Health Policy 119 (2015) 494–502

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Exploring the experiences of EU qualified doctors working in the United Kingdom: A qualitative study Helena Legido-Quigley a,∗ , Vanessa Saliba b , Martin McKee c,1 a b c

London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK

a r t i c l e

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Article history: Received 4 March 2014 Received in revised form 25 July 2014 Accepted 11 August 2014 Keywords: EU doctors Professional mobility The UK Qualitative

a b s t r a c t This qualitative study of 23 doctors from other EU member states working in the UK highlights that, contrary to media reports, doctors from other member states working in the UK were well prepared and their main motivation to migrate was to learn new skills and experience a new health care system. Interviewees highlighted some aspects of their employment that work well and others that need improving. Some interviewees reported initially having language problems, but most noted that this was resolved after a few months. These doctors overwhelmingly reported having very positive experiences with patients, enjoying a NHS structure that was less hierarchical structure than in their home systems, and appreciating the emphasis on evidence-based medicine. Interviewees mostly complained about the lack of cleanliness of hospitals and gave some examples of risk to patient safety. Interviewees did not experience discrimination other than some instances of patronising and snobbish behaviour. However, a few believed that their nationality was a block to achieving senior positions. Overall, interviewees reported having enjoyable experiences with patients and appreciating what the NHS had to offer. © 2014 Elsevier Ireland Ltd. All rights reserved.

1. Background Health professionals have always moved to, from and within Europe but, in recent years, there have been concerns about the consequences of this mobility, with ever greater numbers of health professionals migrating to the UK from the rest of the European Union (EU) [1]. This increase was fuelled in part by international recruitment campaigns initiated by parts of the UK National Health

∗ Corresponding author at: Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK. Tel.: +44 20 7927 2237. E-mail addresses: [email protected] (H. Legido-Quigley), [email protected] (M. McKee). 1 Tel.: +44 20 7927 2229. http://dx.doi.org/10.1016/j.healthpol.2014.08.003 0168-8510/© 2014 Elsevier Ireland Ltd. All rights reserved.

Service and private providers in the 1990s and early 2000s. Successive EU enlargements have provided additional sources of migration [2,3]. The latest figures, published by the UK General Medical Council (GMC) in 2013, suggest that more than 10% (26,002) of doctors on the Medical Register qualified in other parts of the European Union (EU) with nearly 4000 general practitioners (GPs) (6.3% of the total) and 11,859 specialists (15% of the total) [4]. These doctors are mostly from EU-15 countries, although with steady increases from some Eastern European Countries. In 2013, there were 3276 German doctors working in the UK, followed by 2864 Greeks, 2623 Italians, 2023 Romanians, 2023 Poles, 1477 Spaniards and 1442 Hungarians. The 2005 EU Directive on the recognition of professional qualifications established rules according to which Member States recognise qualifications obtained in another member state [5]. In November 2013 the Council of the

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European Union revised the legislation, adopting Directive 2013/55/EU on the modernisation of Directive 2005/36/EC on the recognition of professional qualifications [6–8] following a perceived need to simplify some aspects and thereby facilitate greater professional mobility and harmonize training. However, the British media have highlighted cases where doctors from other EU member states provided markedly sub-standard care [9,10] and, in particular, a 2009 case in which a German doctor gave a fatal overdose to a patient when working his first shift as a GP locum [10]. These cases have stimulated some commentators to argue for a tightening of the existing rules, including language requirements. These concerns were echoed by the UK House of Lords (upper parliamentary chamber) Select Committee on the European Union, which warned that the current EU directive poses a risk to the safety of patients [10]. Other professional bodies, such as the Royal College of Physicians of London, have expressed concerns about language competence and the current Directive’s emphasis on the duration of training rather than competencies acquired [11]. However, it has now been clarified that, contrary to what had been stated by the UK government [12], the General Medical Council has the ability to check the English language skills of EU doctors working in the UK before and after registration [13] if concerns arise [14]. In the midst of these controversies, very little research has focused on the experiences of physicians that move to the UK from other European countries. Most existing research focuses on international medical graduates in other countries (i.e. Canada [14] and Australia [15]) or on non-EU overseas doctors in the UK [16–18] or on the experiences of doctors coming from individual EU countries such as those from France [19], Slovakia [20] and Spain [21,22]. The only research available on the experience of doctors coming from other parts of the EU was conducted by the GMC and focused on the experience of non-UK qualified doctors (including other non-European countries) working within the regulatory framework of the GMC document Good Medical Practice [23,24]. A second study funded by the GMC sought to compare the experiences of newly qualified UK, other EU and non-EU doctors making the transition to the UK workplace, focused on their training experiences [23]. The findings of a recently published cohort study have added to the existing controversy. It asked whether country of medical qualification (including other EU doctors) was associated with the outcomes at different stages of the GMC’s fitness to practice process. It suggested that adverse decisions were more common among nationals of other EU member states. However, it was not clear whether this reflected real differences in fitness to practice or whether GMC processes tended to discriminate against doctors from elsewhere [25]. Whichever is the case, there seem to be problems. This study contributes to this sparse literature by describing the experiences of doctors who decide to move to the UK from other EU member states, exploring their motivations for moving, experience of registering with the GMC and finding a job, adaptation to the NHS, with a focus on language, the patient–doctor relationship and differences in health care systems. We also explored how they

