Welcoming and Valuing International Medical Graduates: Evaluation of the pilot of the induction guidance programme.

“Induction is very important for somebody coming into a new environment where country, culture, system, the work environment it is actually quite different; and the process too is quite different from where you might be coming from, being an IMG. So, it's very important for the person to have a Trust induction, departmental induction; all aspects of help need to be available for the person.”

International Medical Graduate – Pilot Evaluation Interview.

Report Authors:         Dr Stephanie Armstrong, Associate Professor, School of Health and Social Care, University of Lincoln.

Dr Joanna Blackwell, Research Associate, School of Health and Social Care, University of Lincoln.

Kandazi Sisya, Education and Research Officer, NIHR ARC Northwest London.

Professor Mala Rao, Senior Clinical Fellow, Medical Adviser to NHS England on Workforce Race Equality, Department of Primary Care and Public Health, Imperial College London.

Steering Group:         Ms Tista Chakravarty-Gannon, Head of Outreach, Development and Support Operations, Member of NGO UN Commissions on Status of Women, Independent Sexual Violence Advisor, BMJ Leader, General Medical Council.

        Professor Sujesh Bansal, Consultant Anaesthetist & MAHSC Honorary Clinical Professor; Director - Manchester International Fellowship Programme; Associate Director of Medical Education, Manchester University NHS Foundation Trust.

        Dr Sameer Ahmed, Consultant Anaesthetist, International Medical Graduate Tutor, Royal Victoria Infirmary, Newcastle Upon Tyne Hospitals NHS Foundation Trust.

        Dr Saeed Ahmed, Consultant Interventional Nephrologist, Clinical Director Medical Specialities, BAME Staff Network Lead, International Medical Graduate Tutor, South Tyneside Sunderland NHS Foundation Trust.

        Dr Roshelle Ramkisson, Consultant in Child and Adolescent Psychiatry, Director of Medical Education and Associate Medical Director, Pennine Care NHS Foundation Trust.

        Dr Bhathika Perera MBBS, FRCPsych, MMedSci, PGDip Consultant Psychiatrist in Intellectual Disabilities, International Medical Graduate Lead, Barnet, Enfield and Haringey Mental Health Trust.

        Zarina Khan, Head of Quality (Postgraduate Medical Education), Royal Free London NHS Foundation Trust.

        Lynne Rustecki, Education Lead, Specialist Clinical Communication and Linguistic Service, Health Education England.

        Dr Helen Freeman, Director of Medical Education, Consultant Paediatrician, NHS Highland.

        Ashfaq Ahmed, Programme, Transformation and Delivery Manager, People Directorate, NHS England and Improvement.

        Paul Wright, Associate Dean, Health Education England, East of England.

        Tarryn Lloyd Payne, Regional Liaison Advisor, General Medical Council.

        Olivia King, Senior Strategy and Policy Lead, NHS England.

        Janet Gray, Health of Northern England, General Medical Council.

        Tracy Mitchell, Head of Medical and Dental Resourcing and Trust Reward, The Newcastle upon Tyne Hospitals NHS Foundation Trust.

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Table of Contents

1.        Background        5

2.        Introduction        5

2.1.        Aims and objectives        6

3.        Methodological Approach        6

4.        Participants        7

4.1.        Participating Trusts        8

5.        Methods        8

5.1.        Work Package 1 - IMGs        8

5.2.        Work Package 2 – Medical Supervisors and HR Representatives        9

5.3.        Work Package 3 - Cost Analysis        10

5.4.        Data analysis        10

6.        Results        10

6.1.        International Medical Graduates Demographics        10

6.2.        Pre-induction Questionnaires        11

6.2.1.        International Medical Graduates        11

6.2.2.        HR and Medical Supervisors        12

6.3.        Post-induction Questionnaire (IMGs only)        13

6.4.        Medical Supervisor and HR Focus Groups        15

6.5.        Interviews with IMGs        17

6.5.1.        Welcome and day to day living        17

6.5.2.        Professional practice induction        19

6.5.3.        Language and communication        19

6.5.4.        Specialty induction        20

6.5.5.        IT systems induction        21

6.5.6.        Welcome to UK Practice workshops        21

6.5.7.        Induction and ongoing support resourcing and delivery        21

6.6.        Cost Analysis        22

7.        Recommendations for the induction and ongoing support guidance        22

8.        Limitations and recommendations for future research        22

9.        Conclusion        23

1. Background

Up until now there has not been a standardised induction programme for International Medical Graduates (IMGs) within the NHS, although it is recognised that IMGs have been an integral part of the organisation throughout its existence.  This lack of induction has been highlighted as a risk factor for higher rates of complaints against IMGs and poorer performance and progression throughout their NHS careers. An induction programme has been designed to address this significant gap. This suggested programme is also notable in that it is based on a series of focus group discussions with IMGs recruited to work in the NHS in past years, and what they told us about their experience when they started working in the NHS and what would have made their experience better. The overarching goal of the programme is to enable all IMGs who are recruited to work in the NHS, to settle in quickly to working in the NHS and to life in the UK, feel welcomed and integrated into their team, understand NHS values, culture and ways of working and work to their best potential. Based on the findings of the focus group discussions, the programme recommends that a comprehensive induction should be offered to all IMGs recruited to work in the NHS and that at a minimum it should include the following sections: pastoral care, language and communication, the NHS IT system, professional and clinical practice. Attendance at the General Medical Council’s (GMC) Welcome to UK Practice half day induction should be included as a mandatory component, and the induction to professional and clinical practice in the NHS needs to be delivered in 2 parts – a local induction at the place of work and an introduction to the specialty by the royal medical college or specialist association. The induction programme has been in development since 2019 and is now ready for implementation across NHS Trusts. This induction programme has been authored and edited by those with experience supporting and being IMGs. Among them are senior leaders from NHS England and Improvement, Health Education England, the British Medical Association, General Medical Council and Medical Protection Society.

2. Introduction

Nearly 20 percent of the NHS workforce are of Black, Asian, and Ethnic Minority (BAME) background (NHS Digital, 2021). Critically, there is substantial evidence showing that BAME staff are likely to experience racism and discrimination, and will have poorer experience and progression opportunities, and that “the extent to which an organisation values its minority staff is a good barometer of how well patients are likely to feel cared for” (Dawson, 2018, p.7).

In November 2018, a workshop was arranged to bring together senior stakeholders from the Medical Royal Colleges, NHS Trusts, the GMC, British Medical Association (BMA), and representatives of the medical leadership to explore their concerns regarding racism and discrimination in the NHS medical workforce and how these could be addressed. Several recommendations for action were agreed, and the need to develop a national induction programme for IMGs was highlighted as a particularly urgent priority. For this induction programme, an IMG was considered to be a doctor who has received their primary medical training in a country other than the UK and has either never worked in the NHS or has done so for less than six months.

