The Department of Health, Health Education England and the Academy of Medical Royal Colleges have agreed changes to the arrangements for processing applications for MTI Certificates of Sponsorship (CoS) from applicants from countries other than those identified as DfID priority countries or World Bank Low Income and Lower Middle Income Countries (LI&LMI).
It has been reaffirmed by the Department of Health, Health Education England and the Academy of Medical Royal Colleges that the priority focus of the MTI is to provide training opportunities for doctors from DfID priority or LI&LMI countries and have therefore now stated that applicants from countries not considered DfID priority or LI&LMI countries can have no guarantee or expectation of receiving an MTI CoS.
The current prioritising system has been working effectively but has had unintended consequences for applicants not from DfID priority and LI&LMI countries. These applications were considered at the end of each month and CoS’s allocated if there was available capacity from the monthly quota once the allocations to DfID priority and LI&LMI countries had been made. However, the overall volume of applications received, has resulted in a growing proportion of these applications being rolled over for consideration at the end of the following month.
The consequence was that these applicants could find themselves waiting up to several months to confirm an MTI placement. This delay and uncertainty understandably caused real problems for individual applicants, employers, Colleges and Deaneries. The Department of Health, Health Education England and the Academy of Medical Royal Colleges all believe that position was unsustainable and unfair to applicants. For the sake of transparency it was felt better to explicitly state that these applicants can have no guarantee or expectation of receiving a CoS, although they will not be barred from making applications.
The revised process is as follows:
- Applicants from countries not considered DfID priority or LI&LMI countries may apply at their own risk. If there is any remaining capacity at the end of each month having processed all applications from DfID priority and LI&LMI countries, other applicants will be awarded a CoS taken in order of the receipt of their applications. Successful applicants will be contacted to confirm whether they still wish to pursue their application. Those not successful will be informed that on this occasion their application has been unsuccessful due to lack of capacity and asked whether they wish to remain on the list for consideration again the following month. Applicants from these countries and employers will need to recognise that the waiting list may become quite long and reduce only slowly. This means that these applicants may be better off finding alternative routes for employment and immigration through Tier 2 entry.
- This process will commence from 1 April 2017. However, it has been agreed to process all those applications from other countries on the current waiting list as soon as possible.
- New applications from countries not considered DfID priority or LI&LMI countries received after 1 April 2017 will be placed on a revised waiting list and will be processed if and when there is capacity. This will not begin until the monthly quota rebalances to take account of those we process now from the current list. This is unlikely to be before June 2017
- The Department of Health, Health Education England and the Academy of Medical Royal Colleges believe these arrangements:
- Better reflect the intention and purpose of the MTI
- Are fairer overall than the current system of uncertainty and delay that candidates from other countries are experiencing
A detailed statement from the Department of Health, Health Education England and the Academy of Medical Royal Colleges will be going out shortly to all employers, Deans, Colleges and for potential applicants making clear:
- The intention and purpose of the MTI and its focus on DfID priority or LI &LMI doctors
- That MTI placements are intended for training purposes using local spare capacity. They are not intended as method for employers to cover staff shortages and rota gaps
- That applicants from other countries, whilst not barred from seeking to use the scheme, would be better advised to use alternative methods to find medical employment or training in the UK
- Guidance to applicants and employers on alternative routes for employment of overseas doctors using Tier 2 visa arrangements.
A list of the countries which comprise the DfID priorities and the World Bank Low Income and Lower Middle Income countries is set out below. Applicants from any country not in this list will be covered by the new arrangements and can have no guarantee or expectation of receiving a COS.
Central African Republic
Democratic Republic of Congo
Egypt, Arab Rep.
Korea, Dem. People’s Rep.
Micronesia, Fed. Sts.
Occupied Palestinian Territories
Papua New Guinea
Sao Tome and Principe
West Bank and Gaza
Speaking about the publication of the SAS Doctors guidance Kirstin May, Chair of the Academy SAS Committee said:
‘I welcome the new SAS doctor development- Summary of resources and further work document, jointly published by the British Medical Association, the Academy of Medical Royal Colleges, Health Education England and NHS Employers. This important document complements the previously published SAS Charters and gives further guidance to help ensure this important group of doctors is helped to remain fit for practice and develop in their careers. SAS doctors are advised on how to develop and extend their professional roles. This will ensure a motivated and engaged workforce to best meet the need of patients. Boards, medical staffing and human resources departments and medical directors are advised on how to support their SAS workforce and optimize its skills and abilities. Case studies are included to illustrate examples of SAS doctors performing in extended roles, training programmes being developed specifically for SAS doctors.
