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Commonwealth Doctors and Dentists

Volume 447: debated on Wednesday 14 June 2006

Motion made, and Question proposed, That this House do now adjourn.—[Mr. Alan Campbell.]

I regret that a Home Office Minister has drawn the short straw in having to reply to this debate. I shall not cast any aspersions on the Home Office; I shall leave that entirely to the Home Secretary. I want to raise the effects of ending work permit-free entry for international medical graduates who complete their training by working in the national health service, which will affect several thousand doctors—I have heard estimates of between 10,000 and 17,000.

The regulations were suddenly brought in on 10 March, without consultation and without discussion in the Commons. They came into effect on 3 April, and the immediate reaction was fear among international medical graduates working in the health service about their futures. Would they be allowed to stay? Would they have to have a work permit? What would happen to them? The matter was brought to my attention by Pakistani doctors in Grimsby, where more than 100 international medical graduates work in our local hospital trust. The more I found out about what is being done, the more disgraceful the situation looked. There was a working-training relationship whereby graduates from Pakistan, India—which over-produces doctors by a considerable amount—Bangladesh, Malaysia, Sri Lanka and other Commonwealth countries came here to complete their training by working in the health service and did not need work permits to do so. That relationship benefits us, the health service that employs them and the home country, because those doctors return better skilled and better trained.

The NHS has always incorporated international medical graduates, whose initial qualifications were obtained outside the UK, under the permit-free training system. We therefore had a commitment to help train international medical graduates from the Commonwealth, who work as house officers, senior house officers and in other capacities in the health service. Some of them stay on to higher grade posts, some obtain qualifications from the royal colleges and improve their skills when they get back home, and some stay and work as GPs, often in the most difficult and deprived areas of the country, where we need them. Some, of course, go home. The system has served us well. It has served the origin countries well, too, as the training that they get is of a high standard.

Suddenly, under the new regulations, preference must be given to graduates of British universities. Nobody quibbles with that; everybody accepts it. We must have a preference for doctors produced in our own country. The second preference, however, is for doctors from the European economic area. That means that Commonwealth doctors who previously came in without work permits will now be disadvantaged. There are doubts about the linguistic abilities and relevance of the training received by doctors in the European economic area compared with the skills and linguistic abilities of international medical graduates who must take the Professional and Linguistic Assessment Board test to work in this country. The PLAB will not be required for European economic area doctors.

First consideration being given to British and EEA doctors means that many international medical graduates will not even get an interview. Applications will therefore become very uncertain, because hospitals and other institutions will have to prove that no British or European doctors are available.

My first question is why was this measure rushed in, given that it is so far-reaching, and will impact on many doctors and other people working in the health service, and on many relationships with Commonwealth countries? I can see no reason, apart from to allow the Prime Minister to announce a new immigration system for this country, into which doctors suddenly had to be crammed at the last minute. The intention behind the old work permit-free system was to give a preference to Commonwealth doctors, but the organisations concerned were not consulted about the new measure, which was simply rushed in during March.

My second question is, why was there no consultation? I made a mistake in the early-day motion that I tabled on this issue. I said that the British Medical Association was hardly consulted, but it corrected that; it was not consulted at all. It informed me that there was a meeting in January at which the intention of introducing a new scheme was vaguely announced, but no time or other specifics were given; the scheme was announced, rather than discussed. Suddenly, a couple of months later—in March—the scheme was rushed in. So there has been no consultation with the BMA.

Lord Warner, at the Department of Health, continues to tell correspondents that there have been consultations, but there have not. Indeed, I have in front of me a long list of organisations complaining about that issue. For example, I have communicated with the Indian, Pakistani, Bangladeshi and Malaysian high commissions, none of which were consulted. All those countries and their doctors are affected by this scheme. The Overseas Doctors Association, moreover, was not consulted.

I want to read some extracts from statements that were issued to the Home Office, the Department of Health or publicly. The Royal College of Psychiatrists found that

“many trusts have put Senior House Officers on short-term contracts. Many of these contracts will expire this summer.”

In response to this new initiative, work permits will be required. The RCP says that its people, who have come through their training and

“provided a service to the National Health Service…are now at risk of having to go back home.”

It adds that psychiatry, which has always had a high proportion of applicants who are international medical graduates, and which has become dependent on them,

“is likely to encounter the loss of a substantial number of trainees under the New Rules, probably…more than other specialities.”

