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|Source : BMJ|
|A quick guide to working in the United Kingdom|
|Joanne Constable, Isabel Fish, and Claire McKenna give a brief sketch of the basics. For more detailed information, please refer to the websites mentioned
|Who exactly is an overseas doctor? The definition of an overseas doctor can differ greatly according to the angle from which you are approaching the question.|
Immigration rules define an overseas doctor as: "one who regardless of where he/she may have obtained his/her primary qualification, does not have the right of indefinite residence or is not settled in the United Kingdom, or who does not benefit from European Community rights." This definition also includes doctors who may have received a primary medical qualification from a United Kingdom university but who do not have the right of indefinite residence.
The General Medical Council defines an overseas doctor as: "Someone who has obtained their basic medical qualification outside of the UK."
Why would an overseas doctor want to come and work in the United Kingdom?
Overseas doctors are not a homogeneous group. Some doctors may be refugees or asylum seekers who are forced to flee their home countries. Others may be enticed by better living and working conditions or better pay than they receive in their home country. Some doctors may simply want to come to the UK to gain skills which are not available in their home country and bring what they learn back to their patients at home. Still others may come to the UK on a short term basis to teach new skills to doctors in the UK.
Why does the UK government want overseas doctors?
The new European Working Time Directive which has been implemented in the UK is expected to create increasing staffing pressures among doctors, and the NHS is likely to become increasingly dependent on the services of overseas doctors. The UK Department of Health has had a recent overseas recruitment drive. The most recent Department of Health medical and workforce census found that 24% of doctors working in the NHS were not from the UK.
The same report stated: "Clearly, substantial numbers of overseas doctors will continue to be needed in order to meet the expected demand for healthcare."
The next step
After sorting out whether you are an overseas doctor and why you want to come to the UK, and after arranging immigration and visa requirements, the hard work begins. Your main aim before you can begin any clinical work or write prescriptions is to get limited registration with the General Medical Council so that you can be placed on the UK Medical Register.
The Special Case of EEA doctors
One of the most important principles of European law is that of free movement. Doctors who are citizens of an EEA member state and who have qualified in an EEA member state have the right to live and work in any other country in the EEA. Asking EEA nationals to take a linguistic test is unlawful as it would be a barrier to their right to live and work in another EEA country. It is the responsibility of the employer to make sure that the doctor is proficient in written and spoken English.
|This article is a basic guide and does not cover everything in detail. You can obtain a comprehensive guide for doctors wishing to work in the UK from the BMA's International Department (firstname.lastname@example.org).|
Overseas doctors coming to the UK must satisfy UK immigration requirements. Immigration law is very complex and doctors should seek detailed advice from the Home Office (www.ind.homeoffice.gov.uk). If you are outside the UK you should contact your local British embassy or high commission for further information.
Doctors who are citizens of the countries in the European Economic Area (EEA) or of Switzerland are entitled to enter the UK freely and work here.
Doctors from beyond the EEA may have rights to live and work in the UKfor example, if they are the spouse of an EEA national or workpermit holder or because they have Commonwealth ancestry. Doctors who think that they may have such rights should seek advice from the Home Office or the British representative overseas.
Postgraduate permit-free training status
Doctors wishing to do postgraduate training in UK hospitals or community health services must have "permit-free" postgraduate training status, which means that they are allowed to work without a work permit. To qualify for this, the doctor must have GMC registration and show that he or she intends to work in a training post within the NHS. Full details can be found on the Home Office website.
|Fig 1. Overview of process to obtain limited registration with GMC
Doctors working in hospital career grade posts (non-training grades) as consultants or as salaried or locum GPs will require a work permit. Employers must apply for the permit from Work Permits UK. A usual requirement is that no suitably qualified EEA national is available to do the job. A work permit is specific to a particular post and cannot be transferred should you obtain another job before it expires.
Asylum seekers and refugees
The BMA and the Refugee Council jointly run the refugee doctors' database. The project collects details on the number of refugee doctors in the UK, their location, and the stage of their career and registration process. For more information and a copy of an information book for refugee doctors please contact the BMA International Department. For further information about immigration requirements within general practice
Doctors who wish to practise medicine in the UK need to be registered with the General Medical Council (fig 1).