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perceived their future prospects and whether being from another country impacted on their potential to advance their careers. Finally, we asked about contemporary policy proposals and how the system could be improved. 2. Methods 2.1. The data We conducted semi-structured interviews with doctors who obtained their medical qualification in the EU (outside of the UK) and were working in the UK at the time of the interview, including a GP and a specialist who had been unsuccessful in securing positions. 23 participants were recruited using convenience and snowball sampling techniques. We included a range of EU nationalities (N = 11), both specialists working at teaching and general hospitals (N = 18) and general practitioners (N = 5), staff at different grades, with a similar number of males (N = 13) and females (N = 10). We also included doctors that had only just arrived (N = 3) as well as those that had been in the UK for a longer period of time (between 1 and 5 years, N = 10) and those who had been in the country for more than 5 years (N = 5) and more than 10 years (N = 4). Most of our interviewees were based in London (N = 15), but we made efforts to include other areas of the UK to get a more comprehensive picture of their experiences (N = 8). The fieldwork started in July 2011 and lasted until January 2013. We followed four complementary strategies to recruit interviewees. The first involved contacting membership organizations that could facilitate access to our study group. These included: European Union of Medical Specialists (UEMS) representing national medical speciality associations across Europe, Royal College of Physicians of the UK (RCP), and the London Deanery (responsible for postgraduate training). We then contacted personal contacts and key contacts across our networks working in the health field since two of the researchers in this project are from another EU Member State (Spain and Malta), the latter a medical graduate from Malta. These contacts were accessed through email, twitter, Facebook and LinkedIn. In addition we posted messages in health forums (e.g. YoungForumGasteiners). We also contacted our existing research collaborators in 12 Member States and they in turn used their contacts to identify potential interviewees. To gain access to other networks we embarked on two additional strategies [26]. The third involved accessing those networks or organizations that our participants would be more likely to access when moving to the UK. These included: expat networks and recruitment agencies for European doctors. The final strategy involved contacting staff responsible for postgraduate medical education centres and medical directors in hospitals. Interviewees were chosen using a theoretical sampling technique. Although efforts were made to mirror some of the characteristics known about this group, the sampling strategy, following Strauss’ advice, was concerned with deciding on analytic grounds what data to collect next and where to find it [27]. The first stage of our sampling involved drawing a convenience sample to cover a wide range of participants working in different settings, with

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different expertise and seniority and coming from different EU countries. The sampling strategy considered gender, country of origin, type of specialty, position, employment in private versus public facilities, time spent in the UK, and geographical location within the UK. After the initial analysis, we introduced a further criterion and interviewed doctors who had been unsuccessful in entering training programs. The final step consisted of exploring whether we had enough data to enable an in-depth explanation of the emerging areas of interest. The themes that emerged were developed in combination with the identification and verification of deviant cases which were then in turn incorporated into the analysis. 2.2. Analysis Interviews took a narrative form, with semi-structured questions (covering experience of studying medicine in their home country; motivations for migrating; experience of getting a job/training and registering; adapting to and accessing the NHS; language requirements; exploring the differences in health systems; the doctor–patient relationship; challenges/barriers to working in a new environment; the possibility of moving back; and future prospects) used to elicit detailed stories of experiences of health care professionals working in a different environment. Interviews were conducted by two authors (HL-Q and VS). This study is grounded within interpretative approaches. We produced an initial coding frame and some descriptions and analysis of the codes identified through a line by line analysis. Excerpts were discussed line by line among the authors to explore the codes that were emerging. Throughout the process we compared data with data and then data with codes. We adopted a systematic comparative approach to identify regular features or differences across settings to identify contrasts. In order to ascertain the point of saturation, we identified those deviant cases that did not fit our models and explored them further. Examples of deviant cases included a respondent that was very successful in her career in her own country but had failed to find a position in England. While participants were of several nationalities, we believe that we managed to encapsulate the range of opinions so we stopped collecting new data when we saw repetition and the new data collected did not shed further light on the themes identified from the analysis. We coded and analysed all the interviews using NVivo7. Table 1 contains a detailed account of the interviewee’s country of origin, gender, specialty, position, time spent in the country, setting and location. In this paper, M and F signify male and female interviewees respectively, while I1 signified the interview number. The paper presents the issues that interviewees considered most important when referring to their experience of migrating and providing care in an unfamiliar place. It follows a chronological order starting from motivations for moving to the UK; reflections on the process of professional registration and job seeking; the experiences of the NHS; future prospects and the possibility of moving back. The sections discussing the experience of providing health care in a different setting (Sections 3 and 4) focus on the

