The Health Service Journal published a piece on a KPMG investigation of a recruitment scheme run by University Hospitals Birmingham NHS Foundation Trust. All thanks to the one thing Tony Blair did for democracy: the Freedom of Information Act 2000.
The trust recruited hundreds of doctors from lower-income nations under the guise of international training fellowships. An Academy of Medical Royal Colleges scheme, supported by the NHS, set up to give international medical graduates experience of the NHS in exchange for their labour. The findings reveal something worse than poor administration.
What we know
Employment contracts omitted reference to UK employment rights, minimum wage, sick pay, and maximum working hours. The international training fellows were made to do four times as many on-call shifts as UK citizen peers doing the same work. Salary arrangements broke tax laws. Money meant for the fellows is allegedly unaccounted for except that it ended up in a company set up to benefit someone. The trust spent £233,000 on recruitment travel to Pakistan, China, Ethiopia, and Jamaica. Not all the expenditure is accounted for. The BMA, the union for UK doctors, knew in 2023 that the fellows were being paid substantially less than peers doing the same work.
Sir William Macpherson's definition of institutional racism from the Stephen Lawrence Inquiry reads: the collective failure of an organisation to provide an appropriate and professional service to people because of their colour, culture or ethnic origin. It can be detected in processes, attitudes and behaviour which amount to discrimination through unwitting prejudice, ignorance, thoughtlessness and racial stereotyping.
There is no doubt the trust was institutionally racist in how it employed the fellows. There is no doubt the trust colluded in trafficking cheap labour exploited through poor governance and human greed. There is no doubt the BMA failed in its purpose and duty as a union.
Governance went walkabout
At STRASYS, the Decision Intelligence engine for healthcare, we see governance failures through the lens of Board Operating System: an AI-driven evaluation of NHS board dynamics, performance, and risk management. This case is a textbook example of what happens when governance is absent at every level.
The trust HR function was missing in action. The trust board was missing in action. The regulator was missing in action. The union was missing in action. The royal college was missing in action.
Someone drove the recruitment policy. Someone managed the travel. Someone set up the company that received funds. Someone approved contracts that deliberately omitted employment rights. None of this is possible in an organisation where governance systems are functioning.
A CQC Well-Led assessment would ask whether the board had oversight of employment practices, whether whistleblowing channels were effective, whether diversity and inclusion policies were more than documents on a shelf. The answer here is clear. The board either did not know or did not ask.
The trust has closed the scheme because of financial and reputational risks. The KPMG review's funniest lesson learned: a staff travel policy is in the process of being designed.
What governance should look like
The Department of Health and Social Care and NHS England will demand assurance from all trusts running similar schemes. The questions that should follow are harder. Who will be made accountable for the institutional racism? Does the Modern Slavery Act 2015 apply? Who would bother joining a union that strikes for pay but fails on the basics of employment law?
Strasys Board Operating System (SBOS) evaluates whether boards have the decision intelligence to detect these patterns before they become scandals. Board composition, information flows, challenge capability, and oversight of workforce practices. The UHB case is not unique. The scheme itself is an Academy of Medical Royal Colleges programme used by multiple trusts.
Naeem Younis, STRASYS CEO, argues that governance failure is never one thing. It is a system of absences: absent oversight, absent challenge, absent data, absent accountability. The current board gets a pass because it will not be the same membership from when the scheme was designed. But the system that allowed it persists. Without decision intelligence at board level, the conditions for the next scandal are already in place somewhere in the NHS.