(13 years, 4 months ago)
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Lord Crisp
To ask Her Majesty’s Government how they will ensure that the subject of global health is included in the education of all health professionals.
Lord Crisp
My Lords, it is a great pleasure to be able to open this debate. I am delighted to see how many noble Lords have decided to take part in it, and I know that a number of others, for reasons of snow and the fact that we already had a large list, have decided not to take part. There is a lot of interest in this subject, and it is something on which there is a great deal of agreement both in your Lordships' House and outside. That agreement is partly the point of the debate, because what we need now is some action.
Professional education in the 20th century has done a wonderful job, not least in the United Kingdom. Life expectancy in the world as a whole has doubled in the century, but the outside world has changed, which means that there is a need for a change in education. There is a broad consensus on what needs to happen, and we can see it happening in many of our leading schools already. As Richard Horton, the editor of the Lancet, has put it:
“health professionals today are not adequately prepared to address the present and coming health challenges—aging populations, chronic diseases, cultural diversity and higher public expectations”.
It is, if you like, the necessary move from a purely doctor and hospital-based model to something much more diverse and local, more community and more person-based. That was a goal of the last Government and I know that it is a goal of this Government. The difficulty as always is to make it happen.
This Question is about global health and the emerging new discipline of global health. Let me explain why I think it is relevant here. I am talking about global health, not international health, which is what we talked about in the last century when we talked about the health of other people. Global health is about the health of all of us—all the issues that affect us all, wherever we are in the world. It is about our interdependence in terms of disease and how it can fly around the world very quickly; in the 14th century, it took three winters for the Black Death to get across Europe, whereas it took three days for SARS to get around the world earlier this century. We are also interdependent in our use of the same staffing and resources and interdependent in terms of the environment and climate change. All kinds of issues affect our health and we began to understand them much better in this past decade than we ever did before.
The second reason is that the diseases from which we suffer have been changing. There are many more non-communicable diseases, and in that context context itself is vital. We are beginning to understand better the social, behavioural, cultural and economic aspects of global health, and the emerging discipline is about taking on these issues and about understanding and acting on the wider determinants of health. Education needs to do this as well.
Thirdly, global health is about recognising that health is about health systems and how healthcare is delivered to individuals and populations. It is not just the theory of the laboratory and lecture room but the reality of the clinic and the community.
The fourth point that drives very many people is that experience in other countries is extremely valuable to us in the UK. Many who are involved in global health are driven by a passion to do something in poorer countries, but it is good for the UK as well. It develops people personally and they can learn from new examples and new experiences, and of course learn about some of the people living in their own country whose origins may have been far away.
Let me refer to the recent Lancet commission report that was published at the end of November, called Health Professionals for a New Century: Transforming Education to Strengthen Health Systems in an Interdependent World. The commission was chaired by Julio Frenk of the Harvard School of Public Health, and by Lincoln Chen of the China Medical Board, of which I was privileged to be a member. This was the first such attempt to look globally, with a global set of commissioners, and to learn from innovation everywhere in the world—not just Europe and America—and to do so across all professions on which we could collect data. It draws out some key lessons about how education needs to happen in the future: about how it needs to be interprofessional and transprofessional, going across disciplines and outside them to involve the public. Education needs to be competence-based, systems-based and IT-enabled.
The report also shows how our institutions need to change, breaking down barriers and connecting not just across disciplines but going outside health across locations and countries. Let me mention just one example that brings it alive: the IHI Open School. There are now 80 chapters in universities across world in 28 countries. This is a coming together of medical students to learn via the internet about subjects that are not covered in traditional courses: quality improvement, systems thinking and such like. They are studying in one school, maybe in the UK, but adding to it from elsewhere. This is the sort of model that I think we will continue to see.
The final point about the report is that it talks about transformational education: the effort to create professionals who are able to lead and make change in today's changed world. A brief illustration of the wide-ranging thinking on this in this country can be seen from the activities of two groups: Alma Mata and Medsin. Alma Mata is a 1,000-strong group of junior doctors and young health professionals from other disciplines. Medsin is also about 1,000-strong and made up of medical students. They advocate precisely that global health should be included in the syllabus and set out their vision for the doctor of the future, which is very important as they are the doctors of the future.
It is encouraging to see that the establishment is responding, including the Royal Colleges—and we have two former presidents of Royal Colleges speaking in this debate. To take one example, the Royal College of Obstetricians and Gynaecologists is very concerned about the lack of support for junior doctors who want to work overseas and who want to include that in their training and not be disadvantaged in their careers by doing so. There are also organisations such as the London International Development Centre, which works with six London institutions and runs, among other things, courses of students as global citizens. There is a very much wider view here about what needs to change. Indeed, developments in partnerships between institutions are very ably supported by THET, and I am delighted to know that Her Majesty’s Government through DfID have launched an even more substantial scheme to promote these partnerships.
