The NHS’s immigration addiction is bad for our health

The perils of outsourcing healthcare to the lowest bidder

This piece was originally published for CapX in mid-October

A new report, published by the GMC and written by its chief executive, Charlie Massey, has found that too many British doctors of BAME origin and overseas-trained medics are still being reported by their employers for alleged misconduct compared with white British-trained medics as a result of discrimination.

The report offers a comprehensive update on the targets established by the GMC in 2021 to address ‘persistent areas of inequality’. These targets were introduced following ongoing criticism regarding the disproportionate number of UK-trained BAME doctors and internationally trained medical professionals being referred for alleged breaches of their code of conduct.

The report highlights progress toward these targets. For example, the proportion of bodies, such as NHS trusts and health boards, across the UK that referred a disproportionate number of doctors to the GMC based on ethnicity or qualification location decreased from 5.6% in 2016 to 3.2% in 2023.

Similarly, the gap in employer referrals of doctors to the GMC between ethnic minority and white doctors dropped from 0.28% to 0.13% over the same period. In addition to these ‘sustained signs of improvement’ in referrals, the ‘attainment gap’ for internationally-trained doctors entering specialty training is also ‘narrowing’.

Massey told the Guardian that many ‘workplace cultures are still not inclusive enough’, particularly given the NHS’s increasingly diverse medical workforce. The persistent disparities between white doctors, UK-trained BAME doctors and international medical graduates (IMG) remain ‘shaming’ and ‘unacceptable’, he added.

Nowhere, as the Legatum Institute’s Fred de Fossard correctly points out, ‘does this ridiculous article talk about outcomes for patients’. And when it comes to outcomes for patients, there may be perfectly valid reasons for there to be disproportionate fitness to practice referrals that cannot be solely attributed to high levels of racist patients.

The report that triggered this process was ‘Fair To Refer?’, an independent report commissioned by the GMC, ‘to understand why some groups of doctors are referred to the GMC for fitness to practise concerns more, or less, than others by their employers or contractors and what can be done about it’. It took the form of a qualitative study of around 250 doctors.

The report found that IMG doctors ‘were often not perceived to “know the rules” and were offered few formal learning opportunities to understand the “hidden curriculum” for practising “the art of medicine” within the UK’, struggled to decode an unfamiliar socio-cultural context and lost various forms of knowledge and support to which they had access in their nation of origin.

What the report studiously fails to mention when considering the rates of IMG doctor referrals is the potentially lower medical standards for doctors who graduated outside the EEA. That is despite previous GMC research, published just five years earlier, suggesting that half of foreign doctors were not fit to practise in the UK and ‘would fail to reach the standards expected of British doctors’, but were able to practise as the competency exams ‘were too easy’. 

This is particularly baffling, given that ‘Fair to Refer?‘ itself acknowledges that concerns about medical qualification was a primary reason for IMG doctors to be seen as lower-status ‘outsiders’; ‘drawing broadly (but not universally) from our extensive interviews, IMG doctors are typically seen by some of their colleagues as having “not as good medical qualifications”.’ But ‘Fair to Refer?’ takes it as a given that these concerns are evidence of personal prejudices, rather than well-trained doctors having firsthand experience of IMG doctors with poor medical qualifications.

But poor medical treatment may not even be the extent of the problem. The GMC’s plan to support EDI in medicine has developed specific training on being inclusive to trans and non-binary people for doctors, and guides for patients from various protected groups, outlining the standards they should expect from their doctors, including specific information for LGBT patients. Although Fair to Refer? makes no mention of this, it raises the prospect of differing social attitudes playing a role in the treatment of patients – something that is unlikelier in EEA-trained doctors, who are more likely to come from similarly socially progressive nations.

Instead of highlighting concerns about undertrained medical professionals working within the NHS, ‘Fair to Refer?’ shifted the GMC’s focus toward tackling biases in the referral process as its sole solution to the problem. The failure to interrogate this issue is a major policy misstep; in 2022, nearly two-thirds of new doctors had qualified abroad, while the abolition of the Resident Labour Market Test for medical practitioners means UK-trained doctors can no longer be given preference for NHS roles. As a result, over 1,000 UK-trained medical students are losing out on placements for junior doctor training.

The NHS is now, as Sam Freedman puts it, ‘dependent on immigration’ – and our ageing population means that demand for medical staff is only set to increase. The BMA forecasts that the UK needs to create an additional 11,000 medical school places to train the medical workforce it needs by the year 2030. Without a commitment to increasing domestic training and educational capacity, the reliance of the NHS on foreign-trained workforces will, likely, only increase.

While concerns about the standards of care offered to patients are reason enough to tackle this, reliance on foreign-trained medical staff is also a staffing solution that leaves the NHS overexposed to future global shocks and fluctuations in international workforce supply.

DEI doctors are not a long-term solution. The NHS Long Term Workforce Plan offers excellent solutions to this by increasing domestic training and education capacity, yet delays to the rollout were announced as early as this year. 

In order to tackle this, as recommended by David Cowan and I in our paper ‘Selecting the Best’, more than the £2.4bn currently allocated must be spent, with the plan’s targets to reduce reliance on foreign-trained medical staff seen as a minimum baseline rather than a target. Clear and transparent workforce forecasts are needed to ensure that NHS workforce planning can be scrutinized. A workforce-planning organisation should be considered, tasked specifically with delivering the NHS Long Term Workforce Plan and streamlining medical training. Additionally, the exemption of medical practitioners from the Resident Labour Market Test should be reversed to prioritise British-trained staff, ensuring enough placements to match the growth in medical training that could be achieved by scrapping the cap on the number of British medical training places.

It is, of course, discriminatory to want a better doctor. But outcomes for patients should be the primary goal of our healthcare system; the DEI-ification of our healthcare system may have disastrous effects by papering over major policy failings.