Table 1 Interviewees by gender, country of origin, specialty, time spent in the UK and location. Gender Female Male Total Country of origin France Ireland Italy Germany Greece Hungary Malta Portugal Slovenia Spain Netherlands Total Specialty GP Infectious disease Neurology Cosmetic surgery Anaesthesia Psychiatry Gynaecology Oncology Microbiologist Haematology Epidemiology Total Time spent in the UK Not made into the system 1–5 years More than 5 years More than 10 years Total Setting General Practice Hospital Teaching Hospital Private Practice Total Location London Scotland South Coast North West East Anglia Wales Different destinations Total

10 13 23 1 1 3 2 4 2 3 1 1 4 1 23 6 2 4 1 3 2 1 1 1 1 1 23 2 12 5 4 23 4 7 11 1 23 14 1 1 1 1 1 3 23

themes that emerged from the analysis of the data which include: language barriers, the doctor–patient relationship, the bureaucratic nature of the NHS, the non-hierarchical structures, and the drive for evidence and quality of health care experienced in the NHS setting. Section 3 concludes with some policy recommendations as reported by interviewees. 3. Results 3.1. Motivations for moving to the UK Most interviewees reported several motivations for moving to the UK, including work and continuing with

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training, rather than one specific reason. The following exemplifies many reports: One was expand my surgical experience. Two, improve my knowledge. Three, live in London because I really like London. Four, I always thought that foreign healthcare systems are better than in Greece and I really wanted to work somewhere else because I think that this would improve generally my mentality and my personality and my medical skills as well (I5M). The most frequently mentioned reason, encompassing more than half of the sample, involved advancing knowledge, either through further training, gaining experience through work or studying on postgraduate courses. For some, personal growth, which had a variety of aspects, was mentioned as their main reason. Surprisingly, only a minority of interviewees (2 from Hungary and 1 from Greece) reported financial gains as the main reason for moving to the UK. Language was also a key factor; some interviewees reported moving to the UK to improve their English (mainly Spanish interviewees), others reported moving to the UK because it was the language they could speak (particularly Maltese and Greek doctors). Unusually, one German GP reported dissatisfaction with the hierarchical nature of the health care system in Germany as a reason to move to another country “I had a job in Germany that I didn’t like. And I started working there and I found out I just didn’t like the hierarchical stuff that’s going on in German hospitals, so it was really that (I6M)”. Those that wanted to continue learning cited constraints they faced in their home country as triggers of the move. For example, in Hungary it was considered important to learn new skills and perspectives: I think for a small nation like Hungary, we definitely need to move to the Western countries to learn the new things, to learn the new perspectives of anaesthesia (I2F). Interviewees reported a link between their motivations and expectations. For the majority, their expectations were met, although several reported disappointment with the lack of possibilities for learning new skills. A few interviewees commented that those who moved to another country were the ones that were better prepared and had more interest in learning “The people that are, let’s say, the stronger and have the bigger motivation go abroad and try to make their luck in other countries all over the world (I19F)”.

3.2. Reflections on the process of professional registration and job seeking 3.2.1. The process of registration Most interviewees (a total of 13), reported the registration process at the GMC as an easy and straightforward procedure: I did that, you know what application process that everyone else does here and I think in terms of the GMC, I think that was quite straightforward and that they just needed to get some from my medical school, it was fine (I7M).

