In June 1995 Ken Jarrold, then director of NHS human resources, urged employing organisations to make it easier for managers and staff to spend time working overseas, without being penalised on their return to the NHS.
He called for work experience in developing countries to be formally recognised in organisations' human resource strategies, for the provision of paid or unpaid leave so staff could spend short periods in healthcare abroad, and for continued membership of the NHS pension scheme to be offered.
Managers heard similar promptings from the Princess Royal, patron of International Health Exchange, a charity providing health workers with information about opportunities in developing countries, in her speech to managers at the National Association of Health Authorities and Trusts' 1995 conference.
But four years on the response has been patchy, with some in the NHS warning that those who interrupt their career to go overseas should not expect a problem-free return.
'The Executive Letter was helpful but it didn't really change very much, ' says Alice Tgilui, director of International Health Exchange. 'Many health professionals who were trying to negotiate leave still found it difficult.'
Overseas work experience offers unparalleled opportunities for professional development. But the health service and the aid industry often pull in different directions, she believes.
'To stay in the health market there is an increasing pressure to specialise, while in the aid labour market generalists are preferred. In health we have complex shift patterns and on-call arrangements, while in aid we need flexible people who can travel, often at short notice. On top of this, the drive for improved standards is hitting both the health and aid sectors at the same time, placing enormous pressure on individuals who are trying to work in both worlds.'
She hopes that as more managers experience working overseas they will be more supportive of others who want to.
Ron De Witt is one of those managers. Chief executive of King's Healthcare trust , he worked in New Zealand , in nursing and management posts, from 1976 until 1991, when he returned to the NHS. He believes overseas experience is very valuable and, if the will is there, it is possible to release people to enable them to take up overseas opportunities, he says.
'But you have to be realistic about the management pressures in the NHS which can make it difficult always to accommodate people's wishes, ' he adds.
Keith Johnston, chief executive of NHS Personnel, believes that developing countries, in particular, can 'benefit greatly' from the experience of UK health managers, and working overseas helps health managers to develop a different perspective. 'But organisations have to be sufficiently broad-minded to see these benefits, ' says Mr Johnston.
'There is also a risk that, if people go overseas for a long period, they will get out of touch with developments in the UK and find it very difficult to slot back into their old job.
A period of time overseas can often herald a change in career. People come back and see that their future may lie in a different direction.'
Community Healthcare Bolton trust has supported one of its managers, Heather Goil, to work overseas for two years in the Republic of Kiribati, a group of Pacific islands (see box).
Alice Murphy, the trust's director of corporate development, says that now Ms Goil is back in post the trust is reaping the benefits of her experiences. 'She has come back to the trust renewed, with a more rounded feel about healthcare issues, ' says Ms Murphy.
'There has also been a chance for someone to step into her post while she was away, which has been a development opportunity for them.'
Chris May is project director of Southmead NHS International (formerly NHS Overseas Enterprises, wound down in 1997 by the then health minister, Gerald Malone). 'Over the past few years there has been a tightening up of people's availability to work overseas , ' he says. 'It has become very difficult to get people out of the service despite the moves by the NHS Executive to encourage a more open approach to international work.'
Southmead NHS International has projects in Pakistan, Zambia, Russia and Cambodia and is beginning to recruit for work in Uzbekistan. 'Most projects we are involved in are long-term, ' he explains, 'although some involve short visits of two to three weeks at a time.'
The organisation is also in early discussions with the organisers of the NHS leadership programme. 'We want to raise awareness of overseas working as an important development for senior managers, ' says Mr May.
But Andrew Foster, chair of the NHS Confederation's human resources committee, sounds a strong note of caution. 'No doubt, encouraging managers to work overseas is something we should be doing to develop our staff. But at the moment, management in the NHS is run on a shoestring and there is very little slack in the system, ' says Mr Foster.
NHS Pensions urges anyone planning to work overseas to tell the scheme exactly what you are contemplating before taking up employment. Not everyone will be allowed to retain their membership of the pension scheme while they are working overseas. Each case is considered sympathetically, NHS Pensions promises. But it does look for a commitment in writing to come back to work in the NHS.
The Inland Revenue urges health professionals to speak to their local tax office for information and advice. The National Insurance Contributions Office also advises people to contact their local office.
When Brian Carpenter saw an advertisement for a job as human resources development adviser to the South African department of health he applied and got it. The post was for an initial fixed-term contract of 18 months, meaning Mr Carpenter had to negotiate leave of absence from his job as director of human resources with South Devon Healthcare trust. 'It was not easy, ' he admits.
'To leave a director and board member-level job for two years is difficult. I did a deal with the trust and promised to come back at the end of the contract.' He also organised lots of acting-up arrangements and recruited an extra staff member 'to shore up the structure'.
