LAUSR

Since its inception, the National Health Service (NHS) has been dependent on overseas clinicians. Even today, almost one in three doctors working in the NHS has completed their primary medical degree outside the UK. Arguably, as important has been the reliance on international medical graduates (IMGs) who return to their country of origin after spending time in the UK. Historically, they have come to advance their careers and receive education and training, and in turn enrich the NHS with skills, enthusiasm and commitment. On returning home, many forge longstanding training and research links for the benefit of their local population and for the wider community, as well as acting as ambassadors for UK medicine. In 2006, concerns about unemployment among IMGs resulted in withdrawal of the Permit Free Visa, making it challenging for them to work in the UK. In addition, IMGs were often used purely for service provision, with little consideration given to their training needs. Pressure from the medical Royal Colleges and other educational bodies ultimately led to the launch of the revamped Medical Training Initiative (MTI) scheme in 2009. This provides the opportunity for trainees, primarily from the previous Department for International Development’s designated ‘priority’ countries in South Asia and Africa, who have broadly similar medical training programmes to the UK (Table 1, in italics and Figure 1), to spend up to two years in a sponsored NHS training post. Thereafter, they are mandated to return to their country of ordinary residence. Over 4000 doctors have been through the MTI scheme thus far. The impact of the United Kingdom’s so-called ‘Brexit’ on European-origin doctors working in the NHS has been a cause for concern ever since the referendum in June 2016. In addition, the fall-out from the junior doctors’ contract disputes has resulted in many reportedly taking career breaks, leaving medicine or the UK altogether. As a whole, these factors potentially augur exceptionally difficult circumstances with regard to filling training posts. The promise of hundreds of extra home-grown doctors will not materialise for a number of years and even then, external support will, in all certainty, continue to be required. In 2018, the government announced the lifting of the cap on doctors and nurses coming to the UK under the auspices of the Tier 2 visa setup. TheMTI scheme, which operates under the auspices of a sponsored Tier 5 visa (Table 2), has a cap of 1500 across all medical specialties. The main difference between Tier 2 and Tier 5 visas is that the latter grants exemption from the General Medical Council’s (GMC) Professional and Linguistic Assessments Board (PLAB) test. It is also linked to a formally approved training post that is time-limited to a maximum of two years. Another plus point is that it serves to prevent ‘brain-drain’ from countries that are not as well resourced as the UK. The popularity of the MTI scheme is variable across the UK, with London and the Midlands proving to be particularly attractive destinations for candidates (Figure 2).