Overseas doctors are often unloved, weary workhorses, but it does not need to be that way

My second last conversation at NHSI was with two young bright-eyed managers, who had never worked in a provider and were investigating how to expand the Trust grade (staff grade) work force.

Trust grade doctors come at a lower cost, typically work nine sessions on direct care, and are lucky to get one session for appraisal and development. They are more efficient and productive than a consultant is the calculation.

They also have no voice and are moved from pillar to post at zero notice. They are almost all international medical graduates, forming a large proportion of the ethnic minority medical workforce in the NHS. They came to me complaining bitterly, some in tears, about how they were treated personally and professionally.

This workforce is about to grow rapidly.

Pulling on the cord

India has a million doctors and at any one time 15 per cent are actively seeking to work in high income English speaking nations.

Chelsea and Westminster recently took a team to India hoping to scoop out at least 40 doctors to land them into hard to fill locum and gap filled specialities. Recruitment agencies are vying to be the biggest providers from India. The doctors will come once they jump the PLAB, ILETS/OET, Border police, VISA, health tax, GMC hoops.

The NHS did this at scale, albeit with almost no bureaucracy, in the 1960s and 70s. Some stuck to their preferred specialities, too often trapped in staff grade roles. Many reluctantly moved into unloved specialities; psychiatry, general practice, geriatrics and emergency medicine. Not much has changed since the 1960s. Professor Aneez Esmail’s paper is a seminal description of that history, and much more.

Home truths

Once they come they will hear from their longer serving, work weary, largely unloved, trust graders that they are work horses. They will learn that the CEO promises of good quality induction, mentoring, time to do the work, and support to settle were built on sand because investment in people, targeted OD programmes and time isn’t done or done well.

As the new influx get used to being let down, they will learn that there is a more lucrative work available as a locum.

Trusts are generally poor at on-boarding and imbedding. Mission, vision and value statements with branded mugs, and pens isn’t it. The mindset is a problem – we need you working, now, because patients are queuing, targets are bust, and the local politician is writing on the behalf of angry constituents.

On-boarding and imbedding matters for all staff, but even more so for those coming with many misconceptions, who are untrained in the nuances of communication, and will have to deal with unexpected patient expectations without the pedestals they enjoyed at home.

A strategy

To all CEOs drawing on the ex-colonial workforce cord, here is the very least you need to be doing:

1. Honesty

• Be honest about the many challenges – workforce, culture, communication… before and after they leave their homes, families and sign on the bottom line.

 2. Language

• Invest in English language diagnostics and courses – reading, writing, role play and diction, before and after they land. The IELTS/OET tell you something but not everything. Communication failure is your biggest cause of poor patient experience and litigation.

3. Induction

• A month-long induction programme. You want a confident safe start.

4. Development

• Medical professionalism programmes that are ideally a forever offer in your building – face to face, online, and mandatory for all your medical staff.
• Professional mentoring, not based on colour or presumed ethnic matching.
• Rotate them through the ivory towers – they deserve to know the difference, build networks, and understand their real potential
• Ensure the GMC runs a programme in your building for these folk. From landing, and in a constant loop.
• Ring fence study leave time and money for the first five years to ensure they get the time and resources to develop and remain safe.
• Use appraisers trained to engage and develop this workforce, not just tick a few boxes
• Support them through the torture of getting on to specialist registers

 5. Professional organisations

• Encourage joining the BMA. They need good advice independent of myths and scare stories that perpetuate the ghettoisation of IMGs.
• Encourage College and speciality body membership and engagement – mix with your professional colleagues not because of where you are from, but because of your profession and professionalism. If you must join an ethnically defined group, be mindful of group think –  professionally, you are a doctor first.
• Crown indemnity does not provide legal advice specifically to the doctor in the event of litigation. Encourage joining the defence unions to secure the right cover – it is their insurance. Or get corporate cover for them.

6. Settling

• Service leads must have frequent 1-1 meetings to enable timely resolution of issues from misunderstandings through to enabling settling, building a sense of a future.
• Provide subsidised good quality local rental accommodation
• Engage independent financial advisors, ideally from the BMA, to support nesting.
• Provide access to trusted organisations for support outside the work environment.
• Support social activities, from breaking bread to the stereotypical cricket matches.
• Secure their feedback, frequently, formally. Meet them as a group. Give them a voice. Listen to them. If this is a new experience for you, might you be spending too much time on Twitter reaching folk who are already with you?

7. Anchoring

Establish an education contract. Five years. Deliver all that you promise, and the return is committed service linked to development. If the grass is greener elsewhere, they owe you back all that was invested, from recruitment costs through to the development time.

If the CEOs do this, overseas doctors will come, stay and contribute. Costs will go down. “Team” will be a meaningful word. Don’t deliver this and we will be back where we started in the 1960s, and history will have taught us nothing.