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Indian Journal of Surgery, Vol. 66, No. 5, September-October, 2004, pp. 265-269 Special Article Surgical training for overseas doctors in the UK - Facts, realities and solutions! Raghu Ram P National Subspecialty Fellow in Breast Surgery, Nottingham
Breast Institute, Nottingham Code Number: is04069 INTRODUCTION Surgical training in the UK is popular amongst overseas trainees because it is perceived to be good and well thought of abroad. One of the unique features of Postgraduate medical training in the UK is the large number of overseas graduates integrated into it. Currently, over 100, 000 doctors are practising in the NHS. Of these, 45% are Overseas Qualified doctors. This compares with 40% who have qualified in the UK and 15% within the European Economic Area.[1],[2]This article will focus on some of the evidence based facts and realities pertaining to training in general and surgical training in particular in the UK for overseas qualified doctors from the Indian subcontinent. Possible solutions that might help overcome some of the realities faced by overseas-qualified doctors in the UK would be outlined. FACTS Why does an overseas-qualified surgical trainee go to the UK?[3],[4]
The General Medical Council (GMC) has been conducting the PLAB test in the UK for over two decades now. Since 1998, the GMC has spread its wings overseas to 14 countries where it now holds the Part 1 Examination. India is the single largest Overseas Centre for PLAB test. Analysis of the percentage of Doctors sitting the PLAB Test (Part 1) by Country of attempt in 2003 revealed that 51% sat the Exam in India. This compares with 13% who took the Exam in Pakistan, 28% in the UK and 8% from other countries. There has been over three-fold increase in the number of Doctors sitting the PLAB Test (Part 1) and over four-fold increase in those sitting PLAB test (Part 2) since 2000. Interestingly, the Pass rate of PLAB test has doubled from around 35% up until 1997 to over 70% since 2000. INERCOLLEGIATE MRCS[9] There has been a fundamental change in the arrangements for Surgical Training in the UK since 1996.[5],[6] From January 2004, the Intercollegiate MRCS Examination (Member of Royal College of Surgeons) has replaced the MRCS conducted by the individual Royal Colleges. This would be introduced in a phased manner. All new candidates entering the MRCS examination for the first time must take the Part1 and /or 2 examinations under the new Intercollegiate regulations. Under the new regulations, individual Colleges would continue to administer the MRCS Examination as they did previously and candidates may apply to the College of their choice. However, the MRCS examination that trainees sit will be the same irrespective of College / Centre in which it is held. The ′old style′ FRCS Examination has ceased to exist from January 2004. Trainees would be eligible to sit the FRCS only after successful completion of four years of structured Higher Surgical Training in the UK. From November 2004, all trainees, who wish to enter a Type 1 Higher Surgical Training Programme as a Specialist Registrar, may only do so if they have been awarded Certificate of Completion of Basic Surgical Training (CCBST). CCBST will be issued by each College on an Intercollegiate basis.[9],[10] EUROPEAN WORKING TIME DIRECTIVE (EWTD) Historically, doctors in Training in the UK have worked long hours and provided much of the out of hours-medical cover. In 1998, the Council of the European Union has introduced European Working Time Directive (EWTD). This is a Health and safety Legislation which lays down minimum requirements in relation to working hours for Doctors in training. From August 2004, the Legislation will apply to all Doctors in training. The main feature of the EWTD is that by law, from August 2004, no doctor in training would be allowed to work longer than 58 hours per week. This would be further reduced in a phased manner to 48 hours by August 2009.[8] Postgraduate Medical Education and Training Board (PMETB) The Postgraduate Medical Education and Training Board (PMETB) would be functional from 2005. It will replace Specialist Training Authority (STA) and brings together responsibility for all postgraduate medical education (PGME) and will assess doctors completing final postgraduate training in the UK. REALITIES Far more overseas graduates are seeking Higher Specialist Training in the UK than can be trained satisfactorily. Many overseas-qualified doctors arrive in the UK after varying levels of training, qualifications and experience. They consequently have different training needs. There has been an alarming increase in the number of overseas-qualified doctors who are struggling to find a job in the UK. Many encounter real difficulties in securing an initial appointment. They often hold short-term SHO contracts or face unemployment between posts when their contracts end.[12] Many doctors who have passed PLAB test wait for several months and in some instances ranging from six months to a year before they can find a job.