GHF placements – hearing from GP trainees working in South Africa
In February 2017 Dr Bruno Rushforth travelled around rural hospitals within KwaZulu Natal province in South African speaking to UK GP trainees working as Global Health Fellows, to help inform how Yorkshire and the Humber can best support its own GHFs as they prepare in ST1 and ST2 before their overseas placement as part of this exciting new scheme for GP trainees
“Yorkshire and the Humber have recently recruited its first GP trainee GHFs to commence ST1 in August 2017. With a group of Heath Education England (HEE) GHF regional leads, and with Dr Robin While HEE national lead as our main guide, I was fortunate enough to visit South Africa and spent a week travelling around KwaZulu Natal province. Visits included level 1 rural hospitals to talk to the UK junior doctors about their experiences, and understand the challenges and opportunities as they undertake their year out within the GP training programme. We also were accompanied and hosted by the African Health Placements (AHP) staff who are the key Non-Government Organisation (NGO) who facilitate placements at these hospitals and work closely with Robin and the GHF scheme to ensure that the doctors are well supported.
Over the course of the week we visited:
- Catherine Booth Hospital
- Ngwelezana Hospital
- Benedictine Hospital
- Manguzi Hospital (283 beds)
- Mseleni Hospital
- Mosvold Hospital (near Swaziland border)
We heard about the excellent local knowledge and good support from the AHP staff to doctors both at the pre-deployment stage when sorting out employment and registration issues, and also during their South African post. Dr Robin While is certainly a passionate advocate for the scheme and we heard about how he had supported GP trainee GHFs from the South-West of England when the scheme first started before it becoming ‘national’ (England and Wales, with London having a different OOPE offer). We heard about the support the trainees received from formal and informal networks including those who had been out before them, which included help with practical issues. One story we heard was help to sell on of cars from departing trainees to incoming ones to allow more flexibility for GHFs when off duty.
We did hear from GHFs about not underestimating the amount of time in ST2 required to proceed through the paperwork and application process for registration with the South African GMC-equivalent (HPCSA) and hospital employment:
Indeed, trainees told us that this developed ‘resilience’ in them even before arriving!
We heard about how some hospitals can struggle with funding issues from local and central government and about the challenges with basic supplies – e.g. one hospital had had to bus in bottled water for some time due to problems with the local supply.
Trainees we spoke to felt that the Diploma in Tropical Medicine offered a really good applied knowledge base for working in such a setting, especially with the large amounts of HIV and TB work. We also heard about the challenges of ‘stepping up’ to be covering across various specialities (e.g. Paediatrics, O&G and acute adult admissions) while working on-call overnight or at weekends.
All GHF posts in South Africa are supervised posts, although the degree of supervision and the proximity of specialist support can be an issue given the remoteness of many of the hospitals. We found GHFs who felt well supported, with dedicated time for initial training as needed (e.g. spinal anaesthetics or neonate management) although they all talked about a big ‘step up’ in terms of clinical responsibility and range of clinical conditions that they faced.
GHF are currently placed in ‘Level 1’ rural hospitals in South Africa, such as Benedictine Hospital in KwaZulu Natal province
GHFs told us about how practical pre-deployment courses were useful such as ALS / APLS and basic skills training / refresher training (e.g. suturing, management of burns, LPs and chest drains).
Many GHFs chose to live on site in hospital accommodation which was comfortable if not basic, often sharing or living near to other healthcare professionals who were also fairly early in their careers as year-long community placements also form part of the requirements for certain allied health professionals such as OTs and audiologists within South Africa. This often led to a good supportive team dynamic among the hospital’s junior staff with opportunities to also travel together for weekend trips away and to local events.
The visit helped us to think about how we can best develop the Yorkshire and Humber GHF programme to attract dynamic and keen trainees, and how best to support them throughout the full four years of the GHF programme. For example, looking at funding options for Yorkshire and Humber GHF trainees regarding the Diploma in Tropical Medicine (Liverpool or Glasgow) and how best to use the ST1 and ST2 dedicated GHF days to prepare GHFs for their overseas placement.
