International doctors are integral to our NHS

The UK needs international medical graduates – and it needs them to receive fair pay, conditions and training opportunities, writes BMA council deputy chair Emma Runswick

Location: International UK
Published: Friday 28 July 2023
41747 hospital staff
Emma Runswick BMA council deputy chair Emma Runswick

Since the inception of the NHS, doctors trained overseas (commonly called international medical graduates, or IMGs) have been recognised as an integral part of the workforce. IMGs currently make up approximately a fifth of all licensed doctors in the UK.

Consequently, we will not win better pay and conditions unless UK-qualified doctors and IMGs stand together.  

Migrants have a long and successful history in the British trade union movement alongside British workers, from historic dock and factory disputes to now. Recently, the largest ever action by rail cleaners, led by the RMT, was significantly boosted by large numbers of migrant workers.

In the Unite logistics disputes, which have seen significant pay increases; in the GMB fight for recognition at Amazon warehouses; in the IWGB campaigns for security staff at London universities and many other disputes across every industry, solidarity between different nationalities is necessary.

When workers stand together, the union movement is stronger, and workers win better pay and conditions.

There is a similar and opposite history of governments, employers and others attempting to divide workers by race and nationality. The latest government attempt to pit workers against each other with its decision to fund its sub-inflationary pay offer to public sector staff through punitively increasing the immigration health surcharge (the fee paid by international workers to access NHS services) and increasing visa costs is just one such example.

Recently, a group of 25 Conservative MPs dubbing themselves the ‘New Conservatives’ unveiled proposals to stop care workers from overseas being recruited to the UK. One member, MP Miriam Cates, justified this by claiming that closing the care workers’ visa scheme would lead to employers raising their rates of pay to draw workers into the sector.

But this is economically illiterate. There are already around 165,000 vacancies in social care, and wages have not increased to draw workers into the sector – nine out of 10 care workers earn less than £15 per hour.

Without solidarity, workers will be divided and cannot organise successfully. One of the ‘wins’ predicted by supporters of Brexit was that it would reduce immigration in the agricultural sector, meaning there would be more and better paying jobs for British-born workers in farming. But despite this, pay hasn’t improved and conditions for workers in the sector, particularly migrant workers, remain brutal. 

Migrants in general are good for the economy and society – there is lots of evidence that migrants are a net positive for economic growth and productivity.

Given shortages in the UK medical workforce, international doctors are essential.

There are more than 8,500 medical secondary care vacancies in England alone, even with the contributions of our current international colleagues, and these vacancies are having a huge impact on doctors. The majority of us work well beyond our rostered hours (70% of doctors in 2022 report working over and above their hours, up from 59% in 2021) and more than one in five doctors (22%) took a leave of absence due to stress in the last year. There is plenty of demand for our work, and not enough supply.  

Labour demand and supply are not the driving factors in the exploitation of farming, social care or medical workers. Like medicine, both farming and social care serve crucial needs, they are labour intensive, and they are understaffed. Wages and working conditions in these sectors are currently far more influenced by the relationship between workers and employers, and the relative power they have. Like medicine, both sectors are also heavily influenced by government policies and subsidies.

Those arguing for protectionism in these areas – like the New Conservatives – make understaffing worse, weaken the ability of workers to organise by creating fearful undocumented workers, and create an increased threat of deportation and destitution.  

Doctors must not fall into the trap of protectionism as well. Though undocumented medical labour is uncommon, precarious and exploitative jobs are widespread in both the NHS – especially amongst doctors on locally drawn up contracts (LEDs) – and in the private sector with resident medical officers.

The number of UK-trained doctors in training has continued to slowly increase following the addition of all doctors to the shortage occupation list in March 2021, despite competition ratios increasing and the growing number of IMGs joining the workforce. Competition ratios have of course skyrocketed. Despite this, IMGs acquire training jobs at a lower rate than their UK-trained colleagues.   

Artificial competition

The real source of the problem, however, is that despite increasing numbers of medical school graduates, and growing need in our population, the number of training posts has insufficiently increased. Now a workforce plan has been published, but it has no specific targets for postgraduate medical training places, which unless rectified will exacerbate the issues.

This has created artificially high levels of competition amongst colleagues, causing some to target each other rather than the government responsible. 

The problem with pay and conditions of doctors in the UK is not IMGs – it is the Government’s refusal to invest in the workforce. Many other countries offer better pay and conditions than the UK. We are currently haemorrhaging UK-qualified doctors to other countries, where they can earn more: one in seven UK-qualified doctors are currently practising abroad.

And in their most recent survey, the GMC found that 10% of doctors practising in the UK said they were likely or fairly likely to move to practise abroad in the next year. If the NHS wants to retain the doctors trained here, we need higher wages to be internationally competitive, or there will be an exodus.

Not to mention, IMGs also want higher pay. Just like UK-qualified doctors, IMGs could choose to work elsewhere. IMGs too face the cost-of-living crisis and spiralling inflation in the UK, and many have families in the UK to support. IMGs are more likely to experience racism compared to doctors trained in the UK. Our IMG colleagues need support and solidarity, not to be blamed for problems created by the Government. 

Unfair conditions

There have been suggestions that international medical colleagues, who are already vulnerable to visa restrictions and culture shock, should be prevented from direct entry to nationally recognised terms and conditions and training roles to preserve access for the UK-trained. Creating a cohort of doctors who must endure locally employed (exploited) service to progress in the NHS is not to the benefit of those doctors, doctors in training or our patients.

In the choice between solidarity with colleagues and the threat of deportation, solidarity will not always win. This would create conditions of fear around whistleblowing and around challenging unfair treatment, including in situations shared by doctors in training. It would weaken doctors in pay disputes. 

Dividing doctors by calling for restrictions on visas and immigration, by punitively increasing fees for migrant workers, or by placing additional barriers to access nationally agreed terms and conditions, is unhelpful and will make it harder to fight and win together. Doctors are vital to society and there aren’t enough of them – in the UK or elsewhere.

All doctors should be paid fairly and have access to professional development. If the NHS wants to be an attractive place for doctors to work, it needs to pay better wages for all doctors working in the UK, regardless of where they qualify. This will only happen if doctors stand and fight together.