Written evidence submitted by Doctor Professor Meirion Thomas (RTR0017)
POACHING SO MANY FOREIGN DOCTORS FROM LOW-INCOME COUNTRIES TO PLUG MANPOWER GAPS IN THE NHS IS BOTH IMMORAL AND UNETHICAL.
- We cannot continue to import an ever-increasing number of doctors from low income countries to plug manpower gaps in the NHS. Those doctors are desperately needed in their own countries to provide essential services. This serial practice, which has intensified since 2016, is both immoral and unethical.
- In previous annual reports, the General Medical Council (GMC) has expressed concern about our over-reliance on foreign-trained doctors. For decades, successive governments have realised that it is cheaper to import doctors than to train UK students. That error has now reached its tipping-point.
- In 2018, and for the first time, we imported more doctors than we trained: 53 percent. In 2019, this trend increased to 60 percent – we trained 7,343 doctors and imported 10,966.
- Meanwhile, tens of thousands of British students with the required A-level grades have failed to gain entry to our medical schools because the number of places is strictly limited by cost.
- Moreover, these figures overestimate the chances of a British student gaining a place in medical school. Of the 7,343 UK graduates, several hundred were students from EU or international students from countries outside EU.
- We regularly hear praise for the contribution of overseas doctors to the NHS. In most cases it is justified – it goes without saying that some foreign-trained doctors are among the best. Yet rarely is it asked whether it is a good thing for the UK to be so over-dependent on foreign-trained doctors in view of the consequences both for the NHS and the health services in the doctors’ home countries.
- Of the 10,966 doctors imported in 2019, 2,461 came from the European Economic Area (EEA), and were able to register directly with the GMC without tests of skills and competence because their qualifications are recognised here. Few of these came from affluent western European countries. The other 8,505 were International Medical Graduates (IMGs) from outside the EEA, mostly Pakistan, India, Egypt and Nigeria. In order to register, they will have passed the GMC’s definitive Professional Linguistic and Assessment Board examination (PLAB).
- Yet there is convincing evidence that PLAB is too easy. The exam is pitched at the level of skill a British doctor would reach within a year of graduation, at about 25 years of age. Yet, GMC data confirms that PLAB graduates are much older: 70% are between 30 - 49 years of age and 3% are over 50 years (1). Most of these doctors are too old to start training in a major hospital speciality – instead, they are likely to be destined for a minor speciality, or sub-consultant hospital posts, locum appointments or general practice.
- GMC data confirms that in 2018, IMGs represented 23% of GP trainees and that in 2017, there had been a 50% increase in the number of male IMGs who were over 40 years of age and in GP training (1). Is this the ideal solution to the workforce crisis in general practice? Figures for 2019 are needed.
- PLAB consists of two parts. PLAB 1 is a multiple-choice exam consisting of 180 “best answer” questions, each with five alternatives to be completed in three hours. It can be taken in the UK or in one of 22 centers in 16 other countries under the auspices of the British Council. When a candidate passes he or she can progress to PLAB 2, which is a single, short, non-interactive clinical examination featuring actors as patients and must be taken in the UK. To design an examination in medicine where successful candidates can register with the GMC without ever being assessed in an interactive or viva setting is potentially dangerous. The Australian, Canadian and especially the USA equivalents of PLAB are significantly more challenging.
- Two independent articles from UK academic departments of medical education and published in the British Medical Journal in 2014 concluded that the pass mark for both parts of PLAB needs to be raised considerably in order to reduce the difference in performance observed between IMGs and UK graduates (2,3). The authors commented further that if the pass mark of PLAB 1 in the cohort studied had been raised to achieve equivalence with UK graduates, then few of the candidates would have passed.
- One of the tests of equivalence between IMGs and UK graduates was the subsequent pass rate in the two most common postgraduate examinations: MRCP and MRCGP (Membership of the Royal Colleges of Physicians and General Practitioners respectively). The knowledge and skill of PLAB graduates was deemed to be significantly lower than UK graduates, correctable said the authors, only by raising the pass mark of PLAB 1 by 13% and PLAB 2 by 20%
- Increasing the pass mark by any amount would inevitably reduce the pass rate. Yet in spite of these reports the very opposite has happened. Moreover, those who fail can keep on trying. Until 2017 candidates could retake both exams unlimited times. Since then, there has been some tightening up but it is still permissible to take both parts of PLAB up to five times each. What university department allows resits on this scale?
- The GMC is in a difficult position, because a decline in the number of people passing PLAB would have serious implications for workforce-planning in the NHS, especially in less popular specialities. The five new medical schools announced in 2018 by Jeremy Hunt (then Health Secretary) will only produce an extra 1,500 graduates per year, the first of them graduating in 2023. In order to help fill the gap, the GMC has more than doubled the number of IMGs registering over the past two years (from 4183 in 2017) and has industrialised its PLAB 2 facilities in Manchester in August 2019 by doubling its capacity to be able to examine 11,000 candidates per year. This, with the intention of importing even more doctors from abroad in 2020, although that plan has been temporarily slowed by the Covid-19 crisis.
- In 2015, Jeremy Hunt promised 5,000 more GPs by 2020 and failed. In 2016, he also promised that the NHS would be “self-sufficient in doctors” by 2025. In November 2019, Mr. Boris Johnson promised 6,000 new GPs by the end of this parliament. These goals can only be achieved by importing large numbers of doctors from abroad. Mr. Charlie Massey was appointed Chief Executive of the GMC in 2016, transferring from his role as Director General at Department of Health.
