Challenges and expectations of international medical graduates moving to the UK: An online survey

Introduction

International medical graduates (IMGs) account for a large proportion of the UK doctor's workforce with 41% of doctors on the General Medical Council (GMC) register having done some or all parts of their medical or specialist training outside the UK. ¹ Despite this, a recent investigation undertaken by Baroness Helena Kennedy highlighted the underrepresentation of IMGs or those from ethnic minorities in leadership/council roles. ² Further to this, evidence suggests that ethnic minority doctors working in the NHS are twice as likely to be referred by an employer to the GMC when compared to their white counter-parts, and if they are trained outside the UK that figure rises to being two and a half times as likely. ³ A report commissioned by the GMC entitled ‘Fair to Refer’ investigated the possible causes of this disproportionality. ⁴ It highlighted that IMGs are seldom given an appropriate induction, nor ongoing support when arriving to the UK. To compound these issues, IMGs often work in isolated roles, receive minimal constructive feedback regarding their work and offered limited opportunities for career progression.

There is limited published evidence researching the views of IMGs or doctors from ethnic minority backgrounds. Therefore, we conducted a survey specifically looking into the support given to these doctors and whether they are treated as equally as their peers.

Methods

All authors contributed to a survey, written with the aim of identifying the level of support given to doctors when they start working for the first time in the NHS. Contents were fine-tuned after input from senior IMGs with a minimum of 10 years working in the NHS. Free text options were given for people to express their views further. The survey was created on surveymonkey.co.uk platform and circulated via relevant closed medical WhatsApp groups to avoid inappropriate survey answers. These groups contained variable numbers of IMGs and therefore we were unable to adjust for a sample calculation for 95% confidence with a 5% margin of error, which for the population of 160,000 IMG's in the UK workforce would have equated to 384. Instead, we have a sample size that equates to 80% confidence interval with 5% margin of error. The authors recognise that this is a study limitation.

The authors decided that an adequate control group should be 10% of our participants, and these were colleagues of the authors. The authors recognise the limitations of this.

The survey also asked about GMC referrals, whether respondents had ever been referred and the reasons for this referral. It also asked for their opinions on the reasons for these referrals. It was distributed via WhatsApp to relevant primary care and urology groups working in the NHS. This included IMG groups and those that had trained in the UK. The authors decided against sending out the survey through social media to avoid ‘non-medics’ completing the survey. A small number of British doctors were also surveyed in the data, and it was used as controls for the IMGs. IP addresses were used to identify duplicate entries and all responses were anonymised.

The questionnaire included demographics of the participants, date of first NHS appointment, grade at first appointment, familiarity with UK healthcare system (rating: 0–100%), support given to learn the healthcare system (rating: 0–100%), type of first job in NHS (training or non-training), dedicated educational or clinical supervisor in the first job, assigned mentor (during transition) and their input, induction for the first job in UK, local hospital induction, benefit from ‘NHS’ induction (rating: 0–100%), steps to improve induction for IMGs, shadowing period, study leave duration and budget. It also asked them about GMC referral (themselves or anyone known to them) and the reasons for referral. For IMGs specifically, we also asked them about taking English, and Professional and Linguistic Assessment Board (PLAB) exams.

Results

A total of 173 IMGs and 16 British trained doctors were included in the survey. The 189 participants of this survey were a diverse group, spanning different age ranges, gender and career grades as seen in Table 1. The majority first started working in the UK post 2000 (71%), and 22% of participants started working in the NHS in the last 2 years (Figure 1).

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Figure 1.

Date of first appointment in the UK.

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Table 1.

Participant (physician) demographics.

Participant demographics (n = 189)
Age	25–29	23	12%
	30–39	53	28%
	40–49	58	31%
	50–59	38	20%
	60+	17	9%
Gender	Male	111	59%
	Female	76	40%
	Prefer not to say	2	1%
Training	IMG trained abroad	160	85%
	British trained abroad	13	7%
	British trained in UK	16	9%
Current Grade	Trainee	39	21%
	SAS (Staff grade and Associate Specialist)	43	23%
	Locally Employed Doctor (LED)	25	13%
	Consultant	67	36%
	General Practitioner	15	8%

The majority of our participants were ethnic minority IMGs (n = 160, 85%), 7% (n = 13) were British and trained abroad, with 8% (n = 16) being British and trained in the UK. While the first NHS job of participants varied, 46% were trainees in formal training schemes, 29% were locally employed doctors and 22% were staff and associate specialists grade doctors. Only 3 (2%) each were either employed as consultants or general practitioners at their first NHS appointment.

Familiarity with the UK healthcare system was measured by participants rating this as a percentage. Prior to their first role, this was 28% on average for IMGs, 51% for British doctors trained abroad and 77% for doctors trained in the UK. Furthermore, IMGs (non-British and British) felt much less supported to learn the UK healthcare system (31% and 37% respectively), when compared with British doctors who trained in the UK (60%) (Table 2).

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Table 2.

Participants first role in the NHS (ES – educational supervisor; CS – clinical supervisor).