The Association of Anaesthetists of Great Britain and Ireland says that the regulations have been introduced in a manner that shows little

“proper consideration for those who are already working in the NHS”,

and will make it difficult for foreign graduates to come here and get postgraduate experience.

The Royal College of Paediatrics and Child Health says:

“In many areas of the UK paediatric services have depended on these doctors and we have a duty to be fair to them.”

I’ll say we have a duty to be fair to them! It continues:

“Many face uncertain futures at short notice. Some long-standing training schemes are also threatened.”

Not only does the health service depend greatly on the work of these international medical graduates; training schemes that have been developed will have to be wound up, and at short notice.

The trainees committee spokesman of the Royal College of Physicians says:

“I am particularly concerned about care of patients, especially in departments where colleagues from outside the European Community have provided the bulk of care for a long time.”

It adds that

“the implementation of these rules started less than a month later on 3 April 2006. It is our view that the almost immediate implementation of these rules is unfair and potentially deleterious to patient care.”

We have rushed into new regulations that will have a disastrous effect on the health service.

The Forum of International Medical Associations Chairpersons wrote to the Prime Minister saying:

“Not only will it make it impossible for any new doctor from overseas to obtain training in the UK, but doctors already under training will find their career path suddenly blocked.”

The Royal College of Obstetricians and Gynaecologists states that it has

“serious anxieties about this new ruling and the impact it will have on both the short and long term future of the specialty of obstetrics and gynaecology.”

There is a shortage of British recruits in that area, so we are even more reliant on doctors recruited from overseas in the traditional fashion. The president of the college has written:

“We are particularly concerned about the effects on our own specialty where there are at present insufficient UK graduates entering training to develop the workforce to sustain services. The consequences for Women’s Health and for Obstetrics and Gynaecology in the short and medium term look bleak to say the least.”

I have also seen correspondence from various departments of obstetrics and gynaecology. For example, the department in Sheffield thinks that it will be very difficult for it to recruit gynaecologists and obstetricians because it depends on overseas graduates. The East Lancashire Hospitals NHS Trust states:

“Currently, 72 per cent. of our trainee doctors are from outside the EU”.

How will they be replaced? The trust also says:

“The process to obtain work permits is both costly and time consuming (minimum of 3 months in our experience)”.

The hospital will have to put in the administrative work and pay the costs of £145 per work permit—another charge on the health service.

The Royal College of Surgeons, like many of the other royal colleges, has developed sponsorship schemes in co-operation with other nations, in which

“overseas Surgeons come to the UK for short periods to complement their local training. These doctors then return to their home country”.

The RCS has an especially close relationship with Sri Lanka, but it is threatened by the innovation.

The Council of Heads of Medical Schools thinks that the change might affect student numbers and the legitimate needs of students to follow their specialty training. It also believes that it is unfair that students will be allowed only two years of permit-free training in which to complete their foundation training.

Universities UK says that many doctors who come here to train then take further medical degrees at universities, but that will no longer happen. It says that the change will affect

“precisely these doctors who after two or three years in the UK would be those considering taking an MSc to improve their medical education.”

A consultant ophthalmologist, at a conference in Singapore for the south Pacific region, e-mailed me today to say:

“Nearly all the ophthalmologists in Singapore came to the UK for a period of specialist training.

We currently train all the ophthalmologists from Sri Lanka for a period of mandatory training of one year sponsored by the Sri Lankan Government.”

What will happen to that scheme?

What will happen to those doctors training over here who have taken the PLAB 2 examination, which costs £430, but have not obtained a post? Will they get a work permit? What will happen to those doctors in post? Will they have to negotiate a new work permit every time they change jobs and move on to a new position? Are they going to be allowed to complete their training? What rights will they be given? None of that has been considered and there was no mention of it in the announcement. The effect has been to produce uncertainty in the health service and the medical professions, and I do not understand why the Departments involved should have acted as they did. We are talking about a highly skilled work force, to whom we owe a huge debt of gratitude and on whom the health service depends. It is monstrous that this should have happened.

The Department of Health has said that it consulted, so why is there such an outcry? Why were these fears not taken into account? Why were they not discussed and dealt with? What are the Home Office and the Department of Health going to do about it? So far, all the responses on the matter are essentially holding replies. To a reader like me, who gets so many such replies, that suggests that the Departments do not know what they are going to do. In the meantime, they are trying to fob the storm off and hope that it passes.