The principles set out can also be applied to dentists as well as to other doctors who are not in training and whose appointment does not require them to be on the GMC specialist register, eg trust grade doctors.
The Academy is aware that this group of doctors provides approximately 20% of the medical hospital workforce and hence makes a vital contribution to patient care. SAS doctors are a diverse group with a wide range of skills and experience whose development will benefit patient safety. Every doctor should have the opportunity to work to his/her full potential. The SAS workforce should be considered as a possible route to support local workforce plans and resolve skills shortage issues. The Academy is committed to helping SAS doctors develop to have fulfilling careers and to meet the needs of the service and patient care in the future.’
Mrs Scarlett McNally BSc FRCS(Tr&Orth) MA MBA FAcadMEd
What have we done? We have over-intellectualised health. We—the youthful, affluent, busy, well educated elite—run the NHS as we would want for ourselves. We think of how we would choose to get our hernia “fixed” by the best possible surgeon at a time of convenience before going back to work. As an orthopaedic surgeon, I get this. It is tidy.
Yet most healthcare is consumed by those who have few choices, multiple conditions, and financial worries. Seventy per cent of the UK’s annual £120 billion NHS spend is for conditions that might have been preventable. In hospitals 3% of the patients make up 45% of the costs. These aren’t the 3% you might think of—they’re not the patient in the ICU, SCBU, or transplant ward—but somebody’s granny, sitting quietly and trying to be no trouble, with multiple comorbidities and a string of treatments and investigations, as someone seeks an elusive care home bed for them.
Prevention is too important to foist onto primary care or to leave to public health. Unless people in their 50s and 60s get up and become active, we are all doomed to pay for their future social care. Exercise works as primary prevention. One hundred and fifty minutes a week of moderate exercise prevents 25% of breast cancer cases, 30% of dementia, and 30% of strokes. Of course, 75% will still happen, but 25% is still a lot. Divided doses (for example, 30 minutes of exercise five times a week) deliver the best outcomes on glycaemic control, inflammation, and vascular effects. The dose-response curve plateaus at around one hour a day. Yet 25% of UK adults do less than half an hour of exercise a week.
What needs more focus is secondary prevention. For people who already have heart disease, diabetes, mental health conditions, arthritis, fragile bones, or cancer, exercise can prevent complications and reduce deterioration; it should be a major part of their management plan. This effect is better than many drugs and almost immediate.
Three of the World Health Organization’s top five interventions that work to improve diet and physical activity are: “Environmental interventions targeting the built environment, policies that reduce barriers to physical activity, transport policies and policies to increase space for recreational activity”; “Point of decision prompts to encourage using the stairs”; and “Multi-targeted approaches to encourage walking and cycling to school, healthier commuting, and leisure activities.”
The Netherlands had a congestion, pollution, and car problem 40 years ago—their lovely cycle network started as retro-fitting. Finland worked hard and reversed the world’s highest cardiac morbidity by encouraging people and places to support exercise. Wales has introduced an Active Travel Act. Yet in England, developer payments to help support the infrastructure of their area—under Section 106 grant funding or a Community Infrastructure Levy—often come too little, too late, and with too little oversight. The cycle lanes and green spaces on the consultation plans often do not appear in the final structure.
There are huge inequalities in health. To get the intellectuals on board, we need to discuss more embarrassing matters: money, death, and social class.
More people than ever are heading towards needing 24 hour care, which costs roughly £1000 a week, involving three whole time equivalent workers (perhaps on minimum wage around £7.20/hour). Now let’s own up to the biggest taboo: property prices. Our own parents can afford five years of care costs because they had a house worth a quarter of a million that they bought cheaply in the 1970s. But what about future generations? A lifetime’s earnings over 50 years on a low wage won’t pay for that person’s future care home costs. Only 71% of the working age population are economically active to pay for the others. And what about people who now have nothing? We don’t see them. They don’t complain. They sit indoors with the sadness that dependency, and vitamin D deficiency, brings.
