International Doctors: Visas

Steve Brine Excerpts

Wednesday 2nd November 2022 Westminster Hall

[Matt Warman]

I absolutely agree with my hon. Friend that increasing all those routes is hugely important. Of course, we would all like to see more doctors trained in this country, and the Government have gone some way towards doing that, but where people want to work abroad, Britain should be as attractive a place as we can be. That is why, on the GP point specifically, the Government should be removing every single barrier in that visa process.

The most straightforward thing we could do, which would remove the need for a practice to register as a visa-sponsoring practice, is simply to say that when a GP qualifies in this country, they get the indefinite leave to remain that other doctors get. These are people in whom the UK has already invested. They are already here; they already have a visa. The extension of that visa into another form seems simply to be a bureaucratic hoop that we are putting in their way as doctors and in the way of GP practices. We are putting extra bureaucracy into a system, while on the other hand the Government say, “We desperately need people to come to this country to work in the NHS, and we will try to do everything we can.” The health service does hugely good work to try to recruit such people and specifically encourages them to train as GPs, but then we put an additional barrier in their way.

The response from the Government in the past has been, “Actually, the visa process registration is not terribly onerous and GP practices can do it.” They point to the numbers that have and do, which is fine as far as it goes, but it does not answer the question of why we put a barrier in the way in the first place. It should not be a cost of doing business when we say that we really want to make it as easy as possible.

Equally, it should not be a reasonable thing to put different sorts of doctors on different sorts of levels. It is not reasonable to say to people that, just as they have gone through the most stressful part of qualifying with exams, they should also be thinking about their immigration status. That calls into question their probity when we have things such as the General Medical Council making sure that they are upstanding members of our communities, and many of them have tens of thousands of patients to testify to that.

I do not think it really washes when the Government say that we need to put barriers in place, and I do not think that the Department of Health, where the Minister was previously a Minister of State, would agree, in an ideal world, with the Home Office stance. We could work together across Government to try to secure a sensible outcome.

I have talked about GPs, but there are broader issues around visas for doctors, many of which come back to the Home Office backlogs that I know my right hon. Friend the Minister is working really hard to address. There is a good argument for simply scrapping visa fees altogether for people coming to work in the health service. That is an argument for another day, but when it comes to GPs I think that lowering the five-year limit for indefinite leave to remain to three years is the neatest way to address the issue.

On the broader issues, ultimately this comes back to how many doctors we are training in the UK. We all want, as I said to my hon. Friend the Member for Mid Derbyshire (Mrs Latham), to see more people trained in this country. That is what we are doing and that is what the Government continue to pursue, but until we reach that moment—the NHS has never reached entire self-sufficiency in the UK—we should make it as easy as possible for doctors, dentists, nurses, people working in social care, and all those who work in different parts of the health service, to come to the UK. It is not primarily a question about backlogs; it is a question about process. At the moment there is a degree of bureaucracy that simply does not need to exist.

[Steve Brine (Winchester) (Con)]

It is great to hear my hon. Friend making such an eloquent case, as always—more so than I can. The issue matters for all the reasons he has set out, but would he agree that because of the retention challenge in the health service, the more we pour in at the top is sometimes, in part at least, offset by those who go out at the bottom? There is a wider picture here to do with pension pots—the whole retention piece is part of the wider jigsaw, which I appreciate is not the remit of this Minister, but perhaps was in his previous job.

[Matt Warman]

I thank my hon. Friend for that intervention. It is always tempting to ask the Minister to go and have a word with his former self, but we cannot do that. I think he has read the last couple of points that I want to make.

There are a number of relatively low-hanging pieces of fruit that the NHS has repeatedly asked for. I want to thank the RCGP, the British Medical Association, the radiologists, the British Dental Association, and also groups such as EveryDoctor, which have helped me with this debate and have identified the fact, as my hon. Friend implied, that there are a small number of things that could and should be sorted as quickly as possible. Busting the barriers around pensions and the bureaucracy around visas are things that would make a real difference to recruitment and retention across the health service. There are plenty of things that are difficult when it comes to addressing the NHS’s challenges, particularly as we approach winter. On the narrow point of GP provision, we have a visa process that puts pressure on, in particular, small GP practices, where the added burden of registering as a visa sponsoring practice is even greater now as they are under such huge pressure. It is also a burden on GPs at what is a particularly stressful point in their careers.