IMGs have been recruited to work in the NHS throughout its 73-year history, and as of 2021 the number of licensed IMGs in the workforce is over 77,000 (GMC, 2021). Nevertheless, acknowledgement of the need for comprehensive induction to ensure that newly recruited doctors from overseas receive a positive first experience of the NHS and life in the UK, has until now, been limited to papers published by the medical journals (see for example, Bogle et al., 2020; Kehoe et al., 2016) and national reports published by institutions such as the GMC (see for example, Dawson on behalf of NHS England, 2018; GMC, 2014; 2021). The GMC’s State of Medical Education and Practice report (GMC, 2021), identified as far back as 2011 the need for induction to reduce the higher risk of IMGs being referred for fitness to practise investigation.

Adapting to UK medical practice can be hard for any doctor, regardless of where they are from or how experienced they are. There can be significant differences in practising medicine in your home country and the UK, and it can be difficult to adjust to living and working in a new culture. Doctors moving to the UK must follow a new set of legal and ethical standards, which UK graduates learn about throughout their education. To put it in context, there are 32 pieces of GMC guidance which describe the professional values, knowledge, skills, and behaviours expected of all doctors. However, international doctors need to absorb all this while adjusting to living in a new country. Ultimately, the medical profession in the UK relies on the expertise of doctors from overseas. Their contribution and the diversity of experience they bring are invaluable. It is incumbent on us all to support them, and a standardised induction provides an excellent framework to deliver the support needed.

Given the above, the development of induction and ongoing support guidance is a landmark achievement and this evaluation of the pilot phase of this work aims to provide important insights that will help to strengthen the guidance ready for its implementation.

1. Aims and objectives

The evaluation assessed the impact of the induction programme to ensure that it meets the needs of IMGs. A brief cost analysis was undertaken to determine the average cost of delivering the induction.

The objectives were:

• To provide insight into the structure of the induction guidance, and which elements of ongoing support may be beneficial for example mentoring, supervision and ‘buddying’.
• To provide in depth feedback on how the pilot phase of the induction and ongoing support guidance has been received, highlighting the important features of this guidance and any areas for improvement.

3. Methodological Approach

The evaluation of the induction guidance was grounded in Kirkpatrick’s updated four levels of training evaluation and included all the dimensions of induction found in the draft guidance. This included GMC’s Welcome to UK Practice (WtUKP) half day programme. It also included evaluation of Language and Communication induction, which involved a two-stage induction with online learning followed by individual or group feedback and discussion with the educational supervisor. For the purpose of the pilot online language and communication learning developed by the BMA and BMJ were used.  

The Kirkpatrick model evaluates training using the following principles:

• Level 1: Reaction to training – how did the participants find the training, was it engaging and accessible.
• Level 2: Learning – did they acquire the intended knowledge and understanding.
• Level 3: Behaviour – did the participants apply this knowledge to their working practice.
• Level 4: Results – did the training mean that the intended outcomes were met (long term).

We included an additional dimension of Expectations – this was undertaken prior to the induction programme delivery and asked what do the participants (including IMGs, HR delivery and Medical Supervisors) expect of the induction programme and what do they hope to get out of it. Ethical approval was given by the University of Lincoln Human Research Ethics Committee (Ref. 2022_8243).

4. Participants

Three participant groups were recruited to this study from each of the NHS Trusts engaged in the pilot:

1. IMGs
2. Medical Supervisors
3. HR representatives

Each Trust has slightly different processes for recruiting and inducting new IMGs, therefore the research team liaised with IMG leads and HR representatives in each of the participating Trusts to identify recently recruited IMGs.  This included any IMG that had been confirmed in their role between January and April 2022.  A welcome letter was provided by the research team to each Trust to introduce the evaluation. Contact details for those that expressed an interest in participating were passed to the research team along with basic demographic information including gender, country of origin and job role. Each Medical Supervisor and/or HR representative was provided with a password protected Microsoft Excel spreadsheet via a OneDrive link where IMG details could be shared. Upon receipt the research team provided a Participant Information Sheet (PIS) and consent form to each IMG and invited them to participate in the study. For ethical reasons, and from this point onwards no-one other than the research team (SA, JB and KS) was aware of the identity of participants and Trusts were not informed by the research team which IMGs had consented to be part of the study. This was important to ensure that IMGs felt able to express opinions freely.

Medical Supervisors were identified from the below NHS Trusts (see 4.1) via their engagement in the steering group that supported the pilot and evaluation. Each was provided with a PIS and consent form. HR representatives were recruited via snowball sampling, with each Medical Supervisor asked to identify at least one HR representative who agreed to their details being shared with the research team. Again, each was provided with a PIS and consent form

2. Participating Trusts

Six NHS Trusts fully participated in the evaluation; these were:

• Barnet, Enfield and Haringey Mental Health NHS Trust
• Newcastle Upon Tyne Hospitals NHS Trust
• Manchester University NHS Foundation Trust
• South Tyneside and Sunderland NHS Foundation Trust
• Pennine Care NHS Foundation Trust
• Royal Free London NHS Foundation Trust

The Medical Supervisors and HR representative from each Trust also participated in bi-weekly steering group meetings.

5. Methods

The research was conducted in three work packages one for IMGs, one for Medical Supervisors and HR representatives and one for cost analysis between January and June 2022.

3. Work Package 1 - IMGs

IMGs were provided with a link to two online questionnaires using the Jisc survey tool. The first questionnaire was issued immediately following consent and aimed to capture pre-induction expectations and views on need, content, and delivery of guidance (Appendix 1). The second questionnaire was issued a minimum of five weeks after the first to allow time for each IMG to progress through most aspects of their induction, aligning with levels one and two of the Kirkpatrick model. The second questionnaire aimed to capture reflections on the content and delivery of their induction relating to levels one and two of the Kirkpatrick model (Appendix 2). In each case the different elements of the guidance were covered in addition to a section on the WtUKP modules and opportunity to provide general feedback.

So that we could gain a deeper understanding of benefits of the induction programme and determine areas that may need further development 14 IMGs were invited to take part in semi-structured interviews (interviewed by JB and KS. The interviewees were purposively selected to reflect the demographics of the study population including NHS Trust, gender and country of origin, ensuring that the induction guidance was applicable regardless of the country in which the IMG graduated. The interview guide was developed by two of the authors (SA and JB) and was based upon the responses to questionnaires and with levels three and four of the Kirkpatrick model in mind (Appendix 3). Interviews were divided between two researchers (JB and KS), all were conducted via Microsoft Teams or Zoom and took place during May and June 2022.

