Challenges of Brexit for a medical fellowship in the United Kingdom

Background

On the 31st of January 2020, the United Kingdom (UK) officially withdrew from the European Union (EU), an event commonly referred to as “Brexit”, from the blend of the terms British and exit. During the 47 years of British membership, the EU and its predecessor, the European Communities, grew to be of significant social, financial, and political importance to the UK. Consequently, Brexit is expected to have a strong impact both inside and outside the UK. Although some of the effects of Brexit have already been noted, many others remain largely unknown, since the UK is the first and only member state to have ever left the EU. Naturally, the National Health Service (NHS) and its employees are not immune to Brexit. Herein, we outline the process required to be followed by international medical graduates who wish to work in the NHS, and we briefly discuss observed and potential consequences of Brexit on recruitment and retainment of medical staff.

Fellowship in the UK

After the end of the Brexit transition period on the 31st of December 2020, the registration process of the General Medical Council (GMC), which represents the independent regulator for doctors in the UK, has changed for some doctors with non-UK qualifications. Nationals from the European Economic Area (EEA), consisting of the member states of the EU, Iceland, Liechtenstein, and Norway, no longer benefit from automatic recognition of professional qualifications. Holders of an EEA or Swiss primary medical qualification applying for provisional or full registration in the UK must demonstrate a relevant European qualification that is independently verified by the Educational Commission for Foreign Medical Graduates, provide evidence of their knowledge of English, and ensure that their insurance and indemnity offers sufficient cover to practise in the UK. Adequate knowledge of English can be shown by achieving a minimum score in the academic version of the International English Language Testing System or the medical version of the Occupational English Test. Holders of a primary medical qualification from outside the UK, EEA, or Switzerland who wish to apply for registration with the GMC must additionally demonstrate their medical knowledge and skills, which is usually done through the Professional and Linguistic Assessments Board test. Alternatively, they may be eligible to apply for registration if they hold an acceptable postgraduate qualification or are sponsored by an approved UK sponsor. Finally, Swiss applicants can still apply for registration as they did previously, for at least the next three years, under the Citizens’ Rights Agreement. For a more thorough and up-to-date description of the requirements to join the medical register in the UK, we refer the reader to the relevant webpage of the GMC’s website (https://www.gmc-uk.org/registration-and-licensing/join-the-register).

After registering with the GMC, a doctor may apply for a fellowship within the UK that matches his or her skills. A source of vacancies commonly used is the NHS Jobs website (https://www.jobs.nhs.uk). Successful candidates will subsequently have to apply under the UK Visas and Immigration, which is part of the Home Office and responsible for making decisions about who has the right to stay in the UK. This applies to non-EEA nationals, as well as EEA nationals who did not obtain settled status under the EU Settlement Scheme, the deadline of which was the 30^th of June 2021. The UK immigration system is rather complex, with immigration and visa rules changing frequently. Currently, the main route by which international doctors can live in the UK is under the visa regulations for highly skilled workers. In particular, for a qualified doctor to be eligible for a Health and Care Worker visa, she or he must work in an eligible healthcare job from a UK employer that has been approved by the Home Office, have a certificate of sponsorship from the aforementioned employer, and receive a minimum salary. It is worth noting that although doctors are exempt from the immigration health surcharge, their dependent family members are required to pay for it as part of the immigration application. Table 1 summarises key steps of the process for fellowship training in the UK that are needed to be followed by overseas-qualified medical practitioners.

Challenges of Brexit

It becomes apparent that the legal barriers affecting the eligibility of European doctors to work in the NHS have increased. The UK government has committed to recognising medical qualifications that were gained in the EEA for the next two years. However, when medical qualifications from the EEA cease to be automatically valid in the UK, EEA nationals may be discouraged from migrating to or remaining in the UK. A recent example can be found in a reduction of 37% in the number of Indian doctors working in the UK from 2009 to 2016 due to legal restrictions on the hiring of healthcare professionals (1). Furthermore, the poor national economic performance anticipated after Brexit and the associated ramifications on the healthcare system, including staff and resource shortages, may render the NHS a less attractive destination for foreign doctors (2). Moreover, experiences of ethnic discrimination may negatively affect retainment of NHS staff (3). Indeed, in a recent qualitative analysis of comments provided by 52 UK-based European doctors on their views of Brexit, 20 (38.5%) no longer felt welcome in the UK, while 7 (13.5%) explicitly described Brexit as indicative of racist ideology (4). All these legal, social, and cultural constraints may act additively in deterring doctors from working in the NHS.

The strong tradition in research that characterises the NHS is also threatened by Brexit (5). This could be partially attributed to the loss of EU funding and limitations in the collaboration between UK researchers with their EU counterparts (6). An example comes from Switzerland, where measures to decrease immigration from the EU resulted in a 40% reduction in research involvement (7). In addition, the impact of UK medical research may be lessened, since international collaborative research has much greater impact than domestic research (8). A reduction in the role of research as part of the job description for doctors may further decrease the number of those who want to work in the NHS.