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Seven interviewees reported problems with the process, to varying degrees. For most, the problems arose in their home countries as it was necessary to have all the official paperwork translated into English. This was most commonly cited by Hungarians, Spanish and Greeks. A few did not find it an easy process “I wouldn’t say it’s an easy process but there are clear instructions of what to do (I10M)” and a few considered fees for registration as excessive “you just have to pay a significant amount of money, £400 per year, which is not a disrespectful amount, let’s say (I19F)”. Several interviewees expected the GMC to help them with information on how to find a job and were surprised that this was not in their remit.

3.2.2. Job seeking and training requirements The experience of looking for a job was described quite differently depending on whether the physician was interested in a hospital position or in working as a GP. Most interviewees reported that locum hospital positions in the public and private sector were easily available and that an interview was sufficient to get a position with few requirements in place other than checking language at the time of the interview and registration with the GMC. However, GPs described a complex process as requirements differ “In that sense, doctors who want to work in England in a hospital it is easy, for those who want to be family doctors, it is an ordeal (I3F)”. Other European GPs in England and Wales are required to enrol in the GP Induction and Refresher Schemes, which involves an MCQ exam and a simulated patient consultation, but with a £850 fee. The purpose of the assessments is to determine the candidate’s suitability for the scheme and the appropriate length of their induction. GPs asked about this procedure complained that they had not previously been aware of it or informed of the steps to follow. In some cases, interviewees had incurred high costs, in two cases in vain. One GP interviewee based in Scotland described a different experience from that of those moving to England. As she explained: It’s a bit different in England and in Scotland. . . I’m aware that now even for European doctors in England, they have to undertake some kind of induction scheme into the NHS before you can practice independently. In Scotland it’s not that way. As far as you get registered in the GMC and [. . .] you only need an English language certificate and two clinical referees, and a criminal check (I4F). A few interviewees complained vigorously about this procedure as they experienced problems when undergoing the tests. A Dutch interviewee complained that the exams did not reflect the competencies of a GP and they found it very difficult. A Spanish GP passed the exams but she was asked to take a part-time year long induction instead of the six months, which she refused to do, having spent about £5000 in trying to enter the system: When I did everything they said, “you’ve passed all great, but your results are in the lower limit”. So we’re not going to offer six months of training but a part-time whole year . . . which meant that I would get paid D 500 a month for a whole year. I got so angry . . . (I3F).

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The interviewee questioned whether the obligatory exams and induction were compatible with EU law “I think this must be illegal, but as I say since I was finding out as I was going along . . . (I3F)”. There were also reports that UK employees were not sure of the rules. As the same Spanish interviewee commented: But the employers were telling me, “but (before we offer you a position) make sure you can work as a family doctor and that you don’t need three years of previous experience”. They insisted a lot, but they did not know how the process worked (I3F). Interviewees reported that the system had become harder to enter due to the recent scandals and to the fact that demand for doctors had decreased considerably in the last years. Even for family doctors things have changed a lot. I remember five, ten years ago, there was a lot of shortage of GPs in the UK, it was very, very easy for a Spanish GP to come to work here (I5F).

There were two major differences between the UK and the rest of Europe in the doctor–patient relationship. Doctors of most nationalities agreed that doctors provided information to the patient and involved them in the decisions. This was considered very positive as it was moving away from the paternalistic approach which some had experienced in their home countries. As a Greek surgeon explained: I notice that here doctors are much more . . . they spend more time explaining things to the patient and to the relatives. They care quite a lot about communication (I22F). However, some interviewees mentioned a negative aspect. Some Southern European doctors found the relationship with their patients more impersonal and they would have liked to discuss patient’s problems more and show more empathy towards them. Here the relationship can be more impersonal. I’m not saying that the quality of care is poorer here. It might be also a kind of a cultural thing, people in Spain are more open in terms of even speaking about their problems (I4F).

3.3. Experiences of the NHS 3.4. Differences in the health care system 3.3.1. Language barriers Some physicians reported not having problems at all with language (particularly those coming from Malta or with a good command of English) whilst other interviewees (a total of 6) described language as one of the biggest early obstacles. These problems were reported as being much more common when communicating with health care professionals than when discussing issues with patients: This is what I found quite difficult here (language), but also because as a doctor trained in another country my language was not . . . I’m not very good at arguing in English because it’s very difficult to argue in a language that is not yours. Your language skills, your accent are always a point of . . . a weakness somehow (I22F). The most problematic issue reported by interviewees was having telephone conversations with colleagues as such communication was challenging and had an impact on their perceived credibility: When you have to talk on a phone it’s more difficult because the pronunciation in that case, if you mispronounce some words, that is going to have an effect on your credibility with the other person. They will think, who is this person phoning me? She wants me to convince to go and see some patient and she is not even able to pronounce the disease. (I22F). 3.3.2. Doctor–patient relationship All interviewees that reported information on their relationship with patients described this as an enjoyable experience. The most frequently mentioned interactions referred to the politeness and gratitude of patients. Some reported this phenomenon with amazement: But it is one thing about English (patients) that really surprised me, I really amazes me, they were so polite. It was always “Thank you Doctor, please Doctor . . . (I3F).”

