Implications for the NHS of Inward and Outward Medical Tourism: a policy and economic analysis using literature review and mixed methods approaches

Article history

The research reported in this issue of the journal was funded by the HS&DR programme or one of its proceeding programmes as project number 09/2001/21. The contractual start date was in November 2010. The final report began editorial review in October 2012 and was accepted for publication in May 2013. The authors have been wholly responsible for all data collection, analysis and interpretation, and for writing up their work. The HS&DR editors and production house have tried to ensure the accuracy of the authors’ report and would like to thank the reviewers for their constructive comments on the final report document. However, they do not accept liability for damages or losses arising from material published in this report.

Declared competing interests of authors

Stephen T Green is a NHS consultant and director of QHA Trent. QHA Trent is a British company delivering accreditation and consultancy services for hospitals and clinics located internationally.

Copyright statement

© Queen’s Printer and Controller of HMSO 2014. This work was produced by Lunt et al. under the terms of a commissioning contract issued by the Secretary of State for Health. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK.

Background

The impact of globalisation in health and health care has paralleled emerging trends towards increased reliance on individualised health-care provision and ‘consumer’-led access to ‘health-related’ information. Wider system developments include the growth of the cross-border supply of health-related goods and services, greater overseas investment in domestic provision and increased movement of professionals and health providers, as well as trends towards consumption of health care abroad and discounted travel incentives included as part of medical assessment and treatment packages. 3–8 One increasingly popular form of consumer expenditure is what has become commonly known as ‘medical tourism’, a type of patient or ‘consumer’ mobility in which individuals travel outside their country of residence for the consumption of health-care services abroad. 9

Medical tourism takes place when individuals opt to travel overseas with the primary intention of receiving medical (usually elective surgery) treatment. These journeys may be long distance and intercontinental, for example from Europe and North America to Asia, and cover a range of treatments including dental care, cosmetic surgery, bariatric surgery and fertility treatment. 10–12 Some speculate that medical tourism is a US$60B industry internationally. 13

A medical tourist may be defined in two ways depending on the type of health system and how it is funded. First, there are medical tourists who can be categorised as ‘consumers’ because they use purchasing power expressed through the market to access a range of dental, cosmetic and elective medical treatment. There are related questions about access to insurance, the portability of insurance and whether or not voluntary insurance systems extend to the choice of overseas services. Within the USA, for example, several domestic private insurers have looked towards purchasing services overseas. In addition, there are increasing numbers of underinsured consumers who need to pay out of pocket for treatments. 14–17

Second, at a European level, medical tourism may involve exercising citizenship rights to receive medical treatment in another EU member state (better known as cross-border care) and request their national purchaser to reimburse the cost of treatment (see European Court of Justice judgments18–20). The European Parliament and the Council of Ministers formally adopted the patients’ rights to cross-border health care directive1 in March 2011 in an attempt to codify development and clarify the situation for EU citizens (see Appendix 1).

However, although current knowledge of the demand and supply of cross-border health care is growing at European and national levels,21–24 there are no comprehensive data on inward and outward out-of-pocket and third party-funded flows (including government-sponsored) and their health and economic impact. 8 This study therefore contributes to further understanding of patient mobility and its implications for the NHS. 7,25,26 The study was particularly timely given the current global financial context and the likely implications for health expenditure and national health budgets,27,28 and also attempts to encourage NHS institutions to be more outward looking through the launch of NHS Global in 2010:29

While there are already strong examples of NHS Trusts and organisations successfully sharing their ideas and products abroad, we want to create a more systematic approach to this work, and in doing so bring benefits back to the NHS and the UK taxpayer . . . It is now more important than ever to maximise the international potential of the NHS.

NHS foundation trusts will also have more opportunity to undertake international activities should they wish to, including treating international patients (as inward medical travellers are known). Under the 2012 Health and Social Care Act30 the pre-existing cap on non-NHS income, which varied across foundation trusts, was increased. This allowed all foundation trusts to earn 49% of income from non-NHS work, including international patient activity within private activities (in force from 1 October 2012).

How the increase in private activity impacts on the NHS and its patients is not clear and is dependent on whether or not the particular foundation trust is operating close to capacity and whether additional capacity is generated to treat private patients or existing capacity is used. 31 NHS patients may receive benefits if new or enhanced facilities are shared between private and NHS patients. However, if private patients are of greater priority there will – all things unchanged – be a growth in waiting lists and waiting times for NHS patients (Section B155–B156). 31 There is currently no evidence to judge whether or not this will be the case.

A number of factors have possibly contributed towards the growth in outward medical tourism. These include improved disposable incomes, increased willingness of individuals to travel for health services, lower-cost air travel and the expansion of internet marketing – which is a major platform of information for those seeking and providing such treatments. Why do patients choose to travel overseas for treatments when evidence suggests that most patients prefer to be treated closer to home?32,33 Before this research was conducted, purported reasons to travel were said to include cost (e.g. dentistry), availability of treatment, privacy, perceived quality and for the purposes of combining treatment with an overseas vacation (especially for diaspora populations). For instance, UK patients may have to wait to meet NHS criteria on age or circumstance before being offered some treatments, or may be ineligible according to the current criteria [e.g. in vitro fertilisation (IVF), gender reassignment surgery, renal transplantation], and private treatment in the UK may be costly and not offer the range of preferred techniques and technology. Conversely, the reputation of private providers in the UK, and the perceived or actual quality of care in many countries, mean that in some areas of medical activity there is a desire for foreign nationals to seek treatment in the UK. Having completed the project, the evidence about decision-making and drivers is now on a far firmer footing.

Currently, medical tourism for the UK is limited to the private, out-of-pocket sector. However, there are important implications for a publicly funded and provided system such as the NHS. For instance, there may be a range of beneficial and detrimental consequences, such as cost savings from those voluntarily seeking care abroad, costs of follow-up care for those who have been treated overseas, and costs and benefits associated with patients travelling into the UK for paid treatments. There will also be a range of associated health impacts.

Research objectives

Media reports and speculation notwithstanding, we knew little about the historical and likely future development and impact of medical tourism for the UK NHS. The objectives of our study were to:

• generate a comprehensive documentary review of (1) relevant policy and legislation and (2) professional guidance and legal frameworks governing inward and outward flows of medical tourists to and from the UK

• better understand the information, marketing and advertising practices used in medical tourism, within both the UK and provider countries of Europe and beyond (and the benefits and drawbacks of them)

• examine the magnitude and economic and direct health-related consequences of inward and outward medical tourism for the NHS

• understand how decision-making frames, assessments of risk and associated factors shape health treatments for patients (including how prospective medical tourists assess provider reputation and risk) and to collate evidence on the role of intermediaries and brokers in facilitating medical tourism

• better understand treatment experience, continuity of care and postoperative recovery for inward and outward flows of patients

• elicit the views and perspectives of professionals and key stakeholder groups and organisations with a legitimate interest in medical tourism (exploring patient and professional choice, benefit, safety, harm and liability)

• map out the medical tourism industry and chart its development within the UK and assess the likely future significance for the NHS.

Research streams

A preliminary scope of the literature and practical issues identified four streams of evidence that would inform a better understanding of medical tourism and advise policy-makers on strategies to capitalise on its benefits and minimise risks it may present:

Research approach and methodology

The study involved integrating policy analysis, desk-based work, economic analysis and treatment case studies. We used a mixed-method approach of qualitative and quantitative data collection and the study included both primary and secondary data collection/analysis. Activity comprised a preliminary systematic review and broad data collection to address the four research streams. In this chapter we focus on the broad methodology, outlining why a number of data sources were required to understand medical tourism, and the challenges of implementing a project of this nature (see Appendix 2 for the study protocol). The research conducted for this project has been ambitious in that it was trying to establish the level of current evidence and knowledge in an area in which robust routine data are lacking. This required innovative approaches, including in the recruitment of patients but also in obtaining data on inward medical tourism through freedom of information requests. Specific issues with regard to the research process and sample sizes are addressed in this chapter. The entire research project adopted an iterative approach, with authors regularly reviewing methods for data collection. Data collected were triangulated with other sources to ensure that findings presented are an accurate reflection of the data.

The NHS fieldwork was undertaken in the English NHS [with primary care trusts (PCTs) and foundation trusts] although the medical tourists that we interviewed were located UK-wide (including Wales, Scotland and Northern Ireland). The IPS data relate to the UK whereas our trust data for economic costs relate to England. A number of the broader issues regarding outward medical travel and patient decision-making, safety and experience are common to the wider UK population but there are differences between how the English NHS and non-English NHS are organised (e.g. with regard to foundation trust status and commissioner/provider relationships). The policy directions on potentially expanding private care and the directive on NHS Global do not extend outside of the English NHS.

Interview process

As already described the recruitment of patients evolved and we revised the recruitment strategy several times. The different kinds of treatments that formed the basis for the case studies developed in the analysis were informed by findings from the initial systematic review of the literature. This identified bariatric, fertility, dental and cosmetic treatment and diaspora travel as types of procedures for which patients travel to receive treatment.

Initially, we had anticipated hip and heart patients as a further group of patients travelling for higher-risk and higher-cost procedures but, although these were targeted in our initial recruitment strategy, they proved much harder to identify. This is a likely reflection of the project’s UK focus as patients resident in the UK are unlikely to travel for high-cost and complex procedures given that these are available for free on the NHS. This is opposite to the case in the USA where patients may feel more compelled to travel for treatment for complex procedures given the high costs and much larger associated savings.

We made a conscious effort to interview similar numbers of patients across the different groups to maintain a balance within the findings across different treatment types and ensure that the findings can reflect on medical tourism overall, rather than specific conditions. Attempts to identify specificities and commonalities across treatment conditions also informed the analysis process described below.

Although the number of interviews gathered was in part determined by constraints in timing and challenges faced in recruitment, especially of patients, we stopped the interviewing process only once a saturation point was reached and no new themes were emerging from the interviews. Although the sample is not representative of all medical tourists, clear commonalities in motivation and experiences of patients emerged across the sample of interviews.

Interview analysis

Both quantitative and qualitative data analysis involves the common steps of data reduction (and data cleaning), data organisation and data interpretation. The study interview data were analysed using the ‘framework method’ of thematic analysis. 36,37 This allowed a search for conceptual definitions, typologies, classifications, form and nature (process, system, attitudes, behaviours) and explanations. 38 The study had clear research streams and specific questions that it sought to explore. We examined the data for particular ‘outliers’, searching for negative or disconfirming evidence that appeared to be inconsistent with the emerging analysis.

When consent was provided, all interviews were recorded and transcribed (see transcriber confidentiality agreement in Appendix 4). Transcripts were reviewed by four authors undertaking primary data collection and analysis (NL, DH, HK, JH). Interviews were grouped into categories defined in the study framework (e.g. professional associations or patients.). Patient interviews were further grouped into the following categories: bariatric, cosmetic, fertility, dental, diaspora and ‘other’ tourism. Authors read all transcripts and met to generate initial themes for the analysis. Themes were specific to groups of transcripts, for example themes for the analysis of fertility tourists differed from those used for professional associations. Once themes were agreed, one author took the lead on thematic analysis of the specific group of interviews and drafting of texts. These were then cross-checked by a second author to ensure accuracy and avoid bias. As a final step, completed drafts of the texts were reviewed and commented on by all authors.