An online WtUKP questionnaire was also provided to a cohort of staff who were attending workshops arranged by Health Education England in the East of England. These were the same questions regarding these workshops that IMGs were asked and provide an additional layer of evaluation for the WtUKP workshops. Overall, 25 pre-induction and 23 post-induction questionnaires were completed with an additional 8 WtUKP post-induction questionnaires.  Fourteen IMGs consented to being approached regarding an interview and 9 interviews were completed (Figure 1).

Figure 1. IMG pilot induction recruitment flow diagram.

4. Work Package 2 – Medical Supervisors and HR Representatives

A Medical Supervisor or IMG clinical lead was identified in each of the participating trusts (n=6). Due to differences between Trusts regarding the human resources recruitment and support for IMGs, not all Trusts were able to provide a named individual HR representative.  Therefore, only four HR representatives participated in the evaluation. Once identified and upon receipt of consent all Medical Supervisors and HR representatives were provided with a link to an online questionnaire using the Jisc survey tool.  The questionnaire aimed to capture pre-induction expectations and views on previous involvement with IMGs, and content and delivery of guidance (Appendix 4). Focus groups were scheduled in May 2022 with separate discussions taking place with Medical Supervisors and HR representatives. A broad guide was produced by two of the authors (SA and JB) which picked up on some the points raised from the phase one and phase two questionnaires (Appendix 5).

5. Work Package 3 - Cost Analysis

Medical Supervisors and HR representatives were asked to keep a note of the approximate costs associated with delivering their induction programme per IMG.  An Excel spreadsheet with examples of costs such as staff time, refreshments, room hire, and consumables was provided to each NHS Trust (Appendix 6). Participants were advised that additional rows could be added for any costs that had not be previously anticipated (for example one Trust included a cost for locum time to release the IMG to attend a workshop).

6. Data analysis

Summaries of the pre- and post-induction questionnaire data were created highlighting the most frequently seen responses and the free text comments. All focus groups and interviews were recorded, and the audio transcribed by an independent transcription service. Summaries and transcripts were then analysed using reflexive thematic analysis (Braun & Clarke, 2006; 2013). This involved one researcher (JB) becoming familiar with the data, identifying and labelling interesting features of the data, generating initial codes, gathering codes into themes, and reviewing and naming themes. A second researcher (SA) also reviewed the data and agreed the final themes. Cost data were analysed by one author (SA) and a range produced showing the lowest and highest costs indicated by Trusts.

6. Results

7. International Medical Graduates Demographics

Twenty-five IMGs participated in the study of which 58% identified as female.  Most IMGs were Clinical Fellows (45%), with Core or Specialty Trainees the next most common job role (40%) and the remainder identified as Trust Grade Doctors (Figure 2).

Figure 2: Trust identified and self-identified job role of IMG participants.

The country of origin was varied with the majority coming from India (37%), then Nigeria (17%), closely followed by Pakistan and Malaysia (13%) with the remaining IMGs coming from Netherlands, Australia, Jordan and Sri Lanka.  This was a wide range of nationalities in a relatively small number of IMGs and was a good representation of the diversity of the NHS workforce. There were no differences in questionnaire responses between nationalities or job role suggesting that the Induction Guidance is fit for purpose across a range of IMG recruits.  

Figure 3: Country of Origin of IMG participants.

8. Pre-induction Questionnaires

1. International Medical Graduates

Twenty-five pre-induction questionnaires were returned. All questionnaires were completed using the Jisc online questionnaire platform. This allowed participants that were in the process of relocating to the UK to respond as the platform supports mobile use. The pre-induction questionnaire asked IMGs to consider how much value or importance they placed on each element of the induction guidance (a copy of the questionnaire can be found in Appendix 1). Section 1 asked participants to consider the importance of being welcomed and supported for day-to-day living, Table 1 shows a breakdown of the aspects assessed. All participants felt this was an important part of the induction process with high importance being placed on financial issues, accommodation and accessing healthcare. Less important aspects included information about schools and places of worship, however those that did place importance on these aspects felt that this information was essential. This result is not unexpected since only those IMGs with children or a strong faith would find these aspects important. It is, therefore, imperative that these aspects of the induction guidance are not ignored but rather that Trusts should tailor the day-to-day living induction to the specific needs of each IMG.

Table 1: Importance placed on receiving information about various aspects of day-to-day living.

The second part of this section assessed well-being factors.  All participants felt it was important to feel welcomed and that they would like information about how to seek support for their own well-being.  Most (n=24, 96%) also felt that being supported to build relationships with colleagues and integrate into the workplace was important – one participant suggested that prior access to an organisational chart outlining immediate colleagues and their roles would be useful.

This linked with section 2 (Professional Practice Induction) where all participants felt it would be important to understand their role and expectations, as well as how to access necessary equipment including PPE. Comments for this section highlighted early access to provisional rotas and understanding frequency of ‘on calls’ as important.   Section 3 covered language and communication, this is an area that previously has been highlighted as problematic and one that commonly appears in patient complaints about IMGs. All participants felt that guidance regarding communication and an introduction to local dialects would be important, whilst one pointed out that understanding locally used acronyms was vital.  All participants also agreed that an IT induction was important and understanding how to maintain patient confidentiality was essential.  Finally, participants agreed that an induction tailored to their speciality was important although there was some disagreement (n=3, 12%) regarding the need for a tour of the department. By contrast easy access to key policy and clinical guidelines as well as understanding how to access CPD opportunities was deemed to be very important.

2. HR Representatives and Medical Supervisors

The pre-induction questionnaire for HR Representatives (n=4) and Medical Supervisors (n=6) asked participants to consider the draft guidance and the importance of each section of the guidance (see Appendix 4).  They were also asked to reflect on their previous experience of welcoming new IMGs as well as their role in the induction process. Even though participants (90%) acknowledged they had worked with IMGs in the past, less than half (40%) had considered how they could support IMGs and most had not been involved in induction processes previously. Forty percent said that they did not have good awareness of the needs of IMGs. Despite this, all participants felt that induction for IMGs was important, all areas of the draft guidance were important and should form part of a holistic approach to induction of new IMGs.  There were differences in the expectations of their roles in induction, with HR Representatives being mainly concerned with administrative processes such as right to work checks and salary set up.  Medical Supervisors were seen to be more involved in daily operational aspects and ensuring the IMGs were ready for clinical practice.  Both Medical Supervisors and HR representatives highlighted the need for there to be more support within Trusts to develop the induction programme and to ensure good communication at each stage of the process starting from recruitment. One participant suggested that the Care Quality Commission (CQC) should review inductions as part of the inspection process formalising the need for good quality induction.  