First appointment in the NHS (n = 189)
		IMG (160)	British trained abroad (13)	British trained in the UK (16)
Date of first appointment	1980–89	5	0	2
	1990–99	20	1	3
	2000–09	43	4	3
	2010–19	49	6	8
	2020–22	43	2	0
Grade at first appointment	Trainee	69	3	16
	SAS	37	5	0
	LED	49	5	0
	Consultant	3	0	0
	General Practitioner	3	0	0
Familiarity with the UK System (%)	Average %	28	51	77
	Range	0–100	0–100	38–100
How supported did you feel to learn UK health system (%)	1980–89	48	/	50
	1990–99	30	86	63
	2000–09	26	28	58
	2010–19	29	33	63
	2020–22	36	38	/
First job in training (%)		23	8	88
ES/CS in first role (%)		44	38	88
IMG mentor in first role (%)		14	23	/
Induction prior to first role (%)		48	46	79
Shadowing period prior to first role (%)		41	50	62
Regular meetings with supervisor in first role (%)		14	8	19
Study leave in first role (%)		48	53	43
Study budget in first role (%)		41	46	38

Most IMGs (non-British and British) did not start their first job in a national training programme (77%), and only 44% had a dedicated educational/clinical supervisor. About 86% did not have a mentor to assist with the transition to UK healthcare system and only 48% had an induction. Of those that received an induction, non-British IMGs rated it on average as only 32% useful and British IMGs rated it as 41% useful (Figure 2).

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Figure 2.

Support provided during the first appointment.

About 84% of all participants felt that an NHS induction would be useful before starting a clinical role in the NHS. Many also agreed that having a mentor, physical orientation and supernumerary periods would further improve hospital inductions. Other free text suggestions included simulation sessions, communication sessions and sessions on how to recognise and deal with racist or discriminatory behaviour.

IMGs felt that they had very limited support when starting work in the NHS, with only 41% having a shadowing period and 14% having regular meetings with a mentor. This is in contrast with the foundation programme, in which all UK trained doctors receive an educational and clinical supervisor. UK trained doctors also receive a study leave allowance and study budget on starting their first job in the NHS, which is in stark contrast to the 48% and 41% of IMGs who reported they did not receive an allowance of study leave or budget.

In our survey, 59% of participants knew of another IMG referred to the GMC. In their opinion, the reasons for these referrals are outlined (Table 3), and included a lack of knowledge of UK NHS system, communication difficulties, cultural differences leading to misunderstanding and a sense of bias towards them.

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Table 3.

Referrals to the GMC (optional question).

Referrals to the GMC (optional question)
Have you ever been referred to the GMC?	Yes	14
	No	162
	DNA	13
If not do you know another IMG personally who has been referred to the GMC?	Yes	58
	No	118
	DNA	13
Reasons for the IMG's GMC referral
Drop down box:
Lack of knowledge of the UK system		24
Communication difficulties		25
Cultural differences leading to misunderstanding		31
Bias		48
Free text – Other:
Medical error		2
‘Personal Animosity’		1
Racial discrimination		1
Traffic offence		1

The PLAB test is a mandatory test needed to work in the UK if a doctor graduated from a medical school outside of the UK, European Economic Area or Switzerland. The majority (82%) of IMGs took a test prior to starting work in the UK. However, 59% did not find that the PLAB test helped them prepare for working in the UK.

Discussion

The primary aim of this survey was to identify the current plight and areas to improve the support given to IMGs working in the NHS. IMGs comprise an essential part of the workforce as they comprise 41% of the registered doctors in the UK. ¹ In recent years, there has been a 121% rise in IMGs joining the workforce, ⁵ therefore it has never been more important to ensure IMGs are supported, trained and feel equally represented and included.

In our survey, IMGs were not familiar with the increasingly complex UK health service system, and many feel that they didn’t receive the support to learn and adapt to it. Most felt that the induction was inadequate and missed out offering important information that would have aided their transition. Fortunately, some of these points have been recognised by IMG groups, and as such, deaneries of late are starting to deliver NHS inductions specifically for IMGs. ⁶ However, not all deaneries provide this support. Lack of knowledge of the NHS, despite good clinical knowledge, can result in harm to patients and could be another reason why IMGs are more likely to be referred to the GMC. The authors suggest that a more focused and detailed induction to the NHS may improve patient safety and reduce the stress on IMGs starting work in a new country. It would also improve the reputation of the NHS abroad, as being a more supportive service, thus encouraging more doctors to apply to work in the UK.

Only 48% of IMGs received an induction in their first role in the UK. Without an induction to the hospital, it is not only difficult to settle into a new role and understand different processes, but it also makes them less confident and likely to make mistakes. Table 2 stratifies the respondents by their start date. Prior to 2000 only 1 doctor (4%) had an induction. From 2000 to 2009, 52% received an induction, and between 2010 and 2019, 65% received an induction. Unfortunately, of doctors who started working in the NHS most recently (2020–2022), only 56% of doctors received an induction, although this could be a consequence of the Covid pandemic.

