Fear of referral: Fitness to practise and its implications on safety of migrant healthcare professionals in the UK

During our AHRC project we have noted the emphasis placed on a stringent testing of English language skills for the internationally trained doctors and nurses who hope to join the registers and work in Britain. In this blog, I raise a few questions related to language expectations from migrant and refugee health care professionals, and from UK trained healthcare professionals. As it often does, here comparison helps identifying the background assumptions of a context different from our own, and sheds light on our unexamined assumptions.

Increased levels of immigration in the UK means that the healthcare sector ought to be able to meet the needs of changing demographics. For instance, cultural competence and increased diversity in the healthcare workforce[i] are shown to contribute to improve access to services and satisfaction for immigrant patients.[ii]  Research on ‘language concordance’ between doctors and patients demonstrates how it improves doctor-patient encounters and maximises health outputs.[iii] This data supports a better understand of how internationally trained doctors and nurses enrich NHS service provision.

Often, the scrutiny over English language proficiency of overseas-trained professionals, whilst justifiable, emphasises the limits of overseas trained professionals. In turn their widespread bilingualism and multilingualism, often remain unnoticed, or undervalued language skills.  Given changing demographics, these language skills could be valorised as comparative advantages surpassing those of unilingual English-speaking healthcare professionals trained in the UK. As part of its regulatory remit to offer safer care for all, could the government mandate British medical schools to offer language provision and certify trainee doctors’ bilingual language skills. This change to the curriculum could assist British-trained doctors in keeping up with internationally trained doctors’ language skills. In the United States, an increasing number of medical schools offer Spanish language as part of medical education to meet the changing needs of patients.[iv]

A recent paper in the British Medical Journal on language in healthcare provides food for thought.[v]  It explores the experiences of non-Arab healthcare practitioners caring for Arab patients in the United Arab Emirates. The paper is based on in-depth interviews with foreign healthcare professionals not fluent in Arabic working in the UEA.  The research was conducted in English, indicating that the participants were English-speaking. The paper provokes a few elements of comparison between the integration of foreign doctors moving to and working in a place where the language of work is not their first language, in UAE and Britain respectively. It also elicits comparisons between different experiences of caring for patients with whom they do not share a language.

The first noticeable aspect is the terminology used by the authors to describe the participants. The paper does not refer to them as ‘migrant,’ but as ‘expats.’ Both terms evoke being engaged in temporarily labour migration. Yet ‘migrant’ is usually a term reserved for non-white, non-Western migrating to work temporarily, whilst expats, with its more business and ‘professional’ connotations, is a term rather used to describe white, Western people migrating to work temporarily.[vi]

The authors criticise the idea that healthcare providers ‘can learn as they work when working with patients from other cultures.’ They argue that in spite this widespread assumption, expat doctors should ideally obtain formal language training in Arabic before caring for Arabic speaking patients. What we read between the lines here is that ‘learning as you work’ is a possible and accepted option for non-Arabic fluent doctors moving to work in the UAE. We could discuss the pros and cons of such a practice, and the authors do so briefly. However, the surprising comparative point here is this: the notion that refugee and migrant internationally trained doctors could join the UK register and start practicing in the NHS on the basis on their medical expertise, and ‘learn as they work,’ is completely out of line with reality.   Migrant and refugee doctors, regardless of the level of specialty, skills, and the years of experience they acquired outside Britain, do not have the option to care for patients whilst ‘learning the language as they work.’  Their listening, reading, written, and spoken English is tested before they  can begin to work. This is to ensure patient safety. As Al-Yateem and his co-authors explain, there are indeed legal and other risks of misunderstanding and misdiagnosis associated with ‘learning as they work’ approach. And yet, would that be so unconceivable to allow more flexibility around English language skills? Indeed, prior to Brexit, EU medical graduates did not require to pass English tests, and the hiring employer had latitude. Since Brexit EU medical graduates have lost that privileged position vis-à-vis non-EU medical graduates, but we can also ask questions about who can be seen as deserving the benefits of flexibility, and who is seen as needing scrutiny.

The data of the BMJ paper also shows that in the UAE, Arabic-fluent patients respond well when spoken to in broken Arabic,[vii] that patients appreciate the efforts of doctors who try and engage them in their language, that they use humour and laughter to encourage them, and that overall, communication builds on more than language. Reflecting on this with a comparative outlook, I ask myself whether British, English-speaking patients would offer similar positive responses to an overseas-trained medical doctor who would provide them with expert care in broken, or less than perfect English.