9. Post-induction Questionnaire (IMGs only)

The IMGs were asked to complete a questionnaire once they had completed the majority of the recommended induction elements, 23 questionnaires were returned.  The time frames varied between Trusts as some used a more intensive process whilst others felt that ongoing support was beneficial. This questionnaire followed a similar structure to the pre-induction questionnaire with IMGs asked to consider whether they felt the induction programme met their needs. An additional section asked participants to reflect on the GMC Welcome to UK Practice workshops (see Appendix 2).    

Despite the pre-induction questionnaire suggesting that day to day living support was an essential element of the induction process there was still dissatisfaction expressed in relation to this aspect of support (Table 2). Primarily participants felt that they needed more support with housing and housing related issues such as how to set up utility and telephone bills. Two thirds felt that they needed support setting up a bank account and that more help could be given regarding finding schools for their children.  Whilst the majority of IMGs felt welcomed in their Trust, some did not (n=6, 26%).  Similarly, most felt they knew how to seek support and had been supported to build relationships with colleagues. 

Table 2: Extent to which IMGs agreed that the induction programme met their needs for information on day-to-day living.

In general, the respondents were more inclined to use the free text boxes on this questionnaire and this proved insightful particularly when asked if they felt welcomed within their Trust.  This resulted in conflicting views with one stating they were “left alone to figure out things by observation… nobody ever cared if I got housing or [was] satisfied with the program”.  Whilst a respondent from a different Trust stated: “Senior consultants and colleagues extremely supportive, makes workplace environment easy [sic] adaptable”.

Most felt the Professional Practice section of the induction programme was good and that they understood their job role and what was expected of them.  A small proportion (17%) were still not sure how to access equipment needed to do their job.  One participant stated they were: “still trying to figure out where things are placed and asking several times for materials to make my work easy”. The Language and Communication components of the induction were generally well received with all but one participant stating that they found the learning material useful and felt more confident that they understood what is required from professional communication in the NHS.  However, it was pointed out that previous proficiency in English did not necessarily prepare IMGs for work as one stated: “yes I do have previous English language and communication knowledge or training, I am from a country where everyone in school is taught in English in all levels of education, but honestly its different when talking to someone with a different accent, especially when he or she expects you to understand all they have said”. IT was an area that received mixed responses where 25% of respondents felt that they did not fully understand how to use the IT systems even though the majority understood the need to keep patient information confidential.  The specialty training was again generally well received, although some (13%) felt that there could be better explanation of key clinical guidelines and policies.

As part of the induction process the IMGs were also required to attend two GMC Welcome to UK Practice (WtUKP) workshops.  In addition to the IMGs participating in the pilot evaluation 8 IMGs who had completed the workshops but not the full induction programme submitted responses to the questions regarding WtUKP.  There was an overwhelmingly positive response with 90% of respondents agreeing that they now understood the role of the GMC better.  They felt they had a greater awareness of GMC guidance (90%) and understood how to apply the guidance (86%).  When faced with a professional dilemma most felt that they would consult the GMC guidance (83%) and that they would change their practise having attended the workshops (83%).  The second workshop, which focused on complaints, boundaries, and personal beliefs, was slightly less well received with 76% of respondents agreeing that it reinforced their awareness and understanding of the GMC guidelines. Several mentioned that having access to these workshops earlier as soon as they have been recruited and possibly before leaving their home country would be useful.  

In general, the respondents felt that the induction programme should be delivered using a hybrid approach as some elements could be accessed online prior to travelling to the UK whereas once they have arrived, they felt face to face would be preferred.  This would facilitate relationship building in the Trust and feeling supported both prior to and immediately upon arrival. The majority felt that the materials provided (77%) and the delivery of the programme (78%) helped with their understanding.  However, 43% of participants did not agree that the programme covered all the key aspects of induction and 34% did not feel prepared for their role and ready for work.  This would suggest that there are still improvements that could be made at Trust level. Comments in the free text boxes at the end of the questionnaire suggested that more information regarding housing and relocation including pay and taxes were needed.  Additionally, two participants suggested that better mentoring would be useful, one felt that the support should be extended past the induction period whilst the other felt that a point of contact within their department would be useful as they were linked with another person in the same MTI (Medical Training Initiative) who was in a different department.

10. Medical Supervisor and HR Representative Focus Groups

Focus groups were undertaken once the Medical Supervisors and HR representatives had been through the process of inducting at least one IMG.  The participants in the focus groups had somewhat varying views depending on their roles.  

HR representatives tended to focus on practical recruitment issues, supporting IMGs with relocation and visa applications.  HR representatives felt that their role tended to be limited to recruitment and the immediate arrival of the IMGs.  Practical support for IMGs was essential and all participants felt that regardless of the role into which the IMG had been recruited they should be given time to settle in prior to being included in clinical rotas.  One participant shared that they, along with the IMG lead for their Trust, had developed a ‘Welcome to the UK’ pack that all IMGs were sent once their post had been confirmed.  This included information about day-to-day living from aspects such as how to pay council tax (and what council tax is) to car insurance and which side of the road to drive on.  The pack could also include basic information about their role such as typical rotas or if available email addresses and log-on information.  All HR representatives felt that this was a great initiative and that an example of the pack could be included with the guidance document.  

The HR Representative focus group also discussed when the induction process should start and whether this could be before the IMG arrived in the UK.  There was a mixed response with some opinions being that induction could start from the point of recruitment whilst the pre-employment check and visa requirements were being completed.  However, one pointed out:

“…whilst I appreciate that people want the information as soon as they can, my question would be if that person hasn’t been confirmed into work what are they going to do with it?” [HR representative]

It was felt that on balance information should only be shared once the relevant checks had been completed and their arrival date in the UK confirmed. This would prevent information being shared with people that are perhaps not eligible or who did not intend to work in the UK. Related to this, all HR representatives felt that the guidance should advise that supernumerary time be built into the first month when an IMG arrives at the Trust to allow them time to shadow colleagues and attend workshops as part of their induction, as well as generally settle into the country.  After this, there should be time set aside to allow the IMG to check in with a named person to ensure that they do not have any issues, it was suggested that this should be bi-monthly for the first 3 months.  

