opinion & debate The NHS International Fellowship Scheme in Psychiatry: robbing the poor to pay the rich?

The NHS International Fellowship Scheme was launched in 2003 to recruit doctors from outside the UK to fill the shortage of doctors in the NHS. While the intended and stated primary purpose was to fill the service needs of the NHS, a secondary purpose appeared to be the opportunity the scheme would

The NHS International Fellowship Scheme was launched in 2003 to recruit doctors from outside the UK to fill the shortage of doctors in the NHS. While the intended and stated primary purpose was to fill the service needs of the NHS, a secondary purpose appeared to be the opportunity the scheme would offer to overseas doctors to work in a 'unique health care system' (Goldberg, 2003). Doctors would be appointed at consultant level in the NHS for a maximum period of 2 years.
Psychiatry has been a major beneficiary of the scheme, and has already recruited more consultants than all the other specialties combined. By January 2003, a total of 123 consultant psychiatrists have applied and 26 have been appointed to the scheme (Goldberg, 2003).
Although it appears that the scheme creates a win-win situation for all parties concerned (the NHS, the overseas doctor, the Royal Colleges), it fails to take into account one other affected party -the 'donor' country, from where the overseas psychiatrists would come. This article highlights the issues from a developing 'donor' country perspective. In particular, it addresses key issues that affect the mental health care systems of developing countries. Pakistan, a South Asian developing country, is taken as an example to illustrate the problem.

Pakistan: a brief background
Pakistan's population of 140 million and population growth rate of 2.3% are among the highest in Asia. It ranks 132 on the United Nations Development Programme's Human Development Index (HDI), with a third of its population living below the poverty line. Its literacy rate hovers around 35%, with 70% of the population living in rural areas where the literacy rate is even lower. Health spending rarely exceeds 0.5-1% of the annual gross domestic product, and a fraction of that (if any) is allocated for mental health. Since its independence in 1947, the country has been beset with economic and political problems.

Prevalence of psychiatric disorders
Population-based epidemiological studies show the prevalence of common mental disorders in Pakistan to be one of the highest in the developing world -higher even than developing countries with similar socio-economic indicators (Mumford, 2000). These figures range from a low of 25% (urban areas) to a high of 72% (rural areas) for women and between 10% (urban) and 44% (rural) for men (Mumford, 2000). Prevalence of emotional and behavioural problems in school-going children has been estimated to be 9.3%. There are an estimated 3-4 million people with drug addictions in the country. Over the past 10 years, suicide rates have jumped 10-fold (Khan, 1998). Serious mental disorders like schizophrenia, estimated conservatively at 1%, would number approximately 0.5-1 million patients. The rate of severe learning disability is 1.5%, which is among the highest in the developing world.

Mental health services in Pakistan
Mental health services are poorly developed in Pakistan. This is not only due to poor resource allocation, but also a general ignorance of mental health-related issues at all levels of government planning and implementation. Psychiatry and behavioural sciences is taught in only a handful of medical schools, with the result that most doctors in Pakistan have little or no exposure to mental health-related issues. Psychiatry departments in most medical colleges have to cope with enormous numbers of patients and are continuously overwhelmed. There are few quality training positions in the country. Training programmes lack depth and while exposure to general adult psychiatry is good, there is a serious shortcoming of exposure to the sub-specialties.
There are only 150-200 properly trained and qualified psychiatrists in the country; an alarming ratio of one psychiatrist to about a million people. As most of these specialists are located in cities, large numbers of people with mental health problems either remain uncatered for or seek treatment from faith healers.
Despite these overwhelming odds, efforts are underway to improve the situation. The College of Physicians and Surgeons Pakistan (CPSP), the professional body for post-graduate training and certification, has been making concerted efforts to streamline training programmes, and make the examination system more objective and standard. This has led to more doctors sitting and passing the Fellowship examination of the College, qualifying them for specialist and academic positions in various institutions. However, the enormous imbalance that exists between the number of psychiatrists being trained and qualifying each year, and the quantum of psychiatric problems in the country, is far from being redressed.

