide to the NHS, ensuring fair and equal opportunities in the NHS and the long-term effects on damage to healthcare services in the developing world.
23. As regards the points-based system, on the whole the BMA welcomed the simplification of the immigration system, but urged the need for joined-up government thinking when implementing any new system, in order to ensure that the unique nature of the postgraduate medical training system is fully considered when introducing any new immigration categories that will affect the medical workforce.
24. Doctors will fall primarily within Tiers 1 and 2 of the new points-based system. Tier 1 is set to be introduced in the first quarter of 2008. We urge the Home Office to take into account the need for a period of transition, with a specific date from which only the new system would be in operation, and widespread advance publicity about the changing system to ensure individuals are adequately informed. This is even more important given the past 18 months and the changes that have been made to the immigration rules, which have had serious consequences for doctors in training in the UK, and led to extreme confusion and discontent.
25. The BMA calls for doctors already in the UK with a valid expectation to train or work in the NHS to be treated on an equal footing with UK and EEA nationals.
November 2007
References:
1. http://www.bia.homeoffice.gov.uk/6353/11406/49552/Shortage_List_23_July_20071.pdf
2. Since 3 April 2006, non-EEA or non-resident doctors are no longer eligible for the postgraduate doctor and dentist and trusts will need to apply for a work permit before employing such a candidate and demonstrate that there are no suitable resident workers to take up the post in their stead.
3. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_065374
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