The Medical Supervisor focus group echoed much of the HR Representatives group, where it was highlighted that traditionally IMG induction has been under-resourced and often led by an enthusiastic individual.  But lack of support meant that the enthusiasm would quickly wane, and positive steps would be undone.  The most successful Trusts at retaining IMGs were those that had an IMG office and the support of the Trust.  This was seen as an important learning point but several participating Trusts and that the pilot evaluation had given them the impetus to at least have a named individual responsible for IMG induction as part of their role and therefore, they were paid to complete the work.  Participants agreed that the guidance document was useful and moving forward some of the shared resources that emerged from the pilot would be useful to include. This could include links to information about workshops or checklists and processes that Trusts had developed to be able to implement the pilot.  It was suggested that these areas of good practice should be included in the guidance document with links to resources that all Trusts can access.  It was important that the guidance document be seen as a ‘living’ document that should be adjusted to meet the needs of individual Trusts rather than being prescriptive. Participants suggested that a bespoke website that is available to all Medical Supervisors, HR Representations and IMGs would be an effective way of supporting those that had little experience with IMG induction:

“… [they might say] I don't want to be reading a 60-page guide document. So, if the information can be ‘concised’ to a few documents that would be good. The second thing is that it can be made more interactive: on a website where you can click on a few things; get to know the specific areas which you are looking for.” [Med supervisor]

As with the HR representatives the Medical Supervisors felt that it was vital that IMGs be given time to have a full induction prior to being included in the rota.  Similarly, using lived experience of other IMGs within the Trust was important, particularly since people seemed to be far more concerned with issues outside of work rather than the job itself, as one stated:

“So, I brought in a consultant to talk about how to find schools for children. She moved from Ireland many years ago, and she said that when she moved, she had young children, so she talked about how she found schools in England for her kids; so, she was sharing her experience. Because if I said that, it wouldn't make any sense because I don't have any children; and they could relate to her.” [Med supervisor]

In both focus groups (HR Representatives and Medical Supervisor) one of the most important issues was communication, between recruitment organisations, local HR and clinical staff to ensure that IMGs are identified as such when they arrive at the Trust.  This seems to be particularly an issue with those in training roles rather than locally employed. It was suggested that the guidance document should include a progression route that the Trusts could personalise that lists the people who need to be communicated with at each stage, starting from early recruitment to the day the IMG arrives.  

11. Interviews with IMGs

A total of nine interviews were undertaken with IMGs across a range of demographics.  The interviews proved to be a rich source of data and for ease the findings will be reported in relation to the relevant sections of the induction programme.

3. Welcome and day to day living

The overwhelming response from all the data collected was that this element of the induction was fundamental, but that there were many creases to iron out to enable this to be delivered effectively. Some of these aspects are complex and require coordinated effort and financial resources. When this was explored further during IMG interviews, much of the feedback surrounding feeling unwelcomed appeared to relate to a lack of information about or poor support regarding aspects of day-to-day living, and a lack of clarity about their job role. Despite this many IMGs reported having supportive colleagues, knew that they could ask questions if needed, and knew how to access well-being support should they need it.

HR staff and medical supervisors are often the first to contact new IMGs. Having a designated person to contact was found to be important to IMGs and most reported that they had received regular contact with someone and/or knew someone they could raise queries with. Opportunities to meet others and build relationships was also identified as important. Some IMGs felt that relationships would grow in time, further context on the importance of this support was expressed by an IMG from Malaysia working as a Core Trainee:

“They're [fellow IMGs] also going through a similar process like I am, being new to the country, working here for the first time. I feel basically it's their company that is encouraging, because it's kind of encouraging to know that I am not the only one going through this new thing, as well, just sharing information with one another.” [IMG]

Facilitating opportunities for socialisation and peer support through the creation of WhatsApp groups, social events, and buddying new IMGs with a more established member of staff, were identified by both IMGs and Medical Supervisors. This appears to work particularly well when the colleagues are also IMGs, performing the same role or working in the same department, working at the same Trust site or nearby, and where possible from the same country or cultural background. For example, one IMG noted how he had not been able to find places to buy the food he was used to until he met a colleague who was from the same country. In a diverse population like IMG doctors, sharing arrangements for social occasions with other departments and Trusts may increase the likelihood of shared cultural background and widen the networks that can be created. This may be additionally beneficial to smaller Trusts or even multi-site larger Trusts.

Issues related to accommodation, bank accounts and transportation were the most frequently raised concerns during IMG interviews. Further discussion on these aspects with IMGs indicated that each relates to the other. For example, a residential address is the key to other things, such as setting up a bank account or registering with a GP. Poor knowledge about the local area in which they were able to find accommodation also impacted feelings of safety and transport needs. The frustrations with accommodation were often voiced:

“It took five weeks of being in the UK before I was able to get accommodation. And unfortunately, with the Trust being in a city, and not having accommodation for people who are just coming in the country, was not to help at all. Thank goodness I have a younger brother who lives in the UK, and I was put in with him.” [IMG]

Several IMGs stated that temporary short-term housing that they could rent through the Trust would be very helpful. Additionally, some HR representatives mentioned that during the pandemic they had assisted with accommodation due to quarantine requirements and mentioned how international nursing recruits were supported with their early housing needs.

As some IMGs had families, it is also important to highlight the additional need to secure school places for children and impact of having a family to settle in the UK as well as themselves. This adds an additional level of stress as this quotation from an interview with an IMG from Jordan demonstrates:

“I waited seven weeks when they [my children] were at home [unable to access school places] … I was working a full-time job, and also my husband has a full-time job, because we are doctors in the NHS, we can't just take time off… when they [children] settle down, I settle down also.” [IMG]

Perhaps in relation to the issues they had with finding accommodation and schooling, this IMG went on to explain that having been here for four months it is only recently that they have started to feel a little more settled.

The timeliness of the aspects discussed above during the induction process was raised during IMG interviews, with several stating that they would have benefitted from having been able to complete some elements prior to arrival in the UK or at least before starting work:

“It would be very helpful before I came to the UK to have some sort of idea about what I'm going to go through, because there was a lot of things that happened that I didn't really expect would happen.” [IMG]

Some IMGs described how they had received a presentation about the local area from their Trust and found this helpful:

“[The Trust] sent me useful Microsoft slides; so, they sent that to me so I can go through them in my own time. Something like a presentation. Then they listed the important things that mostly IMGs are concerned about. They give us information I want to look at; those I find is actually quite useful and I go through it in my own time.” [IMG]

4. Professional practice induction

Most IMGs involved in the study fed back via the post-induction questionnaire that their induction had helped them to understand where their job role sits, to understand their job description and what is expected of them, and how to access the equipment they need. However, during interviews it was clear that this was not always the case as explained by this IMG from Nigeria:

“Over time, I have been able to find out what my role would be and what I need to do. It wasn't as if I got it clearly right from the beginning; and I would have appreciated it if I got it more clearly right from the beginning… I would have wanted it like a clearly written job description.” [IMG]

There were also some issues expressed regarding the communication about and timeliness of some of the professional practice information:

“I didn't know I was enrolled in mandatory training. So, by the time I had my induction, what I might be doing this and that, what my login was to ESR [the system], by the time I logged in I discovered I had only one week left to finish it. So, it was not easy for me to do a lot of courses, while working, trying to balance the two. I had to do much of it overnight, in the middle of the night, to be able to keep up. So, if there had been an earlier induction, I believe I would have been able to concentrate on many of those things.” [IMG]

Several IMGs described how the health care systems in their country of origin were quite different from the NHS. The data reinforces the need for clear information about job roles and responsibilities as part of the induction process, delivered prior to an IMG starting their role and regularly followed up as part of the ongoing support process.

