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Trusts Accused of Using Foreign Doctors as 'Cheap Labour'

In an investigation published in The BMJ, some NHS hospital trusts in England have been accused of using overseas doctors on fellowship schemes as "cheap labour" .

A report by Madlen Davies, the journal's investigations editor, explained that the Academy of Medical Royal Colleges' medical training initiative (MTI) scheme enables foreign doctors to work as fellows in English trusts for 2 years in order to gain experience, which they can take back to their home countries afterwards. 

Unlike foreign doctors who apply directly to trusts, MTI fellows are required to complete only a general English language test and not the General Medical Council's professional and linguistic assessments board test. The Royal Colleges facilitate GMC registration on the fellows' behalf. 

Trust Told Charging Rate for Fellows Would Be a 'Saving'

Some fellows are sponsored by their home country or other entities, but others are employed directly by the NHS trust in which they work. In some cases this is for the same pay and benefits as trainees employed by the trusts, but as The BMJ discovered, some trusts have special arrangements enabling them to pay less and offer fewer benefits.

In particular, several trusts in the Midlands have an agreement with the College of Physicians and Surgeons Pakistan (CPSP) stating that fellows can be paid at lower rates and are not entitled to paid parental leave while in the UK. The BMJ obtained a document sent to departments hosting fellows at University Hospitals Birmingham NHS Foundation Trust that said the fellows would "remain employed by their overseas employer", openly advertising that, "The charging rate will be less than the standard budget for a junior doctor post, thus representing a saving for the Trust."

Schemes Also Benefit Overseas Countries

A spokesperson for the trust said that while the arrangement benefited the NHS, "in return it benefits the overseas healthcare structure". The trust noted: "Programmes which encourage the upskilling of medical practitioners from countries with less developed healthcare systems have been described by the [World Health Organization] as a 'brain gain and not a brain drain'."

The local director of the CPSP's centre in Birmingham, responsible for its fellows in the UK, told The BMJ that over 1000 Pakistani fellows had now trained in the UK, resulting in improved healthcare in Pakistan, including decreased maternal mortality and better oncology and paediatric care.

The CPSP agreement with the Birmingham Trust also states explicitly that fellows do not receive paid maternity or paternity leave, and any fellow who becomes pregnant while participating in the programme is likely to have their fellowship terminated early. The BMJ cited one instance in 2017 in which a urology fellow's contract was terminated on becoming pregnant. In another example, a fellow at the Birmingham Trust said he had to use 2 weeks of annual leave when his daughter was born because paid parental leave was not available.

Legal Firm Described Arrangement as 'Exploitative'

Employment lawyer Michael Newman from Leigh Day — a law firm specialising in discrimination and human rights cases — described the practice as "outrageous" and the scheme's conditions as "exploitative". He told the journal: "It's a great deal for the Trust, right? Cheap doctors at a time when we need them."

Mr Newman accused trusts of "taking advantage" and opined that should fellows want to launch discrimination or unfair dismissal claims, it was "likely" that a UK employment tribunal would view that it had jurisdiction.

One Birmingham consultant, quoted anonymously in the report, concurred that the trust was using fellows as "cheap labour". 

The CPSP had similar arrangements with Dudley Group NHS Foundation Trust and Walsall Healthcare NHS Trust, according to The BMJ, which said that since its investigation, the CPSP has agreed to review and rewrite some of its guidelines.

Fellows Used to 'Plug Rota Gaps'

The British Association of Physicians of Indian Origin (BAPIO) told the journal that it set up its own training scheme because the MTI scheme was "being abused", with fellows used to plug rota gaps, and the scheme in some trusts lacking any training component. 

The BAPIO Training Academy in the UK recruits Indian doctors on behalf of trusts, and manages their training. Its Executive Director, Parag Singhal, said the aim was for international medical graduates to be treated "as trainees rather than as pairs of hands". However, BAPIO charges trusts for finding trainees, and charges the trainees themselves.

An Academy spokesperson described the issues raised by The BMJ as "very concerning" but said that this was "a matter between the doctor and the NHS organisation that employs them". Since the MTI scheme began in 2009, 6986 doctors from countries including Pakistan, Sri Lanka, India, Egypt, Nigeria, and Saudi Arabia have participated.

Asked to comment by Medscape News UK, a spokesperson for NHS Employers said that it expected doctors to be paid "fairly and equitably" and could advise employers on this. "The MTI scheme provides a range of very valuable opportunities to individual doctors, the NHS organisation providing the training, and the hospital or health system to which the individual returns following the completion of the training programme. It is important that the integrity of the scheme is maintained and any concerns raised, acted upon."

An NHS spokesperson said: "While the salary of these positions is agreed between the individual trust and their international partner, fellows play an important role in treating NHS patients, at the same time as learning new advanced clinical skills in a high-quality and fair learning environment, before returning to their home country."

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