NHS international engagement beyond COVID-19

Chaired by Navina Evans, Chief Executive of Health Education England, the first session of the day covered how NHS staff volunteering in low and middle-income countries (LMICs) can benefit not just the individual, but also NHS organisations.

The session explored how NHS leaders can support this area of work by helping to develop a strategic approach to international partnerships at the institutional level, with Navina sharing her experience of developing an institutional approach to the several international health partnerships developed during her years as CEO of East London NHS FT (ELFT).

Key points:

• Partnership design should include: a return on investment to the trust that justifies the contribution of staff time and Trust resources; a way of using the experience of learnings from LMICs to feed into their continuous improvement of services at the Trust; and the use of specific methodologies to evaluate the institutional benefit to the trust.
• Organisational leadership should be involved in international health partnerships within the NHS to ensure organisations get the most from partnerships.

Professor Ged Byrne, Director of Global Engagement at Health Education England, reflected on the on the importance of working in a LMIC to his own professional development, and why similar experiences can help develop health professionals with the ‘meta skills’ needed to work in the modern NHS, such as emotional intelligence, leadership and cultural competence – now, and in the future.

The experience of working in a LMIC where resources are low, demand high and professionals are stretched has the potential to provide an environment that develops these meta-skills, that could otherwise take a long time to develop if confined to an NHS environment.

Key points:

• Placing NHS staff within LMIC settings can offer more value for money and impact than many leadership programmes.
• International experiences could help meet the ‘meta skills’ gap in health education and training.
• The way of creating sustainability in international engagement for NHS staff is by forming relationships between institutions rather than simply between individuals – in this way, the opportunities for NHS staff to participate become manifold.

Lisa Kelly, COO Nottingham University Hospitals (NUH) NHS FT, had a similarly enriching experience with international engagement, starting when she 16 and went to Ethiopia for the first time, and extending around the world. She now describes having gone ‘almost full circle’, having become the Executive Lead for the NUH partnership with Ginir Hospital, in Ethiopia, as well as spending a year as an Improving Global Health Fellow, teaching leadership and management, and supporting the development of anesthesia services in Zambia.

For Lisa, the experience of working in LMICs helped developed her set of values about the importance of population health, what sort of leader in the NHS she wants to be, and prepared her for the intensely challenging times the Trust now faces during COVID-19.

As a manager, leading this work in an NHS organisation with a nearly 3-decade long health partnership, Lisa is focused on the further improvements she can make to develop a more supportive and permissive environment to enable professional to take up these opportunities.

Key points:

• Participating in international health partnerships can deliver new perspectives and skills that can directly and indirectly contribute to successful leadership within the NHS.
• Organisations can support staff participation through actions such as: improved annual leave practices, study and development, and improving the connection between NHS organisations doing this work. The delegates then heard the perspective of two practicing clinicians and heard how working in LMIC had led to their professional development and improved the care they provide in NHS patients.

Preet Panesar is the Lead Antimicrobial Pharmacist at UCL and last year was the Chief Pharmaceutical Officer’s (CPO) Fellow for Global Health. This Fellowship was based around Anti-Microbial Stewardship (AMS), Infection Prevention and Control (IPC) and Pharmacy expertise and capacity by supporting the development of the AMS roles and responsibilities of the Medicines and Therapeutics Committees at Jinja Regional Referral Hospital in line with the Ugandan national action plan. The partnership also provided training to staff that would support their capacity and collected data on AMS attitudes to enable the continuation of work on AMS after the departure of the UK team.

At the end of the yearlong partnership they left Jinja Regional Referral Hospital with a formalised committee, a detailed work plan for the implantation of AMS, guidelines produced by the Ugandan team for the management of various infections, and an app that makes access to these guidelines easier.

Key points:

• International experience grew her professional connections, skills, and breadth of experience, which has improved her NHS practice.