I know the Minister will make entirely legitimate points around putting a process in place, but the reality is that there is a political choice to be made to ease some of those burdens. There is a powerful, compelling case to be made for doing a small number of easy things that could address the GP crisis in particular, which, as my hon. Friend the Member for Winchester (Steve Brine) alluded to, is acute.

I appeal to the Minister and the Government to work as closely as they can with the Department of Health and Social Care to understand these challenges and see what can be done, and I urge my right hon. Friend to take seriously the suggestion that if someone qualifies as a medical doctor in this country, and in particular as a GP, they should have indefinite leave to remain. At the moment, it effectively comes with that if they qualify in a hospital but not in general practice. That is an inequality that the Minister can look to fix, and I hope he will do so as soon as is practicable.

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[Stuart C. McDonald (Cumbernauld, Kilsyth and Kirkintilloch East) (SNP)]

It is good to see you in the Chair, Mr Stringer. I also start by welcoming the Minister to his place. I wish him good luck; he probably needs it, as much as any Minister in Government, because his is an incredibly challenging post. We will, of course, have significant political differences on this topic, but it is an important issue, so if there is an opportunity for constructive and positive engagement, I am up for that, wherever possible. I thank the hon. Member for Boston and Skegness (Matt Warman) not just for securing the debate but, as ever, for his expert introduction to the topic and advocacy.

Moving to the subject at hand, like other Members I will start by recognising the extraordinary contribution of non-UK nationals to all parts of our NHS. I suspect everybody in the room has benefited from that, never more so than in recent times. GP practice is no different, and nationals of other countries will continue to play an important part, both now and in the future. As the hon. Member for Boston and Skegness alluded to, figures suggest that 47% of new GP trainees in England in 2020-21 were international medical graduates.

Another important context for this debate is the extraordinary pressure that our NHS is under, particularly in the light of covid, but also for all sorts of other reasons, which we could perhaps touch on in another debate. High vacancy rates are among them. As has been mentioned, challenges in recruitment and retention affect GP practices as well as everywhere else.

Against that background, the hon. Member identified what at first seems to be a technical problem in the operation of the immigration system, but one which, when examined, is significant. A failure to solve it leads to some absurd and harmful consequences. As he pointed out, the pain will ultimately be felt by patients. He explained that the three-year GP training regime for IMGs leaves them, on completion, two years short of being able to apply for settlement. That is unlike other specialisms, which have longer training periods.

That requires IMGs to find a GP practice that has become a tier 2 sponsor, which is not easy. The hon. Member for Rutherglen and Hamilton West (Margaret Ferrier) alluded to statistics highlighting that, with half of all IMGs having struggled with the visa process, 30% having considered moving away from GP practice and 17% thinking about leaving the United Kingdom.

The Minister’s predecessors appeared to dig their heels in and say, “We just need more GP practices to become tier 2 sponsors.” I agree with the hon. Member for Boston and Skegness that that prioritises Home Office bureaucracy above the health service. Ultimately, it is the wrong answer for patients who are struggling to access a GP. We are going to lose skilled and dedicated GPs as a result.

There is one issue where I do have some sympathy for the Minister’s predecessors, and that is the rejection of the idea that a route to settlement should simply be shorter. Settlement is an important and significant thing. There are aspects of that where I am open to persuasion on the case to shorten routes generally and in some specific cases, for example, family members. However, an argument to shorten the route to settlement simply because a training course lasts a certain time is perhaps not the most persuasive. It is not one that I am closed to, but it is not one that I immediately find the most persuasive.

However, the Home Office should be pragmatic about other possible solutions that have been put forward. Its current insistence that 8,166 GP practices right across the UK should just invest time—and over £4 million—in becoming tier 2 sponsors on the off chance that they might want to recruit an IMG is simply not realistic. The £4 million in fees from those GP practices would go to the Home Office—I wonder if that has something to do with its intransigence at the moment.

