Additional notes
August 2006
The case for a streamlined application process
There have been calls to establish a regional/national register of clinical attachments that is linked to evaluation and monitoring by a recognised, respected body to ensure quality. Some have suggested that there is a role here for the postgraduate deaneries. Others have suggested regional recruitment, with standard application forms and fixed dates to apply throughout the year.
Some Strategic Health Authorities and refugee health care professionals’ projects have established local systems for allocating attachments to ensure that the programmes are educationally beneficial and so that local trusts are not inundated with requests from IMGs. These are not always restricted to doctors with refugee status so it is advisable to check.
Payment or reward for clinical attachment supervisor
This is a difficult issue. Many have offered excellent clinical attachments for years for no remuneration. If supervisors or their trusts expect to be paid, the risk is that this cost will be transferred to the individual doctor or the voluntary sector who, in the case of refugee doctors, may not have funds.
The different needs of IMGs and refugee doctors
International Medical Graduates are doctors who are not nationals of European Economic Area member states or those not holding a primary qualification obtained in the EEA. Most of these doctors have chosen to come and work in the UK and gained permission from the Home Office to do so.
In the case of refugee doctors the vast majority will never return home and, if able to gain GMC registration, are likely to see out their working lives in service to the NHS. There is usually no restriction on them working after they have received a positive decision on their asylum application. Unfortunately, since July 2003, changes to the law mean that asylum seekers are unable to work until they receive a positive decision on their application.
Understanding the difference between IMGs, as defined above, and refugee doctors emphasises the importance of facilitating refugee doctors’ integration into the NHS workforce, not to mention the benefits to the UK.
These two groups of doctors also have very different educational needs. Refugee doctors generally require a more intensive educational input given the length of time that they are likely to have been out of medicine. According to the latest findings of the Refugee Doctor Programme Evaluation Network (RDPEN) pan-London pilot for refugee doctors the average length of time between coming to the UK and passing PLAB 2 is over 5.3 years. Butler C, Eversley J. Climbing the Ladder: Refugee doctors in London: their numbers, pathways to practice and success in getting jobs. Refugee Doctor Programme Evaluation Network (UK), November 2005 This makes refugee doctors prime candidates for clinical attachments as part of the pathway to medical employment in the NHS. Evidence collected by the RDPEN from projects that have involved clinical attachments demonstrate their benefit to the individual doctors. For example, the London Deanery General Practice clinical experience scheme data shows that 42% of the participants are now working.
The following areas, whilst relevant to IMGs, are particularly relevant to refugee doctors.
Accessibility
Ideally, clinical attachments should be available in as many geographical areas as possible. If attached refugee doctors have to travel, costs should be covered and accommodation offered for the doctors and their family, where possible. It should be noted that district general hospitals in smaller towns might be well placed to offer attachments. Regions with recruitment problems stand to gain by attracting potential new doctors. The recent expansion of clinical attachments in general practice has resulted in a number of doctors being exposed to a specialty which may have been very different in their home country.
Financial matters
The NHS Executive encourages Trusts/GPs to provide clinical attachments free of charge to refugees and, in the case of NHS Trusts, if possible, to provide assistance with accommodation as well (Report of the Working Group on Refugee Doctors and Dentists, Department of Health, November 2000.) Issues of funding cannot be resolved in these guidelines, but it is not financially feasible for these doctors, especially refugee doctors, to pay. Hospital Trusts and PCTs should see attachments as having a recruitment function, not as a fundraising opportunity.
Unfortunately, doctors are increasingly being asked to cover various costs involved in taking clinical attachments such as the occupational health check, CRB check and other administrative charges. Further, some Trusts/PCTs are charging for the programmes in general, although they are on some occasions including training and IMGs are then more able to have input into the content.
Welfare benefits for refugee doctors
We share the aforementioned DH Working Group’s concerns about loss of welfare benefits to refugee doctors during the attachment. Their report states “Under current arrangements, medically qualified refugees undertaking clinical attachments run the risk of losing entitlement to certain social security benefits (e.g. Jobseekers' Allowance) where entitlement to such benefit is conditional upon the individual seeking and being available for work. The Group considers a clinical attachment to be an important stage in the process of building a career in medicine which, in the long term, will result in the removal of individuals from reliance on benefits; this situation should therefore be addressed.” The BMA has been in dialogue with Jobcentre Plus and the Department for Work and Pensions on this issue.
Acknowledgements
We would like to acknowledge the help and assistance of many individuals and organisations who have helped in producing this second edition of the guidelines, in particular:
Ms Anne Appelbaum, Royal College of Surgeons of England
Dr Edwin Borman, Chairman, BMA International Committee and Refugee Doctor Liaison Group
Ms Diana Cliff, North East London Strategic Health Authority
Dr Maeve Keaney, Reache North West
Dr Yong Lok Ong, London Deanery
Professor Davinder Sandhu, Severn Institute
Dr Penny Trafford, London Deanery
This edition is a consolidation of different articles/booklets that have been written about clinical attachments over the last few years. BMJ Career Focus has published a number of articles on this subject that have been used as source material which can be viewed at http://www.bmjcareers.com - go there
First edition by Dr Anita Berlin and Dr Sheila Cheeroth