There is a lot happening in the UK, but this is a worldwide phenomenon and things are moving faster in the US and Scandinavia than here. I can imagine the Minister saying, “Very good, we’re happy to encourage this, but what has this got to do with Government and the Department of Health?”. My answer is that it really does have an impact on us. I stress that this sort of activity is not just for the benefit of foreigners; it is about creating better health professionals who are better able to care for people of this country with our 21st-century diseases and lifestyles.
I suggest three actions. The first is extremely practical. I ask officials in the noble Earl’s department to report to him on what more can be done to help trainee doctors to spend some time abroad as part of their training and to do so in some numbers, not with the odd one or two who take a risk with their careers. That would make this much more mainstream and much more positive.
Secondly, the Minister’s department should meet the universities and the professional education schools of medicine and nursing and the wider health schools to consider the findings of the Lancet commission and decide what action might jointly be taken to develop the education of health professionals and to get some impetus and coordination behind the moves that are happening all over this country.
My third request is that the Minister’s department provides active support for the involvement of NHS people and organisations in the DfID programme of partnership, recognising that this is a difficult time for the NHS but making it clear from the top that this is good thing for people to be engaged in. It is about the future, and there may even be ways of looking at things like the newly announced early retirement scheme, which might actually help in developing these sorts of programmes.
Lord McColl of Dulwich
My Lords, I, too, congratulate the noble Lord, Lord Crisp, on initiating this debate, and I admire the outstanding work that he has been doing on this vital subject. His natural modesty precludes him detailing his extensive work. He is, in fact, joint chairman of the Global Health Workforce Alliance, which is giving a new impetus to the subject nationally and internationally. His report, entitled Global Health Partnerships, graciously gives credit to the many initiatives in this field, especially to THET, which was set up by that pioneer Professor Eldryd Parry.
Medical students have for years spent several months of their clinical training working in developing countries and gaining valuable insight into global medicine. King’s, Guy's, St Thomas's, St. George's and UCL are already running courses on the subject. A great deal is going on, but much more could be done. We can encourage more partnerships to be set up between medical schools in the UK and developing countries, for instance the new medical schools in Ethiopia. The medical schools and hospitals here need to make it easier for our graduates to go to those countries for longer periods, not only to enjoy invaluable new clinical experiences but to help medical students abroad to achieve their goals. They can increase their help to the medical students out there by demonstrating physical signs, new ways of teaching, how to get the best out of their libraries, data collection and so on.
There is unprecedented interest among medical students in helping to develop this field, and good organisations are at work, as outlined by the noble Lord, Lord Crisp. The Royal College of Obstetricians and Gynaecologists recently drew attention to the need for the NHS to help to plan the work abroad of junior doctors. In Guy’s Hospital in 1972 we set up a comprehensive surgical training programme involving a large part of the south-east of England. One of the years of the seven-year programme had to be spent abroad, and that proved very popular.
With the hospital ship part of the charity Mercy Ships, we not only provide free surgical treatment to the poorest of the poor but we teach the local surgeons the kind of operations that are appropriate in their country given their available resources. For instance, in Togo this year three Togolese eye surgeons were taught the best way of removing cataracts without the need for the expensive equipment that is used in the West and cannot be afforded in Africa. Now one surgeon is at work in the north of Togo, one in the south and one in between, so they cover the whole country.
An example of the excellent work done by many of the doctors in global health is a junior trainee at Guy’s Hospital called Abigail Boys. She works for Mercy Ships intermittently and has done so for the past six years. She came across a 13 year-old girl in Ghana whose tumour of her face was too complicated for Mercy Ships to cope with, so she raised thousands of pounds to bring her to the Royal London Hospital, where she had an amazing 11-hour operation, which was carried out successfully by the distinguished surgeon Iain Hutchison, whose wife enhances the Benches opposite. So long as our future surgeons are going to be like this young lady Abigail Boys, who is so passionate about helping the developing world, we can look forward to an ever-increasing participation in global medicine.
Lord Dholakia
My Lords, I thank the noble Lord, Lord Crisp, for securing this debate. I had a quick look at his biography, and three areas stand out: his experience of the National Health Service, his involvement as a fellow of the Institute for Healthcare Improvement and, above all, his political interest in the developing world. It should come as no surprise that he has chosen global health and medical education for this short debate. No longer can we simply concentrate on learning about what is appropriate for the health of people in the United Kingdom; we have to take into account post-war migration and our interdependency with other nations. We also have to accept that the process of globalisation crosses the geographical boundaries of all nations.
