Refugee doctors as doctors ’ assistants in psychiatry

Refugee doctors differ from other international health professionals in that most left their country of origin under duress, rather than being part of the induced migration of many healthcare workers from lowto highincome countries. There are now over 1000 such doctors registered with the British Medical Association Refugee Council voluntary database of refugee and asylumseeking doctors (British Medical Association, 2006). Having obtained refugee status (or indefinite leave to remain), many wish to use their skills within the National Health Service (NHS) and contribute to their host country. However, they need to obtain the requisite qualifications (i.e. 70% in the International English Language Test and passes in both the written and clinical parts of the Professional and Linguistic Assessment Board) before being registered with the General Medical Council. They also need to gain an understanding of the culture and context of medical practice within the UK, as well as good references, if they are to compete successfully for training posts with UK graduates and other international medical graduates. The most recent figures available (September 2005) show that only 77 of those registered with the database are currently working in the NHS and 207 doctors have the required accreditation but are not yet employed (British Medical Association, 2006). The British Medical Association, General Medical Council and some of the Colleges recognise the potential of this group of doctors and encourage ways to support them to overcome these initial hurdles (British Medical Association, 2006). Refugee doctors are dispersed across many regions of England, as well as Scotland and Wales (Butler & Eversley, 2005), but opportunities for paid, supported clinical work while studying are often sporadic and based primarily in the larger conurbations. Psychiatry is often a rudimentary specialty in the countries of origin of many refugees, yet their experiences of persecution within their home country, forced migration and marginalisation by society in this country may give many refugee healthcare professionals insights that would be valuable within psychiatric practice. However, without sufficient exposure to psychiatry a career in this specialty is unlikely to be considered and a potential opportunity for recruitment lost. In response to the European Working Time Directive requirement to reduce doctors’ hours (Department of Health, 2002), as well as recommendations that junior doctors should not be responsible for carrying out routine investigations such as electrocardiography and phlebotomy (Royal College of Psychiatrists, 2003), Oxfordshire Mental Healthcare NHS Trust agreed to the creation of ‘doctors’ assistant’ posts. The role of doctors in these assistant posts was to perform clinical investigations and to ensure that the results were accessible to others working within the trust. These posts were advertised within the trust and also to the local refugee doctors’ group. Two refugee doctors were appointed as doctors’ assistants in May 2004.


Refugee doctors as doctors' assistants in psychiatry
Refugee doctors differ from other international health professionals in that most left their country of origin under duress, rather than being part of the induced migration of many healthcare workers from low-to highincome countries.There are now over 1000 such doctors registered with the British Medical Association Refugee Council voluntary database of refugee and asylumseeking doctors (British Medical Association, 2006).Having obtained refugee status (or indefinite leave to remain), many wish to use their skills within the National Health Service (NHS) and contribute to their host country.However, they need to obtain the requisite qualifications (i.e.70% in the International English Language Test and passes in both the written and clinical parts of the Professional and Linguistic Assessment Board) before being registered with the General Medical Council.They also need to gain an understanding of the culture and context of medical practice within the UK, as well as good references, if they are to compete successfully for training posts with UK graduates and other international medical graduates.The most recent figures available (September 2005) show that only 77 of those registered with the database are currently working in the NHS and 207 doctors have the required accreditation but are not yet employed (British Medical Association, 2006).
The British Medical Association, General Medical Council and some of the Colleges recognise the potential of this group of doctors and encourage ways to support them to overcome these initial hurdles (British Medical Association, 2006).Refugee doctors are dispersed across many regions of England, as well as Scotland and Wales (Butler & Eversley, 2005), but opportunities for paid, supported clinical work while studying are often sporadic and based primarily in the larger conurbations.
Psychiatry is often a rudimentary specialty in the countries of origin of many refugees, yet their experiences of persecution within their home country, forced migration and marginalisation by society in this country may give many refugee healthcare professionals insights that would be valuable within psychiatric practice.However, without sufficient exposure to psychiatry a career in this specialty is unlikely to be considered and a potential opportunity for recruitment lost.
In response to the European Working Time Directive requirement to reduce doctors' hours (Department of Health, 2002), as well as recommendations that junior doctors should not be responsible for carrying out routine investigations such as electrocardiography and phlebotomy (Royal College of Psychiatrists, 2003), Oxfordshire Mental Healthcare NHS Trust agreed to the creation of 'doctors' assistant' posts.The role of doctors in these assistant posts was to perform clinical investigations and to ensure that the results were accessible to others working within the trust.These posts were advertised within the trust and also to the local refugee doctors' group.Two refugee doctors were appointed as doctors' assistants in May 2004.

