Richard Bogle¹ PhD; FRCP; FESC; FACC; DHMSA;

Tunji Lasoye ² FRCS (Eng); FRCEM; MA Med Ed

Simon Winn¹ PhD FRCP; Caroline Ebdon¹ PhD FRCPath;

Dilip Shah¹ FRCP;

Rehan Quadry¹ FRCP; Martina Yanga MA¹   

Joanne Szram³ FRCP,

Anand Mehta¹  FRCP,

Geeta Menon³ FRCS, FRCOphth, FRCP.



¹ Epsom and St Helier University Hospitals NHS Trust, Carshalton, Surrey

² King’s College Hospital NHS Foundation Trust, London

³ Health Education England, South London



Correspondence to Richard.bogle@nhs.net



Cite as:

Bogle, R., Lasoye, T., Winn, S., Ebdon, C., Shah, D., Quadry, R., Yanga, M., Szram, J., Mehta, A., & Menon, G. (2020) Supporting international medical graduates in the NHS: Experiences from district general hospitals in the pre-COVID and COVID environment. The Physician vol 6; issue 2; epub 1 Aug 2020;



DOI: 10.38192/1.6.2.10



Article Information

Submitted         30 Jul 2020

Pre-print           01 Aug 2020

Open access – Creative Commons Licence CC-BY-ND-4.0



Peer Reviewed by



Simon Gregory

completed 03.08.2020



This is a highly relevant piece of work showing how two units valued their IMG colleagues and based a programme on their needs to attract, retain them and deliver safe care. Sadly the strengths of the paper demonstrate the lack elsewhere. I commend the use of the terms, ‘orientation programme and governance structure’ as a better approach than ‘induction’. One minor amendment., we do not yet have the UKMLA so this should be PLAB. 

This would be interesting if further developed to other specialties and if data could be collected comparing sickness absence and retention at theses trusts it might also show return on investment.



Vijay Nayar

completed 10.08.2020

Interesting and timely commentary on their interventions. 

Provides an outline of a syllabus for IMG induction that will be useful for others to follow.

Please define DME as others may not know this role.

More evaluation of the interventions would be helpful and may form the basis of further research.





Introduction

Like many hospital Trusts in the United Kingdom (UK), King's College Hospital and Epsom & St Helier Hospital regularly recruit doctors from outside the UK in a wide range of specialties. International Medical Graduates (IMGs) are now the second largest group of doctors employed by the National Health Service (NHS) and constitute 30-40% of the junior doctor workforce.(1,2) According to the General Medical Council (GMC), 36% of doctors in the UK obtained their primary medical qualification overseas[i] and in 2018 there was a 50% increase in the number of IMGs coming to the UK and taking the Medical licensing examinations.(3) Recruitment of these additional doctors into the NHS is a short-to-medium-term solution to the current workforce crisis.

IMGs are often highly qualified in their home country but struggle with the challenges of adjusting to a different healthcare system and culture. IMGs face multiple challenges while adapting to an unfamiliar training system, medico-legal framework, expectations of roles and responsibilities, and skills. (4) They face hurdles with career progression (5), differences in working practices (6), social (building support networks), communication and common usage or linguistic context.(7) These challenges can hinder performance, progression and significantly impact on wellbeing. Many IMGs find themselves unprepared as they are expected to work without supervision and often without clinical orientation or comprehensive induction to local healthcare systems. For the individual IMG, these challenging experiences can put them off working in the UK, and for the employing organisations, it can lead to unsuccessful recruitment and medico-legal challenges with patient safety or underperformance. It can be a burden to teams often left supporting them. It is clearly apparent that IMGs have learning and pastoral needs that are not met with traditional generic training programs.(4) Hence a robust orientation programme designed to anticipate and mitigate such challenges and facilitate a smooth transition into working in the NHS, is essential. 



In order to address this need, we developed the ‘King’s Overseas Doctors’ Development Program’ (ODDP) in 2013 and the Epsom St Helier ‘IMG Academy Program’ in 2017. This article explores facets of the program of support and development available to this group of doctors. In addition the COVID-19 pandemic has readjusted almost all of the working practices of the NHS and we discuss our responses to this crisis with particular focus on IMGs as part of the black and minority ethnic (BAME) group of doctors that appear to have been affected more significantly.