The globalising economy relies increasingly on the skills of people wherever they are available, and international migration is a key factor in ensuring that Britain benefits from this phenomenon. I shall give an analogy. Climate change is not restricted to a single nation. Last week we dealt with the outcomes of the Cancun climate conference. For the first time there is an international commitment to,
“deep cuts in global greenhouse gas emissions”.
Here is a recognition that a nation cannot act alone. The Medsin UK response on global health acknowledges that the health of people in every nation is interconnected. A global health approach seeks to understand how individuals and population health are determined by global, as well as local, factors.
I realised the need for an international dimension to training when some years ago my wife and I had returned to rural Sussex following a visit to India. After some days, despite having taken malarial precautions, my wife developed a fever. The local doctors could not make a diagnosis and her condition deteriorated. She thought that despite all the precautions she had contracted malaria, and decided to take her temperature at regular intervals. The results demonstrated that she probably had malaria. The doctors were not convinced and took her blood to look for parasites, but they did not find any as they took it at the wrong time of day. She remained undiagnosed and decided to treat herself. She obtained medication and worked out the appropriate doses and timing of the medication. I am pleased to say that, after six weeks of being ill, she made an almost instant recovery.
Let me say that many medical colleges have recognised the need for global health issues. My daughter, who qualified at St Bartholomew’s Hospital Medical College, decided to go to Brazil for her elective experience. She was fortunate during that period not only to spend time in the cities of that country but to work in the Amazon rainforest, which brought home to her the realities of a broader aspect of health, including the impact of poverty on the health of deprived communities.
There are a number of factors that we need to take into account. I urge the Minister to look at the broader determinants identified by Medsin UK: health financing, human rights, migration and environment. I am tempted to criticise the Government’s points-based system of immigration, but I shall refrain from doing so. Suffice it to say that the treatment of overseas doctors by the previous Administration was shameful; we continually moved the goalposts, and many of them suffered serious hardship when having to return to their country of origin.
The present cutbacks in university funding at about 6 per cent, which was announced today, are likely to impact on medical colleges. There is already evidence that some universities will no longer be able to afford training in certain disciplines. It is vital that knowledge is shared with countries abroad. Numerous good practices have been developed in countries such as Taiwan from which we can learn. India is making tremendous headway in providing medical tourism. It is also providing medicines at a much lower cost than we do in this country.
I am delighted that the noble Lord who is to follow me today is contributing to this debate. When I visited Ethiopia, there were those in the healthcare professions who valued his knowledge and advice. That, to my mind, is the acceptable face of our contribution to the third world.
Lord Patel
My Lords, the noble Lord, Lord Dholakia, exaggerates my contribution to Ethiopia or anywhere else but I thank him for that.
On 5 May 2009, Barack Obama, in announcing a $63 billion programme of global health, said:
“We will not be successful in our efforts to end deaths from AIDS, malaria and tuberculosis unless we do more to improve health systems around the world, focus our efforts on child and maternal health, and ensure that best practices drive the funding for these programs”.
The noble Lord, Lord Crisp, to whom I am grateful for initiating this debate, remarked that the USA and certain other countries are well ahead of us in developing global health as a universal programme of the country. That is not to say that many universities in our land have not embraced the issue of global health. I declare an interest. I am affiliated with the University of Dundee in many ways. I am proud that the university has a module in year two of medical students’ training that gives them knowledge and some experience of global health. We run a summer school on a yearly basis that advances epidemiology and global health issues and we also have a major research programme in the university for developing drugs for the less well known tropical diseases.
There are also other universities, including UCL and KCL, which have also started such programmes. We need to do the same as the United States has done and drive this further, to develop a university consortium of global health in the United Kingdom that promotes learning, education, scholarships and also research. That is something we need to address and it could be addressed by the Department of Health because it is primarily a health issue.
Both our research organisations, the Medical Research Council and the Wellcome Trust, have major research programmes and fellowships that drive them. My college, the Royal College of Obstetricians and Gynaecologists, has programmes for global health but the constraint has been the ability to find funding for trainees who wish to take part in overseas training as part of their training. Both the Royal College of Obstetricians and Gynaecologists and the Royal College of Paediatrics and Child Health have such programmes. The modules that these trainees undertake overseas are accredited on a case by case basis. The funding, however, is not available and neither is there flexibility in specialist training. That is something that again the Department of Health can assist with.
I am privileged to be associated with an international organisation that has developed training and service in areas of obstetric fistula from which some 2 million women worldwide suffer. The noble Lord, Lord McColl, has worked in this area and he referred to his commitment to working with Mercy Ships. He deserves the gratitude of those women in areas in which he has worked for years. We have developed a curriculum for training in this area of obstetric fistula which has now been accepted by all the obstetric fistula surgeons worldwide.
