The Medical Training Initiative: much more than learn, earn and return

What is the Medical Training Initiative scheme?

Since its inception, the National Health Service (NHS) has been dependent on overseas clinicians. Even today, almost one in three doctors working in the NHS has completed their primary medical degree outside the UK. ¹ Arguably, as important has been the reliance on international medical graduates (IMGs) who return to their country of origin after spending time in the UK. Historically, they have come to advance their careers and receive education and training, and in turn enrich the NHS with skills, enthusiasm and commitment. On returning home, many forge long-standing training and research links for the benefit of their local population and for the wider community, as well as acting as ambassadors for UK medicine. ²

In 2006, concerns about unemployment among IMGs resulted in withdrawal of the Permit Free Visa, making it challenging for them to work in the UK. In addition, IMGs were often used purely for service provision, with little consideration given to their training needs.^3,4 Pressure from the medical Royal Colleges and other educational bodies ultimately led to the launch of the revamped Medical Training Initiative (MTI) scheme in 2009. ⁵ This provides the opportunity for trainees, primarily from the previous Department for International Development’s designated ‘priority’ countries in South Asia and Africa, who have broadly similar medical training programmes to the UK (Table 1, in italics and Figure 1), to spend up to two years in a sponsored NHS training post. Thereafter, they are mandated to return to their country of ordinary residence. Over 4000 doctors have been through the MTI scheme thus far.

Table 1.

MTI trainees in the UK as per country of origin.

Country of residence		Country of residence		Country of residence
Australia	22	Jordan	9	Qatar	2
Armenia	1	Kenya	6	Rwanda	2
Bahrain	3	Kuwait	3	Saudi Arabia	12
Bangladesh	4	Libya	1	Singapore	16
Canada	5	Lebanon	2	South Africa	2
Chile	1	Malaysia	11	Sri Lanka	113
China	1	Mexico	1	Sudan	7
Egypt	102	Myanmar	11	Turkey	1
Ghana	7	Nepal	11	Trinidad and Tobago	1
Hong Kong	4	New Zealand	2	Uganda	2
India	287	Nigeria	57	United Arab Emirates	6
Indonesia	1	Oman	7	United States of America	4
Israel	5	Pakistan	112	Zambia	2
Jamaica	7	Palestine	3	Zimbabwe	1
Japan	1	Philippines	3
				Total	861

MTI: Medical Training Initiative. Based on data for the academic year Feb 2019–Jan 2020.

Figure 1.

Medical Training Initiative trainees in the UK as per country of origin (based on data for the academic year Feb 2019–Jan 2020).Source: Academy of Medical Royal Colleges.

The impact of the United Kingdom’s so-called ‘Brexit’ on European-origin doctors working in the NHS has been a cause for concern ever since the referendum in June 2016. In addition, the fall-out from the junior doctors’ contract disputes has resulted in many reportedly taking career breaks, leaving medicine or the UK altogether. ⁶ As a whole, these factors potentially augur exceptionally difficult circumstances with regard to filling training posts. The promise of hundreds of extra home-grown doctors will not materialise for a number of years and even then, external support will, in all certainty, continue to be required. ⁷

In 2018, the government announced the lifting of the cap on doctors and nurses coming to the UK under the auspices of the Tier 2 visa setup. ⁸ The MTI scheme, which operates under the auspices of a sponsored Tier 5 visa (Table 2), has a cap of 1500 across all medical specialties. The main difference between Tier 2 and Tier 5 visas is that the latter grants exemption from the General Medical Council’s (GMC) Professional and Linguistic Assessments Board (PLAB) test. ⁹ It is also linked to a formally approved training post that is time-limited to a maximum of two years. Another plus point is that it serves to prevent ‘brain-drain’ from countries that are not as well resourced as the UK.

Table 2.

The differences between Tier 2 and Tier 5 visa schemes.

	Tier 2 visa	Tier 5 visa
Employment	Dependant on a firm offer from a UK Trust; can continue being ‘rolled over’ annually. Requires PLAB if no appropriate qualifications	Royal College sponsored post ‘matched’ to the candidate; exempt from PLAB exam; 2 years maximum
Induction to the UK	Normally local induction only	Local induction plus Royal College support package. These vary but typically include: Royal College-organised induction and training days; International Office support; access to Royal College services
Training	Many service-only jobs but some do utilise spare training capacity and can be formal ‘training posts’ too	Guarantee of training opportunities on par with UK trainees, including use of e-portfolio and formal educational supervision
Dependents	Visa is for the candidate only	Partners and dependents can come to the UK on the same visa and work if they find appropriate employment (non-clinical)

Note that some Royal Colleges offer sponsorship for Tier 2 posts too.