Dr Katrina Webster is a GP and Director of Mental Health and Learning Disability West Hampshire CCG. Katrina spoke about how her time volunteering in Cambodia developed her professional skill, her ability to engage with marginalized communities, and the co-development of services. These experiences enabled Katrina, with just two years locum experience as a GP, to demonstrate her qualification to join the CCG leadership team, a position now held for 9 years and at times questioned by more traditionally experienced leaders. She has applied skills gained in international contexts to the co-development of a Primary Care mental health service in West Hampshire that is improving access to mental health services, without the need for referral to a specialist.

Key points:

• Experiences in international settings can reinvigorate passion for healthcare, grow leadership skills, and motivate service improvement on return to the NHS.

The Q&A focused on the need to develop sustainability in partnerships, the requirement for further peer reviewed evidence collection to demonstrate benefit and generate buy-in, and how to develop these partnerships in a more equitable way with LMIC partners. We discussed how the development of institutional relationships create more ways for staff to participate directly and indirectly in beneficial international partnerships.

Ben Simms, THET CEO, focused on the new Foreign Commonwealth & Development Office (FCDO) UK Partnerships for Health Systems (UKPHS) funding; how NHS organisations can become involved and how other NHS organisations and professionals have made us of similar funding in the past.

Richard Skone James, Head of Grants Management at THET, opened the discussion with details of the successor to the FCO UK Health Partnerships funding that ran from 2011-2018, to the tune of £30 million.

UKPHS is a similarly £30 million funding programme from the FCDO, set to run from this year until March 2024. The funding is split into 4-8 large (<£350k) grants per country and 100 small (<£50K) grants. Large grants will fund projects in 10 strategic countries in Africa and Asia for a period of 30 months, whilst small grants will fund 18-month projects in South East Asian or Sun-Saharan African countries.

Richard explained that the funding will be able to provide support for project management and evaluation costs, travel, associated cost for education and workshops, and communications. They will not be able to fund the direct provision of health services, infrastructure projects and partnerships that don’t have an end date.

Richard concluded by stating that the focus of the projects can be wide ranging but will be determined based on the priorities of the LMIC Ministry of Health. All projects, large and small, will also be required to tackle gender inequality and social exclusion from health services.

Before moving to the second speaker of the session, Ben noted that large grants may feel challenging for those new to this work, and if so, THET very much see the small grants as an accessible means to starting an International Health Partnership.

The session moved to considering how this funding might be used, with a presentation from Evelyn Brealey, Director of Cambridge Global Health Partnerships (CGHP), who shared how the previous UK Health partnerships funding was used by CGHP in Myanmar and Uganda.

Established in 2013 and 2015, respectively, the partnerships worked with the largest hospitals in each country and worked across clinical services of Trauma and Obstetrics, research, education, antimicrobial resistance and infection prevention and control.

There have been benefits to the NHS of these partnerships. Significantly in 2017 the CQC visited Myanmar and declared the partnership an example of ‘outstanding practice’ by Cambridge University Hospitals. Clinicians visiting Uganda have also been able to learn from the skill of the obstetrics specialists at Makerere Hospital who manage 30,000 birth each year (compared to Cambridge’s 6,000).

Going forward, Evelyn shared that the next steps for CGHP will be in developing a textbook, ‘The Principles of Obstetrics in Africa’, new global health partnerships that will make placements more flexible, and facilitating partners from Myanmar and Uganda to come and spend time in Cambridge.

The session was concluded with a presentation by Fran Garraghan, Lead Antimicrobial Pharmacist at Manchester University Hospital and a CPO Global Health Fellow who shared her experience of working in Gulu, Uganda, as part of the Gulu-Manchester Partnership. The partnership focused on evaluating and improving antimicrobial services in Gulu through evaluating baseline AMR prescribing and explore onions and behaviours on the topic.

The project began with an initial 1-week scoping visit and was followed by a 3-week training camp in September 2019 for 212 Healthcare professionals in Gulu. For Fran, it has led to the development of leadership, education and behaviour change skills that she can take back into her NHS practice; as well as a renews appreciation for the NHS. There has also been the opportunity to increase local, national, and international networks on the topic of AMR.

