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Purpose – The purpose of this paper is to present an exploration of the leadership competencies developed by UK GPs through having undertaken international work and the ability to transfer these competencies back to the UK. Design/methodology/approach – The approach taken is a cross-sectional survey. Findings – A total of 439 UK-based, ranging from GP specialty trainees to retired GPs who had worked overseas, responded to an online survey of UK general practice and international work. Doctors were asked to report competency development through international work using the domains of the Medical Leadership Competency Framework (MLCF). The most common competencies developed, to a “moderate or significant” degree, related to “personal qualities” (89 per cent) and “working in teams” (87 per cent). To a lesser extent Doctors developed competencies in “setting direction” (60 per cent), “managing services” (59 per cent), and “service improvement” (56 per cent), and found these competencies harder to transfer back to the UK. A common reason for limited transfer of competency was the lack of leadership opportunities for Doctors when returning to UK locum roles. Overseas posts were more common in low/middle income countries, and these Doctors reported a greater range of leadership roles, including in health policy, management and teaching, compared to high-income countries. Most doctors felt that they were able to develop their clinical skills overseas whilst relatively few Doctors performed research, especially in high-income countries. Originality/value – To the authors' knowledge this is the first cross-sectional survey exploring the international work of UK GPs and leadership development using the MLCF domains.
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International work and leadership
in UK general practice
Peter Young
Harbourside Family Practice, North Somerset PCT, Bristol, UK
Chris Smith
Primary Care, Imperial College, London, UK
Luisa Pettigrew
Department of Primary Care and Public Health,
National Institute for Health Research (NIHR), London, UK
Ha-Neul Seo
Harvard School of Public Health, Boston, Massachusetts, USA, and
David Blane
Department of Primary Care, University of Glasgow, Glasgow, UK
Abstract
Purpose – The purpose of this paper is to present an exploration of the leadership competencies
developed by UK GPs through having undertaken international work and the ability to transfer these
competencies back to the UK.
Design/methodology/approach – The approach taken is a cross-sectional survey.
Findings – A total of 439 UK-based, ranging from GP specialty trainees to retired GPs who had
worked overseas, responded to an online survey of UK general practice and international work.
Doctors were asked to report competency development through international work using the domains
of the Medical Leadership Competency Framework (MLCF). The most common competencies
developed, to a “moderate or significant” degree, related to “personal qualities” (89 per cent) and
“working in teams” (87 per cent). To a lesser extent Doctors developed competencies in “setting
direction” (60 per cent), “managing services” (59 per cent), and “service improvement” (56 per cent),
and found these competencies harder to transfer back to the UK. A common reason for limited transfer
of competency was the lack of leadership opportunities for Doctors when returning to UK locum roles.
Overseas posts were more common in low/middle income countries, and these Doctors reported a
greater range of leadership roles, including in health policy, management and teaching, compared to
high-income countries. Most doctors felt that they were able to develop their clinical skills overseas
whilst relatively few Doctors performed research, especially in high-income countries.
Originality/value – To the authors’ knowledge this is the first cross-sectional survey exploring the
international work of UK GPs and leadership development using the MLCF domains.
Keywords Leadership, International work, MLCF
Paper type Research paper
The current issue and full text archive of this journal is available at
www.emeraldinsight.com/1751-1879.htm
The authors are members of the RCGP Junior International Committee ( JIC) and JIC google
group. The authors are grateful to the RCGP for funding the cost of Survey Monkey software.
Ethical approval not required.
International
work and
leadership
87
Received 6 January 2013
Revised 16 March 2013
Accepted 28 March 2013
Leadership in Health Services
Vol. 27 No. 2, 2014
pp. 87-103
qEmerald Group Publishing Limited
1751-1879
DOI 10.1108/LHS-01-2013-0003
Introduction
The government white paper “Equity and excellence: liberating the NHS” puts
clinicians at the forefront of leadership in the NHS (Department of Health, 2010a). GPs
working within clinical commissioning groups (CCGs) will have a greater role in
transforming services and need additional competencies to be successful at this
(General Medical Council, 2009). To outline these competencies and to facilitate
leadership development during medical training, from undergraduate level to
continuing professional development (CPD), the Academy of Medical Royal Colleges
and the NHS Institute for Innovation and Improvement have produced the Medical
Leadership Competency Framework (MLCF) (NHS Institute for Innovation and
Improvement, 2011). Within the MLCF there are five core domains: demonstrating
personal qualities, working with others, managing services, improving services and
setting direction (Figure 1).
