Policy 2013
Overseas Recruitment to Cover Middle Grade Rota: Benefits of Indo-British Collaboration
Doug Wright
Doug is a Consultant physician and lead Clinician for dept of Medicine, Weston General hospital. Email: douglaswright@nhs.net
Advisory Author
Parag Singhal MD, MPhil, FRCP
Consultant Physician in Diabetes and Endocrinology Divisional Director - Emergency Care
Kerry White
Divisional General Manager Emergency Division, Weston General Hospital.
Nick Wood -
A graduate of the NHS Gateway to leaders programme supported by Kings Fund. Highly operational and service focussed Chief Executive with a 20 year track record of delivery within the public, private and independent sectors. Currently delivering significant strategic change, performance and efficiency.
cite as:
Wright D, Singhal P, White K, Wood N. Overseas Recruitment to Cover Middle Grade Rota: Benefits of Indo-British Collaboration. The Physician
2013 vol2; issue 1; 6-8
Introduction
Despite the Coalition Government's plans to cap nonEU immigrants, junior doctors from India are being recruited to resolve current medical staffing shortage. Present and past preoccupation with immigration takes no account of the impact of such decisions on the National Health Service (NHS) which has a long history of reliance on overseas health workers. The story of
overseas recruitment is not new. Since the 1930s, successive governments have resolved staffing crises through recruiting workers from overseas. This shortage was predominantly due to not having enough medical student numbers and emigration of UK trained doctors to work mainly in United States and Canada, because of relatively poor pay and conditions of the NHS.
The output from UK medical schools was increased in 2000 and this brought a change in attitude towards overseas doctors. By 2005 the government feared that the recruitment of overseas doctors would deny employment to a large number of home-grown medical graduates, especially as International Medical Graduates (IMGs), many of them often highly skilled, and with several years' experience in their chosen field, remained an attractive prospect for the NHS. In a bid to protect junior posts for graduates who were British or EEA nationals, in April 2006 the Department of Health retrospectively sought to prevent non EU doctors from applying for training posts in the NHS. Under new rules, hospitals could only shortlist overseas candidates if they
could prove that they could not recruit a junior doctor from the UK or the EU. The British Association of Physicians of Indian Origin (BAPIO) challenged the Government in the High Court, which ruled in favour of BAPIO stating that the Department of Health's guideline was illegal.
The judgement was upheld by the House of Lords in April 2008, but not before thousands of overseas doctors had had their opportunity of permit-free training abruptly withdrawn not only at great personal and financial cost to themselves and their careers but to the NHS, so much so that UK is now once again facing shortages at different levels especially in acute Medicine, O&G and Paediatrics which are becoming unpopular due to workload and increasing number of admissions. The NHS
is now again looking to recruit overseas trained doctors to fill vacancies especially in Emergency department and General Medicine, Paediatrics and O&G.
We will share our experience in overseas recruitment in the Department of Acute Medicine in Weston General Hospital. Weston General Hospital Medical Registrars in NHS hospitals act as gatekeepers and senior on site clinicians during out of hours. Apart
from clerking, they also supervise foundation doctors and give advice to other specialities. With an ever increasing rise in emergency admissions, it is even more important that the Medical Registrar rota is complete and functions well. Weston General Hospital (WGH) is a small District General Hospital situated between Bristol and Taunton
serving a population of approximately 200,000. WGH is predominantly an Emergency driven hospital making it even more important to have on site medical registrars. Since the change in visa rules, coupled with vacancies at the Deanery level in some specialities and inevitable sickness, the trust has struggled to have a fully compliant medical registrar rota. Various recruitment campaigns proved unsuccessful resulting in significant gaps on the middle grade rota. As a result the Trust has had to rely on Locum registrars, who were employed by agencies, to support the out of hours rota. These locum registrars were of variable clinical competence which was difficult to assess on CV alone. Issues with clinical competence impacted on patient care and often created more work for consultants. Foundation doctors often complained about lack of supervision and teaching and the GMC identified this as area of concern during their visit in 2011.
Governance issues in retrospect were hard to address once the Locum had moved on. It proved to be difficult to provide proper induction as they often arrived at night and worked in unfamiliar surroundings. In addition to governance and quality issues, locum doctors were expensive. The cost of locum provision at Middle grade level in 2011/12 was in excess of 1 million pounds; this is obviously is not good value for money.