The organisation also works with the Bill & Melinda Gates Foundation, receiving funding from them of more than $10 million over a period of five years to develop a strengthened health system across the United Kingdom. In that respect, Scotland has a programme with which the University of Dundee is heavily involved, including a programme in Malawi for health systems. Our fifth-year medical students go there for attachment for a period of six weeks on a yearly basis.
There are good things being done in this country, but both DfID and the Department of Health can help develop these educational training programmes further. I hope that the Minister will comment on that.
Lord Butler of Brockwell
My Lords, as the noble Lord, Lord Crisp, has said, the interest in this subject is demonstrated by the number of speakers who are taking part in this short debate and the number of others who would have liked to have done so. The time could have been filled many times over. We should be grateful to the noble Lord, Lord Crisp, not only for initiating the debate but for the leadership he has given in this subject both by his report in 2007 and in what he is doing now.
I declare an interest as chair of the academic health science centre King’s Health Partners. Academic health science centres are by their nature well suited to promote and give leadership to this subject since they bring together research into global diseases, medical training—which can now be delivered remotely and is anyway a highly international business—and clinical care. The four members of King’s Health Partners—King’s College London, Guy’s and St Thomas’s, King’s College Hospital and the South London and Maudsley—already have individually a proud and established history in various areas of global health. We have had a 10-year partnership with the Tropical Health and Education Trust—THET—to which other speakers have referred. This was recently reinforced in February of this year by the signing of a memorandum of understanding and the co-location of THET Somaliland and the THET executive team at King’s College Hospital in Denmark Hill. We also have partnerships with the University of California, San Francisco and two other organisations that have been mentioned in this debate: Medsin, the national student global health network, and Alma Mata, the national postgraduate doctor global health network, both of which were mentioned by the noble Lord, Lord Crisp.
Being located in south London, where there are such ethnically and culturally diverse communities, this work has local as well as international significance. As others have said, global health these days is not a matter of looking outward to other countries; it begins and has relevance at home. It also has a strategic significance at the national level, which I do not think has been mentioned by other speakers. Quite rightly, investment in reducing inequalities within and between countries is integral to Untied Kingdom and EU global security strategies. The noble Lord, Lord Crisp, said that action now needs to be taken. King’s Health Partners can claim to be taking that action. We seek to bring together the expertise that exists in the various parts of our partnership. We recently agreed to set up a King’s Health Partners global health board, in addition to the board of the partnership.
This subject also, understandably and rightly, inspires young people and young doctors. Having recently attended a half-day seminar on the subject at King’s Health Partners, I saw what a great interest was expressed. The hall was packed to the gunnels. Like others, I eagerly look forward to what the Minister will say in response to the suggestions that have been made this evening to give a boost to this important and internationally vital work.
Lord Jay of Ewelme
My Lords, like other noble Lords, I congratulate the noble Lord, Lord Crisp, on initiating this debate. I declare an interest as chair of the international medical aid charity Merlin, which operates in the poorest countries after conflict and natural disasters. It is from that perspective that I want to speak this evening.
There is a long and fine tradition of trained British doctors and medical staff working in poor countries, bringing expertise, training medical staff on the ground and saving lives. To take one example, more than 70 NHS staff with different skills have worked with Merlin surgical teams in the aftermath of the earthquake in Haiti. This should not be seen just as altruism, important though that is. As the noble Lord, Lord McColl said, it should be encouraged as part of medical training in this country. Like so much in today’s world, medicine is global. This country will benefit directly if the doctors and other medical staff working here bring with them first-hand experience of conditions and diseases elsewhere in the world.
To give one other example, health staff who worked with Merlin on HIV and TB control programmes in Russia and Kenya have gone on to work in an NHS trust that covers Lambeth, Southwark and Lewisham, which have some of the highest rates of those diseases in the United Kingdom. That is to our advantage, as well as the advantage of those they are helping in other countries. So I do strongly support the proposal of the noble Lord, Lord Crisp, that medical training and practice in the UK should encourage and certainly not disadvantage those many British medical staff who wish to spend part of their training or part of their professional life working in poor countries. It seems to me heartening that so many medical staff training and working here should want to spend time working in developing countries and it is very much in our interest that we should encourage them in that laudable aim. There are, of course, problems but it really is in our interest to overcome those and to encourage, for example, deans of medical schools to use their existing discretion to encourage staff to serve in developing countries.
I was reading this afternoon the document Liberating the NHS. It states:
“We want everyone who works in the NHS to reach their full potential and achieve better health outcomes for their patients”.
Indeed we do, but it seems to me that working in developing countries and the experience our staff get there is an essential part of achieving that objective. We are right to be proud of the quality of our medical staff in this country and we are right to be proud, too, of those who wish to spend time helping others in poorer countries. Those two things should go together and not in any way be in conflict. It is very much in our interest that that should be so and, like others, I look forward to the Minister’s comments on that particular point.
