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Creative collaboration is the key to NHS international success Part 2 by Ben Marshall

Creative collaboration is the key to NHS International Success

The second of a two part series

by  Ben Marshall

The first half of this feature described the international interest in accessing the expertise within the NHS, and how the NHS in turn benefits from opportunities to improve global health outcomes, share innovation, and generate revenue for reinvestment into patient care. Given all this, why doesn’t the NHS engage more — or more of the NHS engage — internationally? Four reasons are typically given, based on: (1) lack of capacity; (2) lack of commercial focus; (3) risk to domestic priorities; (4) low level of public/political buy-in. These are valid concerns, but not insurmountable. This article will explore the perceived and real challenges to international success in more detail and will suggest some practical solutions for each.

Challenge 1: The NHS is already stretched too thin, there is not enough capacity to do more

The first part of this statement is true. Despite increased recruitment, there are over a hundred thousand vacancies across the system. Too often the approach to fill them has relied on agency or locum staffing — setting up a vicious cycle that entrenches clinicians against budget holders and cements financial shortages.

Leaders can be creative in freeing up capacity. Conduct an internal audit to identify existing international relationships among staff (which are often developed in silos and could be expanded/coordinated). Explore local partnerships as a way of sharing investment and risk, as well as improving uptake of innovations. Take advantage of less than full time (LTFT) contracts, which are already being used by some Trusts as a way of investing in quality improvement whilst also increasing engagement and decreasing locum costs. By allowing doctors to spend 20-40% of their time on international engagement, Trusts might avoid losing consultants to the private sector and junior doctors leaving training programmes altogether.

Challenge 2: The NHS does not have the history or skillset to compete commercially

This is less true now than it was twenty years ago. While it should always be the case that the NHS prioritises clinical excellence and quality of care, a variety of organisations and initiatives have been set up in response to the complexity of the landscape and the need for commercial responsibility. Trusts, Arm’s-length bodies and others should work with commissioning support units (CSUs), specialist government teams (e.g. Healthcare UK), and Academic Health Science Networks (AHSNs), all of which have commercial expertise and a remit to improve and spread innovations. Keeping those skills within the NHS — rather than leaning on external consultants — will improve outcomes, and hopefully also allow better sharing of medical and business skills across the workforce. These support organisations in turn have a responsibility to more effectively signpost where NHS bodies should go to access different services, and to champion them to potential international partners in a way that they are often too humble to do for themselves.

Challenge 3: Any engagement would jeopardise domestic care priorities

This article does not argue that all organisations in the NHS family should be working internationally. Some operate with known structural deficits; some are too resource constrained or already working at full capacity. But for those that are considering the benefits, it is important to start with a clearly articulated strategy. The business case should lay out the rationale for focusing on a particular geography or specialty and avoid being overly reactive to ‘quick’ opportunities without a well-understood return on investment. Sometimes the best propositions are those which the NHS provider takes for granted but which represent a step change for the country in question. Beware areas with pronounced legal, political or regulatory differences, and invest time in understanding the genuine lay of the land and defining any ‘red lines’. Treating international engagement as something requiring governance and deliverables will make it easier to know when to say yes, and help avoid delivering “poor care to poor people”.

Challenge 4: It would be difficult to get buy-in from key stakeholders (including politicians and the public)

This is a concern often raised by NHS leaders who see the value but now have to communicate it in an already pressurised environment. Again, support is available. Healthcare UK offer an advisory service called the Export Catalyst which includes board-level reporting and facilitation sessions. NHS Confederation is seeing traction in its International Special Interest Group, which allows senior business and commercial directors to share their experiences and access lobbying. There was even an event this week on international barriers and opportunities hosted by the Westminster Health Forum.

The Departments for International Trade (DIT) and Health & Social Care (DHSC), as well as NHS England, have a responsibility to provide more resources that empower local NHS organisations, and provide clearer communication from the centre. Access to case studies, FAQs, and a list of common misconceptions would go some way in addressing the (understandable) public concerns about a form of activity that is new to many people. Some key points to emphasise are that international engagement:

  1. does not mean privatisation of the NHS. Although it often relies on ‘commercialising’ existing activities, the revenue generated by the NHS from international work would stay within the NHS, rebalancing the scales away from private providers who currently capture approximately 85% of UK healthcare exports.

  2. does not mean prioritising foreign citizens during care. Trusts have adopted different models to ensure NHS patients do not subsidise, and are not displaced by, private services, including setting up separate wards, rotas, and systems for international patients.

  3. does not mean monetising patient data. Even genomics (which derives much of its value from gathering information) has strict guidance on overseas collaborators “visiting” rather than “sharing” data.

Although not often raised within the NHS, there is a fifth main challenge to successful international engagement;

Challenge 5: Organisations typically act individually and reactively

Some collaborative groups and have already been set up, but most international work is currently delivered by individual organisations or ad-hoc partnerships in response to opportunities as they arise. This is not surprising given the above challenges and the dispersed nature of the UK healthcare system.

But by working collectively and proactively, healthcare organisations are more likely to secure and deliver projects which are more ambitious and more rewarding. Combine experience to avoid duplication of effort (e.g. legal advice, market research, commercial team-building) and to promote knowledge sharing more generally. Rather than competing, organisations should be sharing opportunities which they need help to (or cannot currently) support. Other countries like Canada, Germany and the Netherlands are already more flexible with funding, more internally aligned, and more practised at healthcare engagement at a national level. The government will need to support the NHS in addressing these areas, and providing the tactical mechanisms for more effective collaboration, if we are to maintain our advantage on the global stage.

International egnagement is not easy; constraints and pitfalls abound. But leaders across the system have the power to work together creatively and ambitiously, building a more permissive environment which develops commercial expertise and insulates domestic priorities. Central government can help ensure this is done in a way that addresses the workforce crisis and is complemented by a coordinated information campaign. These values have been applied through the history of the NHS. Now is the time to use them in unlocking international success.


Ben Marshall is a healthcare adviser for the government, and part of a joint team leading a new strategic initiative outlined in the NHS Long Term Plan. Previously he was a management consultant at Concentra Analytics, where he worked with a variety of public and private organisations in the healthcare and financial services sectors. His Twitter is @bmcmarshall.



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