5. Language and communication

Throughout language and communication has been highlighted as an important aspect of the induction process. Local accents and dialects were identified as a particularly challenging aspect, as noted by this IMG from Malaysia:

“That was quite challenging because I can't really get a proper history from the patients if I don't really understand what they're saying, and it feels a bit rude to keep asking them to repeat themselves.” [IMG]

A helpful addition to the online learning involved simulation and shadowing opportunities, which was mentioned by most IMGs, as highlighted by this IMG from India:

“What helped me best was shadowing along with my consultants; even the psychosocial workers and the psychologists, I shadowed them, and I saw how they communicate and talk with the patient. I had some difficulty initially with the accent, and I was wondering whether I would be able to cope with it or not; eventually after one week it got much better: I could easily catch the local language. So, I would suggest that shadowing, seeing how others take history, and how they communicate with the patients, that taught me the best.” [IMG]

Where simulation and role-play scenarios were offered these were found to be helpful to IMGs, as identified by this IMG from Nigeria:

“A simulation of scenarios in the ICU, we just had two or three hours to practise. I thought we could have done with another session. We just have one session… it was really nice.” [IMG]

Furthermore, opportunities to discuss language and communication formed an important part of the ongoing support offered to IMGs:

“Because my supervisor is also an IMG, he came to the country and arrived years ago, so he is of the opinion that my English language is better than his! Because English is spoken in my own country with ease, it is a primary language really. And there is shadowing opportunities, when we are communicating with patients… after it has been communicated, he gives me feedback and points out areas of improvement to me.” [IMG]

A package of language and communication support that blends online learning, practical application, and supervision would be a beneficial element of the induction and ongoing support guidance.

6. Specialty induction

A good introduction to the department and colleagues working there can be beneficial to the feeling of being welcomed and supported. Most IMGs reported that their colleagues had been very supportive and willing to answer any questions that they had. There has been, however, some confusion expressed about the training programme portfolio as expressed by this IMG Core Trainee from Malaysia:

“When I asked my fellow colleagues who are also in the same training programme, who are also using the same portfolio, they are also quite confused about using it.” [IMG]

This perhaps provides some substance to the post-induction questionnaire comment that indicated that updated information about professional development opportunities had not been provided emphasising the need for clear guidance on aspects relating to specialty training to be included in the induction and ongoing support guidance.

7. IT systems induction

Although a relatively smaller element of the induction guidance it is still an important part, particularly as highlighted earlier where systems are likely to be quite different to those in the country of origin of many IMGs:

“Here in the UK, I realise that it is quite different, you are involved in a lot of administrative work, which you were not involved in where you were coming from, in terms of booking appointments, calling patients if they did not show up for appointments and all that, and a lot of other things too. Then when I was working in Nigeria, it was still put more on paper, but here it is more use of computer.” [IMG]

8. Welcome to UK Practice workshops

The GMC WtUKP workshops were well-received by all the IMGs who had attended these sessions:

“I feel like the council [GMC] is not just a body or organisation that is just there, there is a middle third-party person for us to come in and work in the NHS. I also feel like I am being supported. When they did that workshop, I just feel like for them to come all the way to set up a workshop and to spend time with us, foreign medical graduates who came here for the first time, I feel it kind of shows support.” [IMG]

Much of the positive feedback surrounding online delivery involved how it enabled attendance prior to arrival in the UK, convenience, and assisting with social distancing during the pandemic. IMGs stated that whilst some aspects from in person interaction aided socialisation, a hybrid approach may be an ideal compromise:

“Presentations or lectures on virtual platform is good. But discussion is better with in person participation.” [IMG]

9. Induction and ongoing support resourcing and delivery

Throughout the interviews IMGs also discussed the delivery, materials and support offered as part of their induction. There were differences in delivery style between the six Trusts piloted and those that received an intense induction period, sometimes just one day, felt it would be better spread out, as explained by this IMG:

“I feel like it's better for it to be spread out, instead of all-in-one day, because there's a lot of information that was shared there, to take it all in in one day, it's quite overwhelming.” [IMG]

The researchers that conducted interviews reflected on this, finding that it seems that what IMGs regard as induction is not necessarily all the different aspects of the guidance, and in some cases, induction may only be regarded as the in-person sessions undertaken when first starting work. Clarification by the IMG lead or educational supervisor on what the process may involve from the outset (including ongoing support) may help with the understanding of the complete package available.

12. Cost Analysis

A basic cost analysis was undertaken to determine average costs for the Trust when undertaking the induction.  Participating Trusts were asked to indicate staffing costs to support the IMGs, any material costs including tea and coffee, costs associated with accessing workshops that might include meal costs (a full list of suggested costs can be seen in appendix 6).  The average cost per IMG for the induction was £1860.00. With costs ranging from £1,250 to £2,685 across the Trusts.  Some Trusts only returned costs related to staff time to support the IMGs, whilst others included tea/coffee and meal allowances and additional support.  For example, one Trust included a full day training event and included Locum costs to cover the IMGs whilst they were at the training.  Therefore, it is more likely that the average cost more broadly across the NHS will be towards the lower end of the scale and certainly more likely to mirror the average cost rather than the high-end cost.

7. Recommendations for the induction and ongoing support guidance

Several recommendations can be highlighted from the pilot evaluation.  Firstly, it is important that all Trusts identify an IMG lead who will be a key contact for IMGs arriving in the UK and that this must be part of their allocated job role and support by NHS Trust Boards and system leaders.  For larger Trusts an IMG office that combines Medical Supervisors and HR resource may also be beneficial.  Related to this is the support for the IMGs to be allocated a supernumerary period that enables them to undertake induction activities and importantly to be able to shadow colleagues in the first weeks in the UK.  This will enable them to settle both into their new life and to gain the best understanding of their role and expectations.

