Career focus

Bringing it back to blighty

In our first article, we addressed the developments in public policy that have increased the awareness that overseas work enhances professional development.1 In this article we look in more detail at the benefits that accrue from working in a relief, development, or research setting, both for individuals and for their likeliest long term employer, the NHS.

In theory
Overseas work will be particularly relevant for certain specialties. In general practice this has been recognised by the Royal College of General Practitioners which issued a statement promoting overseas work in 1995. The college "recognises that experience doctors gain overseas contributes significantly towards their professional development and that they return to UK general practice with enhanced clinical, organisation and managerial skills which are of great benefit to their patients, the profession and the work of the college." With regard to public health, the Faculty of Public Health Medicine outlined nine key benefits from overseas experience in a report from their newly constituted international working party.2

"Health services in developing countries embrace economics, politics, planning and advocacy as well as clinical issues. I believe this not only enhances my effectiveness as an NHS consultant, hut also the lecturing, teaching and writing that I do reflects favourably on my hospital and university." Paul Eunson, consultant paediatric neurologist

"You learn to be creative very quickly. Volunteering overseas recharges your batteries, you come back [to the NHS] refreshed and remotivated." Reg Kingston, consultant surgeon

"My experiences in Rwanda, Sri Lanka, and Guatemala have been extraordinary opportunities to apply public health skills. Flexible clinical skills are essential, but the ability to determine best use of limited resources and establish, maintain, and evaluate an effective health programme are equally important for anyone planning a career in the NHS." Peter Greengross, specialist registrar, public health medicine

A few specific initiatives have developed, many through International Health Exchange, the London based non-NHS organisation that exists to facilitate the provision of health workers to developing countries, to promote training for those preparing to work overseas, and to raise awareness among health workers of the health and human resource needs of developing countries. For example, the Royal College of General Practitioners, through its international committee, has held two study days over the past two years in conjunction with International Health Exchange and Voluntary Service Overseas. Several other professional bodies have international committees to oversee the development of international opportunities, such as the Royal College of Nursing and the NHS confederation.

In practice
Despite these initiatives and some interest in overseas work among doctors, hurdlesÑboth real and perceivedÑremain, and few individuals explore the options in detail. Those returning from overseas work confirm the benefit of their experience and consider the time valuable in terms of professional development as well as of benefit to the NHS.3 A wealth of knowledge about primary care exists in developing countries, which is relevant to the NHS.4 Examples of practice where the NHS has followed health care initiatives that were pioneered in developing countries have been described.5 Charles Easmon recently listed names and addresses of agencies and organisations that those considering overseas work could contact.6 Entry requirements, qualifications, and how to apply for such posts were discussed. Interested individuals will need to consider whether they wish to work in the relief, development, or research environment. Inevitably such division is rather artificial, but provides a useful framework.

Benefits of overseas work
Learning to: prioritise and allocate scarce resources plan, monitor, and audit conduct health needs assessment for local populations integrate primary and secondary care manage change manage yourself, finances, and organisations train, teach, and develop human resources multidisciplinary teams and leadership liaise between different sectors and organisations

Relief
The relief environment is one that is concerned with natural and man made disasters. The prolonged nature of many conflicts means that a developmental approach to relief is increasingly appropriate. Relief work has often been hampered by an image of enthusiastic amateurs pursuing unstructured and totally unsustainable projects. While this was so many years ago, increasing accountability to donors and the increasing professionalism of agencies mean that the reality is quite different. Rather than individuals rolling up their sleeves for a couple of weeks on some chaotic mission, programmes are better structured and implemented. Relief teams usually work closely with local and national ministries of health and, where possible, plan for a degree of programme sustainability following the relief team's departure. Early warning systems and disaster prevention strategies are increasingly widespread. Audit and evaluation are becoming recognised as essential tools for improving the quality of work.

Examples of recent programmes indicate the breadth of opportunity available. MERLIN is currently responding to outbreaks of typhoid fever in Tajikistan and Lassa fever in Sierra Leone. These outbreaks have required integrating epidemiology and laboratory surveillance, as well as supplying cost effective materials and medicines. Doctors have had to work with national bodies and international agencies such as the World Health Organisation and the Centers for Disease Control and Prevention. Until recently, we have had a surgical team in Rwanda to respond to the needs of Rwandan refugees returning from Zaire. Although a proportion of their work was trauma related, especially during the mass population movement of November 1996, the majority of operations were routine procedures for a district population of Rwanda. Preoperative and post-operative management in addition to surgical training was integral to the programme.

Development
Overseas development programmes place considerable emphasis on the principles of change management, community participation, health education, and the holistic approach to health. Developing skills in these areas will serve the NHS well. For example, the opportunities of work in the former Soviet Union enable health workers to grapple with many of the same issues that currently confront the NHS, such as resource allocation and the difficulties in moving from a hospital centred to a primary health care led system. MERLIN is introducing a WHO style tuberculosis control programme in Siberia. This change management programme has required MERLIN doctors to work alongside Russian doctors, tuberculosis health services, and local and national ministries of health. The challenges of teaching and curriculum development, and integrating new services into an existing organisation has been described by two British GPs working with the Association of the Physically Handicapped in Bangalore, India.3 The importance of research and development, evidence based practice, value for money and dissemination of information are buzz words for both development and relief agencies in the l990s. These are precisely the issues that are at the forefront of the NHS research.

Learning to appreciate medical and health services research has for a long time been recognised as important in the professional development of the doctor. The same principles in research apply whether in a developing or developed country. There are opportunities through the Medical Research Council and Wellcome Foundation, and several British university departments have collaborative projects with universities in developing countries. Many of these posts provide overseas research opportunities from an academic unit in Britain, allowing for increased job security. Agencies such as the International Centre for Diarrhoeas Disease Research in Bangladesh have an extremely high reputation and provide opportunities for field and laboratory based research.

Many doctors undertaking research in the UK become frustrated with its perceived lack of relevance to health care: research in developing countries is often more applied and the benefits more tangible. Doctors incorporating a spell abroad during any period of research will benefit from an additional breadth of experience. Activities in any of the above areas will benefit returnees to the NHS. Those working among ethnic minority communities will have greater understanding of both their actual and perceived needs and enhanced empathy lor the psychological issues associated with migrant and refugee communities. Work overseas will enable the health care worker to develop a greater understanding of socioeconomic and political determinants of health and consider the benefits of alternative health systems and health care initiatives.

Nicholas Banatvala,
medical adviser,

Annie Macklow-Smith,
human resources coordinator,

MERLIN,
14 David Mews,
London, W1M 1HW.

References

1 Banatvala N, Macklow-Smith A. Integrating overseas work with an NHS career. BMJ 1997; Classified Suppl:24 May.

2 Faculty of Public Health Medicine: International Working Party. Report to the Board. Faculty of Public Health Medicine, London: 1996.

3 Abell C, Taylor S. The NHS benefits from doctors working abroad. BMJ 1995;311:133-4.

4 Johnstone P, McConnan I. Primary health care led NHS: learning from developing countries. BMJ 1995;311:891-2.

5 Cutting WM. Leaning from primary care in developing countries: innovations in developing countries have had worldwide relevance. BMJ 1996;312:249-50.

6 http://www.bmj.com/cgi/content/full/313/7061/S2-7061r.

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