Guide to UK Training in Ophthalmology For Overseas Doctors

The Royal College of Ophthalmologists welcomes to the United Kingdom overseas doctors who wish to undertake a period of postgraduate training in ophthalmology. There are a wide variety of ophthalmology training posts available in hospitals ranging from small district general hospitals to large university postgraduate teaching hospitals. Training posts may offer Basic Specialist Training (BST), Higher Specialist Training (HST), Fellowships or Advanced Subspecialty Training Opportunities (ASTOs). Overseas doctors visit the UK to train at any of these levels. 

The aim of this guide is to provide general information for trainees who wish to undertake postgraduate training in ophthalmology in the UK and to introduce more specific information about postgraduate training posts and the examination structure. 

Who is an overseas doctor?

An overseas doctor is a doctor who does not have settled status in the UK as determined by immigration law. There are separate rules for trainees who are European Economic Area (EEA) nationals (or hold other enforceable EC rights) and EEA qualified; they should contact the General Medical Council (GMC) in the first instance for information. 

Why do Ophthalmologists from overseas come to the United Kingdom?

Postgraduate training in ophthalmology in the UK is considered to be well organised and of high quality. Doctors from abroad come to the UK in order to: 

• undertake a period of BST and HST in ophthalmology. 
• obtain advanced subspecialty training in a particular subspecialty area. 
• obtain a British postgraduate qualification. 
• undertake a period of clinical academic research. 

In order to undertake a period of postgraduate training in ophthalmology in the UK, the overseas trainee must: 

• obtain registration with the GMC. 
• satisfy immigration procedures. 
• be appointed to a substantive, recognised and educationally approved post. 

Doctors cannot undertake any direct patient care in the UK unless they are registered with the GMC. This means that they are unable to obtain any clinical training involving the management of patients without registration. The GMC, by granting registration, gives doctors the legal status necessary to undertake professional duties. There are two relevant forms of registration for overseas doctors: 

Limited registration 

Most overseas qualified doctors who wish to undertake clinical training in the UK will need to apply for limited registration. Limited registration may be granted for a maximum of five years. Doctors granted limited registration will be restricted to supervised employment in approved training posts. 

Applicants for limited registration must meet a number of requirements: 

• have a primary medical qualification accepted by the GMC. 
• have completed overseas at least one year of general clinical training or internship (equivalent to the pre-registration year in the UK). 
• have demonstrated their knowledge of English by achieving a satisfactory score in the International English Language Testing System (IELTS) examination. 
• pass the Professional and Linguistic Assessment Board Examination (PLAB) test, or apply for exemption from the PLAB test to obtain limited registration through one of the many routes the GMC has approved. 

To obtain exemption from the PLAB test please contact the GMC for advice. 

If the overseas trainee can meet the Dual Sponsorship Scheme requirements, the College may recommend to the GMC that the trainee be granted limited registration with exemption from the PLAB test. The Dual Sponsorship Scheme is not available to anyone who has attempted the PLAB test. 

Non-training posts cannot be held with limited registration from the GMC. 

Full registration

Full registration allows doctors to undertake any kind of professional employment so long as there are no immigration restrictions affecting the type of medical practice they can undertake. After holding a training post for a certain stipulated period with limited registration, doctors can apply for limited registration to be converted into full registration. Full details of this can be obtained from the GMC. It should be noted however that full registration does not alter permit-free training or immigration status. 

Some overseas doctors who have obtained their primary medical qualifications from the following universities should contact the GMC direct as they may be eligible for full or provisional GMC registration without having to take the PLAB test or use the Dual Sponsorship Scheme: 

Medical Schools in New Zealand or Australia
The Chinese University of Hong Kong
The University of Hong Kong
The National University of Singapore
The University of Malaya in Kuala Lumpur (doctors who qualified on or before 31st December 1989)
The University of Cape Town
The University of Natal
Stellenbosch University
The University of Witwatersrand
The University of the Orange Free State
The University of Pretoria
The University of Singapore
The University of the West Indies

Overseas trainees who wish to take up a postgraduate training post in the UK must be registered with the GMC and be given permission by the immigration service to stay in the UK for postgraduate training without requiring a work permit (permit-free training). In order to qualify for permit-free training, the overseas trainee must satisfy the following criteria: 

• the overseas trainee must be a medically qualified doctor. 
• proof of eligibility for registration with the GMC is required. 
• the overseas trainee must not have already spent four years in postgraduate training in the UK (excluding one year as a PRHO). 
• the overseas trainee must make known his/her intention to leave the UK on completion of training. 

