Too many overseas trained doctors still not getting NHS induction they deserve

More needs to be done to improve NHS inductions for international medical graduates (IMGs), if we want the NHS and patients to continue benefiting from their expertise and contribution, according to Medical Protection.

In a Medical Protection survey of 737 IMGs who started in NHS roles in the last five years, nearly 6 in 10 (58%) said their induction was not adequate or appropriate for them as an IMG, and nearly half (48%) felt anxious about starting clinical duties because of this.

38% said they did not have sufficient time to shadow other doctors, and 45% said their induction did not include training on cultural differences and acceptability in the UK. 61% went on to say they felt fearful of medicolegal issues arising.

The survey – which marks two years since the Welcoming and Valuing IMGs induction guidance was published – also showed some NHS inductions are falling short on personal support for IMGs, with half (51%) of respondents saying they did not receive help with issues such as finding somewhere to live, opening a bank account, or registering with a GP. 41% said they felt alone and isolated.

Medical Protection, which protects the professional interests of over 300,000 healthcare professionals around the world, helped to develop the Welcoming and Valuing IMGs induction guidance in 2022, alongside others including NHS England, the GMC and BMA. The guidance sets the minimum that NHS Trusts should provide in IMG inductions - covering welcome and pastoral support, professional practice, IT systems, language and communication.

Medical Protection is calling on all NHS Trusts across England to adopt the guidance and ensure every IMG feels welcomed, valued, and supported as they transition to UK clinical practice. It also said the next Government should back a standardised approach to IMG induction.

Professor Dame Jane Dacre, Medical Protection President, said: “Over half of the doctors who joined the workforce in 2022 were IMGs. The NHS has long relied on their dedication and expertise and the need to attract and retain IMGs will continue.

“We expect much of these doctors when they first come to the UK - they must understand a new and complex health system, with different medicines, cultural norms, ways of communicating with patients, regulatory frameworks, and clinical procedures - often whilst adjusting to living in a new country.

“They must adapt to life in the NHS quickly, so they can deliver safe high-quality care and thrive in their careers. A consistent, comprehensive induction is critical to this; without this IMGs face an extremely stressful and anxious start – feeling alone and unsupported and hoping to avoid mistakes and misunderstandings. Understandably, this may result in many questioning their decision to come to the NHS, becoming disillusioned or leaving.

“Some NHS Trusts run exemplary induction programmes for IMGs and are leading the way. We also welcome the unrelenting efforts of key organisations and individuals to bring about a standardised IMG induction framework, and know the GMC’s Welcome to UK Practice workshops play an important role. But the fact remains that too many IMGs are still being let down by Trust inductions. This cannot continue; those who come to serve the NHS deserve more.

“All NHS Trusts must step up – with encouragement by NHS England and the next Government – and adopt the Welcoming and Valuing IMGs guidance. Investing time and resource into getting this right will reduce the anxiety IMGs experience, mitigate against mistakes, and benefit the teams IMGs work with. It will also ensure the NHS and patients continue to benefit from the expertise and contribution of IMGs into the future.”

Professor Mala Rao CBE, Lead for the development of the Welcoming and Valuing IMGs induction guidance and Director, Ethnicity and Health Unit, Imperial College London, said:

“Having led the development and launch of the Welcoming and Valuing IMGs induction guidance, I am grateful to MPS for its input to the guidance and now, for this survey which is enlightening in terms of the stark picture it portrays of the situation IMGs continue to face when getting started in the NHS.

“It reaffirms what I discovered in 2019 in my discussions with IMGs, and why I felt that an induction was key to IMGs settling well into life in the NHS and in England, to their achieving their best potential and, importantly to safe patient care. The development faced considerable scepticism and negativity across the system, but thanks are due to the commitment of the MPS, GMC, BMA and many IMGs themselves for helping overcome these challenges and ensuring its launch.

“The survey is a timely reminder that comprehensive induction as set out in the guidance must become an essential aspect of overseas staff recruitment and retention in the NHS.”

Tista Chakravarty-Gannon, the GMC’s Head of Welcome to UK Practice, said: “We have long called for more consistency in the quality of the inductions doctors new to UK practice receive; it is vital we equip them to succeed from the very start. The MPS’ survey sadly reinforces that a comprehensive induction process remains sporadic, and in some cases lacking.

“The survey highlights that 66 percent of doctors had attended a free GMC Welcome to UK Practice workshop before starting clinical duties. We will continue to deliver these sessions which are integral to Welcoming and valuing IMGs, the guidance on the broader induction for international medical graduates new to working in England. The guidance sets out the minimum standards for effective induction and support and was coproduced with NHSE, the BMA and MPS. We will also continue to work with them and other partners across the system, to see this comprehensive package embedded for all doctors who qualified overseas.

“Together we can make the healthcare profession a welcoming and inclusive environment for all, retaining the skills and experiences of ethnic minority doctors and creating supportive and inclusive environments for all staff, keeping patients safe.”