Alongside the interest in clinical leadership in the UK, there is increasing
recognition of the leadership role of the NHS in global health (Department of Health,
2010b). In 2007 the Crisp report highlighted how the UK contributes to health care in
developing nations, stating: “The UK has shown remarkable intellectual and practical
leadership in international leadership and espoused a very clear focus on supporting
country leadership and local ownership” (Crisp, 2007). The impact of globalisation on
health is now explicit within UK government policy (HM Government, 2008). This
identifies the consequences of UK policy for other countries and how the experiences of
other countries can improve the way that health care is delivered in the UK. Where the
UK has drawn from good examples of leadership in developed nations, there is an
increasing awareness of the reciprocal benefits of leadership in developing nations
(Crisp, 2010; Syed et al., 2012).
Figure 1.
The NHS leadership
framework domains
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In UK primary care, awareness of global health continues to rise through organisations
such as the Tropical Health and Education Trust (THET) that facilitates International
Health Partnerships supported by the Department For International Development
(DFID), Alma Mata, the RCGP Junior International Committee ( JIC), Medsin, and
through university degree programs with a Global Health focus (Department of
International Development, 2012; Leather et al., 2010; Longstaff, 2012; Alma Mata,
2011; RCGP, 2012; MedSin, 2012). A current aim of the Royal College of General
Practitioners (RCGP) is to establish itself as a global centre (Wass and Mather, 2012).
While there is some evidence that overseas experience and training is beneficial to
UK services, little is known about the types of competencies gained by doctors through
international work (Banatvala and Macklow-Smith, 1997; Hockey et al., 2009; Holden,
1998; Van den Hombergh et al., 2009). At present, there are no structured mechanisms
to evaluate and accredit competencies gained by working overseas, and work
performed outside of the NHS is not routinely incorporated into revalidation (General
Medical Council, 2012).
In 2011 an exploratory survey was conducted to learn about the experiences of GPs
who have combined UK general practice and international work (Smith et al., 2012).
The aim of this study is to conduct an in-depth analysis of the survey data on
leadership competencies developed by UK GPs through international work and the
ability to transfer these competencies within UK healthcare.
Methods
The study was conducted via an online questionnaire appearing in August 2011 on the
Royal College of General Practitioners’ (RCGP) website homepage. To advertise the
study, an e-mail invitation was sent to all RCGP faculties to distribute to their
members. The questionnaire was formulated using Survey Monkeywsoftware and
consisted of 12 questions relating to doctor’s experiences whilst working overseas
(Appendix 1). Respondents were asked to answer each question using the scale
provided. The survey also included boxes for free text comments. UK-based GPs were
invited to complete the questionnaire regardless of whether or not they had undertaken
international work. Doctors who had not undertaken international work were asked to
complete question one only.
The questionnaire was tested on two occasions using a small group of GPs prior to
its general release as an online survey. Participants were asked about the nature of
their international work and opportunities to develop leadership competencies as
outlined in the MLCF. Microsoft Excel and N-VIVO software were used to analyse the
numerical and qualitative data respectively. Two authors independently reviewed the
recurring themes arising from the text comments and then discussed any discrepancies
to reach consensus of the findings.
Results
The study received a total of 594 responses from Doctors at varying career levels
(Figure 2). The number of respondents is equivalent to 1.4 per cent of the RCGP
membership. Respondents were on average younger than the UK average for GPs. A
total of 439 respondents (74 per cent) reported that they had worked overseas.
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Career roles before, during and after international work
Before leaving the UK to work overseas, the largest group of respondents was in GP
specialty training posts (24 per cent). A total of 21 per cent of respondents were
working in other specialties and 19 per cent in partnership positions. Within the first
six months after returning from working overseas more respondents took up locum
jobs (23 per cent) with others resuming specialty training (21 per cent) or partnership
positions (20 per cent). Respondents were asked to indicate how many times they had
worked overseas, and whether these episodes had been short ( ,one month), medium
(one to six months), or long (.6 months) (Figure 3). The majority of episodes overseas
were greater than six months long. Taking into account the total time spent working
overseas in all posts, 47 per cent of respondents had spent less than one year, 39 per
cent had spent one to five years, and 15 per cent had spent more than five years
overseas.
Figure 2.
Respondents’ current
stage of career
Figure 3.
Frequency and duration of
overseas work episodes
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Doctors cited a range of clinical and non-clinical roles in their international work.
These included working in local health services, government, the armed forces,
religious organisations, universities, and non-governmental organisations (NGOs).