- In the four years 2016 – 2019, the number of IMGs registering with GMC increased by 148% while the number of EEA and UK graduates has increased by 13.6% and 2% respectively. (See Addendum). During these four years, 22,051 IMGs registered with GMC, amounting to almost 10% of licensed doctors in UK. Did this massive increase happen by chance or by design?
- Opportunistically, to support this increase in medical migration by IMGs, bespoke PLAB training courses have sprung up throughout the UK and several other countries. There were many in major cities in India and Pakistan, and more recently in Cairo and Lagos. Advertisements for PLAB courses do not inspire confidence. One in Mumbai reads: “The time is perfect as plenty of opportunities are unravelling (sic) due to doctor recruitment crisis in the UK”. Another course describes PLAB as the “gateway to the NHS” and claims “98% pass rate in PLAB 2 at first sitting” -- which cannot be true. Some advertisements claim that teaching is provided by previous PLAB graduates, experienced UK GPs and NHS consultants, even previous PLAB examiners. The most disturbing Google advertisement, together with fake audience, is: “SAMSON PLAB 2 course in Nigeria – Facebook”.
- A Channel 4 documentary, “The Foreign Doctors are Coming”, broadcast in August 2018 but still available on catch-up, revealed just how much some foreign-trained doctors have to adjust their attitudes and approach in order to practise in Britain. This course is taught in Manchester by Dr. Ramaswamy, centers on courtesy, empathy and communication skills, qualities that should not normally need to be taught. One candidate is filmed saying “At home we have a patriarchal society. We are God and patients have to listen to what we say”. Another candidate is told: “You have to learn to speak like a doctor to patients”. Dr. Ramaswamy was struck off the medical register in November 2019 for falsely advertising 100% pass rate in PLAB 2 on Google advertisements and videos in order to attract candidates. His courses continued unchanged.
- PLAB tutoring has become big business because the rewards for successful candidates from low income countries are enormous and life-changing. The potential returns from the NHS in terms of salary, pensions, social standing, working conditions and ultimately UK citizenship are transformational.
- All this because the fifth biggest economy in the world has long decided that it is cheaper to import than to train doctors.
- Quite apart from the question of quality of some of the doctors being recruited, there are moral and ethical issues relating to poaching doctors from poor countries. In attracting them to UK, we are depriving those countries of much needed skills.
- The doctor to patient ratio in UK is 1 to 357 while in India, Pakistan, Egypt and Nigeria, it is tens of multiples higher. Based on the World Health Organisation (WHO) recommended doctor to patient ratio, it is quoted that India, with its population of 1.4billion, has a shortage of 600,000 doctors while Pakistan, with a population of 200 million, has a doctor shortage of 200,000. In these four countries, is has been estimated that only about half the population have access to basic medical care.
- These figures emphasise the magnitude of the moral and ethical dilemma which the UK must address as we poach so many doctors from low-income countries, a matter which the Department of Health and Social care and the GMC choose to ignore.
- Why do PLAB candidates feel no obligation to contribute to the far greater workforce crises in their own countries?
- In India, Pakistan, Bangladesh and some other countries (the source of most of our IMGs), the majority of medical schools are private, which introduces another dimension of concern. In October 2019, the Federal government dissolved the Pakistan Medical and Dental Council due to concerns relating to admission and graduation criteria. It was replaced by the Pakistan Medical Council which was charged with enforcing higher standards on the country’s private medical colleges. In 2015, a Reuters special report was titled: “Why India’s medical schools are plagued with fraud”. According to its own website, there are only 16 medical schools in the world that the GMC definitely does not recognise. None of these are in Pakistan and only one in India.
- The UK is a signatory to the WHO Code of Practice on international recruitment of health workers which states that “member states should discourage active recruitment of health professionals from developing countries facing critical shortages of health workers” (4). A similar NHS code of practice, which was drawn up by DoH and DfID which includes a list of 145 countries that UK should not recruit from (5). Yet, some of the countries where the GMC organise PLAB 1 exams locally are on both “do not recruit from” lists: for example: Bangladesh, Nigeria, Sri Lanka and Egypt. Is this not a breach by the GMC of the WHO and NHS codes of practice?
- There are 33 medical schools in the UK each led by a Dean who is a heavyweight academic with experience in research and teaching. The Dean is supported by professors and lecturers in the main clinical specialities. Together in 2019, these 33 schools graduated 7,343 doctors who were able to register with the GMC after being intensively examined in their finals. The GMC has no equivalent academic structure nor are its examinations as rigorous. Yet in 2019, the PLAB machine was able to register 8,505 new doctors.
- It is a national disgrace that successive governments have allowed this situation to happen. Why aren’t British medical school academics collectively more concerned? Surely their responsibility for maintaining standards in the NHS extends beyond their own medical school?
The evidence presented suggests that the GMC is intent on recruiting as many IMGs as possible to the UK while ignoring some national and international guidelines. This practice is happening under the public radar is not in the best interests of the NHS. An external and independent review of the PLAB examination and its utility is necessary and justified. A committee of UK medical school Deans would be ideal.
- GMC annual report. 2018; Page 16; Fig 5. Also: page 29.
- McManus I. C. et al. PLAB and UK graduate’s performance on MRCP(UK) and MRCGP examinations. British Medical Journal 2014; 348: g2621
- Tiffin P. A. et al. Annual review competence progression performance of doctors who passed PLAB compared to UK graduates. British Medical Journal 2014; 348: g2622
- WHO global code of practice on international recruitment of health personnel. https://www.who.int>hrh>resourse
- Developing countries recruitment. NHS Employers. 2018. https://nhsemployers.org
ADDENDUM: DATA FROM GMC ON PMQ. 2016-2019.