Given the highly sensitive nature of the patient and provider data, we endeavoured to ensure the confidentiality and anonymity of individuals and organisations when reporting the findings.

Case study synthesis

The research design included treatment case studies that would allow the team to synthesise findings across the range of data sources (qualitative and, when possible, quantitative) and to draw together primary and secondary knowledge. Five case studies were developed: bariatric, fertility, dental, cosmetic and diaspora (see Section 3). Case study selection was informed by the review of the literature, which indicated that these areas were likely to be of value in understanding medical travel.

This method allows a better understanding of the varying specialties within medical tourism and the dynamics of patient consumer decision-making, risk-taking, and quality and safety of particular treatments. Multiple case study analysis also provides insight over and above that of individual case studies and has advantages over simply seeing the whole data set ‘in the round’. 39

Each case comprises around 10 interviews with patients to illuminate decision-making processes and treatment experiences (e.g. dentistry or bariatric). Cases included quantitative data analysis where possible, based on descriptive statistics covering aspects such as expenses incurred. Case studies also introduced analysis of relevant website and print advice (commercial and professional sources) for that particular specialism. The case studies drew on interview data from industry and clinical interests with a view to assessing current and emerging developments.

The case studies helped facilitate understanding of aspects of medical tourism that were treatment specific and those that were common across different types of treatment. This proved particularly valuable for the analysis of patient motivation and in the costing work. It also helped validate the data.

Ethics

We sought NHS ethical approval to interview representatives of NHS purchaser and provider organisations in the localities selected (managers and non-clinicians within PCT or foundation trust settings). The full ethics application ‘Implications for the NHS of inward and outward medical tourism’ was submitted to the Sheffield Research Ethics Committee for consideration and approval (11/H1308/3). Local research and development approval and appropriate letters of access were then gained for each of our final fieldwork locations (11 sites in total). Sampling for medical tourism patients did not require access to the NHS, nor patient records or materials. We sought clarification with the local National Institute for Health Research Research and Design Service and local NHS research ethics committee and ethics approval for patient recruitment was not required. We recruited ‘medical tourists’ through networks and snowball recruitment, not through the NHS.

Informed consent was a fundamental part of the study approach. Each interviewee was provided with details of the study (which they could retain) and asked to complete a consent form (see Appendices 5 and 6, respectively, for examples of these).

Fieldwork challenges

The project had a number of challenges. It included data collection in familiar health services territory (including NHS managers and professional associations and use of NHS financial information). But it also required fuller engagement with non-NHS interests and groups (non-NHS patients, commercial interests beyond the NHS). A range of data sources was required for the research team to meet its objectives and offer insight around decision-making, patient safety, economic implications and market and provider development.

Sourcing and completing interviews with medical tourists required significant effort, as well as intensive networking, patience and substantial persistence. In some areas of activity (e.g. cosmetic treatment) we recruited in a context in which media outlets would pay hefty fees for patient stories and testimonials. We were also talking about potentially sensitive issues across a range of treatment areas. Each strategy, network and site (detailed extensively in Appendix 7) contributed some part towards meeting our final sample target. The project team was supported by an advisory group (see Appendix 8 for advisory group terms of reference and membership).

For NHS managers, particularly those on the purchasing side, the impending reorganisation of PCTs provided recruitment obstacles. In two sites where we gained ethics approval, interviewees were unable or unwilling to participate in the research. Given the number of recruitment sites (up to 15), obtaining local research and development approvals and access was very time-consuming but necessary under existing governance arrangements.

Report structure

The report is structured as follows. The remainder of Section 1 provides a systematic review of the medical tourism literature (see Chapter 3), highlighting where major gaps in knowledge exist. Chapter 4 provides an introduction to the medical tourism industry. Drawing across all interview data (industry, overseas providers and professional associations, and medical tourists) it undertakes broader conceptualising to explore services involved, the ways in which information is sought, and supply/provider chains. Chapter 5 provides a critique of existing estimates and extrapolations around medical tourist flows and an analysis using IPS data provided by the Office for National Statistics (ONS).

Section 2 examines issues related to patient safety and service quality including the legal and policy context (see Chapter 6), education (see Chapter 7) and EQA and QISs (see Chapter 8), and synthesises interviews from professional associations and NHS managers.

Section 3 includes the treatment case studies. This section contains an initial synthesis (see Chapter 9) followed by five case studies of different treatments (bariatric, fertility, dental and cosmetic; see Chapters 10–13) and diaspora travel (see Chapter 14). The cases include patient interview data, wider interview data relevant to the treatment case (professional, industry, overseas) and material drawn from earlier sections.

Section 4 presents the data and discussion on inward patient flows of international patients into the NHS (policy and background, processes and perspectives) (see Chapter 15), outlines the economic considerations (see Chapter 16) and draws together the policy, management and research implications (see Chapter 17).

Introduction

Medical tourism – people travelling abroad with the expressed purpose of accessing or receiving medical treatment – is a growing phenomenon associated with processes of globalisation. 40 This includes cheaper and more widely available air travel and cross-border communication through the internet, which allows medical providers from one country to market themselves to patients in another. At the same time, increased movement of health workers for education means greater consistency of care offered in origin and destination countries. This has been coupled with an increase in foreign direct investment in health-care providers in destination countries, including by private medical insurance companies. In some instances, US private insurers now allow patients to have treatment abroad. The increasing acceptance of health-care portability is evident in Europe where greater patient mobility led to a EU directive1 on cross-border health care. Together with a rise in out-of-pocket expenditures for health in many high-income countries at a time of economic crisis, these factors (travel, communication, consistency of care, cost and an increased acceptance of the portability of health care) conspire to form a perfect storm for medical tourism.

As a consequence, even in countries with a universal public health-care system, such as the UK NHS, patients are now travelling abroad to receive medical treatment. Data from the ONS indicate that in 2010 63,00041 people travelled abroad for medical treatment.

However, understanding of medical travel is limited. Little is known about which patients choose to travel and why. Details of the volume of patient flows and resources spent remain uncertain. This has hampered efforts to understand the economic costs to and benefits for countries experiencing inflows and outflows of patients. 8 Similarly, the medical tourism industry and the role of private providers, brokers and marketing remains a ‘black box’. 40 Although interest in the issue has grown over the past decade, the effects on patients and health systems are not fully understood. Given the emerging nature of medical travel research, the evidence base is not yet clearly mapped.

This review of the literature aims to outline the current level of knowledge on medical tourism and to better understand this phenomenon, including its impact on the UK NHS. Specific objectives are to better understand patient motivation, the medical tourism industry, the volume of medical travel and the effects of medical tourism on originating health systems. These objectives informed the search strategy and review criteria set out in Appendix 10. The results of the literature review are reported and discussed with reference to subthemes that emerged; special attention is devoted to findings directly relevant to the NHS. Conclusions are presented on current levels of knowledge, critical gaps and future research priorities on medical travel.

Results

An increase in medical tourism research is evident from the prominence of the issue. In 2010 and 2011, five journals devoted special editions to medical tourism: Global Social Policy, Body and Society, Anthropology and Medicine, Tourism Review and Signs.

A rapidly expanding literature over the past 5 years (with an ‘explosion’ in 2010 and 2011) is reflected in the publication dates of papers reviewed, as evident from Appendix 12 (see Figure 9); 73 papers were published in 2010 and 2011. 40,42–45,47,50–52,54–57,59–61,64,67–78,80–95,97,99,102–104,107–121,123,125–127,129–133 This underlines the increase in medical travel and its importance as an issue in UK health-care provision.

Discussion

Perhaps the most surprising finding was the increase in number of papers presenting findings from primary research – a shortfall or gap that had been noted by the earlier literature reviews. 42,55,70 The recent publication date of many papers confirms the increasing amount of research being carried out on medical travel.

Medical tourism is a phenomenon in the private health-care market, which makes it hard to monitor and regulate patient flows. 137 Despite the rapid increase in number of publications over the past 2 years, reliable calculations of the actual volume of patient flow remain rare. This confirms findings from an earlier review,42 which also noted the lack of information on how the figures in the reports by Deloitte Consultancy17 and McKinsey12 were calculated.

The body of literature focusing on medical tourism as a trade in health services indicates that further research investigating levels of such trade is needed. Data on costs and benefits of medical tourism are rare and this limits accurate assessments of its effects to inform policy decision-making. Studies are also needed to empirically observe the effects of medical tourism in practice. The definitions of trade in health services provided,8 together with the framework for measuring its level provided by Siddiqi et al. ,116 set out a methodology for such research.

Understanding of the industry is limited. None of the research-driven papers captured the entire value chain of medical tourism. It is not evident how different industry actors (e.g. referring clinician, websites, facilitators, travel agents and receiving clinicians or hospitals) link together and how their relationships may influence patient experiences and health outcomes. Three papers referred to the role of medical tourism facilitators, drawing on small samples, demonstrating the need for further research in this area, especially to enable regulation or to address the ethical dimensions discussed in the papers reviewed. 118,131,133

Conclusions

This review provides a map of current knowledge on medical tourism and identifies a series of subthemes. The reviewed papers demonstrate the multidisciplinary nature of medical tourism research. There has been an ‘explosion’ in research on medical tourism over the past 2 years. This review clearly identifies limits to current knowledge; many papers remain hypothetical and there are many areas in which further research is needed.

There is still a lack of information on the background of patients and the numbers of patients travelling abroad for treatment. This limits insights into why some patients travel and others do not and restricts evidence about the possible costs and benefits of medical travel.

The absence of information on patients’ social, economic and demographic backgrounds hampers the ability to understand patient decision-making and determinants of travel. The studies reviewed indicate that motivation is complex. Further information is needed to fully understand this decision-making process. It is especially relevant to gain insight into why patients from countries with public health-care systems such as the UK choose to travel abroad.

Little is known about the industry beyond reviews of information materials and websites. Further research, especially qualitative and survey-based research, is needed to better understand how the sector operates and what its motives are to ultimately understand how it drives or affects trade in health services and health outcomes of medical travellers.

Although case studies of patients returning from treatment abroad with complications were reported, these did not quantify the potential cost of medical travel to the patients’ ‘home’ health systems. Given the evidence of an increase in medical travel such research is urgently needed.

There is no research examining the long-term health outcomes of UK medical tourists. Further qualitative and quantitative research, beyond immediate clinical outcomes, is needed to truly understand the effect of medical travel on patients and its cost to the health system.

Implications for the NHS

• There is a need to collect data on the number of patients who return from treatment abroad and are treated within the NHS.

• There is a need for additional surveys and quantitative research to understand more fully the volume of patients who travel abroad and their social and economic characteristics. This will enable a more accurate understanding of the scale of the issue and factors determining patient travel. These ‘push factors’ may in themselves hold valuable lessons that reflect on the NHS.

• There is a need for research to assess the long-term health outcomes of medical travellers to fully understand the effects on individual and population health.

