Active Global Citizenship in National Health Service (NHS) Scotland

Abstract: The National Health Service (NHS) Scotland Global Health Co-ordination Unit (GHCU) was established in 2018 to facilitate and coordinate cross-sectoral health partnership volunteering in Scotland and abroad.  This article describes how the Active Global Citizens work stream was further developed through a partnership between the GHCU (NHS Scotland, 2022a), Scotdec (2022), a Development Education Centre in Edinburgh, and the International Development Education Association of Scotland (IDEAS, 2022) supported by the Bridge 47 project (Bridge 47, 2022).  The focus of the work was to emphasise the transformative education approaches of global citizenship education (GCE) and encourage local active global citizenship within NHS Scotland.  

Key words: Global citizenship; NHS Scotland; Health; Partnership; Bridge 47.
 

Setting the scene within NHS Scotland
As an anchor organisation that employs over ten per cent of the country’s workforce, NHS Scotland plays a crucial role in delivering the United Nations Sustainable Development Goals (SDGs): a set of seventeen global goals that aim to achieve prosperity for all and care for our planet (UN, 2022).  Operating through local, national and international levers provides a mechanism to impact directly on global health, but also indirectly too, via the influence on wider determinants of health and climate action.

The national landscape is encouraging, with Scotland being one of the first countries to sign up to the SDGs in 2015.  The redesign of Scotland’s National Performance Framework in 2018 (Scottish Government, 2022), with its alignment to the SDGs, calls upon policy and service planners in public, private and voluntary organisations to commit to global accountability whilst simultaneously striving to improve the quality of life for the people of Scotland.  These two frameworks recognise the social determinants of health and give permission to the NHS Scotland workforce to embrace global citizenship.

The NHS Scotland Global Health Co-ordination Unit (GHCU) (NHS Scotland, 2022a) was established in 2018 to facilitate and coordinate cross-sectoral health partnership volunteering both in Scotland and abroad.  The Global Citizenship Advisory Board sits within the Chief Medical Officer Directorate in the Scottish Government, providing leadership, support and guidance to the development of NHS Scotland’s approach to global citizenship and the work of the GHCU.  Work streams and priorities are aligned with the Scottish Government’s International Development Strategy (Scottish Government, 2016) and the national policies and strategies of those countries involved in partnerships.

A network of global citizen ‘champions’ exists within regional and specialist health boards, represented by a lead, who attends quarterly lead champion network meetings.  The chair of the lead champion network sits on the advisory board, thus providing a close link from - and to - healthcare staff.  In this way, the network of champions can provide feedback, input, and support to the development and implementation of the different work streams supported by the GHCU.

The Active Global Citizenship work stream was initiated by Dr Bernadette O’Hare, Senior Lecturer in Global Health at St Andrew’s University while seconded to the GHCU.  The focus being to increase NHS Scotland’s global health contribution by empowering NHS Scotland staff to participate in global citizenship through their everyday work in Scotland.  It aims to articulate the connections between day-to-day decisions and the potential impact these choices might have on people with low or limited access to resources, encouraging health care workers to consider their choices and actions within the workplace and positively influence local work and environmental policies for the good for all people, whilst protecting the planet. 

Active Global Citizenship within NHS Scotland is based on three key principles: the understanding that inequity leads to health inequality; poverty causes poor health; and climate change is a public health emergency.  These principles, closely allied with the overarching aims of the SDGs, provided the context for the partnership and the resulting tools that were created. 

Collaboration 
Scotdec, one of Scotland’s five Development Education Centres, has been active in the field of global citizenship education (GCE) for over thirty years.  While its focus has primarily been within the formal and informal education sectors, Scotdec has a long history of collaboration with partners, both overseas and in Scotland, exploring the possibilities of GCE within other sectors.  IDEAS was part of the Bridge 47 project, a European Union (EU) funded project, focussed on furthering SDG 4.7 through advocacy, innovation and partnership work.  Identifying and reaching out to sectors not traditionally associated with GCE was a key driver of the partnership work stream.  Both Scotdec and IDEAS, supported by Bridge 47, identified the GHCU as an impactful potential collaborator, and recognised the opportunity to bring GCE to NHS Scotland in a way that was critical and challenging. 

