Trusts are accused of using foreign doctors as “cheap labour” in fellowship schemes

Fellows save the trust money

A document describing the scheme, obtained by The BMJ, that is sent to departments hosting fellows at University Hospitals Birmingham NHS Foundation Trust, says that trainees “will not be employees of the trust” and instead remain employed by their overseas employer. The document openly states that fellows save the trust money. “The charging rate will be less than the standard budget for a junior doctor post, thus representing a saving for the trust,” it says.

Senior fellows, who can be senior registrars or junior consultants in Pakistan, work as specialty trainee year 3 (ST3) registrars or above when they come to England and are paid a stipend ranging from £2700 to £3600 a month by the CPSP, the equivalent of £32 400 to £43 200 a year. Rahim told The BMJ that fellows do not pay income tax or national insurance on their stipend, but HM Revenue and Customs said that they should be taxed in accordance with UK law because it does “not regard doctors coming to the UK under the MTI scheme as solely coming to the UK as a student.” Fellows also receive an extra £600 to £900 a year to spend on educational materials or conferences. They can also do locum work at their own trust to supplement their income but cannot work for other hospital trusts. The equivalent ST3 doctors employed by the trust were paid £51 017 in 2022-23 and £55 328 a year in 2023-24 as a basic gross salary, according to NHS pay scales. This doesn’t include additional or enhanced hours or on-call work. The University Hospitals Birmingham NHS Foundation Trust would not confirm the exact equivalent salary details of its ST3 doctors after adding additional hours, on-call shifts, and weekend work to their basic salary.

ST3 doctors in the emergency department at University Hospitals Coventry and Warwickshire NHS Trust, including those on an MTI scheme, were paid a gross salary of at least £64 319 after being paid for weekend and on-call work in 2022-23, leaving them with £46 358 after tax and national insurance, more than the take home pay of the highest paid MTI fellow under the CPSP’s agreement (though this calculation does not take into account pension deductions). The fellows at this trust are also entitled to all the same rights as staff members. Great Ormond Street Hospital for Children NHS Foundation Trust told The BMJ that its fellows (who mostly come from the Middle East and are funded by their home nations) are not required to work on-call shifts, allowing them to “maximise the educational opportunities made available to them.” The trust would not share the specific amount its fellows are paid but said, “All fellows are on a skilled worker visa so are paid in line with other medics at fellow level.”

Leeds Teaching Hospitals NHS Trust has fellows on the MTI scheme, including those from the CPSP, but Magnus Harrison, the trust’s chief medical officer told The BMJ that most fellows are employed on contracts “mirroring the terms, benefits, and pay scales offered to UK trainees.” He added: “A small number of trainees are engaged under honorary contracts as they are paid by their home countries; however, there are internal and external processes in place to ensure such trainees receive the same salary and work the same hours/shifts as our UK trainees.”

Fraz Mir, associate dean of the East of England deanery, says that MTI trainees in his area are expected to be paid “exactly the same” and afforded the same training opportunities as any UK based trainees. The agreement with the CPSP is “not how the majority of the MTI scheme works,” he said. “I would say the vast majority of people in the MTI scheme nationally actually come into training post jobs or rota jobs into trusts where they are paid the same as UK people.”

No maternity pay

Under the agreement between the CPSP and University Hospitals Birmingham NHS Foundation Trust fellows do not receive paid parental leave. “Fellows will not be allowed (paid) maternity or paternity as they are not employees of the trust,” the trust’s document says. “Any fellow who becomes pregnant during their programme is likely to have their fellowship terminated early and will naturally return home at that point. This is an agreed position with the trainees’ home employer and sponsors, who remain responsible for their contractual terms and conditions.”

This follows an incident in 2017 in which the Birmingham trust terminated the contract of a fellow who became pregnant. The fellow, who wanted to remain anonymous, told The BMJ that the experience was “traumatic” (box 1). More recently Hassan Bin Ajmal, a fellow at University Hospitals Birmingham NHS Foundation Trust, told The BMJ that he had to use two weeks of annual leave when his daughter was born because paid parental leave was not available. Michael Newman, an employment lawyer at law firm Leigh Day, told The BMJ that by law every worker is entitled to maternity leave after they begin employment, and they are entitled to statutory maternity pay after 26 weeks of employment.

Newman described the conditions of the scheme as exploitative and said that it was likely that a UK employment tribunal would view that it had jurisdiction, should fellows want to launch discrimination or unfair dismissal claims there (though claims can only be made three months after the employment ended or the problem happened). “It’s a great deal for the trust, right?” he told The BMJ. “Cheap doctors at a time when we need them. If the trust wanted to make sure they’re subject to UK employment law, they could do that in a heartbeat. They clearly just want to take advantage of them. It’s exploitation. These people are willing to come in and do their training, and no doubt it looks good on their CV to work in the UK for two years and, and [the trusts are] taking advantage of that. It is difficult to see an alternative explanation for it.”

