Foreign legion

Brent PCT has been successful in recruiting overseas GPs - though with some criticism of the DoH. Mary-Louise Harding reports

The yawning black hole into which a large chunk of London's GP service provision is in danger of disappearing is well documented.

The impending retirement 'time bomb', as one London primary care trust manager put it, is a serious concern, while closed lists are becoming an epidemic.

When Brent PCT put its strategy together last year, each section was dominated by a recurring action point: recruit GPs.

Based in north west London and covering some areas of severe poverty and social exclusion, Brent has a particularly acute problem with closed lists. Its current vacancy rate is just above the London average, standing at 6 per cent.

Brent serves one of the most ethnically diverse populations in the country, whose complex needs mean the PCT must be creative when balancing structural change of GP provision, with offering the right carrot to attract GPs.

'We decided to look at different ways we could appeal to GPs, that would also create new ways of reaching patients, ' said Brent's deputy director of primary care, Jane Lindo. 'We have set up three personal medical services to cater for the homeless and refugees across Brent, while We have also taken over the management of a couple of practices.

'This means we can create contracts that offer new, salaried GPs joining Brent PCT the chance to mix and match days working at a practice and [at] a hostel, say, for a couple of days a week. This variation on the traditional working week has appealed to GPs, especially the younger ones.'

Having taken the decision to 'salary lots of GPs' and build up its own contracts with them, Ms Lindo says opting into the Department of Health's international recruitment scheme was a natural step, as they already had a solid base in place, including a GP recruitment action team.

Roshina Khan had already been given a key management role implementing the PCT's GP recruitment wish list as practice development manager. She was given the overall practical management lead on international recruitment, following the PCT's decision to join the London race to recruit GPs from Europe.

Brent was one of two PCTs that decided to court the European market following the apparent success of a pilot recruitment scheme involving Spanish GPs in north east England.

The PCT decided it needed to add a clinical ingredient to its recipe for GP recruitment success. Salaried GP Dr Emcee Patel, co-chair of the professional committee and clinical lead for PCT GP services, took on the mentoring role.

In addition to the exasperation provoked when the DoH announced it would target French rather than Spanish GPs 'at the last minute', Dr Patel and his colleagues felt the process could be more user-friendly with less DoH involvement when wooing potential candidates.

'It hasn't all gone smoothly because the French GPs feel the DoH communications were not all that great at the start, ' says Dr Patel.

'Unlike other countries, such as Spain, where there are GPs actually out of work, French GPs are all well established, so we needed to identify ways to motivate their interest in coming to the UK - and Brent in particular, ' he explains.

'We found that GPs with families might be interested in experiencing English life for a couple of years, maybe so their children could learn the language. The challenge for us is to ensure we can offer the kind of housing and access to education that will be right for their families.'

The DoH holds the recruitment budget, which means a central team carries out the initial task of travelling to the country, speaking to potential candidates and testing them on basics such as clinical competence and language ability. PCTs are brought in once lists of candidates have been identified.

Ms Khan and her colleagues feel this can be too late. 'It is very difficult to pick up at this stage because they have already established a relationship with the central team - and I might be picking it up with conflicting information, ' she says.

'For example, one of the GPs we approached had been told he would earn£70,000 when we offer all our salaried GPs a standard£60,000 - and I can't get into bargaining because of equal opportunities. So It is difficult to manage expectations if they have been given a false idea.

'If we had been the ones going to France, we could have explained our strategy, our population needs and so on, ' she adds. 'I am convinced we would have recruited a large number if we'd been given the budget to do it on our own.'

Brent has now recruited two French GPs, who are to start in January. Westminster PCT is understood to have attracted another. Brent has since recruited a Swedish GP - who is already in post - through its own advertisement in an international journal, adding to the team's conviction it should be left to its own devices.

'At times it felt that if we had been left to sort ourselves out earlier in the process, it would have been smoother.

'I do not want to be too critical, but it makes sense for us to establish a one-to-one with GPs because they will be working with us, ' explains Dr Patel.

Brent says its commitment to go the extra mile - offering a practical introduction to GPs that have taken the trouble to visit - is the key to success. In addition to finding a French speaker to explain the English tax system (the DoH had conducted its introductory sessions in English) Ms Khan compiled a 'goody bag' for potential recruits, containing useful items such as job descriptions and information on local schools.

'You have got to be very clear what working for the NHS in England can offer, ' says Ms Khan.

The whole process has taken around nine months, and the Brent team says its relative success has relied on staff enthusiasm and commitment beyond the call of duty.

The team is currently evaluating the cost-effectiveness of the process - looking at how human resource time has been used, as well as direct costs. Brent is looking to feed this into a central DoH evaluation process - and is waiting for the request for feedback to come through.

Dr Patel highlights that he was able to induct his directlyrecruited Swedish GP within three weeks, compared to the DoH's three-month induction process.

'I think we need to evaluate if this is the most attractive option, ' says Dr Patel. 'We do not have an international recruitment budget per se. Perhaps the DoH should consider devolving the budget to a PCT with experience. We also need to look at whether the results have been worth nine months of work - a lot of which has been done out of hours - as well as considering costs and patients' perspectives, ' he adds.

It is clear that valuable lessons have been learnt over the nine months. However, at this stage it is impossible to predict if international recruitment of GPs will become routine practice, as has developed in the nursing profession.

The DoH's evaluation of the recent London recruitment drive will make interesting reading for PCTs.

Meanwhile, Brent is working on recruiting suitable GPs wherever it can - and it may transpire that its existing international population provides the most obvious answers yet.

GP training for refugee doctors

City and Hackney primary care trust suffers like many inner city trusts in maintaining GP numbers - by 2011 one in three of current GPs will have reached retirement age while the population will have grown by 5 per cent. At the same time it is estimated that about 5-6 per cent of the UK's total refugee population is settled in the area.

As the Refugee Council estimates there are about a thousand refugees in the UK qualified to practice medicine, this equates to 50-60 potential doctors in the area.

In 2002, using neighbourhood renewal funding, and working with the London Deanery and North East London workforce development confederation, the PCT developed a scheme to fund training for three refugee doctors. This includes 18 months of hospital-based training with Homerton University Hospital trust and 18 months in a Hackney general practice.

Further informationlwww. doh. gov. uk/international-recruitment