PLAB: Professional and Linguistic Assessments Board.

The popularity of the MTI scheme is variable across the UK, with London and the Midlands proving to be particularly attractive destinations for candidates (Figure 2).

Figure 2.

Medical Training Initiative trainees across the UK (based on data for the academic year Feb 2019–Jan 2020).Source: Academy of Royal Medical Colleges.

How does the MTI scheme work?

The MTI scheme is run by Health Education England (HEE) on behalf of the Department of Health (the Government sponsor) and operates under the Home Office Tier 5 Government Authorised Exchange visa scheme. The Academy of Medical Royal Colleges provides a Certificate of Sponsorship, which in turn is used by individual Royal Colleges and other MTI partners to support an applicant’s Tier 5 visa request (Table 3). This International Sponsorship Scheme supports the granting of Tier 5 visas and allows for full GMC registration such that candidates do not need to pass the PLAB test.

Table 3.

A breakdown of MTI trainees according to sponsoring institution, Feb 2019–Jan 2020.

Sponsoring institution (via AoMRC)	Number of MTI trainees
Royal College of Anaesthetists	104
Faculty of Dental Surgery	–
Royal College of Emergency Medicine	25
ENT UK	–
Royal College of Obstetricians & Gynaecologists	68
Royal College of Ophthalmologists	15
Royal College of Paediatrics & Child Health	122
Royal College of Pathologists	19
Royal College of Psychiatrists	38
Royal College of Physicians, Edinburgh	33
Royal College of Physicians, London	143
Royal College of Physicians & Surgeons, Glasgow	23
Royal College of Radiologists (Radiology)	27
Royal College of Surgeons, Edinburgh	47
Royal College of Surgeons, England	63
Commonwealth Scholarship Commission	4
Miscellaneous NHS Trusts/already registered	130

Note: General Practice runs a separate, bespoke recruitment process. Source: Academy of Medical Royal Colleges

AoMRC: Academy of Medical Royal Colleges; MTI: Medical Training Initiative.

To qualify for the scheme, the candidate must satisfy a number of criteria (Box 1). Royal Colleges also assist IMGs who have already obtained a post in the UK through their own contacts, provided the above criteria are met. Eligible candidates are usually short-listed in conjunction with local partner organisations and then invited for interview. These are conducted either in person or via videoconference. The panel will normally comprise Royal College representatives as well as relevant senior clinicians, either local to the candidate or from the appointing Trust/deanery.

Box 1.

Eligibility criteria for the Medical Training Initiative scheme.

• Must hold a primary medical qualification recognised by the General Medical Council

• Must hold a postgraduate medical qualification

• Must have been in clinical practice for 3 out of the last 5 years including the most recent 12 months (including at least 1 year in the specialty in which the candidate wants to train in the UK)

• Must have achieved the required English language skills (either Academic IELTS score – minimum of 7.5 overall and 7.0 in each category or Occupational English Test – OET – minimum of grade ‘B’ in all categories)

• Must have satisfactory references

• Will benefit from a training post in the NHS

• Must possess the skills, competences and understanding of medicine at least equivalent to a UK graduate at the corresponding stage of training

The interviews consist of clinical scenarios and an emphasis on assessing communication skills (Figure 3). The appointments offered are at Core Training or Higher Specialty Training levels, depending on the applicants’ skills and experience. The posts are signed off by the local deanery leads, guaranteeing quality training and no adverse impact on UK trainees, with the employing Trust providing the Responsible Officer. Most positions are in acute/medical specialties (e.g. Acute Medicine, Geriatrics) rather than the so-called ‘craft’ or surgical specialties.

Figure 3.

Medical Training Initiative interviews in Colombo, Sri Lanka, September 2018 (all photographed individuals have consented to the use of the image).

Funding for the scheme varies between the Royal Colleges – some charge a one-off fee to the employing Trust for each trainee placed; others are fully funded by other mechanisms. Most posts need to be salaried by the employing Trust but some trainees may come in to the scheme with a stipend from their country of origin which effectively means they are supernumerary. Even so, the MTI scheme remains a cost-effective and more favourable mechanism of recruiting more doctors compared to expensive locum appointments. Overall, the minimum time from interview to starting work in the UK is around two to three months.