Dr Sai Pillarisetti, Chair of the Post Graduate Committee at the British International Doctors Association (BIDA), said: “NHS Trusts should embrace induction and recognise it as an opportunity to nurture a sense of belonging and mutual understanding. The quality of induction offered has a direct impact on wellbeing and patient safety, and embedding learnings around cultural competence and UK best practices will help address any variations in communication and clinical practice. 

“The data also highlights a lack of support outside of clinical practice, leading to loneliness and anxiety. A strong mentorship network presents an opportunity to address this, and it would be encouraging to see Trusts working collaboratively with IMG organisations on this. IMGs constitute an integral part of our health system and if we want them to stay, we must collectively make a much greater effort to ensure they feel safe and supported.”

Professor Partha Kar, Co-author of MWRES Action Plan, said: “This survey shines a light on an area which NHS Workforce Training and Education and NHS Employers need to tackle with urgency given the commitment made by all in the MWRES action plan - a commitment made to tackle racism in the medical workforce.

“Asking colleagues from other countries to come and work in the NHS but not provide them adequate induction or support in their jobs not only makes the system inefficient and unsafe, but also opens the door to problems for the IMGs concerned.”

Dr Ramesh Mehta CBE, President of the British Association of Physicians of Indian Origin (BAPIO) said: “BAPIO is delighted to collaborate with Medical Protection in ensuring effective induction for IMGs. The survey points to pitfalls in the current approach. A good induction is vital for IMGs to adapt quickly to their new working and living environment. BAPIO looks forward to working with Medical Protection and Trusts across the country to improve induction programs offered to IMGs.”

Anonymous quotes from IMGs who took part in the Medical Protection survey:

“I was very anxious and worried as working clinically without induction and very brief period of shadowing... I was just lost.”

“I had to ask around myself, join Facebook groups, I didn't even know what indemnity was until I was made aware of it by accident.”

“I learned about appraisals from trial and error, navigated the software on my own, and trained up my incoming colleagues as a means of paying it forward. My consultant was a mentor to me but was not expected to be, and as such, helped manage a lot of anxieties in the workplace. This was due to his goodwill rather than a system that supported me.”

“I had my induction 3 months after I started.”

“I asked several times about induction to be told that I will just learn on the job and ‘it will be fine’.”

“Absolutely felt completely unprepared for the job. All that happened is that I was sent several documents with some basic information that might be helpful to know, and that was it.

“I was offered my log in details and how to access the IT system and that was it.”

“I love my trust, but when it comes to supporting new IMGs and feeling valued, they fail horribly.”

“Completely devastating experience and even now while I am writing my feedback I feel very stressed about what happened with me.”

ENDS

For further information please email [email protected]

Notes to editors:

• In this press release International Medical Graduates (IMGs) is used to refer to doctors practising in the UK who qualified and gained their primary medical qualification outside of the UK.
• The Medical Protection survey of IMGs in England, received 737 responses and was in the field from 1 May-21 June 2024. The respondents started in NHS roles in the last five years.
• Key findings:
  • 61% of IMGs said the induction they received when they joined the NHS was not tailored to them as an IMG.
  • 58% said their NHS induction was not appropriate or adequate for them as an IMG.
  • 48% said their induction did not equip them with the knowledge and training they needed to undertake clinical duties.
  • 48% felt anxious about starting clinical duties in the UK due to the inadequacy of their induction.
  • 38% said they did not have sufficient time to shadow other doctors.
  • 45% said they were not trained on cultural differences and acceptability in the UK versus other countries.
  • 51% did not received help and advice with practical issues such as finding somewhere to live, opening a bank account, registering with a GP or to pay Council tax etc.
  • 44% were not made aware of career development options.
  • 57% were not assigned a mentor in the department.
  • 56% did not know how to handle a complaint.
  • 45% were not made aware of available mental wellbeing support/resources.
  • 41% felt alone and isolated.
  • 61% felt fearful of medicolegal issues arising from their work.
  • 38% questioned their decision to come and work in the NHS.
• The Welcoming and Valuing IMGs induction guidance was led by Professor Mala Rao CBE. A wide range of organisations and individuals with expertise in this area contributed including MPS, GMC, BMA, Oxford University Hospitals NHS Trust, NHS England: https://www.e-lfh.org.uk/programmes/nhs-induction-programme-for-international-medical-graduates/

• The GMC Workforce report 2023 states that over half (52%) of doctors who joined the workforce in 2022 were IMGs. It also estimates that in 2036 almost a third (32%) of all doctors will be IMGs: The state of medical education and practice in the UK - GMC (gmc-uk.org)

• The GMC’s State of Medical Education and Practice report identified as far back as 2011 the need for better induction as a means to reduce the higher risk of IMGs being referred for fitness to practise investigation.

• In Medical Protection’s Priorities for the next Government paper, launched in May 2024, a key call to the next Government is to properly support IMGs from the moment they arrive in the UK – working with NHS England to require that Trusts establish a thorough and standardised approach to induction, based on the Welcoming and Valuing IMGs induction guidance: Priorities for the next Government (medicalprotection.org)

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