English hospital trusts have been accused of using foreign doctors as "cheap labour" as part of fellowship schemes in which they can be paid less than trust-employed doctors and sent home if they become pregnant, an investigation by The BMJ has found.
Foreign doctors come to English hospital trusts as "fellows" as part of the Academy of Medical Royal Colleges' Medical Training Initiative (MTI) scheme, explains investigations editor, Madlen Davies.
They work for two years in the NHS to gain experience that they will take back to their home countries afterwards. A proportion of fellows are sponsored, for example by their home country, and others are employed directly by an NHS trust.
According to the Academy of Medical Royal Colleges (AoMRC), there have been 6,986 trainees through the scheme since it began in 2009 from countries including Pakistan, Sri Lanka, India, Egypt, Nigeria and Saudi Arabia.
In some NHS trusts fellows receive the same pay and benefits as trust-employed doctors, but University Hospitals Birmingham NHS Foundation Trust (UHB), Dudley Group NHS Foundation Trust, and Walsall Healthcare NHS Trust have a specific agreement with the College of Physicians and Surgeons Pakistan (CPSP) as part of which The BMJ has found the fellows can be paid less than trust-employed trainees and have fewer benefits.
For example, senior fellows from Pakistan who work at UHB as grade 3 specialty trainee (ST3) registrars or above are paid a stipend which can range from £2700 to £3600 a month by CPSP, the equivalent of £32,400 to £43,200 tax-free a year. They are not guaranteed extra payment for overtime and enhanced hours or on-call work.
UHB would not confirm the exact equivalent salary details of its ST3 doctors, but according to NHS pay scales, ST3 grade 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, excluding any overtime or enhanced hours payments.
ST3 grade 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 CPSP's agreement (though this calculation does not take into account pension deductions).
Under the UHB agreement fellows also do not receive paid parental leave. This follows an incident in 2017 in which UHB terminated the contract of a fellow who became pregnant. The urologist, who wanted to remain anonymous, told The BMJ the experience was "traumatic".
The doctor said it was clear from starting the fellowship that "I was not the priority and that the trust's trainees and trust grade doctors were the priority. I was told, you are just to cover the clinics and on calls." There was no enhanced payment for on-call or weekend work, she said. When she fell pregnant, she was sent home. "One lady from the international team seemed angry and said "we don't expect you guys to get pregnant while you're here" and that my fellowship would be terminated. It was a shock to me how she spoke," she told The BMJ.
Michael Newman, an employment lawyer at law firm Leigh Day, described the conditions of the scheme as exploitative, adding that a trust terminating someone's fellowship because they became pregnant and refusing to pay for maternity leave was "outrageous."
One consultant at UHB, who agreed to talk to The BMJ anonymously for fear of repercussions from the trust, said it was using fellows as "cheap labour." Another former consultant at the same trust praised the scheme in terms of the training opportunities but lambasted the lack of equal pay and rights.
In light of The BMJ's findings, CPSP has said it will review and re-write some of its guidelines, but says the scheme, which has seen more than 1000 Pakistani fellows being trained in the UK, has improved healthcare in the country.
A UHB spokesperson said: "Undoubtedly the programme benefits the NHS system, but in return it benefits the overseas healthcare structure. Programmes which encourage the upskilling of medical practitioners from countries with less developed healthcare systems have been described by the WHO as a 'brain gain and not a brain drain'."
An AoMRC spokesperson 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 it has 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.
