Acculturation of international medical graduates into the NHS

Background

Since the inception of the NHS in 1948, international medical graduates (IMGs) have been a part of its workforce. IMGs are defined as having graduated from medical schools outside of the UK or the European Economic Area (EEA); these graduates require a General Medical Council (GMC) registration with a licence to practise obtained either by passing the Professional and Linguistic Assessment Board (PLAB) exams or by obtaining sponsorship from their respective royal colleges having satisfied their requisite entry criteria.

Workforce

According to data from 2019, 37% of the total doctors working in the NHS are not trained in the UK: 26% qualified outside the UK/EEA and 11% from the EEA.^1,2 According to 2020 State of medical education and practice in the UK by the GMC, the UK medical workforce is increasingly ethnically diverse. Fifty-four per cent of the doctors joining the register in 2020 identified as Black and minority ethnic (BME). Between July 2019 and June 2020, over 10,000 IMGs joined, more than the UK and EEA combined. IMGs constitute 30%–40% of the junior doctor workforce.³

Problems faced by IMGs

As outlined in the GMC's Welcome to UK practice workshop, adapting to the UK medical culture and ethics can be difficult for any doctor, regardless of their ethnicity and experience. Furthermore, the differential attainment report by the GMC explored that IMGs face additional risks in view of inexperience with UK assessments and recruitment, culture differences, poor relationships with peers and fitting in the system. Factors such as these can discourage IMGs from considering a career in the NHS.

The initiative: a successful model

A clinical attachment programme has been initiated at Ashford and St Peter's Hospitals NHS Foundation Trust (ASPH) by a group of clinicians, administration staff and the medical director. At its inception, in January 2018, this programme was termed ‘the Kerala project’ as it initially mainly recruited doctors from Kerala, India. This has now successfully increased in scope to include IMGs outside of the sub-continent and at all levels of experience. The first individual attachment took place on 21 January 2018, but the first cohort programme commenced on 19 March 2018. There have been approximately 54 doctors inducted into this programme and are currently working in the NHS. The recruitment process includes undergoing a strict scrutiny of curriculum vitae, background, experience, competencies, and face-to-face or videoconference interview. The selected doctors then go through a 6-week clinical attachment programme which includes a formal induction to the trust, IT training and a shadowing period in various departments of interest.

They practise history-taking skills, attend consultant-led ward rounds, join multidisciplinary team (MDT) meetings, and observe different ward procedures and surgeries. This provides first-hand experience of duties and responsibilities of foundation doctors. Regular weekly assessments of clinical and IT skills are conducted. Additionally, they are introduced into research, audits and quality improvement projects as well as a compulsory attendance of educational half days. Certificates are issued upon successful completion of these mandatory programmes, audits and presentations. Weekly meetings with the clinical and educational supervisor are held to ensure wellbeing of the doctors, provide required guidance and check the individual doctor's progress. Hospital accommodation is also provided.

Selection process

The programme concludes with an interview process and an objective structured clinical examination (OSCE) that includes safety assessment profiles, clinical aptitudes, knowledge breadth and basic skills to ensure that attachment doctors meet the essential and desirable person specification for employment as outlined by the ASPH. If a candidate is found employable, they are offered a 2-year contract with the trust as a foundation year-2 or core trainee-1 trust-grade level depending on the individual's level and evidence of experience. Rotational posts are also provided to allow experience in different departments. Regular guidance is provided on career progression and appraisals by meetings with allocated clinical and educational supervisors and previously employed attachment doctors acting as mentors. They are encouraged to join royal colleges, the British Medical Association (BMA) and defence unions, and are given access to a Horus portfolio for completion of work-based assessments, multi-source feedback and competency sign off. Trust-grade doctors’ representatives, with local committees and the BMA, help support IMGs. These steps help to reduce risk of differential attainment.

Some of the achievements made by these doctors are that three original research articles have been published, four papers are being reviewed for publication, and 13 international and national poster abstracts and numerous audits have been presented that have contributed in better medical practice.^4–6 Twenty doctors have successfully received a national training number in various specialist programmes: 11 in general practice, four in internal medicine, two in paediatrics, one in psychiatry, one in obstetrics and gynaecology, and one in core surgical training. There are numerous clinical attachment programmes within the UK such as the LEAD-it project started in the emergency department at University Hospitals of Leicester NHS Trust that have similarly attempted to acculturate IMGs into the NHS and UK medical practice.

IMG COVID-19 surge contribution

The arrival of the COVID-19 pandemic has highlighted the fact that NHS staff can often feel burdened by the surge and sheer workload but, with the additional support of IMGs, it has enabled the NHS to facilitate a way to overcome challenges and decrease burnout.⁷ Doctors redeployed to patient-facing roles were able to use clinical skills and experience to deliver good patient care, whereas the others on wards utilised their attachment experience to handle all the patients even if understaffed. This difficult time exemplifies the symbiotic relation shared between the two.