http://www.theguardian.com/society/2015/oct/10/nhs-workers-from-abroad-coming-over-here-saving-our-lives?CMP=fb_guNHS workers from abroad: 'I don't think people here appreciate what they have'
One in four doctors in the UK is now non-British, and there are thousands more foreign-trained nurses. Do they feel welcome? And how does healthcare in Ghana or the Philippines compare?
Janet Cobbinah
Janet Cobbinah trained in Ghana and works in London.
Genevieve Fox and Rosie Ifould
Saturday 10 October 2015 11.03 BST
‘In Ghana, they just deliver their babies and go’
Janet Cobbinah, 43, trained as a nurse and a midwife in Ghana. She moved to the UK in 2000, and worked first as a nurse, before switching to midwifery six years ago. She lives with her two children, and works at the Whittington hospital, London.
I trained as a nurse for three years; then, after I had my son, I did my midwifery training. In Ghana, they allocate you to the place where you are most needed. I worked in villages, and sometimes in the bigger city hospitals.
In the villages, you do everything. You are the doctor, you are the midwife, you are the nurse. In the city, you focus more on one area, like antenatal. But wherever you are in Ghana, you have to pay for everything. A basic antenatal check would cost around £5; a normal labour around £50. You’re paying for things like gloves, sutures, sheets. If you have a Caesarean, it costs around £100. For some people, that would be a month’s wages, or even two or three months’ wages; the whole family would have to borrow money to pay for it. You only go to hospital if something’s really wrong.
People are more anxious about birth here. At home, you often won’t see a patient until she’s eight months’ pregnant; then they just deliver their babies and go. Twelve-week scans are very rare, and there’s a big difference in the way women use pain relief. You have to pay for gas and air, so 90% of women go through labour with nothing. You just scream through it. Some of the older midwives would try to scare women, saying things like, “You need to push your baby out, or it’s going to die.”
Here, I spend a lot more time talking through the different options, looking at birth plans, asking women what they feel their pain threshold is. Of course, a lot of women still want to give birth as naturally as possible, but they have a lot more choice. I’m based in London, so see a lot of families from different ethnic minorities; there are occasions where you can see that a woman wants pain relief, but her family encourages her not to.
Back home, no men are allowed in the labour room. Labour is just for the woman, and her mother, maybe her mother-in-law. Often, a woman will go to her mother’s house to deliver the baby and then, afterwards, the grandmother gives a lot of help. She will wash and change the baby, and make sure the mother is fed. The fathers tend to take care of the financial side.
I think I’ll spend the rest of my working life here. I go back home on holidays, and sometimes I’ll do a bit of charity work at my old hospital, in Takoradi. I don’t think people here are appreciative of what they have. You can see it with things like missed appointments: we spend so much time chasing people because they just don’t turn up. You don’t get that in Ghana.
‘At home, you would never get anyone in hospital for intoxication’
Merwyn Agcaoili, a nurse from the Philippines.
Merwyn Agcaoili, 39, was born in the Philippines, where he qualified as a nurse in 1996. He came to the Queen Elizabeth hospital King’s Lynn NHS foundation trust from Singapore in 2001. Married, with a nine-year-old son, he is now a ward manager on a general surgical ward.
King’s Lynn is a fishing village – my friend and I read that in the Lonely Planet guide. We were both working for Singapore general hospital at the time; I was a general surgery nurse, working on the colorectal ward. We decided to explore the world. Flicking through the guidebook, we saw windmills, rolling green fields, so we thought we’d go to East Anglia. But when we got here, the fish were all wrapped in plastic in the supermarket. We caught an old bus from the airport and passed fields that were yellow. I started crying. Later, I discovered it was harvest time.
In my first week here, I was asked if a patient on my ward was ready to go home. I was shocked: at home, that decision is made by a doctor. In the Philippines, discharging a patient is simple. You say, ‘You are going home tomorrow’, and you provide a letter from their doctor and a list of medications. They provide the transport and sort out someone to look after them when they get home. And they go home on time: they need to, because they are paying by the hour.
In the UK, when you discharge a patient, you have to find out where the keys to the house are, who will be cooking, how they will get home. Do we need to link up with the community nurses or GP, or send someone from the hospital to follow up? It becomes very, very complex.
People pay for everything in the Philippines, which makes them self-reliant. Rural centres educate people, so they can manage their own health before going to hospital. You would never get anyone coming in for alcohol intoxication or diarrhoea. They would know how to make their own oral hydration solution using water, sugar, salt.
‘We had just one patient who self-harmed. Here, it’s so prevalent’
Dr Annie Swanepoel is from South Africa.
Dr Annie Swanepoel, 45, is a consultant child and adolescent psychiatrist working in Hoddesdon, Hertfordshire. She is from South Africa.
There were two main reasons we decided to leave South Africa. First, was the crime: most of the people we knew, family and friends, had suffered brutal assaults, and we knew it would happen to us at some point. The other reason was that we wanted to give our children a better chance of gaining good qualifications.