The discussion for this session focused on the speed of change in NHS participation in international health partnerships, and the recognition that the sometimes-slow speed is reflective of the immense time pressures faced by professionals in the NHS. Moving forward, greater advertising and communications of opportunities by funding organisations and engagement of diaspora NHS workers can build a greater interest among professionals; whilst a more competitive application process and formalized evaluation of learning can professionalize the experience and build greater respect for this work among organisations and professional groups.

The final session of the morning explored the significance of frugal innovations developed in LMICs to the NHS.

Chaired by Dr Matt Harris, Clinical Senior Lecturer in Public Health, Imperial College London, the session began with an introduction to frugal innovations by Dr Yasser Bhatti, Senior Lecturer in Innovations and Strategy at Queen Mary, University of London.

Yasser explained that, frugal innovations are the antithesis of the common-sense argument that the more you invest, the better the outcome. Explicitly trying to achieve a high performance with low capital investment means subscribing to the 3A’s: Adaptability, Affordability, Accessibility. They can be used in multiple contexts, at a low cost, to provide for many people.

Frugal Innovations can also be defined by the 4R’s: Reuse, Repurpose, Redesign and Rapidity. Yasser shared examples of the 4R’s in the context of COVID-19 such as Dexamethasone (Reuse), trains being converted to be mobile hospitals for patient transfer (Repurpose), Ventilator adaptions (redesign) and rapid new ventilator design and production (Rapidity) all serving as examples.

It is Yasser’s hope that the COVID-19 mandated shift to using frugal innovations will mean that as a population we will become more accepting of frugal innovations and adopt them at an increased rate across High Income Health systems.

From there the session moved to examples of application to the NHS, presented by Dr Ted Adams, Medical Director at Bridgewater Community NHS FT who shared what he has learned so far as he attempts to implement a community health workers model originally developed in Brazil over 50 years ago, to support the Trust’s response to COVID-19.

Ted explained that the amount of effort required to adopt a frugal innovation shouldn’t be underestimated, that the upfront cost of development, business planning, and preparation isn’t that frugal, and that enthusiasm from stakeholders shouldn’t be equated with buy-in. In the short term, all these obstacles will take a lot of time to overcome and may make the innovation seem less-than frugal; however, they should be pursued nevertheless in order to achieve the long-term efficiency that is being pursued.

The presentations were rounded off by Dr Neville Young, Director of Enterprise and Innovation at Yorkshire and Humber AHSN, who explained the role that the AHSNs play in supporting the efficacy and financial evaluation of new innovations and how AHSNs can support their adaption across the health system.

Throughout the AHSN network they are attempting to bridge the gap between the promise of innovation and what is realised within the NHS. To do this they are providing the space to determine what impact the innovation will have across the whole system, not at any single point; as well as using a more hands-off, real world approach to determine value. They believe that by approaching innovation in this way they can take a ‘geography blind’ approach to evaluation that doesn’t discriminate on the origin of the innovation in question.

The session ended with some Q&A with the other delegates, initially focused on how to translate the learning by volunteers during their international placement into NHS practice. Neville explained that through the diverse professional working at the AHSNs they are in the position to work with these volunteering to understand how this learning could be adapted and applied to the NHS; though he warned that due to the bandwidth pressures all in the NHS face, failure to plan and engage early makes these opportunities harder.

The discussion moved to the necessity for more innovation and whether it was more an issue of utilising what is already available and winning the hearts and minds of individuals to the merits of frugal innovations. Here the panellists were united that innovation is the application of invention, and this includes adopting a practice or device to a new context, regardless of how long it has existed elsewhere. The scalability across the health system separates an invention from an innovation.

The following links were provided by speakers and delegates during our ‘NHS Beyond COVID19: Global Health’ event, on 29 of October 2020. They detail the opportunities currently available to those in the NHS, as well as providing support in developing international health partnerships.