[19],[20],[21],[22],[23] Having spent several thousand pounds towards PLAB fee, international travel and local subsistence in the UK, doctors who have been unsuccessful in securing a job for several months borrow money and eventually get into debts. Although, some manage from their own resources brought from home, there are others who have returned back to India. Furthermore, whilst waiting for their first job placement, many doctors face difficulties with the Home Office in trying to get their VISA extended in the UK.[24] In England about half of all doctors in training are Senior House Officers (SHOs) and one third of SHOs are non-UK graduates. As a group, the SHOs have been described as ′the workhorses of the NHS′ (implying a disproportionate amount of service work compared to training) and a ′lost tribe′ (suggesting a lack of coherence in the organisation of training). Their aspirations for career advance are frequently unmet.[12] There is a glaring disparity between the number of trainees in pursuit of Higher Surgical Training (HST) and the number of posts available. The competition to get onto a structured HST programme is fierce. Stringent requirements and tremendous competition have made entry onto the Specialist Registrar Grade very difficult. On an average, there are about 200 - 250 basic surgical trainees competing for 1-2 slots on a Higher Surgical Training Programme.[11],[12],[15] Moreover, the number of HST positions, mainly those available to overseas trainees has been reduced. There has been recognition of the need to train more surgeons for work within the UK leading to greater number of UK trainees displacing those in Overseas Registrar posts. Many visiting registrar posts have been redesignated to substantive Type 1 Training Posts. The risk to trainees from overseas is obvious.[11],[13],[18] Inadequate Consultant expansion has had an enormous effect on the SPR posts available. In addition, for the very first time, there was a reduction of 25 training numbers in General Surgery in 2000/2001. Although there has been a steady increase in Training numbers in 2002 and 2003, the bottleneck at the SHO/SPR interface is getting worse.[8],[12],[13],[15],[16],[17],[18] There is now a huge waiting list in many Hospitals across UK for non-paid honorary clinical attachment Posts. Prior to 2001, there was not much demand for a Clinical Attachment Post. In fact, some Hospitals provided free accommodation to these doctors. The huge influx of post PLAB trainees from overseas has dramatically changed the situation. Currently, free accommodation is no longer provided. More importantly, some Hospitals have resorted to charging the doctor for having provided a non-paid Clinical Attachment Post![24] Over the last few years, many overseas doctors, who have gone to the UK with the intention of obtaining structured surgical training, have unfortunately taken up Non Consultant Career Grade (NCCG) jobs. As such, there is no hope of any career progression in this grade and doctors in this grade would always work under the supervision of a consultant. It is estimated that nearly 70% of doctors taking up NCCG Posts are overseas qualified and nearly all of them have been unsuccessful in obtaining a structured training leading to a Consultant Post in the UK. It is disheartening to note that there has been a dramatic and alarming (600%) increase in NCCG posts in the UK since 1996.[14] Several overseas doctors with Postgraduate qualifications from India have changed their Specialty interests just to be able to secure a job and earn a living in the UK. Over the past four years, the number of overseas doctors qualifying as General Practitioners has increased by 50% - with overseas applicants up by three fold.[25] Up until 2002, overseas-qualified doctors who did not have a right of indefinite residence (Permanent Residence Status) in the UK were not allowed to apply for General Practice Training Programme. But the doors have now opened to overseas-qualified doctors. In the light of the current scenario, an increasing number of doctors who had come to UK with the hope of obtaining structured higher specialist training in surgery and medicine are opting to become general practitioners. In view of the impending EWTD legislation and reduction in Junior Doctor working hours, NHS Trusts have been actively recruiting doctors onto the Non Standard Grade Posts (commonly referred to as ′TRUST GRADE POSTS′). The vast majority of these Posts are ′SHO equivalent′ and are not recognised for training. Trusts advertising these posts expect them to be filled by overseas doctors, most of whom are from the Indian subcontinent.[26] Recently, analysis of the proportion of Non Standard Grade Posts (Trust grade Posts) advertised in the British medical Journal Careers Section was published. This interesting Study revealed that nearly a quarter (25%) of advertisements for non-consultant jobs in the UK are for Non-standard Grade Posts (Trust Grade Posts). These Posts have been created to keep the NHS functioning. Sixty different job titles have been used by Trusts across the UK for these Posts. Although the exact figures are unknown, it is estimated that around 3,500 - 4000 overseas-qualified doctors have taken up these Non Standard Grade Posts up and down the Country. If the Trusts maintained at this level of vigorous recruitment, it is anticipated that around 7000 doctors would take up these posts before the end of 2004.