Brexit has been largely opposed by doctors, including the British Medical Association, which constitutes the trade union and professional body for doctors in the UK (9). Indicatively, a survey-based, cross-sectional study of 1,172 doctors found that 79.4% of respondents voted to remain in the EU in the 2016 referendum compared with 48.1% of voters as a whole (P<0.001), while the median score for the impact of Brexit on the NHS on a scale of 0 (worst) to 10 (best) was 2 (interquartile range, 1–4) (10). There is already some evidence suggesting that European doctors are leaving the UK because of Brexit and its consequences, including work pressure and understaffing (4). In a survey conducted in 2019, 63% of higher specialist doctors and 40% of consultants reported daily or weekly gaps in hospital medical cover (11). Such rota gaps denote insufficient number of senior medical staff to ensure the quality and safety of training of junior doctors, who may be withdrawn from hospitals as a result, thereby further worsening these gaps (12). Importantly, challenges in staff recruitment and retainment may exacerbate existing problems of increased workload and associated stress, which in turn can have a detrimental effect on doctors’ well-being (13).

Future perspectives

The UK medical system must act as a whole to overcome the obstacles and uncertainty brought on by Brexit. Initially, health policy makers must provide legal and financial support to international doctors who wish to work in the UK. The introduction of the Health and Care Worker visa and waiving the immigration health surcharge for NHS workers are certainly steps in the right direction, but many more will be needed. For instance, to facilitate recruitment of European doctors, medical qualifications from the EEA should continue to be automatically valid in the UK. However, acquisition of information about fitness to practise may be discontinued due to the loss of access to the EU’s Internal Market Information system (5); hence, increased awareness regarding fitness to practise will be crucial for successful recruitment (14). Furthermore, the UK should preserve the quality of NHS employment and guarantee current labour law protections, including working time legislation. Lifting the European Working Time Directive, which limits the maximum amount of time that employees in any sector can work to 48 hours per week, may negatively impact doctors, and thus pose risks to patients (3). Moreover, the prospects of research for doctors must remain at high level. This will require not only continued participation by UK research entities in EU programmes but also the necessary regulation of clinical trials to maintain collaborative research activity between the EU and UK. Finally, health providers must address the fears of foreign doctors for discrimination and ethnic intolerance. This could be achieved by ensuring equal opportunities for career progression, by promoting inclusivity, and by eliminating feelings of uncertainty. Such and many other measures are imperative not only to continue making the NHS an attractive destination for doctors, but also to ensure patient safety and maintain high standards of care.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editors (Francesco Guerrera and Anna Elisabeth Frick) for the series “Training and Education in Thoracic Surgery: the European Perspective” published in AME Surgical Journal. The article has undergone external peer review.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://asj.amegroups.com/article/view/10.21037/asj-22-3/coif). The series “Training and Education in Thoracic Surgery: the European Perspective” was commissioned by the editorial office without any funding or sponsorship. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Baker C. NHS staff from overseas: statistics. House of Commons Library Briefing paper Number 7783;2016.
2. Holmes J. Brexit and what does it mean for the health and care system [Internet]. The King’s Fund 2021 [cited 2021 Jan 1]. Available online: https://www.kingsfund.org.uk/publications/articles/brexit-end-of-transition-period-impact-health-care-system
3. Costa-Font J. The National Health Service at a critical moment: when Brexit means hectic. J Soc Policy 2017;46:783-95. [Crossref] [PubMed]
4. Milner A, Nielsen R, Norris E. Brexit and European doctors’ decisions to leave the United Kingdom: a qualitative analysis of free-text questionnaire comments. BMC Health Serv Res 2021;21:188. [Crossref] [PubMed]
5. van Schalkwyk MCI, Hervey TK, McCarey M, et al. How will Brexit affect the healthcare workforce? BMJ 2020;371:m4439. [Crossref] [PubMed]
6. Fahy N, Hervey T, Greer S, et al. How will Brexit affect health services in the UK? An updated evaluation. Lancet 2019;393:949-58. [Crossref] [PubMed]
7. McKee M, Galsworthy MJ. Brexit: a confused concept that threatens public health. J Public Health (Oxf) 2016;38:3-5. [Crossref] [PubMed]
8. Adams J. Collaborations: The fourth age of research. Nature 2013;497:557-60. [Crossref] [PubMed]
9. Kmietowicz Z. BMA votes to oppose Brexit “as a whole” and calls for public final say on deal. BMJ 2018;361:k2821.
10. Mandeville KL, Satherley RM, Hall JA, et al. Political views of doctors in the UK: a cross-sectional study. J Epidemiol Community Health 2018;72:880-7. [Crossref] [PubMed]
11. Trudgill N. Focus on physicians: Census of consultant physicians and higher specialty trainees 2018. London, 2019.
12. Rolewicz L, Palmer B. The NHS workforce in numbers - Facts on staffing and staff shortages in England [Internet]. Nuffield Trust. 2021 [cited 2022 Jan 2]. Available online: https://www.nuffieldtrust.org.uk/public/resource/the-nhs-workforce-in-numbers
13. Moss PJ, Lambert TW, Goldacre MJ, et al. Reasons for considering leaving UK medicine: questionnaire study of junior doctors' comments. BMJ 2004;329:1263.
14. Fahy N, Hervey T, Dayan M, et al. Assessing the potential impact on health of the UK's future relationship agreement with the EU: analysis of the negotiating positions. Health Econ Policy Law 2021;16:290-307. [Crossref] [PubMed]