Additional stress and anxiety caused by day-to-day living challenges was highlighted through the evaluation and therefore this must be seen as a vital part of the welcome and induction process.  Accommodation was a cause for concern and whilst this is a complex issue Trusts should be prepared to explore solutions such as a memorandum of understanding with local rental agencies or ‘buying in’ temporary accommodation. An information pack that includes information about practical living advice should be sent to every IMG pre-arrival and examples of this ‘Welcome to the UK’ pack should be included with the induction guidance. This should be considereda ‘living’ document and guidance to wider Trusts should include information that the documents should be tailored to the requirements of the Trust and the local area. Finally, it is important that IMGs are supported to become part of both the work and local community into which they are moving.  Buddy systems and social events that include both previous IMGs and UK medical graduates can all help new starters to feel welcomed and supported.

8. Limitations and recommendations for future research

The Covid-19 pandemic has affected everyone, and in particular it has had a significant and continuing impact on the NHS and its workforce such as increasing workloads and burnout. This was highlighted in the recent State of Medical education and practice report (GMC, 2021). The pandemic has also impacted IMG movement both into and out of the NHS, with numbers of doctors registering with the GMC from countries previously contributing large numbers to the NHS workforce, such as India, falling significantly (GMC, 2021). These stressors understandably have a bearing on the development and piloting of the induction and ongoing support guidance. However, this also perhaps reinforces the need to headline this work as an important means to support the NHS workforce going forward.

Recruitment to the evaluation was not able to achieve a large participant sample. Whilst this may in part be due to the above pandemic related issues, 45 percent of IMGs joining the piloting NHS Trusts and agreeing for their information to be shared with the research team did not consent to be part of the study. Whilst not within the scope of this evaluation it would be useful to try to follow up with these IMGs to understand why they no longer felt able to participate.  

The evaluation itself completed what it set out to do and we were able to gain a deeper understanding of the importance of induction and feed into the final draft of the induction programme.  However, it is clear that longitudinal research is needed to further understand how a comprehensive induction process might impact on aspects such as retention of workforce and reduction of complaints. Any future research would also benefit from including IMGs from across the NHS including primary care physicians that were not represented in the evaluation.

9. Conclusion

The overarching goal of the induction and ongoing support guidance is to enable all IMGs who are recruited to work in the NHS, to settle in quickly to working in the NHS and to living in the UK, feel welcomed and integrated into their team, understand NHS values, culture and ways of working and work to their best potential. Using the Kirkpatrick model, the evaluation has provided good evidence that the elements identified in the draft induction and ongoing support guidance are relevant and in sync with what IMGs, Medical Supervisors, and HR representatives require to help ensure the best for everyone; IMGs themselves, NHS Trusts, and the people served by the NHS. The evaluation has also identified additional intricacies on how the different elements of induction and ongoing support can be delivered at Trust level and the system changes that are required to make the process successful. It is acknowledged that secondary care IMGs are only one part of the international workforce that makes up the NHS and that there are pockets of good practice across the NHS. It is hoped that this evaluation and the subsequent launch of national NHS induction and ongoing support guidance will provide an ideal catalyst to galvanize support right across the NHS and government.

References

Bogle, R., Lasoye, T., Winn, S., Ebdon, C., Shah, D., Quadry, R., ... & Menon, G. (2020). Supporting international medical graduates in the NHS: Experiences from the pre-COVID and COVID environment. The Physician, 6(2)

Braun, V. & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77-101

Braun, V. & Clarke, V. (2013). Successful Qualitative Research: A Practical Guide for Beginners. Sage

Dawson J. (2018). Links between NHS staff experience and patient satisfaction: Analysis of surveys from 2014 and 2015. https://www.england.nhs.uk/wp-content/uploads/2018/02/links-between-nhs-staff-experience-and-patient-satisfaction-1.pdf

General Medical Council. (2014). The state of medical education and practice in the UK. https://www.gmc-uk.org/-/media/documents/SOMEP_2014_FINAL.pdf_58751753.pdf

General Medical Council. (2021). The state of medical education and practice in the UK. https://gmc-uk.org/-/media/documents/somep-2021-full-report_pdf-88509460.pdf?la=en&hash=058EBC55D983925E454F144AB74DEE6495ED7C98

Kehoe, A., McLachlan, J., Metcalf, J., Forrest, S., Carter, M., & Illing, J. (2016). Supporting international medical graduates’ transition to their host‐country: realist synthesis. Medical education, 50(10), 1015-1032

Kirkpatrick partners. (2022). The New World Kirkpatrick Model. https://www.kirkpatrickpartners.com/the-kirkpatrick-model/

NHS Digital (2021). NHS workforce. https://ethnicity-facts-figures.service.gov.uk/workforce-and-business/workforce-diversity/nhs-workforce/

APPENDIX 1

International Medical Graduate Induction programme evaluation - Pre-induction questionnaire                              

You are being asked these questions to gauge your expectations of and what you feel is important to the different aspects of the NHS induction programme. This is part of a pilot project with a number of NHS Trusts, prior to a nationwide rollout of an induction programme for International Medical Graduates.

There are five sections to complete, aligning with the five phases of the induction programme. Please indicate your responses by checking the box that you feel best represents your answer. Free text boxes are provided at the end of each section for you to add any specific comments you wish to make. This questionnaire should take no longer than 15 minutes to complete.

APPENDIX 3

International Medical Graduate Induction and ongoing support programme evaluation –

 Post-induction questionnaire                              

Having undertaken your NHS Trusts induction programme, you are being asked these questions to understand how you felt this programme met your needs. This is the second part of a pilot project with a number of NHS Trusts for International Medical Graduates.

There are seven sections to complete, aligning with the five phases of the induction programme, including the Welcome to UK Practice element, with one additional section on the induction programme generally. Please indicate your responses by checking the box that you feel best represents your answer. Free text boxes are provided at the end of each section for you to add any specific comments you wish to make. This questionnaire should take no longer than 40 minutes to complete.

APPENDIX 3

IMG induction and ongoing support guidance evaluation - Interview guideline

What would you like me to call you?

What is your job role?

Thank you for joining me today and being part of the evaluation. Gathering your views forms a really important part of the pilot phase of this work. We would like this interview to take the form of a discussion. We have some things in particular we’d like to pick up on, these are based upon the questionnaires you have completed. But we’d also like you to share your thoughts generally about the guidance.

We expect the meeting to last no longer than an hour. We would like to record today’s meeting. The audio will be transcribed after the session, the video will not be used, but if you are not comfortable with the video being recorded, please turn your camera off.

1. We’ll start with your thoughts on induction generally, how important is an induction programme to you?

2. Are there designated people or a designated person who you have been able to contact throughout? Is that contact important to you?

3. Let’s break down the different elements of the guidance now. Firstly, from the pre-induction questionnaire responses, day to day living and the pastoral element seemed to be a really important aspect. However, the post-induction questionnaires indicate that not everyone felt they had a good experience with being welcomed and supported to set-up their lives and settle in the UK. What can you tell me about your experience?