The alternative approach of a practice only becoming a sponsor once it has already had an application for an IMG is also far from ideal. The delay that that causes is bad for all affected, and the pressure on IMGs to find a tier 2 sponsor to satisfy immigration requirements prior to their existing visa expiring means that they cannot wait. As evidence given to the Health and Social Care Committee earlier this year highlighted, newly qualified GPs have received removal letters from the Home Office soon after their qualification. That is absurd, because we not only need them but have spent tens of thousands of pounds on training them to do a job that we urgently need them to do. I hope good sense will prevail over the Home Office’s current intransigence.

I now turn the other solutions, which I think are perfectly reasonable, that the Royal College of General Practitioners has put forward. The first solution is to create a new post-medical training visa that works in the same way as a graduate visa. The second is to create umbrella bodies that could operate as a sort of super-sponsor. That could be the NHS or whichever training body had already sponsored the first three years of the IMG’s presence here. Who knows—it could be the Royal College of General Practitioners itself. I do not have the answer as to which option would be best, but any of them would clearly be better than the absurd situation we find ourselves in.

[Steve Brine]

I have a suggestion, at least for England: the primary care networks or the new integrated care boards could quite easily act as an umbrella sponsor, thereby taking the bureaucracy away from the practices, which is part of their purpose.

[Stuart C. McDonald]

That is a valid proposition, and we could do the same with health boards in Scotland. If we knock our heads together, we can come up with a way to fix this. It just requires a little bit of pragmatism.

There is a second issue I wanted to raise—when I saw the motion for this debate, I wondered if the hon. Member for Boston and Skegness would raise it. That issue relates to recent reports from the BBC flagging complaints of poor treatment and conditions for international doctors in private hospitals, as well as highly questionable recruitment practices. I will touch upon it briefly because it has not been raised, although it is important to draw it to the House’s attention and to see if the Minister will investigate and respond. There were reports from 11 October suggesting that doctors from some of the world’s poorest countries were being recruited, by Nuffield Health in particular, to work in private hospitals under conditions prohibited in the NHS. There are reports of doctors being on call 24 hours a day for a week at a time, not being able to leave the hospital grounds and, unsurprisingly, suffering from extreme tiredness, putting both patients and doctors at risk.

Nuffield Health denies those allegations, but a British Medical Association and Doctors’ Association UK questionnaire of 188 resident medical officers adds some credence to the claims. It shows that 81% of respondents were recruited from Nigeria, and most complained of extreme working hours and unfair salary deductions. The conclusion of the Doctors’ Association UK was that we now have a two-tier system: one for the NHS and one for other international recruits in the private sector. I ask the Minister to look into that.

That issue highlighted to me another fundamental problem with how the immigration system operates. We have all sorts of checks and regulations that focus on ensuring that people who come to work here abide by their visa conditions, and they include the doctors we have been talking about—the IMGs—where the Home Office is on their case as soon as they have qualified to see what they are doing next. However, little or no checks are done to protect people who come here. That is not just in the NHS and with doctors; I have been firing off parliamentary questions and freedom of information requests in relation to the agricultural sector. That is a sector wide open to exploitation, but as far as I can see there is no concerted effort to protect people from that exploitation.

As the Minister will appreciate, Nigeria is a red-list country for recruitment. According to both the World Health Organisation and the Government, that is not where we should be finding doctors.

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[Stephen Kinnock (Aberavon) (Lab)]

It is a pleasure to serve under your chairship, Mr Stringer. I thank the hon. Member for Boston and Skegness (Matt Warman) for securing this important debate. His speech was an excellent example of a constructive critique of where his own party is on the issue, and he put forward some practical and thoughtful ideas. I hope the Minister has taken note. I suspect there is more chance he will take note of the hon. Member’s comments than he will of mine, but we never know. This debate is a great example of the cross-party discussion that we can have in this place.

Let me start by setting out the Labour party’s position on work-based migration in Britain, as it is important to set the context before drilling down into the specifics of the issue we are discussing today. In a nutshell, we support the points-based immigration system for migrant workers; it was of course the Labour Government in 2008 that introduced that system for immigration from outside the European Union. We are clear that there will be no return to the European Union’s freedom of movement. We want to build on and improve the points-based system currently in place. It is a very blunt, one-dimensional instrument that could be significantly improved.