Services

Medical tourism treatment pathways involve a number of services (both clinical and ancillary) that together give an overall experience. Although not all of these services are integrated in each and every patient journey, the variety of services illustrates the full range of possibilities:

• conferences and media activities: for example fertility trade fairs that market, inform and connect potential travellers with overseas services

• websites: prospective travellers use the internet to find out about medical travel and to support decision-making, including clinic websites, portals (which may contain details of numerous clinics) and consumer-driven sites such as chat rooms and discussion boards

• intermediaries: (facilitators and brokers) provide information (web-based and one-to-one) for prospective patients about treatments and services and make arrangements for treatment and services

• preconsultation: this may take place in the UK or abroad at a preliminary clinic undertaken by the surgeon or doctor, or screening may be provided by a contractor based within the UK

• treatment: (provided by clinics and hospitals) may involve outpatient treatment, day surgery or longer-stay hospital admission

• forms of accreditation: (available to clinics, hospitals and facilitators) seek to offer assurance around the quality and safety of products; accreditation is itself typically a commercial activity with competing accreditation bodies offering their services

• financial products: available to patients to fund the costs of travel and treatment

• insurance products: developed to insure for travel and loss, and seek to cover the costs of further treatments that may be required as a result of complications and dissatisfaction following surgery abroad

• travel, hotel and concierge: flights, accommodation (for accompanying family and companions, or for patient recuperation) and support services (e.g. translation) are purchased

• tourism and wellness: for some medical tourist destinations and treatments, attempts are made to promote the cultural, heritage and recreational opportunities

• aftercare: may be arranged within the treatment country or within the home country (including dressings, stitches, pharmaceutical arrangements, monitoring and follow-up).

There are particular stages in the treatment pathway during which issues arise that have a bearing on the NHS. First, can individuals obtain appropriate information to ensure that they are able to make an informed choice and ensure their safety? For example, is non-commercial advice and input available at trade fairs and on websites, for example travel guidance and checklists? Second, what advice should the Department of Health, commissioning bodies and GPs provide to individuals seeking to travel abroad? Finally, are appropriate aftercare arrangements made, given that there may be expectations of receiving NHS care and financial implications if aftercare services are required.

Information

Searching for information may be time-consuming, confusing and overwhelming. Individuals may be unclear how best to go about finding and validating trustworthy sources of information. Looking across the range of patient, commercial and stakeholder interviews, analysis identified three idealist models whereby prospective medical tourists gather information and source their destination and provider (see Appendix 13).

Clinical provision

Within medical tourism there is a diversity of participating clinics and providers [as Ackerman139 suggests, ‘cottage industries and transnational enterprises’ (p. 405)]. Providers are primarily from the private sector but are also drawn from public sectors. Relatively small clinical providers may include solo practices or dual partnerships, offering a wide range of treatments in areas such as cosmetic surgery. At the other end of the scale are extremely large medical tourism facilities in which clinical specialism is the order of the day. Hospitals may be part of large corporations or wider affiliations of general and specialist clinics. Although there are smaller independent, specialist clinics, it is these large complexes that dominate the Spanish industry.

Larger clinics and providers have moved to offer a range of services (financial products, insurance, hotel, translation, accommodation, aftercare) within a horizontally integrated supply chain. Services may be more loosely or fully integrated and emphasise upstream integration (finance, preconsultation, travel), downstream integration (recuperation, aftercare, follow-up) or both.

Country strategies

A range of national government agencies and policy initiatives (both in Europe and beyond) have sought to stimulate and promote medical tourism in their countries. Many countries see significant economic development potential in the emergent field of medical tourism. Before and during our fieldwork period we attended large international trade fairs and conferences supported by the Hungarian, Maltese, Croatian and Turkish governments, all of which sought to promote their comparative advantage as medical tourism destinations. In Appendix 14 we present a synopsis of what we assess their strategies and developments to be (drawing on provider and wider industry discussions, trade fairs and online information).

Implications for the NHS

• The wide range of clinical, ancillary and support services involved in medical tourism complicates efforts to inform and educate medical tourists, or to regulate aspects of the industry.

• Some European countries and beyond are seeking to explicitly market to prospective UK patients.

• There is strong competition, as well as volatility and changeability within mainland European provision, for some treatments.

• Medical tourists use a range of information points (intermediaries, direct and networks), which complicates practical attempts to improve information quality.

• The European market for medical tourism is dominated by solo practices and small providers, although there are some moves to national organisation and professional affiliation in some countries. Monitoring quality and outcomes across this range of providers (and outside of the large and publicly financed institutions) is problematic.

Problems with numbers

Authoritative data on numbers and flows of medical tourists between nations and continents are difficult to identify. Although there is consensus that the medical tourism industry has grown over the past decade, and that there are particular bilateral flows, there remains disagreement as to the current and potential size of the industry.

A key issue is that the primary source of data relating to numbers and flows is the industry stakeholders themselves. Given the possible scope of what is often a private and confidential industry in an increasingly borderless world, it is inevitable that the industry stakeholders are best placed to provide the most reliable information. The problem of course is that such information may not be reliable at all; aside from the fact that such stakeholders have a vested interest in presenting a picture of a vibrant and growing industry, those prepared to accurately record patient numbers, flows and profiles face a range of difficulties.

Whether estimates are taken from industry stakeholders, the grey literature or the academy, they are consistent in one respect: all of the numbers cited are either estimates or extrapolations. These estimates of the global numbers of medical tourists generally lie on a continuum between statistics published by the Deloitte management consultancy at one end of the spectrum and a more conservative estimate by McKinsey at the other. Deloitte placed the number of US citizens leaving the country in search of treatment at 750,000 in 2007 and this number was projected to reach somewhere between 3 and 5 million by 2010. 17,140 Given that US tourists are thought to represent roughly 10% of the global number of medical tourists,12 this would suggest that total worldwide figures would lie somewhere between 30 and 50 million medical tourists travelling for treatment each year. However, analysts at McKinsey suggest that, although the potential for such large numbers exists, a more accurate worldwide figure would be between 60,000 and 85,000 medical tourists per year,12 although these numbers do appear rather small and unrealistic.

The real problem when searching for reliable data is, as mentioned, that it is stakeholders with a vested interest who are providing the data. 141 So successful have these stakeholders been that their numbers and the numbers offered by Deloitte have transcended commercial literature, with Deloitte’s ‘750,000 Americans’ statistic being reproduced not only on commercial sites but also in grey literature as well as peer-reviewed academic literature. It could be argued that, by providing the parameters within which the industry is discussed (i.e. huge), Deloitte has managed to normalise the rather grandiose claims of organisations such as Bumrungrad International Hospital as well as countless national tourism boards.

None of this is problematic of course if Deloitte’s statistics are correct, but here we encounter a real problem. In both Deloitte’s original 2008 publication17 as well as in their 2009 updated projections,140 the numbers cited have not been generated by any scientific method. Indeed, the source of their numbers is simply an online article for India Daily,142 which simply states that 750,000 Americans will travel in 2007 and that by 2010 the number will reach 6 million. No evidence is offered; the figure is an estimate provided with no source of support and there is absolutely no suggestion that the figure has been reached as a consequence of any data collection. Approaching industry estimates with caution may seem like common sense, but it is important to note that such sources have also informed the wider grey and academic literatures, often being repeated in articles within well-respected journals.

So where should we look for data? Ideally we would look to well-designed, unbiased empirical studies from within the academy. Here, though, it is clear that there exists no credible authoritative data at the global level. The empirical work that has been published is generally small-scale and qualitative and these studies often avoid making market estimates. The reality is that no authoritative, reliable and unbiased data at the global level exist in the public domain. Although this cannot be fully addressed, the IPS can provide some illumination with regards to the flows into and out of the UK. The survey has some methodological flaws, especially in terms of how representative it is, but it is nonetheless an unbiased, quantitative source of data that allows time series analysis over the last decade.

The IPS, conducted by the ONS, collects information from passengers as they enter or leave the UK. Started in 1961, it aims to collect data on credits and debits in the UK balance of payments; provide information on visitors to the UK to inform tourism policy; provide data on migration; and collect information to help aviation and shipping authorities (IPS, J Hanefeld, London School of Hygiene and Tropical Medicine, 2012, personal communication). Passengers are randomly selected as they travel through passport control (entering or leaving) and a brief survey is administered. This includes basic questions about an individual’s age, sex, origin and destination, as well as questions about whether the travel is part of a package, with company or for business, the class of travel and the likely length of stay abroad or in the UK and likely pattern of expenditure. One of the survey questions asks passengers to define the primary purpose of their travel and ‘medical treatment’ is one of the possible answers, thus providing insight into the number of passengers travelling for this reason.

The main limitation of these data is the number of passengers sampled. In 2007, for example, 255,000 interviews were conducted, representing 0.2% of travellers to and from the UK overall. 41 However, given the absence of other reliable data on numbers of medical tourists, their characteristics and where they travel, the IPS does represent the single most comprehensive data quantifying medical travel to and from the UK. The IPS data have important limitations, which inhibit nuanced statistical analysis. As such, a more descriptive analysis is appropriate and, given the dearth of trustworthy data pertaining to medical tourism, is incredibly valuable.

Data from the International Passenger Survey

As Figure 1 shows, the number of people from the UK travelling to access medical treatment has increased steadily over the past decade. The number of patients travelling to the UK has held reasonably steady over the decade. (The IPS codes all passengers travelling from the Channel Islands and the Isle of Man as inbound medical travellers, that is, those coming to the UK to access treatment. As these patients are part of the NHS and are likely to have been referred for medical treatment to the mainland UK, these have been excluded from the sample of inbound patients to give an accurate picture of the numbers.) At the time of data analysis, figures for 2011 were available only for three quarters of the year, so are not included in the graph (see Appendix 15 for a regional breakdown).

FIGURE 1.

Line chart showing the numbers of people who travelled into or out of the UK for medical treatment during the period 2000–10.

Destination of UK outbound medical travellers

For UK residents who travel abroad for medical treatment, Northern, Western and Southern Europe are the most common destination regions, as evident from Figures 2 and 3, with France being the most visited country over the decade. Appendix 15 charts these trends over time.

FIGURE 2.

Pie chart showing total outward medical travel by UK residents by destination region over the time period 2000–10.

FIGURE 3.

Map depicting total numbers of medical travellers from the UK and their destinations over the period 2000–10.

Central and Eastern Europe are the second most popular destinations. Appendix 15 (see Figure 15) clearly shows high numbers of travellers visiting Poland, the second most popular travel destination over the decade, and the most popular in recent years with approximately 11,000 and 13,500 travellers in 2009 and 2010 respectively. It also indicates the popularity of medical travel to Hungary since 2006.

South Asia (primarily India) attracts large numbers of UK patients, making it the most frequently visited non-European region (see Figure 2). The most recent data show the relatively stable pattern of travel to India, Pakistan and (in much lower numbers) Sri Lanka and Bangladesh. Medical travel to East Asia shows a different pattern to that for South Asia. No medical travellers from the UK to East Asia were recorded by the IPS before 2003, when 1500 people travelled from the UK to East Asia. In 2010 > 4000 people made the same journey, which represents an increase of 171%. By 2010, 15% of all UK medical travellers went to East Asia. North America, the Middle East, Africa and Central and Southern America account for a small percentage of those undertaking medical travel.

