Doctors without borders

Over the past couple of months, several right-of-centre newspapers in the UK blasted headlines about foreign doctors. “Indian doctors are FOUR times more likely to be struck off than those trained in Britain,” screamed the Daily Mail , pointing to recent statistics released by the statutory body, General Medical Council (GMC).

Meanwhile in April, the Daily Telegraph cited a University College of London study on the Professional and Linguistics Assessments Board exams that foreign-trained doctors are required to take before practising in the UK. “Half of all foreign doctors in Britain do not have the necessary skills to work here but can practice because the competency exam is too easy,” the newspaper contested. It added that the latest figures fuelled domestic concerns over the National Health Service’s reliance on foreign doctors.

To those close to the issue, the headlines — designed to alarm as they were — are simply the latest in a long stream of negativity that has gone hand in hand with the prominent role of foreign and, in particular, Indian doctors in the UK over the years.

Ever since 1892, when the GMC, Britain’s General Medical Council, recognised degrees from Indian medical institutions, Indian qualified doctors have been part of Britain’s medical system — often rising to prominent positions. Writing on the historic role of Asian doctors, Manchester University Professor Aneez Esmail notes the significant role many of them played even before the the NHS was set up (1948).

This lot include Dr Baldev Kaushal, awarded an MBE for his bravery and tending to the injured during the Second World War or Dr Chuni Lal Katial, who began practising in the country in the late 1920s, setting up a centralised health centre in the London borough of Finsbury — a borough of which he subsequently became the mayor.

From 3,000 in the 1950s, the numbers rose dramatically in the early 1960s as Enoch Powell, then a Conservative’s Health Minister, began an aggressive programme of recruiting doctors from overseas to cover domestic shortage in a fast expanding NHS.

Some 19,000 doctors were recruited from India and Pakistan and following another recruitment drive in the late 1960, nearly a third of NHS doctors had qualified overseas.

Right from the start it was a relationship fraught with tension: in a speech to Parliament in 1961, Lord Cohen, President of the British Medical Association and President of the GMC, while noting that hospitals “would collapse” without foreign doctors, warned there had been a “general lowering of standards of hospital care”. He pointed to a number of perceived problems, including with communication, cultural differences , inexperience in certain areas of practice and so on.

Complaints against Indian trained doctors were frequent. Esmail, who conducted a comprehensive study of letters to the British Medical Journal over the period of 1961 to 1975, noted the disproportionately high number of letters from other doctors complaining abut doctors from overseas “covered in polite code and hidden under discussions about difficulties in understanding intonations of Indian speech, their language problems, their standard of education and the impact that this was having on the health care of the population.”

Such problems continued over the decades. Research by Esmail identified clear disparities in the treatment of ethnic minority doctors: between 1982 and 1991, ethnic minority doctors were more than six times likely to be brought before the Professional Conduct Committee.

He noted significant differences in the handling of complaints in a number of areas including some relating to sexual harassment and “disregard for responsibility to the patients.”

Several decades on, little appears to have changed. Following the latest media frenzy, the British Association of Physicians of Indian Origin (BAPIO) expressed its frustration with the way the figures had been used and the lack of any official support for the ever-so-crucial role played by international medical graduates (IMGs) .

BAPIO President Dr Ramesh Mehta said: “When all this happened in the media we thought it was the duty of the government to stand up for foreign doctors, the majority of whom do an absolutely superb job.” BAPIO has been forced into a number of legal battles to protect the Indian medical community in the UK.

In 2008, it successfully battled the Department of Health to retrospectively implement new rules limiting the ability of international medical graduates to apply for training posts in the NHS (the NHS had to prove that they could not find a domestically trained doctor before being able to hire an IMG).

In the past couple of years it has also taken on the Royal College of General Practitioners (RCGP) over the CSA, a crucial clinical skills test doctors must pass to become a GP, on the grounds that its design was racially discriminatory (Indian IMGs are nearly 16 times as likely to fail the exam than a British graduate).

While a judge recently ruled against BAPIO, he raised concerns about the existing system, warning that the RCGP had to change its assessment procedure and describing it as “if not a legal victory then a moral success” for BAPIO.

BAPIO is far from the only organisation to raise concerns about biases in the NHS system.

In a report on the “Snowy Peaks” of the NHS, Roger Kline of Middlesex University found that ethnic minority representation in top NHS positions in London (both on boards and in senior executive positions) had fallen even further from a low level eight years ago (just 2.5 per cent of CEO and Chairs of NHS trusts in London come from an ethnic minority, despite 41 per cent of staff coming from a BME background).

It is overall a worrying situation; while changes to the immigration system have meant a significant recent drop in the number of IMGs coming to the UK, they still account for a sizable part of the NHS (nearly a third of all doctors over 50 registered in the UK are IMGs).

And despite the recent hysteria, there is no denying that the under-pressure NHS still desperately needs IMGs, particularly to fill shortfalls in high stress positions such as in accident and emergency units. In fact, earlier this year, BAPIO was enlisted to help the NHS recruit doctors from India for these units.

There are, however, reasons for optimism. Alongside working with the GMC and RCGP, BAPIO held its own conference last month to examine the best way forward.

This would involve helping doctors themselves through training and promoting the concept of equality within the medical establishment.

A follow on conference in cooperation with the GMC is set to take place later this year. “There is clear willingness from all parties to work together to move forward, at the end of the day, for the sake of patients” says Dr Mehta.

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