There are four different types of registration with the GMC: provisional, limited, full, and specialist.
Allows doctors who have qualified in the UK and EEA (who are also EEA nationals) and those qualified in Australia, Hong Kong, New Zealand, Singapore, South Africa, and the West Indies, to work in preregistration house officer posts which are approved for the purpose of preregistration service.
Allows overseas qualified doctors, who hold an acceptable qualification (included in the World Health Organization's list of Medical Schools) to practise in supervised NHS training posts (preregistration house officer, senior house officer, specialist registrar) which are educationally approved. It is also granted for locum posts at these grades. (Note that although the post you may take is at JHO level you need to be at an SHO standard to pass the PLAB exam needed to get GMC registration.)
Allows doctors to practise in unsupervised medical practice in any post in the NHS and in private practice. This type of registration is needed to work as a general practitioner.
|(Credit: LIANE PAYNE)|
Allows doctors to take up a substantive or honorary consultant post in the NHS. No doctor can take up these appointments unless they are on the specialist register.
Temporary full registration
There are also some special cases where overseas qualified doctors can be granted temporary full registration. This is for doctors who are coming to the UK to provide a temporary specialist service (for example, demonstrating a particular technique that is not available in the UK) for a short period of time. All other overseas doctors have to apply for limited registration.
How long does limited registration last?
Limited registration is granted for periods totalling no more than five years. Overseas doctors who have just passed their PLAB examination will normally be given one year and one week. Registration expires at midnight on the last day of registration shown on your certificate of limited registration. You can apply to renew your registration up to three months before the date on which you need further limited registration.
How do I renew my limited registration?
Before further limited registration can be granted, the GMC needs to be satisfied that a doctor's performance complies with the standards of competence, care, and conduct described in the GMC's publication Good Medical Practice. The assessment of this is carried out by the doctor's supervising consultants, using a GMC report form.
Application forms, report forms, and fact sheets can be downloaded from the GMC website (www.gmc-uk.org). You should aim to submit the application form for renewal of registration as early as possible. Make sure you have all the evidence and fees required, or this may delay your application.
How do I progress to full registration?
You normally need at least 12 months' experience at SHO or specialist registrar with limited registration to apply for full registration. (See the GMC's website for a factsheet giving all the criteria for full registration.) Again, you need to supply an application form (available on GMC's website), a consultant report from your supervising consultants, and a registration fee.
What are the costs involved in registration?
You will need to pay a fee every time you apply for registration. The amount depends on which type of registration you are applying for and whether it is an initial registration or a renewal. For information on exact fees see www.gmc-uk.org/register/fees.htm. Unfortunately, there are no exemptions from payment of fees for doctors who may not be able to pay
One of the registration requirements for all doctors who qualify outside of the European Economic Area is that they must demonstrate that they have the necessary knowledge of English by obtaining a satisfactory score in the IELTS (the International English Language Testing System).
|(Credit: LIANE PAYNE)|
|Facts about IELTS
- IELTS is a test of the skills that are needed for study in an academic context in the UK
- The test has four separate components: listening, speaking, reading, and writing; each is scored individually and an overall score awarded
- It is not a pass/fail exam: the test is banded from 1 to 9, with 1 indicating a very basic knowledge of English and 9 indicating language
skills at native speaker level
- The GMC asks for an overall score of 7.0,
with a score of at least 7.0 in the speaking component and a score
of no less than 6.0 in the other three components. To be exempt
from the PLAB tests you must gain at least 7.0 in all four
sections of the IELTS test.
How can I apply for IELTS?
Candidates can sit the examination in centres all round the world. For information on your nearest IELTS testing centre go to www.ielts.org.uk. IELTS preparation courses run in many colleges and universities across the UK and in other countries. For more information contact your local testing centre (found at most universities and some colleges).
How much does IELTS cost?
IELTS currently costs £73. Payment should accompany the completed application form.
How long does IELTS last, and how often can I do it?
The IELTS test report form is valid for two years. Any doctor who has not obtained registration within this time, or in the case of PLAB test candidates has not passed part 1 of the PLAB test within this time, will need to take the IELTS again. There is no limit on the number of times a person may sit the exam. However, a candidate is not allowed to sit the exam within three months of a previous attempt.
