An apple a day? What’s keeping doctors away?

A decent splash in the Independent is disappointingly let down by an absence of the italics and exclamation marks necessary for a screaming headline …

The content is very interesting though, saying that NHS employers who have recruited doctors abroad have been unable to get the Certificates of Sponsorship they need to bring them into the UK….

Doctors who have been offered jobs by NHS hospitals desperate to fill rota gaps are being blocked from coming to the UK by the Home Office because visa quotas for non-EU immigrants set seven years ago are already full.

Despite passing interviews, a necessary language test and receiving licences to work in the UK by the General Medical Council (GMC), dozens of medics waiting to work in the health service are stuck abroad as their Certificate of Sponsorship (CoS) applications — necessary to secure a Tier 2 (General) workers’ visa — have been rejected.

The quota stand at 20,700 a year, and so regardless of your views on whether immigration is a good thing or not, it might seem odd if that sort of quota doesn’t have room for a few dozen doctors. Yet ‘experts’, yes them (!), apparently are blaming 1. the quota and 2. a tightening of immigration criteria…

Experts have blamed the 20,700 annual cap for skilled workers, split into monthly limits, set by the Coalition government in 2011, as well as a more recent tightening of immigration criteria, for the blockages.

The quota is allocated at the beginning of the year and it ‘profiles’ allocations over the months of the year to give a basic allocation per month in advance at the beginning of the year starting in April. The profile for this year is exactly the same as that for last year.

Now I don’t remember any previous headlines at any point during the 21 months this chart covers saying that doctors recruited from abroad have been unable to come to the UK. So on the face of it, the reason doesn’t seem to be likely to be the level of the annual cap for skilled workers per se. But what’s this ‘more recent tightening of immigration criteria’ that the experts blame? The Independent report says

the Home Office … are currently rejecting some doctors that are not … earning at least £55,000 a year — up from the usual £30,000. Applicants also needed to reach 55 points last month — up from 21 in November — to pass.

Taking the earnings first, it’s true that to come here to take up a job offer, the employer in most cases has to have offered you at least the ‘rate for the job’ and for most doctors this will mean at least £30,000. This is to ensure that employers aren’t bringing in people from abroad to under-cut UK workers. That rate has not changed. As to points, each applicant gets scored on a scale that essentially starts at 21, the score comprised of a small number of elements, one of which is pay, and which give a score of 30 to a typical doctor offered £30,000 a year. If the job did have a salary of £55,000 a year then the score would be 55 points. These scores have not changed.

So what’s happened? Well remember that the profiling of the annual allocation means effectively monthly quotas as above. If there are fewer applications than certificates available then everyone can get a certificate as long as they reach the minimum of the scale. Any surplus or unused certificates get carried forward and added to the next months quota until the end of the year when the clock is reset. During 2016/17 the number of certificates actually available was consistently higher than the profile allocation as the number of certificates issued and used fell short of the number available. This means that everyone who wanted a certificate got one. After the clock was reset at the beginning of 2017/18, the carry-forwards became much lower, showing that although everyone who wanted one was still getting a certificate, rather more of the available certificates were being issued. Remember that the generally lower overall height of the columns in 2017/18 doesn’t mean fewer certificates available in 2017/18 but fewer unallocated or unused month after month. So this doesn’t represent a ‘tightening of immigration criteria’ restricting the supply of certificates but an increase in demand for them.

However, if there were more applications than certificates available, then more or less mechanistically the certificates are allocated to those with the highest points scores. In the period we’re looking at leading up to December 2017 because there were in every month fewer applications than certificates available, so as long as you had the minimum 21 points you would get a certificate. This means any £30,000 a year doctor (with 30 points) would comfortably have qualified for one. But if in December the points requirement went up to 55 this implies not that the criteria were tightened (in the sense of some kind of policy decision by the Home Office) but that unprecedentedly in recent history there were more applications than certificates available, and that there were so many applications with high points scores that ordinary applicants for jobs offering less than £55,0000 got knocked out. This isn’t impossible, as there might have been a surge in applications for ‘shortage occupation’ jobs which score a massive 130 points even with low pay, or for very high-paying jobs, or a combination of the two. Bearing in mind that this would represent a very sharp deviation from trend, while possible, could it be plausible? It might be, but the real reason appears to something different entirely.

The published Home Office statistics show that every month while availability is increased by the carry-forward of unallocated and unused certificates, it is decreased by the number of certificates “granted by exceptional consideration outside of monthly allocation during previous month”. Typically, the number is tiny in comparison with the carry-forward. However, the statistics show that there must have been an unprecedented number of these exceptional allocations in October that would have to be deducted from the certificates that would otherwise have been available in December, and that this was significantly more than the routine carry-forward. In fact there were 388 exceptional allocations, which as illustrated below far exceeds the usual number.

This meant that unprecedentedly the number of certificates available in December 2017 for ordinary applications was less than the profiled allocation and this appears to have put on a squeeze such as to raise the points bar from the 21 it has been throughout the period all the way to 55.

Indeed the squeeze was such that some certificates were actually borrowed forward from January 2018…

So, whoever the Independent’s experts were, were they correct that the annual cap of 20,700 was keeping the doctors stuck abroad? In a sense, clearly. But was it because of any tightening in the immigration criteria? Clearly not, as they haven’t changed. What has actually kept the doctors away is an unprecedented number of exceptional grants outside of the usual allocation process. What is the reason for this and who are the people to whom these certificates were issued? I haven’t the slightest idea! But that’s where anyone interested has to look …..

P.S. on 25 Jan (errata)

To avoid adding extra complication to an already complicated tale, matters were slightly simplified above and all the cases to be deducted from the certificates available monthly were described as ‘exceptional allocations’ and illustrated as such in the third and fourth charts above. However, they included certificates issued for Croatians, which while deducted from available certificates prior to the routine allocation are strictly a separate class from certificates “granted by exceptional consideration outside of monthly allocation during previous month” and not part of the ‘known unknown’ in which we’re interested. So while they make no difference to the points made in the original blog (or materially to the numbers) I’ve changed the number stated for exceptional allocations to 388 and provide below alternative versions of the charts in question with certificates for Croatians identified separately. Peer closely and you should be able to see them…

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