Overseas doctors can face a bleak future after PLAB
Hundreds of doctors from the Indian sub-continent are struggling to get jobs, months after passing the Professional and Linguistic Assessments Board (PLAB) test.
While the NHS craves manpower, many of these doctors are living in cramped and squalid conditions. Some face the prospect of returning home broke, having spent a great deal of money to come to the UK to take the test and live here while they apply for clinical attachments and jobs.
More worryingly, many find themselves in breach of visa conditions and take jobs in petrol stations and fast food restaurants to make ends meet.
Increasing numbers of doctors are coming to the UK from India under the impression that training opportunities are plentiful.
Dr Ramesh Mehta, consultant paediatrician and president of the British Association of Physicians of Indian Origin (BAPIO), explains: 'A few years ago the Government launched a campaign all over the world to recruit senior doctors. People thought there was a big demand for doctors and didn't realise it was for senior, and not junior doctors.'
While the campaign, launched in 2001, resulted in the recruitment of 87 consultants plus another 222 through a separate international fellowship scheme, there has been a deluge of junior doctors from the Indian sub-continent. However, there are not enough training posts for them.
The PLAB exam, which is compulsory for overseas doctors who want to work in the UK, is in two parts. The first can be taken abroad, while the second has to be taken in the UK. GMC figures on the numbers sitting PLAB 2 show a jump from 1,349 in 2000 to 6,755 in 2003.
Dr Umesh Prabhu, a consultant paediatrician and overseas doctors' mentor at Fairfield General Hospital, Bury, says: 'More people are taking the exam because they have read that the UK is short of doctors. It will get worse because 9,000 are expected to come over from India next year.'
This is close to treble the 3,500 people who graduated from medical schools in England in 2002-03. Dr Mehta says there are 300 to 800 applications for every one training post.
More junior doctors may be needed to cope with the Working Time Directive, but trusts often employ doctors in 'trust posts' rather than training posts. It is therefore difficult to get accurate data on SHO vacancies.
While the Department of Health (DoH) recognises that 'the number of doctors taking PLAB exceeds the number of SHO posts that are immediately available', it does not believe there is a problem.
A spokesman says: 'There is considerable mobility and turnover in the SHO grade. Several thousand move on to posts as SpRs or GP vocational trainees each year and around a third of overseas qualified SHOs leave the NHS.'
Taking into account those who fail PLAB 2, 'the figures are not vastly higher than recruitment figures in recent years,' he adds.
However, PLAB doctors believe there is a problem because many of them spend the equivalent of three years' wages in India to wait for a job which sometimes does not materialise before they have to return home in debt.
They argue that no information is made available on the difficulty of obtaining a job other than the fact that the PLAB test does not guarantee a post. They want to see figures on how many jobs there are and the average time a PLAB doctor takes to get a job.
Eighty per cent of respondents in a BAPIO survey of 50 post-PLAB doctors felt they were poorly informed before coming to the UK and almost all felt that job opportunities were 'bad' or 'hopeless'.
Dr Ayush Khurana, a PLAB doctor working as a locum at Bedford Hospital, says: 'It's a vicious circle. Doctors can't afford to live here without working. People start borrowing and then they don't feel like going back home because they wouldn't be able to pay it back.
'There was hardly any information on the GMC and DoH websites. If there was objective information, doctors would be able to make an informed decision.'
The DoH acknowledges the campaign to recruit consultants 'could have resulted in some increase in the number of doctors taking PLAB', but says it is up to doctors 'to ensure they research the likelihood of securing a post'.
A spokesman says: 'There is already a great deal of information available to doctors on how to obtain their first post in the NHS, including information about the strong competition for these posts.'
He adds that both the DoH and GMC websites link to the National Advice Centre for Postgraduate Medical Education, which provides advice to doctors looking for their first post in the NHS.
But PLAB doctors do not understand why the GMC is conducting so many PLAB tests if it doesn't need doctors.