Baroness Tonge
My Lords, I join in congratulating the noble Lord, Lord Crisp, on securing this debate and also on his work in this field.
Eight years ago I was in Malawi as a member of the All-Party Parliamentary Group on Population, Development and Reproductive Health. We were looking at health provision in that country generally as well as focusing on maternal health. It was of course at the height of the AIDS epidemic in Malawi. I have never forgotten the visit we had to one of the hospitals there. From the distance we saw a pleasant enough building but as we entered the gates we saw people lying on rough, old blankets on the grass outside, brought in by relatives who needed to get back to their own work as quickly as possible, there being no help at all out in the villages outside the hospital. Inside the hospital itself, every ward was packed with dying AIDS patients; on bedsteads, on mattresses under the bedsteads and packed in between the beds. We saw ward after ward of human misery in a hospital totally unable to cope. Those patients received no treatment except some rehydration if they were lucky. It was a scene from hell.
At that time, for a population of around 10 million, there were 43 doctors in Malawi and so few nurses in that hospital that it was coping with well over 100 patients to each nurse. Even with that scant provision there was a 40 per cent vacancy rate. The staff were exhausted and demoralised and many had left after their training to work in South Africa or Europe where they could be guaranteed decent work experience and in-service training. It was not just the poor salaries that drove them away; and who could blame them?
The Malawi Government soon resolved to take action and with overseas aid, including, I am glad to say, a good deal from our own Department for International Development, more staff were trained. Salaries were increased combined with contracts to stay in Malawi. Students’ fees were paid if they contracted to work for at least three years after qualification and volunteer doctors were brought in from abroad—yes, also from this country—to provide in-service training to staff and better care to patients. Of course the advent of anti-retroviral drugs for AIDS stemmed the tide of that scourge. Healthcare is now slowly improving in Malawi, but very slowly.
What can we learn from this? First, we must make our doctors and nurses aware of these problems. We can do this by better education at undergraduate and postgraduate level—deans, please note. We must make it easier for young doctors to take a year out in the developing world. The current pressure on them in their postgraduate training prevents this, because it does not count towards their certificate of complete training and the year abroad will not be recognised by the NHS. Sabbaticals are difficult to obtain. I have discovered that they need something called an “out of programme experience”, and the bureaucracy involved makes it more like an out of body experience. It is a huge deterrent to young people wanting to go abroad. Hospital trusts will not want to employ locums and there is no national directive to encourage them to release doctors.
The national conscience should dictate that we help developing countries to upgrade their health systems. Their staff have helped our National Health Service for decades at the expense of their own people in their own countries. It is payback time and I hope the Minister can reassure us that action will be taken.
Baroness Cox
My Lords, I, too, warmly thank my noble friend for introducing this important debate so comprehensively. In declaring an interest as an honorary vice-president of the Royal College of Nursing, I will focus on nursing education for global health and I have some positive developments to report.
First, at pre-registration level, the Nursing and Midwifery Council has stated that,
“Some aspects of the programme might be undertaken outside the UK for up to six months”,
and many universities are now taking advantage of this opportunity for placements abroad. Post-registration, there is a wide variety of continuing professional courses for nurses in global health issues, including the diploma in tropical nursing and the diploma in reproductive health in developing countries at the Liverpool School of Tropical Medicine, in which I also declare an interest as an honorary vice-president.
Sheffield University also runs an online masters programme in midwifery and maternity care, fostering many international links and contacts. VSO offers nurses opportunities to work in countries such as Cambodia, Uganda, Sierra Leone and Malawi; and nurses are given extensive training prior to their placement. The VSO’s Skills for Working in Development course is accredited by the Royal College of Nursing. At PhD level, the International Network for Doctoral Education in Nursing and the European Academy of Nursing Science offer many opportunities for research exchanges in global health and international collaboration.
I should briefly like to give one practical example of nursing’s contribution to healthcare in this context. I returned just two weeks ago from a visit with my small NGO, the Humanitarian Aid Relief Trust, to the hill tribe people in Chin state in Burma. They are of course suffering at the hands of that country’s brutal military regime, but many people in Chin’s hill tribes in remote areas are denied access to any healthcare at all. An outstanding young man from Chin state grew up seeing women die in childbirth on kitchen tables, and children dying unnecessarily from diarrhoea because of lack of access to healthcare and lack of any health knowledge. He was determined to become a doctor. He qualified in Armenia and immediately returned, having overcome many difficulties as a doctor, and is now training 315 community health workers from villages deep inside Chin state, where there is no healthcare. As much of this training could be undertaken equally effectively by community nurses and midwives, I introduced this resourceful young doctor to the College of Nursing in Mizoram state in India, where the staff are deeply interested in remote-area primary healthcare and have become interested in his programme. Nurses from the United Kingdom are very willing to help to train these community health workers, who are taking back life-saving knowledge and healthcare to the villages that previously had nothing. Many lives have already been saved.