Permission is given for a period of up to three years in the first instance, after which an application can be made for renewal. Permit-free training at the BST level is allowable for a maximum period of four years; extension of permit-free training is subject to the approval of the postgraduate dean. For HST there is no pre-set time limit for training; the amount of permit-free time allowed will correspond to training goals and is in addition to BST time and again this needs the support of the Postgraduate Dean. 

Application for permit-free training

Application must be made on the correct application form that can be obtained from The Application Forms Unit (see address of Immigration and Nationality Directorate in Appendix to this guide or telephone 00 44 (0)8702410645). 

Registration with the police is required for those trainees from overseas who are not Commonwealth citizens. A passport and two passport sized photographs should be submitted to a local police station. A fee is charged for such registration. 

To obtain a copy of the 'Guide to Immigration and Employment of Overseas Medical and Dental Students in the United Kingdom' (HSG(97)18), please write to: Department of Health Distributions, PO Box 410, Weatherby, LS23 7LL, or fax 00 44 (0)1937 845381. Please quote the document code (HSG(97)18) as well as the title of the Guide. 

Medical Services in the United Kingdom

The majority of residents in the UK obtain their medical care from the National Health Service (NHS), which is funded from National Insurance contributions (a form of taxation) and is free at the point of delivery. The NHS provides comprehensive care and everybody resident in the UK has the right to use it. It is a founding principle of the NHS that care is provided according to the individual's clinical needs rather than the ability to pay. Doctors in the NHS are divided into two groups; firstly, General Practitioners (GPs) who provide primary care and, secondly, doctors working in hospitals who provide secondary care. 

Primary Care

General Practitioners normally work in group practices serving a defined geographical area. The GP will be the first point of contact for most patients and, for many disorders, the GP will undertake investigation and treatment. GPs refer patients who have more complex problems, or who are more acutely ill, to the local hospital. 

Secondary Care

There are over three hundred major district general hospitals and teaching hospitals in the UK which provide a range of hospital services including accident and emergency services, outpatient specialties, maternity and paediatric care. Patients are generally referred to the hospital by GPs but some patients go directly to accident and emergency departments with acute medical problems or trauma. Similarly, referrals to ophthalmology departments are usually made by local GPs but some patients with acute problems may go directly to hospital emergency eye clinics. 

Private Care

A small proportion of the UK population use private medical services rather than the NHS. There are very few private practitioners in primary care but many hospital doctors do undertake some private work in addition to their NHS work. Private patients are generally seen initially by GPs in primary care and are then referred to a private clinic or hospital. Most private hospitals do not undertake emergency work but tend to deal with patients with elective (predominantly surgical) problems. Overseas trainees cannot work in the private sector as such posts are not Royal College of Ophthalmologists recognised. 

Ophthalmological Services in the United Kingdom

Ophthalmological services in the United Kingdom are organised into primary and secondary care and the majority of patients who have ophthalmological problems present first to their GP. The GP may treat minor problems such as blepharitis or conjuntivitis but will refer other patients either to an optometrist (if the GP believes the problem to be refractive) or to the Hospital Eye Service (HES). Individuals who have experienced blurred vision may decide to consult an optometrist who will prescribe a refractive correction if this is the cause of visual impairment. If the optometrist discovers any form of eye pathology he/she is obliged to refer the patient back to his/her GP who will decide whether referral to the HES is appropriate. Optometrists do not in general refer directly to the HES unless a very urgent problem such as a retinal detachment is suspected. Some ophthalmologists, called Ophthalmic Medical Practitioners (OMPs), undertake refractive work under the auspices of the NHS usually working in optometrist's premises. 

The Hospital Eye Service

The HES provides ophthalmic medical and surgical care in ophthalmic units in district general hospitals or teaching hospitals. The clinical teams are led by consultant ophthalmologists working with non-consultant career grade ophthalmologists, ophthalmic trainees, hospital optometrists, ophthalmic nurses and orthoptists, and supported by clinical, photographic and other services. Most district general and teaching hospitals have ophthalmology services including outpatient clinics, day case surgical facilities and inpatient ward and operating theatres. 

Ophthalmologists in the Hospital Eye Service

Ophthalmologists who work in the HES include those in career (or non-training) grades, such as Consultants, Associate Specialists, Staff Grade Ophthalmologists and Clinical Assistants, and those in the training grades. The training grades include Pre-registration House Officers (PRHOs), Senior House Officers (SHOs) and Specialist Registrars (SpRs). 