Partnership
Establishing a working partnership was key to the success of this work.  A shared understanding of the SDGs already existed, and clear foundations had been laid by the GHCU and the Global Citizenship Champions’ network, which was instrumental to progressing the work around Active Global Citizenship.  It was recognised by all members of the partnership that there was a need to challenge the notion of global citizenship as purely volunteering overseas, to demonstrate that NHS Scotland staff can also be global citizens at home.  Initial scoping activities focussed on how best to ensure the local expression of GCE.  Although the language of global citizenship was used, it was noted that the understanding did not encompass the transformative education approaches of GCE and there was a need to interrogate this approach further within the context of the Active Global Citizenship work stream. 

Scotdec was invited to deliver two facilitated workshops at the NHS Scotland Global Citizenship Annual Conference in November 2019.  This provided an initial window for Scotdec into NHS Scotland staff views and expectations of Active Global Citizenship.  This, alongside further scoping activities, was really important in order for the partnership to flourish.  While Scotdec has expertise in GCE, it was necessary for them to gain an understanding of not only GCE’s place within NHS Scotland, but also to appreciate the diversity of the staff, their roles and the dynamics of the sector as a whole. 

Two needs-analysis workshops were conducted with the support of an external facilitator, to scope out the thoughts of NHS staff in the Global Citizenship Champions network, on what would best support the local expression of Active Global Citizenship within the Scottish NHS.  These workshops were instrumental in deciding the focus of the work. They also opened up an important space for reflecting on the key touch points where GCE resonated with staff, and for Scotdec and IDEAS to better understand what Active Global Citizenship might look like for healthcare staff working in NHS Scotland. 

Impact of the pandemic
At the outbreak of the COVID-19 pandemic, NHS Scotland partners were initially re-deployed to urgent response work.  However, during the summer of 2020, it was felt that there was an even greater need for staff to have the space to critically explore the role of the NHS in delivering the SDGs.  In August 2020, the partnership hosted an online webinar for NHS Scotland staff: Imagining Better Futures: Global Citizenship within NHS Scotland, Taking Action for a Just and Sustainable World (Bridge 47, 2020).  It offered participants the opportunity to build their confidence in identifying the interconnections between local actions and global impacts, familiarising them with the SDGs, and exploring the crossovers between personal and professional values.  Eighty-four per cent of participants agreed that the course increased their awareness of the synergies between global citizenship and their professional role.  Feedback from the session highlighted the need for this work and participants desire to engage, as well as providing ideas for how to further develop the planned resources and support.  As one participant commented: ‘Networking with others in events such as this is so important for such a huge public sector organisation.  This work has brilliant potential to show what can be done’. 

The online webinar also enabled the partnership to think further about the type of training and resources that would be most useful in a world shaped by the COVID-19 pandemic and a climate emergency.  It was recognised that the most value would be gained from developing free, accessible resources for staff to be able to use at any time, both individually or with colleagues or friends.  Participants had consistently flagged up the need for accessible examples of what Active Global Citizenship might look like across the NHS and the partnership was keen to address this need.  A mapping exercise was carried out to identify organisations, networks, or case study examples of work already going on linked to NHS Scotland and spoke to the concept of Active Global Citizenship.  The culmination of this process led, in November 2021, to the launch of the Active Global Citizen resources: a digital booklet, seventeen digital SDG cards and a package of training materials (NHS Scotland, 2022b).

SDG booklet and cards
The aim of the booklet and cards is to increase knowledge and understanding of the SDGs within NHS Scotland.  It uses a GCE approach to help negotiate the tensions between local actions and global impacts and support critical engagement with complex issues.  The aim with the cards and booklet is to stimulate discussion and provide a starting point for any NHS Scotland worker to talk to their colleagues about wider global issues and sustainability.  The booklet provides some activity ideas to support individuals, small groups and teams to engage with Global Citizenship Education and the SDGs at a level appropriate for their context.  They are written to be accessible, adaptable and to encourage critical reflection. 

A flashcard for each of the SDGs was published with reflective questions designed to stimulate critical thinking and debate, plus examples of relevant networks and case studies which highlight current connections and practice relating to the SDGs.  Through highlighting wider organisational policies, support networks and case studies, the intention is to enable workers to recognise the opportunities they have as individuals to indirectly impact on global health here in Scotland. 