Evaluation
A 3608 evaluation was undertaken of improvements in service following the appointment of the doctors' assistants.A postal survey of all junior doctors on the three sites where the scheme was in place was undertaken at the end of the first year of the project.Rates of haematological investigations before the scheme and at 12 months were compared.A small number of in-patients were asked for their views on the role of doctors' assistant, and those involved in the scheme were asked to assess the impact of the new posts.

Junior doctors
Junior doctors were surveyed at the end of the first year of the project.Of 20 senior house officers, 15 completed the survey; 14 said that their workload had been significantly reduced and commented that this had given them more time to spend with patients in a therapeutic role.All those who responded rated the doctors' assistants (on a five-point scale) as either 'efficient' or 'extremely efficient'.Moreover, 14 of 15 respondents rated their liaison with other clinical staff as either 'good' or 'extremely good'.Several also commented that their reliability and specialised skills in performing investigations made the experience less distressing for the patients.Others remarked that they did not consider routine phlebotomy as a medical task and therefore it was right that this was no longer required of them.

Investigations
One concern had been that by making it easier for doctors to request investigations without having to perform them, there would be an inappropriate rise in the number of investigations.Data provided by the local pathology department, to which all samples are sent, were audited to determine the number of requests for full blood count and urea and electrolyte tests over two time periods.Over 3 months, before the appointment of doctors' assistants, the pathology department performed 394 full blood counts and 55 urea and electrolyte tests.Over the same time period 6 months after the introduction of the doctors' assistants, there were 411 full blood counts and 47 urea and electrolyte tests.This suggests that there was no overall increase in investigations performed, although the clinical skill of the two assistants might have been partly responsible for this; if there is a request for a recent investigation to be repeated without an obvious clinical indication, this is clarified with the doctor making the request before the investigation is undertaken.

Pharmacy
Oxfordshire Mental Healthcare NHS Trust has never established a specific service for patients requiring regular blood monitoring (e.g.those receiving clozapine or lithium).In-patients frequently required urgent samples to be taken before the pharmacy was able to dispense clozapine according to the regulatory requirements.With the introduction of a partial shift system for senior house officers, this situation was expected to worsen, resulting in greater inconvenience to patients and cost to the trust.The doctors' assistants, in conjunction with the pharmacy, have devised and implemented a system for more efficient clozapine monitoring across the in-patient units, which has substantially reduced the need for urgent blood tests and has facilitated the recent introduction of a 'near-patient testing' system for clozapine.

Patients
Psychiatric in-patients are a particularly vulnerable group whose care is significantly affected by staff changes and non-adherence to treatment.A consecutive series of inpatients requiring phlebotomy were asked for their opinions on the role of the doctors' assistants.The clinical skill and continuity offered by the doctors' assistants were highly valued by those patients requiring regular investigations, as was their dexterity with the needle when compared with the psychiatric senior house officers.One patient commented: 'Before, someone different did it [took blood] every time, you never knew if it would hurt or not.This way is better, you build some trust.'

Refugee doctors
Both doctors' assistants have access to training and resources that help them work towards registration with the General Medical Council.They are learning about the NHS and the way care is delivered, which will enable them to contribute as fully accredited doctors at the earliest opportunity.The library have been generous with access to study resources, including extending membership to other refugee doctors not working within the trust, so that they could continue to study as a group.All four study-group members passed the recent Professional and Linguistic Assessment Board part 2 exams, and attribute this in part to the ability to study together in a wellresourced environment.In addition, both doctors' assistants acknowledge that their own sense of self-esteem has increased now that they are using some of their considerable clinical skills to enhance patient care, rather than being required to work in unskilled non-clinical posts.
Finally, both doctors' assistants have been able to observe the effectiveness of treatments for severe mental illness within the in-patient settings, as well as the context in which psychiatry is practised.One author (A.H.L.) is now aiming for a career in psychiatry.

Conclusions
The doctors' assistants have made an impact at both personal and institutional levels within the trust, beyond that anticipated when we devised these posts.They bring with them a wealth of experience and are an important positive image for refugees in this country.

Declaration of interest
None.