The Epsom & St Helier IMG Academy Experience

At Epsom St Helier Hospital, a standard orientation program for IMGs working in Department of Medicine was developed using principles of quality improvement intervention through each of the processes of recruitment, support, orientation, training, assessment and integration. Doctors were recruited at Core Medical Trainee (Senior House Officer) and Specialist Trainee (Specialist Registrar) level based on their prior clinical experience. They had GMC registration after success in the Professional Linguistic Assessment Board (PLAB) UK medical licensing examination and obtained a certificate of sponsorship (Tier 2). Alternatively, doctors with more extensive non-UK postgraduate medical experience at Senior House Officer (SHO) or Registrar level were recruited through the Medical Training Initiative (MTI) sponsored by the Royal College of Physicians of London. These doctors had a certificate of sponsorship (Tier 5) via the Academy of Medical Royal Colleges.

We invited prospective candidates via social media and personal contacts, arranged telephone screening interviews (conducted by a consultant) and successful candidates were advised to apply online to nationally advertised vacancies. Formal interviews were based on the UK national recruitment model via videoconference and consisted of curriculum vitae (CV) review, clinical case scenarios and ethical scenarios.

All newly recruited IMGs underwent a structured Clinical Orientation Program (COP) 6 weeks duration for SHO and 12 weeks for registrars. During this period IMGs were supernumerary, received close clinical supervision, mentoring, pastoral support, and underwent multiple clinical assessments. At the end of the COP, after completion of specified targets, the doctors were assessed as competent to work in independent roles as junior doctors by their educational supervisor. Training was provided under an umbrella named “The Academy”, with an appointed Training Programme Director and a committee consisting of representatives from Division of Medicine, Human Resources, postgraduate medical education, consultant physicians and the Trust’s Responsible Officer. Other stakeholders included the clinical and educational supervisors.

Almost 96% of IMGs (n=21) recruited to our Trust in 2019-2020, successfully completed the COP and the support provided facilitated their development and contributed to their clinical exposure, learning opportunities comparable to training provided to UK-trainee doctors. Many continue to remain in the employment of the Trust. The resources needed to support this programme was provided by the Trust and were viewed as an effective utilisation for successful recruitment and ensuring safe delivery of clinical care.

International Medical Graduates: The King’s Overseas Doctors Development Program

The King’s Program consists of regular teaching days (every 4-6 weeks), freely available to all IMGs including Staff and Associate Specialist Grade (SASG) and trainees. The first session is a focus group discussion with the IMGs, to help identify their learning and development needs specific to their UK medical practice. This diagnostic approach is repeated in brief at the beginning of every session. This has resulted in an iteratively derived list of learning needs (Figure 1).

The program is distinct from the usual UK training days as we aim to provide a safe space for the IMGs to be completely open and honest about their challenges and difficulties. Each study day consists of a variety of teaching activities (Figure 2). A key tenet is to align the IMGs’ existing values and beliefs alongside those expected in the NHS.

The enlisted faculty consists of an ethnically diverse group of consultants and medical education fellows, many of whom are IMGs who have had to overcome similar challenges. Faculty members are provided with formal training in the principles of coaching and mentoring and they provide IMGs with on-going coaching support in between contact days. Participants are able to attend sessions as long as needed, until they feel comfortably settled into their UK practice. There is no formal assessment.

The King’s Program feedback has been positive, with 100% of participants rating the program ‘good’ to ‘excellent’. Candidates describe feeling supported and valued. Candidates particularly value career guidance and support.

‘’This was my third overseas programme session, I have attended and they honestly get better every time. As an Foundation year 1, dealing with clinical emergencies was relevant and made this the best session so far’’

‘’It was very helpful. Not only for the information but also for having the possibility to share some feelings with others who feel the same’’

"I attended all the modules of the overseas doctors’ development programme ‎and I must confess the programmes has made my journey through the NHS less stressful.”

Being flexible to their needs and utilising the skills and personal experiences of the faculty leads to a more enriching experience that leaves them feeling valued and supported. Extra time is factored into each session as learning is negotiated throughout the day and the candidates may be at very different levels of seniority.













We found simulation to be a powerful tool for stimulating reflection on some of the key issues facing IMGs, such as: end-of-life care, assertiveness and communication. For example in some cultures “strong words” (e.g. dying) are avoided and in the NHS this can lead to ambiguity and confusion. This became apparent in a simulated exercise where the candidate had to explain a ‘Do Not Attempt Resuscitation’ order to a relative. Often IMGs are not familiar with simulation-based learning techniques and for some candidates, suspending disbelief can be challenging to begin with.

The flexible and bespoke nature of the programme requires commitment and leadership from the faculty and postgraduate medical education.