Interviewees reported a wide variety of differences between their own health care system and the NHS. A total of twenty-three different categories of difference were identified, although this was unexpected as we interviewed health care professionals from 11 EU member states. Those mentioned most frequently by our interviewees were: the bureaucratic and regulatory nature of the NHS; nonhierarchical structures and differences in the role of health care professionals; and drive for evidence and quality of health care. 3.4.1. Bureaucratic and regulatory nature of the NHS Several interviewees reflected on the bureaucratic and regulatory nature of the NHS and how they were not used to so many regulations, so much paperwork to fill in, and having to write long medical notes. The following is an example of such reports: Oh, my god, that much paper. They have forms for everything. If you take a note – they have forms for this and for that, they have forms, so I think they use too much paper. They have protocols and forms for everything that you can possibly think . . . (I23F). 3.4.2. Non-hierarchical structures Ten interviewees made reference to hierarchy in their responses. For some, the British organizational structures were similar to those in their own system, particularly for Maltese doctors since their system is based on the NHS “Sure, so the hierarchy, it’s, I would say, similar to the one used in Malta, because Malta’s based essentially on the British system (I12M)”. However, for most interviewees, the system in the NHS is less hierarchical, particularly with the way in which consultants work and how much responsibility interviewees mentioned having as junior doctors, which they contrasted with the responsibility they would have in their home

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countries. This was mainly reported by interviewees coming from Germany, Hungary, Italy and France. Whilst most reported this as a positive aspect of the NHS, as junior doctors felt more valued “Here, they seem to be open to my ideas and it makes me feel I’m confident (I2F)” they also saw its disadvantages, related to not knowing who is responsible for what “And it was very difficult to find my role, my job, when shall I make a decision alone and when shall I ask for help (I2F)” while in some cases it resulted in feelings of isolation: I think it’s an advantage (work alone) but also a disadvantage; you might sometimes feel a bit more isolated and sometimes it’s probably not the most productive way (I14F). Exceptionally, a Dutch GP felt the UK system was more structured and hierarchical “Like you have a consultant who is very high in the hierarchy. So, for example, if you’re a GP, you wouldn’t call with the consultant (I16M)” perhaps reflecting the more egalitarian nature of the Dutch system. Overall, at hospital level most interviewees appreciated the environment whereby they considered that those at different grades are more respectful to each other. 3.4.3. Drive for evidence and quality of health care A total of six interviewees described the NHS having a drive for evidence based medicine and clinical guidelines “I think, specifically, in the health system, I think there is already quite a big drive on guidelines and evidence based medicine a bit more in the UK than it was in Slovenia at the time (I1M)”. For all those who reflected on this component, it was considered beneficial. However, while there was praise for evidence based medicine and the overall quality of health care in the NHS “The NHS system is definitely better, definitely a higher level of care (I2F)”, there were some concerns about the cleanliness of hospitals and the safety of patients. Several interviewees referred to how dirty the wards were and how shocked they were by this occurrence: The first thing that shocked me is how old everything was here, you know, how backward the wards seemed; we’re talking about people that were separated by curtains and 20 beds put in a row, dirty cutlery, broken dishes and glasses, [. . .] paper towels stained with coffee and dirt and unhygienic; it was grim, really grim (I9M). The safety of patients was mentioned when interviewees discussed the responsibilities borne by trainees. While most agreed that it was good to be independent if they were to learn new skills and acquire additional responsibilities, some believed that it could compromise the safety of patients. As an Italian doctor explained: About the safety of patients, if I have to be honest I don’t think the patient in this system is very safe. I had this impression when I was working because basically everything in your case is managed by young doctors. [. . .] Sometimes they are completely left on their own. So if you are a patient and you go to a hospital at night, maybe you are . . . the first doctor that takes care of you is a young doctor after the degree (I23F).