Ophthalmology Training Posts

Pre-registration House Officer (Houseman) Training

The PRHO posts are filled by newly qualified doctors who have passed their final qualifying exams in medicine and are then entitled to provisional registration with the GMC. They are obliged to work in approved hospital posts as a PRHO for twelve months and, on satisfactory completion of this twelve month period, will be recommended to the GMC for full registration. There are very few PRHO posts in ophthalmology and where they do exist they are usually combined with another surgical post. 

Basic Specialist Training as a Senior House Officer

Most UK graduates who have completed their PRHO posts subsequently obtain SHO posts in order to fulfil general professional training or the first stages of training in their chosen specialty. Most overseas trainees who wish to undergo training in ophthalmology in the UK also undertake a period of BST in the SHO grade. SHO posts are widely advertised and are filled in open competition. An exception to this arises when overseas trainees are placed in SHO posts as part of the Dual Sponsorship Scheme. The tenure of the SHO post is usually a minimum of six months and posts may often be extended subject to satisfactory performance. Increasingly, SHO posts are linked into rotations between different hospitals to give a wider clinical experience.

In ophthalmology, SHO posts are usually undertaken for between two and three years. Trainees who wish to apply for SpR posts in ophthalmology must (i) have completed at least two years BST in College approved SHO posts (ii) have passed the MRCOphth examination or equivalent qualification by the date specified and (iii) attended a College run Basic Microsurgical Skills Course, usually within the first four to six months of taking up an SHO post (for trainees who started Basic Specialist Training after 1 April 2001). Trainees who have met these criteria should apply for a Certificate of Eligibility for Entry into Higher Specialist Training (CEEHST) from the Royal College of Ophthalmologists. This certificate is a pre-requisite for appointment to the SpR grade. 

• Full details of Basic Specialist Training are set out in the College BST guide and curriculum (please see Appendix III). 

SHO posts in ophthalmology are generally advertised in the British Medical Journal (BMJ), the Lancet, Hospital Doctor and other publications. The most useful publication for looking for job vacancies is the BMJ. This is available on line (at http://www.bmj.com). Training posts in the UK are very competitive and applications are made directly to the hospitals concerned, a short-listing process and a selection interview follows this. Training posts through the Dual Sponsorship Scheme can be offered through the above process or given as direct placements. Trainees should only apply for posts that have educational approval from the Postgraduate Dean and educational approval from the Training Committee of the Royal College of Ophthalmologists. It is very important when applying for such posts that the trainee sends with the application a clear and well presented curriculum vitae. Once shortlisted, it is important to try and make an appointment to see the hospital before the interview date and to make enquiries about the post with the current SHO and other junior staff. A shortlisted trainee may also wish to make an appointment to see the consultants working in the department to discuss the post with them. 

A panel, which is usually made up of consultant ophthalmologists involved in the rotation, will interview shortlisted candidates; there may also be a representative of the Postgraduate Dean. There is usually a lay chairman. The questions asked will mainly relate to the 'person specification' of the post and the shortlisted candidate's curriculum vitae, i.e. previous clinical experience including any research and audit activities and interests outside medicine. 

After successful interview, the hospital Personnel Department will make a formal offer of appointment, make arrangements for salary to be paid and arrange for the trainee to attend an induction session at the hospital. The Personnel Department will be able to advise the trainee about the procedure for obtaining a National Insurance number. Hospital accommodation is often available. Trainees will also be given an educational supervisor who is usually the College Tutor. He or she will be able to give advice about teaching and research within the department and postgraduate courses that may be useful to attend. 

Higher Specialist Training as a Specialist Registrar (SpR)

Training at SpR level involves one or more training placements and potentially encompasses all of the subspecialty areas in ophthalmology. There are two types of SpR training; Type I and Type II training. 

Type I Training

This is a HST programme of four and a half years, which, if completed satisfactorily, will entitle the doctor to a Certificate of Completion of Specialist Training (CCST), which is awarded by the Specialist Training Authority (STA) on the recommendation of the Royal College of Ophthalmologists. Entry to Type I training is highly competitive and is open to both UK and overseas doctors who are in possession of the CEEHST. Trainees who have been awarded the CCST are recommended for inclusion on the GMC's Specialist Register and are thus eligible to apply for an NHS consultant post. 

Type II Training

Type II training is available to overseas doctors who wish to undertake a period of training at SpR level in ophthalmology but do not wish to complete the whole HST programme leading to a CCST. Trainees undertaking Type II programmes must apply for Fixed Term Training Appointments (FTTAs), which last for a minimum of six months. It is possible to undertake FTTAs in different training rotations. FTTAs are available to overseas doctors without a right of indefinite residence in the UK. 

Trainees who wish to convert from a Type II to Type I training must fulfil the entry criteria for HST i.e. a possession of a CEEHST. 