Overall, episodes overseas were more frequently undertaken in low/middle-income
countries (575/ per cent of survey respondents) compared to high-income countries
(286/ per cent of survey respondents). Doctors from both high and low/middle-income
countries described their international work as predominantly clinical. More doctors in
low/middle-income countries had a greater role in health policy, management, research,
and teaching, than those working in high-income countries (Figure 4).
Leadership competencies gained through international work
Doctors reported that they had developed a range of leadership competencies through
international work (Figure 5). These ranged from developing personal attributes to a
better understanding of services and the needs of patients:
My visits abroad have all been transformational experiences in different ways and have given
me a greater awareness of cultural differences and opportunities to develop leadership skills
and to improve care for patients.
In particular doctors reported “moderate or significant” development of personal
qualities such as self-awareness and integrity (89 per cent) and working with others (87
per cent), whilst also developing skills in setting direction (60 per cent), managing
services (59 per cent) and improving services (56 per cent). A common theme was that
doctors were more aware of “new ways of working” or “thinking outside the box”. One
doctor after their sabbatical in a high-income country said:
The ability to work overseas and understand and learn about other healthcare systems is
hugely beneficial. I’ve come to learn and better understand the values of the NHS, but I’ve also
Figure 4.
Roles undertaken
during periods of
international work
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learned about the benefits of improved access through extended hours, the pros and cons of
dual registration, and benefits of rapid access to diagnostics.
Similarly, another doctor stated:
The experience of working in another country/culture even though similar to ours, is great for
expanding horizons, swapping cultural intelligence and changing attitudes. I think that
Doctors and patients both benefit from this kind of exchange.
A doctor who had worked in a low-income country believed that their international
work provided new managerial experience:
I gained significant experience in report writing, project planning, managing budgets and
particularly human resources (recruitment, interviewing, contracts, appraising colleagues
and disciplinary procedures).
Doctors working in low-income countries described different responsibilities and
leadership challenges than they might have in the UK:
I have learned how to manage a 165 bed hospital in a semi-rural district, with limited
resources.
I was responsible for 25,000 patients, a Community Hospital and four Health Centres, so I got
an amazing amount of experience.
An amazing opportunity to do a lot of independent work at a relatively junior level. This
comes with drawbacks and challenges but also presents a very positive challenge. I was able
to develop areas such as leadership, decision making and coping strategies.
A small number of doctors felt that they did not gain additional leadership
competencies from their international work:
I learned more at home as it took a while to settle in to a different health care system.
Figure 5.
Competencies gained
through international
work
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I think I could have learned the same things in jobs in the UK. However in Australia they
have great emergency departments and good emergency training, so this was a benefit.
In addition to the competencies relating to the MLCF domains, doctors also reported
“moderate or significant” development in their clinical care (79 per cent), teaching (56
per cent) and to a lesser extent research skills (19 per cent). The number of Doctors
carrying out research in a high-income country was particularly low (8). One doctor
working in a low-income country stated that their international work provided “a huge
potential for research”.
Ability to transfer competencies back to the UK
Respondents felt that certain leadership competencies were easier to transfer back to
the UK than others (Figure 6). Of those leadership competencies that were transferable
to a “moderate or significant” degree, the most common were personal qualities (82 per
cent) and working with others (81 per cent). Less than half of all respondents felt that
they were able to transfer competencies of setting direction (45 per cent), managing
services (43 per cent), and improving services (41 per cent) to a “moderate or
significant” degree.
For doctors working in health settings and cultures comparable to the NHS, the
ability to transfer competencies gained seemed more straightforward:
I spent a year in New Zealand and a year in Australia on separate occasions. The experience
gained was directly transferrable to medical care in the UK.
Where services or cultures were very different from the UK there was a indication that
some competencies were harder to transfer:
I worked in a rural hospital with very basic facilities so most clinical care was not relevant to
GP work in UK but confidence, flexibility and ability to keep calm was all very useful.
Figure 6.
Degree to which able to
transfer competencies to
the UK setting
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To be honest, not much was transferable back to the UK. I developed culturally specific skills
most relevant for the developing country I was working in.
In contrast, culturally specific skills were also seen as an advantage:
The ability to work with people of very different cultures and expectations was very useful.
A common theme was that there were few opportunities to use the leadership
competencies gained on returning to the UK. For some this was because of the lack of
leadership opportunities in locum or sessional GP roles:
Opportunities to set direction, manage, teach or improve services are very limited as a locum.