What can MTI trainees expect?

In short, trainees can expect a working experience of the British model of healthcare, culture and society that satisfies the IMGs’ desire to spend time training abroad in the UK. MTI doctors have identical clinical responsibilities to UK doctors, which will normally include out-of-hours on-call duties. Trusts are advised to give the candidate at least a two- to three-month run-in period during which duties will be limited while the candidate accustoms themselves to UK working practices and is supervised more closely by trainers. MTI doctors are paid at standard rates of pay, similar to UK trainees with similar experience, unless they come with funding from their country of origin. ¹⁰

The Royal Colleges and HEE take training of MTI doctors very seriously. All IMGs are matched to training posts which they will benefit from and allocated an educational supervisor. They can be signed up to the training e-portfolio, which allows documentation of educational progress not just in their specialty but also in generic skills including 360° appraisal by peers, patients and associated health professionals. Trusts and deaneries are encouraged to provide specific induction training and support programmes (the so-called ‘on-boarding’ packages) for all new appointments. The Royal Colleges often offer tailored inductions too.

How does the UK benefit?

The aim of the scheme is to provide mutual benefit to both the IMGs and the NHS, ultimately benefiting patients in both countries by forming lasting ‘links’. By attracting highly qualified doctors, the scheme also allows IMGs to share their experiences and expertise with UK colleagues. They have often practised for a number of years in healthcare systems that are less well resourced than the NHS. Indeed, the Hindi term jugaad (a flexible approach to problem-solving that uses limited resources in an innovative way) has even entered the English lexicon. ¹¹ IMGs often have a valuable understanding of doing ‘more with less’ in an ambulatory setting, tropical medicine, toxicology, infectious diseases and dealing with higher volumes of patients. The concept of ‘generalism’ in medicine and surgery as well as same-day emergency care is the norm in countries like India and Nigeria and something from which the UK could learn. In future, it is hoped that UK trainees may also be able to train more readily abroad under more relaxed training requirements. The main stumbling blocks remain funding and formal recognition of training time abroad. In addition, an MTI scheme for research would also be very welcome and undoubtedly prove fruitful with high-quality epidemiological data readily accessible and ripe for publication. Furthermore, joint conferences and meetings would serve to further cement links between UK institutions and those in MTI ‘donor’ countries.

What do the MTI recruits think of the scheme?

In general, candidates speak very positively of their experience (Box 2). There may be difficulties for some. For example, it can take some weeks to get used to life in a new country and a different medical system but help is available in the hospital from peers, their educational supervisor and from the Colleges themselves. Often they will have family or friends in the UK who can also provide valuable support and assistance as can a multitude of UK diaspora groups.

Box 2.

MTI trainee feedback.

Experience living and working in the UK

• The experience is not limited to patient care but extends to the way the hospital is organised as well as the healthcare system at large as well as the role of medical research in patient care.

• It was a very good experience for me and I gained a lot during these two years.

• It is an excellent time for me to get lot of experience in UK management and good patient care and good learning environment

• Living and working in UK experience was excellent. It makes us more mature in thinking and doing things. It will surely help me in making my department and hospital in India better in terms of patient care as well as working environment.

Overall quality of training in the UK

• I have excellent training with this department. All the consultants are very helpful to me. Especially my supervising consultant arranges all teaching events for me.

• During my stay in UK, I polished my clinical skills and learnt new technologies which are not available in Pakistan at present.

• In UK there was standard protocol for management of almost all clinical problems. And it was wonderful to see that all clinicians and staff follow it.

• The consultants I worked with were fantastic. They were always easily approachable for advice and support. The nurses and paramedic staff were very friendly and with time considered me to be part of the ‘AMU team’ in Darlington.

• Even though it was a busy unit I was given plenty of opportunity to pursue my academic needs.

• Though medical technology wise, India and UK are almost equal now but we surely learned a lot about patient, ward and department management. Developing and implementing local protocols for each clinical problem was very good and we are looking forward to implementing it here in India as well. It will benefit our clinicians as well as will improve patient care. Annual appraisal of doctors is another very useful thing we learned in the UK.

• I have excellent training in the UK. I learn lots of advance management of different types of dermatology cases. All consultants are very helpful to me. Especially [my supervising consultant] discussed lots of cases which are uncommon in my practice.

Quality of the supervision in the UK

• Had an excellent guidance in the clinical work and lot of encouragements in the academic work including exams and workshops.