We moved to Germany first. My father is German, I speak German to my children, and it’s where my husband got his first job outside South Africa (he’s a mathematician). I had been working in A&E in South Africa, but I had done psychiatry as part of my training, and it had always been one of my interests. So I decided to retrain.
In South Africa, there’s the state system and the private system. The state system is very different because there’s a huge demand and very few resources. Patients are seen for 10 minutes, so it’s more like a GP consultation; you could only really focus on symptoms and the side-effects of medication. There was no time to look at the rest of the person’s life. Here, the standard time is an hour, similar to the private system in South Africa.
The way people see mental illness in South Africa depends on their culture. For more traditional people, there’s less of a stigma. There has been research showing that people with schizophrenia from developing countries do better because it’s often seen as a gift. So the witch doctors, or sangomas, often have visions and hear voices; there’s a belief that they’re communicating with ancestors, so they might have increased status.
When I was a student in South Africa, we had just one patient who self-harmed, and we were all really struck by him. Here, it’s so prevalent. A World Health Organisation study in 2014 found that 20% of British schoolchildren will self-harm at some point. It’s becoming more prevalent in South Africa, but nowhere near the levels we see here. I was speaking to a child psychiatrist in South Africa recently, and she said the main problem they had was HIV/Aids, because of the effects that infections can have on the brain: this is manifesting in different psychiatric presentations. In the South African state system, there probably wouldn’t be a service for children with depression or anxiety. They wouldn’t get the service unless they basically couldn’t function at all.
I much prefer working for the NHS, because in private practice it’s more difficult to work in a multidisciplinary team. It can cause problems if you’re paid by a client directly; for example, if a child is being maltreated and you need to tell the parents they have to change their behaviour. What’s great about the NHS is that you can focus on what the child really needs without having to think about the finances.
That was another reason we emigrated. I was working in A&E in Pretoria and a severely injured young man was brought in by ambulance. I wanted to start treating him immediately, but I wasn’t allowed to until they had checked his credit card details. That was awful. The NHS is something really precious, I don’t think people here realise how precious. Healthcare is far too important to leave to people who want to make a profit.
‘The patients I treat here wouldn’t have survived through adulthood at home’
Hesham Saad works in Manchester and studied in Cairo.
Hesham Saad, 39, born in Libya and raised in Egypt, is a clinical fellow in cardiology and anaesthesia. He studied in Cairo, graduating in 2005. He started work at Manchester Royal Infirmary in September 2012. He is married with three young children.
I worked in the university hospital in Cairo, which, like Manchester Royal, is big and very busy. Although both serve the public sector, the level of care and funding is much higher here. For example, a transoesophageal echocardiogram (ultrasound scan of the heart) is an essential and routine part of our practice here. Back home, university hospitals didn’t have the machines. I saw them only in private hospitals.
What strikes me most is the number of adult congenital heart patients we operate on here. The majority of my heart surgery and valve-replacement patients are over 70. Here, these people have survived through adulthood, which they don’t in Egypt. I had never done adult congenital surgery back home.
British patients approach the side-effects and complications with a sort of courage and acceptance. Back home, people were more anxious. We didn’t go into that much detail about the surgery and its outcomes; the belief was that it would stress patients. They weren’t thinking about themselves, but about their relatives and the people they were responsible for. An elderly man would say, “If I don’t make it, how is my wife going to survive? What about my kids and my grandchildren?”
If I was in Egypt, I would be more senior now, with trainees underneath me. Here, I am still supervised most of the time, but everyone has been very supportive, from consultants to nurses and trainees. I approve of the UK system of being more open and frank. Back home, if an operation went wrong, the relatives would be very shocked; they had not been warned.
‘I see very young children who need 12 or 14 extractions’
Ursala Jogezai trained as a dentist in Pakistan.
Ursala Jogezai, 32, is from Pakistan, where she trained and worked as a dentist before moving to the UK in 2009. She has worked in special care dentistry, and recently moved to Newcastle to start a job in oral and maxillofacial surgery.
When I first came to the UK, I was surprised to see that people were using the same technology and materials that we use back home. It wasn’t until I had experience of private practice in the UK that I saw really advanced, cutting-edge technology.
In Pakistan, we have state-funded hospitals. The care is free, but not always easily accessible because resources are very limited and those requiring care are many. Then there are the private hospitals, which are charging huge amounts and flourishing. I worked in both; the level of private care is the same as you might get in London.
Infection control is way, way better on the NHS. The dental profession in Pakistan isn’t as well regulated, which obviously isn’t great for the patients or the clinicians, but there is a flipside: I had a lot more freedom to improve my skills.
Something that has come up recently is the number of people inappropriately referred to hospital for extractions; the hospitals feel these procedures should be managed by graduates, but increasing litigiousness means they are worried about making mistakes. We live in a society that isn’t very forgiving.
The lovely thing about the NHS is that there is a system where people can have their oral health maintained by visiting their dentist regularly from every three months to two years, depending on the condition of their teeth. Whether they actually do is another story, but at least the system exists. In Pakistan, we tend only to look at the problems and sort them out.
