National Primary Care Research and Development Centre and the Manchester Centre for Healthcare Management

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1 April 2003 Executive Summary 28 The International Market For Medical Doctors: Perspectives On The Positioning of The UK Background to the Project Addressing the pressures associated with shortfalls in the medical labour market is one of the main challenges for workforce planning and development in the NHS. In addition, the NHS Plan set ambitious targets to expand consultant, GP and trainee doctor numbers. Although long- term solutions will come from adjusting medical education, training and employment structures in the UK, attracting doctors from the European Economic Area (EEA) and elsewhere overseas is seen as important for the short-medium term. Main Objectives The Department of Health (DH) commissioned this project in 2000 under its Human Resources Research Initiative: To document the broad geography and structure of supply and demand in the international medical labour market and to outline the UK s present position: To provide a clearer understanding of the factors influencing international medical migration to the UK in the light of labour market competition by other countries; To highlight the major components of change likely to affect UK supplies; and To help inform the UK s recruitment and retention policies for EEA/overseas doctors in practical ways. Research Methods To meet the objectives, the study brought together information from the following sources: A review of existing literature and secondary data on the international medical labour market and physician migration; An analysis of large-scale computerised datasets collated by the NHS Executive namely the GP principal, GP registrar and HCHS (Hospital & Community Health Services) Censuses for the period 1991 to 2000; Semi-structured interviews with key UK stakeholders (e.g. BMA, GMC, Royal Colleges, Post-graduate Deaneries, Directors of Post-graduate GP Education, STA(Specialist Training Authority), British Council); Interviews with equivalent organisations in five case study countries selected because they occupy different labour market positions relative to the UK the USA, Australia, Spain, Poland and India.

2 By exploring the perceptions and judgements of key organisations acting in the international marketplace, the research complemented a companion project on the experiences of individual EEA/overseas doctors already in the UK. The latter was commissioned from the Open University Centre for Education in Medicine. Summary of Key Findings The Overall Picture of EEA/overseas Supply to the UK There is an overall shortage of doctors in the UK, from general practice to many hospital specialties and from basic training grades to the fully qualified doctors. Presenting these gaps to the international marketplace is complex. It includes such factors as: supply and demand for that particular speciality; the regulatory framework governing different types of training and posttraining jobs; the point on the medical career ladder at which entry is sought. Demand is represented by those undergraduate education, post graduate training and post training positions into which migrant doctors slot, depending upon the constraints they face in a given context. Between , South Asia and the EEA followed by Southern Africa, were the largest suppliers of doctors entering the UK labour market from abroad. Within the various global regions, the countries that supplied greatest numbers were: Germany and the Republic of Ireland in the EEA; Poland in Eastern Europe; Iraq in the Middle East; Egypt in Northern Africa; India in South Asia; Australia in the rest of the world. Overall, EEA doctors tended to be younger than but with similar sex and ethnic distributions to UK qualified doctors. Those who qualified elsewhere were more likely to be Asian, male and older compared to their UK counterparts. UK qualified doctors stayed longer in the NHS than EEA doctors, who in turn stayed longer than those from non-eea countries. II

3 General Factors Underpinning International Doctor Migration The main incentives for doctors to migrate were identified as: At the country-level: Relative economic and social expectations and the prospects for higher financial gain; Wider quality of life issues, including personal safety and the prospects for political stability and greater freedom. At the medical organisation/professional-level: Relative prospects for obtaining career improving postgraduate training; Home country bottlenecks to career development and progression; Perceptions of enhanced job satisfaction and working conditions. At the individual-level: The stage doctors have reached in terms of career development and family formation; Their particular medical field and the health system in which they gained their experience/training; Whether or not individuals and their families are considering migrating for the short or longer-term. Migration to the UK in the Light of Labour Market Competition The incentives seen as giving the UK an advantage over other countries were: The availability of post-graduate training opportunities and the kudos of UK qualifications (particularly from the Royal Colleges), which enable doctors to enhance their skills and career prospects; The English language, which is relevant both for ease of entry to the UK labour market and as a passport to wider opportunity elsewhere; The information, recruitment, job matching, induction/training and follow-up support systems being developed to ease individuals throughout the migration and labour market entry process. The Shape of International Labour Market Competition The study revealed a wide range of demander countries looking to source a substantial proportion of their medical supply from outside their own health systems. This is in response to both national shortages by speciality and/or to particular pressures in deprived or underserved locations. As well as global migration between continents to match these demands there is movement at regional and country-to-country levels. Examples include: USA/Canada; USA/Central and South America and the Philippines; Australia/New Zealand and the Pacific Rim, UK/EU-EEA, UK/Commonwealth; and South Africa and the rest of Africa. Within this highly competitive global context, the UK appears primarily to operate in a group including Commonwealth countries such as Australia, Canada and, to some extent, New Zealand. All are competing across the same three factors identified above as providing the UK with its competitive advantage. In the European sub-market, countries such as Sweden, Norway and Germany are also actively recruiting in, or have existing strong migration links, with current/potential UK suppliers (e.g. Spain and Poland). III