• Both my educational and clinical supervisors helped me a lot in adjusting to the completely new environment and always guided me through every stage in my training.

• Most of my senior physicians were good in teaching and guidance. They were easily accessible and approachable as well.

• My supervisor was very keen to guide me not only for the teaching but also for the other aspects during training

• My academic and work progress was continuously monitored using the e-portfolio. I was given good guidance to improve.

• Very good interpersonal relationship among senior clinicians and registrars is a gem of the NHS … I really enjoyed all learning under their care.

Note: Comments collected from a number of MTI trainees based in different hospitals around the UK as part of feedback for the RCP London’s MTI scheme (2016-8).MTI: Medical Training Initiative.

Box 3.

Summary of how the MTI scheme works.

• The Royal Colleges/Trusts assess applicants and training posts

• Successful candidates are matched to suitable NHS training posts

• The Royal Colleges facilitate GMC registration and the supporting of Tier 5 MTI visas

• The Royal Colleges provide a comprehensive support package for those on the scheme. In conjunction with Trusts and deaneries, MTI trainees are provided professional, educational and pastoral support.

GMC: General Medical Council; MTI, Medical Training Initiative.

What do patients think of the scheme?

This is an area ready for exploration. Although not formally surveyed more broadly, informal feedback of MTI trainees from patients in a Cambridge hospital has been overwhelmingly positive. The patients valued the important role the trainees were playing. As long as they were assured of the doctors’ competence in clinical and communication skills, they felt comfortable being under the care of MTI doctors, just like any other clinician.

The future

Efforts are underway to simplify and streamline the MTI scheme and its processes. Given the current workforce circumstances, it is likely that the importance of the MTI scheme will increase. Better awareness of the scheme, with a greater emphasis on its benefits and advantages to individual trainees, their countries of origin, the NHS and patients globally will continue to ensure its popularity, and hopefully, expansion. It is ethically more palatable than attracting doctors from resource-challenged countries on Tier 2 visas indefinitely. Consequently, an increase in the cap for Tier 5 visas is urgently needed. Indeed, comments from the new Health Secretary could be seen as being supportive on IMG recruitment too. ¹² Longer term, a reciprocal arrangement via which UK trainees can gain clinical and academic experiences abroad would also be welcome. Building stronger research links via the MTI scheme, especially in epidemiology and public health, is likely to be of significant mutual benefit.

Patient involvement

While not surveyed formally, informal feedback of MTI trainees from patients in a Cambridge hospital has been overwhelmingly positive. The patients valued the important role the trainees were playing. As long as they were assured of the doctors’ competence in clinical and communication skills, they felt comfortable being under the care of MTI doctors, just like any other clinician.

Key messages

• The MTI is a UK government-sponsored Tier 5 visa scheme via which IMGs can work and train in the UK for a maximum of up to two years.

• The scheme is ideal for doctors at core and higher specialty level and has a number of benefits compared to the larger Tier 2 visa scheme.

• It is of mutual benefit to MTI clinicians and the NHS.

Declarations

Competing Interests

None declared (except that the authors are involved in the promotion and running of the MTI scheme).

Funding

None declared.

Ethics approval

Not applicable.

Guarantor

FAM.

Contributorship

The article was conceived and drafted by FAM, with input to a previous version from colleagues at the Royal College of Physicians, London. RJ and SS co-ordinate the national sponsorship scheme for tier 5 visas on behalf of the Academy of Medical Royal Colleges. They provided all the data presented in the paper and expert opinion about the scheme.

Provenance

Not commissioned; editorial review.

Acknowledgements

Jeannie Hyslop Parsons and Carolyn Deakin (RCS Ed), David Calderon-Prada (RCoA), Ninette Premdas (RCP Edinburgh), Neil Sutcliffe (RCS Eng), Peter Bourdillon (Commonwealth Scholarship Commission), Janet Stephen (ENT UK), Ellen Cook (RCPsych), Victoria Dewitt (RCEM), Lisa McManus (RCPS Glas), Ruth Gibson (RCR), Zuzana Lescisinova (RCPath), Aleksandra Dubanowicz (RCOG), Daniah Ahmed (RCOphth), Monika Ma (RCPCH) as well as Peter Trewby, Laura Bailey and James Clayton (all formerly of the RCP London) for input into an earlier version of this article.

ORCID iD

Fraz A Mir https://orcid.org/0000-0002-4238-807X