Mr Carpenter saw the South Africa job as 'a development opportunity'. The trust chair and chief executive believed the trust would also benefit from the experience, he says.
The job was at a high level. 'I was working on projects advising the department of health on the people aspects of managing change and also helping to develop the HR function in all provincial health administrations, so I travelled all over the country, ' he explains.
'I hope I made a contribution. My contract was extended by a further six months by mutual agreement and I have been asked to go back every three months for the next year for two weeks at a time, to check on progress.'
His salary was paid by the trust, which was reimbursed every quarter by the Department for International Development. 'My pay was in sterling, which was like having a pay rise because the pound was much stronger than the rand, ' says Mr Carpenter.
He also came back 'a much more mellow and tolerant person' and with an extra family member - his wife gave birth to a daughter in South Africa.
'I have a greater sense of humility, having seen such a huge range of extreme wealth and absolute poverty, ' he says. 'I also learned a lot of new skills - I was an information technology dinosaur but came back quite proficient. I am also more self-sufficient. I didn't have a secretary in South Africa, so I had to do everything for myself.' And he acknowledges that what his trust did was 'quite brave'.
Anna Hardy had spent most of her working life in the NHS - first as a nurse, then as a sister, followed by several years as a senior nurse manager. She then did a degree in HR and took a post as a HR manager. 'But I found I spent most of my days inputting data into a computer. I could not bear the thought of doing that for the rest of my life.'
She is now about to embark on her third mission with Medecins Sans Frontieres, having spent two years working with the organisation in Brazil, followed by three months in Sri Lanka. MSF works in 80 different countries, including operations in Kosovo, Albania, Macedonia, Sierra Leone, Siberia, Cambodia, Sri Lanka and South America.
'We do emergency work in countries that have experienced war or natural disasters, not long-term rehabilitation, ' says MSF spokeswoman Polly Markandya.
'I joined MSF for a completely different life, ' Ms Hardy says, 'and I have not regretted one moment.'
The minimum commitment is nine months. To work in a medical capacity applicants must have at least two years' post-qualification experience, plus some experience of living, working or travelling in developing countries, a tropical medicine diploma, some teaching or training experience and, if possible, a working knowledge of French, Spanish or Portuguese.
On the personal side, the organisation needs people who are flexible, co-operative, good co-ordinators, good at working both in teams and independently, and able to cope with stress. The lower age limit is 25 - there is no upper limit as long as volunteers are fit and healthy.
Volunteers are paid£500 a month, four-fifths of which is paid directly into their UK bank account, with the remainder paid in local currency in the field. Flights and accommodation are also paid for by the organisation.
Ms Hardy's new life has not been achieved without sacrifices. 'I sold my beautiful sports car to fund the course in tropical medicine and I have had to let my house on a long-term basis. But I hope the rest of my working life is spent overseas.'
MSF became involved in working with the Indian population in the Amazon following a cholera epidemic and a serious malaria outbreak. Ms Hardy and a team of five expatriate staff - two nurses, a doctor and a logistician - together with various local staff visited 18 villages on a three-monthly rotation basis to give essential medical care and undertake supervision of basic care and treatments.
'Communications skills were the most important part of my work. Despite an HR degree, I had never come across such weird HR problems in all my working life - such as trying to get one of our wrongly accused local staff out of jail.
'But I enjoyed being able to get on with things without having to jump through the 50 hierarchical hoops I had to in the NHS.'
After Brazil, Ms Hardy spent three months in Sri Lanka, which was at times scary. 'There was shelling almost every night. I was more frightened for my staff than for myself - as project co-ordinator I was responsible for their safety.'
Then she had the opportunity to come back into the NHS for six months, as temporary director of nursing at Milton Keynes General Hospital. 'It has been a wonderful time, ' she says.
'Your perspective changes when you have spent time in a developing country. The NHS has problems and there is a lot of pressure. But I get less uptight about things and there has been a lot of improvement in the service in the time I have been away.' But she does not plan to stay in the NHS. In September she will take on another mission for MSF.
The NHS should make it easier for its staff to spend time working overseas, Ms Hardy believes. 'Even if someone goes overseas for just a few months they come back with fresh ideas, enthusiasm and energy.'
A different perspective, however, is provided by one principal nursing officer, who is back in the UK after many years in Africa and the Middle East.
She says she cannot believe how bad the NHS now is and claims she would not want a job working in the service.
She has had a series of temporary appointments in a number of London hospitals and these experiences have shown the NHS to be 'disgusting', she says.
'The average level of politeness is abysmal. There is the worst don't-care attitude I have ever come across.