For links to some excellent sites with information on IELTS, practice papers, and tips for IELTS candidates, see www.britishcouncil.gr/english/materials3_ielts.htm.
The PLAB (Professional Linguistics Assessment Board) examination is a difficult examination said to be somewhere between finals and postgraduate examinations in level of difficulty.
What does the PLAB test involve?
There are two parts to the PLAB test:
- Part 1 consists of a three hour extended matching question examination which emphasises clinical management but also includes science as applied to clinical problems.
- Part 2 is an
Objective Structured Clinical Examination (OSCE) with 14 stations.
The aim of the OSCE is to test candidates' clinical and
communication skills in a number of controlled situations.
Requirements for taking the PLAB test
Candidates must have:
- A primary medical qualification acceptable for limited registration (see WHO list http://www.who.int/health-services-delivery/med_schools)
- Taken and obtained an acceptable score in the IELTS. The GMC currently requires a higher IELTS score for doctors who are exempt from the PLAB.
- A valid IELTS report form dated not more
than two years before each attempt.
Although newly qualified doctors can apply for the PLAB, you need to be competent to standard of an SHO to pass (even though you will only be allowed to work as a preregistration house officer), so clinical experience is advisable before applying.
Where can I take the test?
Part 1 of the test can currently be taken in the UK, Egypt, India, Nigeria, Pakistan, Bangladesh, Sri Lanka, and Bulgaria. A list of specific test dates and centres can be obtained from the GMC's website.
Part 2 of the test can only be taken in the UK.
Passing the PLAB test does not guarantee a job, and you need a job to get limited registration with the GMC.
How much will taking the PLAB test cost?
Current fees are £145 for part 1 and £430 for part 2 (but see the website for more up to date information). Refugee doctors living in the UK do not have to pay the fee for Part 1 on their first two attempts, but there is no exemption from part 2. Eligible doctors need to send the GMC a copy of a letter from the Home Office confirming their refugee status.
How many times can I take the PLAB test?
There is no limit on the number of times you can take part 1 of the PLAB test. You may have four attempts at Part 2, which must be within two years of passing Part 1. If you fail the PLAB test on the fourth attempt you must retake the IELTS and Part 1 again.
How do I apply for the test?
You must fulfil all the preconditions and complete and return an application form (which you can down load from www.gmc-uk.org/register/plab.htm) with the appropriate fee.
Exemption from PLAB
If you are a doctor on the Overseas Doctors Training Scheme (ODTS), or are sponsored by the British Council, you will be exempt from PLAB (see below).
|(Credit: LIANE PAYNE)|
|Sponsorship by the Medical Royal Colleges
The Overseas Doctors Training Scheme (ODTS) is a scheme run jointly by the Department of Health and the Medical Royal Collegestherefore it is also referred to as a double-sponsorship scheme. However, some royal colleges no longer operate the double sponsorship scheme and sponsor overseas doctors independently; contact the relevant Royal College for the latest information.
|What are the Medical Royal Colleges?
- These are colleges which represent the main specialties (including general practice) within medicine in the UK. Specialists in a particular area become a member of their particular royal college, which represents their needs
- The colleges conduct postgraduate medical examinations, training,
education, and research in medicine and advise the government, the public, and the medical profession on health and medical matters
- Presidents of the medical royal colleges become members of the Specialist Training Authority of the Medical Royal Colleges, which issues
certificates for completion of specialist training in the UK (CCST) and approves doctors for entry to the specialist register held by the GMC
- There are 18 royal colleges in the United Kingdom, together with the Irish colleges and the Faculty of Dental Surgery; they are represented at the Academy of Medical Royal Colleges (www.aomrc.org.uk)
The scheme allows very competent overseas doctors to be exempt from the PLAB examination, so that they can continue their specialist training in the UK before returning home. The scheme is not designed for overseas doctors to remain in the UK after completing their specialist training.
Requirements for sponsorship vary, so you would need to contact the individual colleges to find out details (go to www.aomrc.org.uk/netscapepages/links/collegelinks.html for the college relevant to you).