As Appendix 15 (see Figure 15) illustrates, France, Poland and India are the most popular destinations for UK medical tourists, with France holding relatively steady, India demonstrating a gradual increase and Poland experiencing a rapid increase as of 2007. The French case may be explained as a historical and geographical option, with its proximity to the UK proving convenient alongside a familiarity of British holidaymakers with France. Similarly, both Belgium and Spain can be found in the top 10 destinations across the decade (fifth and eighth, respectively), perhaps for similar reasons.

Poland has demonstrated the largest surge in popularity and by 2009 was the most visited destination for medical travellers from the UK. This may reflect the fact that the UK is home to a large population of people with historic and familial ties to Poland, a population that has burgeoned considerably during the second half of the last decade. Although this is likely to be the case, the proximity to and accessibility of Central and Eastern Europe and the emergence of a reputation for high-quality cosmetic care (whether this is accurate or not) are also undoubtedly factors. Hungary, with a reputation as a leader in dental care, is, like Poland, easily accessible by low-cost airlines operating from the UK and is the fourth most visited destination by UK travellers. Similarly, the Czech Republic is the 12th most visited destination and, like both Hungary and Poland, has developed a reputation for particular types of treatment and is well served by budget airlines.

India has proven to be a popular and increasingly visited destination during the time period analysed, which, as with Poland, might reflect the fact that the UK has a large population with historic ties to India and that travel to this region has become much more accessible in recent years. Indeed, it may even be that those travelling retain Indian citizenship. Similarly, Pakistan was the 10th most popular destination for UK medical travellers, once again possibly a reflection of a large population of people in the UK with historic ties to Pakistan.

Inward medical travel

The largest numbers of inbound medical travellers are from Northern, Western and Southern Europe (Figure 4). Looking at individual countries, the greatest numbers of patients travelling into the UK for treatment are from Ireland and Spain and these two countries also show a growing trend of patients coming to the UK. In the case of Spanish (and perhaps French) residents, it is highly likely that a substantial number will be UK expatriates and it is unclear whether these engage in out-of-pocket medical treatment or whether they use NHS services. The numbers of Greeks and Cypriots travelling into the UK to access treatment rose rapidly in 2009 and 2010. This increase may be the result of the economic crisis, which in turn has meant severe public sector cuts including in health. 143

FIGURE 4.

Map depicting total numbers of medical travellers to the UK and their countries of origin over the period 2000–10.

A significant number of patients also travel from countries in the Middle East (specifically from the United Arab Emirates and Kuwait, although visitor numbers dropped sharply in 2008 and 2009 respectively).

Despite some variation over the years, a stable inward flow of medical travellers from Nigeria is also evident over the past decade.

Comparing numbers of inbound and outbound medical travellers from 2000 to 2010 (see Appendix 15), a trend in increasing outbound medical travel is visible. Despite a temporary drop in patients from the UK travelling to access treatment in 2008, the data show that the number of outbound travellers in 2010 exceeded the number of inbound travellers for the first time.

Characteristics

Most inbound medical tourists are in the age group 35–44 years (22%), with 18% of medical tourists between the ages of 45 and 54 years and 19% between the ages of 55 and 64 years; 16% were aged ≥ 65 years. A much smaller number of children and young adults were inbound medical travellers.

Interestingly, this differs from the demographic profile of those travelling from the UK to seek treatment abroad. Almost one-third (30%) of all UK patients travelling abroad are aged between 25 and 34 years, 20% are aged between 35 and 44 years and 16% are aged between 45 and 54 years. Overall, Figure 5 shows outbound medical travellers to be comparatively younger than those who travel into the UK to access medical treatment.

FIGURE 5.

Medical travellers by age.

There is also a difference in gender split between inbound and outbound medical tourists. More women than men travel out of the UK to access medical treatment, whereas a greater number of inbound medical tourists are male. This appears stable across the decade when looking at the average across 2000–10 and considering the last couple of years individually.

Discussion

Data analysis highlights the characteristics of inbound and outbound UK medical travel. The largest number of patients travelling into the UK are from Ireland and more than half of all UK patients travel to Europe (both Northern, Western and Southern Europe and Eastern and Central Europe) to access treatment, with France being the most popular destination country for UK patients when looking across the decade (see Appendix 15, Figure 15). This seems to confirm the importance of proximity for patient choice of destination observed in other empirical work. 85,116

It is also worth highlighting the fact that many of those who have travelled into the UK for treatment may be expatriates, especially those travelling from countries such as France and Spain. It is possible that this group of people may be using – knowingly or otherwise – NHS services when they are not entitled to do so. Given that such high numbers of inward travellers are from regions with high concentrations of UK expatriates, this issue deserves further study.

Travel to South Asia on the other hand has remained relatively stable over the past years. Studies that demonstrate the importance of diaspora linkages for medical travel87,94 may offer a likely explanation for this. Diaspora linkages could also be an explanation in the past for the large number of inbound medical travellers from Ireland.

Data confirm that the UK is a destination for medical travellers, including from the Gulf States in the Middle East (see Appendix 15, Figure 16). Taken together with the information available on age groups of inbound medical travellers, it may be likely that patients from the Middle East are accessing specialist care in the UK private sector.

Demographic factors such as age and sex of outbound medical travellers from the UK – comparatively younger and more women – could potentially indicate that cosmetic and fertility treatments are key areas of medicine for which patients travel, as has been shown in incidental reports102 and recent survey results. 104

Obtaining personal and provider information

To begin their treatment journeys, patients (at some point in their decision-making) may seek to obtain their own personal medical (or dental) records and attempt to ensure that they have adequate information about medical treatments available overseas. Individuals in the UK are entitled (under the Data Protection Act 1998144) to have access to their personal health information, including NHS and private health records held by a GP, optician or dentist or by a hospital (e.g. dental records and radiographs). An administration fee may be charged depending on whether records are held electronically or in paper format. Under the Data Protection Act, requests for access to records are required to be met within 40 days. However, government guidance for health-care organisations states that they should aim to respond within 21 days. A request may be refused if it is believed that releasing the information may cause serious harm to an individual’s physical or mental health or that of another person.

With regards to provider information, medical tourism services are marketed and advertised vigorously and a key driver for such promotion is the high-profile technological platform afforded by the internet for consumers to access health-care information and advertising from anywhere in the world. Within the UK, the advertising of medicines for human use is tightly legislated and is regulated by a unit within the Medicines and Healthcare products Regulatory Agency (MHRA). The advertising of treatment services, including medical travel abroad, is outside the MHRA’s remit of responsibility for medicines and devices.

Within the UK, health care has not traditionally been viewed as simply another product to be advertised. However, the marketing of domestic cosmetic surgery is increasingly commonplace in the UK (including billboards) and the Committee of Advertising Practice has released guidance on the interpretation of rules in the British Code of Advertising. 145 The Advertising Standards Authority (ASA), which is independent of the government and the advertising industry, is the main body responsible for dealing with complaints in the UK. The ASA investigates complaints and proactively monitors and takes action against ‘misleading, harmful or offensive advertisements, sales promotions and direct marketing’. 146 If a complaint is upheld, the advertiser must withdraw or amend the advertisement and not use the advertising approach again. The remit of the ASA includes online advertising for paid advertisements, marketing messages on a provider’s own website and marketing communications in spaces that include Twitter™ and Facebook™. ASA’s coverage is limited, however, to UK websites.

The ASA has on occasions ruled on domestic advertising of treatment services. For example, it ruled against advertising that promoted invasive cosmetic surgery as being without risk and ‘safe’. It stated that such content was irresponsible and misleading and breached clauses relating to social responsibility and truthfulness. 147 The body has also criticised a billboard advertising campaign that emphasised the speed and costs of cosmetic treatment because, in its judgement, this trivialised cosmetic surgery and conflicts with advice elsewhere in the advertisement about the need for consultation before surgery. 148

From the standpoint of professional standards, a major function of the General Medical Council (GMC)149 is to foster good medical practice. Its good medical practice guidelines150 contain a number of implications for treatment promotion and marketing, noting:

If you publish information about your medical services, you must make sure the information is factual and verifiable.

You must not make unjustifiable claims about the quality or outcomes of your services in any information you provide to patients. It must not offer guarantees of cures, nor exploit patients’ vulnerability or lack of medical knowledge.

You must not put pressure on people to use a service, for example by arousing ill-founded fears for their future health.

Reproduced with permission from GMC. Good medical practice 2006. URL: www.gmc-uk.org/Good_Medical_Practice_Archived.pdf_51772200.pdf (accessed 9 September 2013). © GMC.

It should be noted that the 2006 guidelines, quoted here, were withdrawn on 22 April 2013 and replaced with an updated set of guidelines (see www.gmc-uk.org/gmp for the latest edition). The GMC also has responsibility for keeping an up-to-date register of qualified doctors and seeks to deal firmly and fairly with doctors whose fitness to practise is in doubt.

The EU E-Commerce Directive (2000/31/EC)151 has implications for website quality and requires all companies to display ways in which the website can be contacted. The European Court of Justice has ruled that this may include a telephone number and a contact form that is answered within an hour. The ruling impacts on e-businesses operating within the EU and requires that the name of the service provider, the geographical address of the service provider and service provider details including the e-mail address where it may be contacted at short notice must be provided before a contract can be entered into through the website. As our own review of websites found, many European sites (but not all) adhere to these requirements and the vast majority carry clear privacy statements on how personal data are protected.

Potential medical tourists face the dilemma that there is no guarantee of the veracity or legitimacy of claims made on websites. Treatment outside of jurisdiction poses problems for the effective regulation of advertising and promotion. Although the ASA will refer complaints about advertising that originate from outside the UK to the European Advertising Standards Alliance (covering 24 European countries) and to some countries outside of Europe (including India), the reach of these is unlikely to prevent companies breaking regulations through their internet-based advertisements. The sheer number of websites operating in the medical tourism field further complicates the issue. Similarly, cross-border complaints against GMC-registered clinicians operating outside of the UK are less likely to result in charges than if such individuals were practicing within the UK.

In summary, the rise of medical tourism has been a largely online phenomenon and it is the internet that provides the arena in which all key stakeholders (from the patients, through the facilitators, to the providers) can interact. In the offline world where such decisions are taken in doctors’ surgeries and hospitals, there is at least a sense that information is authoritative, impartial and trustworthy. There is a general appreciation of the existing and potential problems related to health information on the internet, especially given the increasing quantity of health-related websites. Issues of accuracy have long been a concern, although perhaps compounded by the burgeoning number of sites whose primary purpose is to market products rather than inform. What is less clear is how (if at all) the quality of information provided to medical tourists should be regulated, with suggestions beyond legislative control ranging from codes of conduct to self-taken quality labels, user guidance tools and third-party quality and accreditation labels.

