ABSTRACT
Introduction International medical graduates (IMGs) are required to fill foundation-level posts in the NHS. Recruiting for these posts is difficult and time consuming. In 2016, we created a link between the Great Western Hospital, Swindon and Charles University, Prague to recruit to these posts. Here, we describe in detail the recruitment process, level of support and outcomes after 6 years, including the success rate of completion of foundation training and their career progression.
Methods Formal structured interviews occurred in Prague or online. Support included tailored educational/clinical supervision and additional simulation sessions. Data collected included exception reports and sick leave records. In 2022, a survey established satisfaction levels with the project and subsequent career progression.
Results All 51 doctors (100%) recruited as IMGs completed foundation training. Exception reporting and sick leave were below the Trust average. Of those doctors, 39 (76%) replied to the survey. All reported that the appointments helped them progress in their careers and 23 (45%) have subsequently been appointed successfully to a national Specialty Training Scheme.
Conclusions This project improved recruitment of non-deanery foundation doctors, prevented rota gaps and provided adequate staffing of junior doctors in our hospital. Concerns around employment of IMGs can be offset by providing a supportive and developmental environment.
Introduction
The UK has a low ratio of doctors per head of population in both primary and secondary care compared with other European countries, with 3.2 doctors per 1,000 inhabitants.1 In addition, the number of graduates from UK medical schools is inadequate to fill all the junior doctor posts that hospitals have, despite recent increases in UK graduate numbers.2 A previous study noted that there is a shortage of ∼100,000 NHS staff, which is due to increase to ∼230,000 by the end of this decade3 and includes shortages in junior medical staff. International medical graduates (IMGs) are doctors who graduated from a medical school outside of the country where they practice medicine. Within the UK, 30–40% of junior doctors are IMGs, of whom 11% qualified from the European Economic Area (EEA).4–6
The foundation programme launched in 2005 whereby a fixed number of newly qualified doctors were allocated by each deanery to each hospital trust for a 2-year period. Foundation doctors rotate at 4-month intervals around varying specialties to obtain basic training and provide the service needs of each department before choosing a specialty in which to train.
The Great Western Hospital in Swindon (GWH), UK, serves an estimated population of 450,000 but the annual increase in catchment numbers and the increasing age and morbidity of the population has meant that more doctors at all levels have been required to meet the demand. As the allocation of foundation doctors was fixed by the Severn Deanery, additional trust doctors were required to fill vacant positions, which arose as a result of increasing departmental workloads, absence because of illness or leave, or less than full time training. Recruiting for these posts was difficult and time consuming for both the human resources (HR) department and senior clinicians involved in the recruitment process; and failure to recruit resulted in the very expensive necessity to employ locum doctors. Individual posts were advertised and applicants were interviewed from a variety of locations and with a varied experience. Before Brexit, EU regulations meant that previous sources of English-speaking graduates (from Australia, New Zealand and South Africa) were not available.
Charles University in Prague (CUP) is one of the oldest medical institutions in Europe. It has an exceptional reputation, attracting students from all over the world looking for an internationally recognised course taught in English.7 Many of these students are UK residents or have the ability to obtain a UK visa to work.
Therefore, we considered the possibility of recruiting from this one institution but had concerns that the ability of these graduates to adapt to working in the NHS might be difficult, particularly because their clinical experience was less than that of a UK graduate. Here, we describe the recruitment process, the support system put in place for these doctors and the outcomes of this project, including both the junior doctor and the Trust's experience of their performance, difficulties and successes, as well as their career progress on completion of the foundation programme.