Training packages
The partnership initially planned to facilitate training sessions in various regions within Scotland.  However, due to the pandemic there was a period of reassessment and consideration for the new landscape, and with this came the realisation that providing training package materials would likely provide the most benefit, as this would enable staff to access them at a time most convenient to them.  The training materials (NHS Scotland, 2022b) use a Global Citizenship Education approach to encourage deeper engagement with the key principles of Active Global Citizenship within NHS Scotland: the understanding that inequity leads to health inequality; poverty causes poor health; and climate change is a public health emergency.  The sessions utilise the active enquiry orientated methodologies of GCE while linking to examples and practices within NHS Scotland. 

A further strand of the training package provides reflective activities for those involved in, or planning to embark on, partnerships with the global South.  Drawing on school partnerships managed by Scotdec, they provide a critical lens through which to consider global North / South partnerships.  They encourage deep reflection on: power, identity and privilege; strategies for facilitating dialogue with partners; and ideas on how to share experiences of volunteering in or partnership with the global South with dignity and solidarity.  Each training session includes suggestions for self-study with further reading, listening, reflection and ideas for action (Ibid). 

Impact so far 
A small pilot of a hard copy of the SDG cards and activity booklet was carried out during the spring and summer of 2021 to get feedback from NHS Scotland staff on how these resources may best be received, and whether they needed any further supportive materials.  Responses from this pilot were encouraging and indicated that the SDG cards were an effective tool for starting conversations around the SDGs with staff. 

“I really liked that the resources included examples from Scotland of the SDGs in action.  The graphics and size of the cards made them accessible and easy to use.  The questions were simple but encouraged reflection within the team.  People were really keen to engage with resources and I was amazed at how naturally team members made connections between their own lives and experiences and the SDGs.  The cards encouraged reflection and allowed for broader discussion about the place of our team and NHSS in the global setting” (Consultant, NHS Lothian).

Overall the responses were encouraging; the materials were accessible, provided easy ways into the topics and the local examples of Active Global Citizens were valued.  Feedback also suggested further ideas on how to disseminate this material throughout the workforce and highlighted their potential use for opening up conversations with patients as well as staff. 

A formal launch of the resources took place in November 2021 as part of the Scottish Government Let’s Do Net Zero events for COP 26 at the Climate-smart healthcare: The opportunity of Global Citizenship in NHS Scotland webinar (NHS Scotland, 2021).  Professor John Brown, the Chair of Greater Glasgow and Clyde Health Board and Chair of the Global Citizenship Advisory board, spoke at the event highlighting both the potential impact NHS Scotland can have in implementing the SDGs in Scotland as well as stressing the relevance of this work to everyone whatever role they have (Ibid).  Recognition of the importance of this work at both strategic level and patient-facing level by the Global Citizen Champions network is important to the implementation process. 

Currently the resources are located on the NHS Scotland GHCU website, and are free to download (NHS Scotland, 2022b).  Information and awareness has also been disseminated to staff via the lead Global Citizenship Champion network, advisory board, and contributors to the SDG card case studies, including relevant networks.  Many NHS Scotland staff are already familiar with the ‘train the trainer’ approach to learning, and use of this model has been incorporated into the plan for further dissemination via established staff networks.  Regional and Specialist Health boards will be encouraged (via the lead Global Citizenship Champions) to incorporate use of these materials during staff training, and presentation of the resources has already taken place during a large health board executive board development session.

Three of the training package materials were used during online facilitated workshops that took place at the NHS Scotland Global Citizenship Annual Conference in November 2021.  Feedback from the conference demonstrated that the workshops were highly valued and stimulated a lot of helpful reflections and discussion.  In recognition of the benefit to staff engagement with climate action and global citizenship, the resources have also been included as a resource link in the Consultation Draft NHS Scotland Climate Emergency and Sustainability Strategy 2022-2026 (Scottish Government, 2021).  Building greater links with the Sustainability Action initiative (NHS Scotland and Sustainability Action, 2022) in Scotland and linking with the NHS Sustainability Champions to explore the synergies between them and the Global Citizenship network is an important way to build support for the SDGs and the NHS Scotland Climate Emergency and Sustainability strategy.  

