Difficulties for international medical graduates working in the NHS
Authors: Mohan Bhat, Ali Ajaz, Nuruz Zaman
Publication date: 12 May 2014
Over a third of doctors working in the United Kingdom qualified in other countries, yet these doctors continue to encounter a number of challenges. Mohan Bhat and colleagues examine the problems faced by international medical graduates working in the NHS
The NHS has a long tradition of welcoming trained medical graduates from all over the world, and the United Kingdom has relied heavily on the skill and commitment of this group of doctors.
General Medical Council figures from 2013 showed that doctors with a non-UK primary medical qualification made up 37% of registered doctors (consistent with 2012). Of these, 10% (25 503) were from the European Economic Area, and 27% (67 125) gained their primary medical qualification elsewhere, a group often known as international medical graduates (IMGs).
Recently, high profile reports have highlighted concerns about the professional practice and regulation of doctors who qualified outside the United Kingdom, including publications from the House of Commons Health Committee and the National Clinical Assessment Service.  These reports have shown that doctors who qualified outside the United Kingdom were proportionally more likely to be subject to an investigation by the General Medical Council about issues such as poor clinical skills and knowledge, lack of knowledge of the law or codes, and inadequate participation in medical education. They were also more likely to be investigated about these issues within the first two years of joining the UK register. Non-white doctors who qualified overseas were also more likely to be referred to the National Clinical Assessment Service.
Previous studies have suggested that IMGs may encounter a number of problems. These include lack of preparation for working in an unfamiliar healthcare system, lack of knowledge about regulatory frameworks, communication difficulties, and conflict between the social and cultural practices to which they are accustomed, such as how these practices inform the doctor-patient relationship.
In 2008 the General Medical Council commissioned a study after growing concerns over ethical decision making by doctors moving to the United Kingdom, especially in relation to the Good Medical Practice regulatory framework.  In total, 106 non-UK doctors were surveyed, and 26 participated in detailed interviews. An additional 30 UK medical graduates were also surveyed.
The study found that there was limited information available on ethical and professional standards and that the main source of information was the Good Medical Practice document that doctors receive on registration, but this is not always read, understood, or interpreted accurately. The opportunity for training before registration in the United Kingdom is also limited, so that recognition of ethical, legal, and cultural contexts does not begin until starting work.
IMGs responding to the survey were unfamiliar with patient based concepts, such as individual autonomy, duty of confidentiality, and informed consent to treatment, and had a range of communication problems, such as feeling unsupported in clinical environments, in particular non-training posts. (Doctors from the European Economic Area share difficulties with IMGs regarding communication and lack of familiarity with the shared decision making model of care.) The study also established that considerable difficulties, including issues around probity, health, and maintaining good medical practice, can arise early on in doctors’ UK careers.
We wanted to learn more about the current issues facing IMGs in training in the United Kingdom. We did an online survey of 226 IMG and European Economic Area trainees who had moved to the United Kingdom and were currently working in the London Deanery. We also surveyed consultants with experience in supervising doctors who had graduated outside the United Kingdom. In total, 102 IMG trainees and 59 supervising consultants replied, representing a response rate of 45% and 26%, respectively.
A large proportion of IMG doctors reported being underprepared to work in the United Kingdom (table). They described particular difficulties in understanding the legal framework and the cultural expectations of patients when working in the United Kingdom. Consultant supervisors reported experience of IMGs having difficulties with communication skills, the quality of doctor-patient relationships, confident use of English, and the cultural understanding needed to work in the United Kingdom. Supervisors consistently considered their trainees to have more problems in most domains than the trainees themselves recognised.
|Area of practice||% of trainees reporting being underprepared (n=102)||% of supervisors reporting problems (n=59)|
|GMC’s Good Medical Practice||24||29|
|UK ethical standards||36||27|
|Legal framework for practising medicine||52||24|
|Quality of doctor-patient relationship in the UK||36||53|
|Cultural understanding of multicultural London||50||66|
|Confidence in use of English||15||66|
*As reported in online survey of 226 international medical graduates and European Economic Area trainees
Doctors identified a number of other important areas relating to more personal aspects of their transition to the United Kingdom. These ranged from help with registering with the General Medical Council (38%) and a medical indemnity organisation (38%), finding a place to live (36%), opening a bank account (34%), information on childcare and schooling (30%), obtaining a National Insurance number (30%), and qualifying for a driving licence (24%).
