Dr Hannah Phelan / Adventure Medic News Editor & UK Anaesthetic Trainee / Zambia
Hannah Phelan, an anaesthetic trainee and member of Adventure Medic’s editorial team, is currently working on an anaesthetic project in Zambia. A passionate advocate for uniting UK medical training and global, humanitarian medicine, Hannah talks us through an incredibly important document that supports, and helps justify at a governmental level, international volunteering. If you’re looking to take time out, whether for a few days’ study leave or for a full-blown career break, there is a treasure trove of information in here for you. Well worth a read.
In May The Royal College of Physicians and Surgeons of Glasgow (RCPSG) published Global Citizenship in the Scottish Health Service – The value of international volunteering. Commissioned by the Scottish Global Health Collaborative and authored by Stuart Fergusson and Michael McKirdy of the RCPSG, it set out to determine the extent of international volunteering by Scottish health care workers. It looked to explore the benefits to all involved, including NHS Scotland, and make recommendations for how Scotland can support such work in order to uphold its commitment to the Sustainable Development Goals (SDGs) and Global Citizenship.
So let’s break it down.
As long as poverty, injustice and gross inequality persist in our world, none of us can truly rest… overcoming poverty is not a gesture of charity. It is an act of justice.
Nelson Mandela 03.02.05 and the opening sentence of the RCPSG report.
In 2005 Scottish Government produced its first International Development policy, which provided a focus for Scottish involvement in tackling global inequality. In 2016, a year after the creation of the SDGs, Scottish Government refreshed their strategy and made a commitment to the concept of Global Citizenship. In their executive summary, Scottish Government named utilisation of Scottish expertise as one way in which they intend to:
Fight against global poverty, inequality, injustice, and promotes sustainable development via the mechanism of the UN Global Goals.
The Scottish Global Health Collaborative (SGHC), founded in 2015 and chaired by Scotland’s Chief Medical Officer Catherine Calderwood, aims to help steer the Scottish health service towards a coordinated, effective and supportive contribution to the national commitment to Global Citizenship. With this mandate in mind they asked the RCPSG to produce a report outlining current involvement of Scottish health care workers in international development, determine the benefits of such work and assess the support given to such activities by NHS Scotland in order to formulate recommendations to help realise their goals.
The report involved extensive research carried out over 18 months, including the collection and collation of quantitative and qualitative data from a head-spinning number of sources.
The authors consulted with the senior management teams of all 22 Scottish health boards, while the SGHC provided online questionnaires answered by over 400 health service workers, to build a picture of the current level of involvement in overseas volunteering and its perceived benefits. The research also encompassed a review of reports, policies, published and non-published literature, and other governmental and academic experts, charitable and professional organisations and individuals were consulted.
From this data the report provides a definition of international volunteering, including the various ways in which it can be undertaken, the history of political involvement, and current NHS Scotland policy for Scottish health care workers wanting to formally train in, or time out of work to engage in, international volunteering. The report goes on to compare NHS Scotland with the rest of the UK and other select European countries.
This is roughly divided into general considerations, benefits to the individual volunteer and benefits to NHS Scotland.
There is no doubt that participation in international volunteering is a moral undertaking. However, it is important to point out that this is not just for the benefit of the country visited, but also for the benefit of the health inequalities in all of our home nations. As highlighted by the RCPSG report, there are ever-increasing similarities between the challenges faced by health systems worldwide. Four key challenges discussed in the report are:
- Infectious disease: Multi drug-resistant organisms are a global problem and epidemics of infectious disease do not respect international borders.
- Prevention and management of non-communicable diseases: Conditions such as diabetes and cardiovascular disease are on the rise worldwide, and place a significant burden on health care systems.
- Increasing demands on available resources: The costs of providing health care for ageing populations, combined with improvement in, but rising costs of, technology and limited human resources.
- Rural populations: The difficulties posed by being required to provide equitable health services for remote and rural populations, including the problems encountered in recruiting staff to such settings.