For the past year I have worked in special care dentistry, with patients who have difficulty accessing care on the high street. They may have learning disabilities, be physically or medically compromised, or have conditions such as dementia or severe dental phobia. A large part of my work is with very young children referred from high street practices because they won’t cooperate with treatment or they have lots of dental decay. Out of 20 milk teeth, they might need 12 or 14 extractions under general anaesthetic. The number of children who need treatment makes me terribly sad. I don’t recall seeing such huge numbers with that level of decay in Pakistan, but there are a lot of people living in villages who don’t have access to care. So who knows what the real picture might be.
‘In the villages, they think doctors are God’
Jomon Joseph, a nurse in Poole, trained in India.
Jomon Joseph, 39, a senior nurse and endoscopist, trained in India. He arrived in the UK in 2001, and since 2014 has been working at the Dorset Cancer Centre at Poole hospital.
It’s entirely different in India. Hospitals are mainly private. Patients get more support from their relatives, who are allowed to sleep on the couch at the hospital and take care of personal hygiene and feeding. But they are less assertive. In India, if a doctor tells a patient they need a canula, it’s accepted without question. Here, people have a right to question: why do I have to have a canula, and how will you do it? In the villages especially, they think doctors are God; less so now in the main cities.
Everyone is equal in the NHS; I find that amazing. In India, you can’t challenge a doctor, even if he is wrong. Here, a nurse can tell them straight away. In that respect, we are delivering the best care for the patient. There would be fewer opportunities for me in India. Competition is intense; here, if you are competent, you will get opportunities.
I am passionate about cancer treatment, which is why I joined the screening programme. I get more continuity with my patients, and can follow them through their journey. In India, there is more bowel cancer. We don’t have the same screening centres, which is the huge difference. You get good treatment – if you have money. When I worked in theatre in India, the equipment and techniques were more advanced, because it was private. The UK is 15 years behind with some of its technology. In India, money means you can get everything you want – if you have it.
‘At home, people have to fly to get to a specialist hospital’
Dr Benjamin Robertson qualified in Australia.
Dr Benjamin Robertson, 35, has been a craniofacial clinical fellow at Alder Hey Children’s NHS foundation trust in Liverpool since January 2015, on a 12-month fellowship. He qualified as a maxillofacial surgeon in Australia in 2013.
The UK is an excellent system to train under. You get exposure to a much broader range of conditions and a far greater volume of cases than in Australia, because our population is a third of the UK’s. I see patients from Leeds, Newcastle, Scotland, all over. Some have driven three or four hours to see me, and they think that’s a long way. But in Brisbane, patients have to fly to get to a specialist hospital. I treat children who, through no fault of their own, have acquired a condition that makes them look or act differently. We have the ability to help them feel more normal, like any other child. That’s what I love about my job.
The craniofacial family has treated me so well. They understand the difficulties involved in packing up your life to move halfway across the world. The people of Liverpool are fantastic – so lovely and welcoming – though I have a bit of trouble understanding the accent. The weather is the only thing I struggle with. Coming from Queensland, I was used to having sunshine for most of the year. It is completely different in Liverpool, where you may experience four seasons in one day. Every single morning, I look out across the Mersey to the Wirral to see where the tide is and what the clouds are doing. It’s my way of checking in.
‘In Spain, they are shutting down beds for the elderly’
Dr Pedro Broggi was born in Peru and trained in Spain.
Dr Pedro Broggi, 34, was born in Peru; his mother is Peruvian and his father Spanish. He finished his training in Barcelona, and in 2013 became a doctor in geriatric care at Macclesfield hospital. Last year he was promoted to consultant physician in acute care of the elderly.
Spain is trying to avoid the problem of an ageing population, rather than adapting to it. In the UK, we are trying to find solutions, whereas in Spain they are adopting an ageist position. They are closing beds for care of the elderly; we are trying to fulfil their needs.
I came here on a one-year contract as a middle-grade doctor. At the beginning, I was completely lost; I didn’t know how anything worked. It took about seven or eight months before I started feeling as confident as I had been in Spain.
In Barcelona, people live in flats, and for the elderly, losing mobility can mean the end of socialising, which leads to depression and isolation. Here, people live in houses and rely on driving or public transport to move around. Carers are difficult to find, particularly in rural settings where the distances to shops or pubs are greater. So the issues around isolation are the same.
The main difference is that here you have the power and freedom to develop the services you think will work best. Even if you are a top consultant in Spain, the bureaucracy makes this really difficult. Here, if you knock on the right door with a decent proposal, it will happen.
But the NHS was not created for the care of the elderly. What we need is coordination and communication between primary and secondary care, and between social services, GPs and hospitals. Social services sit on a different budget, which is a big, big mistake. We also need the electronic barriers to come down, so we can access a patient’s history when they arrive at hospital. A demented patient can’t give me this information. We can’t have people queueing for A&E and dying on trolleys; this is the UK in 2015, not the third world .