From the survey results and the free text responses, we have established a number of themes that have guided the development of a dedicated e-learning induction programme incorporating our findings around gaps in communication difficulties, cultural awareness, and working within the NHS healthcare system. The programme is available on the London Deanery website at [Link] .
Experiences of international medical graduate trainees
Trainees reported a limited benefit from existing induction programmes. The inductions conducted at their individual trusts were generic and not tailored to support their particular needs, and there was an expectation that doctors were already familiar with the overall healthcare system in the United Kingdom and how the different services were integrated. Some of the free responses were:
“There are many things taken for granted in the induction assuming we know, but with which we become familiar only after more experience in UK”
“It was a general induction for all doctors. Not targeted to IMGs”
“The only induction I was requested to attend was the IT services registration . . . I did not know anything about the UK system, not even where to check when in doubt, not even the NICE [National Institute for Health and Care Excellence] guidelines. It is very difficult to start working straight away from another country and not safe if you do not know the protocols”
“To get instant up-to-date information of UK health care system”
“How NHS works. Different trusts’ policies and where to get it. Who are the people and what their role within the service is. How to prescribe or where to get the protocols etc.”
Communication and cultural awareness
Trainees’ biggest difficulty was their lack of awareness of particular communication and cultural skills required within the NHS. Trainees found a considerable cultural shock, with the expectation of patient involvement and consultation as opposed to the more paternalistic approach to which they were more accustomed. Trainees also expressed a lack of understanding in appropriateness of language, dress, and team and patient relationships. Some trainees said:
“Video examples of how to deal with patients [and] what to expect while working with [the] population. In UK medical practice [it] is professional relationship between adult to adult and empowering patient. In many countries it is still parent-child interaction.”
“Examples of different consultations and reflection on them. Why is it a good consultation? Importance of British language and culture. Basic things such as how to dress smart. In my country we wear jeans every day for work and this was a massive difference for me when I moved here. I did not know it was important so at the end the manager showed me a massive protocol about how to dress at work.”
These themes were mirrored by the consultant supervisors, who identified the same areas of focus for IMG and European Economic Area doctors before starting their first post in the United Kingdom. One supervisor commented:
“Information regarding expectations of UK patient relationship, need to fully inform and work in partnership, importance of respect for other professionals and multidisciplinary working legal framework such as safeguarding procedure.”
Trainees noted they had underappreciated the considerable personal challenges they would face working in the United Kingdom. In particular, they overestimated their ability to converse with local people and struggled to settle in and access wider community facilities. They also found it more difficult to settle into more extensive and multicultural teams:
“Initial misunderstandings to role of different professionals”
“The main difficulty I faced was poor confidence with my use of English”
“The perception of IMGs among the medical staff is varied and I constantly felt that I had to prove my competence, despite being as competent as other doctors at my level”
“Lack of family support leading to childcare nightmare especially in school holidays”
“Sometimes, difficulties associated with being an immigrant in a society endemically racist with unabashed subtle discrimination, even at work places. Sometimes, the impression that you are just tolerated because of your ethnicity hangs heavily in the air”
“I lost my status and professional level (general practitioner) and entered a new specialty, I was bullied and I think the price is too high to pay”
“Still miss the social support and family even after eight to nine years in UK.”
We thank Jocelyn Hewitt, education lead, professional development, Professional Support Unit, Professional Development Department, Shared Services Health Education North Central and East London, Health Education North West London, and Health Education South London.
Competing interests: We have read and understood the BMJ policy on declaration of interests and have no relevant interests to declare.
- General Medical Council. The state of medical education and practice in the UK report: 2013. GMC, 2013.
- House of Commons Health Committee. 2012 accountability hearing with the General Medical Council. Stationery Office, 2012.
- National Clinical Assessment Service. Concerns about professional practice and associations with age, gender, place of qualification and ethnicity—2009/10. NCAS, 2011.
- University of Warwick. Report for the General Medical Council. Non UK qualified doctors and Good Medical Practice : the experience of working within a different professional framework. February 2009. [Link] .
- General Medical Council. Good medical practice. GMC, 2013.
Mohan Bhat director of medical education
North East London Foundation Trust, Medical Education Department, Goodmayes Hospital, Ilford, Essex, UK
Ali Ajaz specialist trainee year 6, forensic psychiatry West London NHS Mental Health Trust, Broadmoor Hospital, Crowthorne, Berkshire, UK
Nuruz Zaman fellow in medical education North East London Foundation Trust, Medical Education Department, Goodmayes Hospital, Ilford, Essex, UK