Ready, willing but unable to work

Highly qualified, English-speaking doctors who have escaped oppression, civil wars and torture are being prevented from practising in the UK for want of a formal language qualification. Claire Sanders reports on a scheme to help tap this valuable source of talent.

In a small lecture theatre in the basement of the Royal London Hospital, an intense teaching session is taking place. Doctors Emma Leaver and Sheila Cheeroth are acting out an interview between a depressed patient and a psychiatrist. Members of the audience are invited to participate.

The questions, always tactfully put, flow thick and fast. "How long have you felt like this?" "Can you sleep?" "Do you wake early?" "How is your appetite?" "Have you ever thought of harming yourself?"

The audience is made up of refugee doctors who come every Monday night for two hours to update their skills in preparation for the exams that will allow them to practice in this country.

The irony of the situation is not lost on them. "Here we are, every one of us depressed, asked to diagnose depression," one of them says afterwards. The refugee doctors describe the classes as a "lifeline" and a chance to mix on equal terms with other professionals. In some cases, it is quite clear that their knowledge extends beyond that required in the exams.

"Keep your answers simple," they are advised again and again as lively debates spark up on recent findings and novel treatments. Cheeroth has been running the study classes for five years, but last month received a £300,000 grant from the Mercers' Company of the City of London that will enable about 30 refugee doctors a year to complete a comprehensive education programme, allowing them to register and work in England. The funding is initially for three years.

Cheeroth, a clinical lecturer at Queen Mary, University of London, and a member of the British Medical Association's Refugee Doctor Liaison Group, says: "I ask fellow doctors to imagine what it must be like to falsify death certificates for people murdered by the state. For an Algerian doctor, refusal put his life in danger and he had to flee. Doctors are influential people in most societies, and that is perhaps why they are disproportionately represented among refugees."

She also asks fellow doctors to imagine what it must be like to flee and then be unable to work. "These people are isolated. Some are very worried about their families who have been unable to get out. To come to a medical institution and be treated as fellow professionals is important," she says.

The lecturers at the study club are volunteers. But the new money will allow Queen Mary to pay staff to lecture regularly and to cover the full curriculum. And it will pay for space, access to medical laboratories, computers and small hardship and travel grants. "The courses will be free to the refugees," Cheeroth says. The money will also enable the refugees to have their learning needs assessed. "Some of the refugees are highly qualified, others less so, and we want to match their studies to their needs," she says.

The BMA, which has set up a database to collect information on refugee doctors, lobbies for their skills to be recognised. "The database probably just represents the tip of the iceberg, and there are many qualified doctors out there whose skills are untapped," Cheeroth says. "There is no one group lobbying for these people. They need far more support."

Dr Aziz (not his real name) arrived in the UK in 1998 after fleeing from Iraq. He prefers not to go into detail about the circumstances of his flight, but as he talks it becomes clear that he has spent time in jail and is receiving medical treatment for the effects of torture.

All he will say is that "terrible things happened". He has now been granted indefinite leave to remain by the Home Office, and his family was recently able to join him after a tortuous journey here. His over-riding desire is to return to a peaceful and safe Iraq and continue with his life and work there.

When he arrived after his traumatic escape, he was hopeful that he could work as a doctor in the UK. "I really expected to get work," he says. "I knew that the UK was short of doctors and our systems of medical education are very similar - the curricula and reading material are the same."

Aziz could be forgiven for thinking that the UK might be keen to use his skills. He is a highly qualified paediatrician, graduating originally from Basra University and then obtaining a diploma in paediatrics from Baghdad University. For a number of years he worked in hospitals in Baghdad. He also ran a private clinic in Iraq. "The building is still there," he says. "Along with my car. It is all waiting for me to go back."

But using his skills in the UK has proved impossible. Aziz gained the International English Language Testing System qualification on his sixth attempt. "It took me two and a half years to pass it," he says. "It was torture, absolute torture. I was baffled because I had studied in English in Iraq, the language was not new to me and I felt competent in it."

Many refugees and overseas doctors complain about the IELTS exam, arguing that the marking is erratic and that it does not really test the English they need for their work.

The effect of repeated failure was depression. "As a refugee you are depressed anyway, but it is possible to get worse and worse at the IELTS test as your confidence goes," Aziz says.

Doctors must pass the IELTS before they can take the Professional and Linguistic Assessment Board test. And they can register as doctors in the UK only once they have passed the PLAB. "While I was trying to pass the IELTS I was determined not to be idle, I qualified for membership of the Royal College of Paediatrics and Child Health," he says. "I study for four or five hours a day, keeping up to date in my subject."

Aziz was finally able to sit for part one of his PLAB test in March. "But I have to wait until May for the results, and only when I know my results can I book to take part two - and then I will have to wait months before I can do that exam. And if I fail I cannot retake part one until September."

It is only on passing part two that refugee doctors can be registered to work in the UK. If, however, two years have lapsed since they took the IELTS test, they have to do it again.

The waiting is difficult for refugees claiming benefits. "The JobCentre is always chasing me. How can I tell them that I have to wait again for results and then to sit more tests? I am grateful for the money I receive, but it is intimidating money. I keep telling myself that I survived torture, I survived jail, that I can survive this," he says. "But a doctor without work is nothing, he is just a number."

Aziz managed to find a clinical attachment through a friend. "The consultant was very helpful, but day to day I had to deal with a registrar who was very hostile to me," he says. "He simply told me that I could not come on the ward rounds with him. I was so humiliated. The attachment did not work out. There should be a proper system for attachments, with support structures. At the moment you just find what you can and hope."

Clinical attachments are typically for four months - and unpaid. New guidelines from the BMA on clinical attachments for refugee doctors, which Cheeroth helped draw up, set standards for educational and training quality and for practical support.

The Monday study skills class is a lifeline for Aziz. "It is a very important network for me. I meet not just other refugee doctors but also the doctors who are prepared to come and lecture us," he says. "I do not want sympathy, but the fact that they are prepared to help and to care is so important."

Aziz is determined to qualify and to work. "When I have done that I will help others in my situation," he says. "I will never be able to turn my back on people struggling."

Dr Ali (not his real name) is also from Iraq. He wants neither his name nor his speciality used. "There are so few doctors in my speciality that if you were to publish it, I would be immediately identifiable," he says. He is a highly qualified doctor who has been working for nearly ten years, three years as a specialist. He arrived in the UK 18 months ago and passed his IELTS test first time.

He took part one of his PLAB test in March and faces a long wait for the results and an even longer wait before he can sit part two.

He has also worked towards membership of the Royal College of Physicians and has completed a Cambridge certificate in communicative skills and a computer course.

It cost him £225 just to sit the Royal College of Physicians exam. The General Medical Council now waives fees for refugee doctors for their first two attempts at part one of the PLAB test, but not for part two, which costs about £450. Each attempt at the IELTS test costs £70.

Ali has not been able to find a clinical attachment. "I would love to do one, but the attachments are unpaid and you need money just to get to the hospital and even for the clothes you have to wear there," he says. "Many of my friends have tried but have been turned down."

He is living on benefit and describes the Queen Mary classes as "very, very important. The exposure to clinical information and the opportunity to speak with professionals - as opposed to just sitting at home and working towards exams - is wonderful."

But, he says: "It is terrible not to be able to work. It destroys your confidence."

NoREADY-5 'I keep telling myself that if I survived torture and jail, I can survive this. But a doctor without work is nothing - he is just a number'