A CEEHST is not required to undertake time in FTTA posts, but time in an FTTA post cannot count towards HST unless the doctor was in possession of a CEEHST prior to commencement of the FTTA post. 

Appointment to a series of FTTA posts does not lead to the award of a CCST.

Locum Appointment Training (LA-T)

Overseas trainees who wish to undertake a period in the SpR grade may also apply for a LAT post. LAT posts are open to any ophthalmologist who has met the entry requirements for the SpR grade and has obtained a CEEHST. Trainees who are subsequently appointed to Type I training may have time in a LAT post counted towards their CCST. For further information on LAT posts counting towards the award of the CCST, please contact the Education and Training Department at the College. 

Flexible Training Posts

The aim of flexible training is to provide an opportunity for doctors in the NHS to continue training when they are not able to work full-time. Part-time training has to meet the same educational requirements as full-time training, differing only in the amount of time that the trainee spends in medical activities during the week. The total duration of Type I training is similar for part-time and full-time trainees i.e. the period to the CCST is extended pro rata for part-time trainees. Ophthalmologists who wish to undertake flexible training at SHO or SpR level should, in the first instance, discuss this with their Postgraduate Dean who will be able to advise them on the procedure for applying to train flexibly. Overseas trainees who do not have a right of indefinite residence in the UK can apply to train flexibly.

• Full details of Higher Specialist Training are set out in the College HST guide and curriculum (please see Appendix III). 

Approved ASTOs and advertised fellowship posts are offered by training units on request for specific purposes for periods not exceeding one year. The Royal College of Ophthalmologists does not arrange such posts and trainees are requested to communicate with individual units.

Clinical attachments are helpful with orientation and gaining familiarity with the practice of ophthalmology in the UK and can be arranged by trainees communicating with hospital consultants directly as the Royal College of Ophthalmologists does not arrange them centrally. Clinical attachments are honorary posts and trainees are accepted as observers and hands on experience is not permitted. 

Organisation of Postgraduate Training in the UK Deaneries

Postgraduate Dean

Postgraduate ophthalmic training is organised and co-ordinated within 'deaneries' that are based around university medical schools and number between one and three within any given 'NHS region'. The Postgraduate Dean has overall responsibility for the appointment funding, employment and training of SpRs in HST and for establishing training contracts with NHS Trusts in accordance with national guidelines. In contrast, individual NHS Trusts are responsible for the appointment and employment of SHOs undertaking BST. Nevertheless, the Postgraduate Dean provides fifty percent of the basic salaries of SHOs and one hundred percent of the basic salaries of SpRs (MADEL budget). The Postgraduate Dean must give educational approval before SHO or SpR posts can be advertised. The Postgraduate Dean, usually through an Associate Postgraduate Dean, takes special interest in educational issues such as flexible training or training for overseas doctors. 

Programme Director

The Programme Director is responsible to the Postgraduate Dean for the overall delivery of HST in the deanery in accordance with College guidelines. The Programme Director's remit includes preparation and publication of the prospectus of HST, the devolution of elements of the College HST Curriculum to individual training units through College Tutors, the equitable allocation of SpRs to individual training placements, and direct involvement in SpR appointments and annual (RITA) assessments as a regular member of the deanery Specialty Training Committee (STC) panels charged with these responsibilities. 

College Tutors

College Tutors are responsible to the Programme Director for the delivery of formal teaching and of specified elements of the HST curriculum within their units; they also have specific responsibility for the quality of SHO training locally (in liaison with the Trust Postgraduate Clinical Tutor) as the 'Educational Supervisor' of those in BST. They are responsible for the formal appraisal of, and for ensuring the induction and formal assessment of, trainees on BST and HST placements within their units. 

Full details of the organisation of postgraduate training in ophthalmology may be found in the Guide to Postgraduate Training in Ophthalmology (please see Appendix III). 

Examination Structure of the Royal College of Ophthalmologists

Under new rules adopted in 1998, the Royal College of Ophthalmologists no longer requires candidates for its examinations to have worked in approved training units. Candidates must have completed the requisite period of training in any ophthalmic unit in order to be eligible to sit the examinations. This change should make it much easier for overseas trainees to take the examinations without the need to have worked in the United Kingdom, but overseas candidates must still be eligible for registration with the GMC of the UK. Please note however, that for those trainees wishing to obtain a Certificate of Eligibility for Entry into Higher Specialist Training (CEEHST), a minimum of two years BST must take place in College approved Basic Specialist Training posts.

