Chapter 10 – Support for international medical graduates coming to the UK
By: Dr Kirstin May
Help to settle into the NHS
Even if you are an experienced doctor, it can be difficult to settle into a new healthcare system. As soon as you have your General Medical Council (GMC) registration, we suggest you book into one of their free workshops for doctors new to the NHS Welcome to UK practice – GMC (gmc-uk.org), which is ideal for doctors within their first 12 months of NHS practice. Attendance is optional but many doctors have found this very helpful in the past. The workshop can be attended online or in person. It will give you guidance, a chance to connect with other international doctors and explore ethical issues and how we deal with them in the UK. You will need a GMC account to register. The Royal College of Anaesthetists (RCoA) is also offering introductory days incorporating the GMC workshop; please look out for them on the events pages of the RCoA.
Once you have a work email address, we also recommend you register for an account with NHS England’s e-learning for Health Home – elearning for healthcare (e-lfh.org.uk). Here you will find a wealth of free educational resources, including many specifically for anaesthetists. There is a valuable programme with induction resources for international doctors NHS Induction Programme for International Medical Graduates – NHS England elearning for healthcare (e-lfh.org.uk). Many areas that new staff struggle with are covered here.
Your workplace should help you by offering you an induction to understand the place, procedures, working practices, staffing structures and local processes. You will also need to be taught how to use written paper and electronic patient records correctly. Ideally, you should be integrated into induction arrangements made for other doctors who commonly rotate into new jobs in August and February each year. You should also be offered a clinical supervisor or mentor, and maybe a buddy who might be able to support you with non-work-related issues. Recommendations on what should be included in your induction can be found at Welcoming-and-Valuing-International-Medical-Graduates-A-guide-to-induction-for-IMGs-WEB.pdf (e-lfh.org.uk). A good introduction to UK practice will not only make your life easier but also your professional practice safer.
Common difficulties: consent, confidentiality, record keeping, duty of candour
International doctors often experience difficulties of a non-technical nature for which they were not prepared before their arrival. The professional standards for the interaction between doctors and patients, relatives and the public are outlined by the GMC: https://www.gmc-uk.org/ethical-guidance. The GMC website covers not only the skills and knowledge required by doctors but also the values and behaviours required from medical professionals. It contains educational resources, flowcharts and decision tools to inform and guide what is expected from you in the UK. If you have any doubts how these standards should be applied to a particular situation in the workplace, it is wise to seek advice from your seniors. Commonly difficulties are encountered in the following areas:
A) Confidentiality
The patient’s right for their personal and medical information to be kept private is an important principle in the UK. It is a doctor’s legal and ethical duty to protect patients’ personal information and medical details. Unlike in many other countries, this includes information that may be given to close family and next of kin, but also what can be shared with other healthcare providers. It is important to familiarise yourself with the rules of confidentiality, but also with when, how and to whom information can and should be disclosed.
B) Consent
Doctors in the UK are expected to give patients the information they need to make informed decisions about their healthcare, as well as the time and support to understand the information. Patient autonomy is a very important principle in the UK. The provision of information and the support given by the professional should be tailored to the individual patient. Treatment options and alternatives, potentially including non-treatment, should be explained. This is often described as shared decision-making.
Unlike in many other healthcare systems, relatives in most circumstances cannot agree or refuse treatment on behalf of a patient who lacks capacity. This is a complex legal area within healthcare and you are likely to require support from more experienced colleagues to navigate this correctly. For such situations, there is a legal framework called the ‘Mental Capacity Act 2005.’ You should learn about this in the guidance from the GMC, during your induction, through your statutory and mandatory training via your employer and from your colleagues.
C) Duty of candour
It is an important requirement in the UK for a healthcare professional to be open and honest with patients (or, where appropriate, their advocate, carer or family) when something has gone wrong. You must also be open and honest with colleagues, employers and regulators. This includes reporting incidents and ‘near misses’ and taking part in investigations. Employers have systems through which untoward incidents should be reported, and you should be introduced to these during your induction. You may wish to enlist a colleague for help if you have to report an incident for the first time. Incidents are also often shared and discussed in departmental meetings, to share learning and avoid future repeats, rather than to apportion blame. Your duty of candour includes a duty to raise concerns where appropriate and not stop others from doing so.
D) Technical aspects of working
You may come across many pieces of anaesthetic equipment that are unfamiliar to you. Please do not be afraid to ask questions and please insist on being properly familiarised with your professional tools. Prescribing rules can also be very different and this includes how medicines are administered, by whom and how administration is recorded. Some drugs, notably opiates, but also ketamine and some benzodiazepines, are subject to secure storage and recording rules.
When and how to ask for help
It is not only acceptable but considered important to ask for help from your seniors when you feel unsure or out of your depth about a patient and their treatment. The GMC ‘Good Medical Practice’ guidance states that you must recognise the limits of your competence and ask for help when necessary. If you are asked to work outside your competence you must raise your concern. You should never be ‘too proud’ or embarrassed to ask for a second opinion or help. This includes asking a senior to come into the workplace from home when on call out of hours.
