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Amid the chaos over applications for medical training posts in the UK, everyone is asking: how could the government have got its numbers so wrong? Lynn Eaton reports
In the quagmire of statistics relating to the issue of training posts for junior doctors in the United Kingdom one fact stands out clearly: more than 30000 doctors are applying for about 20000 training posts. How did this happen? Who are the applicants? And are they all on an equal footing, or are some more equal than others?
A large number of people will undoubtedly fail to secure a training post through the medical training application system (MTAS) and will end up in the less desirable staff grade position, from where it will be almost impossible to become a consultant. Some might not get a job at all; some will undoubtedly go abroad. But it is not clear who will fall into each category.
Until the government announced in March this year that doctors who qualified in countries outside the European Economic Area (EEA) would be eligible to apply for the training posts (which had not been the plan in 2006), the figures were not quite so startlingly mismatched. As many as 11400 of those currently applying may have qualified abroad, although many are already working in the NHS. If that number is subtracted from the estimated number of applicants (which varies from about 32000 to 36000), and the number of jobs is about 20000, the shortfall might have been as little as 600—although there would still have been a shortfall. But why should doctors who qualified outside the EEA not be allowed to apply?
Doctors in foundation year 2 (F2) posts: 6000
Senior house officers (SHOs) in England: 18200
SHOs in Scotland, Wales, and Northern Ireland: 4000
Doctors in staff grade posts in UK (out of a total of >6000): Not known
Doctors working outside the European Economic Area (EEA): 2000
Doctors currently working inside the EEA (but outside UK): Not known
The applicants, whether home grown or trained overseas, fall roughly into four categories: those in foundation year 2 (F2) posts; those in senior house officer posts; those in staff grade posts; and doctors working abroad—some in the EEA and some outside it.
Almost 6000 of the applicants are doctors in F2 posts, who are coming out of their second year of training and applying for a post in their first year of specialist training (ST1). This group is considerably larger than it would have been five years ago because of the big expansion in medical schools' intake, which over the last six years has seen the number of medical graduates increase from less than 4000 each year to more than 6000. Inevitably this creates more pressure for jobs.
The second category is doctors in senior house officer (SHO) posts. The current shake-up in doctors' training, known as Modernising Medical Careers, is intended to make it easier to become a consultant sooner. As a result of the changes the post of senior house officer is disappearing. So, doctors who are currently in such posts are having to apply for specialist training posts, albeit at higher levels (ST3 and ST4).
Currently England alone has some 18200 SHOs. Although it is difficult to get accurate data from published sources, it is estimated that there are a further 2000 SHOs in Scotland, about 1000 in Wales, and just under 1000 in Northern Ireland. Some SHOs are in “trust” or staff grade posts, rather than training posts, but NHS Employers has been unable to tell the BMJ how many.
At one stage it looked as though changes in immigration rules, announced in March 2006, might have prevented SHOs who had graduated from countries outside the EEA and were here with “permit free training” immigration status from applying. But two things have happened to alter that situation.
Firstly, there was a legal challenge to the ruling that all doctors from non-EEA countries needed work permits. Although the organisation bringing the challenge, the British Association of Physicians of Indian Origin, lost in the High Court in February, (BMJ 2007;334:333, 17 Feb doi: 10.1136/bmj.39125.369178.DB), it was given leave to appeal. Pending the results of that appeal the Department of Health has said that non-EEA medical graduates on permit free training will be considered in the first round of MTAS. What will happen to them in the second round is still unclear. (See www.mmc.nhs.uk/pages/oseas.)
Secondly, many of those doctors already working in the NHS as SHOs but who qualified outside the EEA have switched from their previous permit free training status to that of “highly skilled migrant,” which automatically entitles them to be considered as equals to EEA applicants.
The third category of doctors who could be applying for the new training posts are those in staff posts who will apply in the hope of one day becoming a consultant.
Currently, some 5710 doctors are working in the NHS in England in staff grade posts. Many of them (3676) are from outside the EEA and could, like the SHOs in training posts, face difficulties meeting the new immigration requirements introduced earlier this year—unless they have acquired highly skilled migrant status (bmj.com, 22 April 2006, News Extra, doi: 10.1136/bmj.332.7547.932). Doctors in staff grade posts outside the NHS in England could also be applying. There are approximately 200 such posts in Wales, for example, but it is difficult to ascertain from published statistics how many staff posts there are in Scotland and Northern Ireland.
Finally, there is the category of doctors working abroad, itself falling into two groups: medical graduates from other EEA countries, who do not face a problem with immigration status, and those who qualified outside the EEA.
At the moment, only the statisticians at Modernising Medical Careers know how many of the EEA candidates have chosen to apply through MTAS for postgraduate training here (and they couldn't provide these statistics before the BMJ went to press). They are eligible to apply without first passing the General Medical Council's Professional and Linguistics Assessment Board (PLAB) test, unlike applicants from outside the EEA.
The MMC team estimates that, of all the applicants who are currently working abroad, about 1500 to 2000 qualified outside the EEA.
Despite changes in the immigration rules, these doctors can still apply for specialist training, even if they lack the necessary work permit. Specialist training posts can be offered to them only if there is no EEA applicant who is suitably qualified to do the job, which is unlikely.
But who can blame them for trying? Many overseas medical graduates were encouraged to consider working in the UK in the past and had their hopes raised in recent years when they were offered the chance to take the PLAB test in their home country. This test of clinical and language skills was first held overseas in 1998, in India.
The GMC saw a huge rise in the number of candidates passing the test, in the UK and overseas: from 1000 in 1998 to 3700 in 2003. In a paper to its council in September 2005, the GMC laid part of the blame at the Department of Health's door, for its international campaigns to recruit consultants and GPs.
Although the number of candidates taking the PLAB test has fallen since then, it's small wonder that overseas graduates who have passed the test will try their luck in MTAS.