We heard from those juniors working in South Africa about how they felt they had significantly enhanced both clinical skills and leadership applied skills, including being involved in quality improvement activities which would hopefully leave a legacy of improvement for clinicians and patients alike.
Perhaps one of the most important aspects to GHFs’ learning through their South African placement was described to us as the opportunity to understand the impact of health beliefs, including religious beliefs, and cultural practices, on how patients respond to both their symptoms and to offers of treatment.
GHFs told us that they enjoyed not having the usual requirements of weekly eportfolio entries to upload, although the requirements around this may change as the national GHF scheme develops. Yorkshire and Humber GHFs are expected to undertake a quality improvement activity and log this on their eportfolio and are encouraged to make reflective entries as they wish, although the latter is not a requirement (at present).
We were told how the AHP staff are key individuals providing support to junior doctors and have well developed links with hospital management and staff.
One aspect of the GHF scheme which we heard about is the desire that doctors fulfil their 12 month obligation of service delivery at their placement hospital. Leaving early creates significant problems for the hospital and can have a real impact on clinical cover. Yorkshire and Humber GHFs will be expected, as for all GHFs, to stay for the full 12 month placement. The hospitals invest in training GHFs to get them ‘up-to-speed’ and towards the end of the post is when we heard that trainees were best able to make a full contribution to the team.
We had a taste of some of the basic challenges facing GHFs in that we had to turn back from our attempt to visit the first hospital on our itinerary – Nkandla Hospital – as we got stuck in the clay-like mud on the un-surfaced road some miles away; it had been raining hard and some of these rural level 1 hospitals can become cut off for several days.
We heard how when on-call there might be only two junior doctors on-site working at a level 1 hospital and so training in spinal anaesthesia and C-sections is often undertaken at the start of placements as trainees may be faced with having to manage these presentations.
Shift patterns and workload varied between hospitals; we heard that a common rota might be working a standard 40 hour week with perhaps up to 40 hours on-call in addition per month. However, one hospital we visited used external locum doctors for each weekend, so that the juniors worked hard in the week including overnights, but then had the weekends off.
Durban has a large population of Indian ancestry, and there are many South African born doctors from this heritage working in hospitals in the KwaZulu Natal region.
Most level 1 rural hospitals where GHFs will be placed operate, when staffing allows, ‘outreach’ clinics where GHFs have an opportunity to practise medicine more within a primary care environment, and we heard how GHFs enjoyed the variety this work can provide.
GHFs told us that they found the Cheltenham Crash Course in Overseas Medicine to be a good short course pre-deployment, but we are aware that with the roll-out of the GHF scheme there is likely to be issues regarding capacity.
GHFs agreed that it was good to get their AKT done in ST2 to build their clinical knowledge and confidence. Those who had taken time to look at basic Zulu language skills found that this was welcomed by patients and helped build rapport even when GHFs only knew a few words.
We were surprised at the extent of the excellent mobile phone coverage in South Africa and GHFs and all the doctors used their smartphones to access apps and other clinical information sources which proved invaluable in their day-to-day practice.
Some GHFs had been to the RCGP Global Health / International Health conference which appears to be now running annually and found this useful.”
Meeting with UK junior doctors in one of the hospital’s doctors’ office, with Tracey Hudson (AHP) in white top supplying useful resources (textbooks and AHP-branded scrubs) to one of the team. Mohammad in the background is a GHF in the South-West with Dr Robin While, HEE GHF national lead, as his GP mentor.
Dr Bruno Rushforth
17th April 2017
For further information about the Yorkshire and Humber Global Health Fellows scheme, see the OOPE section of the HEE Yorkshire and Humber GP website or contact Dr Lynda Carter, Dr Bruno Rushforth or Dr Lucie Brittain: