UK health workers have key role in international disaster relief
Authors: Sakib Rokadiya, Colin Stewart Brown, Geraldine O’Hara, Angela McBride
Publication date: 03 Nov 2015
Sakib Rokadiya and colleagues highlight the important part played by NHS staff in the response to the Ebola epidemic in west Africa
In early December 2013 a 2 year old boy living in Meliandou, a rural town in Guinea, developed a febrile illness that was subsequently identified as Ebola virus disease and died suddenly. Few could foresee the trail of devastation that would follow: by July 2015 over 27 000 individuals in west Africa had been infected with Ebola, with more than 11 000 deaths.
The international response was poor in the early stages, with Médecins Sans Frontières one of the few organisations on the ground. Despite repeated warnings about the seriousness of the situation, it was only in August 2014 that the World Health Organization declared Ebola in west Africa a public health emergency of international concern. This, a legal designation used only twice previously, along with UN Security Council Resolution 2177, helped to galvanise the international community to pursue a rapid, effective, efficient, and coherent response to the Ebola epidemic.
By March 2015, the United Kingdom alone had pledged £427m (€578m; $648m) to lead the global effort in Sierra Leone. This included more than 750 Ministry of Defence personnel, such as engineers, healthcare workers, logisticians, and military staff.
By January 2015, more than 1600 NHS staff had volunteered to go to west Africa through UK-Med and other non-governmental organisations, such as Médecins Sans Frontières or King’s Sierra Leone Partnership. However, we have been unable to verify how many actually went to the three worst affected countries.
When we reflect on this outbreak, it is clear that NHS workers are an important global health resource who, if well trained and coordinated, are well equipped to respond rapidly and effectively to tackle future national and international medical emergencies.
Different routes to engagement
The Department for International Development funded several Ebola treatment centres in Sierra Leone, recruiting NHS volunteers to work in these centres through the UK International Emergency Medical Register. The register was maintained by UK-Med, a Manchester based charity established in 1995 to facilitate the provision of UK based healthcare workers to support hospitals in war zones and natural disasters.
Employees with a substantive NHS contract could be released on the agreement of their employing trust or heath board. Employers were supported in this action by the Department of Health and NHS England, with funds being made available to provide locum cover while individuals were in service. Deployments were for a maximum of nine weeks, which included pre-departure and in-country training, working in Ebola treatment centres, and a post-deployment period of 21 days in quarantine.
Volunteers to UK-Med were initially interviewed by telephone, attended an open evening, and completed pre-deployment health screening. Successful applicants attended a week long pre-departure residential course familiarising themselves with Ebola, personal protective equipment, and the sociopolitical context of the outbreak.
Opportunities to volunteer also existed outside UK-Med. King’s Sierra Leone Partnership, a development charity with long term institutional links between King’s Health Partners and the Ministry of Health and Sanitation of Sierra Leone, The College of Medicine and Allied Health Science, and Connaught Hospital, the only adult medical referral hospital in Sierra Leone, provided pre-departure support, in-country training, and distance psychological support for their volunteers.
Individuals volunteering with Médecins Sans Frontières undertook a short residential course in Brussels before deployment, followed by a day of extensive briefing on the situation in west Africa and access to psychological support.
Individuals holding non-substantive posts or those who wished to deploy with specific non-governmental organisations negotiated on an individual basis with their employers, often using a mixture of study or annual leave to facilitate deployment. As trainees in internal medicine and infectious diseases at University College London Hospitals, we were granted special leave to assist with a variety of non-governmental organisations’ relief efforts and through the UK International Emergency Medical Register.
The support of NHS trusts, academic departments, and colleagues must not go unrecognised as it often entailed considerable individual sacrifice for those remaining in the United Kingdom.
Learning from the Ebola epidemic
Paul Arkell—core medical trainee, St George’s Hospital, London; King’s Sierra Leone Partnership volunteer, December 2014 to January 2015
“Between January and July 2014, I worked with King’s Sierra Leone Partnership in Freetown, Sierra Leone. My team and I watched anxiously as the outbreak emerged and spread through Guinea, and cases spilled across the border. As it became apparent that Ebola would enter Freetown, I worked full time on Ebola preparedness at both Connaught Hospital and with the Ministry of Health. In partnership, I helped to design and build a 16 bed Ebola holding unit, train nursing and auxiliary staff on how to use personal protective equipment and safely treat suspected cases, and manage the first confirmed cases of Ebola at Connaught Hospital.
“Sadly, I returned to the UK at the end of July to start my core medical training at St George’s Hospital, but in December 2014 I took out of programme experience and returned to work as a volunteer with King’s Sierra Leone Partnership in Freetown. I provided clinical support at the same Ebola holding unit at Connaught Hospital that I had helped initially design, which by then had managed over 500 confirmed cases of Ebola, and regularly carried the on-call Ebola phone. Having built strong relationships with many of my colleagues, I was designated a leadership role at a smaller health centre, where I was the only international team member and only doctor.
“The NHS has provided me with strong translational skills that were essential during my work. This, along with having more appreciation of cultural sensitivities through my time in Freetown previously, enabled me to work in partnership with over 100 local nurses and auxiliary staff to improve infection prevention and control at their unit, including overhauling their Ebola waste management system, and allocate job responsibilities—roles for which I had not had specific training. However, utilising my broken Krio and liaising constantly with the head office at Connaught and senior colleagues, I felt safer and more confident—especially compared to my first few days working with Ebola.
