FOREIGN doctors received lower pay and reduced benefits compared to their UK counterparts under a controversial scheme in English hospital trusts, an investigation has revealed.
Doctors from outside the UK arrive at NHS trusts as ‘fellows’ under the Academy of Medical Royal Colleges’ medical training initiative (MTI) scheme, spending two-years in the NHS to acquire experience they can later apply when they return to their home countries.
However, a British Medical Journal (BMJ) investigation said such doctors might receive lower compensation than UK-based doctors hired by trusts. Foreign doctors can also be returned to their home country if they get pregnant, the BMJ found.
At certain NHS trusts, fellows are provided with identical compensation and advantages as doctors who are formally employed.
However, the University Hospitals Birmingham NHS Foundation Trust, Dudley Group NHS Foundation Trust and Walsall Healthcare NHS Trust have an exclusive arrangement with the College of Physicians and Surgeons Pakistan (CPSP).
The BMJ found fellows received lower pay and had reduced benefits than trainees employed by these trusts under this agreement.
Critics, including employment lawyers, doctors, and the fellows themselves, condemned the arrangement as “exploitative”.
Since its commencement in 2009, approximately 7,000 participants from countries such as Pakistan, India, Sri Lanka, Egypt, Nigeria, and Saudi Arabia have engaged in the programme led by the Academy of Medical Royal Colleges (AoMRC).
An internal document obtained by the BMJ revealed that fellows save the trust money, as their remuneration is lower than the standard pay for junior doctors’ posts.
Further investigation highlighted that fellows under the CPSP’s agreement received a stipend ranging from £32,400 to £43,200 a year, while the equivalent pay for ST3 doctors employed by the trust ranged from £51,017 to £55,328 a year, excluding additional or enhanced hours, on-call work or pension deductions.
In 2017 the Birmingham trust terminated the contract of a fellow who became pregnant, the BMJ report said.
She described her ordeal, saying, “I informed my department about my pregnancy at around 20 to 24 weeks. They asked me to tell the international team so that, if there was a maternity package, I could get one. The moment I involved the international team, doctors at the trust who ran the scheme arranged for a meeting. I have tried to forget the way it was all dealt with, but I still get flashes of how rude and inconsiderate they were and the remarks they made.
“The international team told me that they would terminate my fellowship and my contract would end on 30 June. My baby was born on 27 of June, only eight weeks before the end of the fellowship.
“The mental stress had an effect on my physical health. So after my baby was born I just let it go. My husband got a job in the UK and could sponsor us on his visa. The whole thing was a traumatic experience, and it shook my trust on so many levels.”
Hassan Bin Ajmal, a fellow at University Hospitals Birmingham NHS Foundation Trust, said he used two weeks of annual leave when his daughter was born because paid parental leave was not available.
The CPSP promised to review and restructure its guidelines after criticisms emerged regarding the harsh conditions imposed on the fellows.
Asad Rahim, a consultant endocrinologist at Birmingham Heartlands Hospital and regional director of the CPSP’s centre in Birmingham responsible for trainees in the UK, said the scheme had benefits. He was quoted as saying, “Since the scheme, the mortality rates for pregnant women in Pakistan have decreased and there’s been an improvement in medical oncology care and paediatric care, which are demonstrable in the data.”
He added that lack of maternity pay needed to be balanced against the greater good the scheme was having in terms of improving healthcare in Pakistan.
Rahim said fellows receive 25 days of yearly leave and an additional 10 days that can be used for unforeseen situations, such as family emergencies. If they take more time off, it could affect their two-year training term. They are advised to return to their home country, pause their training duration, and resume in the UK when feasible.
Depending on specific circumstances, the CPSP might consent to continue paying the fellows their stipend during leave. For instance, there was an instance where a fellow was given their stipend for four months while caring for their ailing father in Pakistan.
The Ceylon College of Physicians informed BMJ that in the past, some trusts collaborated with Sri Lankan trainees as honorary fellows. These trainees received a £2,000 monthly stipend from the Sri Lankan health ministry.
Unfortunately, due to economic challenges in Sri Lanka, this funding was discontinued for new fellows, although existing trainees in the UK continued to receive their stipends.
In the east of England, Sri Lankan trainees are currently paid by the trust, with additional payments formerly provided by the Sri Lankan government for on-call and weekend work.
Meanwhile, the British Association of Physicians of Indian Origin (BAPIO) established its own training programme due to concerns about the misuse of fellows to cover staff shortages in some NHS trusts. The organisation’s aim was to treat international medical graduates as trainees rather than just additional staff.
“I think what we really wanted to create is a system whereby all these international medical graduates are treated as trainees rather than as pairs of hands,” said Parag Singhal, executive director of BAPIO Training Academy, an organisation in the UK that recruits Indian doctors on behalf of trusts and manages their training.
A representative from the Academy of Medical Royal Colleges expressed concern about the issues highlighted by BMJ. They emphasised the importance of all doctors receiving fair compensation for their work, whether they are part of the MTI scheme or not. However, they noted that this matter pertains to the doctor’s agreement with the NHS trusts that employ them.
University Hospitals Birmingham NHS Foundation Trust told the BMJ: “Undoubtedly the programme benefits the NHS system, but in return it benefits the overseas healthcare structure. Programmes which encourage the upskilling of medical practitioners from countries with less developed healthcare systems have been described by the [World Health Organization] as a ‘brain gain and not a brain drain.’”
A spokesperson for the Academy of Medical Royal Colleges told the report: “The issues The BMJ is raising here are very concerning. All doctors should be paid the correct rate for their work, regardless of whether they are on the MTI scheme or not. But this is a matter between the doctor and the NHS organisation that employs them.”
CEO of the Dudley Group NHS Foundation Trust, Diane Wake, was quoted as saying, “As we do not directly employ staff who are a part of the medical trainee scheme, we are therefore not responsible for their remuneration. Our trust has not received any concerns from our MTI colleagues.”
Viram Jasani 