[26],[27] SOLUTIONS! In a country where there are one million patients waiting for inpatient treatment and two million waiting for their first outpatient appointment, it is an irony that there are so many unemployed doctors in the UK. Although there is an acute shortage of trained Specialists (i.e. Consultants), there are not enough training Posts in most front line Specialties. The fundamental reasons for this are poor workforce planning and Organisations working in isolation. There are a number of overseas-qualified surgical trainees who have completed their Basic Surgical Training (BST) and part of Higher Surgical Training (HST) in India. There is not much point in this subgroup of trainees undergoing BST for a further couple of years in Britain. The Association of Surgeons of India (ASI) has amongst its membership several towering personalities who have close links and personal friendship with several eminent Surgeons in the UK. There is a potential to develop a One-year Exchange Subspecialty Fellowship Programmes between the ASI and its Speciality Sections with Counterpart Organisations in the UK namely The British Association of Surgical Oncology, Coloproctology, Upper GI Surgeons and Endocrine Surgeons. Posts that could provide targeted Subspecialty training in Centres of excellence in both India and UK could be identified and inspected by a Committee from both Countries. A standardised Selection process should then be used to grant the Exchange Fellowship to those trainees who would potentially benefit from this Exchange Fellowship. The hassles associated with passing the PLAB test and the struggle associated with getting onto a Structured HST amidst intense competition in the UK could be bypassed. I have every confidence that this proposal is feasible and achievable. Further to my suggestion extensive consultation and negotiations to develop an Exchange Fellowship in 2003, I am delighted to report that a preliminary meeting has taken place between the Executive members of British Association of Surgical Oncology (BASO) and Indian Association of Surgical Oncology (IASO) at the Annual Conference of IASO held at Jaipur in September 2004. On principle, it was agreed by both organisations to establish Exchange fellowship. This would be the First pilot project of its kind that hopefully would help Higher Surgical Trainees from India to obtain subspecialty training at centres of excellence in Britain. At the moment, very little information is available to overseas-qualified doctors in their Home Countries regarding the precise training opportunities available to them. The General Medical Council (GMC) in association with the Department of health (DoH), UK and Higher Training Offices across all specialties must publish an annually updated National Guidance Document. This Document must contain clear, readily available information on the opportunities for Postgraduate medical and surgical training in Britain and must be made available to all overseas qualified doctors before they sit the PLAB Test in overseas centres. It must provide information on precise training opportunities available for overseas qualified doctors at the SHO and SPR grade. The document must also spell out specialities in which training opportunities no longer exist so that false expectations could be minimised. The GMC should seriously consider restricting the numbers of doctors who can appear for the PLAB test in Overseas Centres. Further expansion of NCCG and Trust Grade Posts must be stopped and Trust Grade Posts must be banned as soon as possible. Trust Grade Posts are to be condemned as they potentially exploit doctors and mislead patients. There must be a centralised system of clinical attachments in General Surgery and other sought after specialties. This would significantly ease the waiting lists for these non paid Posts and would immensely help overseas-qualified doctors to familiarise themselves with the working practice in the NHS. MY ADVICE TO PROSPECTIVE UK TRAINEES
CONCLUSION Majority of Overseas qualified surgical trainees go to the UK to train in a specific aspect of General Surgery. Significant reorganisation of surgical training has occurred and MRCS has replaced FRCS. Entry to get onto a HST Programme is getting more and more competitive with chances of being selected ranging from very difficult to apparently impossible, depending on the region and deanery. The tradition of training in the UK is long established and has made significant contribution to the Health Services of both Britain and India. However, momentous changes that have been introduced to Postgraduate training in the UK has demoralised many Overseas-qualified doctors in the UK. Strategic planning by the ′powers that be′ both in the UK and India is essential to deal with this current crisis. ACKNOWLEDGEMENTS The following Surgeons have given me their suggestions and advice during the preparation of the article: Prof. P. V. Chalapathi Rao, Prof. H.G. Doctor, Dr. R. B. Singh, Prof. K. Gopinath, Prof. Gautam Sen, Prof. N. Rangabashyam, Professor S. Vittal and Dr. Uma Krishnaswami. REFERENCES
Copyright 2004 - Indian Journal of Surgery |
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