1. What do you think could be done differently?

2. In particular are there ways you can think of that would help you to build relationships with colleagues and make friends?

4. Now let’s move onto your induction into professional practice. Can you talk about how well you were supported to understand your job role, what was expected of you, and where to find equipment and items you need to perform your role?

1. Prompts: What else would help you to feel supported?

5. Moving on to language and communication. Have you been given the opportunity to talk to a supervisor about your language and communication needs? And how has the induction process supported you to address these needs?

6. Let’s now talk about your induction to your specialty role. Can you talk about how well you were supported in your specific area of specialism?

1. Prompts: What else would help you to feel supported?

7. Thinking about the General Medical Council Welcome to UK Practice workshops, how useful were these workshops? and did they enhance your understanding of the GMC and its role in supporting doctors?

8. Moving on to induction delivery. How do you think the different elements of induction and support should be delivered?

1. Prompts: as one package or spread out, some prior to arrival, dedicated time off-rota to complete tasks, online, in-person or hybrid?

9. How could the materials used to deliver your induction be improved to enhance your learning and understanding?

10. What else could be done to help you feel prepared and ready for your work and your specific role?

11. Is there anything else you would like to add?

APPENDIX 4

International Medical Graduate induction and ongoing support guidance evaluation - Pre-induction questionnaire

(HR & Medical Supervisors)                            

We are evaluating the draft NHS induction and ongoing support guidance for IMGs and are interested in understanding the impacts, both negative and positive, on those who have been given specific responsibilities as part of the induction and support process. There are no right or wrong answers. We are collecting your views as they add value to our effort to understand the needs of IMGs, HR and medical supervisors.

The questionnaire involves a mix of yes/no questions, scale questions and free text boxes. For scale questions, please indicate your responses by checking the box that you feel best represents your answer. Free text boxes may ask specific questions or are provided for further details relevant to the yes/no or scale questions. The final section of the questionnaire provides space for you to add any further comments you wish to make. It should take no longer than 15 minutes to complete this questionnaire.

1. Cast your mind back to before you commenced the pilot, did you deal with IMGs at all?  Yes/No

2. Cast your mind back to before you commenced the pilot, were you involved in IMG induction and ongoing support? Yes/No – If yes go to Q4.

3. If no, did you offer to help with IMG inductions prior to commencing the pilot?  Yes/No/ N/A – If no or N/A go to Q5.

3a. If yes, what kind of help did you offer?

4. If you were involved prior, what level of involvement did you have?

5. Cast your mind back to before you commenced the pilot, was there a designated person leading recruitment and supporting the arrival of IMGs? Yes – a HR representative / Yes – a Medical supervisor / No / Unsure  - If No or unsure go to Q.7

6. If yes, were you aware who that person was? Yes / No / I was the designated person

APPENDIX 5

HR focus group discussion guideline – 13th May 2022

Thank you for joining us today and being part of the evaluation. Gathering your views forms a really important part of the pilot phase of this work. We would like this session to take the form of a discussion. We have some things in particular we’d like to pick up on, these are based upon the questionnaires you have completed. But we’d also like you to share your thoughts generally about the guidance.

We expect the session to last no longer than an hour. I (Steph) will be leading the discussion, with Jo taking notes and contributing as appropriate. We will be recording today’s meeting. The audio will be transcribed after the session. We will not use the video as part of the evaluation.

We hope everyone feels they have an opportunity to share what they would like to. To help with this, use of the raise hand function would be helpful so we can ensure everyone can be heard in an organised way.

1. The pilot appears to have served to raise awareness of IMG needs amongst medical supervisors and HR staff. For those not involved in IMG induction prior to the pilot, did you have any knowledge or thoughts about IMGs working within the NHS or specifically your Trust?
2. Several people indicated that they did not know who the designated person was or that there was no designated person for IMGs at the Trust. Can you talk a little bit about how important this aspect is? And why?
3. How induction content is delivered featured in the feedback received. What are your thoughts around how content is best delivered? e.g. spread out over first few weeks/months of employment, in blocks, all at once
4. Let’s now talk about the content itself. Your feedback indicated that all the different aspects featured in the guidelines are important. Can you share your thoughts on the guidelines?

1. Prompts

1. Some felt the content may be a bit ambitious and difficult practically to deliver (e.g. don’t know where people live to tell them what is nearby)
2. Some felt there were distinct parts for HR to deliver and others for medical supervisors

5. There was some feedback about the role of HR, and the level of involvement, as well as the roll-out including guidance on how to set this up. Can we talk more about that?
6. How important is the HR role? And do you see that changing following the pilot?
7. Are there any general thoughts you would like to raise about the guidelines and their roll-out?

Medical Supervisors focus group discussion guideline – 6th May 2022

Thank you for joining us today and being part of the evaluation. Gathering your views forms a really important part of the pilot phase of this work. We would like this session to take the form of a discussion. We have some things in particular we’d like to pick up on, these are based upon the questionnaires you have completed. But we’d also like you to share your thoughts generally about the guidance.

We expect the session to last no longer than an hour. I (Steph) will be leading the discussion, with Jo taking notes and contributing as appropriate. We will be recording today’s meeting. The audio will be transcribed after the session. We will not use the video as part of the evaluation.

We hope everyone feels they have an opportunity to share what they would like to. To help with this, use of the raise hand function would be helpful so we can ensure everyone can be heard in an organised way.

1. The pilot appears to have served to raise awareness of IMG needs amongst medical supervisors and HR staff. For those not involved in IMG induction prior to the pilot, did you have any knowledge or thoughts about IMGs working within the NHS or specifically your Trust?
2. Several people indicated that they did not know who the designated person was or that there was no designated person for IMGs at the Trust. Can you talk a little bit about how important this aspect is? And why?
3. How induction content is delivered featured in the feedback received. What are your thoughts around how content is best delivered? e.g. spread out over first few weeks/months of employment, in blocks, all at once
4. Let’s now talk about the content itself. Your feedback indicated that all the different aspects featured in the guidelines are important. Can you share your thoughts on the guidelines?

1. Prompts

1. Some felt the content may be a bit ambitious and difficult practically to deliver (e.g. don’t know where people live to tell them what is nearby)
2. Some felt there were distinct parts for HR to deliver and others for medical supervisors

5. There was some feedback about the role of HR, and the level of involvement, as well as the roll-out including guidance on how to set this up. Can we talk more about that?
6. How important is the medical supervisor role? And do you see that changing following the pilot?
7. Are there any general thoughts you would like to raise about the guidelines and their roll-out?

APPENDIX 6