He added that a trust terminating someone’s fellowship because they became pregnant and refusing to pay for maternity leave was “outrageous.” “The fact that the trusts feel they can just do it nakedly is appalling. They clearly feel that this structure allows them to do so,” he says.

Fellows might not want to complain or take complaints to a tribunal for a variety of reasons, he adds. “People may not want to bring these claims because they have concerns about their wider training, or they don’t want to rock the boat. They probably don’t want to be sent back home, which they realise will be a consequence of them raising an issue.”

CPSP promises to rewrite guidelines

Rahim, who represents the CPSP, told The BMJ that the guidelines in the document obtained by The BMJ were “harsh” and written before he came into post. “I’ve asked for those guidelines now to be withdrawn . . . and I will be writing those guidelines in a more appropriate manner,” he told The BMJ.

He said that fellows were given 25 days of annual leave and a discretionary 10 days of extra leave for emergencies, including family illnesses. Any extra leave might mean they cannot fulfil their two years of training, so after they’ve used their leave they are encouraged to return to Pakistan, stop the clock on their training, and return to the UK when they can complete it. On a case by case basis the CPSP might agree to continue to pay fellows their stipend while on leave, including a recent case where a fellow was paid his stipend for four months while he was caring for his ill father in Pakistan.

One consultant at University Hospitals Birmingham NHS Foundation Trust, who agreed to talk to The BMJ on the condition of anonymity for fear of repercussions from the trust, said that the trust was using fellows as “cheap labour.” “These are good doctors. Their work ethic is extraordinary,” they said. A former consultant at the same trust praised the scheme in terms of the training opportunities but lambasted the lack of equal pay and rights, saying that the trust had “managed to get so called cheap labour on the context that we are educating them, which is very true because we are, and they have benefited from that. The returning countries have benefited as well.”

Fellows have gone back to their home countries and performed complex operations that were not previously widespread, the former consultant continues. “In Pakistan, over the past decade, they were not doing certain complex operations like laparoscopic kidney operations for cancers, prostatectomies for prostate cancers, and cystectomy for bladder cancers. Because we have trained these guys over the years, and now they’re running with it and they really shifted things around,” they say.

“So I’m actually a good supporter of the scheme, but what I cannot support is this idea of two laws. We are in one land and there should be only one law. We should look after them like how we look after ourselves. These guys just don’t moan about it because they learn so much, they get so much experience, they just put up with it. And then they’re gone. And then it really helps with their career progression when they go back home,” the former consultant says. Mir also praised the scheme but said that it needed “standardisation and uniformity” in light of the CPSP agreement.

The Ceylon College of Physicians told The BMJ that some trusts used to work with Sri Lankan trainees as honorary fellows, and the Sri Lankan ministry of health paid them a stipend of £2000 a month, but this was stopped when the economic downturn in Sri Lanka meant that the government could no longer afford to pay. Trainees that were already in the UK would continue to be paid, but no new fellows would be funded. Mir said that Sri Lankan trainees in the east of England are now paid by the trust. He said that, in the period when they were paid by the Sri Lankan government, they received extra payments for on-call and weekend work by the trust on top of their stipend.

The British Association of Physicians of Indian Origin also told The BMJ that it set up its own training scheme because the MTI scheme was “being abused” with fellows being used to plug rota gaps and that in some trusts it lacked a training component. “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. As part of this scheme, BAPIO charges trusts and charges the trainees themselves.

Thousands of trainees since 2009

The Academy of Medical Royal Colleges says that there have been 6986 trainees through the MTI scheme since it began in 2009, with 759 from September 2021 to September 2022.2 In that year the top six countries of origin of trainees were Pakistan, Sri Lanka, India, Egypt, Nigeria, and Saudi Arabia.

One advantage for MTI trainees, compared with those from abroad applying to trusts for jobs directly, is that MTI trainees must complete an English language test but do not have to complete the General Medical Council’s professional and linguistic assessments board test; the royal colleges facilitate GMC registration on their behalf. They come to the UK on a tier 5 visa, which is limited to two years, but allows them to bring their families to the UK for that period.

A spokesperson for the Academy of Medical Royal Colleges said: “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.”

Diane Wake, chief executive of the Dudley Group NHS Foundation Trust, told The BMJ: “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; however, should they have any that they would like to raise with us directly, we would be more than happy to look into them.” She added that any overtime would be paid at the bank rates used for all trust medical staff and that fellows all receive 28 days’ free accommodation on arrival.

Walsall Healthcare NHS Trust said that it had recruited three MTI fellows under the CPSP scheme, due to start in November, but doesn’t have any in post at present. “The job description, person specification, and rota patterns have been reviewed and approved by the dean,” a spokesman told The BMJ.