NHS Scotland Global Citizenship Framework: setting the direction for global citizenship in NHS Scotland

Section 2 – The Ten Principles

In developing the Framework, we acknowledge several existing statements of values and principles which are applicable in the global health and international development space; many of which are referred to throughout this document. The principles set out in this Framework do not seek to replace or diminish those. Instead, our aim is to provide clarity to the NHS Scotland Global Citizenship Community on the position of the Programme within the wider global citizenship landscape in NHS Scotland and the principles that underpin it.

These principles are:

1. Alignment

2. Leadership

3. Environmental Sustainability

4. Equality, Diversity and Inclusion

5. Power and Privilege

6. Health Board Commitment

7. Quality Improvement

8. Monitoring and Evaluation

9. Learning and Good Practice

10. Working with Others

Methodology

The Framework and updated Equality Impact Assessment (EQIA) for the Programme have been developed collaboratively with a broad range of groups and individuals from across NHS Scotland, Scottish Government, academia, third sector and the wider international development and global health community within Scotland and beyond.

This work has been overseen by the Advisory Board who would like to thank all of those who made time to engage and share their views on the future of the Programme.

Equality and human rights issues have been considered throughout the development of the Framework and a summary of the results of the EQIA are published alongside the Framework.

Principle 1 – Alignment

Aim: The Programme is aligned to the Scottish Government’s commitment to good global citizenship, addressing health inequalities in Scotland and overseas, and being led by partner country priorities.

This Framework sits within, and is aligned with, higher level Scottish Government and NHS policies (see Annex A). The Framework reflects our commitment to strengthening partnerships in the area of health, in line with the Scottish Government’s International Development Strategy^[8] and the 2020/21 review of its approach to international development^[9]. The review also commits to:

• ensuring a feminist approach is mainstreamed in spending
• mainstreaming climate justice considerations
• supporting a shift in power to the South

The International Development Programme Principles, designed as part of the review process, are detailed in Annex B, and provide an important foundation for this Framework.

This collaborative approach across the Health and International Development portfolios reflects the Scottish Government’s commitment to Policy Coherence for Sustainable Development and commitment to the implementation of the United Nations Sustainable Development Goals^[10].

Partner country priorities

Alignment should be considered in the context of direct health priorities, and wider priorities that interact with health, for example increasing resilience to climate change.

The Programme promotes learning and good practice (Principle 9); global health work should be aligned to partner country needs and priorities, as set by their national government. In this context, the term ‘partner country’ refers to any other country working alongside and in partnership with NHS Scotland staff or Health Board.

Future direction

The Programme aligns to Scottish Government priorities and approaches in Health and International Development, and promotes global health work that respects international partner priorities, to ensure it delivers for the people of Scotland and partner countries.

Principle 2 – Leadership

Aim: Leadership of the Programme reflects the diversity, skills and experience of the communities it serves, here in Scotland and overseas.

The Programme’s Advisory Board is committed to ensuring its leadership consists of a diverse group of people with the necessary skills, experience, values, behaviours and relationships. This includes acknowledging the power imbalances that exist in global health, and the influence and privilege that the Programme’s leadership holds.

This position reflects ‘The Blueprint for Good Governance in NHS Scotland’^[11] which highlights the importance of a diverse leadership team, including:

• reflecting the communities they serve
• diversity of thought to improve decision making and to avoid ‘group think’
• ultimately improved organisational culture and increased public confidence

Leaders as role models

Senior leaders at national, local and departmental levels have an opportunity to influence organisational culture across NHS Scotland. We encourage NHS leaders to champion the values of good global citizenship, ethical practice and environmental sustainability in their work and engagement with colleagues and staff.

Future direction

The Programme will ensure NHS Scotland Global Citizenship leadership represents the interests of the communities they serve and have influence over, in Scotland and overseas.

Principle 3 – Environmental Sustainability

Aim: The Programme encourages the NHS Scotland Global Citizenship Community to incorporate environmental sustainability into their global health work and consider how they can contribute to the response to the climate emergency.

The World Health Organization has identified climate change as “the single biggest health threat facing humanity”^[12]. and the Lancet Commission described addressing climate change as “the greatest global health opportunity of the 21st century”^[13].

Global citizenship can be thought of as “thinking globally, acting locally”, a phrase that is also commonly used by environmental groups. For example, the NHS Scotland Climate Emergency and Sustainability Strategy set out plans to reduce its impact on the environment and to ensure resilience to changes in Scotland’s climate^[14]. It makes clear that environmental and climate action can have co-benefits for health if delivered with the right intent.