'Poaching' by the NHS
Whatever little progress is being made in the area of mental health in Pakistan is now being seriously undermined due to 'poaching' by the NHS through its so-called International Fellowship Scheme. In its effort to solve manpower problems, the NHS is bending all kinds of rules and cutting corners to lure overseas qualified psychiatrists to work in the UK. No professional and linguistic assessment board, no approved psychiatric training, no higher training, direct registration with the General Medical Council, registration on the Specialist Register or an Honorary MRCPsych. On top of this are the huge financial inducements -fellows are paid on the NHS consultant salary scale, but in addition there are relocation and return expenses of up to »16 000, and an allowance to pay for accommodation expenses of up to »30 000 in London, »20 000 in the South East and »15 000 elsewhere. This is in addition to an all-expenses-paid round trip to the UK from the candidate's home country, with full boarding and lodging, for the interview process. Little wonder then that to fill 50 positions in the NHS, there were 400 applications, out of which 123 were psychiatrists.

The 2-year period of the Fellowship
Ostensibly, the scheme is designed to 'attract people who wish to work abroad for a limited time' and who 'need to maintain commitments at home' (Goldberg, 2003). This is quite untrue. People who have gone on the scheme have resigned from their posts in their home countries. They have no commitments back home and do not have a real reason to return if they choose not to. The scheme is clearly 'open to Fellows to remain beyond their 2 years, either in the same post if their employer agrees, or by seeking another post in the NHS on the same terms and conditions as other NHS employees' (Goldberg, 2002). It is quite evident that the NHS is looking to retain people beyond the 2 years. The loss to the mental health system of the donor country would therefore be long-term.

The role of the College
Why has the College consented to go along with the scheme is beyond comprehension. But by doing so, it has made a mockery of the whole process of approved senior house officer training, approved higher specialist training, entry to the Specialist Register and the MRCPsych exam. From my own personal experience of working both in the UK (from a trainee to a consultant level) and in Pakistan, and of the feedback I have received from some of the selected candidates, I find it incredulous that the College is willing to validate an overseas psychiatrist's experience and qualification without as much as a semblance of critical appraisal of the candidate's training programme and the standard of examination in his/her home country. It appears the only real (and objective) qualification being asked for is the ILETS (International English Language Testing Service) score.

The effect on a small academic department of psychiatry
In my own small but busy academic department of four full-time psychiatrists, the result of the Fellowship scheme has been devastating. One junior faculty has been accepted on the scheme, effectively and immediately reducing our strength by 25%. Another is seriously considering it. This has serious and long-term repercussions on our undergraduate and post-graduate teaching, clinical, research and administrative activities and sets us back many years. There is no way a small psychiatric department in a developing country can compete with the huge inducements a health service in a developed country has to offer.

Is there a way out?
Getting doctors from overseas to fill their service gaps by bending the rules is not the way the NHS should behave. Developed countries like the UK must act responsibly, and not only in their own self-interest and for their shortterm goals. They need to keep the bigger picture in mind. We frequently talk of improving the health service, training and research capacity in developing countries. This is only possible if enough trained and skilled personnel can be retained in the developing countries. How is this possible when the few that are there are being lured away?
As we in the developing countries struggle to look for solutions that are home-grown and relevant to our settings, the UK and the NHS must also look for solutions closer to home. I find it odd that hundreds of excellent staff grade psychiatrists (many with quality training as well as the MRCPsych) are languishing in dead-end jobs, doing as much as a consultant (in some cases more) and yet cannot get on the Specialist Register. Does it make sense to appoint an International Fellow, often without any higher specialist training, over such staff grade doctors?

Conclusion
Although the International Fellowship Scheme in Psychiatry may help the NHS make up its shortfall in the short term by recruiting abroad, the scheme is playing havoc with the mental health system of the 'donor' countries, the vast majority of them being developing countries and particularly from the Indian sub-continent. Developed countries like Britain need to be cognisant of the health care needs of developing countries. People should certainly have the right to choose where they want to live and work, but bending rules for one's own personal gains and allowing people to enter the system through the back door, without considering the serious repercussions of actions on other affected parties, is not behaving responsibly.

Declaration of interest
None.