“Although professional development was far from my primary intention, I cannot help but acknowledge how much I have gained. I was often the most senior clinician and therefore made independent clinical decisions on a daily basis. I was frequently managing large teams of people and needed to act as a role model, mentor, manager, and problem solver. Finally, I worked with several different governmental and non-governmental actors, which required robust communication skills to maintain productive and professional discussions in very stressful circumstances. All these things have undoubtedly made me a better core medical trainee, and I believe will continue to contribute positively to my practice within the NHS for the rest of my life.”
Phoebe Byrne—senior nurse, University College London Hospitals, Hospital for Tropical Diseases; UK-Med volunteer with International Medical Corps, January to March 2015
“In January 2015, I was deployed through UK Med alongside 20 other NHS professionals to work with International Medical Corps in an Ebola treatment centre in Makeni, Sierra Leone. We worked in small teams of NHS and national staff as medical and psychosocial staff, as well as large numbers of water, safety, and hygiene team members. I had the opportunity to work as lead nurse within my team. We worked closely, ensuring both that the patients’ needs were met and that all members remained safe. It was hot and uncomfortable, often requiring heavy manual work in personal protective equipment.
“Although treatment choices were often limited with minimal diagnostic equipment, as a nurse it was interesting to be more involved in making clinical decisions. Training was a large component of our work, and our aim was always to assist the national staff in running the Ebola treatment centre independently. These experiences have been extremely rewarding professionally: leadership and resilience are just some of the skills I have enhanced and continue to use daily at the Hospital for Tropical Diseases. I also have more confidence in training and leading others, which benefits my NHS practice daily. Personally, I feel enriched for having been able to contribute during this terrible epidemic.”
Benefits of international partnership
There has been longstanding recognition of the dual benefits of partnership between UK institutions and other countries and health systems. The Tropical Health and Education Trust currently leads the Department for International Development’s International Health Links scheme, which supports up to 50 such partnerships, including King’s Sierra Leone Partnership, and was in a unique position to help develop Ebola care models from the outset of the outbreak owing to its close links with governmental, education, and hospital leaders.
There are many examples of long term sustainable links, with a review of partnerships conducted by the All-Party Parliamentary Group on Global Health concluding that submissions were “unequivocal in highlighting the value that UK institutions attach to their overseas programmes.” A toolkit has been produced to help organisations develop new links and capture staff benefits on return to the NHS. One recent review highlighted that overseas working benefits the NHS through the “reinvigoration, self-sufficiency, training and management, flexibility and teamwork, new skills and ways of working and resource allocation” of returning staff.
As trainees working in Ebola management in west Africa, we have gained all of these skills and attributes, and more. The experience we gained includes holding and treatment unit design; construction; operational running and governance, including designing standard operating procedures, stocking pharmacies, and delineating care pathways; developing algorithms for quality assurance and patient safety; managing complex interdisciplinary teams of healthcare workers; and working on regional and national policy with governmental and international partners. The experience we came back with is invaluable for our development.
On return to the UK we have helped care for repatriated Ebola patients, developed local protocols for viral haemorrhagic fever preparedness, designed and delivered training packages within our hospital, supervised pre-departure courses for future UK-Med volunteers, and presented our experiences and advocated for support for a sustainable responsive deployment force at senior Department of Health meetings.
Helping NHS staff who want to volunteer
The Ebola epidemic has highlighted the key part NHS healthcare workers can play in tackling future disease outbreaks or health disasters worldwide. It will also help build on the international reputation the UK has developed in contributing to disaster response—for example, through the Disasters Emergency Committee.
UK-Med has developed a pathway for rapid screening and deployment of staff to affected regions. Organisations such as King’s Sierra Leone Partnership have shown how the reach of NHS hospitals through international links can bolster organisational response. International non-governmental organisations such as Médecins Sans Frontières will remain a critical part of the emergency medical response.
We must find ways to facilitate those wishing to volunteer, with predefined routes for release and cross cover, as we know of many who faced contractual, managerial, and logistical challenges with deployment. For example, on wards relying on agency staff it was difficult to release trained and qualified staff willing to volunteer. Agency staff themselves could not be deployed through UK-Med because of their lack of permanent employment.
Learning and education boards may wish to partner with UK-Med, and there could be further links—for example, with sponsored international programmes—to enhance preparedness. The benefit of this engagement has recently been recognised by key leaders in the health service, and Sally Davies, chief medical officer for England, recently chaired University College London Hospitals’ medical grand round to offer support and give thanks for our contributions. We strongly support the appropriate deployment of trainees to aid response and develop invaluable skills.
We greatly appreciate the support of our colleagues in allowing us the time to volunteer. Mike Brown, Philip Gothard, and Sarah Logan have been instrumental in facilitating our time in west Africa, and we wish to express our sincere thanks to them for all of their help.
Competing interests: We have read and understood the BMJ’s policy on declaration of interests and have no relevant interests to declare.
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Sakib Rokadiya core medical trainee, University College London Hospitals
Colin Stewart Brown specialist registrar in infectious diseases and medical microbiology, Hospital for Tropical Diseases, London
Geraldine O’Hara academic clinical lecturer in infectious diseases and general medicine, Hospital for Tropical Diseases, London
Angela McBride core medical trainee, University College London Hospitals