Method
In 2016, contact was made between GWH and the CUP final-year medical student representative and it was established that there were CUP final-year medical students, most of whom were UK or EEA nationals, looking to practice in the NHS. A consultant respiratory physician, a consultant orthopaedic surgeon and an HR administrator from GWH drew up an application form, which required candidates to detail their qualifications and medical experience, as well as extracurricular activities, such as research, projects and teaching. Candidates applied and were shortlisted. The GWH team travelled to Prague to conduct interviews and select candidates, pending success in their graduation, registration with the General Medical Council (GMC) and visa application. The interviews were structured and focused on questions about clinical skills and, in particular, the ability to manage common medical emergency situations. Candidates were deemed unappointable if they fell below a certain standard on these questions even if they performed well in the rest of the interview. The team was expanded to other physicians and surgeons as the number of interviewees increased in successive years, along with at least one alumni appointee who had experienced the project. During Coronavirus 2019 (COVID-19) lockdown, the presentation (see below) and interviews were conducted online.
GWH offered accommodation and a week-long induction programme to the appointees. Trust foundation doctor rotations were established, initially in care of the elderly, trauma and orthopaedics and acute medicine, but widening to other specialties, such as general surgery and diabetes & endocrinology, as more posts were created.
Medical qualifications from the Czech Republic are classed as relevant European qualifications, as per the GMC. Full registration with a licence to practice is awarded upon submission to the GMC of the Diploma of Graduation issued by a Czech University in the curriculum of general medicine.8
Although CUP graduates qualify for full GMC registration and, therefore, can be employed as foundation year 2 doctors (FY2), we strongly advised them to start at foundation year 1 (FY1) because they have limited clinical experience, which was generally readily accepted by the appointees. No other restrictions, such as prescribing limitations, were put in place during their first year.
With each successive year of the project, the number of applicants and appointees increased. Each year, GWH prepared an oral presentation that was delivered to the students of the multiple medical faculties at CUP. This provided the students with an overview of the job description, which, despite being a non-deanery post, had all the same support and training opportunities, including educational and clinical supervision and protected training time in line with deanery posts, as well as details of the hospital premises and the town. An opportunity was provided to question alumni, who shared their previous experiences of the process, including the transition to living and working in the UK.
The successful applicants then underwent a formal Trust induction, IT training and a period of shadowing of the junior doctor whom they were about to succeed. During this time, they attended consultant-led ward rounds, and observed and practiced day-to-day tasks and procedures under direct supervision. They were also introduced to academic competencies, such as audits, quality improvement projects (QIPs), research and compulsory educational teaching days.
Clinical and educational supervisors were allocated and access to the foundation programme e-portfolio was provided by the Postgraduate Office for completion of structured learning events, team assessment of behaviour and practical competencies, which were required to be achieved to the same standard as deanery foundation doctors. Weekly education committee meetings were held to discuss progress and the recruitment team kept in regular contact with the departments in which the IMGs were placed to nip any problems in the bud and put in extra support where required. This comprised both academic and pastoral support, including simulation training sessions on the management of patients, interpretation of echocardiograms (ECGs) and chest X-rays, insertion of canulae, phlebotomy and arterial blood sampling, as well as one-to one sessions on how to navigate the e-portfolio. Shadowing of the CUP doctors on the ward was also organised so that alumni could give advice on how to conduct a ward round, document in the notes and write a plan.
Upon completion of a successful appraisal with the educational supervisor at the end of the first year, subsequent FY2 trust-grade posts were offered allowing continuity of training for the doctors in their careers. Records of any difficulties, extra supervision or training, or problems with completing the FY1 competencies were confidentially collated.
In April 2022, an email survey was sent to all those appointed to confirm completion of FY1 and FY2, to obtain their opinion on their experience of the project, and to enquire about their subsequent career progress either within or outside the NHS. Specifically, the survey asked whether they thought that the GWH posts had helped them in their career progress in the NHS and whether they would recommend their particular rotations to other IMGs.
Results
The recruitment process started in 2016 when six applicants were appointed as trust-grade FY1 doctors, and peaked in 2019 with 11 successful appointees. Since 2016, 51 doctors have been employed within rotational posts of 4 months each in a variety of specialities, as described above (Fig 1).