Cleanliness is appalling and communication with staff very poor.
'Coming back here and going round the NHS hospitals has been a shattering experience. I hope to be able to go back overseas, but I certainly don't want a job in the NHS.'
The mother who had to wait: 'I'm much more globally aware now' Heather Goil had to delay her departure to the Republic of Kiribati, a group of Pacific islands which used to be known as the Gilbert Islands, because her two grown-up daughters found it hard to come to terms with their mother wanting to work overseas for two years, as a public health trainer with VSO.
'But I was determined to do it, ' says Ms Goil, who returned to her post as corporate relations manager with Community Healthcare Bolton trust in January. And she believes her experience setting up a curriculum in public health for registered nurses has helped her to become 'much more globally aware of health problems and health inequalities'.
Ironically, in a country which often has interrupted electricity supplies, Ms Goil mastered IT skills and these will be put to good use now she is back in the NHS, she says. But she has developed itchy feet and, as she approaches retirement age, she intends to do further work in developing countries, although probably on a shorter-term basis.
The main problem in organising her trip was letting her house. 'I was misled by the lettings agent which meant that, although I returned in January, I won't get back into my home until the summer, so I have had to lodge with a friend, she says.
But she has also had some interesting experiences - such as being invited to attend the celebration for a young girl's first menstruation.
'This is a very big event in Kiribati and the celebrations go on for three days.'
Northern Ireland meets Zimbabwe: 'We're different from the usual consultants' The Health Management Strengthening Project set up with the Ministry of Health in Zimbabwe has brought together experienced health professionals in Zimbabwe and Northern Ireland since 1993. The project has combined traditional elements of management consultancy with problem-solving and supporting sustainable change.
It has involved managers from finance, supplies, management information and health service planning departments from Northern Ireland's Western health and social services board. John Evans, the board's organisational services adviser, has been involved in the project since its inception, going out on two to three-week visits, on average twice a year. He was based in Harare and Bulawayo, dealing with six hospitals. He oversaw the introduction of new stores systems in five of the hospitals, while three hospitals had their supplies organisation computerised.
'We would roll up our sleeves and get on with whatever needed to be done, ' he says. 'We were clearly quite different from the usual management consultants.'
Tom Frawley, the health and social services board's general manager and another of the team, says they had the opportunity to concentrate on objectives without the added pressure of day-to-day management responsibilities. 'I think we have become much more conscious of the problems faced by our counterparts in countries like Zimbabwe.'
Rejected returnee: 'I thought my experience would count' Dr Mike Cooper applied to 92 hospitals for work when he came back to the UK after working overseas. He received replies from three.
He had been working as a senior nursing officer in Scotland before taking up a post with the Department for International Development (then the Overseas Development Agency) as a principal nursing adviser in the West Indies.
His next post was in Nepal, where he had responsibility for closing a Gurkha military hospital.
Negotiations with the governments of India and Nepal resulted in this establishment being turned into a regional medical institute which is still going well, he says.
His next move was to become a consultant hospital administrator in Saudi Arabia - a job which lasted more than four years.
Then Saudi nationals were recruited to all such administration posts and he had to leave. Dr Cooper has a clutch of nursing qualifications, a masters degree and a doctorate.
His experience has been broad-based, both clinically and managerially.
Yet he has found it impossible to get a job in the NHS and is now a deputy nursing home manager.
'I never believed it would be like this, ' he says. 'I wasn't expecting the red carpet when I came back, but I thought all my experience would have counted for something.'
His advice to managers is not to work overseas if you want to continue a career in the NHS. 'If you do leave for any length of time don't expect to get back in at the same grade, ' he warns.
'You have to start again, if not on the first rung of the ladder then probably the second.'
Township hospital builder: 'You're not there to enjoy the scenery' Dr Mike Owen used to use his annual leave entitlement to work overseas, but for the past three years, he has been able to negotiate six weeks' special leave a year with his employer, North and East Devon health authority. Dr Owen, the HA's director of public health, has been working on projects in Zambia since 1993 with the Department for International Development. While he is overseas, DFID pays his salary, plus around 15 per cent to the HA to cover his absence.
He has been involved in the creation of eight 30-bed community hospitals in township areas around Lusaka, evaluating the impact of these new resources on patient flows, and working closely with local communities to help define their health needs. But he has not seen much of the Zambian countryside.
'If you are engaged on short-term consultancy work you are either at work or in your hotel, ' he says.
'You are paid by the day and you are worked hard by the day. You are not there to enjoy the scenery. I have only been outside of Lusaka once in eight visits to the country. It is very focused and disciplined work.'
1 Overseas Work Experience and Professional Development of NHS Staff . EL(95)69.