Legal redress

The lack of an internationally agreed framework to regulate medical tourism or offer legal redress begs a number of difficult questions concerning:

• the grounds for seeking legal redress

• who is responsible – the clinic, surgeon or broker?

• in which jurisdiction to seek redress

• the time frame to seek legal redress.

It is common practice in many countries for a patient to sue for negligence if he or she has suffered avoidable harm as a result of poor-quality medical treatment. Under the law of ‘tort’, a patient may seek compensation if he or she can provide proof of fault. He or she can also claim under a breach of contract. The grounds for seeking redress vary from country to country. For example, in the case of an Australian citizen,152 domestic legislation would provide an additional third potential route for redress in the form of action under the misrepresentation of Trade Practices (contracts) Act 1974,153 which in January 2011 was replaced by the Competition and Consumer Act 2010. 154

In the UK, treatment is considered negligent if the court accepts that a patient has suffered injury and loss as a result of the negligence, or that the doctor or surgeon is in breach of his or her duty of care to the patient and has failed to act in accordance with the accepted standards of a competent practitioner in his or her area of expertise. 155 However, some foreign companies may insist that medical tourists sign a legal disclaimer before their treatment. These may include clauses that seek to limit where a case can be held, the law that governs the claim and liability limitation, which can reduce potential options for redress. (An emergent area of specialist legal services provides clients with the opportunity to seek legal redress for adverse outcomes of medical tourism. Some legal practitioners specialise in particular treatments, for example fertility treatment abroad.) In the UK, exemption clauses that exclude a doctor or clinic from liability for negligence are not enforceable and disclaimers are subject to legislation governing the fairness and legality of their contract terms.

When attempting to sue for medical malpractice abroad, there are decisions to be made about who the patient should sue (clinic, surgeon or facilitator) and the particular jurisdiction where any legal case would be heard and the laws and legislation that would be used. Ordinarily, when both the patient and the clinician are within the EU, the clinician has to be sued in his or her home country. However, as patients are likely to be considered as consumers, under EU consumer contract rules they can opt to sue in their home country. 155 Clinics outside of the EU would be subject to the same issues discussed above, for example if they advertise in the EU they can be sued in the EU.

The case for seeking legal redress in the UK is strengthened if any initial consultations, written consent or the signing of contracts or payment have taken place within the UK. 155 A clinic that consulted in London and treated in Belgium was recently successfully pursued using grounds of negligence and breach of contract. 155 The initial consultation was in English, the contract was signed and agreed in England and payment was made in sterling. For litigation purposes it can work in a patient’s favour if an overseas clinic has advertised within the UK. Clinics that specifically target UK citizens, for example by advertising in the UK, having an office based in the UK or having a ‘.co.uk’ website address, may become subject to the jurisdiction and laws of the UK, which has implications for litigation. Overseas clinics with a UK base or a UK-targeted advertising campaign may not be fully aware of the implications. Payment for treatment using a credit card could allow a case to be brought in the UK against the consumer credit card company under Section 75 of the 1974 Consumer Credit Act. 156 This route has been pursued for the cost of replacing Poly Implant Prosthèse (PIP) implants in cases in which the surgery was undertaken in the UK.

Beyond the liability of brokers, surgeons and clinics, questions arise with regard to potential liability issues for UK-based health professionals (e.g. within the fertility field). For example, when the initial consultation and advice are delivered privately in the UK but treatment is subsequently obtained overseas, albeit recommended through the UK facility, who is liable? Under such circumstances, should UK facilities be expected to accredit physicians within their overseas treatment network (and, if so, how would they do this)? Are such UK health professionals likely to be subject to vicarious liability if complications arise from treatment, or is this avoidable through their clear statement of disclaimers?

Medical clinics are normally liable for the failings of their employees, including surgeons. A clinic is usually responsible for advertising and arranging a patient’s treatment and the patient’s contract will be with the clinic. It is therefore the responsibility of the clinic to pursue litigation against a surgeon if it so wishes. As Vick155 states: ‘despite offering the package of care to the patient clinics may seek to divert blame to surgeons with whom the patient had no contract’ (p. 108). Even if the surgeon is registered with the GMC in the UK, his or her indemnity cover [with the Medical Defence Union (MDU) or Medical Protection Society (MPS) in the UK] is unlikely to cover treatment undertaken outside the UK. 157 Conversely, the surgeon’s insurance may not cover the clinic and thus clinics must also ensure that they have adequate insurance in place. If a clinic is not insured for a case brought in the UK, it may not be possible to enforce a judgement in a UK court and turn the award into financial payment. Once liability is established, it may be necessary for the patient’s legal representative to apply to the court in the clinic’s home country for recognition of the UK judgement and permission to enforce it in that jurisdiction. 157 Finally, in some cases the jurisdictions of both the patient and the clinic may be applied.

A patient may have to pursue legal action in the country where the operation took place. This could result in the patient having to return to that country and having to instruct a specialist lawyer in that country, all at extra personal expense. If a patient seeks legal action abroad he or she must be prepared to deal with complications related to language, local culture and unfamiliar law and legal traditions. Some argue that there is a particularly high risk of foreign patients not being adequately protected from malpractice in developing countries. 26 Patients should be made aware that other countries might have different malpractice laws and legal traditions and that these will impact on the size of malpractice payouts. For example, Malaysian standards for proving medical negligence are said to defer to physicians to determine whether the standard of care has been breached, rendering it extremely difficult for foreign patients to successfully prosecute. 26 In India a civil case could be brought using the Fatal Accidents Act158 and Section 357 of the Code of Criminal Procedure159 (or via a consumer route under consumer protection legislation); however, 95% of cases are said to be dismissed because there is not a culture of professional critique. 160 Favourable judgements handed down in an overseas jurisdiction may therefore be very difficult to enforce. Some countries may have a damages cap on the amount of compensation or may not allow compensation, for example for loss of earnings or the cost of care. For example, in India the level of compensation is likely to be extremely modest compared with Western standards. 26 In the UK and many other jurisdictions, for example, when a patient is awarded compensation this usually includes general damages for the psychological and physical consequences of the negligence and special damages for past and future financial losses incurred from the negligence. 157

A further issue concerns the time frame within which legal redress may be sought, which varies from country to country. Adverse after-effects arising from a particular treatment may not occur for several years, for example as has been the case in the recent PIP implant debate. 161 As illustrated by the PIP events, surgeons may be difficult to trace and clinics may no longer be in business. 162 In the UK the deadline for filing a personal injury claim is 3 years from the treatment or the patient’s date of knowledge of complications, but other countries may have shorter time frames for seeking legal redress. Even within the EU the time limit varies, for example from 1 year for claims in Spain to 3 years for claims in the UK. 155

In summary, we are entering relatively uncharted and rapidly changing territory with regards to the legal dimensions of outward medical travel, and the increased use of the internet further complicates this legal uncertainty (see Appendix 16 for a discussion of this in relation to fertility treatment). There is no clear legislative picture or developed body of case law to guide practice in this area. There are clear limitations in the current legal framework that blunt one point of the medical tourism safety and quality diamond. Although cases have been successfully argued (see Appendix 17 for an example), patients looking to rely on the existing UK framework in the event of adverse outcomes should be warned: caveat emptor – buyer beware.

Implications for the NHS

• Prospective patients may not be aware of the lack of clear avenues for redress should treatment abroad give rise to unexpected complications.

• Legal uncertainty and complexity bedevils all phases of treatment abroad: access to information, preconsultation, treatment itself, aftercare and follow-up.

• Longstanding safeguards for UK health care (e.g. GMC registration) may have little relevance if treatment is received out of jurisdiction.

• The need to seek redress and the subsequent legal implications may become apparent many years following treatment, when complications have emerged.

Website analysis of outward medical travel

A key driver of medical tourism is the platform provided by the internet for consumers to access health-care information and for advertising. The aim of the following discussion is to provide a systematic review of medical tourism websites, describe their range and content and begin to examine their quality and the implications of this in relation to decision-making.

We first present an overview of medical tourism websites and a conceptual framework to understand these. This is followed by a detailed review of 100 commercial medical tourism websites for dental tourism using checklists adapted from proposed questions that consumers should ask, according to a number of national-level bodies. Finally, we present a consideration of the broader implications of these findings.

There has been a burgeoning of websites dedicated to providing information for medical tourists in recent years. Although restricting its coverage to English-language websites, one scoping study suggests that a useful typology of websites can be drawn: (1) commercial portals (to aid the search for treatments and information about them); (2) media sites (e.g. carrying weekly features and updates); (3) consumer-driven sites (including discussion boards and blogs); (4) commerce-related sites (advertising ancillary products such as finance or accommodation); and (5) professional contributions (from professional associations, policy-makers and regulators). 90

Medical tourism websites perform a range of functions. First and foremost the scope of the websites is to introduce and promote services to the consumer. The main functions of the websites can be separated into five main processes: as a gateway to medical and surgical information; to provide connectivity to related health services; for the assessment and/or promotion of services; commerciality; and an opportunity for communication. 90

The range of medical tourism websites and related content raises familiar concerns associated with unregulated online health information. 163–165 The sites are relatively cheap to set up and run and contributors may post information without being subject to clear quality controls. A contextual deficit means that selective information may be presented, or information may be presented in a vacuum, ignoring issues such as the need for and availability of postoperative care and support. There is also the possibility of unreliable products being marketed via the internet: poor-quality surgery or inadvisable treatments or unnecessary and even dangerous medical care.

Clear evidence from other studies suggests that the quality of health information online is variable and should be used with caution. There have been some suggestions that the quality of information has been improving as a consequence of the increasing use of peer reviewing of information on increasingly interactive websites;166 however, it is still best characterised as being of variable and suspect quality. 167–169 In one study concerned with the quality of information on the internet pertaining to inflammatory bowel disease, researchers found that only 14% of websites offered high-quality information. 170

A review171 of patient-oriented methotrexate information on the internet found many of the same issues identified by Bernard et al. ,170 especially that the level of technical language was restrictively high and so not easily understandable by prospective consumers. However, this study did note that there were some examples of extremely high-quality information that were not only available but also presented on the first page of the Google™ search engine returns. One of the issues that they identified was not that information supplied by websites was erroneous but rather that some of the information that experts would expect to be provided was simply missing. 165

It is of course possible that missing information simply reflects the specific focus of a website or perhaps is even a reflection of frequently asked questions (FAQs) posed of a site. However, there is also the scope to provide misinformation simply through the omission of important information. Mason and Wright95 suggest that this is a very real concern where medical tourism websites are concerned. Their review of 66 medical tourism websites noted a distinct overselling of the positive aspects of medical tourism and a significant downplaying of the risks.

Discussion

The rise of medical tourism has been a largely online phenomenon and it is the internet that provides the arena in which all of the key stakeholders (from the patients through to the facilitators to the providers) are connecting. But it is not necessarily a safe arena; in the offline world where such decisions are taken in doctors’ surgeries and hospitals there is at least a sense that information is authoritative, impartial and trustworthy. The internet does not offer this and it is hard not to see the marketing interests behind even the most reassuring information found on the internet. With regard to the websites that we reviewed, there were many affirmations of integrity, quality and caring services. There was an abundance of guarantees of professionalism, safety and a continuation of care. However, there can be no assurance that such guarantees are anything but empty promises. How we reconcile the potential of the internet, its endowment of individuals with ever-increasing levels of choice, with the risks inherent with an unregulated and uncontrollable content in a way that empowers patients is unclear and undoubtedly not straightforward.