Number of junior doctors recruited from Charles University, Prague to Great Western Hospital from 2016 to 2021 (n=51).
Over the 6 years, seven doctors were appointed who subsequently declined to accept the post, but these positions were filled by the next-ranked candidate at interview. Once appointed, the main areas requiring extra support were a lack of knowledge of NHS systems, and experience of practical procedures and skills compared with UK-trained doctors. This led to the development of a 4-week mentorship programme for 5th year CUP medical students who were thinking of applying the following year. The mentorship programme comprised small group workshops, clinical skills sessions and shadowing on the ward, so that they were able to learn and practice these skills. This initiative narrowed the gap once they started at GWH.
No doctor who started at GWH failed to complete foundation training. Two doctors required extra simulation training, one required 2 months of shadowing as a supernumerary doctor before being able to work independently, and four doctors were unable to start on the required date because their visa had not been issued, although this only delayed the start by an average of 2 days.
In total, five Exception Reports were filed with the Guardian (a system of flagging up where excessive workload requires doctors to work extra hours), which represented 0.16 reports per doctor per year, significantly below the Trust average of 0.58. A total of 27 days of sick leave was recorded by 5/51 doctors, which equates to 0.88 days per doctor per year, again well below the Trust average of 1.7 days per FY doctor per year
Of the 51 doctors surveyed, 39 (76%) replied, and two were uncontactable. All 39 doctors (100% of those that replied) stated that they felt that GWH had helped them in their career progress in the NHS. In addition, 36 doctors (92% of responders) stated that they would recommend the hospital and the process they experienced.
Of the 51 doctors, 23 (59% of responders, 45% of group as a whole) were either currently holding or were due to start a specialty training post from August 2022 (Fig 2).
Career progression of the Prague recruits. This chart does not include those who have not yet completed foundation training.
Table 1 represents the breakdown of specialities undertaken for the training posts, with GP training being the most popular choice. Eight doctors are still working within the NHS in non-training roles, and another eight have left the NHS to follow other career pathways.
Numbers recruited to each specialty
Discussion
This report demonstrates the success of the pathway created by GWH to tackle understaffing issues by initiating a recruitment process of IMGs from CUP. The initiative was also designed to allow a smooth transition into the NHS, and to offer an environment exactly equivalent to deanery foundation doctors so that there was every opportunity for career progression within the NHS. Our success is shown by a 100% completion rate of foundation training and high satisfaction rates with the project. The figure of 45% of recruits achieving specialty training numbers is a minimum, because nine doctors had not yet applied for these positions and several more might apply after a further period of working within the NHS. This figure compares with the national data on all FY2 doctors, which shows that, in 2016, only 46% of doctors had entered specialty training immediately after their FY2 year (although this steadily increased with each subsequent year after FY2 completion, to 90% by year 6); in 2021, this figure (entering specialty training immediately after FY2) had fallen to 30%.9
The lower rates of exception reporting and sick leave are open to interpretation, because, if a junior doctor felt insecure, they might be unwilling to make themselves conspicuous by reporting an unsatisfactory situation or by going off sick; however, this might also suggest that this cohort of doctors is resilient and able to withstand the increased stresses that they undoubtedly felt on starting work, as well as the success of the support system in place to help them with these stresses.
There were several risks identified. First, CUP medical students have less direct patient contact experience compared with UK medical students and some other international medical schools. There was a risk that the lack of clinical experience could put patients at risk if the CUP doctors had been left unsupervised and an emergency situation arose. As stated in the Method, we were careful not to appoint candidates who could not give an account at interview of the safe management of an emergency situation.
