Frequently Asked Questions (FAQs)

Other than the obvious and immediate benefit to patients, who receive improved access to good urological care, durable solutions appropriate to the locality are often left behind after visits. in addition, there are now well-recognised and compelling reasons for investing in improving global surgical care, prinicipally in Low, or Low Middle Income Countries (LMICs). Further detail about the value of durable benefits to the healthcare system in a LMIC can be obtained in the policy brief from the Lancet Commission on Global Surgery 2030: "The powerful economic case for investing in surgical care in LMICs". **

(** Low & Middle Income Countries)

A survey of BAUS members has highlighted the benfits of undertaking work overseas:

• renewed energy and motivation;
• a more open-minded attitude;
• a better understanding of different cultures;
• a greater desire to train and teach others;
• better operative skills;
• a more innovative approach to service delivery;
• greater confidence in clinical decision-making;
• increased awareness of the limitations of NHS practice; and
• enhanced communication and leadership skills.

It has been shown that overseas volunteering has measurable benfits to the NHS by enhancing individual's professional development. The benefits of working abroad are, however, far more than just professional. Experiences outside the UK help to foster durable relationships with the centres visited, and these relationships may last for the remainder of a professional career.

Working abroad has the potential to renew your enthusiasm for medicine, and may be an experience that gives insight into medical and social care that is not part of routine UK-based practice. It goes without saying that a period abroad enables you to travel and maximise any opportunities offered in the locality during what leisure time you may have.

You may find the following articles helpful in understanding the benefits of volunteering abroad to NHS workers.

Zamora, B., Gurupira, M., Rodes Sanchez, M. et al. The value of international volunteers experience to the NHS. Global Health 2019; 15: 31. https://doi.org/10.1186/s12992-019-0473-y

Yeomans D, Le G, Pandit H, et al. Is overseas volunteering beneficial to the NHS? The analysis of volunteers’ responses to a feedback questionnaire following experiences in low-income and middle- income countries. BMJ Open 2017; 7: e017517. doi:10.1136/ bmjopen-2017-017517

All Party Parliamentary Group on Global Health. Improving Health at Home and Abroad: How overseas volunteering from the NHS benefits the UK and the world. 2013 'Improving Health at Home and Abroad - Full Report

There are risks wherever you work, including in the UK. Those risks are, undoubtedly magnified when you are working in unfamiliar surroundings, in a fundamentally different culture which has different standards and with people you are not used to working with. Those risks are substantially lessened by good preparation and making your intial visit as part of a team who have prior knowledge of the location, its infrastructure and social conventions.

You are well advised to research the most up-to-date information about the safety and health situation in the country you are planning to travel to on the Foreign, Commonwealth and Development Office (FCDO) website.  This will give you invaluable information about the political and public health climate of the locality you are visiting. Being very well prepared for all aspects of your trip, understanding the environment you will be working in (sun, clothing required and the key essentials you will need for your trip) and maintaining good communications will improve your safety whilst you are away.

There are a few basic rules you need to consider having taken this advice into account:

before you go

• Have established local contacts and a means of liaising with them.
• Have all appropriate vaccinations.
• Ensure you have medical insurance.
• Learn the laws for common social practices in the locality, and obey them!

whilst you are there

• Understand how to get about safely and how to ‘pay’ locally.
• Maintain hand hygiene and know what medical support is available if you are sick or injured.
• Maintain durable communication with your colleagues, and home, at all times. Keep your 'phone charged.
• Blend into the local surroundings.
• Stay safe at night. This Crimestoppers website gives useful advice that is appropriate wherever in the world you are.

Urolink does not specifically recommend locations for medical students wishing to have an elective period in the developing world; they are advised to seek advice from their faculty's elective office.

However, anyone wanting to become embedded in a Urolink team going to a specific centre for part of their elective period is encouraged to contact one of the team leaders for designated centres. They can also apply for potential financial assitance for inclusion in a Urolink team visit or workshop.

