Exploring recent patterns of migration of doctors to the United Kingdom: a mixed-methods study.

INTRODUCTION: A shortage of doctors is currently one of the biggest challenges faced by the healthcare workforce in the United Kingdom (UK). While plans are in place to increase the number of medical school places, in the short-term this gap will need to continue to be filled by the international recruitment of doctors. The aim of this study is to identify key factors that explain the patterns of migration of doctors to the UK, in order to aid the development of policies to recruit and retain a sustainable workforce. METHODS: We analysed General Medical Council (GMC) secondary data on the patterns of migration of internationally trained doctors (2009-2019). Qualitative interviews were conducted with 17 stakeholders by videoconferencing which were audio-recorded, transcribed and thematically analysed using NVivo. RESULTS: In 2019, 34.5% of UK doctors were trained internationally mainly in India, Pakistan, Italy, Nigeria, Greece, Romania and Egypt. Most new registrations by internationally trained doctors from 2009-2019 did not have a specialty at the time of initial registration (96.2% in 2019). Only a relatively small number of these doctors go on to gain specialist or GP registration (11.6% within 5 years and 27.2% within 10 years of registration). The stakeholder interviews highlighted training opportunities and career progression as the main drivers of migration. The barriers internationally trained doctors face regarding specialty training included differences between UK and destination health systems, systematic bias, bureaucracy and selection processes not being accessible. CONCLUSION: This study makes a contribution to the literature by identifying recent patterns in the migration of doctors to the UK. The UK's dependence on internationally trained doctors has important global implications as source countries are losing skilled health workers which is undermining their health systems. In keeping with the WHO Global Code on the International Recruitment of Healthcare Personnel, policymakers need to consider how to reduce the UK's reliance on internationally trained doctors, particularly from countries on the safeguard list whilst continuing the drive to increase medical school places. Additional support is required for internationally trained doctors, to ensure that they get on the training programmes they seek, enabling their career progression.

Drivers and barriers of international migration of doctors to and from the United Kingdom: a scoping review.

BACKGROUND: Many high-income countries are heavily dependent on internationally trained doctors to staff their healthcare workforce. Over one-third of doctors practising in the UK received their primary medical qualification abroad. Simultaneously, an average of around 2.1% of doctors leave the UK medical workforce annually to go overseas. The aim of this study was to identify the drivers and barriers of international migration of doctors to and from the UK. METHODS: A scoping review was conducted. We searched EMBASE, MEDLINE, CINAHL, ERIC and BEI in January 2020 (updated October 2021). Grey literature and citation searching were also carried out. Empirical studies reporting on the drivers and barriers to the international migration of doctors to and from the UK published in the English language from 2009 to present were included. The drivers and barriers were coded in NVivo 12 building on an existing framework. RESULTS: 40 studies were included. 62% were quantitative, 18% were qualitative, 15% were mixed-methods and 5% were literature reviews. Migration into and out of the UK is determined by a variety of macro- (global and national factors), meso- (profession led factors) and micro-level (personal factors). Interestingly, many of the key drivers of migration to the UK were also factors driving migration from the UK, including: poor working conditions, employment opportunities, better training and development opportunities, better quality of life, desire for a life change and financial reasons. The barriers included stricter immigration policies, the registration process and short-term job contracts. CONCLUSIONS: Our research contributes to the literature by providing a comprehensive up-to-date review of the drivers and barriers of migration to and from the UK. The decision for a doctor to migrate is multi-layered and is a complex balance between push/pull at macro-/meso-/micro-levels. To sustain the UK's supply of overseas doctors, it is vital that migration policies take account of the drivers of migration particularly working conditions and active recruitment while addressing any potential barriers. Immigration policies to address the impact of Brexit and the COVID-19 pandemic on the migration of doctors to and from the UK will be particularly important in the immediate future. Trial registration PROSPERO CRD42020165748.

An informal school-based peer-led intervention for smoking prevention in adolescence (ASSIST): a cluster randomised trial.

BACKGROUND: Schools in many countries undertake programmes for smoking prevention, but systematic reviews have shown mixed evidence of their effectiveness. Most peer-led approaches have been classroom-based, and rigorous assessments are scarce. We assessed the effectiveness of a peer-led intervention that aimed to prevent smoking uptake in secondary schools. METHODS: We undertook a cluster randomised controlled trial of 10 730 students aged 12-13 years in 59 schools in England and Wales. 29 schools (5372 students) were randomly assigned by stratified block randomisation to the control group to continue their usual smoking education and 30 (5358 students) to the intervention group. The intervention (ASSIST [A Stop Smoking In Schools Trial] programme) consisted of training influential students to act as peer supporters during informal interactions outside the classroom to encourage their peers not to smoke. Follow-up was immediately after the intervention and at 1 and 2 years. Primary outcomes were smoking in the past week in both the school year group and in a group at high risk of regular smoking uptake, which was identified at baseline as occasional, experimental, or ex-smokers. Analysis was by intention to treat. This study is registered, number ISRCTN55572965. FINDINGS: The odds ratio of being a smoker in intervention compared with control schools was 0.75 (95% CI 0.55-1.01) immediately after the intervention (n=9349 students), 0.77 (0.59-0.99) at 1-year follow-up (n=9147), and 0.85 (0.72-1.01) at 2-year follow-up (n=8756). The corresponding odds ratios for the high-risk group were 0.79 (0.55-1.13 [n=3561]), 0.75 (0.56-0.99 [n=3483]), and 0.85 (0.70-1.02 [n=3294]), respectively. In a three-tier multilevel model with data from all three follow-ups, the odds of being a smoker in intervention compared with control schools was 0.78 (0.64-0.96). INTERPRETATION: The results suggest that, if implemented on a population basis, the ASSIST intervention could lead to a reduction in adolescent smoking prevalence of public-health importance.