Dr A, who asked not to be named, says: 'People do the PLAB test because they want to work here. It's not like a degree. If they don't want doctors, why don't they stop it? I feel exploited by the PLAB system and depressed because all this time I've been out of touch with medicine.'
He says in the UK he is at a disadvantage to local graduates, but if he had to go home, he would be at a disadvantage to his peers. 'It will take me a year or more to get into my career and two or three years to pay off my loans.'
Dr A is working in a wine shop for £3 per hour - the national minimum wage is £4.50 - because he doesn't want to take more than the £5,000 he has already borrowed from family and friends.
The GMC argues that its role is to maintain standards and ensure doctors wishing to practise in the UK are competent, not to make decisions about how many people take the test. This year the GMC launched a dedicated PLAB assessment centre to accommodate 10,000 candidates a year.
Dr Prabhu says: 'Young doctors are having their dreams shattered. I know three who have gone home after trying for a year to get work and two on clinical attachments who passed PLAB last September and have each applied for 600 jobs and not been shortlisted for one.'
On top of the costs of flying to the UK and of living, doctors will usually pay for a course to prepare them for PLAB 2. They also have the cost of the test at £430 (although the GMC doesn't profit from this), visa extensions and hundreds of applications, with all the photocopying and postage that entails. They often also have to pay to do a clinical attachment.
The BAPIO survey found most had already spent over £4,000. Nearly 40 per cent took between two to four months to get a clinical attachment, through which they hope to gain experience and contacts in the NHS. The usual route after this is to do locum work before hopefully securing a post.
Dr B, who also asked not to be named, has been here for a year, completed four clinical attachments and been shortlisted for jobs three times without success.
She has spent £12,000 since arriving in the UK and written 2,000 job applications. In four months' time, her visa will run out. 'I had friends here who said you have to wait two or three months and write 300 to 400 job applications before you get a job, so I expected that. But if I knew I'd have to wait a year, I wouldn't have come.'
Dr B says she has lost four offers of locum work in the past two months because she has not been able to get registered with the GMC in time. It takes the GMC five days to register a doctor once it has received a letter of employment from the trust, but hospitals generally need someone immediately.
The GMC has now announced a change in its registration policy. From April 2005, overseas doctors will be granted full registration with a licence. There will also no longer be a requirement for a doctor to secure an offer of employment before registration is granted. Although such a move is welcomed, critics believe the move is 'a drop in the ocean'.
PLAB doctors are on a six-month visitor visa, which can be extended twice at £150 a time. It doesn't allow them to work, but they can do clinical attachments.
For trust posts, they have to apply for a work permit. Only once they've been offered a training post can they apply for permit-free status.
'Some are broke and have no choice,' says Dr Mehta. 'People are having to work in petrol stations or corner shops. Is it fair, that at a time when the NHS is starved of doctors, these people are suffering? Shouldn't we be looking after them?'
Amanda Watson, director of registration and education at the GMC, tells Hospital Doctor that the vast majority of PLAB doctors secure jobs. Figures show 90 per cent of those who took PLAB in 2002 had obtained limited registration by 2003.
However, she admits data has not been kept on the quality of jobs and it is unknown how many had obtained training posts rather than locum work or trust jobs.
To rectify this, the GMC has conducted a survey of doctors who passed PLAB in May 2003 and is collating responses to see what their experience has been.
The situation may appear worse than it is, says Ms Watson, because PLAB doctors are writing hundreds of unsolicited applications, which could give the impression that there are hundreds of doctors without jobs. She suggests that as there is only one NHS, there is merit in a 'centralised job recruitment vehicle'.
Dr Mehta would like the DoH to set up a central clearing house so PLAB doctors only have to fill out one web-based form and have access to information on job availability.
He says the relevant parties should agree how many jobs are available and number of people applying and provide that information to overseas doctors. He argues that as it is a Government priority to attract overseas doctors, those coming to the UK should get a one-year visa to give them an opportunity to find a decent job.
