International work and leadership
in UK general practice
Harbourside Family Practice, North Somerset PCT, Bristol, UK
Primary Care, Imperial College, London, UK
Department of Primary Care and Public Health,
National Institute for Health Research (NIHR), London, UK
Harvard School of Public Health, Boston, Massachusetts, USA, and
Department of Primary Care, University of Glasgow, Glasgow, UK
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
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.
Received 6 January 2013
Revised 16 March 2013
Accepted 28 March 2013
Leadership in Health Services
Vol. 27 No. 2, 2014
qEmerald Group Publishing Limited
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).
The NHS leadership
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.
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.
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.
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
stage of career
Frequency and duration of
overseas work episodes
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
during periods of
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
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.
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
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.
Degree to which able to
transfer competencies to
the UK setting
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
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
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
Another common barrier was keeping up appraisal in light of the recent changes to GP
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.
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
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
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.
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
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Appendix. International work and leadership in UK general practice
International work and
leadership in UK general
International work and
leadership in UK general
International work and
leadership in UK general
International work and
leadership in UK general
Peter Young can be contacted at: firstname.lastname@example.org
International work and
leadership in UK general
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