How do teenagers and primary healthcare providers view each other? An overview of key themes.

BACKGROUND: Teenagers have often been asked for their opinions about health services. However, relatively few studies have involved quantitative and qualitative methods of assessing them. Furthermore, there have been no United Kingdom studies of providers' views on the health of teenagers or of providers' opinions about their role in teenage health. AIM: To determine how teenagers view primary care, to discover how primary care providers view teenage patients, and to note any differences in opinions between the two groups. DESIGN OF STUDY: Questionnaire survey, focus group discussions, and semi-structured interviews. SETTING: Two thousand two hundred and sixty-five teenage patients, 16 general practitioners (GPs), 12 practice nurses, and 12 general practice receptionists in South Wales valley communities. METHOD: Selected practices provided age-sex registers of patients aged between 14 and 18 years and questionnaires were sent to these patients. Focus groups were assembled from those teenagers who had completed and returned the questionnaire. Semi-structured interviews between one member of the study team and GP surgery staff, chosen randomly from staff lists in the selected surgeries. RESULTS: The teenagers reported a lack of knowledge of services available from primary care, a feeling of a lack of respect for teenage health concerns, poor communication skills in GPs, and a poor understanding of confidentiality issues. The providers did not always share these concerns and they also had differing views on communication and confidentiality issues. CONCLUSION: The data demonstrated important findings about how teenagers would like primary care services to be improved. There was an apparent gulf between teenagers' own opinions about health care and the opinions held by primary care providers.

Survey of attitudes of pregnant women towards Down syndrome screening.

This study aimed to examine whether pregnant women made informed decisions based on an accurate understanding of the antenatal screening process and to explore their attitude to screening and termination of a Down syndrome fetus. Women's aspirations were the keystone that informed the development of the first strategy for antenatal screening for congenital anomalies. Semi-structured interviews were carried out with a sample of pregnant women in South Wales in 1995. A total of 34 women aged less than 35 years, who were 20 weeks pregnant, were interviewed. These women were selected because the screening policy differed between hospitals for this age group. The majority of women were not aware that screening tests were voluntary: tests were presented as routine. About half of the sample were not well informed to make decisions. Only five out of a sampling frame of 101 women refused screening; they tended to be better educated and of higher social class. All women wanted to be given the choice whether to be screened. Seven out of 34 would not terminate an affected fetus. Staff communication skills, especially in delivering risk estimate, were criticized. The survey findings supported the view that women required an information package tailored to their individual needs.

Effects of idiosyncratic stimulus variables on functional analysis outcomes.

As the methods for the functional analysis of problem behavior have continued to develop, there has been a greater focus on the specificity of controlling variables, both antecedents and consequences. Accelerating research interest in the role of antecedents reveals that a large array of stimulus variables can influence the rate of problem behavior. Indeed, the variety of these stimuli is so great that it is sometimes possible to overlook specific stimulus variables during initial assessment. The present study shows that a failure to identify these very specific (idiosyncratic) stimulus variables is serious because their presence can systematically alter the outcomes of functional analyses that are designed to assess the motivation of problem behavior. Guidelines are therefore discussed concerning when to suspect that idiosyncratic stimuli might be acting to influence assessment data, thereby promoting a search for additional stimulus variables whose identification can aid in improving the design of functional analysis conditions.

Empirically derived consequences: a data-based method for prescribing treatments for destructive behavior.

Behavioral treatments are often prescribed on the basis of a functional assessment. However, in a significant number of cases, functional assessment results are equivocal or suggest that internal stimuli are maintaining the behavior. In this investigation, we evaluated an alternative data-based assessment that may be useful in such cases. This assessment was used to identify reinforcers and punishers based on the reinforcement assessment procedure described by Pace, Ivancic, Edwards, Iwata, and Page (1985). We then assessed whether empirically derived reinforcers and punishers could be combined to treat the destructive behaviors of two clients. For both clients, the rates of destructive behavior decreased markedly. The results suggest that empirically derived consequences may be useful in decreasing destructive behavior when a functional assessment is inconclusive or is consistent with the hypothesis that the behavior is stereo-typic and maintained by internal stimuli.

Evaluation of syringe-exchange for HIV prevention among injecting drug users in rural and urban areas of Wales.

