Better learning, safer practice

Authors: Rich Bregazzi 

Publication date:  15 Jun 2012

Rich Bregazzi looks at induction for overseas doctors new to clinical practice in the UK

In September 2011 the Northern Deanery held its second induction course for overseas doctors new to clinical practice in the United Kingdom. Eighteen doctors from seven NHS trusts, from countries as far apart as India and the Netherlands, spent the day discussing a range of issues with local and national representatives of the wider NHS. Topics were as diverse as the audience, from advice on local secondary schools to the principles and values of the NHS. It was, according to one attendee, “one of the most useful courses I’ve attended.”

Why did we do it?

To integrate into UK living and NHS working, doctors who trained overseas and are new to clinical practice in the UK. These doctors have to overcome challenges over and above those of their UK trained colleagues. Challenges include language; culture; NHS systems and ways of working; relationships between clinicians, patients, and health teams; and living in the UK. These difficulties may compromise their experience of life and work in the UK. The General Medical Council has acknowledged this by publicising its concern that overseas doctors were not appropriately inducted into the clinical workforce, and the case for induction has been advocated by the British International Doctors Association for some time.

In the Northern Deanery we have monitored our educational outcome statistics for several years and have found that a disproportionate number of overseas doctors fall behind in their postgraduate education. We also know that, nationally, a disproportionate number of these doctors find themselves involved in some form of disciplinary action. Yet these are highly qualified and motivated clinicians, without whom the NHS could not function.

The deanery already had experience of working directly with overseas doctors new to UK practice[1] and had identified a direct responsibility to support the induction of training grade clinicians so that their experience of education was not compromised. The deanery felt a further responsibility to support post-training grade clinicians as part of its commitment to faculty development. Our challenge was to support all these doctors to help them integrate into the NHS and into the UK.

What did we do?

Our first task was to get the active support of trust education managers and local overseas consultants. The response was immediate and positive, and we quickly convened a working group through which we devised a three pronged approach: induction; facilitated peer support; and a half day development session for overseas and UK born doctors, “Cultural stumbling blocks.” This article concentrates on induction and peer support.

Induction programme

Our induction programme had to be relevant and to complement in-trust induction. We also recognised that the scope of need was greater than could be resolved in just a single day. Hence we needed to offer insight into a range of topics, provide time for open discussion, use the induction to launch our continuing facilitated peer support groups, and help doctors to find support according to need. After much debate and advice, we agreed on a programme (see table).

Induction programme

Topic Objectives
Ice breaker/introductions
Things I wish I’d known Reflection on experience of working in the NHS
Particular concerns To identify particular concerns within the group about living and working in the UK
Comparative study of overseas and UK doctors new to practice To report on research project
Working and learning in the NHS
Patient journey (primary and secondary care); principles and values of the NHS (duties of a doctor, clinical governance, the General Medical Council) To clarify the patient’s demands/expectations of the NHS, the primary/secondary care relation, and the principles and values of the NHS and how these are expressed in duties of a doctor
Working relationships: within the team, with patients; the challenge of communication To clarify norms and expectations in relation to team and patient relationships, with reference to personal experienceTo discuss difficulties of communication in a multicultural environment
Learning in the NHS: workplace learning; expectations To briefly explain how different groups of doctors are expected to manage their learning: foundation; staff grade; consultant continuing professional developmentTo discuss the behavioural expectations of learners in the service environment
Career pathways To clarify the main career outcomes and sources of advice/support
Equality and diversity in the NHS To discuss what equality and diversity mean in the context of the NHS, challenges and concerns
Living in the UK
Government, finance, housing, schooling, transport, leisure opportunities/social networks, other To enable group discussion in relation to social and domestic issues
Professional support
Patient safety and medical mistakes—how to avoid them Behaviours and support to ensure patient safety
Support organisations To clarify the roles of the Medical Protection Society, Medical Defence Union, and BMA—when and how you should get in touch
Developing support networks
Facilitated peer support To introduce and obtain commitment to peer support groups

The joy of delivering the programme was the enthusiasm of all parties and the commitment of a range of facilitators, from our own deanery staff, trust staff, and consultants to national representatives from the BMA and British International Doctors Association.