Aim
The aim was to build flexibility and surplus in the Medical Registrar rota to internally cover any potential absences and provide a safe, competent and reliable workforce at this level. It was believed that internal cover with the established workforce would have financial advantages and would provide better quality service, improve the morale of the work force and overall be of benefit to the Trust.
Methodology
After receiving approval from the executive team of Weston Area Health Trust for extra funding, prestigious Medical colleges in India were contacted and short listed candidates were interviewed face to face in India using appropriate college based interview format. The candidates had to have post graduate qualifications in general medicine with necessary experience to work at registrar level. The candidates were informed about the rules regarding Medical Training Visa which is only valid for 2 years and the requirement for them to go back to the country of their origin after two years of training. Details of successful candidates were forwarded to the Royal College of Physicians and Surgeons of Glasgow after recommendation from the Post Graduate Dean of Severn Deanery. The Royal College sponsored the successful candidates for GMC registration and once
registered, applications were forwarded to the Border Agency for MTI (medical training visa). All candidates were given an opportunity for training in a speciality of their choice along with General Medicine experience. Overall 3 overseas trained doctors were recruited to work as medical registrars. All the candidates received a 1 month long induction during which they were paid full salary and were provided with free accommodation.
Induction included the following:
- Tour of the hospital
- Resuscitation assessment/training session - they had their capability assessed in a session with a trust resuscitation trainer and they were also sent on an ALS course as early as possible
- IT Training - training on the millennium system, access to the IT systems and emails
- Stat Man Training - health & safety/manual handling/infection control/child protection/fire
- e-learning modules - blood transfusion, information governance, using telepath, NG tubes, equality and diversity, safeguarding adults, VTE
- Meetings were arranged with the Medical Director, Divisional General Manager and Matrons.
- Shadowing for half a day in ITU and ACC (ambulatory care centre) staff.
- Shadowing medical registrars for few night shifts (and an on-call shift where applicable).
- Shadowing their Buddy at all other times during the induction period.
- Educational and clinical supervisor allocated
Results
Since 1st August 2012, there have been 11 Registrar grade doctors on the rota instead of the normal establishment of 9 Registrars. Over establishment has led to a reduction in frequency of on call duties and has given more training opportunities to Specialist Registrars to enhance their skills and meet their training requirements. All the teams led by consultant now have a registrar along with other junior staff. Overseas registrars, despite induction, needed support from consultants to overcome their initial difficulties and settle down. All 3 overseas registrars are committed to complete MRCP and are progressing well.
Foundation doctors have found their presence on the wards extremely beneficial and feedback to the Deanery and GMC has been very positive. Since the implementation of this scheme, all absences of any kind have been covered internally without the
need to recruit locum doctor of any description. Trust management is pleased with the investment and the faith they showed in the proposal put forward by the division. Savings of £400k have been achieved up to the financial year 2012-13.
Discussion and Conclusions
The emigration of overseas doctors is built on Britain's historical links with its ex-colonial territories, especially India. As a direct result of colonial rule, by the time of Indian Independence in 1947 Indian medical schools and hospital administration ran along the lines of the British model. Medical education and training were delivered in English, and geared towards meeting the requirements of the General Medical Council. This ensured that Indian-trained doctors would be able to work in Britain, and encouraged overseas medical graduates to come and gain further training and experience that they would then take home. For this reason, India was chosen as the first choice for recruitment. Weston General Hospital being a small District General
Hospital does not have the flexibility and extra workforce seen in teaching hospitals e.g help provided by research registrars during unforeseen circumstances like sickness. These unforeseen circumstances are either dealt with by calling upon the existing workforce to help or employing agency locums. With rising admissions especially elderly patients who have significant co morbidities, medical registrars play a key role in decision making and support consultants and foundation doctors both in and out of hours. We believed that building a surplus in the workforce would lead to resilience, flexibility, improved morale, reduction of workload, better understanding and eventually reduce sickness by making the hospital a better workplace.
Our experiment clearly demonstrates that building a surplus into the rota when there has been an inability to recruit is desirable. The benefits of doing this are three fold.
- Firstly, there is improved clinical governance, teaching, supervision of foundation doctors and patient safety outcomes. This is due to the consistency in the rota with substantive doctors who understand the hospital’s systems and processes.
- Secondly, there is improved team morale with the remaining doctors not being asked to continually cover gaps or pick up additional work.
- Thirdly, there is a clear financial benefit as one shift covered by an agency locum doctor can cost three times as much. It also supports the ability to accurately forecast the expenditure for the year rather than the huge variability in expenditure when locums are required.
In summary, recruitment of international doctors directly at Registrar/middle grade level is safe if appropriate selection methodology is applied and good induction provided. Over establishing leads to better training opportunities for Specialist Registrars and is associated with significant financial benefits. We believe that this concept should be rolled out
across different health professions e.g nursing where sickness, vacancies and extra capacity is often filled by agency nurses.
We sincerely thank Prof Davinder Sandhu, Postgraduate Dean, Severn Deanery for supporting the recruitment.
POLICY End of Life Care in England
Julian Abel
Julian is a consultant in palliative care at Weston Area Health Trust and Weston Hospice care. Between 2008 and 2013. He has been part of the Transform Programme for improving end of life care in acute hospitals and works closely with the National End of Life Care Intelligence Network on a number of projects. Email: julian.abel@nhs.net
cite as: Abel J. End of life care in England. The Physician
2013 vol 2; issue 1: 9-11
Introduction
Significant developments in end of life care have taken place in England over the last eight years. In 2005, the government at the time undertook a public consultation, Your Health, Your Care, Your Say [1] about what people felt were their priorities for the NHS. One of the key themes was making sure that the quality of end of life care was good, wherever people chose to die. This topic was further explored in the White Paper,
Our Health, Our Care, Our Say [2]. End of life care became a work stream of the NHS Next Stage (Darzi) Review. The outcome of the Darzi review was combined with a piece of work that had already been ongoing, led by Professor Sir Mike Richards, on a wide-ranging consultation with health and social care professionals working in end of life care.
The
National End of Life Care Strategy was published in 2008 [3] and the National End of Life Programme, which has overseen the strategy implementation, led by Claire Henry, was formed at the same time. Since then, through a process of engagement in a variety of different areas, we have seen significant changes in where people die. There has been a reversal of the trend of increasing numbers of people dying in hospital, with a reduction nationwide in the percentage of hospital deaths End of Life Care in England and increasing proportions of people dying outside of hospital, mainly in care homes and people’s own homes [4].
Figure 1. End of Life Pathway (Courtesy of National End of Life Care Programme and adapted from the End of Life Strategy 2008).
The programme was founded on a number of basic premises. These are that healthcare professionals should be able to identify those people with chronic illnesses who could be in the last year of life; a health professional who knows the patient well should then begin advance care planning discussions about where the patient would like to die; these wishes then need to be available to the broader health community, using electronic palliative care coordination systems
(EPaCCS), initially known as end of life registers, so that when the time came for terminal care, the patient’s and family’s wishes were known; well coordinated care then means that the patient’s wishes can be respected; the quality of care should be excellent and appropriate for end of life care wherever the patient has chosen.
National surveys [5] have shown that the majority of people would like to die at home. In 2005-2007, 58% of people were dying in hospital [6]. Finally, care after death should be sensitive and efficient, with bereavement support available for those who need it. These themes were brought together into a single diagram. These basic premises are common sense and apply to all of us. To quote Benjamin Franklin, ‘Nothing is certain except death and taxes’. We are all going to have to face death and we would want the quality of care we receive to be excellent. Not only do we want this for ourselves, we want it for our loved ones. Many of us would like to be able to choose where we die, with the majority of us choosing home. The challenge for the National End of Life Strategy has been turning these common sense and very human principles into practice.
Has the Implementation of the National End of Life Strategy Succeeded?
There is now increasing evidence to show that there is a shift over time in decreasing numbers of people dying in hospital [7]. This change has now been sustained on a year-on-year basis since 2008. It is hard to demonstrate clear
causal evidence, from a scientific perspective, that this has been specifically due to the efforts of implementation of the National End of Life Strategy. However, the links between the efforts that have been made, along with new evidence from different components of the strategy, strongly suggest a causal relationship. One of the key markers of change in end of life care has been death in usual place of residence. Care homes are included as well as homes, as many people live in these care homes for significant periods of time. Others may spend their last weeks of life in a nursing home and may choose not to be transferred to hospital for terminal care. These figures indicate that the varieties of interventions
that have taken place in end of life care are having an impact on where people die. At the same time, the national VOICES survey of bereaved relatives [8] has been published, and a baseline has been set to try and gain an insight into the quality of care that has been given. The survey will be repeated on an annual basis. The reports are geographically divided up into cluster clinical commissioning groups. This will help to provide new commissioning bodies and health and wellbeing boards, with both qualitative and quantitative information on end of life care.
How has this change in end of life care taken place?
The National End of Life Programme has helped coordinate information on end of life care and has commissioned the National End of Life Intelligence Network to gather together multiple sources of data on end of life care, which has provided a unique insight into both what has been happening and monitoring of change [9].
Figure 2. Quarterly percentage deaths in usual place of residence 2007-2012.
The National Programme ran a project to see if EPaCCS were an effective way of coordinating end of life care. Eight pilot sites across the country were involved in this two-year project, with the production of a report which offered great promise for these systems10. Work is ongoing and the latest figures from a variety of different centres indicate hospital death rates are low for patients who are on an EPaCCS at time of death. These figures are valid for cancer and non-cancer patients with chronic life-limiting disease, including heart failure, COPD and dementia. Some centres have had EPaCCS running for more than two years. We are now starting to see results from various centres with many thousands of patients dying in their place of choice. Data from 3171 patients who died and were on an EPaCCS in the
South West has shown an overall hospital death rate of 10% (unpublished). The current national figure is 53%. This data included 990 non-cancer patients. Outcomes of this data are due to be published in early April by the National End of Life Programme in a report on the economic evaluation of EPaCCS.
The financial implications of the shift from hospital death to death in usual place of residence are significant. Estimates of cost vary. Cost of hospital care in the last year of life has been estimated to be £350011, with a reduction of seven days spent in hospital. Community care has been estimated to be somewhere between £500 and £1500 cheaper than hospital care. There are approximately 600,000 deaths per year in the UK. If the hospital death rate shifts from 53% to 40%, using a figure of £1000 saving per patient, the reduction of cost to the NHS would be £78,000,000. Over the last year, the Programme has focussed on transforming end of life care in acute hospitals. In the first year, 26 acute hospital trusts were part of the pilot. The focus of this programme has been to encourage the use of five key enablers that are considered to be a fundamental part of end of life care in hospitals. These are: identification of people who could be in the last year of life; use of advance care planning; use of the AMBER care bundle (a decision-making tool for ceiling of care in patients who are deteriorating and have an uncertain outcome, possibly dying within one to two months); rapid discharge home to die pathways; and use of an integrated care pathway for the last 48 to 72 hours of life, such as the Liverpool Care Pathway. A report on the outcome of the first year of the Transform Programme is due to be published in March 2013 and in keeping with other interventions that have taken place in end of life care, the progress made is encouraging.
Practical Implications for Clinicians
There are significant challenges for clinicians to change their practice if end of life care is going to continue to develop. Successful implementation of the end of life strategy involves the whole health community. Developments in each area, including community services, acute trusts, ambulance services, district nursing services, out of hours services and hospices must be linked together and coordinated. This means that clinicians need to think about how their service relates to the broader provision of end of life care. Thus for GPs, overseeing identification of patients who may be in the last year of life, use of advance care planning and EPaCCS, as well as ensuring that end of life drugs are in the home for the final days of a patient’s life, are all part of what needs to be done. In the same way, hospital clinicians need to be alert to identifying people who may be in the last year and to work out how they can hand this information on to primary care in an effective way. All clinicians who look after these patients need to develop their communication skills, so that they can work out sensitive ways of engaging in advance care planning discussions with patients and families Hospital consultants need to be able to oversee this process for their teams, and to be able to participate and
communicate what has been done to the broader health community. Particular challenges face those clinicians looking after patients with long-term conditions, including heart failure, COPD, dementia and frailty, as these are the areas where improving care will have the biggest impact moving forwards. Palliative care services have led the way over the last 40 years in looking after cancer patients at end of life. Hospital death rates for non-cancer patients are still high, varying between 60% and 70%. Some centres have hospital cancer death rates of less than 35%. Whether it is possible to achieve the same levels of non-cancer deaths outside of hospital as for cancer remains to be seen, but much of the progress is encouraging and it looks as though a significant shift from where we are now is possible.
What we do know is that if we are going to progress end of life care, clinicians across the whole health community need to be involved. Individual clinicians need to ask themselves, are they aware of what is happening with end of life care in their locality and how can they participate with their patients? Until we are sure that all of those patients who would like to have had the opportunity to discuss end of life wishes have done so, we will need to continue to redouble our efforts. The changes in end of life care are so widespread that every locality has made some progress, so linking with
these efforts will be effective.
What does the Future Hold?
End of life care is part of the NHS mandate [12]. It is specifically mentioned as a key area for the NHS Commissioning Board and will be led by Dr Martin McShane as part of domain 2, long-term conditions, as one of the five domains covered by the NHS Commissioning Board. Currently, the National End of Life Programme is ensuring continuity of a successful implementation programme of the National End of Life Strategy by forming transition arrangements over the
next year. This will help to ensure that the good work of the programme continues into the new structures of the NHS over the forthcoming years.
References
1. Opinion Leader Research for Department of Health. Your health, Your Care, Your Say. London 2006
2. Our Health, Our Care, Our Say: a new direction for community services. Department of Health 2006
3. End of Life Care Strategy. Promoting high quality care for all adults at the end of life. Department of Health 2008
4. Gomes B, Callanzani N, Higginson I. Reversal of the British trends in place of death: Time series analysis 2004–2010. Palliat Med. March 2012 vol. 26 no. 2 102-107
5. Gomes B, Higginson IJ, Calanzani N, et al. Preferences for place of death if faced with advanced cancer: a population survey in England, Flanders, Germany, Italy, the Netherlands, Portugal and Spain. Ann Oncol. 2012 Aug.23(8):2006-15. Epub 2012 Feb 16.
6. National End of Life Care Intelligence Network. Variations in place of death in England. 2010, p30
7. http://www.endoflifecare-intelligence.org.uk/data_sources/place_of_death.aspx Accessed February 3rd, 2013
8. National Bereavement Survey (VOICES), Office for National Statistics, 2011
9. http://www.endoflifecare-intelligence.org.uk/home.aspx, accessed February 3rd, 2013
10. End of Life Locality Registers evaluation. Final report, Ipsos Mori Social Research Institute, 2011
12. The Mandate. A mandate from the Government to the NHS Commissioning Board: April 2013 to March 2015. Department of Health, 2012
POLICYInequalities in CSA Exam: BAPIO Taking the Bull by the Horns
In recent years, racial equality and to some extent human rights have dropped out of popular use within the political vocabulary. Of those who are hurt by the system, only those with some revolutionary consciousness of justice dare to raise concerns over inequality! Most doctors may acknowledge the fear of the unhealthy culture, known for its secrecy and frequent vindictiveness towards those who dare to raise their voices.
Buddhdev Pandya MBE
buddhdev.pandya@bapio.co.uk
Buddhdev is Director of Corporate Affairs of British Association of Physicians of Indian Origin (BAPIO) and associated with the organisation since its inception and heads the central office of BAPIO.. He was a member of the core team for the development of Medical Defence Shield, unique initiative developed by doctors to provide advice and representation support. He is a member of a Hospital Authority and instrumental in establishing many healthcare initiative in the community. He is a member of the BAPIO CSA Campaign Team. He is Managing Director of BAPIO Publications Ltd. and Director of Global Association of Physicians of IndianOrigin-Europe.
cite as: Pandya B. Inequalities in CSA Exam: BAPIO Taking the Bull by the Horns.
The Physician 2013 vol 1; issue 1: 12-13
It is fair to say that most international medical graduates do feel that when it comes to the issues affecting ethnic minorities, trade union officials usually drag their feet. On critical issues, such as when the career of a very large number of clinical skills assessment (CSA) trainees are in serious jeopardy, most protection bodies are still operating in an aura of what seems superficial remedies. Where the time for action is the real essence of the hour, they engage ‘ethnic minority’ forums at merely discussion level.
International medical graduates (IMGs) in GP training are facing catastrophe in their careers as a result of what is described as ‘hugely’ differential pass rates. Frankly, those affected by what is at the centre of the controversy – unfair examination – just cannot wait for the ‘talk shops’ to discuss what is already in the public domain.
This is why one can vindicate the actions by British Association of Physicians of Indian Origin (BAPIO) in relation to the CSA issue. The aspect of disproportionate failure rates has been debated for over a year, at least within BAPIO. According to BAPIO there has been serious dialogue by BAPIO officials, and other supporting groups such as BIDA, to see if RCPGP and GMC can be influenced to seek the potential causes and remedies for preventing a blatant injustice to the IMGs through the CSA exit test.