4 Overall, the USA was the dominant player internationally, effectively out-competing all other contenders for EEA/overseas doctor supplies. Its position was seen as unassailable due to its strong image of economic and lifestyle opportunities and particularly well-funded health facilities. Ensuring the UK s Future Supplies of EU/overseas Doctors The most significant UK suppliers (e.g. Australia, New Zealand, South Africa and particularly India) were felt to be relatively secure. There are also prospects of new supplies, for example from eastern European countries joining the EU. However, there was a view that the UK may be "resting on its laurels", or "trading on its past reputation" to attract EEA/overseas doctors. Given that standing still can only be associated with a competitive penalty, the UK needs to improve the face it presents to the international marketplace. Key Ways for the UK to Respond to Changing Market Conditions Both UK and overseas interviewees emphasised the need: To improve the UK s general market positioning by: Focusing advertising and recruitment on specialties and career stages where doctors are needed most; Clarifying whether the intention is to recruit and retain, or train doctors primarily to return to source countries. To provide better information on available opportunities through: One-stop access to personal advice in the UK, and in supply countries through recruitment campaigns or building on existing British Council arrangements; A central website covering everything from professional regulations, immigration requirements and links to Royal Colleges, the BMA, Deaneries etc, to English language training packages and general tips on relocating and living in the UK. To reduce UK labour market entry barriers through: More access generally to the Professional Linguistic Board Assessment (PLAB) examination in overseas locations; Earlier access to PLAB Part 1(i.e. during undergraduate education) to compare better with the United States Medical Licensing Examination (UMSLE); Fast-tracking past PLAB for doctors who already have higher training and qualifications, including Royal College examinations taken overseas; More use of the Shortage Occupations List and Highly Skilled Migrant immigration category for the specialties with greatest shortages; Issuing work permits to recruitment agencies for them to employ doctors directly; Allowing in those whose first language is English (e.g. Australians) or who may not reach International English Language Testing System (IELTS) requirements without further practice (e.g. refugees). Reducing the time spent in the Certificate of Completion of Specialist Training (CCST) to compare more directly with EEA countries; Streamlined application and placement via a centralised brokerage system. IV

5 To tailor recruitment, induction and training packages more effectively to individual needs. This will help migrant doctors to make the most of their time in the NHS and ensures quality in the workplace through effective social integration. To improve structures for communicating UK opportunities to the international marketplace. NHS Workforce Confederations might, for example, present a view of local education, training and employer needs. Central coordination (e.g. through the DH) could help prevent regions from competing with each other against national interests; and provide scale efficiencies in advertising, information provision and recruitment. Conclusion The main UK stakeholders the DH, Royal Colleges and other bodies are addressing many of the actions set out above. It is important to continue a more proactive approach to the process of recruiting EEA/overseas doctors. This is due particularly to the ethical considerations of recruiting large numbers of skilled professionals from countries that cannot necessarily afford to lose them. In the final analysis, EEA/overseas doctor recruitment needs to be seen in context. It is a significant element of the government s plans for medical workforce expansion. However, much wider skill-mix and UK education/training solutions are needed to meet the challenges of job matching for a future NHS. V

6 Study team contact details For more information about the study please contact: the project lead Dr Ruth Young at Manchester Centre for Healthcare Management ( or Jenny Noble, Research Associate at NPCRDC About NPCRDC NPCRDC is a multi-disciplinary centre, established by the Department of Health in 1995, with funding for an initial ten year programme of policy related research in primary care. Our centre is a collaboration between the Universities of Manchester and York, with our main base at the University of Manchester. We are committed to excellence in primary care research and dissemination. About MCHM The Manchester Centre for Healthcare Management is one of the leading centres in the United Kingdom for research, teaching and consultancy in health policy and management. Our academic staff are skilled and experienced in working at the interface between theory and practice, and helping NHS organisations to put ideas into action. Our research reports are an important part of our academic work, and are designed to help disseminate the ideas and findings from our research and to spread good practice. We are a self-financing, not-for-profit centre within the Manchester Business School, and are part of the University of Manchester. If you would like furher copies of this summary, please contact NPCRDC. Communications Unit, NPCRDC 5th Floor, Williamson Building The University of Manchester M13 9PL communit@fs1.cpcr.man.ac.uk Telephone: Download this summary from VI