This paper considers the prevention of HIV in rural and urban areas among both opiate and non-opiate drug injectors. A 2-year study evaluated specialist and community based syringe-exchange provision in Wales. Numbers of clients and patterns of attendance at eight syringe-exchange schemes were monitored together with comparative cross-sectional studies of attenders (n = 152) and non-attenders (n = 176) from the population of drug injectors in 1990 and 1991. A total of 1171 clients made 7553 visits in the 2-year period, 110,000 syringes were issued and 80% of needles and syringes were returned. There were few demographic differences between attenders and non-attenders, but large and significant differences in HIV risk behaviour; only 9% of attenders had recently shared syringes in 1990 (10% in 1991) compared to 41% of non-attenders (39% in 1991). The catchment areas of specialised services were limited (5 miles or less) and insufficient in rural areas. Alternative community approaches to syringe distribution and exchange are examined.

Selegiline in narcolepsy.

We examined the effect of the specific monoamine oxidase-B (MAO-B) inhibitor selegiline (deprenyl, Eldepryl), 20-30 mg p.o. daily, in 21 subjects with the narcoleptic syndrome for 4 weeks. Selegiline was compared to no treatment (7 subjects) or conventional central stimulant drugs, including dexamphetamine or mazindol (14 subjects). Severity and frequency of narcolepsy, accessory symptoms, and effects of selegiline on mood were measured. Selegiline, as well as causing MAO-B inhibition, is interconverted to amphetamine. Urinary amphetamine and methamphetamine excretion were determined in 18 subjects after 4 weeks on selegiline and the results were compared with amphetamine excretion in subjects on dexamphetamine. The effect of selegiline, 20-30 mg p.o., on alertness and mood was similar to that of dexamphetamine in the same dosage, with comparable sympathomimetic side effects. Selegiline, 20 mg p.o., caused a subjective increase in alertness for 4-8 h. Mean urinary amphetamine excretion on dexamphetamine, 15-70 mg daily (mean 29 mg) at pH 5.6-6.6, was 5,184 micrograms/24 h, and on selegiline, 20-30 mg daily (mean 22.5), was 4,127 micrograms/24 h. We conclude that selegiline, 20-30 mg daily, requires further evaluation in narcolepsy.

Immune factors in narcolepsy.

Most but not all subjects with the narcoleptic syndrome have the human leukocyte antigen (HLA) DR2 (and DQ1). The narcolepsy-DR2 association is the highest disease-HLA linkage known, and occurs in nonfamilial as well as familial cases of the narcoleptic syndrome. In other forms of daytime drowsiness, there is no relationship with a specific HLA, although some subjects considered to have "essential" hypersomnolence probably have the narcoleptic syndrome. The cause of the narcoleptic syndrome remains unknown, although in a few instances the condition follows infection. There is no evidence for a circulating sleep factor in the blood or in the cerebrospinal fluid of narcoleptic subjects, and no unequivocal marker of cellular immunity has yet been found. However, a few subjects with the narcoleptic syndrome have oligoclonal bands or raised immunoglobulin concentration in the cerebrospinal fluid. It is highly likely that the narcoleptic syndrome is an immune-mediated disorder, occurring in a genetically susceptible (DR2/DQ1-positive) subject.

Comparison of levodopa with carbidopa, and levodopa with domperidone in Parkinson's disease.

In a comparison of the effects of domperidone and carbidopa during levodopa treatment, 20 patients with idiopathic Parkinson's disease were treated with fixed dose regimens of either levodopa 500 mg-domperidone 20 mg or levodopa 100 mg-carbidopa 25 mg; each for 8 weeks. Clinical response, incidence of side effects, and plasma levodopa concentration resulting from each treatment were compared. Overall, in the dosages used, Parkinson's disease was less well controlled with levodopa-domperidone than with levodopa-carbidopa. In eight subjects there was a severe deterioration 2 to 7 days after changing from a fixed dose of levodopa-carbidopa to levodopa-domperidone. In nine subjects who completed the trial, the clinical response, occurrence of dyskinesias and of nausea and vomiting, were similar with both treatments, although peak plasma levodopa concentration and levodopa bioavailability were greater on levodopa-domperidone than on levodopa-carbidopa.

Genetic markers in narcolepsy.

Narcolepsy has long been known to have a hereditary familial basis. All of 37 patients with narcolepsy expressed the major histocompatibility complex antigen HLA DR2 compared with 21.5% of 200 normal controls. This finding confirms the genetic basis for the disease, and furthermore links it with the short arm of chromosome 6. If the sleep disturbance in narcolepsy is due to a gene-determined defect in a neurotransmitter or receptor factor, the responsible agent may be DR2 itself or an enzyme determinant linked to DR2. This is the strongest HLA-disease association so far discovered.

Naloxone increases the nicotine-stimulated rise of vasopressin secretion in man.

Intravenous nicotine was administered to a group of six subjects during the concurrent intravenous infusion of either the opiate antagonist naloxone, or of saline. Nicotine stimulated vasopressin secretion in all subjects. Naloxone infusion increased both the plasma vasopressin response to nicotine and the resulting rise in urine osmolality.