On returning to the UK six years ago I have found it difficult to move on from sessional roles
so I have had little opportunity to express the skills I learned in Nepal. However, I’ve now just
become a GP principal and opportunities are opening up.
Another doctor felt that the leadership competencies gained would be more relevant
later in their career:
Because I’m still in training I can use the management/leadership skills further on in my
career.
With regard to transferring clinical skills to the UK setting many respondents had
positive experiences. A total of 62 per cent of respondents felt that they were able to
transfer their skills to a “moderate or significant” degree:
I cannot emphasise enough how seeing a mind-bogglingly large number of seriously ill people
has helped me in my subsequent career.
The reported ability to transfer research work was poor. One respondent felt that
research in lower income countries was not directly applicable to work in the UK:
All my research is based on primary health care in low and middle income countries. So
nothing so far has been directly applicable to UK research.
Barriers to international work
Respondents reported a range of barriers to international work. Of the barriers
reported as “moderate or significant” the greatest barrier was leaving family and
friends (45 per cent). Several Doctors commented that having children, or caring for
elderly parents prevented them from working abroad or that moving country would
disrupt the career of their partner. Other barriers commonly selected were financial
considerations, for example loss of earnings (21 per cent) and loss of pension (22 per
cent), as well as the ability to secure a job on return from overseas (26 per cent). One
respondent wrote:
I had no concerns on the first two trips, however I am now working as a GP in Australia and
am a little concerned about getting a job on return, pensions and keeping up appraisal.
Pensions seemed to be a greater consideration for more experienced GPs:
I was too young and altruistic to think about pensions but I probably should have thought of
this.
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Another common barrier was keeping up appraisal in light of the recent changes to GP
revalidation:
I am abroad currently and it is still not clear how I will be appraised.
I would be much more concerned about revalidation now than I was in 1992.
A number of respondents reported mixed experiences in gaining out-of-programme
experience (OOPE) during specialty training:
Because it was an OOPE I had no concerns about appraisal and getting a job on coming back.
My barrier was getting approval from the deanery (for OOPE).
Others stated that there were barriers to working abroad on a sabbatical or re-joining
the NHS on return from international work relating to the primary care trust (PCT):
A significant barrier was the lack of ring fenced money to support a sabbatical.
Getting on the performer’s list has been the biggest problem since coming back.
Discussion
The study illustrates that GPs, at all career levels, develop leadership competencies
through a wide range of international work. Doctors recognise that international work
is a good way to develop personal qualities and team working attributes and are
positive about the ability to transfer these competencies back to the UK. To a lesser
degree GPs feel that international work enables them to develop competencies in
setting direction, improving services and managing services, and find these harder to
transfer back to the UK. The findings may reflect that doctors, especially those at more
junior grades, may be more familiar with developing themselves rather than the
services they work in. Historically, the majority of doctors in the NHS have had little
experience in transforming services and many GPs may not have gained significant
managerial experience until later in their careers in GP partnerships.
In practical terms, overseas working may be more accessible to younger GPs who
have fewer family and financial commitments and may take up international work
during training or during periods of job transition. The study suggests that many
doctors return to sessional work where opportunities to lead are poor. Senior GPs who
may be more settled within their family and career roles, despite having a greater
wealth of leadership experience, may find more barriers to undertaking international
work. Attempts to reduce such barriers by UK health services should focus on job
security on return to the UK, appraisal and CPD, and pensions (BMA, 2009). There may
be valuable learning points from adopting integrative programmes such as sabbaticals
within GP training programmes and GP partnerships, alongside longer-term
international institutional partnerships.
The study indicates that leadership experiences reported by doctors may be
different depending on the fiscal status of the host country. Doctors working in
high-income countries were more focused on non-relief clinical work and described
learning from areas of good practice and training that were easily transferable to the
UK. Doctors working in low/middle-income countries reported a greater range of
leadership activities, including health policy, management, as well as more
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involvement in teaching. There were some examples from doctors working in
low-income countries, where services and cultures were very different to the UK, that
competencies may have been more difficult to transfer. However, an understanding of
the cultural influences on health is of growing importance to the NHS. Since 1993 the
share of foreign-born people in the UK’s total population has increased from 7 per cent
to nearly 12.3 per cent and continues to rise (Rienzo and Vargas-Silva, 2012).
Overall, it was not common for GPs to perform research whilst overseas, with
relatively fewer doctors engaging in research in high-income countries compared to
low/middle income countries. This may be concerning if it is a reflection of differences
in access to patients and the role of medical ethics committees between countries.