Working in LMICs provides a myriad of different experiences for the trainee previously only exposed to work in the developed world. Trainees wishing to work abroad, however, needs a basic skill set to capitalise on the experience available, which may be exposure to different conditions not commonly encountered in the UK and different surgical options within an environment with substantially limited resources. You need to have the resilience to make any work worthwhile in very different conditions to those seen in the UK, so you are best advised to make such a trip towards the end of training when it least conflicts with the pressures of accreditation exams and hunting for Consultant posts.

It often takes a surprisingly long time to arrange an extensive trip - so adequate planning early in your career is essential.

Urolink has agreed learning objectives and has signed a memorandum of understanding with the five, principal link centres. Educational activity is designed to enhance your UK based training and to give you experience of working outside your home health service. As part of this process, it is essential to document and record outcomes from both educational and operative interventions.

Trainees can play a vital role in data collection and quality improvement during Urolink visits, as well as carrying out theoretical and practical teaching sessions for local trainees.

If you want to become involved then the committee would recommend that you look at the following things. 

• Urolink home page: Lots of stuff for trainees just scrolling through the pages. Look especially at the Learning Resources pages where there are lots of archived trainee-led Webinars. You can also get a flavour of how trainees have been involved previously by reading the UK urologists page and the Visits pages.
• Look at the videos of past BAUS ASM Urolink sessions; these show what Urolink has been able to do to help.
• Listen to some of the Podcasts about Urolink what it has been up to and about its history.
• All newsworthy things, relevant to  working in LMICs, are posted on the ‘Latest News’ section of the homepage which has links to opportunities coming up. You can also contact the BSoT member on The Urolink exec, to find out what is going on.
• The Urolink/UTH Zambia Webinars are a good way to get involved; if you want to lead one of those sessions then get in contact with Mike Ng in Exeter. Should you want more generic help about what its like being involved in working in an LMIC then THET has a large amount of information on its site.

Working, and living, in a very different environment can be both challenging and rewarding. Urolink generally advises that, when undertaking a first visit to work abroad, you travel as part of a team or with another member of the Urolink faculty who has experience of the journey, the documentation required, the locality and accommodation, the lead local surgeon, the environment and the link institution. They will also be aware of any leisure options if you have downtime, which is often significantly limited as dusk falls early the closer to the Equator you are.

You may well be exposed to living, and dietary, conditions which are outside your travel experiences in high-income countries (HICs) and to healthcare conditions, and facilities, that are completely outside your experience within the NHS. You would be advised to consider looking at the 'Personal Survival Guide' and discuss any proposed trip with a member of faculty who has visited that centre in the recent past.

As a consultant you may need to negotiate with your Trust about taking time out for working in a LIMC as part of your study leave entitlement.

For trainees, the older concept of training out of programme (OOP) has now been refined, and categorised, by Health Education England (HEE). Currently, only OOPT (T for training), or OOPR (R for research), to an accredited centre will not have an impact on your Completed Certificate of Training (CCT). Most people's experience in LMICs, falls into the categories OOPE (experience), or OOPC (career break), and will not count towards training time despite its significant value to the professional and personal development of the individual.

The HEE PGMDE site has useful FAQs about when, how and where to apply for an OOP.

Keep your eyes and ears open about what visits are coming up. Plan as far ahead as possible with your Educational Supervisor, where you are or will be working, and the Training Programme Director (TPD) in your region. The COPMED Gold Guide 2020 OOP form is a useful thing to have for your discussion with them:

OOP Form This will need to be signed off by the Postgraduate Dean responsible for your training programme, before you can take significant time out from your UK training programme.

Visa

Check in advance if a visa is required, whether this can be obtained online, on arrival, or if it is necessary to apply to the relevant embassy. You may require the following when applying for a visa:

• A recent digital image scaled down to passport size. Many countries have a limitation in the file size that is acceptable;
• A scanned copy of the photopage of your passport (again be mindful of the file size);
• A means of online payment;
• Your host's details and a  letter of invitation for the duration of your visit

If purchasing your visa in country take the correct amount of money required; this is often in US dollars.