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3.5. Future prospects and moving back 3.5.1. The training trap: it is difficult to progress One of the most sensitive issues discussed during interviews, was whether interviewees felt they could progress within the system. Most agreed that it was very difficult to get into a training scheme and that most of the positions offered to other Europeans were only for a few years. A Greek doctor who had not succeeded in obtaining a position explained that her training in Greece allowed her to join as an F2 (foundation year 2) doctor, but these posts were nearly impossible to get if you were not already in the system. As a result, she left the NHS to concentrate on an academic career. As she explained: In terms of the Greek university this is a trap. You skip the first year but you cannot find a job as a second year. There are few standalone posts. In order to find a standalone post someone has to leave the job, die, be pregnant, leave the job, something happen which is not that common (I19F). Similarly, to advance to a consultant post was considered nearly impossible. Overall, one of the major barriers reported by interviewees was the difficulty in entering and progressing through the training system. As a Greek doctor explained: So you’re not a proper British trainee and if they have a proper British trainee they will choose him. So it’s very good for example stay here two, three, four years in that post, but if I wanted to stay indefinitely in the UK that would be a major, major problem because although I have the credentials to stay – not the credentials, but the CV to stay, I would never be appointed as a consultant here. My chances would be minimal. [. . .] No, you don’t have the same chances. That’s definite (I5M). 3.5.2. Hidden social hurdles The most sensitive issue discussed during interviews was whether interviewees felt any type of discrimination because of not being from the UK. Most interviewees reported no discrimination in the NHS and that nationality was not a concern: “No, no, absolutely not. From a professional point of view my nationality or my ethnicity has never been a problem (I2M)”. However, there were several reports of ‘stereotyping’ and ‘patronising behaviour’, although it was not considered very serious. This was described by an Italian doctor: Stereotyping a little bit and being a bit patronising. Sometimes I felt that they patronised a little bit if you are from another country. I had this feeling, but then it’s not something very serious let’s say. You can cope with that. It’s much easier to say something bad about you because you don’t understand very well. You are from another system (I22F). A few participants did report some kind of discrimination, while others reported how British people felt that their system was the best and that it was difficult to bring something new into the system:

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So when you have to compete with people from this country you would be discriminated a little bit always. I always have this feeling because I think you always have to show that you twice as good as an English person (I22F).

now year 9 so it’s close but then again with the economic situation in Greece – everyone’s actually trying to leave now while we want to come back. So my parents are saying you know don’t come back now (I8M).

Finding it difficult to reach higher positions was the most negative remark made by interviewees. In those instances, it was suggested that ‘old boys’ networks’ are required and if you are not part of these networks it is very difficult to reach some of the top positions. When comparing the reported experiences in the medical field and academia, interviewees mentioned that academia was a safer environment since it was much more international. The following is an example describing the experiences of a doctor having a senior position who was told of the ‘hidden social rules’:

Some mentioned that they would consider moving to another country that would allow them to progress further within the system, with Germany being cited as an example.

I was approached and nominated by other people and they interviewed me for one of the [xxxx] medical directors and the person from the head-hunting agency, she was very honest and she said ‘xxx, you have the track record for clinical leadership, so you’ve led other doctors. . . you know evidence based medicine and you’ve got a research background’, etc., but she said ‘you miss one thing and that’s connections [. . .] . . . so she asked me ‘how many lords do you know?’ and so yeah, it’s that kind of level; those who are close to the secretary of state or to the minister of Health, your colleagues or friends, that you could pick up the phone and talk to them. Yeah, and I feel this is also where there’s the ‘old boys networks’ that start to kick in (I1M). 3.5.3. Moving back All interviewees that had managed to make it through the training programme were not considering returning to their home country. Family reasons and personal circumstances played a major role in their decisions. My initial response would be no, I am not planning to go back to Spain for many reasons. As much as England can be difficult, it’s where I live and I’ve got my family here and children so there are a few things that keep me in a place not just the profession (I5F). For those that were considering going back, several mentioned that the experience they had obtained in the UK would be viewed positively, although most were not sure if it would fully be recognised in their home countries where colleagues might be reluctant to accept their acquired new skills. Others thought that the experience they had gained would be very positive for their own health care system and would help in improving the quality of health care back home “They’ve definitely had to develop the Hungarian system with the doctors moving to the UK and got experience there, it’s a very important thing (I20M)”. Financial considerations were important when deciding to return; whilst most had moved to learn new skills, those from countries that are currently suffering a financial crisis recognised that it would be very difficult to return under current circumstances. As a Greek doctor explained: At the moment I am nearing the end of my training and we always said we would stay here for 10 years, this is

