The on-going threat to strike by junior doctors’ shows starkly how they feel about looming changes to their contracts. While strike action in December was averted at the eleventh hour, negotiations between the Department of Health and the British Medical Association (BMA) have again broken down, with the government apparently set on making terms and conditions for junior doctors distinctly tougher – at least in the eyes of doctors.

Leaving aside the question of whether the junior doctor’s contract should be changed, this perception that doctors are about to get a worse deal could have consequences for the British healthcare system that reach further than first meets the eye. This is because there are grave implications for the vital contingent of doctors from overseas working in the UK. Furthermore, the proposed new contract is just one of a growing series of barriers to attracting and retaining much-needed medical talent from abroad.

Huge contribution

To understand how serious an issue this is, it is worth noting the scale of the role that medics from overseas play in the UK healthcare sector. Think tank the Health & Social Care Information Centre published research last year that revealed that 11% of staff in the NHS and community health services are not British. Furthermore, the research showed that some 26% of doctors here are from abroad. A BMA spokesman says simply: “Overseas doctors make a huge contribution to the NHS.”

Carla ThomasSenior Account Manager at DavidsonMorris, says: “It is generally agreed that there is a shortage of medical practitioners of all kinds in the UK, so we do need doctors from overseas, especially to support the NHS.” Foreign medical students from outside the European Economic Area (EEA) also contribute financially to the UK healthcare system: They pay around three times what a British student pays for their education, effectively subsidising the training of home-grown doctors.

The skills shortage and battle to attract vital medical talent applies equally in the private sector. Alex Goude, a physiotherapist who runs a clinic in March, Cambridgeshire, explains how vital overseas professionals are in her field: “Recently, despite extensive job advertisements we were unable to find a suitably qualified applicant from the UK – there is a clear lack of physiotherapists. We have therefore recruited an individual from abroad who is educated to masters level and has considerable experience.”

Immigration Issues

Despite how badly we need non-British doctors, bringing them into the UK is surprisingly difficult. It is not impossible, if you have the right expertise, but the need for professional advice in itself shows how complex the process can be.

For Goude, for example, her recruit from overseas was from outside the EEA and he was not fulfilling a role on the national list of shortage occupations. The immigration process for this candidate was therefore beyond the capabilities of Goude’s clinic, which needed to appoint an immigration solicitor.

Goude says: “The complex application procedures and guidelines which are not clear to someone who is not used to navigating through them meant that to attempt the process on our own entailed a significant risk of failing.”

Furthermore, the government is making a series of rolling changes to immigration rules that means that the business of hiring someone from overseas has become something of a moving feast, which can catch out employers. Goude says, for instance: “Immigration procedures changed the day before we due to submit our paperwork to the Home Office.”

Tortuous immigration procedures led directly to Goude’s business suffering, she says: “The length of time it has taken to recruit means that we have had to cancel and turn down numerous work contracts. It has also put extra strain on current staff. Overall, the immigration rules have meant that recruiting someone from overseas has ultimately cost the business a considerable amount of money.”

Meanwhile, from the perspective of candidates from outside the EEA, this onerous process could be enough to put them off coming to work in the UK. Thomas says it is worth remembering that these candidates are in demand globally and could easily choose a country where they perceive immigration to be easier – and indeed where they feel more welcome: “We are competing for medical staff with countries like the US, Canada and Australia, so the idea of making it difficult for candidates to come here does not make sense.”

Obstacles looming

Yet there are new obstacles looming for much-needed doctors considering working in the UK. The proposed new junior contract and the accompanying outcry from doctors in itself could be enough to deter some from choosing the UK of course. However, the new contract could also have an impact on immigration processes, adding extra challenges that could give overseas doctors just one more reason to give up on the UK – or simply preventing from staying even if they wanted to.

If a new junior doctor’s contract introduces, as the government has said it should, longer working hours, this could prevent overseas doctors from qualifying for a Tier 2 (General) Visa which is required for those from outside the EEA to work in the UK. This is because the visa requires the applicant to earn a minimum salary on a pro rata basis, assuming 39 hours of work per week.

Thomas says that therefore: “If a doctor earns £26,000 but works 45 hours, on a pro rata basis his salary is lower than the required threshold. If terms and conditions change significantly for junior doctors, then, it may impact on their Tier 2 status.”

In addition, doctors moving from student status to employed status may face a new challenge. A good number of doctors come to Britain from overseas for training on Tier 4 Student Visas. Thomas says: “At present it is simple for them to switch from studying to working here by moving fairly seamlessly from their student visa to a Tier 2 (General) Visa.”

In such cases, unlike many other cases where a non-EEA recruit is hired, the Resident Labour Market Test does not apply. Therefore there is no need for the post that the junior doctor fulfills to be advertised for 28 days. Thomas says:

“At the moment employers can hire someone on Tier 4 and put them straight on Tier 2 on the same day. This is particularly vital for those undertaking medical training, who in any case will need to complete their Foundation studies via training on the job.”

Now, though, the government is talking about making the process of transferring from Tier 4 to Tier 2 less straight forward. Thomas says: “There are proposals being discussed to require students to return to their home country at the end of their studies and then make an application for a Tier 2 (General) Visa. This would mean someone trained, living in the country and ready to start work has to go back to their home country while the employer advertises the role for 28 days.” The employer would then have to sift through all applications and if it did finally chose the overseas candidate, it would have to submit a request to the Home Office for approval.

Employers must wait until the 5th of the month to submit such a request and then the department consider these requests on the 11th of each month. The employer is then told the decision on either the same day or the following day.  Approval is far from guaranteed since the government’s quota system means that the Home Office can only approve 1,650 Tier 2 visas per month.

After all that: “Only once the home Office approves the request can the doctor then apply for a visa,” says Thomas. She adds: “Cutting the link between Tier 4 and Tier 2 would not only break the continuity of doctors’ training but would also create a real risk that doctors trained here won’t come back.”

Importantly, removing the link could also hinder non-British doctors from obtaining Indefinite Leave to Remain, for which they need to have lived in the UK for five years continuously. Thomas says: “For a non-EEA doctor thinking about which country to work in, this would be one more hurdle making a long term stay in the UK look less appealing.”

The BMA says in its response to the Migration Advisory Committee’s call for evidence for its current review of Tier 2: “It is essential that a link is maintained between Tier 4 and Tier 2; this route is essential for overseas graduates of UK medical schools to progress from the Foundation Programme into Specialty Training. The current design of Tier 2 (General) [gives] employers the flexibility to employ doctors on Tier 2 (General) when and where the need arises.”

Perfect Sorm

A perfect storm is forming that could leave resources within the UK healthcare sector more stretched than ever. The UK’s immigration processes for overseas doctors and medical students are complex as it is. But if they are made more onerous while at the same time a new junior doctor’s contract is introduced which both worsens terms and conditions and adds further barriers to immigration, the UK will become an increasingly unattractive destination for non-EEA doctors. Thomas says: “The government may feel that it wants the UK to become unattractive to migrants but in bringing this about we could be deterring very valuable, skilled junior doctors furthering their education here and then joining the NHS.” With overseas staff making up a quarter of doctors in the NHS and community health services it is clear that this a scenario we can ill afford.