Evidence shows that health-care consumers increasingly use the internet to access both information and health-care products and that an even greater proportion of people would consider doing so. 172 This includes people who are using, or would consider using, the internet to organise treatment abroad. 173 It is evident that information is often confusing, overwhelming and even contradictory – a fact that is acknowledged by many health-care regulatory bodies. 137

Medical tourism is a consumer industry primarily marketed online and as such there are serious potential issues facing those considering travelling abroad for treatment. Issues of accuracy are longstanding, although perhaps compounded by the burgeoning number of websites whose primary purpose is marketing products, as is the case with websites that promote medical tourism. It is common to identify misinformation, unsubstantiated scientific claims, fear-provoking threats and a lack of information on the uncertainties and the risks of particular services. On the whole, websites do not mention long-term risks or problems, limiting themselves to acknowledging that further treatment may be necessary as a consequence of hitherto unknown circumstance. 95,174

Whether or not it is possible to guarantee a universal minimum standard for the quality of medical tourism information is unclear. To this end, suggestions range from the development of codes of conduct, user guidance tools and third-party quality and accreditation labels,166 to educating users and assisting those wishing to search for information. 164,165,169 However, a large and ever-increasing number of quality measurement tools (many of which represent commercial ventures) exist, which makes selecting an authoritative tool impractical. Moreover, many of these systems are not accessible to a lay audience. 175,176

Some studies also recommend that prospective e-patients or e-health consumers should be educated by their ‘offline’ medical professional. Lawrentschuck et al. 169 go as far as to suggest that professionals should take the time to provide a steer to ethical, accurate, readable and accessible websites. This is echoed by Scullard et al. 165 and both studies make the recommendation that, if health-care professionals can direct patients to government websites or other such reputable sources of information, patients will be able to minimise risk. There are of course several problems with this approach. First, patients are motivated on the basis of what they find on the internet, rather than from having visited a health-care professional offline. Second, even when potential e-patients/consumers have visited health-care professionals it is not necessarily the case that these professionals will be aware of reputable sites beyond perhaps the broad and often general sites such as NHS Direct. Third, some of the sites assumed to conform to quality-based expectations do indeed fall short.

Others argue that debates over the quality of information should simply ‘move on’. 166 The new features of many websites brought about by the advent of Web 2.0 have, they insist, inspired a ‘health 2.0’ to emerge. They argue that the increased interactivity through the use of blogs, wikis and podcasts, often provided by not just health-care professionals but also researchers and the general public, has helped formulate a new e-health era that is tailored to the needs of those who access it. Crucially, this ‘bottom-up’ approach involves a process that is analogous to peer reviewing, drawing on real-life experiences, but always ensuring that an expert source is nearby. However, the findings of our study, alongside with other findings mentioned in this discussion, suggest that, at least for those new to searching the internet for health information, there is a lot of poor-quality information that is likely to be found, and discerning what is useful and what is not is no easy task.

It is perhaps easy, albeit misleading, to think of the relationship between patients and health-care providers having fundamentally and irrevocably changed as a consequence of the internet. Even now there is a feeling that word of mouth is still the main driver behind new patients registering with dental practices177 and that this relationship of trust between professional and patient may hold the key to how the internet can be best harnessed for patients, with trusted professionals playing a larger role in providing health-care information online.

Analysis of medical tourism travel information, advice and guidance

Given that web-based resources have clear commercial interests, prospective medical tourists may seek to look towards more objective impartial advice. Travel for medical treatment combines both the potential uncertainty of travel arrangements (travel delays and cancellations, risks to personal safety) and the risks inherent in receiving medical treatment. We sought to understand the range and nature of travel advice that prospective medical tourists could access to assist them in making informed decisions about overseas travel for treatments.

An internet-based search was conducted to determine where potential medical tourists are able to find information, advice and guidance and what that may include. The research team identified and discussed the potential professional, regulatory and policy organisations in which there were clear implications of medical tourism or that had commented, published or spoken about medical tourism. These sites, alongside those suggested by a broader search of keyword combinations (‘guidance’, ‘guidelines’, ‘advice’, ‘checklists’, ‘travel’, ‘treatment’, ‘surgery abroad’, ‘medical tourism’), contributed towards the corpus. We also explored the sites of consumer/advocacy organisations and during our website review (see Appendix 20) recorded sites on which guidance and advice was offered by commercial providers and entities. When repetition was evident within these searches, and leads did not provide additional sites to investigate, we took this to signal that data saturation had been achieved.

A total of 30 websites were identified as potential sources of information, advice and guidance; these were reviewed for their content about medical travel. The sites can be grouped into four different types: professional, regulatory, consumer and commercial. Table 4 details a small, non-exhaustive selection of organisations that offer information, advice and guidance regarding medical tourism. These are grouped based on the primary role of the organisation, although there is likely to be some overlap, especially between professional and regulatory organisations.

Half of the professional sites did not contain information, advice or guidance about medical treatment, medical travel or medical tourism. Regarding the information, advice and guidance that was available to medical tourists (in particular from professional and regulatory bodies), such material was often difficult to find, requiring specific searches within organisation websites, and was rarely signposted from industry sites. Information, advice and guidance were in a number of formats and the depth and quality of advice varied considerably. Information and checklists are the most common formats across all types of sites, but a few sites from across the types include guidelines or FAQs sections. A total of 14 sites provided detailed information, advice and guidance specifically related to travelling abroad for treatment.

The FAQs across the websites vary from focusing on practical questions that prospective patients are likely to ask, such as ‘how do I know if the clinic is clean and safe?’,178 to more generic ones about the industry, such as ‘what types of treatment do people travel for?’179 Guidelines often take the form of information provision, such as the British Association of Aesthetic Plastic Surgeons consumer safety guidelines. 180 Checklists and ‘questions to ask’ are tick box exercises that attempt to ensure that patients have all of the information, advice and guidance that they need. A more detailed analysis of the advice, information and guidance can be found in Appendix 20.

Implications for the NHS

• There remain doubts about whether or not website information facilitates treatment choice which ensures that care is ‘effective, personal and safe’.

• The risks of treatments are not fully detailed; unsurprisingly, there exists an imbalance of information and marketing material.

• A range of UK advice exists for prospective travellers; typically, this focuses on treatment decisions and does not clearly identity the lack of a clear framework for redress and that patients may be personally liable for treatment costs that do not fall within NHS entitlements.

• The onus is on prospective medical tourists to locate guidance and advice.

The importance of external quality assessment for medical tourism

There is a diverse range of different types of EQA and regulation employed by organisations (for a full review see Appendix 22) and consumers are therefore likely to feel confused and anxious when trying to assess which clinic to access.

When making a decision about which clinic and surgeon to select, medical tourists are likely to expect safe treatment as a minimum and are also likely to be motivated by considerations including quality and cost. How best to judge quality and safety is one of the most difficult issues for a prospective medical tourist to address in their decision-making process. In searching for providers, there is a plethora of labels and symbols (on website and marketing materials) professing some form of accreditation, certification or professional registration. However, few would understand the bewildering array of EQA and badges used by different companies and countries. With a lack of international regulation or legislation governing this field, providers and patients alike may look to accreditation and certification to prove their standards and inform their decisions respectively.

As part of our investigation into this area, empirical research was undertaken to examine the role of accreditation and certification used by providers. A systematic review of websites for dental, bariatric and cosmetic surgery was undertaken to understand how they reported their EQA and registration status.

Quality information systems

The public release of information on the absolute and relative performances of health-care providers may improve the quality of care and promote transparency and accountability among health-care consumers and payers. 185,186 There is a range of information systems reporting on the quality or performance of providers of health care (‘quality information systems’) that could, plausibly, be of value to prospective medical travellers.

Quality information systems may have multiple aims and objectives including facilitating patient choice, improving quality by changing provider behaviour and systems, and providing greater clarity and accountability for provider–commissioner relationships. However, development of such systems is patchy, particularly among those countries that are lower-cost destinations. 185 Aside from the availability of such information, evidence suggests that there is a low uptake of published information, it does not sufficiently meet patients’ information needs and it is not easily understood. 187–189

With regard to the UK context, for example, there are a range of dimensions for the publicly funded system (Table 5). However, it would appear that relatively few systems exist that are publicly available and accessible for the prospective medical tourist and facilitators seeking to arrange travel to other EU and non-EU countries. For example:

• Thailand. There are no clear information portals or sources that gather/compare health-care providers for purposes of statutory reporting requirements. Beyond a site provided by the Tourism Authority of Thailand that lists hospitals and other providers of medical services, there is little available information. There are numerous privately owned websites, but information is descriptive with regard to the services, treatments and facilities that are available. Information is not routinely collected/published for key indicators by national or regional agencies and so meaningful comparison across facilities is difficult (e.g. infection, outcomes, adverse effects).

• Spain. There are numerous commercial sites providing details of hospitals and facilities, which may include statements about the quality standards that are held by institutions. The Ministry of Health website provides information on the Spanish NHS system; however, there does not appear to be a solid information system on quality. There are extensive reports on accreditation and quality in terms of patient safety but there are no comparisons between providers.

• India. Although it is possible to identify > 5500 hospitals by region, there are no clear quality assessment results. There are commercial search engines but no QIS data that would facilitate an informed choice. The Ministry of Health and Family Welfare, the governmental body that looks after quality control in hospitals and clinics, is said to be establishing minimum quality standards to reassure patients seeking treatment abroad.

• Cyprus. Most large health-care providers are owned by the public sector and there are no clear comparisons between them. On the Ministry of Health website there is a section that is supposed to provide statistical information on hospitals but it does not work in either English or Greek. Again, most of the websites that list providers are international ones for promotional purposes.

• Poland. Nothing was identified that details information on quality or allows comparison between providers.

Implications for the NHS

• There is a plethora of EQA and registration details displayed on websites.

• There are no clear patterns in take-up of different EQA forms, perhaps reflecting that European clinics within the medical tourism market are relatively small.

• How EQA and registration details are presented assumes significant health literacy by website users.

• EQA does not fulfil the function of providing relevant signposting to patients.

As part of the research, 16 representatives of professional associations and agencies (including Royal College and Clinicians’ Associations representatives) were selected in a purposeful sample based on their knowledge and experience of the possible impact or consequences of medical travel to and from the UK and were interviewed. We also interviewed individuals within NHS commissioning organisations to explore issues and implications for the NHS arising from UK populations travelling abroad for treatment. These included six NHS managers based in PCTs and strategic health authorities (roles included director of public health, head of commissioning and community partnerships). Further, we spoke to a small number of NHS clinicians who wished to share their insights on specific issues arising from medical tourism (in bariatric surgery, hepatology). Overall, the aim was to better understand the impact of medical travel on the UK NHS including considerations around the patient safety and service quality diamond: legal, education, EQA and QIS dimensions. The detailed data are provided in Appendix 23. In summary:

• Specialists (often in the private sector), dentists and cosmetic clinics are likely to see a greater number of complications and follow-up cases after treatment abroad, whereas GPs or NHS clinicians are likely to interact with a comparatively smaller number of patients.