Our long-term ambition is to make sure that every employer across the private and public sectors is recruiting and training more home-grown talent to fill vacancies before looking overseas, but we recognise that simply turning off the tap of labour from other countries without having the appropriate workforce structures, plans, training, skills and productivity strategies in place, our private sector and our public services will deteriorate, our businesses will struggle to meet the Labour party’s ambitions to make, buy and sell more in Britain, and we potentially risk jobs disappearing overseas.

We cannot have a situation like the one we have had in the farming sector over the past year, where 30,000 pigs were slaughtered and £60 million-worth of crops were burned. Indeed, we cannot have a situation in the NHS where we are short of doctors, all because our immigration system puts up red tape and barriers that prevent, or at least severely discourage and disincentivise, doctors who have come to the UK from overseas to do their three years of general practitioner training from staying on to fill critical vacancies in the job market. That is utterly counterproductive, not least because 47% of new trainees in England in 2020-21 were international medical graduates. Labour’s shadow Health Secretary, my hon. Friend the Member for Ilford North (Wes Streeting), has been clear that it is madness for the NHS to lose GPs whom the British taxpayer has paid to train.

Successive Conservative Governments have already cut 4,700 GPs over the last decade, meaning that patients are finding it next to impossible to get an appointment. There is a chronic lack of doctors, nurses and healthcare staff in the NHS. Staff shortages are reaching dangerous levels, when the need for NHS treatment is incredibly high, with huge backlogs and millions of people forced to wait for treatment. Patients are finding it impossible to get a GP appointment in many cases, and GPs are leaving the health service at an alarming rate. Last year, one in six people who tried to speak to a nurse or GP were unable to get an appointment at all. The hurdles placed in front of international medical graduates are a barrier to our NHS filling vacancies and providing the medical care that the British public deserve.

A survey by the Royal College of General Practitioners found that around 30% of all IMG trainees consider not working as an NHS GP because of all the difficulties and red tape with the visa process. The first of those difficulties is that IMG GPs are not eligible to apply for permission to stay permanently until two years after completing their training. GP training takes three years to complete, and it is only after five years that IMGs can apply for indefinite leave to remain, in line with wider UK visa rules. That problem is unique to general practice: other medical specialty training takes a minimum of five years to complete.

The second difficulty is that international GPs must find employment with a GP practice with a visa sponsor licence before their existing visa expires in order to be eligible for a visa that allows them to stay and work as a GP after their training, and ultimately apply for permission to stay permanently. However, practical and bureaucratic obstacles can make that extremely difficult, because GP practices may struggle with the costs and bureaucracy associated with obtaining a licence to sponsor a foreign worker. The Royal College of General Practitioners warns that the cumulative effect of visa difficulties on IMGs is that some are

“feeling forced to take roles elsewhere in the NHS and others considering leaving the NHS, and in some cases the UK, altogether.”

The Government have so far been utterly intransigent on the issue of IMGs, and on tweaking the visa system to remove the red tape. Labour would look closely at the issue as part of our wider improvements to the points-based system. Those improvements would involve the Government working hand in hand with employers, trade unions and other key stakeholders to ensure that we have a properly planned, sector-by-sector approach, with a proper strategy that works for businesses, workers, the public sector, customers and patients alike. As part of that, we will review the length of work visas, processing times and the existing path to citizenship to ensure that they are all working for our economy and for the public.

Labour already has a long-term workforce plan for the NHS. That involves doubling the number of medical school places, which in turn will deliver more home-grown GPs. At the heart of the plan is the doubling of medical school places—an increase of 7,500—which means we will double the number of doctors trained in a year. Our shadow Health Secretary will also produce long-term workforce plans for the NHS for the next five, 10 and 15 years, which will ensure that we always have the NHS staff we need to get patients treated on time. The plans will not only provide good jobs for British workers and fill shortages in our NHS, but prevent us from having to do dirty deals, as mentioned earlier, with some of the poorest countries in the world—those on the WHO red list—and from recruiting medical professionals from impoverished communities that desperately need that medical knowledge locally. That is exactly what the British Government have done recently with Nepal.

In the short term, Labour has consistently pushed for a fix to punitive doctors’ pension rules. The fix would do away with the cap above which NHS workers incur additional tax burdens. That would support short-term recruitment and prevent the exodus of workers. The Government are yet to deliver on that.