Although one respondent did not feel that their research overseas was applicable to the
UK setting it should be understood that the principles and process of research are
directly transferable between countries. Given that leadership requires a sound
evidence-base, GPs should work closely with CCGs and academic institutions and
engage more in research with a service improvement focus.
Limitations of study
The study was widely circulated to a large number of doctors via the internet. However
it was not possible to determine an overall response rate as the number of doctors who
were made aware or were able to access the online questionnaire is unknown. Although
the first question was intended to estimate what proportion of GPs had undertaken
international work in the past, authors suspect that there was self-selection bias toward
GPs with an interest in international work. It is therefore hard to draw firm conclusions
about how common international experience is amongst UK GPs.
The study was biased towards people able to access the RCGP website and to those
who are more familiar in the use of online surveys. Several doctors were still working
abroad, or had only been back in the UK for a short period, and would therefore have
been unable to fully account for the transfer of competencies. Future studies may
benefit from a more detailed perspective of the international work of senior GPs, as
well as cross-comparison with GPs who have not worked overseas.
Implications for future research or clinical practice
There is potential to enhance leadership competencies gained by GPs through
international work especially in regard to managing and improving services. Trainee
doctors will benefit from a greater understanding of global health and the complement
of leadership competencies outlined in the MLCF, in addition to proficient clinical,
research and teaching skills. Extended GP training may represent an opportunity to
take this forward (Irving et al., 2012; Rughani et al., 2012). In conjunction, doctors
require greater exposure to clinical leadership roles at all career levels, for example
being involved in service improvement projects, whether during hospital training or in
the community.
Having a robust form of appraisal during periods of international work will
facilitate leadership development. In preparation for working overseas, doctors should
identify their learning needs to include a good knowledge of the foreign health system
and how they will impact on services. Performance could be charted using a
comprehensive reflective log that could be assessed by an appraiser in the home
country and, where possible, supported by an appraiser in the host country.
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Consideration should be given to providing doctors with learning modules on topics
such as quality improvement methodology, management skills, the principles of
policymaking, epidemiology, and how to make a needs’ assessment.
Appropriate and well planned international work in low-income countries, whilst
providing invaluable support to impoverished and underserved health systems, offers
a wide range of leadership opportunities for UK doctors, and more consideration
should be given to how these experiences can benefit UK services. Volunteering and
performing both clinical and non-clinical work are legitimate ways to develop medical
careers and to make sustainable contributions to the developing world. In high-income
countries, doctors should look to broaden their leadership activities beyond traditional
clinical roles, learning from good practice within health policymaking, management
and clinical leadership.
As the role of global health continues to grow within the UK primary care setting, a
key area to consider is how GPs can effectively integrate international working with
their NHS commitments. Incorporating international work into revalidation could be a
valuable way of improving career continuity whilst recognising that competencies
gained by working outside of the NHS are transferable and of immense benefit to UK
healthcare provision.
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Appendix. International work and leadership in UK general practice
Figure A1.
International work and
leadership in UK general
practice
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Figure A1.
International work and
leadership in UK general
practice
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Figure A1.
International work and
leadership in UK general
practice
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Figure A1.
International work and
leadership in UK general
practice
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Corresponding author
Peter Young can be contacted at: pyoung15@hotmail.com
Figure A1.
International work and
leadership in UK general
practice
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... Literature that explores what and how healthcare professionals learn from temporarily working or volunteering in a low-resource setting tends to report anecdotes or single reports, which provide a lower level of evidence [4,10]. Furthermore, benefits are detailed in broad categories, with 'leadership' , 'communication' and 'cultural awareness' being frequently reported [3,[11][12][13], with a focus on one of these skill sets in depth or a list of outcomes under umbrella terms, such as communication or leadership skills [3,14]. These broad labels make an assessment of the learning outcomes difficult as they might contain multiple underpinning knowledge, skills, practice and attitudes. ...
... Ability to manage projects 'I gained significant experience in report writing, project planning, managing budgets and particularly human resources'. [11] Ability to think through problems in a logical way Increased workforce productivity 'Increased workforce productivity' [3] Reduction in NHS drop outs Increased staff retention 'Attraction & retention of (more/better quality) workforce' [3] Increased international reputation (of the United Kingdom) ...