Facilitated peer support groups

The thinking behind the facilitated peer support group was to provide a means of continuing support to help group members resolve individual challenges of NHS working and living. Group membership was limited to overseas doctors new to working and living in the UK, and group size was a maximum of seven. Facilitators were volunteers: local consultants, overseas doctors themselves, who had also trained as mentors. Each was faced with the challenge of fitting the role into their busy clinical schedule, as well as that of delivering the role. Their job was:

  • To facilitate group meetings

  • To facilitate discussion that reflects and informs the concerns of the group

  • To assure the emotional safety of participation in the group and appropriate confidentiality of discussions, and

  • To offer a point of contact and gateway to a wider support network.

We planned for two facilitators for each group, to give mutual support and provide differing perspectives. It was agreed that a facilitator support group should meet two or three times a year, and links were also forged with Umesh Prabhu, of the British International Doctors Association, to provide further advice and support as necessary. Groups were to be self managing, each group deciding how often to meet and whether and for how long to continue. Initially two groups were set up, one in the north and one in the south of the region, with a third following in the west of the region.

Response and lessons learnt

Attendees were mostly registrars and foundation programme trainees who had qualified outside the European Union. Doctors came from nine of our region’s 11 trusts. Our immediate success was to create energy around this issue and to generate motivation to continue to develop support for overseas doctors. Immediate feedback from attendees was positive. They valued hearing of the “experiences [of] people who have been in my place” and found the course “one of the most interesting and helpful courses I’ve ever attended.” “Every presentation was fantastic and worth listening [to].” The advice of attendees was to run the induction course more often: “Make it more popular, so more people benefit” and “I think more information regarding this course should be given to HR [human resources] to promote this course to new Doctors from overseas.”

It is important when developing new initiatives to hear the appreciation of those concerned, but what about the lessons learnt?

(1) There is a huge amount of enthusiasm for the programme, from “new” overseas doctors and from those who are established within the NHS and who guided the work.

(2) It is important to harness this motivation and ensure a leading role for overseas doctors in the development and facilitation of the programme, for their insight and as role models. The deanery function is to offer its own expertise, to facilitate, coordinate, and administer.

(3) It is important to obtain the active support of trusts, via consultants and education centres, to ensure that overseas doctors know about and are encouraged/allowed to attend the programme.

(4) Transport may be difficult (Northern Deanery is extensive) and trusts should be encouraged to lay on transport to and from the venue.

(5) Individual needs differ; opportunities to raise and discuss individual issues and to follow these up (via the peer support groups or by referral for expert advice) should be given within the programme.

(6) A one day induction is not sufficient; follow-up meetings and facilitated peer support groups should be considered.

(7) Despite enthusiasm, self managed peer support groups are difficult to maintain and attendance is variable. Their administration should probably be based within provider trusts.

(8) We cannot presume the needs of overseas doctors; they need what they need when they need it. We should therefore aim to identify the main areas of need and provide continuing opportunities for them to obtain the advice and help they require as it emerges. Our work suggests to us the following areas:

  • NHS systems

  • NHS values and working, including the duties of a doctor, the softer skills of being a good doctor, and patient relationships (involvement, engagement, empowerment)

  • Patient safety, quality, and governance

  • Communication

  • UK living, family, and social issues

  • Support structures

  • Medical education, continuing professional development, and career development

  • Clinical practice.

I acknowledge with thanks the guidance and enthusiasm of Julie Oakley and Umesh Prabhu, Sushma Saksena, Sethu Wariyar, Sachin Mannikar, and Santosh Gupta in the development of this work.

Competing interests: None declared.


  1. Bregazzi R, Harrison J. From Spain to County Durham; experience of cross-cultural general practice recruitment Education for Primary Care   2005;16:268-74.

Rich Bregazzi education development and governance adviser, Northern Deanery, and associate lecturer School of Medical Sciences Education Development, Newcastle University, Newcastle upon Tyne, UK

Cite this as BMJ Careers ; doi: