Does overseas working benefit the NHS?
Authors: Simon J Forrington, Kate Grady, Iain H Wilson
Publication date: 02 Sep 2014
Doctors are increasingly seeking opportunities to spend time working overseas. Simon Forrington and colleagues look at whether the NHS benefits from these experiences
Short term work placements, longer term development work, sabbaticals, out of programme training, and out of programme experience are increasingly popular with medical practitioners and allied health professionals in the NHS. A great variety of opportunities exist for people to share their experience and skills with colleagues in the developing world, but do these appointments benefit the people taking part and the NHS on their return?
In 2006, Nigel Crisp, the then chief executive of the NHS, was asked by the government to produce a report on how UK expertise could best be used to improve health in developing countries. The recommendations from his report included encouraging UK health professionals to provide intellectual and practical leadership in training and education and increasing access in the developing world to knowledge about best practice derived from high quality research. The anticipated reciprocal benefits of this included healthcare professionals and organisations learning from overseas institutions, and the development of stronger global relationships and health partnerships.
In 2010 David Nicholson, who succeeded Crisp as chief executive of the NHS, emphasised in his introduction to The Framework for NHS Involvement in International Development  the personal and professional rewards available from working in developing countries. He stated that the NHS could learn good practice and new ways of working from colleagues overseas.
Nicholson’s framework and other documents have argued that, through playing a part in improving global health, doctors can develop leadership and other skills in the NHS.   Innovations from developing countries can also inform health systems in the developed world and this spans all six of the World Health Organization’s health system components. Areas of benefit included skills substitution, creative problem solving, and communicable disease control.
What are the benefits to the NHS?
Working in a developing country offers an opportunity to appreciate and value the NHS. Consultants have normally been trained with a narrow focus on becoming a specialist. Their wider appreciation of how the NHS functions is drawn from their experience in the workplace and courses aimed at securing a consultant job.
The NHS’s delivery of care depends on effective management and leadership, skilled clinical teams, careful planning, resourcing, education, and links between primary and secondary care. For clinicians, all of these functions take place automatically. Working in places without well developed support services can sharpen their focus on the importance of non-clinical roles, such as estates, human resources, payroll, equipment maintenance, and procurement. It can also lead to a greater appreciation of colleagues, such as nurses and operating department practitioners, and their role in making our job easier. In addition, the importance of a basic safety culture, with regular mortality and morbidity reviews, is underlined when it is absent.
Most of the roles taken up by NHS medical staff tend to be providing basic care that is not available locally, or providing education and training, but some jobs provide extensive specialist clinical experience. These include attachments to mercy ships, where training in anaesthesia for patients with difficult airways provides world class experience. Obstetric experience internationally, where resources are limited, provides experience and training in eclampsia and other complicated obstetrics in numbers that cannot be seen in the United Kingdom. Surgeons, physicians, and all other specialists return to the NHS with their clinical skills improved and tested.
In addition, most hospitals visited by overseas teams are smaller than those in the NHS. This demonstrates the value of teams running the institutions, and the vital part played by responsible spending. These insights are of direct relevance to the NHS.
The daily routine of healthcare, and being on call over weekends and evenings, can become a grind and often result in doctors feeling as if they are just cogs in an enormous, impersonal NHS machine. Holidays go so far, but only allow the contrast between work and leisure. Time away in a different environment, possibly in a new country and within a different culture, can provide new challenges and a fresh perspective on healthcare and its role in society. Entering a world where healthcare workers are in short supply also provides a new perspective on personal skills and value.
We all benefit from being stimulated by clinical challenges, particularly when our basic clinical skills are our most important tools. Clinical decision making, communication, and planning care in a different environment, and with teams often very different from those in the United Kingdom, allows us to use our skills and leadership in ways that are rarely tested in the NHS.
The range of clinical experience is very different in low and middle income countries, as are the facilities to deal with them. Congenital disease, trauma, advanced presentations, unmanaged sepsis, and obstetric dilemmas are daily presentations. Successful outcomes depend on our willingness to adapt and respond to these challenges.
In the developing world, help and assistance are in short supply, and may not be available at all. If something goes wrong with your equipment, or your patient has an unexpected bad reaction, you may be the only person available to help. This results in increased levels of fastidiousness, self sufficiency, assuredness, and confidence in crisis situations, and a much improved understanding of our role in patient safety.
Lack of assistance may be one challenge, but lack of clinical supervision, support, and advice is another, particularly in an acute medical situation. Although training authorities and organisations supporting those on overseas experience try to guard against this, absence of immediate senior support and supervision may be inevitable. In the wrong situation there can be feelings of isolation, stress, danger, and being overwhelmed by the clinical presentation. It is important therefore to take advice about the job you choose.
Training and management
Many roles for UK doctors working in low and middle income countries will have training as a core component of the job. This is highly rewarding as it gives an insight into the value of education in changing healthcare for patients and staff. Rather than the UK culture of tickbox medicine, the challenge is to identify priorities, work with the local staff to find solutions, and then develop and put into action the accompanying education and training. Examining often becomes part of the role, providing an insight into how education and professionalism work.
Flexibility and teamwork
Working in the health systems of countries or communities that are less well resourced than the NHS demands greater flexibility than would be expected in usual UK practice. Often, a piece of equipment or a medicine is just not available and you will have to adapt to what is there. With different cultures and educational levels, working well with people and understanding them is key. In the UK, this is not something that is particularly challenging as certain norms and behaviours are expected, but experience in low and middle income countries challenges assumptions and provides vivid lessons in working in different teams.
New skills and ways of working
New environments provide new ways of working. As well as teaching local staff how we do things in the NHS, staff on overseas placements or out of programme experiences can learn new ways of working. There is a creativity and resourcefulness in countries where resources are scarce that is rarely found in the UK. Thinking outside the box is a daily requirement, and interventions that are standard in the UK are often much less available, requiring a return to the fundamentals of clinical practice.
Improvement in services is often accompanied by an increase in costs. But initiatives such as enhanced recovery, WHO’s surgical safety checklist, and efforts to prevent hospital acquired infections have also taught us the value of using resources more efficiently. These gains are substantially more important in less well resourced hospitals, and lessons learnt overseas in budgeting focus on the importance of this area of management.
We thank Andrew McLennan, consultant anaesthetist at University Hospital of South Manchester.
We have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare.
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- Department of Health. The framework for NHS involvement in international development. NHS and DH, 2010.
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- Academy of Royal Colleges. Academy statement on volunteering. Health professional volunteers and global health development. Academy of Medical Royal Colleges, 2013.
- Saed SB, Dadwal V, Rutter P, Storr J, Hightower JD, Gooden R, et al. Developed-developing country partnerships: benefits to developed countries? Globaliz Health 2012;8:17.
Simon J Forrington year 5 specialty trainee in anaesthesia and intensive care medicine
A1 University Hospital of South Manchester, Manchester, UK
Kate Grady consultant in anaesthesia and pain medicine A1 University Hospital of South Manchester, Manchester, UK
Iain H Wilson consultant anaesthetist A2 Royal Devon and Exeter NHS Foundation Trust, Devon, UK