What next? 
The resources and training package are a lasting legacy of this partnership between Scotdec, IDEAS and the GHCU.  The partners are grateful for the funding that the Bridge 47 project provided, which developed from a chance meeting at a conference in 2018, to be realised in the work outlined above.  Scotdec and the GHCU are exploring further opportunities to work together, to deliver further training and support the ‘train the trainer’ model.  NHS Scotland’s commitment to Global Citizenship, both at home and overseas, recognises the important benefits to both individuals and the sector as a whole.  For individuals there is the development of important skills, communication and teamwork and building personal resilience.  Whilst wider benefits such as enhancing recruitment and retention, system learning and capacity building, professional development of the workforce, and improved patient experience have all been identified in the Global Citizenship in the Scottish Health Service 2017 report (Royal College of Physicians and Surgeons of Glasgow, 2017). 

The 2030 Agenda for Sustainable Development with its 17 Goals aims to address the challenges we all face by calling for a transformation of vision about our relationships with each other and with nature.  It argues that transformation is required since business as usual is unable to meet the needs of all people within the means of the natural environment.  The SDGs provide a framework and shared understanding which enabled this partnership to flourish; GCE needs to continue to build these partnerships in sectors like NHS Scotland if we are to realise this process of transformation.
 

References

Bridge 47 (2020) Imagining Better Futures: Global Citizenship within NHS Scotland, online webinar, 27 August, available: https://www.bridge47.org/events/27-august-2020/imagining-better-futures-global-citizenship-within-nhs-scotland (accessed 21 March 2022).

Bridge 47 (2021) Out of the Comfort Zone: GCE and Cross-Sector Partnerships for Sustainable Development, 21 July, available: https://www.bridge47.org/partnershipspublication (accessed 21 March 2022).

Bridge 47 (2022) available: https://www.bridge47.org/ (accessed 21 March 2022).

IDEAS (International Development Education Association of Scotland) (2022) available: https://www.ideas-forum.org.uk/ (accessed 21 March 2022).

NHS Scotland (2021) Climate-smart healthcare: The opportunity of Global Citizenship in NHS Scotland, an online webinar, 12 November, available: https://www.scottishglobalhealth.org/event/climate-smart-healthcare-the-opportunity-of-global-citizenship-in-nhs-scotland/ (accessed 21 March 2022).

NHS Scotland (2022a) ‘NHS Scotland Global Citizenship Programme’, available: https://www.scottishglobalhealth.org/ (accessed 21 March 2022).

NHS Scotland (2022b) Resources, available: https://www.scottishglobalhealth.org/resources/ (accessed 21 March 2022).

NHS Scotland and Sustainability Action (2022) ‘Our NHS Our People Our Planet’, available: https://nhssustainabilityaction.co.uk/ (accessed 21 March 2022).

Royal College of Physicians and Surgeons of Glasgow (2017) Global Citizenship in the Scottish Health Service: The value of international volunteering, available: https://rcpsg.ac.uk/documents/publications/global-citizenship-report/204-global-citizenship-in-the-scottish-health-service/file (accessed 21 March 2022).

Scotdec (2022) available: https://scotdec.org.uk/ (accessed 21 March 2022)

Scottish Government (2016) Global Citizenship: Scotland's International Development Strategy, 21 December, available: https://www.gov.scot/publications/global-citizenship-scotlands-international-development-strategy/ (accessed 21 March 2022).

Scottish Government (2021) NHS Scotland climate emergency and sustainability strategy 2022 to 2026 - draft: consultation, 10 November, available: https://www.gov.scot/publications/nhs-scotland-draft-climate-emergency-sustainability-strategy/ (accessed 21 March 2022).

Scottish Government (2022) ‘National Performance Framework’, available: https://nationalperformance.gov.scot/ (accessed 21 March 2022).

United Nations (UN) (2022) ‘The 17 Goals’, available: https://sdgs.un.org/goals (accessed 21 March 2022).

Emily Broadis is a Specialist Registrar in Public Health

Charlotte Dwyer is Director of Scotdec www.scotdec.org.uk