• The recent PIP breast implant scandal is an example of how there can be a significant delay in complications, making it harder for patients and doctors to contact the original treating physician.

• Adequate mechanisms to collect information about the ongoing costs of medical tourism are required to sample GPs, private clinics, dentists, accident and emergency (A&E) departments, NHS surgical facilities and infectious disease facilities.

• There is a need to clarify the role of the new strategic NHS Commissioning Board and clinical commissioning groups in providing information, advice and support with regard to medical tourism.

• There is a need to clarify the role of the Care Quality Commission (CQC) with regard to upholding the quality and safety of care provided to outward medical tourists.

The NHS

Across each treatment type our respondents all had something to say about the NHS. Their responses (whether positive or not) usually reflected whether or not they had ‘got what they wanted’ out of the NHS. Of course, given that we have sampled only those who have travelled abroad for treatment, opinions will be skewed towards those who did not get what they wanted. Despite this, discussion around the NHS was not wholly negative. Indeed, there are many examples of people praising the support of NHS staff throughout their treatment journey, even if they had been initially disappointed to learn that their treatment could not be provided on the NHS:

I have an extremely, extremely lovely doctor and she gave me all my medication for free. I’ve been able to consult with her all the way through from the very beginning. She’s the best doctor that I’ve ever had.

FT3

When I came back I told him I’d had the surgery and what had taken place and he has been very supportive since that.

BT6

Yeah, I’ve spoken to my GP about it. I do get a lot of help from my GP and he does give me tablets to try and counter my weight problems.

CT6

Discussion of the NHS loosely fell into three subthemes: availability, distrust or dissatisfaction, and aftercare. We will discuss in more detail the issue of availability in the section on motivations but, in brief, the overwhelming majority of our sample travelled abroad mainly because they could not access their desired treatment in the UK. However, even within this common theme there exists much variance: for some, treatment was simply not practised or not commonly practised within the NHS (most notably with bariatric surgery) whereas, for others, the treatment was available but they were not eligible. In many cases issues of eligibility and whether the procedures were regularly performed within the NHS were less prominent than the waiting times to access treatment. Here, we encounter yet more variance, with some suggesting that the long waiting times had been conveyed by professionals, others hearing from friends, some reaching this conclusion having read published figures and others appearing to have simply assumed long waiting times:

With regard to the egg donation I was told [by a friend] there’s a five year waiting list at that time for eggs.

FT4

I then had to wait a long time on the waiting list. I would phone up the secretary and see where I was on the waiting list to be pretty much told there are people with cancer out there and you’re not a priority [. . .] I’d been told that I was going to be done in the January and then in January I was told June and I thought I don’t think I can hang on till June.

BT8

The second subtheme that emerges clearly from our interview data related to the NHS is that of distrust or dissatisfaction with previous treatment. Interestingly, those who held such views were often those who had cultural or familial ties to other health systems (e.g. OT2). This was also linked with treatments for which there is no NHS eligibility/provision, such as cosmetic surgery or cosmetic dental treatment, rather than fertility or bariatric surgery. Indeed, this distrust was not confined to the NHS, with many of those who talked of distrust or dissatisfaction extending that feeling to private provision in the UK as well: ‘So I actually went to see a private dentist and I always thought I’d get better and prompter treatment and that is just an illusion’ (DT3).

The issue of aftercare in the NHS was also discussed, sometimes at length, by a range of respondents. Again, those who had travelled for procedures that they may have hoped or even expected to have been provided on the NHS, such as bariatric or fertility services, generally had some form of interaction with the NHS on their return as part of some ongoing care. In many cases this was care that would not have been needed (although other care may have been needed at some stage) and can be described as a pressure on NHS resources entirely as a consequence of medical travel. How NHS staff were described as responding to this desire for post-travel care seems to differ depending on what type of treatment our respondents accessed abroad. Those who travelled for cosmetic or dental work were less likely to seek NHS aftercare, but those who did were less likely to be provided with aftercare than those who had travelled for bariatric or fertility treatment. The response to bariatric travellers was much more varied than the response to those who had travelled for fertility treatment. In their entirety, our fertility sample all accessed NHS antenatal care and in many cases neonatal care. In each case, irrespective of any previous frustrations with NHS ‘rationing’, respondents were wholly positive of the antenatal and, when relevant, neonatal care that they received. There was a sense from both cosmetic and bariatric travellers that there was unwillingness on the part of individual GPs to engage with them after they had travelled for treatment. Whether this was genuinely the case or simply perceived is hard to ascertain; however, as the literature suggests, some GPs may be mindful of assuming responsibility, and perhaps even clouding issues of liability, by providing aftercare. 190 On the other hand, some of our respondents simply never visited their GPs on their return.

I went to a private doctor at a skin clinic and got antibiotics and just paid £20 for them rather than go to the NHS. Mainly because of my pride really. I don’t want a GP waving his finger and going you shouldn’t have done it and I told you so.

CT4

Interestingly, no respondents who travelled for fertility treatment mentioned any examples of unwillingness on the part of the NHS to provide continuation of care that had, in essence, begun overseas.

Motivations for travelling

Cultural/familial

We interviewed members of the Somali and Gujarati communities regarding their experiences of travelling for medical treatment; here, the issue of diaspora was prominent, but these were not the only interviews to touch on this subject. An ability to speak a certain language, the existence of family members in the vicinity of the health-care facility or, in the case of some of those who travelled for fertility treatment, phenotypical similarities with likely donors were all important motivators for travel and, most importantly, for determining where to travel. Such considerations were not confined to a particular treatment type and undoubtedly reflected the sample who we recruited.

Figure 8 provides a graphical representation of the various motivations cited by our sample and the relative importance of each within our bariatric, fertility, cosmetic and dental samples. This underscores the point raised that many of the motivations were common to all treatment types; however, the relative importance varied between our treatment case studies. The graphic represents the importance of the motivations on a 0–5 scale with 0 (at the centre) indicative of a motivation that was not of import within our sample. Some motivations register scores of 0 in each of our case studies but have been included as they have been highlighted as important in other studies. Individual motivation wheels for each treatment case study can be found in Appendix 24.

FIGURE 8.

Motivation wheel depicting the relative importance of various motivations in the four treatment case studies.

The medical tourism process

In this section we look at how people found their information regarding the facilities that they eventually visited, how they then organised their care and the process of travelling for care.

The medical tourism experience

In this section we discuss how our respondents found their experience, their satisfaction levels with regard to the process and, to a certain extent, the clinical outcomes (although this is rather limited as it was not the focus of our study), their feelings about the level of aftercare that they received and the ongoing support that they were given.

Implications for the NHS

We have seen that medical tourism, irrespective of the treatment that is being sought, involves much that is similar across all patients. It is clear that accessing the required treatment in the desired time frame is the primary motivator for travel, but that issues of cost, culture and even to a lesser degree tourism all play a role. We have also seen that the internet, as well as networks both online and offline, play an important role in informing prospective medical tourists, but that on the whole it does not appear that those who travel are truly informed, especially with regard to the risks involved. Despite this, our respondents have nearly all registered satisfaction with their experience and would travel again, or recommend the process to others.

The positives must be set in a wider context that is at least cautious. Our sample is undoubtedly skewed towards those who are satisfied with their experience and yet even here we can see quite profound examples of ill health, poor clinical outcomes and what are likely to be long and expensive requirements for ongoing care. Clearly, with some of our respondents this must be offset against the ill health and need for care that was already being experienced, but it important to note that treatment abroad represents no panacea, either for those who travel or for the NHS.

Subsequent chapters detail the nuances of particular forms of medical tourism and their implications. At the broader level we can say that medical tourism presents the following potential implications for the NHS:

• Medical tourists are unlikely to be fully informed or understanding of all associated clinical risks.

• Medical tourists pay more heed to soft information than hard clinical information.

• There is little effective regulation of information, hard or soft, online or overseas.

• Patients travelling overseas leave the regulatory safety of the UK and the NHS. Although patients may not ever be fully informed or understanding, if they access care within the NHS then health-care professionals will have played an important role in ensuring that appropriate treatment is being administered. This cannot be guaranteed abroad. There is clearly scope for health-care professionals within the NHS to become part of the networks of information and support that can be accessed, even by those who in the end do still seek treatment abroad.

• Even when medical tourists travel to professional, reputable clinics, returning for aftercare or continued support is not usually viable.

• Aftercare in some form is usually required.

• Aftercare or ongoing care can be extremely intensive.

• The NHS will play some role in providing ongoing care for many of those who travel for treatment. This can be expensive and can continue through the life course. It may be that the treatment that has been accessed overseas was risky or inappropriate and alternatives in the UK could have been offered.

• Interviews with professional stakeholders clearly identify the need for guidance and information for patients and staff working within the NHS. Our analysis points to a vacuum in policy guidance. It highlights the need for information and guidance about quality and safety issues that patients may wish to consider before travelling.

• Clarification is needed in relation to the roles and responsibilities of the NHS in pre and post care and this should be communicated effectively to those who may engage in medical tourism.

• Further Department of Health guidance for NHS providers and patients on what to request from foreign providers may go some way to address the challenges in continuity of care described.

Findings from bariatric surgery patients

Although many issues identified across our sample of patients were common to bariatric patients’ motivation to travel (such as issues relating to distance and eligibility), there were also clear differences within each subtheme identified that were specific to bariatric tourism. These hold important lessons when trying to understand and address the specific factors determining bariatric patients’ travel and follow-up needs.

Implications for the NHS

• The need for clearer guidance on bariatric surgery or for patients considering bariatric surgery is evident. Patients lacked consistent information on possible complications, but also on the long-term consequences of surgery and the maintenance requirements, whether they were travelling abroad or seeking treatment in the UK.

• Equally, greater information for and education of GPs is needed to enable them to educate patients and to deal with the possible consequences of weight loss surgery. Our data suggest that, even when patients travel abroad to access treatment for obesity, they are likely to consult their GP. This presents the opportunity to provide guidance and information either on procedures or on medical travel or both.

Distinctive features of fertility tourism

Although there are many similarities between travelling for fertility treatment and travelling for other forms of medical treatment, there is much that sets fertility tourism apart. Discussion here is informed by interviews with NHS professionals, representatives of professional associations and those who play a role (be it commercial or otherwise) in overseas treatment, as well as those who have travelled for some form of what can be termed ‘fertility treatment abroad’. The purpose here is to highlight the differences between fertility treatment abroad and other forms of medical tourism, and attempt to explain such differences.

As with the findings of other studies, the availability of treatment in the UK was the single biggest motivator to travel abroad for fertility treatment. All respondents discussed their ineligibility for publicly funded treatment, which again was the consequence of a range of factors: some were outwith the age criterion, others were deemed as having an extremely low chance of success, one had exhausted her publicly funded opportunities and one, although eligible, could not access the treatment in a time scale that she felt was reasonable. Typical comments were:

Well, the NHS wouldn’t even consider us. It was just a non-starter.

