This article discusses the history of clinical attachments in psychiatry and recent changes in this area, including work permit regulations, which can make it increasingly difficult to obtain an attachment. The advantages and disadvantages of clinical attachments are considered for both the clinical attaché and the UK health service. Good practice points for clinical attacheés and their supervisors are presented. The future of the scheme is discussed and potential solutions to difficulties are suggested.

What is a clinical attaché (sometimes known as honorary senior house officer (SHO), clinical fellow, or honorary fellow)? One commonly held view is that clinical attachés are overseas doctors who gain unpaid work experience in the high-quality National Health Service, in the hope of then gaining paid employment and training and skills to eventually bring back to their country of origin. An alternative view is that they are doctors, wealthy in their home countries, who desert their needy compatriots in order to earn lots of money and settle permanently abroad, working in a system that is happy to asset-strip poorer countries. Similar arguments rage regarding the NHS International Fellowship Scheme (Reference KhanKhan, 2004; Reference HolsgroveHolsgrove, 2005). The reality may be somewhere in the middle of these polarised views.

The exact number of doctors seeking clinical attachments is unknown, but many hospitals and consultants receive hundreds of applications annually. This high figure is because of the potential rewards if successful, and perceptions abroad that the NHS is short of junior doctors (advertisements in foreign newspapers for doctors in the UK may encourage this view). Changes in registration procedures and to the Professional and Linguistics Assessments Board (PLAB) examination (including overseas sittings) by the General Medical Council (GMC), and profits made by the GMC and some trusts may be factors in encouraging applications.

Anecdotal evidence suggests that many aspiring clinical attachés are unaware of the true picture in terms of how difficult it is to be successful; ‘ failed’ doctors are reluctant to give the true reasons for their return home, and doctors may be blinded to the reality by their own hopes (Reference AlcockAlcock, 2004).

Currently, clinical attachments in psychiatry are obtained predominantly through personal contacts in the UK. Doctors also try their luck by sending curriculum vitae to unknown consultants or medical staffing departments. There is much variability among hospitals and consultants; some take no clinical attachments (and may have policy accordingly), some take a few, some perhaps take too many. There are no national standards, although there are guidelines (Reference Cheeroth and BerlinCheeroth & Berlin, 2001). In some hospitals there may be formal or informal procedures, waiting lists, or structured schemes for clinical attachés.

Benefits for clinical attachés

The primary purpose of clinical attachments is to provide overseas doctors with experience of the NHS and how psychiatry is practised in the UK. They are also opportunities to enhance curriculum vitae, thereby improving the attachés’ prospects of getting paid employment (Reference Berlin, Cheeroth and AgnellBerlin et al, 2002). Clinical attachments give overseas doctors opportunities to improve aspects of practice that may be emphasised more in the UK than in overseas training systems.

The benefits for individual doctors in terms of career prospects in the UK and elsewhere, remuneration, opportunities for family members to live in the UK, etc. must also be borne in mind.

Benefits for trusts, the NHS and others

Any experience and skills gained by clinical attachés benefit patients in the UK if those doctors go on to work in the UK. More tangible benefits for trusts include the ability to recruit into SHO posts from current and past clinical attachés; it is clear that the informal knowledge of these candidates gained during their time as clinical attachés by members of interview panels can affect who is called for interview or offered a post. Another clear benefit for trusts is that clinical attachés constitute a pool of doctors willing, indeed often desperate, to do locum work. This helps trusts fill service gaps and adhere to the European Working Time Directive, and provides cover for leave taken at short notice. There are cost savings for the state, as the NHS can increase the medical workforce quickly and relatively cheaply.

Problems for clinical attachés

Getting an attachment is largely a result of persistence, luck and help from consultant or junior doctor friends. Many doctors lament that they had to wait months to secure an attachment, or that responses to enquiries to medical staffing departments were usually discouraging.

The difficulties continue even after securing an attachment; there is ongoing uncertainty owing to the short-term nature of contracts offered, periodic visits to the Home Office for expensive visa extensions, pressure to get paid employment and get accepted onto a training scheme, and financial pressures. Attachments are by no means guarantees of future employment. The cost of living (especially accommodation) in the UK is high, and people with short-term visas and no employment contract find getting a private rental contract difficult. The practice in some trusts of charging for attachments is in our opinion undesirable, especially as the quality of the experience offered is often no better as a result, although we accept that such fees are legal and are dictated by market forces.

Attachments vary in quality; there are many instances of attachés being mistreated in various ways (see Box 1), not least because of their dependence on the sponsoring consultant. Some consider that even the best attachments are not meaningful experiences, owing to limitations on patient contact, inadequate teaching from SHOs and senior doctors, the pressures noted above and the steep learning curve in general.

Problems for trusts, the NHS and others

Many mental health trusts are reluctant to accept clinical attachés because of the costs of processing applications, providing accommodation and pre-employment screening. Clinical attachés are sometimes perceived as unreliable, for example not turning up when expected, leaving with little notice and not paying bills. Trusts may be reluctant to provide training for a doctor without guarantee of any reciprocal benefit.

Medical and other students may receive fewer educational opportunities if clinical attachés are also present (bearing in mind that clinical attachés should not see patients alone).

Individual consultants may have little experience of clinical attachés, or may have ethical objections to recruiting from poorer countries. Doctors from different countries may not have equal opportunities to gain an attachment. Some believe there is an ‘old boys network’; there are reports of consultants accepting as attachés only doctors who have graduated from the consultant's own alma mater.

Impact of recent changes in immigration regulations

Until 3 April 2006 doctors in training did not require work permits to train in the UK. From this date the only doctors who will be covered by the permit-free arrangements are those who have completed their medical degree in the UK and have been appointed to a 2-year foundation programme. In making appointments, doctors from other European Economic Area (EEA) countries must be considered for posts along with UK applicants. A post must be offered to an adequately qualified UK or EEA doctor even in preference to a better-qualified overseas doctor. If recruiting overseas doctors, NHS trusts will have to show that a sufficiently qualified UK or EEA national was not available to fill a post. These measures introduce a two-tier system of recruitment, heralding the demise of the meritocracy in appointing doctors.

Doctors who have leave to remain under the Highly Skilled Migrant Programme can still take up any posts offered, without the need for Home Office permission.

Following discussions with the Department of Health, the Home Office has decided to limit the amount of leave granted for clinical attachments to 6 weeks at a time and 6 months in total, in line with the purpose of these posts, to allow overseas doctors to familiarise themselves with UK working practices and prevent overseas doctors remaining in the UK when there are no suitable posts available.

Predicting the future is difficult in the light of these changes, but it is clear that opportunities for overseas doctors will be fewer because of increased competition from EEA doctors. The current flood of applications for clinical attachments is likely to become a trickle, but is unlikely to dry up completely in the immediate future.

Solutions

Clinical attachés and supervisors would benefit from some of the good practice points suggested below.

Declaration of interest

R.O. is the Immediate Past Chair and S.N. was a member of the Psychiatric Trainees' Committee, Royal College of Psychiatrists at the time of writing.