I ask the Minister whether Her Majesty’s Government will continue to support the nursing profession’s capability to respond to global healthcare needs, both in educational initiatives and in practical terms, such as in international partnerships and secondments, to which reference has been made in the medical field, to those developing countries. Secondments benefit those in the developing countries and employers here in the United Kingdom, because practitioners return with enhanced initiative, knowledge, skills and experience—particularly those which transcend cultural borders.
I could give many other examples from our experiences Sudan, Nigeria and East Timor inter alia, but I hope that the example I have given from Burma reinforces the importance of this significant subject raised by my noble friend.
Baroness Hollins
My Lords, I, too, welcome the initiative of my noble friend Lord Crisp in calling for this debate.
As a former VSO volunteer myself in Nigeria many years ago—an experience that I consider to have had a major influence on my career and outlook—I am keen to give more opportunities for healthcare professionals today to gain a better understanding of global health issues. I should like to discuss attempts to develop greater awareness of global mental health issues, particularly in postgraduate psychiatric training by the Royal College of Psychiatrists, and I declare an interest as a former president of the college.
With the help of Professor Rachel Jenkins of King’s College, a scheme called the college volunteer programme was established about five years ago. We had wanted to set up a programme with VSO, as two other colleges had done, but this was difficult because VSO responds to requests for volunteers and it was not receiving requests for psychiatrists. In a way, that indicates the low priority given to, or low recognition of, mental health issues in many of the countries where VSO works. Therefore, we set up our own programme and gained agreement to the principle of out-of-programme placements abroad, fully approved for higher training. We put in place some safeguards, which included an in-country mentor providing supervision of all placements, with supplementary e-mail supervision from a UK-based consultant who had relevant overseas experience and who would have helped to prepare the volunteer in advance.
The intention was threefold, as I shall set out, although not in any particular order. The first was to provide a training experience in global mental health for UK trainees so that they would better understand the health perspectives and needs of migrant communities here in the UK. The second was to do that through meeting an identified need in the host country in a sustainable way. Often such needs were identified through our own college members and fellows who live and work in low and middle-income countries around the world. The third was to ensure that trainees would be equipped and motivated to be able to contribute to health services in low and middle-income countries in the future.
A number of mental health trusts have set up a specific link with a country, and I give as an example the trust where I have an honorary consultant contract—the South West London and St George’s Mental Health NHS Trust. While I was president of the Royal College of Psychiatrists, I talked to the chair of the mental health trust about ways in which he could help us to develop our volunteer programme. We thought that Ghana would be a good country with which to establish a relationship, partly because of its political stability but also because we were aware that the trust employed a number of Ghanaian staff, and the catchment population included many West Africans. The scheme at our trust was helped off the ground by a charity called Challenges Worldwide, which helped to set things up in Ghana. The scheme involved the trainee volunteer forgoing one month’s salary to cover the overheads involved in setting up the placement. The royal college fundraises to provide bursaries to support trainees’ travel costs. I shall quote two recent trainees who have each spent three months in Ghana. One said:
“This was for me the best professional training experience of my life … The support I received was excellent”.
The second said:
“My placement in Ghana was the most fascinating and perspective-changing experience in my career”.
Let us reflect on the fact that the NHS has for many years received the benefit of large numbers of health professionals from low and middle-income countries. Does the Minister agree that the value to the NHS of supporting training placements overseas far outweighs any short-term local costs? Also, can he confirm that all medical postgraduate curricula include core competences in global health issues, and will he comment on what more the professional regulatory bodies can do to ensure that enough appropriately supervised and integrated global health training placements are provided so that trainees have a realistic chance of acquiring some of those core competences?
Baroness Thornton
My Lords, the noble Lord, Lord Crisp, has a passion for this important issue, and I congratulate the noble Lord on initiating this debate tonight, the quality of which has proved his passion to be correct.
Good health in one country cannot be maintained if there is widespread ill health and disease in so many others. I have always felt privileged to be able to participate in debates in your Lordships’ House when such expertise and personal commitment is shown and, as so many noble Lords have said tonight, in a globalised and interdependent world, one in which disease certainly knows no boundaries, health is a global issue. The rich world has a responsibility to the developing world to support the growth of their health infrastructures and the growth of their medical education.
The nature of our responsibilities includes without doubt the need for overseas doctors to train in the UK without unacceptable barriers being placed in their way, or expense, and indeed the need for UK doctors to spend time abroad. We recognise that is a legitimate part of their qualifications, as mentioned by the noble Lord, Lord Patel, and others. It also includes the need to prepare our own UK-based doctors for the implications and effect of globalisation in our own health service and the UK population. The noble Lord is quite right—our medical training must encompass this challenge and its complexity.
