Career Focus

Integrating overseas work with an NHS career

BMJ 1997; 314 doi: (Published 24 May 1997) Cite this as: BMJ 1997;314:S2-7093
  1. Nicholas Banatvala, medical adviser,
  2. Annie Macklow-Smith, human resources coordinator
  1. MERLIN,14 David Mews,London, W1M 1HW.

    Is overseas work a blot on the CV? The reverse, say MERLIN's Nicholas Banatvala and Annie Macklow-Smith, and recognition of this fact is growing.

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    Nearly two years have passed since an NHS Executive letter alerted trusts and health authorities to the benefits of overseas experience for NHS staff and suggested that NHS bodies encourage release of staff.1 Two years after that letter what progress has been made?

    New horizons for trusts

    Since the executive letter a handful of trusts-including Edinburgh Royal Infirmary, Edinburgh Sick Children's Trust, and the Worthing and Southlands Hospital NHS Trust-have signed agreements with aid agencies such as Voluntary Services Overseas (VSO) and MERLIN. These enable staff to take leave of absence to work overseas if they have more than two years' service in the trust. Up to two years' leave can be granted, with a guarantee of return to the former post (or a similar one). Eligible staff include doctors, nurses, other professionals allied to medicine, and other staff such as medical laboratory scientific officers. However, nurturing interest and generating such agreements at trust or health authority level is time consuming and inefficient. A more radical approach-in which a contract is held between the NHS at a more central level and a registered group of aid agencies- is required.

    BMA encourages initiatives

    Last year the British Medical Association ran a workshop that explored the barriers-both real and perceived-that prevent doctors from volunteering for overseas work. In addition priority areas for further action were discussed as were current innovative schemes to assist those wishing to work overseas. The workshop identified three key problems: lack of networks and role models for those wishing to work overseas, training and accreditation issues, and lack of continuum of opportunities in combining an NHS career with developing skills in the aid arena.2 The workshop recognised the value of retired health care workers who providebreadth of experience with career flexibility. This group is particularly valuable as local mentors and for on the job training of younger members of the profession.

    Professional development

    The royal colleges and their faculties are in general agreement that doctors and nurses can benefit from being part of a well structured overseas programme, be it research, development, or relief. There are at least five areas where overseas work enhances professional development: empathy, accelerated clinical learning, a cost conscious approach to health care, taking responsibility for developing quality of care, and flexibility. Depending on the specialty, particular skills will be especially relevant. The Royal College of General Practitioners and the Faculty of Public Health Medicine have working parties or committees dedicated to disseminating the value of overseas work in their particular field. The benefits of overseas work that can accrue from involvement in a relief, development, or research programme will be the subject of a future article.

    A few specific initiatives have developed, many through International Health Exchange, a 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 International Committee of the Royal College of General Practitioners has held two study days over the past two years in conjunction with International Health Exchange and Voluntary Services 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 (formerly the National Association of Health Authorities and Trusts).


    Many of the difficulties in establishing opportunities to contribute to international health have already been identified.3 Integrating overseas work with NHS and training commitments requires commitment from trusts, British and overseas universities, postgraduate deans, head of departments, colleges and faculties, as well as non-governmental agencies.

    In addition, commitment at government level is needed to encourage individuals, brought up through the increasingly narrowly focused NHS career path, to learn from other health care systems.

    Questions in the house

    Translating this vision into reality at national level will require political intervention. The brief and rather lame reply from former health minister Gerald Malone in March that “decisions on whether to release staff to work overseas are a matter for local National Health Service employers” suggested either that the former government did not have a full understanding of the benefits of overseas work or lacked real commitment to its implementation. Labour's recent strategy for international development cooperation similarly fails to address the issue.4 On the bright side, the NHS Executive recently wrote to the BMA to say that the formal expiry of the 1995 executive letter in no way diminishes its policy of encouraging NHS employers to recognise the value of overseas work.

    Until now, the NHS Enterprise Scheme has acted as one conduit for supplying British health workers for the overseas market. Set up in 1988, it has developed a database for those wishing to be considered for overseas work and the scheme has been involved in some 50 projects a year. But NHS funding for the scheme will be withdrawn in the near future and as a result an important resource and lobbying agency will be lost.

    Almost all of MERLIN's volunteer doctors have returned to the NHS: a far cry from the popular myth that doctors interested in working overseas are trained by the NHS, only to be lost to developing countries for ever. In fact most return after one or two years overseas and are a valuable resource to trusts or health authorities.

    Despite this, opportunities for consultant grade doctors are less likely to be fewer for those in training. With the commitment to service activity that consultants have, at present it is unlikely that trusts will release these individuals, partly because of difficulties with finding locums. One option may be to recognise a proportion of overseas work for continuing medical education and professional development.

    Calman and overseas work

    One objective of the new training packages is to standardise European medical training. There is provision in the European Specialist Medical Qualifications Order 1995 to allow the Specialist Training Authority to assess overseas (non-EEA) specialist training qualifications as equivalent to standards for the certificate of completion of specialist training. For this to be implemented colleges and faculties will need to draw up new mechanisms to accredit and possibly inspect overseas posts. This is likely to be a lengthy process. Considerable encouragement by overseas institutions, aid agencies, trainers, and trainees will be needed for this to become a reality.

    The more realistic approach comes through the recognition that Calman, rather than being inflexible, allows for opportunity. Provided that the specialist registrar undertakes the necessary time in a supervised and approved post, there is no reason why work overseas cannot be accommodated. The flexibility allows for both those who wish to precede rapidly through to consultant level, as well as those who wish to spend some time overseas and prolong their training. The key is gaining a training number-with this, a year out of a recognised training post can be accommodated. A well constructed programme can provide the basis for a project that the Royal College of Pathologists and Faculty of Public Health Medicine use. Planning ahead is vital; the inevitable bureaucracy means that it is not feasible to expect a trust to release a doctor at very short notice from a training post, with the support of the postgraduate dean.

    The period between the end of specialist training and prior to taking up a consultant post provides another opportunity to work overseas. At this stage the individual will be accredited and, as outlined above, experience is likely to benefit his or her future career in the NHS.

    The future

    The benefits of overseas work in an NHS career are often best understood by doctors and others with managerial responsibilities. While there are opportunities for doctors of all levels and all disciplines to work overseas in well structured relief, development, or research projects, organisations promoting such work will need to strive harder and consider innovative approaches in outlining the many benefits. What is lacking is an integrated approach with the British training programme. It is likely that over the next few years this will improve, and we have even heard some individuals talk about the value of a mandatory period of training outside the NHS. At present, however, the onus remains on the interested individual to take the initiative, and investigate and seize available opportunities.5

    Planning and lobbying interested parties remain essential activities. Many college advisers, postgraduate deans, heads of departments as well as research, development, and aid agencies are open to innovative suggestions to combine NHS training with overseas experience. The likely increase in job changes for career grade staff in the NHS, early retirement, the new specialist training, and ironically the gradual reduction in job security, may provide greater opportunities to work abroad.

    For those in training, even if work abroad can neither be awarded prospective or retrospective accreditation, there is increasingly recognition that well structured work in Third World countries will prove to be highly creditable in an NHS career. The development of a greater understanding of health and health care will almost certainly be the result of working in a different environment.


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