3.5.4. Policy recommendations Most interviewees when asked what could be improved to make their experience in the NHS more positive mentioned having proper information about the NHS on arrival. Whilst most GPs were opposed to the compulsory exams and associated induction, most doctors working in hospitals complained that they received very little training on how the system worked. Most specialists would welcome information provided by human resource departments, a shadowing scheme “For example, maybe two weeks shadowing could be enough to understand how the system works (I22F)” or a voluntary brief induction. Interviewees did not have very strong views on whether a language test should be compulsory or not. Most mentioned that the job interview was an implicit assessment of their language skills. Few saw any need for the GMC to introduce language requirements, although they did not oppose it strongly: I don’t think that it should be done from the GMC, not that I would have any problem, but I think that this is something very practical that can be easily done through an interview (I5M). Finally, an area that concerned many interviewees and has already been discussed in this paper is the opportunity to enter the training system and have a career path. Some interviewees suggested that the system should be more flexible: Sometimes yeah, I have the feeling if you’re not into the system it’s very difficult. So one thing could be . . . make the system more flexible. The London Deanery should be . . . for example could give the opportunity to enter maybe for specialists, could give the opportunity to enter also in senior registrar positions (I22F). 4. Discussion This paper contributes to the so far very limited literature on the experiences of EU doctors working in the UK. Interviewees’ responses have highlighted some aspects that work well and others that need improving. The GMC registration process was reported as straightforward by most. The exams and induction procedures in general practice were major hurdles for some interviewees. There was a consensus that information provided by hospitals about the health system was inadequate. Some interviewees reported initially having language problems, but most felt that these were quickly resolved. Importantly, overwhelmingly they reported very positive experiences with patients; enjoying the less hierarchical structure of the NHS; and appreciating the emphasis on

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evidence-based medicine and the learning opportunities available. Negative aspects included the amount of paper work, concerns about cleanliness of hospitals, and patient safety. In addition, some participants from Southern European countries reported relationships with patients being more formal than they were used to. These findings are consistent with our earlier research in Spain exploring the healthcare experiences of British pensioners. British pensioners reported being impressed with the cleanliness of Spanish facilities and contrasted the empathy displayed by Spanish health professionals with that experienced in the UK [28,29]. Most of our interviewees, contrary to media reports, were well prepared and their main motivation to move to the UK was to learn new skills and experience a new health care system. Interviewees also noted that their compatriots who came to the UK were those who were best prepared and most willing to learn new skills. This is consistent with research by Illing et al. who found that overseas-qualified doctors felt more prepared for clinical practice than UK graduates [23]. Our interviewees did not experience discrimination but there were some episodes of patronising and snobbish behaviour. However, it is cause for concern that some believed that their nationality would not allow them to reach certain positions where ‘old school networks’ are needed. However, this may also apply to UK doctors from less advantaged backgrounds, signifying institutionalized social inequity rather than discrimination although further research is needed to ascertain whether cultural differences do influence progress into senior positions. This has been suggested in research on nursing [30–32]. However, given the small numbers, it is not possible to know whether there is an institutionalized problem in the NHS or whether these were exceptional accounts. A clear message to emerge from this study is the need for better information on how the NHS functions. A study conducted by the GMC concluded that nonUK-qualified doctors (including those from elsewhere in the EU) experienced a number of difficulties related to practising within a different ethical and professional regulatory framework. The study recommended the provision of information and educational resources before registration, together with in-practice support [24,33]. Our results suggest that these measures would be welcomed by interviewees. The newly adopted Directive 2005/36/EC introduces new measures to facilitate the mobility of health care professionals. It will introduce an electronic certificate that will be exchanged between competent national authorities through the Internal Market Information System (IMI); it establishes some minimum training requirements; language skills can be verified once the professional qualification of the individual concerned has been recognized; and an alert mechanism will be introduced via the IMI to notify any health care professional suspended or prohibited from practicing [8]. The modernised Directive 2005/36/EC provides a basis for member states to explore areas where they might reach agreement. However, given