It would be more sensible to be honest and admit that there has been a cock-up. The two Departments involved should introduce a new scheme to keep the graduate students here and allow the NHS to have continued access to them. We are still going to need them, as the European economic area cannot produce enough graduate doctors to fill the huge gap that is going to open up. At present, between 10,000 and 17,000 such people work in the health service: we will not get that many from Europe, so we must work out how to deal with the consequences of ending the scheme.

It is possible that we could run the scheme down in a gradual manner. That would be better than suddenly imposing new rules out of the blue, which will cause great damage to the NHS and to trainees who provide a valuable service in many parts of the country. My constituency, for instance, depends heavily on people who should not be treated so shabbily, with the two Departments involved rushing in measures without either consultation or consideration.

I have written to the Health Department and the Home Office to ask whether they will jointly receive a delegation of interested parties to discuss the problem. I am sure that the relevant high commissions and other organisations are making their own lobbying arrangements, but the most important thing is to find a way to avoid the consequences of the measure’s sudden imposition. We must begin a consultation process, as should have happened much earlier on, and thus find a way to ease the transition. We need to introduce the changes gradually, rather than impose them abruptly in the space of a few weeks.

I begin by assuring my hon. Friend the Member for Great Grimsby (Mr. Mitchell) that I am pleased to be here to answer this debate, and that I do not believe that I drew the short straw this evening. I welcome the opportunity to talk to the House about the recent change to the immigration rules for postgraduate doctors and dentists. However, before I get into the detail of the change and address the points that have been raised, I want to take this opportunity to set out the Government’s position on migration, and to set the change in context.

The five-year strategy on asylum and immigration was published over a year ago, in February 2005. It sets out the premise that we need to be clearer about which migrants we need in the UK, and why. That is the basis of our immigration system, and of our manifesto commitment to introduce a points-based system for managed migration.

It is the job of the Government to manage migration into the UK so that the needs and rights of UK citizens are maintained. That is why the points-based system for managed migration, on which we consulted widely between July and November last year, went back to first principles to identify and select the migrants whom the UK really needs, and who benefit the UK by being here.

The Government are, and have always been, very clear that migration makes a substantial contribution to economic growth because it helps to fill gaps in the labour market, including key public services, such as health and education. Migration also increases investment, innovation and entrepreneurship in the UK. Culturally, we are enriched by people with diverse backgrounds from other countries.

With an expanded EU, there is an accessible and mobile work force already contributing to our growing economy, closing many gaps experienced by employers. Our starting point is that employers should look first to recruit from the UK and the expanded EU before recruiting migrants from outside the EU. Migration needs to be properly managed. It also needs to be robust against abuse. Only those of benefit to the UK should be admitted and, once here, they must comply with the conditions of their leave.

That, then, is the underlying strategy. On that basis, we outlined our proposals for a five-tier managed migration system in the Command Paper, “A Points-Based System: Making Migration Work for Britain”, which was presented to the House on 7 March. The aim of the new system is to develop a more efficient and transparent migration system that sets out clearly who is permitted to come to the UK and why. We want to design a system that is better able to identify and attract those migrants who have the most to contribute to the UK—one that offers a more efficient, transparent and objective process and that improves compliance while reducing scope for abuse. As part of that work, we have reviewed existing routes for employment, training and study with a view to identifying which are of most benefit to the UK.

Underpinning the new migration system will be a five-tier framework, which will replace more than 80 work and study routes. That will help people to understand how the system works and will direct applicants to the category that is most appropriate for them. Tier 1 will cover those highly skilled individuals who can contribute to growth and productivity. Tier 2 will be for skilled workers with a job offer, who can fill gaps in the UK labour force. Tier 3 will provide for limited numbers of low skilled workers, needed to fill temporary labour shortages. Tier 4 will accommodate overseas students. Tier 5 will cover what we describe as youth mobility and temporary workers: people who are allowed to work in the UK for a limited period of time, primarily to satisfy non-economic objectives.

We also intend to set up an independent body to identify employment shortages across all sectors of the economy. It will be known as the skills advisory body and will build on existing structures and expertise—in particular the skills for business network, which is funded in part by the Department for Education and Skills. Shortages identified by the skills advisory body will inform Government decisions on the use of migrant labour within tiers 2 and 3 of the points-based system.