International volunteering helps to provide a communication network through which the world can unit together to address these challenges and improve healthcare for all.
Before this potential can be realised, it is of great importance to ensure that the project undertaken benefits the country visited. This benefit can be difficult to quantify as the interactions within such a setting are complex. However, encouraging improvements in morbidity and mortality, knowledge, skills and confidence, quality of care provided, development of new services, training and education capacity, institutional governance, policy development and system enhancement, have all been observed by studies such as that carried out by The Tropical Health Education Trust (THET). Following on from their study, THET went on to review their own data, and interviewed several of their partners in low and middle income countries (LMICs) in order to identify crucial themes required for the success of a project:
- Addressing country need: UK partners need to understand local contexts- both institutional and national, and not impose their own priorities.
- Transparency: If lacking, can result in resentment and confusion.
- Ownership: LMIC partners need to be co-producers of all aspects of strategy as well as delivery.
- Sensitivity: Careful respect of cultural values and clearer alignment with national plans. (THET 2016 summarised in RCPSG report)
Benefits to the individual volunteer and NHS Scotland
The report has produced two helpful infographics to display the benefits of international volunteering to the individual and NHS Scotland. For those who already engage in international volunteering, or who support international projects, the findings may seem obvious. This report, however, has really got down to the nitty gritty of the matter, and, what is more, has provided evidence.
The benefits to the individual read like a hit list of the essential and desired attributes seen on most person specifications for health care positions in the NHS; we dedicate training time to improving our clinical skills, policy awareness, and leadership and management skills, to mention just 3 of the 7 benefits identified in the report. The collective evidence shows that these attributes can be developed within the global health setting while undertaking international volunteering, and that this setting provides a breadth of experience which may not always be attainable within the NHS.
In many NHS settings, health care workers can struggle to gain sufficient experience in taking on leadership and management roles. This is not the case when volunteering. Often these are the roles which are most required, the roles which overstretched clinicians on the ground need help with and the roles through which visiting clinicians can really test their resilience. Quite apart from improving their skills, volunteers often return with a higher appreciation of the difficulties faced in these roles within their own healthcare setting, and return better able to face challenges having taken on more challenging roles overseas.
There is no end to the ways in which an individual can boost their powers of communication and teamwork. Placed in an unfamiliar environment, often for a relatively short placement, and faced with numerous new colleagues with different clinical experience, multi-layered language barriers (Zambia, for example, has 8 official languages and up to 72 dialects), the demands of absorbing daily cultural norms and occasionally complex political situations… requires volunteers to sprint up a vertiginous learning curve of communication and camaraderie. In addition, many throw themselves into compiling written or video blogs, and return to give presentations, or hand in descriptive reports, to colleagues, departments or funders. They have been found to return with a new and improved take on how to conduct themselves within a team and, the a-word once again, an ‘increased appreciation’ of the importance of communication and good working relationships.
What else? Experience education, training and research outside your home zone; involvement in global health partnerships provides an international platform for academic collaboration that you may have not tapped into before. Work with policies that are unfamiliar, and your ability to remain flexible and problem-solve will help see you through many a challenge within the NHS or elsewhere. Gain different clinical abilities, skill-share with wildly varied resources, and experience a better understanding of other cultures and infrastructure: it can be invaluable. You gain perspective, reach a greater personal capacity for resilience and innovation, and return with an enthused engagement with basic skills and awareness of opportunities in your own health system.
Essentially, ‘enhancing recruitment and retention’ in an ‘exactly-what-it-says-on-the-tin’ benefit. By providing the enticement of opportunities to engage in the ever-more popular field of Global Health, NHS Scotland can hope to stem the flow of health professionals out of the NHS. Although this does not apply exclusively to doctors, a ‘Career Destination Report’ from the UK Foundation Programme Office showed a distinct decline in trainees choosing to continue straight into speciality training. In 2015 only 52% of doctors did so, compared with 71% in 2011. They also found an increase in doctors of all grades taking career breaks, from 4.6% in 2011 to 13.1% in 2015. Supporting engagement in Global Health, thus providing a more enticing career opportunity, will undoubtedly prove more cost effective than current reliance on locum agencies. It will also improve the work-life balance of those health care workers who often find themselves filling in empty shifts out of good will.
A current key objective for NHS Scotland, instigated by Chief Medical Officer Dr Catherine Calderwood and described in her annual report ‘Realising Realistic Medicine’, is the rationalisation of the provision of healthcare in Scotland. It has been described, by the WHO no less, as a public health revolution. Apart from championing a more patient-centred approach, Dr Calderwood is attempting to steer NHS Scotland away from wasteful practices, and waste of both time and resources. Through international volunteering in low-resource settings, much can be learnt about the ways in which this can be achieved. We can also learn how to provide and maintain health service coverage to remote areas of a country, such as the highlands and islands of Scotland. And how, in an increasingly specialised world, to retain high quality, generalist skills in these settings.
The authors do not claim that taking part in international volunteering comes without its challenges. It has already been mentioned that projects can fail to meet the needs of the country visited and the report groups other potential challenges together into six main ‘domains’: Service delivery, financial costs, personal safety, opportunity costs, regulatory issues and reputational risks.
The first is by far the most commonly talked about challenge at global health conferences and the authors state that:
At an institutional level, the most frequently cited challenge to international volunteering was the resultant temporary loss of staff from Scottish health boards.
A recent demonstration of this was seen following the call for UK health care workers to provide personnel during the Ebola crises. Not all who volunteered were released for deployment by their NHS health board. Although this may seem frustrating, concerns about maintaining sufficient staffing levels at home must be taken seriously. Global Health does include our base countries too. Saying this, there are some solutions to this challenge, such as UK-Med whose financial support extends to cover the NHS for costs incurred ‘back-filling’ the rota. Other possible methods include various permutations of annual hours, or less than full time contracts. It should also be reiterated that supporting engagement in international volunteering has the potential to boost recruitment to an NHS health board, and thus stem the flow of health care workers leaving in search of the greater contract flexibility offered elsewhere.
The personal financial impact of international volunteering is of concern, and sometimes prohibitive, to health care workers. This does not only relate to a drop in, or lack of, salary whilst away, but also the reduction in pension owing to time spent outside of paid employment. There are, of course, ways around this. Some NHS boards provide honorary contracts to maintain years contributed to a pension, while others provide funding for medical equipment or necessary vaccinations. Outside of this there is also the option to boost your pension by buying extra years’ worth of contributions, and occasionally charitable organisations will offer to help with contributions for posts over a certain duration. Some voluntary posts come with a basic salary to cover expenses such as living costs, travel to work, resources for teaching, internet, and necessary costs including return flights, visas and medical registration. Other organisations will have inbuilt insurance and indemnity which covers their volunteers. Much of this comes from governmental or external funders so can be intermittent. Many health care workers also apply for personal funding from their colleges or associations, as well as charitable or private companies.
Personal health and safety risks are easy to recognise when we discuss situations like the Ebola Crisis, or numerous other humanitarian disasters currently occurring throughout the world. The threat of contracting a fatal infection, regional violence or being the target of an extremist fraction, is hard to ignore. However, many organisations who operate in these settings take this into consideration, for example the thorough briefing and debriefing that occurs throughout UK-Med deployments.
This fulsome approach remains aspirational for many volunteering initiatives.
What gains less attention are opportunity costs, regulatory issues and repetitional risks.
Opportunity costs relate to the encroachment of time which would have been used to engage in training, spend time with family and friends or simply enjoy a holiday. The report recognises that there is an increase in short-term ‘more focussed placements’ within international health, and an increase in the use of study leave to participate in such deployments. One could also add that engagement in international volunteering is a form of training in itself but that many in the field of global health would recognise the importance of rest, relaxation and time spent with their personal support networks.
