Migratory waves rocking the boat?
‘Health at a glance’, the international survey published this year by the Organisation for Economic Co-operation and Development (OECD), provides a high-level statistical snapshot of the health workforce and international migration.1 The General Medical Council (GMC) in its report on the state of medical education and practice in the UK (2015) provides fine detail on the numbers of doctors entering and leaving the UK.2 Both make interesting reading, particularly if one recalls that in July last year, in the ten days after Jeremy Hunt announced his proposed new contract for NHS staff, 3,468 UK doctors applied to the GMC for certificates to practice abroad.3
First – how many doctors does the UK have? About one-quarter of a million.2 The ratio of doctors to population in the UK in 2013 was 2.8/1,000, up from 2.3/1,000 at the turn of the century.1 This is below the average for the 34 OECD countries surveyed – currently 3.3/1,000 – but there is a huge range with Greece, Austria and Russia at the top and South Africa, India and Indonesia at the lower end. Among the countries most attractive to would-be emigrants from the UK, Australia is above the average at 3.4/1,000, New Zealand identical to the UK, and both Canada and USA below at 2.6/1,000.
Second – where do the UK's doctors come from? In 2013, 28% of UK doctors were trained elsewhere – 48,000 individuals in all. Their main countries of origin were Asian – one-third from India, one-tenth from Pakistan and a similar number from other Asian countries – but currently over 20% come from other EU countries, which is a striking change from the huge dependence on the Indian subcontinent which characterised the NHS at the end of the last century. The UK of course is not alone on being dependent on foreign-trained doctors – the UK's 28% is exceeded by New Zealand at 43% and Australia at 30%, and fairly closely tailed by the USA at 25% and Canada at 23%.
The reliance of the NHS on doctors qualified abroad and the insecurity of this supply was well recognised from the 1990s, and was the major driver behind the rapid increase in medical student places in the UK at the beginning of this century. Between 2000 and 2013 the number of new medical graduates per year doubled – although notably the number of places was then reduced by 2% by the Department of Health to guard against an oversupply of doctors.
So – moving from these macro-figures to the details of the UK's current medical workforce, where are we? The GMC's report highlights areas both of concern and of reassurance. First, as a consequence of the expansion of medical school places the UK has one of the youngest medical work forces in the world – only 15% of UK doctors are over 55 (compared to 33% among all the OECD nations). One of the myths rebuffed is that of the ageing general practitioner (GP) workforce – disillusioned and leaving the profession in droves: there is a substantial flow of younger doctors into general practice, and no evidence that GPs are leaving the profession at any higher rate than other doctors.
The GMC's data allow a detailed examination of the flow of doctors along the training path – from the foundation years, through specialist registrar or GP traineeships, to either specialist or GP registration. One of the most striking observations is however the huge proportion of licensed doctors who fall into the ‘none of the above category’ – not on a register and not in training – nearly 20% of the UK's licensed doctors; and this group has by far the highest proportion of international medical graduates (non-UK, non-European Union), and indeed probably the highest proportion of EU graduates. The new ‘lost tribe’ of staff and associate specialist doctors in the NHS remains with us.4
To those who work in hospitals, the analysis of different specialty groups will be of most interest. Apart from pathology (which fell by 1%), all specialty groups have increased their numbers – by 20% for medicine and 35% for emergency medicine, over 2010–2014. Notably, the number of non-UK graduates in these specialties is rising, with over one-third of the change being due to the increase in international medical graduates.
But in the context of medical migration, the inflow and outflow rates have particular importance. In 2013, for the whole specialist register, just over 5,000 doctors joined, of whom 2,500 joined from UK specialist registrar training posts. In the same year about 3,500 doctors left. Of those under the age of 50, just under 1,500 left, 85% going to posts overseas, and of those 312 were UK graduates. One way of looking at that data is to relate the UK graduates leaving to the UK-trained specialist registrars entering – a calculation showing that UK graduates under the age of 50 leave the register to emigrate at about 10% of the rate at which UK trainees enter. The calculation holds true in medical specialties as well as for the entire specialist register.
The GMC's report paints an encouraging picture of a steady increase in both specialists and GPs in the UK, but also points out that this is sustained by employment of an increasing number of overseas medical graduates and EU doctors, and a greater reliance of doctors over the age of 50.2 But the situation is labile, and in particular events that altered the emigration rate for the under 50s would have substantial consequences. Though the supply of UK-trained doctors has risen hugely over the last decade, each now has an international passport to work. When one sees that in 2011, Australia, a significant importer of doctors as we have seen, recruited 22% of its specialists and 13% of its GPs from the UK,5 it will be salutary to observe the fall-out from the recent stand-off between government and junior doctors.
- © Royal College of Physicians 2016. All rights reserved.
References
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- OECD
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- Council General Medical
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- Campbell D.
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- Health Education West Midlands
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- Waldron D
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