Postgraduate dean and vice-chairman of the Conference of Postgraduate Medical Deans Dr David Graham says there is a move to better organise clinical attachments. His deanery in Merseyside is 'trying to find leads in trusts willing to take on clinical attachments'.
Certificate of UK Induction courses have also been running for a couple of years for overseas doctors who obtain a post. The deans are trying to facilitate training for overseas doctors but 'it must remain an open competition for training posts,' Dr Graham says.
While training posts are expected to be created as the number of UK graduates increase, there are not enough to accommodate the increasing numbers of overseas doctors. But if they wait long enough, they may get a trust post. That may suit the NHS, but is it fair to overseas doctors?
case study 1
'Let down by lack of information'
Dr Amish Jain came to the UK from India in January and lived in a cockroach-ridden house in East Ham until he passed the PLAB exam in February. He is on clinical attachment in Rochdale, but despite 90 applications, has yet to find a job.
He held an SHO equivalent post in India and had the option to start a paediatric rota but thought there would be better opportunities in the UK.
'I thought there was a better structure for training here and I would be a better doctor,' he says, adding that he feels 'let down' at not being given an accurate picture of the job situation.
'If they don't require doctors, why do they do the exam so often? I know the GMC has no legal responsibility to limit people taking PLAB but it has a moral responsibility to guide us. They should give us the right information so we know it's difficult to get a job.'
He also suggests that the visa requirements are changed to allow PLAB doctors to work so they can fund themselves while waiting for a medical post.
Dr Jain came to the UK with £3,000, but with only £300 left, he faces returning home. 'It's terrible. I apply for everything advertised. I look at the post every day and live in hope. So far I've not been lucky. If I can't get a job in the next two months, I'll have to go back. People are going home with bitter feelings because it's such a waste of time and money.'
case study 2
'Accommodation was sub-human'
When Dr Ayush Khurana arrived in East Ham to do his pre-PLAB course last September he found himself living in 'sub-human' accommodation.
'There were 11 people in a three-bedroomed house. In my room there was a single bed and a bunk bed. There was no shower, just a bath and a bucket and no washing machine. And water from the bathroom leaked into the kitchen.
'There were rats in the house and one time I put something in the microwave and heard popping sounds. I opened it and realised that there were cockroaches in there.'
He has managed to get some locum jobs, but still hasn't found a training post. He tried to research the job situation before coming to the UK but to no avail. 'I tried the DoH and GMC websites but there was no information on the number of jobs available or average waiting times.'
He is urging more co-ordination between the NHS, GMC and DoH to provide such information. 'This is a developed country where information should be a basic right. Why is it not there? I would have been able to make an informed decision.'
Since passing PLAB, he has applied for 550 jobs, and was only shortlisted at one, Bedford Hospital, where he did a clinical attachment.
He is better off than many colleagues in that he has relatives in the UK who put a roof over his head and lent him money.
Now, he says, he would take a trust post on the basis that 'something is better than nothing'.
Author: Hospital Doctor Reporters

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Best wishes
Dr Philip Hardo

يبدو إني بدي أغير رأيي في بريطانيا
شو دكتور فيليب؟
أنا بدي اختصاص ما ممكن أحصله في أمريكا
وبدي أكمل الدراسات العليا في بريطانيا ... بإذن الله ...

بس هيك الوضع مخيف كتير ... شو بتنصحني؟

Dear Friend
Nothing is impossible in life but UK is becoming more and more difficult for Non-European doctors. Simply they do not want them for cultural reason!!! You may call it polite racism.
I do not wish to be depressive but only wish to give you and all medical students the real picture about UK to avoid any disappointment. This is important because I can see from the survey many of you wants to come here. Ahalan Wa Sahalan but not many will be successful.
My advice is therefore, if you can find another place for Postgraduate training go for it first.
Other options for you for the UK is to 9-12 Diploma degree in Radiology, Cardiology, Respiratory medicine, Neurology…. with an average cost of 10,000 ponds.
I hope this is helpful
Best wishes
Dr Philip Hardo