I met up with the President of BAPIO, Dr Ramesh Mehta, who himself is a well-established examiner, to ask why his organisation is now pursuing a legal challenge route. His response was quite clear: “You see, we want fairness and equal treatment for the IMG trainees. For the qualifying bodies it should be an extremely worrying point if a large number of trainees from a particular background are failing, despite most successfully completing three years in training under supervision and actually servicing live patients.”
I wonder why a good employer would accept the fact that its training package that costs taxpayers nearly half a million pounds per trainee has been failing to prepare adequately for the final exam! To be fair, under the scheme, each of the trainees work under supervision and are assessed every year before they are moved on to the next year. If these processes are effective, then one would assume that the weaknesses would have been spotted earlier. Is not the purpose of supervision supposed to be the ability to identify and plan to remedy issues for improving performance?
Dr Mehta says, “It is not only that it takes little account of the fact that there is also a huge diversity in the patient population, it still uses a simple yardstick to measure a doctor who has successfully worked for three years and passed the Applied Knowledge Test (AKT). It is ironic that a test lasting a couple of hours involving actors - not real patients - decides the fate of these doctors; in many cases after having served more than 3000 patients during the training without complaints.” It appears that the whole structure of training and assessment is in need of a thorough overhaul, since obviously it seems to be lacking in cultural and linguistic sensitivity with unexplained race bias.
Professor Allen, who had examined the General Medical Council (GMC) fitness to practise procedures, found that a higher proportion of referrals to the GMC from public bodies were about international medical graduates, and that there were differences in the nature of the allegations made (Policy Study Institute Report, 2008). The Chief Medical Officer at the time noted that there was no explanation for the Preliminary Proceedings Committee sending relatively more international medical graduates to the Professional Conduct Committee. He remarked, “In [a] nutshell what it really meant is that, once within the General Medical Council, international medical graduates were more likely than their United Kingdom counterparts to be referred to the disciplinary procedures.” Sir Liam Donaldson, CMO, also stated that “Examining the relationship between ethnicity and doctors is complex. Whilst many institutional barriers have been removed and much has improved, there are still areas that cause concern. Addressing these issues will require culture and behaviour change.”
The Royal College of General Practitioners (RCGP) commissioned a review of possible racial and sex biases in the exam in 2010 that admitted that ethnic-minority candidates were continuing to perform ‘differently’ to other candidates. RCGP figures for 2010-11 indicate that the failure rate for IMGs taking the CSA component of the MRCGP is at 63.2%, compared with 9.4% of UK graduates. That was some years ago - we are in 2013 now.
According to BAPIO’s own survey, one of the respondents highlighted, “I have good references from 20 hospital consultants, several GP trainers, 40 excellent MSFs, 100 PSQs, have been working for NHS for seven years, have seen at least three thousand patients in GP surgeries, passed AKT with good marks.” Is it not odd if he cannot pass CSA? If he was not fit to practise, why did his trainers not raise concerns; instead leaving it to the last stage for the RCGP actors to decide his fate? Are the RCGP actors more qualified than the actual patients they have served over the period of three years? BAPIO has quite rightly centred on the ethos that while patient safety is of utmost importance, so is maintaining the standards of examination to provide a fair and just environment for the professionals.
According to Dr Satheesh Mathew, Vice President BAPIO, “These IMGs continue to endure immense strain on their families, creating personal anxiety, stress and financial ruin, having spent tens of thousands of pounds on exam fees and courses. All this is because of unfair assessment.” British International Doctors Association (BIDA) chairman, Dr Sabyasachi Sarkar, wrote to GMC, “The failure rate is simply staggering.”
The GMC has launched a review into the failure rates for different groups of medical graduates taking the MRCGP exam. Meanwhile, BAPIO has taken legal advice for a judicial review application with a potential for greater ramifications that may lead to a review of assessment processes by all the colleges, postgraduate deaneries and the GMC. There are also plans to approach the Health Select Committee in Parliament over the issue, since it is costing taxpayers a huge amount in the loss of skilled professionals. The Equality and Human Rights Commission undoubtedly has a role in monitoring such anomalies, and is potentially ripe with inequalities against the IMGs.