However, all colleges will require a score of at least 7.0 in all four bands of the IELTS test, at least two years' experience in the specialty in which they wish to practise, and a primary medical qualification acceptable to the GMC for Limited Registration. However, there are some criteria for excluding applicants from the scheme (see box)
|Applicants to the ODTS will be excluded if they:|
- Have previously failed the PLAB test
- Do not hold Part 1 of the relevant royal college's examination (clarify requirements with appropriate royal college)
- Qualified in or are nationals of an EEA country, or a country with enforceable EC rights
- Are already working in or are
resident in the UK or another member state of the European
|Many of the colleges will not accept applications directly from candidatesonly appropriate sponsors may apply on their behalfbut some do, so check it out (see www.britishcouncil.org/health/nacpme/odts.htm for more information). |
|Fig 2. Overview of a doctor's career path in the UK
|British Council sponsorship and trust fellowships
- The British Council also sponsors overseas doctors, usually with at least three years' experience in their chosen specialty, to come to the UK for part of their postgraduate training, exempting them from the PLAB.
- There are country-specific criteria for sponsorship and there are some management fees involved: £700 plus VAT for first arranging registration and £400 plus VAT for renewal.
- A minority of the doctors who the British Council sponsors hold scholarships. These doctors can be placed in honorary trust fellowship positions.
- The British Council is reluctant to publicise its scheme as it is growing by 30% a year by word of mouth and is already oversubscribed - it says the administrative arrangements will not cope with a vastly increased demand.
- So be aware of the limitations, but to find out more information and get a pack detailing criteria call the National Advice Centre for Postgraduate Medical Education (NACPME) on 01609577218 or go to www.britishcouncil.org/health/nacpme/
|What are clinical attachments and why might you do them?
A clinical attachment is a work placement carried out at a hospital where you are able to shadow a doctor and find out about the work they do and how the hospital works. You will not be paid for a clinical attachment; it is purely for your own benefit. You will normally have a named supervisor who is responsible for you. Clinical attachments normally last between two and four months.
Clinical attachments can be very useful, especially before the second (clinical) part of the PLAB examination. It is probably best to do an attachment after passing the IELTS examination so that you can get the most out of it and get a good reference.
Clinical attachments may help to give you an understanding of how the NHS works and how medicine is practised in the UK. They might also help you to brush up on clinical skills, which may be rusty if you have been out of work for a while, and give you some insight into the knowledge base that is required of UK doctors.
A clinical attachment might also help you overcome cultural differences that you will face in the UK, as well as familiarise you with local accents and peculiar phrases you might not be used to. There may also be diseases and investigations that are common in the UK but you may not be so familiar with.
An attachment may be the only way an overseas doctor can get a reference from a UK consultant, which could prove very helpful when it comes to looking for jobs.
There is no central body which arranges clinical attachments. The best way to find an attachment is to write to individual hospitals, enclosing a CV. Personal contacts can also be useful. The BMA has published guidelines on clinical attachments, which are available on www.bma.org.uk/ap.nsf/Content/Clinical±attachment±guidelines-±introduction (and see article on p s160).
Finding a job (to get Limited Registration)
To recap, in order to get limited registration with the GMC you need to find a job in a supervised NHS training post. Before that, you need to have passed IELTS and PLAB exams (or be exempt from the PLAB).
Most jobs in the NHS are advertised in BMJ careers (go to www.bmjcareers.com). You have to apply to the employer directly and send a CV (see p s165) or an application form (check the job advertisement to see if an application form is required). Employers then form a "short list" of all the applicants and invite these applicants for an interview. You need to be shortlisted and pass the interview to get the job. However, the process of securing a job is fraught with difficulties.
Higher specialist training
The process of obtaining higher training and obtaining registration as a specialist (fig 2) is rather bewildering, even for those of us living in the UK. There are many alternative career paths which do not lead to registration as a specialist but allow you to work at a higher level not in a specialist training programme. Hopefully figure 3 will help make sense of it all.
For specialist registrar training, appointment is by open competition to the relevant deanery. The minimum entry requirements are two years in the SHO grade plus the first part of a postgraduate qualification (for example, part 1 of the MRCOG exam.) Those who are successful in getting a specialist registrar post will get a National Training Number (NTN). Unfortunately the number of NTNs is limited.
|Special note: Catch 22|
To get limited registration with the GMC, you need to have found a job. It is difficult to find a job if you don't already have limited registration.
|Fig 3. Career options after SHO training
Type I specialist registrar training
After entry into type I specialist registrar training, there are annual assessments called RITAs (Record of In-Training Assessment), which you need to receive a satisfactory grade in. After you have completed all of them, this will lead to the award of a Certificate of Completion of Specialist Training (CCST) and entry to the Specialist Register held by the GMC. The Specialist Training Authority (STA), supported by a recommendation from the relevant royal college or faculty, decides whether or not an individual doctor has met the standard required for a specified training programme, to merit the award of a CCST.