The previous Government, with no small help, I suspect, from the noble Lord, Lord Crisp, produced Health is global: a UK Government strategy 2008-13 in September 2008. In it there was recognition of the fact that a healthy population is fundamental to prosperity, security and stability. It also linked the Government’s domestic and international objectives to the issue of improving global health. Could the Minister tell the House, therefore, what the Government are doing to continue this work? Has the department embraced the recommendations contained in that strategy?
We can look at the threat that global disease can pose. SARS and swine flu are two of the most dramatic examples where the world had to work together to protect itself. There is no doubt that a weakness in the healthcare in one country can put millions at risk. Nearer to home, however, in the UK, and particularly in London, we only have to think about TB and the communities most at risk. I am reminded of this by the noble Baroness, Lady Masham, who questioned me many times when I was a Minister about this.
Seventy-two per cent of UK cases of TB are among people born abroad, and about 40 per cent of cases in England are in London. It is vital, therefore, that the health service in London understands the nature of this problem, the communities at risk, and what needs to happen. The increase in migration into the UK means that UK doctors treat patients from all over the world, and medical students must be prepared for this change and understand its implications.
The report, Tomorrow’s Doctors, referred to by several noble Lords, has very wise words on these matters. It says that this is,
“leading to demands for greater cultural competency in the doctor-patient interaction”.
That is quite right. It continues:
“Medical students have to be prepared carefully for this change, with curricula exposing them to an understanding of why migration happens and specific migrant health issues as well as how to treat a broad range of diseases not routinely seen in the UK”.
Can the Minister say, therefore, whether TB and other conditions and their management are adequately included in the training of doctors in the UK? Indeed, would the forthcoming change of the Health Education Board mentioned in the document referred to by the noble Lord, Lord Jay, which will be an issue for the House in months to come, encompass the proposal made by the noble Lord, Lord Crisp, and other noble Lords today?
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, I thank the noble Lord, Lord Crisp, for calling this debate and express my gratitude for his strong and continuing commitment to issues of global health. I found his speech extremely helpful and thought provoking.
The Government are deeply committed to issues of international development. In this year’s spending review we confirmed that, as well as protecting the NHS budget, we will keep our promise to spend 0.7 per cent of gross national income on aid from 2013, helping the billion people who live in extreme poverty around the world. We are equally committed to doing everything we can to meet the millennium development goals. In particular, we are taking bold action to tackle malaria and to improve reproductive, maternal and newborn health. In answer to the noble Baroness, Lady Thornton, we are currently reviewing the previous Government’s cross-Whitehall global health strategy to ensure its relevance and effectiveness in the coming years.
The noble Lord, Lord Crisp, has linked issues of development with those of the appropriate education of health professionals, which itself has enormous implications both for our nation’s health and for that of the rest of the world. As he knows, there are many aspects of the education of health professionals, encompassing pre- and post-registration training, as well as continued professional development. The responsibility for setting the standards required for professional pre-registration sits with the professional regulators. The higher education institutes then design training curricula to meet these standards in partnership with NHS service providers and the regulators. The Department of Health, along with the local NHS bodies that commission professional training, continues to work with the regulators and higher education institutes to ensure that their standards and curricula reflect the changing needs of patients and service delivery.
In terms of pre-registration education for doctors, we look to the General Medical Council for leadership. Its 2009 publication Tomorrow’s Doctors provides the framework that UK medical schools use to design detailed curricula and methods of assessment. I was glad to see the framework was well received by the authors of the recent Lancet Commission publication, Health Professionals for a New Century. The framework also highlights the importance of a global dimension. New graduates must be able to demonstrate awareness, from a global perspective, of the determinants of health and disease and of the variations in healthcare delivery and medical practice. Postgraduate medical training curricula are developed by the medical royal colleges for approval by the GMC. Most of the topics highlighted in this debate are covered in the foundation programme curriculum and core competence framework for doctors developed by the Academy of Medical Royal Colleges.
We have come a long way since the noble Lord wrote his report on medical training, Global Health Partnerships, in 2007. My noble friend Lord McColl is absolutely right that there is already significant good practice in the UK in terms of incorporating the global dimension into pre- and post-registration training. This is one part of the answer to the noble Lord, Lord Crisp, who asked me to consider what more might be done to support this type of activity. Medical students can study global health; they can spend a year studying international health as part of an intercalated degree or can choose to travel to developing countries for the elective component of their undergraduate training. There are also opportunities for post-registration medical doctors to spend part of their specialty training in developing countries, as part of the out-of-programme training and research arrangements. Here, I reassure my noble friend Lady Tonge and the noble Baroness, Lady Hollins, that, if prospectively approved, training of this type counts towards the certificate of completion of training. Details of this initiative are provided in the Gold Guide, a guide for postgraduate specialty training in the UK agreed by the four UK health departments for core and/or specialty training programmes. This sets out a clear process as a guide for post-graduate deans.