We must be braver about imploring middle aged people to get moving every day: out of cars, off sofas, and away from computers. Modern sloth and gluttony hide in busy lifestyles and procrastination. With exercise, there is a positive message to communicate and endorphins work each time. There is no drug company sponsorship behind having walking/running shoes ready by the front door or encouraging older people to do squats, dance, or go out to the shop. Small solutions like these can also help anger management or social isolation. Almost one and a half million people work in the NHS and 1.6 million in social care. In East Sussex, one third of working people work in health, social care, or education. Each person has neighbours and family. Our power for change is huge.
For individuals, we need to nudge, cajole, and support each other to find “exercise, the miracle cure.” For societies, we need to legislate for environments that allow this. The UK has started building up to a million new homes and rolling out major transport infrastructure. We should demand play parks, running tracks, and cycle lanes alongside roads and through all developments; cycle parking by all public buildings; and inspection regimens including staff wellbeing.
Senior figures privately fear that if more people get fitter they would live longer and need more healthcare. Ironically, we extrapolate from our knowledge of hip replacements, which are almost unique in the atlas of variation in increasing with age, affluence, and activity. Nothing else does this. Humans are already living longer, but then we stop. The human body is built to be active, then die after a short illness. There is a natural human lifespan, as for all mammals.
The longevity curve is rectangularising, but only if you are wealthy and/or active. For many individuals, there are decades of ill health. Nine per cent of people aged over 65 are living with dementia, 16% with heart disease, and 20% with depression. Seventy year olds live with an average of three long term conditions. From an actuarial perspective, being fitter only adds a few years of total life, but it adds many years of disability free life. If a person can lose the burden of just one of their multiple comorbidities, this improves their independence and happiness.
Even Japan—which has an obesity rate of 3.5%, small portion sizes, and cycle lanes to die for—is now tackling the “locomotive syndrome” (inactivity) as their ratio of older people to working aged people increases.
In Oxford, 43% of adults cycle regularly and in Cambridge 58%, whereas in Eastbourne only 15% do and in Rochdale only 10%. Is the Oxbridge effect money, social class, or exercise? Public schools emphasise sports, which establishes lifestyle habits. We select doctors and NHS managers using objective criteria that find the driven, intellectual, alpha individuals. We should work harder at the art of medicine, understanding what might be possible within each patient’s circumstances, and save the science of intervention for last resort. Exercise, education, and efficacy win every time.
We have done it with seatbelts and dog poo. A combination of legislation and individual expectation changes culture. The NHS needs to lead on this. We should acknowledge the numbers and develop a new paradigm for health. Now we must mention activity in every consultation, give space and time to every cyclist or pedestrian, open swimming pools and playing fields, and lobby for more active societies and environments. What if the NHS could challenge people, staff, local government, the Treasury, education, and transport to reduce health inequalities? The effects would start immediately. And what if we don’t? We’re looking at not just the NHS’s failure and avoidable misery, but wholesale UK economic meltdown. Let’s get going.
Scarlett McNally is a consultant orthopaedic surgeon at Eastbourne District General Hospital.
Competing interests: Scarlett McNally is an elected council member of the Royal College of Surgeons. The views in this article are her own and do not represent those of any organisation to which she is affiliated.
Firsts published in the BMJ in February 2017
Professor Dame Sue Bailey, Chair of the Academy of Medical Royal Colleges said,
‘High quality patient care comes from the high quality training our medical schools provide and UK’s doctors are among the best trained in the world thanks to the high standards we set ourselves.
The GMC’s proposal to standardise and streamline the process of securing a license to practise and ensure the rules apply to all doctors, whether trained in the UK or not, must surely be welcomed.’
The NHS has a remarkable record in providing cost-efficient, effective and equitable care for everyone. Services and staff are, however, currently, under pressure as probably never before which is inevitably impacting on patient care.
The Academy of Medical Royal Colleges has already called for immediate increased resources for social care and overall additional resources. But whilst addressing immediate problems is vital, along with many other organisations and individuals that care about the way healthcare is delivered across all four nations of the United Kingdom, we believe there needs to be an open and honest debate about how we meet the challenges facing the NHS in the long term and how we provide a sustainable health and social care system for the future.
That conversation must involve patients, politicians, clinicians and the public at large because, ultimately,it is for all of us to decide as a nation what service we want and what resources we are prepared to put in to provide it.