The respondents to our survey also suggested that their induction to the hospital and clinical practice were inadequate (only 32% IMGs reported their inductions as being useful). About 78% of respondents felt that having a mentor would improve their induction and 76% felt that a physical induction was necessary, with a further 61% commenting that a period of being supernumerary would assist a smooth transition. Other suggestions included having sessions on career progression and three respondents stated that assistance with how to deal with racist or discriminatory behaviour would have helped them in their first role.

Another way of supporting IMGs in their period of transition to the NHS would be to have a dedicated educational and clinical supervisor (Table 4). In 2018, a joint statement from the UK's leading training and education governing bodies stated that all doctors in training require a clinical and educational supervisor to ensure trainee safety and professional development. ⁷ This guidance should be transferred to all junior doctors, whether locally employed or in a training programme and should be especially relevant to doctors undertaking a transition such as starting work in the NHS. Evidence has shown that providing open, honest and timely feedback to a doctor protects them, thereby reducing complaints and referrals to the GMC. ⁴ Interestingly, British trained doctors did not have regular meetings with supervisors in their roles (19%) and they felt that they had limited support to learn the UK health system.

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Table 4.

Suggestions to improve IMG induction.

What could be done to improve hospital inductions for international medical graduates?
Drop down box:
Teaching sessions (on NHS structure and processes, prescribing in the NHS etc.)	152 (80.42%)
Having a mentor	148 (78.30%)
Physical orientation before starting work	144 (76.19%)
Supernumerary period	116 (61.37%)
Paid induction	79 (41.80%)
Free text - Other suggestions:
Local area induction (guide to UK/bank accounts/tax/ pensions etc.)	4
Sim sessions	1
Communication session	1
Slow introduction to on call shifts	1
How to recognise, deal with and report racist and discriminatory behaviour	3
Further information on how to progress in training	2
Buddy scheme	1

In our survey, only 17% of IMG participants had a mentor to assist with the practicalities of moving to the UK. Other help would include things like setting up a bank account and finding accommodation to assist their first job. Some trusts have a dedicated department to assist with these queries, but many don’t, and IMGs rely on unofficial guides on the internet. ⁸

Study leave allowance and study budget are essential for career progression and professional development. About 48% of IMGs had a study leave allowance in their first job, with 41% having a study budget. Both the study leave and budget encourages doctors to continue their own professional development, allowing them to pursue their academic and clinical interests. Regulations around study leave are primarily aimed at doctors in training, ⁹ whilst individual trusts fund and decide study leave allowances for locally employed doctors. Most IMGs in our survey did not have their first job in a training programme (74%), which could potentially highlight the need for further regulations on study leave in ‘non-training’ roles.

In our survey, we asked doctors their opinions on the PLAB test. This test ensures that doctors who have trained outside the UK are qualified to work in the UK, testing both English language proficiency and medical knowledge. About 46% of the IMGs in our survey took the PLAB test and although the primary aim of the test is to ensure quality of doctors working in the UK, 41% of those who revised for the test also stated that it helped them prepare for working in the UK.

Finally, one of the main motivations for this paper is the inequalities in GMC referrals with doctors from different ethnic minority backgrounds and especially of those who trained outside the UK. ¹⁰ The authors believe that greater support for IMGs in the workplace, including adequate induction, clinical and educational supervision could potentially reduce the disproportionate GMC referrals (Figure 3). In our survey, 14 (7.4%) doctors had been referred to the GMC at some point in their careers with 58 (30.7%) doctors knowing an IMG personally that had been referred. When asked the reasons for these referrals, many stated that the majority of these were for bias, cultural differences, communication difficulties and lack of knowledge of the UK health system.

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Figure 3.

Recommendations to improve support for IMGs.

Limitations of this study

The authors recognise some limitations in their study design due to the lack of calculation of sample and control groups. However, the value in this paper lies in the trends outlined above, which can shed light on the challenges that IMG's face when starting their first role in the UK.

The questionnaire was conceived, created and reviewed by the authors. The senior authors, both IMG's, have worked in the UK for over 25 years and aware of the challenges faced. However, it might have impaired their recall of events in their first role in the UK. In addition, the survey had not been externally validated which could have improved the quality of questions. It is important to note that IMG's have a variety of different educational and cultural backgrounds. It was impossible to confound for this when creating this survey and this could be a limiting factor of this data.

Conclusion

This paper reflects the views of doctors regarding the support given to IMGs during their first NHS appointment and subsequent jobs in the NHS. This survey confirms that the majority of IMGs are not being given equal or adequate support when starting their first role in the UK. This is unacceptable given their increasing percentage in the UK workforce.

IMGs require a focused and detailed induction, educational and clinical supervision and mentorship throughout the transition to the NHS. IMG support should be held to a similar high standard as deanery trainees, with an emphasis on professional development.

Finally, many IMGs have experienced racial or cultural discrimination, with recent surveys reporting that 76% of respondents having experienced racism in the workplace over the last 2 years. ¹¹ Adequate teaching on how to escalate any issues and support from the wider medical community is essential to accelerate the culture change which is needed hand-in-hand to their professional progress and development.

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