... Factors which influence outcomes (Continued)'a LMI country may present a temptation to students to undertake medical care or procedures which they would not be permitted to perform at home' (Lumb, 2014) 'learning the local language will enable nurses to succeed in developing relationships with patients or nursing students. In doing so, they will begin to move to the third level of cultural competence' (Paterson, 2014) 'unclear whether those who participated wanted to learn from the experience or whether they saw themselves as aiding the perceived 'unfortunate"(Button, 2005) 'the range of professionals that are not qualified so they have to be supervised when they go out' (workshop participant) 'In practical terms, overseas working may be more accessible to younger GPs who have fewer family and financial commitments and may take up international work during training or during periods of job transition'(Smith, 2014) 'the process of critical reflection was uncomfortable for some. Critical reflection facilitated in a safe place may support individuals to transform their way of thinking'(Briscoe, 2013) 'Participation in health links provides in depth experience of these increasingly global pathologies' (Peate, 2008) 'cannot emphasise enough how seeing a mind-bogglingly large number of seriously ill people has helped … in [their] subsequent career.'(Seo, ...
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Background Qualitative narrative analysis and case studies form the majority of the current peer-reviewed literature about the benefits of professional volunteering or international placements for healthcare professionals. These often describe generalised outcomes that are difficult to define or have multiple meanings (such as ‘communication skills’ or ‘leadership’) and are therefore difficult to measure. However, there is an interest from employers, professional groups and individual volunteers in generating metrics for monitoring personal and professional development of volunteers and comparing different volunteering experiences in terms of their impact on the volunteers. In this paper, we describe two studies in which we (a) consolidated qualitative research and individual accounts into a core outcome set and (b) tested the core outcome set in a large group of global health stakeholders. Method We conducted a systematic review and meta-synthesis of literature to extract outcomes of international placements and variables that may affect these outcomes. We presented these outcomes to 58 stakeholders in global health, employing a Delphi method to reach consensus about which were ‘core’ and which were likely to be developed through international volunteering. Results The systematic review of 55 papers generated 133 unique outcomes and 34 potential variables. One hundred fifty-six statements were then presented to the Delphi stakeholders, of which they agreed 116 were core to a wide variety of healthcare professional practice and likely to be developed through international experiences. The core outcomes (COs) were both negative and positive and included skills, knowledge, attitudes and outcomes for healthcare organisations. Conclusions We summarised existing literature and stakeholder opinion into a core outcome set of 116 items that are core to healthcare professional practice and likely to be developed through international experiences. We identified, in the literature, a set of variables that could affect learning outcomes. The core outcome set will be used in a future study to develop a psychometric assessment tool. Electronic supplementary material The online version of this article (10.1186/s12960-018-0333-5) contains supplementary material, which is available to authorized users.
... Over the last 40 years, across multiple jurisdictions, a pattern has emerged whereby a disproportionate number of physicians continue to practice beyond the traditional retirement age of approximately 65 years old [1,2]. Accordingly, healthcare organizations often do not have effective succession strategies in place to manage their aging medical staff. ...
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Background Physician retirement planning and timing have important implications for patients, hospitals, and healthcare systems. Unplanned early or late physician retirement can have dire consequences in terms of both patient safety and human resource allocations. This systematic review examined existing evidence on the timing and process of retirement of physicians. Four questions were addressed: (1) When do physicians retire? (2) Why do some physicians retire early? (3) Why do some physicians delay their retirement? (4) What strategies facilitate physician retention and/or retirement planning? Methods English-language studies were searched in electronic databases MEDLINE, Web of Science, Scopus, CINAHL, AgeLine, Embase, HealthSTAR, ASSA, and PsycINFO, from inception up to and including March 2016. Included studies were peer-reviewed primary journal articles with quantitative and/or qualitative analyses of physicians’ plans for, and opinions about, retirement. Three reviewers independently assessed each study for methodological quality using the Newcastle-Ottawa Scale for quantitative studies and Critical Appraisal Tool for qualitative studies, and a fourth reviewer resolved inconsistencies. ResultsIn all, 65 studies were included and analyzed, of which the majority were cross-sectional in design. Qualitative studies were found to be methodologically strong, with credible results deemed relevant to practice. The majority of quantitative studies had adequate sample representativeness, had justified and satisfactory sample size, used appropriate statistical tests, and collected primary data by self-reported survey methods.Physicians commonly reported retiring between 60 and 69 years of age. Excessive workload and burnout were frequently cited reasons for early retirement. Ongoing financial obligations delayed retirement, while strategies to mitigate career dissatisfaction, workplace frustration, and workload pressure supported continuing practice. Conclusions Knowledge of when physicians plan to retire and how they can transition out of practice has been shown to aid succession planning. Healthcare organizations might consider promoting retirement mentorship programs, resource toolkits, education sessions, and guidance around financial planning for physicians throughout their careers, as well as creating post-retirement opportunities that maintain institutional ties through teaching, mentoring, and peer support.