International Medical Graduates and COVID-19

The COVID-19 pandemic has changed working practices in the NHS and has had a significant effect on IMGs. Reports that people from ethnic minority backgrounds constitute 14% of the population but account for 34 per cent of critically ill Covid-19 patients and a similar percentage of all Covid-19 cases are of considerable concern. (8)

Moreover, of the initial 119 NHS staff known to have died in the pandemic, 64% were from an ethnic minority background, yet only 20% of NHS staff are from an ethnic minority background. (9)(10) (11) The COVID-19 pandemic represents a challenging situation for all our doctors but in particular our IMGs. Firstly there is the emerging data that BAME staff appear to have higher risk from COVID-19; secondly, IMGs have a reduced level of social support networks and more difficult contact with family members and thirdly they are working in a healthcare system under extreme stress in which they may find accessing information and support more difficult.



Supporting IMG doctors through COVID-19

For each of the interventions that were implemented in our organisation, we considered the impact and applicability to our IMG doctors. We considered that three important facets to underpin our response; (i) honest and timely communication, (ii) fostering team working and cohesion and (iii) access to psychological and well-being resources.

Communication: Clear lines of communication between the teams that can effect rapid change on the shop floor, is essential. We had regular briefing sessions with the Chief Registrar who was able to report back to the Trust Silver command on frontline issues affecting junior doctors. In addition, walkabouts on the wards were undertaken regularly by senior staff. These walk-abouts enabled us to reach staff including IMGs and to gain from them, invaluable direct feedback in a situation which was changing rapidly. 

The IMG doctors reported feelings of vulnerability much like other staff. Whilst the hospital communicated with daily e-briefings (sent out via email) we were concerned that many staff, especially IMGs were not accessing these briefings. We instituted a policy of displaying it in the doctors’ mess in each of our hospital sites. The mess acted as a sanctuary, away from the clinical environment, where doctors could relax, find peer support and refreshment.

Psychological Support and Wellbeing: We were offered support from the South West London and St George’s Trust psychotherapy services. A psychologist supported staff deployed to our Intensive therapy unit (ITU). The junior medical staff were often reluctant to discuss emotional issues in front of their supervisors and preferred to speak with someone neutral. Hence, we set up wellbeing support for junior doctors with facilitated (virtual) talking groups (as drop-in), or individual sessions. We also sign-posted staff to the virtual Wellbeing Hub established by the Professional Support Unit of Health Education England.  

Personal Safety: Personal protective equipment (PPE) was a major concern for the entire workforce, but with media reports about the lack of availability, even on COVID-19 wards, staff were understandably anxious. Often this resulted from difficulties in communication and from conflicting guidance received from Public Health England or professional bodies such as the Resuscitation Council (UK), particularly with reference to aerosol generating procedures. The anxiety among staff was further exacerbated by the very high sickness rates, especially in the early part of April 2020. There was the added complication of challenges in obtaining COVID-19 testing for staff much of which was organised on a remote “drive in” site that was not simple for IMGs to access. 

At the beginning of the pandemic, the Trust rolled out a Medical Staff Skills Survey to assist in redeployment and working with occupational health department to identify those with underlying health problems who would require shielding. Many of these were consultant staff from BAME groups and they were re-deployed to home or non-patient facing work, in co-ordinating research and working the bereavement office.

Library and Information Services: We utilised the library and information services to roll out use of video conferencing and also make available on-line educational resources. In addition, the libraries in each of our hospital sites became a hub for drop-in groups and support sessions.  The Director of Medical Education (DME) led the re-deployment of over 50 medical staff working with Human resources and medical rostering teams. The close liaison between clinical and educational leadership teams was important to ensure that redeployment was based on strengths and recognised potential vulnerabilities of staff.  
Conclusions

In order to address the perpetual NHS medical workforce challenge, we have developed innovative strategies to improve overseas recruitment and retention of junior doctors to our Trusts. The success of our strategy depended on developing a structured program for new IMGs (naive to the NHS) leading to a safe, culturally sensitive, supported transition into the workplace facilitated by an ethnically diverse faculty and appropriate investment of resources.  
This group of doctors commonly report feeling unsupported and under-valued and our programs improved their experience, helped them settle into their UK jobs quickly and provided them with a strong foundation for a successful career. In our view, Trusts should make effective support and development of IMGs an important goal of their ‘People’ Strategy; for the benefit of patients, IMGs and their colleagues. The arrival of COVID-19 placed additional pressures on IMGs and a co-ordinated approach supporting the welfare and well-being of these doctors is an important part of any organisational response.