Second, it was a risk to employ significant numbers of doctors from one institution because they might all have found the transition to working in the NHS difficult. This would put a strain on the other members of staff within each department by requiring additional support from both senior and junior doctors, such as educational and clinical supervisors and peers left to deal with additional workload. Potentially this could be even more difficult to manage than a rota gap. Difficulties were indeed faced by the Prague IMGs, the main one being the transition into the working environment of the NHS, because, for most, this was their first working experience within the system. Although the cohort comprised multiple UK nationals, there were also diverse cultural and ethnic backgrounds, which required adaptation to a new country and its culture. These factors caused a few individuals to struggle initially, requiring additional support.
In creating a supportive and developmental atmosphere, more CUP graduates were attracted to the project, thus creating a community for them as well as simplifying and reducing the costs of our recruitment process.
Despite not being a deanery foundation post, the job offered several academic opportunities to these doctors, including research, QIPs, audits, the foundation management and leadership programme and attendance at the weekly foundation teaching programme. They were further encouraged to take up the advanced life support (ALS) course within the hospital to increase their confidence and competencies in managing life-threatening emergencies. In particular, high-quality academic opportunities were created for the development of their portfolio; according to Noaman et al,10 the portfolio section of the interview is the section in which IMGs score the lowest for their National Training Number (NTN) interview.
This pathway also proved advantageous to the CUP IMGs because their final exams are in June, which means that they are not able to apply, via ORIEL, to the foundation training pathway (which usually happens in January–February). Therefore, rather than waiting a further 6 months for their application, they can start working straight after completing their studies in a well-supported environment where they personally know colleagues who share a similar background in terms of medical education or have had the chance to meet previous alumni who also shared their experiences since joining the Trust.
Particularly noteworthy in this evaluation was that all the doctors who replied to the survey felt that GWH helped them progress and provided the first stepping-stone in the process. This was further reinforced because 91% of the same cohort stated that they would recommend the hospital and the process they underwent.
Our HR department was very happy with our recruitment process because it filled permanent positions and reduced the time, effort and cost of recruiting and paying locum rates to fill rota gaps. Figures from 2015 showed that NHS acute trusts located within England were estimated to be spending 25 times more capital on locum agency fees than they were for recruiting doctors to permanent positions.11 In addition, we have added to the NHS workforce generally, contributed to increased equality, diversity and inclusion, and have provided more doctors entering specialty training programmes, which will no doubt lead to the filling of NHS consultant posts in the future.
Our study has several limitations. Given that this project has only been ongoing for 6 years, the sample size of doctors recruited remains small. This is a single hospital study, and other hospitals might not be able to reproduce these results because of various factors, particularly if they do not have the necessary academic and pastoral care input from their postgraduate training departments.
Given that two of the authors have undergone this initiative and took the journey from Prague to a training post within the NHS, there is the possibility of some author bias. However, the demonstration that over half of the junior doctors recruited to the workforce went on to serve the NHS as trainees in different fields shows the undeniable success of this project.
In recent years, UK medical school places have been significantly increased, which will in time lead to an expansion of foundation doctor numbers. As a consequence, the need for IMG recruitment might be reduced; nevertheless, demand also continues to rise and, therefore, it is likely that this or similar projects will be required for the foreseeable future.
Conclusion
This project improved our recruitment of non-deanery foundation doctors to reduce rota gaps and provide adequate staffing levels of junior doctors in a busy district general hospital. By establishing this link, we have shown that concerns around the employment of IMGs can be offset by providing the right supportive and developmental environment. Proof that this has been successful is shown by the 100% completion rate of foundation training, the 100% satisfaction rate of the doctors on their experience at GWH, and the fact that almost half have secured NTNs in a variety of specialties to date. In an NHS environment where demand outstrips the supply of all doctors, we hope that the success of the project acts as an example to other trusts and encourages them to adopt this policy.
Acknowledgements
We acknowledge the help of the HR Department at GWH, including Danny Little, Latoya Hulcoop and Elaine Middleton. We would like to also acknowledge the help of Beverley Taylor, from GMC, who provided data for our report.
- © Royal College of Physicians 2023. All rights reserved.
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