Health Education England

• Developing the body of evidence that supports the assertion that international engagement supports the improvement of NHS services is currently a key issue. To this end, HEE has developed an evidence base collection toolkit that enables professionals working overseas to document the knowledge and skills they have gained through an international placement.
• The Improving Global Health Fellowships are an HEE programme designed to help professional, both clinical and non-clinical, undertake 6-month placements in Low and Middle Income Countries. The programme helps early-to-mid-career professionals develop leadership skills, using system strengthening methods, by supporting the sustainable development of resource poor healthcare.

Cambridge Global Health Partnerships (CGHP)

• Cambridge Global Health Partnerships works with NHS organisations (principally Cambridge University Hospitals) and other health institutions to deliver sustainable healthcare improvements in Africa, Asia and Latin America.
• In order to quantifying the value of health partnerships to the NHS CGHP contracted Powering Partnershipsnto undertake Social return on Investment (SROI) analysis. This found that for each £1 invested broadly £3 are returned in social value.
• They have also produced a short film that explains the work that they do.

Tropical Health Education Trust

• The Tropical Health Education Trust (THET) is an international NGO founded in 1988 supporting the education and training of health professionalsin the world’s poorest countries. They work with NHS Trusts, Arms-Length Bodies, Royal Colleges and Academic Institutions to deliver their work. They are currently the administers of £30 million in funding from the FCDO, through the UK Partnerships for Health Systems (UKPHS) programme. To find out more, visit their website. THET will also provide a match-making service by connecting High Income Country Institutions with partners in Low and Middle Income Countries. Details on your institution can be provided to THET via this survey.

• The ongoing COVID-19 pandemic has halted international travel and overseas participation in health partnerships; however, this hasn’t halted participation with new means of volunteering being developed to overcome this travel restriction. Read about how Health Partnerships are developing during COVID-19, and virtual volunteering opportunities

• For those that are new to the developing an international health partnerships, THET have produced a guide to the background to the Health Partnerships model, and guidance that will provide support to organisations looking to establish a Health Partnership.

• Evaluation is an important component of any international Health Partnerships in order to demonstrate value to both institutional partners, and the professionals involved, and as such evaluation is a funded component of all UKPHS grants. An evaluation of the previous health partnerships funding details some of these benefits.

• For those professionals that are interested in undertaking voluntary work overseas but would like to know more about why this work is so rewarding, this blog by Dr Isioma Okolo details her experience of working in Uganda as part of a Royal College of Obstetrics and Gynaecology (RCOG) Partnership.

Reverse/frugal innovation

• There are several names that can be applied to innovations that are produced with low capital investment (frugal), often originating in low and middle income countries (reverse). Despite these semantic differences reverse and frugal innovations offer the potential of great benefit to the NHS as they provide high performance at a lower cost than traditional innovation and support high rates of access to care.
• The reverse Innovation collection, published in Globalization and Health, showcases effective healthcare innovations from low-income countries that have been, or have the potential to be, utilized in the health systems of high-income countries.
• Frugal Innovations: Models, Means and Methods, is an award-winning book by Dr Yasser Bhatti, Senior Lecturer in Innovation and Strategy, Queen Mary University, London. It is a study taking a research-based approach to innovation in resource scares and complex institutional contexts.
• One of the current challenges facing frugal innovations is their documentation and uptake into the NHS. The Health Innovation Platform, hosted by THET and developed by the Institute of Global Health Innovation, Imperial College London, supports innovators to foster and develop their innovative ideas. This work is further supported by the THET and Imperial College Innovation Toolkit for Health Partners that provides  those taking part in international health partnership, or other voluntary work in LMIC, the tools to maximise their placement by overcoming the barriers to innovation identification. The toolkit has been summarised by the NHS Confederation with a particular focus on what NHS managers can do to support the most effective participation by those in their organisations undertaking internal placements.