Regulatory issues have been raised in previous adventuremedic.com articles. For UK doctors, the GMC now requires a process of annual appraisal to achieve revalidation every five years. This can affect both duration of placements and engagement in international volunteering after retirement. There are loop holes, but these can be time-consuming and costly.
Reputational risks allude to the detrimental effects, specifically for the donor country, of a poorly organised project or health partnership. One hopes that the now widespread focus on accountability, transparency and professionalism of international volunteering, with the institution of lists of reputable organisations, will help to improve the delivery of global health and reduce the instances of ‘inappropriate, unskilled and culturally insensitive volunteers’ giving their home nations, and fellow volunteers, bad press.
From their extensive research, the authors came to the conclusion that the best way to harness the unquestionably bidirectional benefit of international volunteering is to aim for a coordinated and supportive approach to global health partnerships. The authors have made eight key recommendations.
In simple English, the eight recommendations read as:
- Development of a strategic approach: Coordinate the advice given to Scottish NHS health boards, in the form of guidance and policy documents, and develop a strategic approach to Scottish involvement in international volunteering. Currently Scotland has established links in Zambia, Rwanda, Pakistan and Malawi: this recommendation would see these becoming a Scottish-wide special focus, and a springboard for health care workers wanting to be involved in the field of Global Health. However, the report makes it clear that voluntary posts which fall outside this ‘special focus’ should still be supported, as even an individual-to-individual partnership has the potential to be an established institutional relationship of the future.
- Professionalising support and coordination: Create a central body which can provide a panel to create guidance and policy documents, help with all organisational aspects of international volunteering, including holding a directory of volunteering posts, and act as a point of contact for employers and interested health care workers.
- Maximising the benefit: This recognises the potential for boosting morale in the health service. A health worker who can engage in work outside of their normal environment not only learns a plethora of new skills, but returns feeling motivated and empowered. A health board who is seen to encourage and support such experiences, can expect to see increased recruitment to their institutions.
- Ensuring effectiveness: There is a growing understanding that the focus of international volunteering requires a change from the provision of aid to a need-led partnership. This recommendation would aim to prevent unwanted interventions and instead promote sustainable projects. Continual evaluation would be encouraged at an institutional body and individual practitioner level.
- Valuing collaboration: Collaboration is an important way to overcome the barriers and challenges which stand in the way of global health equality; it also helps garner funding and avoid overlapping projects. There is already a wealth of Scottish expertise in the field of global health. This should be shared throughout the UK and globally with other institutions and individuals, and the knowledge and expertise of these groups harnessed, in order to further improve the impact of international volunteering.
- Expressing local commitment: In order to encourage local health boards to support international volunteering, attention should be paid to the way in which other NHS health boards, who have established international health links, have improved the quality of service delivery in their institutions.
- Defining support mechanisms: The majority of health workers embark on international volunteering during annual leave or between training jobs. Some health boards allow the use of study leave, which shows an understanding of the personal development gained by such work. This recommendation asks that study leave, unpaid leave, sabbaticals and career breaks are all considered as options for involvement in international volunteering, and points to Dutch and Norwegian global health training or sabbatical models that could be considered.
- Setting expectations: The focus of this recommendation is the individual Scottish health care worker planning to carry out international volunteering. It is in keeping with the international move towards best practice, accountability and professionalism in humanitarian work. For NHS Scotland it would be a way to inform the individual of their responsibilities and avoid the serious repercussions of poorly conducted programmes for all involved.
Further Reading – a selection
- ‘Toolkit for the collection of evidence of knowledge and skills gained through participation in an international health project’. (Health Education England 2015)
- BMA article: On a mission to boost healthcare. 08.06.2017
- Health Education England website: International office
- Health Education England website: Improving care by volunteering abroad
- International Health Coordination Centre website (Wales)
- Republic of Ireland Global Health Programme website
- Irish Forum for Global Health: which has some useful academic resources
Mr Stuart Ferguson, joint author of the RCPSG report, will be participating in a Q&A session with theadventuremedic.com – watch this space…
Photos courtesy of Hannah Phelan: a selection from those employed in international volunteering.