My noble friend Lord McColl—
Baroness Northover
This is a time-limited debate and the Minister has 12 minutes to reply. There is no possibility of intervention.
Earl Howe
Perhaps the noble Lord and I can speak after the debate.
My noble friend Lord McColl stressed the need for taking longer periods overseas and providing greater support for achieving the goals that we have all been talking about. Universities support medical student electives as long as the plans are carefully drawn up to ensure the best possible experience for them and, of course, for the host institution abroad. I emphasise to the noble Lord, Lord Patel, lest there be any doubt in his mind, that we strongly support the principle that trainees should have opportunities to gain experience overseas both for their own benefit and that of the host countries. Also, the noble Baroness, Lady Cox, was right to say that there are opportunities for postgraduate medical doctors to spend part of their specialty training in developing countries, as I have mentioned, and these can count towards clinical medical training.
In answer to my noble friend Lady Tonge, we take on board comments about reducing the level of bureaucracy in this process, and we welcome suggestions for improvement. However, we need to ensure both that service can continue to be delivered effectively in the NHS and that training overseas is appropriately recognised, supervised and assessed, which is not necessarily straightforward in every case.
Earlier this month, the Lancet Commission published a report, Health Professionals for a New Century. In response to some of its specific proposals, I should like to highlight the progress that has already been made in a number of areas. For example, the Department of Health is taking forward its technology-enhanced learning strategy to promote greater use of information technology for learning, harnessing and sharing global education resources. The Medical Training Initiative allows a small number of doctors from developing countries to work and train in the NHS before returning home. The National Leadership Council works with clinicians from all professions to develop their leadership skills and embed leadership across all undergraduate and postgraduate curricula. The Health Partnership Scheme, launched in November by my honourable friend in another place, Stephen O’Brien, will enable NHS professionals to share their skills with nurses and doctors in developing countries through teaching, training and practical assistance. We should also mention the report from the noble Baroness, Lady Deech, entitled, Women Doctors: Making a Difference. It makes recommendations on a range of issues that include improving access to mentoring and career advice, improved access to childcare, more flexible and part-time training, and encouraging women into leadership positions.
We must always look to improve the standards of medical education in this country. For this reason, as has been mentioned, we have today published Liberating the NHS: Developing the Healthcare Workforce, the consultation on the education and training aspects of the NHS White Paper, Equity and Excellence: Liberating the NHS. The White Paper signals a new approach to workforce planning, education and training by,
“giving employers greater autonomy and accountability for planning and developing the workforce”,
alongside greater professional ownership of the quality of education and training. The consultation will enable my department to do the second thing proposed by the noble Lord, Lord Crisp, which is to meet with relevant parties to consider the findings of the Lancet Commission report. With the changes set out in the NHS and public health White Papers, the system of healthcare in England is changing, and it is imperative that our system of education and training reflects that change.
The noble Baroness, Lady Hollins, asked whether curricula include global competences. They do, and in acknowledgement of the case presented by Medsin UK, a global health dimension is included in the 2009 GMC guidance, Tomorrow’s Doctors, which states that new graduates must be able to demonstrate,
“an awareness from a global perspective of the determinants of health and disease, and variations in healthcare, delivery and medical practice”.
In fact, most of the topics highlighted by the report of the noble Lord, Lord Crisp, which I mentioned, are covered in the foundation programme curriculum published this year. All topics are at least partly described in the core competences for doctors in the Academy of Medical Royal Colleges’ Common Competences Framework for Doctors, published last year.
The noble Lord, Lord Crisp, urged that we should find ways to give active support for doctors to take part in health partnership schemes. We agree that we need to support doctors and other health professionals to take part in that scheme and I can reassure him that the Department of Health is working closely with the Department for International Development on this initiative. I mentioned the partnership scheme earlier.
The noble Lord, Lord Butler, referred to the role of academic health science centres and I welcome the initiatives taken by the AHSCs, both in teaching and research, in global issues. They can contribute a huge amount but perhaps two things above all: the partnerships which they can and do form overseas and their ability to develop cultural competence in UK graduates.
My noble friend Lady Tonge referred to the need for ethical recruitment. She is absolutely right. She probably knows that the UK was the first country to produce international recruitment guidance based on ethical principles and the first to develop a robust code of practice for employers.
The noble Lord, Lord Crisp, made some extremely constructive and important points, as did all other speakers, for which I am very grateful. I shall make sure that these are taken into account during the consultation process.
In closing, I should like to take this opportunity to invite all interested parties to engage with the consultation to help us develop the recommendations made in the Lancet Commission report and to help shape the future system of education for health professionals.