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the diversity of national health systems and beliefs on the nature of professions, there is a need for caution. As our previous research on the systems of licensing and registration of doctors in Europe showed, these have developed within specific national contexts and vary widely [34]. Our research on systems to ensure continuing competence of doctors in Europe also highlighted inconsistency in scope, coverage, and content [35]. This inevitably creates problems in the context of increasing mobility of professionals [34]. Notwithstanding these concerns, greater clarity about the systems involved can help to establish a reliable system that is trusted by all parties, including health care professionals from other countries, national policy makers and regulators, health care providers, and most importantly patients. The strengths of this paper are that we were able to elicit accounts of a very varied group of EU doctors working in different settings both in primary health care and hospitals, at different levels of seniority and working in different specialities. We were able to undertake an in-depth analysis of their experiences on a series of topics, some of which were quite sensitive, such as progress through the system when one has a different nationality. The fact that both interviewees were themselves from another EU Member State might have facilitated these discussions. We have attempted to provide a comprehensive account of physicians’ views by including as many European nationalities as possible, although perhaps under representing some Eastern European countries. A limitation of this study is that our sample comprises mostly successful candidates. We made efforts to recruit participants that had not made it into the system. Most of those that we identified had returned to their home country and we were only able to identify and interview three, despite strenuous efforts [35]. The picture that emerges is one of a system that is performing fairly well for both doctors from elsewhere in the EU and their patients. The problems the doctors experienced are related to lack of information; language; and difficulties accessing specialist training and achieving senior positions. Overall, interviewees reported having enjoyable experience with patients and enjoying what the NHS had to offer. This paper provides the first detailed account of how EU doctors view the NHS and it will be of relevance to regulators such as the GMC and to policy makers at national and European level working in the field of professional mobility.

Ethical approval The research was approved by the Ethics Committee of the London School of Hygiene and Tropical Medicine. All participants were informed about the content of the study and its likely outcomes and were informed of their right to refuse to answer any question which they did not wish to answer. A consent form provided information on the research, including the confidentiality and anonymity of interviewees’ responses. All read the information sheet, signed the consent form and gave written consent to their interview data being included in publications.

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Funding This paper is the result of research that was requested by the European Commission’s Directorate – General for Health and Consumers and co-funded through the EU’s FP7 Cooperation Work Programme: Health (contract number 242058; contract acronym EUCBCC). The European Commission is not responsible for the content of the paper. Responsibility for the facts described in the report and the views expressed rests entirely with the authors. References [1] García-Pérez M, Amaya C, Otero A. Physicians’ migration in Europe: an overview of the current situation. BMC Health Services Research 2007;7(201). [2] Young R. A major destination country: the United Kingdom and its changing recruitment policies. In: Wismar M, et al, editors. Health professional mobility in Europe – evidence from 17 European countries. Brussels: European Observatory on Health Systems and Policies; 2011. [3] Young R, Noble J, Mahon A, Maxted M, Grant J, Sibbald B. Evaluation of international recruitment of health professionals in England. Journal of Health Services Research & Policy 2010;15(4): 195–204. [4] GMC. List of registered medical practitioners – statistics; 2013. Available from: http://www.gmc-uk.org/doctors/register/search stats.asp [cited 03.06.13]. [5] European Commission. Directive 2005/36/EC on the recognition of professional qualifications 2005/36/EC. European Union: European Parliament and of the Council; 2005. [6] European Commission. Directive of the European Parliament and of the Council amending Directive 2005/36/EC on the recognition of professional qualifications and regulation on administrative cooperation through the Internal Market Information System, COM(2011) 883 final; 2011. [7] European Commission. Consultation paper by DG Internal Market and services on the professional qualifications directive, Brussels; 2011, 20 pp. [8] Directive 2013/55/EU of the European Parliament and of the Council of 20 November 2013 amending Directive 2005/36/EC on the recognition of professional qualifications and Regulation (EU) No 1024/2012 on administrative cooperation through the Internal Market Information System (“the IMI Regulation”); 2013. [9] Meikle J, Campbell D. Doctor Daniel Ubani unlawfully killed overdose patient (04/02/2010), in The Guardian; 2010. [10] Dyer C. Rules on EU doctors threaten patients’ safety, says House of Lords report. British Medical Journal 2011;343:d6793. [11] Physicians RCo. Review of the professional qualifications directive: mobility of healthcare professionals, London; 2011. [12] Dyer C. UK spread the myth that doctors’ language skills may not be tested, says EU commissioner. British Medical Journal 2012;344:e589. [13] BBC. Foreign doctors face GMC’s English language tests; 2014. Available from: http://www.bbc.co.uk/news/uk-28011620 [cited 25.07.14]. [14] Hall P, Keely E, Dojeiji S, Byszewski A, Marks M. Communication skills, cultural challenges and individual support: challenges of international medical graduates in a Canadian healthcare environment. Medical Teacher 2004;26(2):120–5.

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