I want to turn to the place of doctors and dentists within the migration system. The massive investment that we have put into NHS staff and reforming medical training to build up UK NHS capacity has worked. We now have more than 117,000 doctors working in the NHS—27,400 more than in 1997—as well as record levels of doctors in training in UK medical schools and we do not need to rely on overseas doctors as much as we did in the past. That investment and expansion, coupled with the reform of medical education, is leading to increased competition for medical posts. It has become clear that, owing to the changing labour market, the specific category within the immigration rules for doctors and dentists that allowed permit-free training could lead to the displacement of UK graduates. There has been a growing consensus that changing the rules is the right thing to do.

That is a hypothetical fear. There is not unemployment among British-trained doctors. At the moment, there are 20,000 Commonwealth doctors working in hospitals in the health service, and we are dependent on them. What will happen to them? That is the big question. What will happen to their futures? It is all right to say that we need to protect British doctors—everybody agrees with that—but why now, so suddenly and so abruptly?

Those are the very points that I am addressing at the moment. Despite the changes, there is nothing to say that overseas doctors from outside the European economic area cannot work in the national health service. It only has to be demonstrated that such a doctor is needed because a post cannot be filled by a doctor from the UK or the EEA. We do not expect a mass exodus of the doctors who are here at present.

Such a decision will have to be made by the appointing hospital. If it could not find anyone from Britain or the EEA, it could then call in applications from international medical graduates and Commonwealth doctors. However, such applications could not be called in until that point, so the hospital would not necessarily be choosing the most able people because the search would be insufficiently wide and it would have to make appointments by category. Additionally, some medical graduates from overseas might not even get an interview. People are basing their careers and planning their lives around a period of training in this country and their qualification depends on that. However, they now have no certainty about what will happen.

If I can make a little progress, some of the answers to those points will perhaps become a little clearer.

It is only right that jobs and training programmes that are available in the UK for junior doctors should go first to UK nationals. That is the principle of ensuring that UK workers have access to jobs, which is the principle at the heart of our migration system and, indeed, the migration systems of developed countries throughout the world. I make no apology for the fact that the Government are committed to fostering the talent and harnessing the abilities of our own citizens.

The changes that we have made to the immigration rules for postgraduate doctors and dentists do not mean that we will no longer allow doctors and dentists from overseas to come and train in the UK. They mean that, as in other sectors of the economy, UK and EEA nationals must be considered first. Non-EEA nationals who wish to come to the UK as new doctors or dentists will still be able to do so, but they will have to apply in a way that is the norm for other overseas workers. That means that employers who wish to appoint an overseas doctor or dentist first have to demonstrate that they cannot find a UK or EEA national to fill the post.

When considering the changes, we wanted to reduce as far as possible the burden on NHS trusts, postgraduate deans and individual hospitals. We thus announced the changes in March so that we could give people as much time as possible to plan for their effect before the next round of appointments to posts started in August. I recognise that we did not provide full details of the changes before they came into effect, but we took steps to ensure that all relevant stakeholders were consulted on, and informed about, the general intention of the changes. Officials from the Department of Health and the Home Office outlined the proposed changes at a NHS work force planning meeting in January, which was held well in advance of the changes coming into effect in April. Since then, officials have had several meetings and discussions with stakeholders, so I do not accept the allegation that we did not consult adequately on the change.

There have been some regrettable reports in the media regarding the change, such as suggestions that all overseas doctors and dentists training in the UK will be asked to leave before they complete their training. Those with leave granted under the previous rules still have that leave and are subject to the same conditions as they were before the changes were made. That means that they can complete ongoing posts and take new posts within the period for which they have leave. We have also put in place transitional arrangements to allow certain doctors and dentists who are in the middle of training programmes or training posts to switch into the work permit system without requiring employers to advertise the job and demonstrate that they cannot find a UK or EEA national to fill the post.

As well as making transitional arrangements for those already in training, we have retained some provisions for overseas doctors and dentists in the future. If people have chosen to study medicine or dentistry in the UK and completed their degree here, we have made provision for them to stay on in the UK to undertake the next stage of their training.

The changes are not the end of the road. They are a step on the way to a more coherent and consistent migration system and a response to the success of our programmes for recruiting and training UK doctors.

The motion having been made at Seven o'clock, and the debate having continued for half an hour, Madam Deputy Speaker adjourned the House without Question put, pursuant to the Standing Order.

Adjourned at half-past Seven o'clock.