The Labour party is committed to making the points-based system work, and to our NHS workforce plan. The current system is simply not fit for purpose, and at this time of crisis we risk losing newly qualified GPs because of unnecessary red tape. The Conservatives have broken promise after promise on GPs. Their 2019 manifesto promised to deliver 6,000 more GPs by 2024-25. The former Health Secretary, the right hon. Member for Bromsgrove (Sajid Javid), admitted that the Government are not on track to deliver that.

In contrast, the next Labour Government will put patients first, ensuring that they are able to get a face-to-face appointment when they want one, bringing back the family doctor to deliver continuity of care and implementing our workforce plans. The current Government are out of ideas, and we need practical solutions.

[Steve Brine]

It is interesting that the hon. Gentleman mentioned continuity of care, because he will be aware that that came up yesterday during Health questions. Would the Opposition introduce direct management of lists back into the GP contract from when it is next renegotiated? That is how we achieve continuity of care.

[Stephen Kinnock]

The key piece of our plan is to cancel non-dom status, which is estimated to generate approximately £3.2 billion for the Exchequer, and to use that money to invest in more GPs, doctors and nurses—indeed, doubling the numbers. We can have the best plans and legislation in the world, but we need the resources to deliver them. That is how we will pay for our plans and generate the kind of care that we need for our public. It is time for that Labour Government, so that we can clear the backlogs holding our country back, which we see right across Government, and get Britain’s public services back on track.

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[Robert Jenrick]

The hon. Gentleman makes a valid point. Of course, one could apply that to a number of other regulated professions, whether that be lawyers, nurses or others making significant contributions to the United Kingdom. It is an important step to obtain indefinite leave to remain, and not one that we should give away lightly. Asking an individual to spend five years here in order to demonstrate that level of commitment to the UK feels to me about the right length of time, but I am open and interested to hear other contributions on that point. At the moment we do not have plans to reduce the length of time that skilled workers would need to complete in the UK in order to apply for settlement.

The SNP spokesperson, the hon. Member for Cumbernauld, Kilsyth and Kirkintilloch East (Stuart C. McDonald), raised a number of cases that I am aware of from my former role at the Department of Health and Social Care about allegations of the mistreatment of foreign workers—including doctors and nurses—coming to the UK. That is something we take seriously, and the Department of Health and Social Care and NHS England are investigating. If I receive further information from the Ministers in the Department of Health and Social Care, I will be happy to write to the hon. Gentleman.

On the broader question of the ethics of recruiting healthcare professionals internationally, the NHS takes that responsibility seriously. We have ethical guidelines nationally that are set by NHS England and individual trusts in England—that may well be the case in Scotland as well—and of course we take heed of the red lists, which give a strong indication of countries from which we should not be recruiting healthcare professionals because they clearly need them to satisfy their own healthcare requirements. The NHS proactively works with countries that have an excess of doctors and nurses, or that train individuals specifically for export. In fact, one of the last meetings I had as Health Minister was with the Chief Minister of the state of Kerala, which specifically trains nurses to be exported to other countries around the world.

That sort of arrangement is sensible and defensible by the UK, although it is not a sustainable answer in the very long term because we live in a globally ageing society; there will be competition from other states to recruit professionals. That is one of the many reasons we should be training more doctors and nurses in the UK and considering measures such as raising the cap on medical school places, if we are able to do so. That, of course, is a matter for the Treasury and the Department of Health and Social Care, not my Department. It is worth saying that it is an extremely expensive measure over time, and that the Opposition’s proposal would cost several billion pounds to deliver. That is not to say that it is not an important step, but it is worth bearing in mind the significant outlay.

[Steve Brine]

The Minister is responding very clearly to the points raised. What we really need is an independent health workforce assessment, supported by the Treasury. He will be aware that that was called for by some Members who are no longer on the Back Benches. Dare I say that he could encourage that through his good offices, because only once we have the answer will we get to a better place. If we ask the NHS what we need it will answer with what we can afford. Those are not the same questions.

[Robert Jenrick]

For a long time I have believed that one of the virtues of a national health service is that it should be able to plan for its workforce needs long into the future. My hon. Friend raises the specific campaign of our right hon. Friend the Member for South West Surrey (Jeremy Hunt), when he was Chair of the Health and Social Care Committee. I am sure that he will consider that carefully now that he has his hands on the controls as Chancellor of the Exchequer.