The ‘expat’ non-fluent in Arabic doctors who took part in the research on which the BMJ paper is based, shared with the researchers their experience of working in a foreign language environment. Once again, the research findings bring out surprise:  participants explained that they should be ‘pro-active in learning basic medical terms in Arabic.’ More tellingly, ‘participants in the study recommended using professional medical interpreters to overcome language barriers in the healthcare context.” Perhaps such self-confidence should not surprise, coming from Western, non-Arabic fluent, English-speaking doctors working in Arab settings. The contrast with the attitude of non-British doctors trained overseas, which we interviewed as part of our research project, is striking. After having conducted more than thirty interviews with participants and having analysed secondary literature on overseas trained doctors and nurses wishing to work or currently working in Britain, my colleagues and I have not encountered a level of self-confidence and self-importance resembling that of the BMJ paper participants. Not a single participant has expressed the idea that a medical translator could be a solution at hand to translate what they have to say to English-speaking patients. Regardless of key issue of healthcare funding in British and UAE systems, there is a clear difference in attitudes, which rehearses the hegemony of English language across healthcare contexts.

The BMJ paper’s conclusion wraps things up nicely: “learning basic medical terms in patients’ native language offers an innovative and effective solution to address the language barrier issue and improve healthcare services for Arab patients.”[viii] Sounds relatively straightforward. For several reasons, it is unlikely that British medical registration of internationally trained medical graduates will move in that direction. But still, could some lessons be learned from this example; could we envisage a more open and grateful attitude towards international healthcare providers who migrate to Britain, equipped to provide healthcare to British patients?

After all, although they may be necessary, English language skills are not sufficient. ‘The ability to speak English does not make one a good doctor,’ and many British-trained doctors with excellent English struggle to communicate well with patients.[ix]

[i] Andrea Baumann, Mary Crea-Arsenio and Valentina Antonpillai, ‘Global Migration and Key Issues in Workforce Integration of Skilled Health Workers’ in Margaret Walton-Roberts, eds, Global Migration, Gender, and Health Professional Credentials: Transnational Value Transfers and Losses, University of Toronto Press, 2022, 95-109 at 96.

[ii] Id.

[iii] Naomi Cano-Ibáñez et al. Physician–Patient Language Discordance and Poor Health Outcomes: A Systematic Scoping Review Front Public Health. 2021; 9: 629041, Published online 2021 Mar 19. doi: 10.3389/fpubh.2021.629041; Julian Simpson, Migrant Architects of the NHS. South Asian doctors and the reinvention of British general practice (1940s-1980s), University of Manchester Press, 2018.

[iv] Rose Molina and Jennifer Kasper, ‘The power of language-concordant care: a call to action for medical schools’ (2019) 6: 19 (1) BMC Medical Education 378, doi: 10.1186/s12909-019-1807-4

[v] Nabeel Al-Yateem et al, ‘Quality and safety issue: language barriers in healthcare, a qualitative study of non-Arab healthcare practitioners caring for Arabic patients in the UAE’ British Medical Journal  22 December 2023 https://doi.org/10.1136/bmjopen-2023-076326

[vi] Sarah Kunz, Expatriate: Following a Migration Category, Manchester University Press, 2023; Amanda Klekowski von Koppenfels, ‘What’s the difference between a migrant and an expat? The Conversation, 20 December 2016. A similar distinction can be drawn between mobility and migration. Expats or ‘mobile professionals’ rarely depend on immigration decisions, and if they do not achieve their goals, often have the choice of returning home or moving somewhere else; however highly skilled migrants do not have access to that same mobility. See: Agnieszka Weinar and Amanda Klelowski von Koppenfels, Highly skilled migration: between settlement and mobility, Springer 2020; Agnieszka Weinar, European citizenship, and identity outside of the European Union. London/New York: Routledge, 2019.

[vii] “However, at times the use of broken Arabic was considered helpful, especially when words/phrases were correct. Participants noted that many patients and their families appeared to be more comfortable with this form of communication and were receptive of the messages.

Many of them will be surprised when I say it in Arabic words; they will like it and laugh, and they look more engaged, even with the simple words that I use. (P13), Ibid

[viii] Ibid.

[ix] Interview with Dr Selladurai Shanmugadasan, Audrey Gillan, ‘Knowing English does not make you a good doctor’ The Guardian, 2 September 2000.