Type II specialist registrar training
Overseas doctors can also work as type II specialist registrars on fixed term training (FTT) appointments. Type II training programmes are specifically designed to meet the needs of the individual overseas doctor, but they do not lead to a CCST. Doctors are able to transfer from a type II to a type I post if they are successful in open competition (where they will be awarded a visiting training number, VTN).
The specialist registration process
By law in the UK, doctors must have their names on the GMC's Specialist Register before taking up a fixed term NHS consultant post, but this does not apply to locum NHS consultant posts.
Difficulties in job hunting
- The UK does have a shortage of doctorsbut only in certain parts of the country and in certain specialties. The most popular specialties are the surgical subspecialties, so it may be difficult to get a job in one of these
- In the job market, you will be competing against doctors from the UK and there is strong competition for training posts. It may be wise to check out the job opportunities in the specialty you are interested in before coming to the UK
- Even though passing the PLAB exam means that you are competent to work up to a level of senior house officer, you may have to take a preregistration house officer post if you can't get work as an SHO
- If you receive the results from
your PLAB exam after the traditional times for the
changeover of jobs (August and February) it may be too late
to apply for these posts. You may have a wait of several
months before getting a post. During this time you might
want to keep your skills up to date by restarting your
clinical attachment (although you are not allowed to
prescribe until you have GMC registration).
|Although it is a legal requirement to be on the Specialist Register, it is not a legal requirement to be on the register in the exact specialty in which a doctor may wish to practisethe employer decides if the doctor has the particular skills and expertise required. Being listed on the specialist register does not automatically mean you will be shortlisted for or appointed to a consultant post.
|Specialist Training Authority (STA)|
The STA (along with the Joint Committee for Postgraduate Training General Practice, JCPTGP) currently approves curriculums for specialist training and judges whether individual doctors have reached the standard set for them by satisfactory completion of training. One of the STA's roles is to approve or reject applications for specialist registration from doctors with overseas qualifications.
For overseas doctors, the medical royal colleges act as agents of the STA and undertake an initial assessment of an application, seek references and further documentary evidence, and submit a recommendation to the STA. Once the STA receives the recommendation with the applicant's details from the relevant college or faculty, it will make a decision on each application on whether a Certificate of Completion of Specialist Training (CCST) should be awarded.
It is proposed that the Medical Education Standards Board (MESB) will soon replace the STA (see www.doh. gov.uk/medicaltrainingintheuk/ mesb-consultation/)
Some frequently asked questions
What if I have specialist qualifications awarded outside the UK?
You can apply to the Specialist Training Authority (STA) for entry to the Specialist Register. You will have to convince the STA that your qualification is equivalent to a UK CCST or that you have the level of knowledge and skills required by a consultant in the UK.
How do I apply for specialist registration?
Contact the college or faculty relevant to you; they will provide you with an information pack with details of the criteria for overseas applicants and an application form. If you think you are eligible to apply, send off the application form to the college or faculty, with all the documentation that is requested.
How long does it take to process an application?
Normally about three months, if referees
respond promptly. When the assessment process is complete, the
college or faculty will forward a recommendation with details
of your overseas training and specialist qualifications to the
STA. If your application is successful, the STA will send a
form for you to complete, to apply to the GMC for entry to the
Other work options
All doctors, with or without right of indefinite residence or settled status and irrespective of their training status, are also eligible for locum appointments for training (LAT), which offer opportunities for training similar to the type I training programme, and locum appointments for service (LAS), which are not training appointments.
Non-consultant career grade doctors
The term non-consultant career grade doctor
(NCCG) is an umbrella term for associate specialists, clinical
assistants, hospital practitioners, and staff grade or trust grade
doctors. There is much debate in the UK about the non-consultant
career grade. Some doctors find job satisfaction in these posts,
which have the advantage of extensive clinical contact but avoid the
bureaucracy and the administrative and management responsibilities
that consultants have. However, often NCCGs are appointed by trusts
to fill gaps in services when doctors in training are not available.
