International recruitment and the fellowship programme

Having spent my working life entirely in Germany up until 1997, I decided to move to East London. Since then, I have been directly involved in the recruitment of more than 20 overseas psychiatrists, in roles ranging from headhunter to member of appointment panels. Only one of the recruits on consultant level has left the UK, and that was for personal reasons. All the others are still here, and most of them appear reasonably satisfied with their jobs. They not only fill otherwise vacant posts, but are often seen as highly committed and skilled colleagues who have made a positive difference to services. If international recruitment is beneficial to all parties, how can it be promoted?

Psychiatry is not the only specialty with shortages of consultant numbers in the National Health Service (NHS). For example, anaesthesia, clinical oncology, thoracic surgery, clinical radiology and histopathology share the recruitment crisis. However, there is significant investment in play to address the issue. The Government has promised an average 7.4% growth in health spending in England over the next 5 years. Much of this will need to go towards paying for more staff if plans to recruit at least 15 000 more general practitioners and consultants are to be realised by 2008.

Rekindling undergraduate interest in psychiatry, and increasing training places at senior house officer and specialist registrar levels, are of course central to the solution. The Royal College of Psychiatrists and the Department of Health are working on this. Even if all the planned initiatives materialise, however, the resulting growth in consultant numbers will be slow - it could be 2015 before some of these strategies begin to translate into real increases at consultant level.

We cannot afford to wait, and the other specialties struggling to fill their consultant vacancies no doubt share the sense of urgency. But what they have not shared, at least so far, is our level of success in finding short-term answers in international recruitment initiatives. Real progress for psychiatry has been achieved through the Department of Health-run International Fellowship Programme (IFP). Since the launch of the IFP through Professor Sir David Goldberg in 2002 (Goldberg, 2003), the programme has recruited more consultant psychiatrists than all other specialties put together. Some 199 fellows have been appointed to date - 124 of whom are psychiatrists. This, amazingly, is almost 5% of the total workforce of consultant psychiatrists! The IFP is just one strand of a wider Department of Health campaign to appoint doctors and other staff from abroad to difficult-to-fill positions in the NHS. The programme offers consultants from abroad a fellowship of up to 2 years in the NHS, followed by practical and financial help to relocate to their home countries once the fellowship comes to a close. While the scheme is specifically designed to attract experienced consultants who want to work in the UK for a limited time, subsequent substantive employment in the NHS is not ruled out. Realistically, many will seek this.

Yet despite its success over a relatively short period, many NHS Trusts have not yet made use of the programme. They may not yet be familiar with the opportunities it offers, or have for other reasons been slow to advertise posts within it. One reason might be the inflexibility and lack of initiative of some human resources departments. Given that most fellows have so far been recruited from India, Trusts may also have picked up on the ensuing debate about the ethical implications of recruiting from developing countries (Patel, 2003). The Department of Health has been vehement in defending its recruitment activities on this front (Mellor, 2003). It stresses that it only recruits in countries where governments explicitly welcome the wider development opportunities that working in the NHS can offer their doctors. The ethical debate will - and must - continue, but is not addressed in this brief paper. It should still be noted that international recruitment campaigns arouse suspiciousness in many countries, not just in the developing world. Most current member states in the European Union either already have problems in recruiting consultant psychiatrists (e.g. Germany) or might soon get them (e.g. France). Alhough countries are not necessarily pleased to see psychiatrists leave - medical training costs taxpayers’ money - the fact is that the international rules increasingly favour an open labour market, not just for highly-paid footballers, but also for consultants.

There are many qualified doctors who are ready to uproot themselves and sometimes their families, relocate and embrace a whole new set of cultural and clinical challenges. That they have the appetite for such upheaval is testament not only to their personal energy and professional commitment, but also to what the NHS, and mental health in particular, have to offer in this country. Why do they want to come, and why does the NHS manage to attract experienced consultants from as far afield as central Europe, Scandinavia, the USA and the Philippines?

The reasons certainly vary, and include the following (Goldberg, 2003):

1. • The salary, which is competitive as compared with most posts elsewhere - outside the private sector in a few rich countries.

2. • The high degree of autonomy in conducting the job, with a flat hierarchy above the consultant level.

3. • The focus on effectiveness with practically no financial incentives for individual clinical decisions.

4. • The possibility of working in different in-patient and out-patient settings, and in the community rather than in only one place.

5. • The genuine teamwork in many services and the widespread acceptance of professionals from other cultures.

6. • The chance to have a real influence on service delivery and service development, and an environment in which honest commitment is often valued and rewarded.

7. • The encouragement to develop new services; while the funding levels are low, they are likely to be increased so that the discussion is on how to improve services rather than how to cut down from a previously high level. Related to this is the high interest in mental health issues in the UK, with mental health being one of the top three clinical priorities for the Government.

8. • The chance to have protected sessions for personal development and research.

9. • Above all: a pleasant working atmosphere with the famous British sense of humour and mostly constructive collaboration with other clinicians and managers.

Although no recruits expect Nirvana in the NHS, it is worth remembering that benefits that have often become invisible to those who have grown up in the system may prove powerful attractions to those from other backgrounds.

Mental health services can benefit from new recruits in several ways, not least from their energy and the fresh perspective they lend to everyday situations. In a recent interview David Amos, Deputy Director of Human Resources at the Department of Health, points out that international recruits are not just another pair of hands. They may be instrumental in leading clinical services, and initiating change and service development (Amos, 2003).

There are several official initiatives to support Trusts with international recruitment. Undoubtedly important are the Department of Health-led Global Recruitment Campaign and the International Fellowship Programme. The latter can be seen as a golden opportunity for Trusts, as well as candidates with significant material advantages that are paid for centrally and not out of Trust budgets. Unsurprisingly, there have been hiccups with the organisation of the programme. Some Trusts have been disappointed by delays in getting their fellows onto the specialist register and through the language assessment. The Department of Health is now recognising these weak points and has promised an overhaul of how the programme is administered.

Clinicians and managers in Trusts themselves also have a role to play in making the programme, and international recruitment in general, successful. A key element of this is realism. References and CVs from international candidates come in many shapes and sizes. Trusts need to adjust to this; they must be prepared for a limited understanding of NHS issues; and they should assist their recruits with well-managed induction, peer-support mechanisms and mentoring. Finally, Trusts should be willing to treat experienced consultants from abroad fairly when it comes to contracts, including salaries and discretionary points.

International recruitment may sound like hard work, but the pay-offs appear worth it. As David Amos suggests, the alternative to not spending money on international recruitment is not having doctors in place delivering health care and leading clinical teams or - one might add - to waste more money on over-paid and under-qualified locum staff.

International consultant recruitment remains a viable and often exciting possibility to develop mental health care in the UK, and - based on my experience - we can do much better on this than we have done.

For more detailed information on the International Fellowship Programme, see the Department of Health website at http://www.doh.gov.uk/international-recruitment/nhspro-int-fell-sch.htm.