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Introduction Past research has reported considerable benefits of international health professional volunteering for British healthcare professionals; however, there are also some negative outcomes reported. Negative outcomes reportedly happen on a personal, professional and organisational level. However, there is little evidence of the frequency they might occur. Methods We aimed to understand what the negative outcomes of health professional volunteering in low-income and middle-income countries were, and how frequently they occurred, in an opportunistic sample of UK health professionals. We used a questionnaire developed using potential negative outcomes reported in the peer-reviewed papers. We conducted secondary analysis on cross-sectional questionnaire data from 222 healthcare professionals. Results This research provides an indication of the frequency that negative outcomes might occur. Post hoc analyses revealed that some outcomes were experienced by the majority of health professional volunteers, for example, lack of formal recognition (131/169, 78%) and financial cost (92/169, 68%). While others happened less, for example, a reliance on agency or locum work (12/169, 7%) and loss of pension (31/169, 18%). Conclusion The outcomes reported in this research quantify some of the concerns that have been raised in previous literature. Negative outcomes might be associated with certain features of volunteering and further research is needed to prospectively compare different features. Organisers of volunteering opportunities should be aware of the potential negative outcomes and engage with the research into negative outcomes to generate and apply findings about minimising potential negative outcomes, carefully balancing these against the needs of the host country.
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Purpose – The purpose of this paper is to describe a novel approach to leadership development for UK healthcare workers, while contributing to health service improvement in a developing country. Design/methodology/approach – A quality improvement faculty are used to teach and mentor National Health Service (NHS) International Development Clinical Fellows in quality improvement (QI) methods. Using accepted QI methods, sensitive and practical improvement projects are selected in partnership with local people in Cambodia in order to start achieving United Nations Millennium Development Goals related to child and maternal health. Simultaneously, NHS International Fellows gain an unparalleled opportunity to develop their leadership skills, which should benefit the NHS on their return to the UK. Findings – Healthcare quality improvement methods, developed in First World countries, are transferable to the developing world and also function as a vehicle for developing leadership skills in experienced healthcare workers. Practical implications – This leadership development programme fits with the stated aims of the Global Health Partnerships report, which encourages the NHS to play a global role in healthcare development in the developing world. Other First World healthcare systems could adopt this leadership development method to both improve the leadership capability of their own staff while also making a significant contribution to less well-developed healthcare systems. Originality/value – The combination of leadership development through quality improvement is novel – promising to benefit both providers and recipients.
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In 1978 the World Health Organization (WHO) made a public declaration in Alma-Ata advocating the use of primary healthcare systems globally.1 Twenty-two years later the United Nations (UN) agreed eight Millennium Development Goals (MDGs) to be attained by 2015.2,3 Core to the delivery of them, although not explicitly mentioned, is the primary healthcare model as set out in the Alma-Ata Declaration. In 2008 the WHO Regional Office for Europe reiterated that effective primary health care was essential to the delivery of quality health services for individuals and populations by publishing the Talinn Charter.4 This too included a commitment to attain the Charter’s targets by 2015. As we approach the 2015 deadlines for both the MDGs and the Talinn Charter, governments and policy makers are increasingly interested in primary health care. At the Royal College of General Practitioners (RCGP) we observe this by a steadily growing number of international requests to support primary care development. We are entering a critical window of political activity in health funding and global health systems reform. The MDGs committed world leaders to combat poverty, hunger, disease, illiteracy, environmental degradation, and discrimination against women. The goals related to the eradication of disease specifically drew international attention to communicable diseases (including HIV/AIDS, malaria, and tuberculosis) and focused resources on vertical models of health care for disease-specific diagnoses and treatment. This diverted attention away from the implementation of a horizontal model of primary health care with its less immediate yet longer-term benefits as demonstrated so clearly by Barbara Starfield.5 This imbalance in systems reform was recognised in 2012 when the UN General Assembly published a political declaration on the prevention and control of non-communicable diseases (NCDs).6 The document acknowledges the need to address the …
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To conduct an exploratory study to learn about the experiences of GPs who have undertaken international work. Cross-sectional survey Online survey of UK-based GPs. Members of all UK RCGP faculties were invited to participate by email and the survey was publicised on the RCGP website All UK-based GPs Types of UK and international work undertaken, barriers, competencies gained, influence on career and future plans. The study identified 439 respondents, in a variety of GP roles at all career stages, who had undertaken international work in their role as a doctor. GPs are undertaking international work in both high and low/middle-income countries, engaging in a wide range of clinical and non-clinical activities. Respondents reported gaining a range of competencies from international work, which could be transferred back to the UK setting to a variable degree. Commonly cited barriers to international work were having to leave friends and family, and concerns regarding future employment and pension. Most reported that engaging in international work had influenced the direction of their career, with the largest proportion stating that they wish to work predominantly in the UK, with some international work in the future. The study highlights the variety of ways in which UK GPs are combining UK general practice and international work, competencies gained with such work, and ability to transfer these back to the UK setting. Historical barriers to international work still exist and future research could further examine the value of such work.