Environmental sustainability is a central part of the NHS Scotland approach to Global Citizenship, as detailed in the Active Global Citizenship resources.

Globally, the healthcare sector is responsible for approximately 5% of global net emissions^[15]. This means that if the health sector were a country, it would be the fifth-largest emitter on the planet. It is therefore important that we are mindful of the impact that global citizenship activities can have on the planet and commit to making decisions with planetary health in mind.

For example, global health partnership work frequently involves air travel, often to and from Global South countries that are already disproportionately affected by the effects of climate change. Careful thought is needed around the use of air travel, and the balance of this against the benefits of in-person meetings between partners. The growth of remote and videoconferencing technologies allows meetings and conferences to be held virtually and should be considered in the first instance.

Consideration of the potential environmental impacts of other aspects of global health work is also important. This could be as a result of activities such as the introduction of new clinical practices, medical devices or medicines. There is much to learn from other countries’ approaches to climate adaptation. Working in partnership to identify opportunities that maximise positive environmental and health co- benefits is essential to achieving a more sustainable model of healthcare delivery.

Future direction

The Programme will:

• raise the profile and importance of environmental sustainability to the Community and create opportunities to consider the impact global health activity can have on the environment
• promote global health work which supports more sustainable practices in healthcare delivery.

Case study

Active Global Citizenship resources

The Programme worked with Edinburgh-based education charity Scotdec, and Bridge 47 – Building Global Citizenship network to develop a range of resources for NHS Scotland staff who wish to engage in global issues and sustainability. These resources cover ‘Responsible Consumption’, ‘Poverty at home and abroad’ and ‘Power and Partnership’.

Principle 4 – Equality, Diversity and Inclusion

Aim: The NHS Scotland Global Citizenship Community is as accessible as possible for all NHS Scotland staff.

Participation available to all

The opportunity to participate in the Community is available to all NHS Scotland staff. The Programme does not align to any particular ideology or religion and welcomes participation from all secular or religious backgrounds. The Programme supports the Scottish Government’s opposition to racism in all its forms^[17].

Participation accessible to all

The Programme is aligned to the NHS Scotland policy on Equality, Diversity and Human Rights^[18]. Socially constructed barriers may make it more difficult or unlikely for some people to participate in the Community than others. An Equality Impact Assessment has been conducted which looked to understand potential barriers for people with protected characteristics and the lessons learnt have been incorporated into the Framework.

The level of rights given to some population groups varies significantly around the world and this may make it difficult for NHS staff to feel confident in making an informed decision regarding how and where they work abroad. For example, homosexuality is a punishable offence in some partner countries. The Programme supports decision-making in complex and nuanced situations such as these, by providing good quality education materials for the Community (Learning and Good Practice - Principle 9).

NHS staff participate in global citizenship in a range of different ways and from different backgrounds, including professional groups. The Programme will promote the range of ways clinical and non-clinical NHS staff are involved in global health activities, including remote working and other options, through sharing stories and signposting to resources.

Future direction

The Programme will identify and promote the variety of ways that all NHS Scotland staff can participate in global health work.

Principle 5 – Power and Privilege

Aim: The Programme works to minimise power imbalances within global health recognising that it has influence beyond Scotland’s borders, and in particular in the LMICs in which the Community is active.

The international development and global health sectors are heavily influenced by colonial legacies which have left behind power imbalances and positions of privilege which can continue to influence health partnership work today. Issues around power, identity, privilege and how these affect the delivery of SDG 17 ‘Partnership for the goals’ are explored further in the NHS Scotland Active Global Citizenship resources.

Concerted action is required to ensure such legacies are addressed and do not unintentionally perpetuate racism, inequity and the centring of Global North knowledge structures and cultures.

The Programme will do this by:

• Amplifying Global South voices, both at home and overseas – making links between the Community, its leadership on the Advisory Board, others with academic expertise and with lived experience, for example diaspora NHS staff and ethnic minorities as well as partners overseas (see also Principle 10 – Working with Others).
• Education and Learning – developing good quality educational resources for NHS staff, as well as highlighting and signposting to existing good practice guidance that addresses issues around ethics in international volunteering, cultural competence, racism and social justice etc. (see also Principle 9 – Learning and Good Practice).
• Language and Imagery – ensuring the use of language and imagery reflects the Programme’s commitment to ethical and sustainable health partnership work with partners. The Scottish International Development Alliance have developed a useful Guide to Inclusive Language^[19] which aims to help those operating in the sector to avoid bias, stop reinforcing existing power structures, and convey respect.