If you ask for assistance, it is useful to state clearly what you are looking for, particularly if waking someone from sleep: do you feel you just need to inform a senior about a given situation, are you seeking advice or are you requesting their presence for in-person assistance?
Medical students and doctors in training in the UK are taught to assess patients in formal and systematic ways. This can include how they as doctors communicate with colleagues and seniors in the most efficient way. There are different techniques for such systematic communication and your employer may have preferred ones they wish you to learn and use.
Example SBAR: SBAR stands for situation, background, assessment and recommendation. You may receive handovers from other staff in this format or give information and requests for help following this to your seniors. https://www.england.nhs.uk/improvement-hub/wp-content/uploads/sites/44/2017/11/SBAR-Implementation-and-Training-Guide.pdf
Situation: what is happening?
Background: what are the circumstances, or maybe the past medical history, leading to this situation?
Assessment: what is your assessment of the patient? Ideally this should also be systematic, for example following an A (airway), B (breathing), C, D, E model.
Recommendation: what is your recommendation to improve the situation? This may include the request for in-person assistance.
Protecting yourself and your family
A) Indemnity
NHS bodies and organisations are financially responsible for the clinical negligence of their employees. Your professional practice in the NHS comes with indemnity provision details of which can be found here: https://resolution.nhs.uk/wp-content/uploads/2018/10/NHS-Indemnity.pdf
Medical students and doctors in the UK usually take out their own professional indemnity insurance in addition to this to cover private work, non-clinical negligence, unpaid medical volunteering outside the NHS, etc. Your own personal indemnity cover also gives access to medico-legal support should you receive a complaint, advice should you have to appear in court or at an inquest, and support in the event of an investigation by the regulator. Insurance, indemnity and medico-legal support - information for doctors on the register – GMC (gmc-uk.org). The cost for this is tax deductible and varies between specialties and grades of doctors. The main providers are the Medical Defence Union (MDU), https://www.themdu.com), Medical Protection Society (MPS), https://www.medicalprotection.org and Medical and Dental Defence Union of Scotland (MDDUS), www.mddus.com).
Should you be unlucky enough for a patient to complain about you or the treatment you have offered or given, please seek help from seniors in answering to this. There are rules requiring Trusts to respond to complaints within defined and quite short timescales, so you may have to answer very quickly, so do not put this off.
B) Healthcare
You and your family should register with a family doctor (GP ‘general practitioner’) as the GMC strongly discourages you to provide medical care for yourself or members of your family. (https://www.nhs.uk/nhs-services/gps/how-to-register-with-a-gp-surgery/). You are also not allowed to prescribe or send medicines for friends and family back home, whom you may have treated in the past. As GP practices usually have catchment areas you would usually choose one local to where you live. You should register as early as possible, do not wait until you are ill. The rules around free healthcare provision are complex and may change: https://www.gov.uk/guidance/nhs-entitlements-migrant-health-guide. If you are entitled to NHS treatment it is mostly free at the point of use. This includes hospital visits, family doctor consultations and preventative care, but in most circumstances, there is a fee for prescriptions. There are also costs associated with NHS Dental care.
In the case of minor ailments, some medicines are available in supermarkets and pharmacies over the counter. Some other medicines can be accessed via prescriptions at pharmacists.
Help if you are in difficulty
If you are experiencing personal or professional difficulties, which may affect your work, please do not hesitate to seek help. Your educational supervisor/mentor or line manager may be your first port of call. If you are looking for support from the outside, there are a number of other options. View the wellbeing pages on the Association website.
Every NHS Trust has access to an occupational health department, which keeps people well at work: physically and mentally. If you have a health problem that caused you to be absent from work or may affect how you are able to work, you may be referred for an occupational health assessment. Some occupational health departments also accept self-referrals (Occupational health – NHS Employers).
There are over 1000 ‘Freedom to speak up guardians’ in the NHS who support workers to speak up about things in the work place that get in the way of doing a great job. For details and to find out who they are see: https://nationalguardian.org.uk/. Speaking up can be about processes or behaviours that may have an impact on your wellbeing or that of the people you work with or patients. You can speak up openly, confidentially or anonymously.
Work admin
Every NHS employee should have access to the Electronic Staff Record, via a computer or the App. Home – ESR Hub – NHS Electronic Staff Record. You need an NHS email account to access it. Here you find the HR and payroll information your employer holds for you and importantly your payslip and P60.
The NHS pay day is the 27 of the month, or the last working day before the 27. Pay in the NHS for doctors is usually monthly. Pay and tax are not always correctly calculated, so check your payslip carefully.
The GMC requires licensed UK doctors to undergo annual appraisals and revalidation every 5 years. Your employer will identify an appraiser for you and is likely to have a preferred platform to present the relevant evidence for your appraisal. It is your professional responsibility to ensure you collect and present the required evidence, actively participate in and complete this process as required.
Your employer will require you to take part in statutory training, which is required to ensure the Trust is meeting any legislative duties. In addition, mandatory training is an important organisational requirement to limit risk and maintain safe working practice.