There are no rules on safeguards regarding their appointment, no
formal educational opportunities, and little possibility of career
NCCG posts are often filled by overseas doctors who have come to the UK for training but have failed to find training posts or have been unsuccessful in passing examinations.
(SG) was introduced to make up the shortfall of doctors in the "middle grades" following the limitations in the number of Specialist Registrar posts in order to "find a way of providing essential support to consultants in the acute specialities without training doctors for non-existent posts."1
(AS)this is a senior grade usually filled by doctors who have, for one reason or another, chosen not to complete higher medical training or, having completed higher specialist training, have not taken up a consultant appointment. They must have completed 10 years' medical work since registration.
Are unapproved non-training posts invented by trusts to fill service gaps. Often they have no national terms and conditions of service.
Training as a GP
Currently, you need full registration to work or train as a general practitioner in the UK. You can either make up your own training scheme by applying for individual accredited posts or apply for a place on a vocational training scheme (VTS), which will organise these posts for you. VTSs are organised by local directors of postgraduate general practice education. There is no defined order in which posts should be completed.
The training path for a GP in the UK is to:
|Special note: Service Grade|
Some publications you may read use the term Service Gradeit is basically made up. Sometimes it is used as an umbrella term to encompass NCCGs, consultants, and general practitioners; other times it is used to mean the same as a NCCG post.
The training work experience permit
- Work as an SHO for two years in a hospital rotating round hospital specialist posts that have been accredited for GP training. You can do this with Limited Registration with the GMC. The accreditation process is overseen by the Joint Committee on Postgraduate Training for General Practice and the Royal College of General Practitioners.
- Work in an approved general practice partnership under the guidance and instruction of an approved GP trainer. This is called the GP registrar post, and you need Full Registration to enter it.
- During training, doctors undergo an assessment (Summative Assessment) process to test their competency (see www.rcgp.org.uk/rcgp/information/publications/information/rcf0009/Rcf0009c.asp)
- Towards the end of their training many doctors elect to take the Royal College of General Practitioners membership examination: the MRCGP. But this is not a necessary requirement for completion of GP training.
- On completion of the training programme a
doctor is eligible to apply for a Certificate of Prescribed
Experience from the competent authority for GP training. This is
currently the JCPTGP, but its functions are soon to be transferred
to the Postgraduate Medical Education and Training Board (see
www.doh.gov.uk/medicaltrainingintheuk/gptraining.htm for more
An overseas doctor who wishes to enter a GP registrar post must obtain a training work experience (TWES) permit (see www.workpermit.com/uk/twes.htmtalk and www.jcptgp.org.uk/certification/overseas_doctors.asp and contact your local postgraduate deanery for advice).
Holders of TWES permits are normally required to leave the UK at the end of the period for which the permit was granted; however, the Home Office has agreed that those undertaking GP registrar training on TWES permits will not be subject to normal TWES restrictions.
All overseas doctors who are successful in applying to a deanery for a general practice training programme will be funded by the NHS for the GP registrar element of their training programme.
|Once you have finished training as a GP registrar, two options are open to you. You can apply for salaried GP posts, for which you will need a work permit, or you can become a GP principal and apply to remain in the UK through the Highly Skilled Migrant Programme (HSMP) (see www.workpermit.com/uk/highly_skilled_migrant_program.htm and www.workpermit.com).
You can also apply to the HSMP if you are already a fully trained GP in your own country. However, you must obtain a Certificate of Equivalent Experience from the JCPTGP before you can take up a post.
Joanne Constable, email@example.com
Isabel Fish, International department, BMA, London Ifish@bma.org.uk
Claire McKenna, Former BMJ Clegg scholar and third year medical student , Queen's University, Belfast
Thanks to Chris Finlan from the BMA's Junior Doctor's Committee and John Maingay from the BMA's General Practice Committee for their help in checking the factual content of this article.
Guide for doctors new to the UK. London:BMA, 2002. (Available free from the BMA International Department.)
1. Department of Health and Social Security. Hospital medical staffing: achieving a balance. London: DHSS, 1986.
|© BMJ 2002|