Future direction

The Programme will seek to minimise paternalism, colonial narratives and power imbalances through continually reviewing its work, language and imagery and by equipping the Community to be able to do the same.

Principle 6 – Health Board Commitment

Aim: Global citizenship is embedded within Health Board structures, governance and policies.

The benefits of global citizenship participation by NHS staff to the Health Service are detailed in the policy report “Global Citizenship in the Scottish Health Service” and include:

• support wellbeing and professional development of staff
• improve Scottish patient experience
• system learning and capacity building
• enhancement of recruitment and retention

To achieve this, organisational commitment to global citizenship is required at Board level. This includes:

• A nominated local Global Citizenship Lead Champion in every Health Board – to act as a local co- ordinator for health partnership work in the organisation.

Several Health Boards have combined the role of Lead Champion with other related priorities such as inducting and supporting staff from overseas or support for migrant workers and asylum seekers settling in the local area. In these instances, NHS staff have benefited from dedicated time and practical support to undertake the role.

• A senior sponsor at the highest level – to champion global citizenship across the organisation.

Some Health Boards have a nominated senior sponsor for global citizenship on their executive team helping embed a culture of global citizenship across the organisation.

• Local Global Citizenship Guidance for staff – explaining the application of NHS HR policies locally within Health Boards to support global citizenship.

Decisions on the release of staff are a matter for individual Health Boards who are best placed to consider such requests alongside ensuring safe staffing levels and continuity of services.

Future direction

The Programme will:

• explore how best to support NHS Boards to embed global citizenship into their structures, governance and HR policies
• continue to promote the benefits of global citizenship to the NHS, the work of Lead Champions and make the case for dedicated time and support for those in that role.

Case Study

In 1991, staff members from NHS Borders established a health partnership with Zambian colleagues to support work to improve education, service delivery and patient experience at St Francis Hospital, Zambia. A formal partnership between St Francis Hospital and NHS Borders was confirmed in 2008. This ongoing health partnership is supported by the charity, the Logie Legacy Trust.

Principle 7 – Quality Improvement

Aim: The Programme encourages health partnerships to adopt QI methodology to support collaboration, co-development, and sharing of knowledge.

NHS Scotland has a long track record of commitment to quality improvement. Initially focused on improving the quality of health care, Scotland has led the way in demonstrating the transferability and applicability of the improvement methodology beyond health and into the wider public services, creating unique collaborations among very different sectors and areas of work^[20].

Quality improvement methodology provides a means of delivering better services, care, and improved health and wellbeing outcomes for the people of Scotland and in partner countries overseas. The ‘Quality Improvement Journey’ provides a framework for developing, testing and implementing changes leading to improvement and can be applied to a variety of different projects and initiatives at local and national level^[21].

The WHO ‘Twinning Partnerships for Improvement’ (TPI) initiative provides advice and support for any health institution interested in improving the quality of health service delivery through twinning partnerships^[22]. TPI is based on a “doing while learning” model in which the collaboration, co-development, and sharing of knowledge are core elements. The WHO supports institutions in establishing strong relationships, implementing effective improvements and spreading the learning across local, regional and national health systems.

Future direction

The Programme will encourage the Community to adopt quality improvement methodology in their health partnership work.

Case study

Quality Improvement for Health Partnerships Programme

NHS Scotland is participating in a tripartite health partnership with the Ministries of Health in Zambia and Malawi, with funding in support of the partnership from the Scottish Government’s International Development Fund. The purpose is to improve quality of care through sharing knowledge and experience across the partnership, on quality improvement (QI) capacity building and using QI approaches in patient safety initiatives. Established with support from the WHO, this partnership is led on the Scottish side by NHS Healthcare Improvement Scotland (HIS), with a strong ethos of all partners bringing expertise to the table and learning from each other.

Principle 8 – Monitoring and Evaluation

Aim: The Programme encourages health partnerships to integrate monitoring and evaluation into their work to ensure best value for all.