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Developing countries can generate effective solutions for today's global health challenges. This paper reviews relevant literature to construct the case for international cooperation, and in particular, developed-developing country partnerships. Standard database and web-based searches were conducted for publications in English between 1990 and 2010. Studies containing full or partial data relating to international cooperation between developed and developing countries were retained for further analysis. Of 227 articles retained through initial screening, 65 were included in the final analysis. The results were two-fold: some articles pointed to intangible benefits accrued by developed country partners, but the majority of information pointed to developing country innovations that can potentially inform health systems in developed countries. This information spanned all six WHO health system components. Ten key health areas where developed countries have the most to learn from the developing world were identified and include, rural health service delivery; skills substitution; decentralisation of management; creative problem-solving; education in communicable disease control; innovation in mobile phone use; low technology simulation training; local product manufacture; health financing; and social entrepreneurship. While there are no guarantees that innovations from developing country experiences can effectively transfer to developed countries, combined developed-developing country learning processes can potentially generate effective solutions for global health systems. However, the global pool of knowledge in this area is virgin and further work needs to be undertaken to advance understanding of health innovation diffusion. Even more urgently, a standardized method for reporting partnership benefits is needed-this is perhaps the single most immediate need in planning for, and realizing, the full potential of international cooperation between developed and developing countries.
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The need to strengthen health capacity in developing countries is widely documented. The World Health Organization has called for an increase in the number of health workers in all countries experiencing critical shortages, a significant scaling-up of training and more efficient use of existing health workers. Health Links, long-term mutually beneficial partnerships between UK health institutions and their counterparts in developing countries, are helping to fill these gaps. Links allow for the reciprocal transfer of knowledge and skills between partners, enabling the UK's expertise in health service delivery and training to be channelled towards the needs of those in developing countries, while also bringing a wide range of benefits to the UK. Examples of Health Links in Ethiopia demonstrate such benefits. An increasingly supportive policy environment is enabling a significant expansion in the number of Links. However, the quality of these Links is critical to their impact and thus there is a need both to continue to support those engaging in Links to develop sustainable, mutually beneficial strategic partnerships, and to strengthen the body of evidence of their impacts.
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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. 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). Commitment 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. ReferencesNHS Executive. Overseas work experience and professional development. Leeds: NHSE, 1995.(EL9569.)British Medical Association. Report of returned volunteers' workshop London: BMA, 21 February 1996.Easmon C. Working Overseas. BMJ 1996; Classified suppl: 5 October.A fresh start for Britain: Labour's strategy for Britain in the modern world. Part VI: a strategy for international development cooperation. London: Labour Party, 1997.Johnstone P. How to do it: work in a developing country. BMJ 1995; 311: 1 l 3–5.
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Whether driven by statute or by societal and scientific forces, the NHS is undergoing radical change. How, then, will training adapt so that future GPs have the skills and, importantly, the motivation to meet the challenges ahead? Here, drawing on our experience with the Royal College of General Practitioners’ curriculum and assessments, we comment on the why, the what, and the how. Given the limited exposure that GP specialty trainees have to the community context, it is remarkable that GP training achieves the standards that it does. The recent acceptance by the Medical Programme Board (of Medical Education England) of the educational case for enhanced and extended training has reinforced the need for the changes we set out here. If enacted as we hope, these changes will equip future trainees to address the significant challenges, some of which are illustrated below, that they will face as independent GPs. GPs must be simultaneously proficient in using communication to develop trusting relationships, make decisions in situations of uncertainty, manage time and events, and grasp learning opportunities. They also need to show commitment to values and to people, including themselves. This remarkable conjunction is required for the majority of problems, however small. In the future, GPs will need to engage proactively with their communities and take greater responsibility for leading improvements in population health and reductions in health inequalities.1 On the demographic front, we are moving from an era of mortality from misadventure or ‘straightforward’ causes of …