Be aware of commercial organisations who purport to be the country's visa office; they will arrange a visa for you but often charge considerably more than the national visa application service if this is available online!

Police certificates

Sometimes a country may require you to have a Police Certificate either as part of your visa application, or as another piece of sumitted documentation. The certificate details whether or not you have a criminal record in the United Kingdom, impending prosecutions and offences that are under investigation and may also include foreign criminal history information where it has been disclosed to the UK. The certificate is only available in a paper form and there is a cost attached.

To apply for a Police Certificate go to the ACRO website.

If you are going to be working with children whilst out of the UK you may be required to have an International Child Protection Certificate (ICPC). If you need to apply for this, go to the ICPC page on the ACRO site.

Work permit

If you will be carrying out surgery during your visit, you may need a local work permit. Check this with your local host. If one is required he/she will need to arrange this for you, and this may require some or all of the following:

• a curriculum vitae;
• a letter of invitation stating your length of stay;
• a passport photograph;
• the photo page of your passport; and
• your certificate of registration, or a certificate of good standing, with the GMC

HIV, hepatitis-B & other blood-borne viruses

You may be asked for evidence of your HIV, hepatitis and yellow fever immunity status. For information about the prevalence of HIV and hepatitis-B in Africa, and what to do if you sustain a needestick injury or other exposure to contaminated body fluids, see the document prepared by Philip Thomas,  on HIV and Blood-Borne Virus Infection.

Your professional indemnity cover will entirely depend upon where you are going and what you are going to be doing. You would be best to approach the organisation providing professional indemnity to sort out what cover you will be provided with whilst out of the UK.

If you are travelling to LMICs then short periods of practical experience abroad will often be covered by your UK indemnity. Longer periods, on an entirely humanitarian basis, may be covered by a reduced cost "missionary" levels of cover.

The arrangements are often agreed on a case-by-case approach, so take the opportunity to discuss your arrangements personally with your protection society. Follow these links to the 3 largest indemnity providers:

MDU

MDDUS

MPS

Before leaving the UK, you should:

• ensure that you have adequate travel insurance;
• ensure that you fulfil the GMC's requirements regarding medical indemnity cover;
• check with a travel clinic about immunisations and anti-malarial prophylaxis; and
• check with the Foreign Commonwealth and Development Office (FCDO) regarding general travel safety.

It is essential to check with the local surgeons, before you leave the UK, what equipment and disposables are available to them on site. Plan to take instruments or disposible items they don't have, and you will need, with you, usually with the intention of leaving this behind when you return home. Electricity supply can be tenuous in many situations and battery powered headlights are often seen as essential pieces of personal kit for open surgery.  

Donations of equipment from the UK need careful planning. Any equipment donated should be recorded on a spreadsheet, along with the serial numbers, make & model. These details should be passed to Urolink, to ensure that the appropriate disposables are organised for future visits. A letter of donation should also be provided to the host institution.

There are some important points when considering equipment donation:

• ensure that the equipment is in full working order and that all components are present;
• consider whether repair and maintenance of the equipment will be possible;
• check compatibility (e.g. appropriate manufacturer);
• get import documentation (including a letter from Urolink);
• get agreement from the local surgeons that the equipment is "on loan" and is for use primarily in the public sector by all trained surgeons in the department;
• if you are carrying the equipment, check excess baggage policy;
• agree in advance what is being "loaned" and to "whom";
• request feedback after use of the equipment; and
• notify the hospital services of new equipment.

There are plenty of examples of broken or unwanted equipment (pictured below) being "donated" to hospitals in Africa. This can be a burden because it may be difficult to dispose of damaged equipment.

Further guidance on the donation and maintenance of medical equipment can be found using the links below:

Health Partnership Scheme	New Medical Equipment Program	Medical Equipment Life Cycle	Hilditch Group	Amalthea Trust