The Organisation for Economic Co-operation and Development’s (OECD) ‘Guidelines for Project and Programme Evaluation’^[23] identify the purpose of evaluation as being:

• Learning from experience – reflecting on what worked and what didn’t, can help improve projects
• Transparency – evidence how resources have been used and to what effect
• Deepening understanding – through collaboration and discussion with partners throughout the evaluation process and on the back of the findings
• Improved communication - encourage communication and understanding within and between different groups

All health partnership work should incorporate rigorous monitoring and evaluation processes. This work can build on the quality improvement approach set out under Principle 7. Monitoring and evaluation can be difficult, but not if started during the initial planning phase.

The Tropical Health and Education Trust (THET) have produced a range of resources to support health partnerships to monitor, evaluate and reflect on their activities and results^[24]. This includes a monitoring and evaluation plan and number of case studies exploring how others have approached this work.

The Development Assistance Committee (DAC) Network on Development Evaluation has set out recommendations to ensure the protection of those involved in evaluation^[25]. These include complying with all relevant ethical standards, seeking participants’ informed consent, ensuring individually identifiable information is only featured (with participant permission) when there is no possibility that its use will lead to negative consequences and that media (e.g. photos, videos) should only be taken with informed written consent and is used carefully with due consideration for the protection and dignity of the consenting individuals involved.

Future direction

The Programme will encourage rigorous and collaborative monitoring and evaluation of health partnership work and sharing of results with all those involved.

Principle 9 – Learning and Good Practice

Aims:

a) The Community has access to resources to enable them to conduct global health work ethically and sustainably, according to recognised good practice.

b) Learning from the Community is captured, shared and reflected upon for wider application, and examples of good practice are promoted.

The Programme promotes good practice

The Programme raises awareness of important areas of good practice in global health work, including:

• minimising power imbalance and the legacy of colonialism
• the importance of cultural competence
• prioritising partner country needs and priorities
• the climate impact of global health work
• using Quality Improvement methodology
• safeguarding

The Programme signposts to credible, high-quality guidance in global health, such as:

• The Health Partnership Model: based on co-production, reciprocity and bi-directional learning. It is supported by the WHO, THET and the Scottish Government’s approach to international development
• Good practice guides: such as the ‘Twinning Partnerships for Improvement’ (TPI) guide, THET’s Principles of Partnership^[26], the ‘10 Steps to Safe Medical Equipment Donations’^[27].

The Programme promotes bi-directional learning

The Programme creates opportunities for the Community and partners to share learning from their work with a wider audience. This can be at NHS Scotland Global Citizenship events or in published materials.

Celebrating Successes

NHS Scotland staff and their partners are recognised for their commitment and dedication to improving health globally. Excellence in global health work is recognised at Scotland’s Health Awards, at local awards within Health Boards, and other initiatives.

Future direction

The Programme will:

• Support the Community to practise ethical global health involvement, with good quality educational resources
• Explore how learning from global health work between NHS staff and partners can be better captured, shared and reflected upon for wider application across the health service.

Case study

NHS Scotland Global Citizenship Conference

The Programme organises an annual conference to showcase global health work by NHS Scotland staff and partners, and to facilitate conversations around topics important to the Community. The shift to an online format over recent years has opened up the event to international partners, speakers and experts from all over the world.

Principle 10 – Working with Others

Aim: The Programme works with and engages a wide range of internal and external partners to address global health challenges.

The Programme works with and engages a wide range of groups and communities, in the recognition that global citizenship is a broad and interlinked discipline.

There is a vibrant community of NHS staff across Scotland with active experience and/or an interest in becoming involved in global health work. The Programme creates opportunities to bring the Community together to share learning and exchange knowledge. This is done in ways that encourage inclusivity and relationship-building.

Scotland is an increasingly diverse country, and the Programme seeks to capitalise on the expertise and experience within our borders, to ensure that the values that underpin the Programme and the practices the Programme supports are ethical, respectful and promote solidarity.

The Programme also engages and collaborates with a wide range of stakeholders in the field of global health more generally. This includes administrations across the UK, charities and the third sector, the academic sector and professional bodies such as the Royal Colleges.

Future direction

The Programme will:

• continue to work to engage NHS staff with diaspora heritage, who bring expertise and perspective from partner countries
• continue to forge links with a wide range of groups and organisations that share common interests, to learn, listen and seek opportunities for joint working.

Case study

10 Steps to Safe Medical Equipment Donations

NHS Scotland, the Scottish Government and 3rd sector organisations collaborated to review the standards required for donations of medical equipment to LMICs. The findings of the review have informed the development of a new 10 Step guide for safe and effective medical equipment donations.