Published: 05/12/2002, Volume112 No. 5834 Page 28 29

Recruitment of GPs is becoming increasingly tough.

But a pilot programme to bring Spanish doctors to English surgeries is proving effective.Dr Tony Mathie reports The NHS plan signalled a target of 2,000 additional GPs by 2004 and it is anticipated that this target will be reached through various initiatives, one of which is international recruitment, expected to contribute 200 doctors.

But the Department of Health's annual GP recruitment survey, published last month, showed the number of unfilled vacancies as 322 - double the previous year - and fewer applicants for each post.

In 2001, a government-to-government agreement was concluded to recruit specialists and GPs from Spain in the light of their significant overproduction of doctors.A pilot was set up in north west England, funded by the DoH and building on the experience of recruiting Spanish nurses. Funding included the costs of recruitment in Spain and England, the initial residential induction course, the salaries of the Spanish doctors during four months of induction and the fees for supervision, language training, and some relocation and accommodation costs. In all, the costs were around£750,000.

The old North West region of England, comprising Cheshire, Merseyside, Lancashire and South Cumbria, is currently over 400 GPs short of the target of 53.2 GPs for every 100,000 people; a vacancy factor of almost 10 per cent.

Health authorities in the North West with less than the national average number of GPs were invited to take part in the pilot and agreement was reached with Liverpool, Sefton, St Helens and Knowsley, North West Lancashire, East Lancashire, Salford and Trafford, and Wigan and Bolton.A project team was set up comprising the DoH's international recruitment team, representatives from North West region, and the two GP directors.

HAs recruited suitable practices in which the Spanish doctors would work. These were volunteer practices which generally had long-term vacancies, were keen to recruit from overseas and judged to have the capacity to integrate Spanish doctors into the NHS. Initially it was envisaged that these would all be personal medical services practices, but in some areas this was not possible, and both PMS and general medical services practices were recruited.

The committee drafted a job description and a project plan. The doctors would be salaried assistants and would be paid a fixed salary of£40,000 per year for a two-year contract, with a break clause after mutual assessment at nine months. The salary has recently been re-negotiated and a figure of£45,000 is now the minimum expected.

It was decided that the doctors would receive travel and agreed relocation expenses, but pay their own General Medical Council registration and medical defence fees.As there is no equivalent of the British Medical Journal in Spain, small advertisements were placed in Spanish national newspapers at a cost of around£10,000. Later recruitment rounds have depended more on personal contacts and roadshows in individual regions of Spain. Around 50 applications were received. Applications from doctors from Cuba and South America, though entitled to work in Spain, were rejected as ineligible to work in the UK. Thirty-five doctors were invited to an initial selection weekend held in the British Embassy in Madrid in October 2001.

At this initial weekend, I gave a presentation on the NHS, and Dr Racquel Martin Delgado, a Spanish GP working in Manchester, talked about the pilot scheme. A team from Liverpool University described the language support available and a representative of the North West tourist board gave a talk on the area. Applicants were then divided into small groups and each group had 45 minutes of structured conversation, including discussion of some clinical scenarios, observed by the English language assessors. The doctors were also asked to write a short piece in English and to complete a standard NHS occupational health questionnaire.

At this stage, two candidates were judged to be insufficiently prepared. Everyone else was invited to the UK for a second selection weekend. In retrospect, it was clear that much of the information provided at this first weekend had been too detailed and had not been absorbed, and that the recruiters had paid insufficient attention to the need for proficiency in English. Candidates were understandably more interested in arrangements for income tax than in national service frameworks.

Following this exercise, the recruitment team met all the potential host service practices at an evening meeting to describe in detail the process and to provide reassurance about the quality framework and the support packages that were to be included.

The second recruitment weekend was held in Bolton and there were further sessions to impart information, a coach tour of the North West which was abandoned due to appalling weather, an opportunity to meet HAs and service practices, an objective structured clinical examination (OSCE), and a social programme. It had initially been anticipated that the Spanish doctors would take this opportunity to match with their eventual service practices. In the event, this proved impossible. The Spanish doctors were quickly overwhelmed by the amount of information presented to them and neither the hosts nor the Spanish doctors were prepared to commit themselves without a visit to the practices and a meeting with practice partners and staff.

In fact, matching turned out to be extremely protracted, with decisions eventually being made in many cases less than two weeks before transfer to the practices. This highlighted the differences in practice between Spain and the UK, with Spanish doctors having little or no experience of interviewing potential employers and negotiating job plans.

The OSCE was held in the clinical skills laboratory of Liverpool University using experienced actors to simulate patients and experienced GP assessors.

It was designed to identify the overall educational needs of the group and potentially to identify individuals whose communication or clinical skills were not adequate.

As is usual for GPs, it was run in a simulated surgery format with the doctors sitting in rooms and the patients moving round. It was a relatively short exercise with six stations face-to-face with the patients and a station to undertake a range of paper tasks. GP assessors followed the patients and they and the patients marked the candidates. Though stressful, the candidates considered this exercise appropriate and relevant to their daily work.

At the end of this second selection weekend, a number of candidates dropped out and two were advised to apply again after further preparation.

Twenty doctors were offered posts on the pilot and 10 each opted for the Liverpool and Manchester areas. There were an equal number of male and female doctors, two-thirds of the doctors were vocationally trained in Spain and one-third have acquired rights to work as GPs. The youngest is 29 and the oldest is 52. One of the Manchester doctors was unable to free himself from commitments and did not come to the UK.

While the recruitment of doctors was proceeding, the directors were recruiting suitable practices for them to work in during their initial induction period. Early in the development of the pilot, it had been hoped that the Spanish doctors would go direct to their service practices and be supported in situ. The GP directors, however, made a case for a properly supported induction in either undergraduate or postgraduate training practices.

Initially, it was anticipated that the Spanish

Key points

A pilot project, funded by the Department of Health, resulted in the recruitment of 17 Spanish GPs to practices in Liverpool and Manchester.

The doctors are employed on two year contracts with a salary of£45,000.

The scheme has shown that Spanish GPs are not experienced in interviewing potential employers, or negotiating job plans.

The initiative includes a four-month induction period in a training practice.

The importance of language support and a senior champion for the scheme are key factors.

Dr Tony Mathie is director of postgraduate general practice education, Liverpool University and NHS North West.

Career off course? The situation for Spanish doctors Number of doctors:130,000 (35:10,000 patients) 65,000 GPs 33,000 hospital specialists Unemployed doctors:19 per cent (24,000) 2,500 GPs 6,500 specialists 15,000 non-specialists Source: NHS Careers.