The Membership (MRCOphth) examination has replaced the old-style Fellowship (FRCOphth). It consists of three parts: 

Part 1, which consists of 2 multiple choice question (MCQ) papers and one short answer paper. The subject material covers basic science in relation to ophthalmology and includes anatomy, physiology, pathology, immunology, microbiology and statistics. Part 1 can be taken at any time once the pre-registration year (or equivalent) is completed. 

Part 2 or Clinical Methods, which explores a candidate's ability to conduct the necessary examinations required to assess a patient including refraction. The MCQ paper also tests theoretical knowledge in optics and refraction. There is a practical refraction examination and two objectively structured examinations, one clinical and one object-based. Part 2 can be taken after twelve months of full-time ophthalmic training. 

Part 3, which is a clinical examination. From September 2003 there will be a new examination structure for the Part 3 MRCOphth. The examination will consist of an extended matching question paper, a pathology and microbiology structured oral examination, and a clinical multi-station examination. The examination syllabus and entry requirements will remain the same for the present time.

The new-style FRCOphth or Fellowship Assessment is taken by those in Type I training towards the end of HST (i.e. after three years of HST) once core curriculum has been completed. It consists of a written casebook of ten chapters including case reports and an audit, plus an interview of up to two hours duration. 

• Full details of the College exams are available from the Examinations Department (please see appendix below). 

The format of the MRCS(Ed) is similar to that of the MRCOphth. There are two routes to the CCST, one via the Fellowship Assessment of the Royal College of Ophthalmologists and the other through the Specialty Fellowship Examination in Ophthalmology of the Royal College of Surgeons of Edinburgh. Candidates wishing to take the Edinburgh examinations should contact that College for full details. These are the only two qualifications that are recognised for entry into HST leading to the CCST. The Royal College of Physicians and Surgeons of Glasgow and the Royal College of Surgeons of Ireland also offer Fellowship examinations in ophthalmology that are not recognised towards entry into HST and the details regarding eligibility, syllabus and structure of the examinations can be obtained by writing to these respective Colleges. Since 1999, the FRSGlas and the FRCSI are no longer recognised for entry into HST and will not provide a route to the CCST, but may be accepted by the General Medical Council for limited registration. 

Appendix.

Useful Addresses

The Royal College of Ophthalmologists
17 Cornwall Terrace
London
NW I 4QW

Website: http://www.rcophth.ac.uk/

Enquiries about the Dual Sponsorship Scheme and training should be addressed to:

The Deputy Head of Education and Training (at the above address)
Tel: 00 44 (0)20 7935 0702 Ext. 207
Fax: 00 44 (0)20 7935 9838
Email: beth.barnes@rcophth.ac.uk

Enquiries about the College exams should be addressed to: 

The Examinations Assistant (at the above address)
Tel: 00 44 (0)207935 0702 Ext. 212
Fax: 00 44 (0)20 7487 4674
Email: exams@rcophth.ac.uk

Enquiries about the Ophthalmic Trainees Group (OTG) should be addressed to: 

The OTG Co-ordinator (at the above address)
Tel: 00 44 (0 )20 7935 0702 Ext. 207
Fax: 00 44 (0 )20 7935 9838
Email: otg.rcophth@btopenworld.com

Other useful addresses 

General Medical Council 
178 - 202 Great Portland Street
London
W1N 6JE

Website: http://gmc-uk.org/
Tel: 00 44 (0)20 79153630

Immigration and Nationality Directorate
Lunar House
4 Wellesley Road
Croydon, CR9 2PY

Website: http://www.ind.homeoffice.gov.uk/
Tel: 00 44 (0)8706 067766

The British Council
10 Spring Gardens 
London 
SW1A 2BN

The British Council
Bridgewater House
58 Whitworth Street
Manchester M1 6BB

Website: http://www.britcoun.org/
Tel: 00 44 (0)20 7930 8466 
Tel: 00 44 (0)161 957 7000

British Medical Association
BMA House
Tavistock Square
London
WC1H 9JP

Website: http://www.bma.org.uk/
Tel: 00 44 (0)20 7387 4499

Overseas Doctors Association
ODA House
316A Buxton Road
Great Moor
Stockport SK2 7DD

Tel: 00 44 (0)161 456 7828 

Medical Defence Union 
3 Devonshire Place 
London W1N 2EA

Medical Defence Union
192 Altrincham Road
Manchester M22 4RZ

Website: http://www.the-mdu.com/

Medical Protection Society 
33 Cavendish Square
London W1M 0PJ

Tel: 00 44 (0)20 7399 1300 
Fax: 00 44 (0)20 7399 1301

Medical Protection Society
Granary Wharf House
Leeds LS11 5PY

Tel: 00 44 (0)113 243 6436
Fax: 00 44 (0)113 241 0500