FT5

No [there was no chance of treatment on the NHS], because of my age.

FT1

Despite this, all respondents reported positive experiences of the NHS. For some, frustration or disappointment regarding a lack of eligibility was balanced by high levels of support from their GP or other NHS staff throughout their treatment journey, in terms of both help received with organising tests and accessing required fertility drugs before treatment and the antenatal care accessed after pregnancy was successfully achieved. When respondents were less positive regarding the support that they had received pretreatment abroad, they were unanimous in their satisfaction with subsequent NHS antenatal care. Perhaps surprisingly, not all were frustrated with their ineligibility for publicly funded fertility treatment, with one respondent remarking:

It’s my choice in a way that I’m this age wanting to have a family [. . .] so in a way I think it was my lifestyle choice and I knew that that could be a potential issue in the future so I’m not sure health-care systems should have to pay for my lifestyle choice.

FT1

An interesting finding from our interviews was that support from NHS staff for those who had undertaken private treatment varied. In some instances NHS staff aided patients in accessing necessary pretreatment scans and tests free through the NHS, whereas others would provide no such access to drugs and scans:

She looked at the list and she said I can make an excuse to have that one done for you and that one and that one and that one. So she did absolutely as many as she could on the NHS, which was fantastic of her.

FT5

I tried to go to my GP to get the blood tests done but he wouldn’t do it. It depends on your GP. He told me to go to my local GUM [genitourinary medicine] clinic and pretend I’d slept with a waiter on holiday to get a test for HIV [human immunodeficiency virus] and Hep and stuff.

FT8

Here, it is likely that a complex range of considerations has informed a GP’s decision whether or not to provide NHS resources, from a desire to help at the most human level perhaps to a fear of vicarious liability at the other end of the spectrum. As one NHS respondent noted (NHS18), some NHS staff may worry about playing a role in facilitating the overseas journey of a patient to a country with different ethical and legal principles of medicine.

The main reason cited by our respondents for travelling abroad for fertility treatment was waiting times; even privately in the UK, the wait for egg donors in particular can feel prohibitive for those seeking fertility treatment:

With regard to the egg donation I was told there’s a five year waiting list at that time for eggs. This would have been in about 2002/03. So I thought about it and I thought well I’m 40 so if I wait five years I’m going to be 45, my son is going to be eight, I don’t think I can wait that long.

FT4

Although there is the hope that recent legislative changes allowing greater remuneration for sperm and egg donors will increase supply, numbers are still low (PA7). In total, five of our respondents required egg donation (sometimes alongside other procedures) and for all the lack of availability both publicly and privately in the UK precipitated their decision to travel. Other studies suggest that a high proportion of those travelling globally for fertility treatment are receiving some form of egg donation. Shenfield et al. 114 suggest figures of roughly 45% Europe-wide and Culley et al. 57 report figures of 59% in a small study of UK fertility travellers. The figure is even higher for patients from Germany where there is a shortage of donors. 202 It was not only the availability of donor eggs that motivated our respondents to travel; in one case concerns were raised regarding the quality of UK-sourced eggs (FT8).

A review of the literature suggests three other common motivations for seeking CBRC: success rates, legal restrictions and issues of anonymity. 72 In our sample, as with other UK-focused studies,57 there was no discussion of legal restrictions. With regards to anonymity, only one respondent (FT2) suggested that this had played a role in travelling abroad and even here it was a minor consideration. On the contrary, other respondents who did mention anonymity professed to find the anonymity offered to donors abroad to be a concern (FT1). This was clearly the case for one respondent (FT9) who struggled to access vital information when her offspring was being tested for certain genetic conditions. This is perhaps surprising in the context of the interviews we conducted with professionals and stakeholders, as well as the wider literature. Here the suggestion seems to be that anonymity is a key motivator for those who seek fertility treatment abroad (NHS17, NHS56). Perhaps equally surprising was the fact that only two respondents (FT6, FT8) directly addressed the issue of success rates and in only one case (FT6) did this seem to be a key (although still not the sole) motivator. One NHS professional (NHS15) did remark that it was unlikely that overseas clinics could actually offer better success rates than are available in the UK, or innovative procedures that are unavailable in the UK.

Unlike other forms of medical tourism, information gathering on the internet was limited to searching for clinics, rather than information about procedures. GPs and other NHS staff represented the main source of information regarding the procedures that our sample travelled for. The internet was simply a location in which the clinics offering the required treatment could be identified.

The websites of clinics were not the only source of information that respondents engaged with. Most had some contact with an online fertility support group or forum, which proved useful in terms of both gaining information about the experiences of others and obtaining specific clinician reviews:

I went to [support forum] website and through there I started looking at clinics. And I saw similar problems to mine so I contacted the [clinic] and went for a consultation.

FT2

So I had heard from people on [support forum] website about the clinic in the Czech Republic and they had been successful there and they just said it’s a wonderful clinic.

FT2

The role played by support forums is clearly substantial here, with one respondent from a support organisation presenting extremely large membership figures (IND2). Moreover, they acknowledge the power that a post on such trusted sites can have, with visitors to sites happy to take the recommendations of others based on a clinic or clinician being ‘nice’ over ‘hard’ evidence regarding success rates (PA12).

Although the internet played an extremely important role in identifying and selecting overseas clinics, it would appear that it played a much more minor role, if any, in gathering information regarding the conditions that people suffer from and possible treatment options. Rather, all had engaged with the NHS (or the French national health system in one case) and diagnosis had occurred here. Further diagnosis may have occurred at private clinics, but regardless of the public or private setting much of the information gathering regarding the procedures that our sample travelled for was undertaken as part of the diagnosis procedure. As such, it can be argued that the fertility patients in our sample could have been considered as having expertise beyond that of lay persons when searching the internet for foreign clinics. As one professional association respondent noted (PA12), all had a clear idea of what procedure was needed and the questions they would need answering.

With regards to how fertility travellers organise their treatment, the picture was mixed. At one end of the spectrum we heard from somebody who paid a flat fee to a private UK clinic, which then organised all pretreatment tests, flights, accommodation, treatment and follow-ups:

It’s all included. They basically arrange it on different budgets. So there’s an expensive hotel in [city], there’s a cheaper hotel in [city]. I think you get all your meals. It’s very, very well organised. They tell you what flights you can have. You’re quite limited on your flights [. . .] I took my son with me because we didn’t have a babysitter really and he was about eight at the time. So they arranged everything.

FT4

At the other end of the spectrum respondents had contacted clinics directly, had organised their own flights and accommodation and had responsibility for organising any pretreatment scans and drugs. In the most extreme case there was no guidance offered as to which drugs, tests and scans were needed and when they were needed:

That was the only thing about having treatment abroad is that they don’t tell you that you have to have anything prior to going out there. I was using my own eggs so therefore I had to take all these drugs prior to going out to [destination]. But having done four cycles in the UK I knew the procedure [. . .] so I organised those scans privately in a private hospital in [UK city].

FT3

As with other types of treatment most plotted a journey in between these two extremes, with parts of the process packaged with the treatment. What is hard to tell is whether our respondents opted for a more or less comprehensive package as a reflection of a desire to relinquish or take control. Even in cases in which our respondents have an increased level of responsibility, say for organising tests, scans and drugs, they are following an extremely prescriptive and strict plan. Other studies have highlighted the importance of agency and the feeling that fertility travellers were their own ‘project manager’ (p. 577). 203 We have certainly witnessed this with other treatment types, notably bariatric treatment; however, the tone of our interviews does not seem to suggest that the process has been engaged with as a form of exerting control over a part of life that is out of the respondents’ control. Although the fertility issues are clearly out of the respondents’ control, there appears in our interviews to be a sense of this being a last chance rather than a means to assert control. Indeed, when the issue of control is addressed it is an admission that the process does not endow the person seeking treatment with any control: ‘If people wanted complete and utter control over it then that’s fatal. You don’t have control over the process’ (FT7).

What is particularly interesting is that, even with regard to the organising of tests, scans and drugs, for which respondents have responsibility if only a little control, most had at least attempted to source these through the NHS.

Overall, the experiences of our travellers mirror those that our professional interviewees have come across and those that have been discussed in published studies inasmuch as they are largely positive. 72 There is undoubtedly a sampling issue here as all of our interviewees had been successful in achieving pregnancy. Indeed, potential respondents have withdrawn their participation as a consequence of treatment being unsuccessful.

All mentioned that clinical staff were proficient in the English language although quite often nurses had little command of English. Communication was not seen as an issue by any of the respondents, although it had been a concern in advance of travelling for some. Interestingly, almost all of the respondents seemed at pains to highlight how clean the overseas clinics were, with some contrasting the clean, clear and ‘un-hospital-like’ nature of the overseas clinics with conditions in UK clinics and hospitals (FT1, FT4).

In contrast to other treatment types, such as bariatric or cosmetic surgery, there was little to probe with regard to aftercare and complications. As alluded to earlier, for all the majority of aftercare was dealt with on the NHS as with any ‘traditional’ pregnancy. All respondents mentioned that they received follow-up communications from their private clinic and some attended a first scan and blood test post implantation at their private clinic, although this was usually for those who had travelled abroad through a UK clinic. However, there was no detailed or continuous care or communication. None of the respondents seemed to expect this and seemed happy to engage with NHS antenatal services. In only one case did a respondent discuss a complication from the treatment that she had received, expressing frustration that the apparently well-known risk of such a complication was not communicated to her (FT4). Here, the intracytoplasmic sperm injection (ICSI) procedure precipitated a twin pregnancy that resulted in a premature birth at 29 weeks and subsequent intensive treatment.

Multiple births

Although others do not speak directly of complications, a number of respondents had multiple births as a consequence of their fertility treatment abroad. In all cases, whether we consider multiple births as a complication or not, these outcomes of fertility treatment abroad were addressed in the UK within the NHS. One professional respondent (NHS15) suggests that complications are extremely rare, with the outcome simply being pregnancy or non-pregnancy. Others were keen to stress the seriousness of multiple births, with regard to not only the chance that a pregnancy would last until term, but also complications such as disabilities that might not manifest or present themselves until months after the birth (PA7, PA12). Multiple births have long been seen as more likely after assisted reproductive technology (ART) than after spontaneous conception,98,193 but evidence also suggests that the likelihood is even higher when patients undergo ART abroad. 98 This is almost certainly a consequence of higher numbers of embryo transfers being permitted in some countries than in the UK (PA7). In our sample, one respondent even speaks of having four embryos transferred (FT3). This is particularly worrying if we consider the implications of fertility tourism or CBRC for the NHS. As both professional association and NHS respondents are keen to stress, the cost of care during and after multiple pregnancies is considerably higher than that for singleton pregnancies (NHS15, NHS17, PA7, PA11). Neonatal care is itself an expensive process, which, within the NHS, is subsidised in part by private income generated from other procedures. Simply increasing the number of births is a problem but, given that the average length of pregnancy for a carrier of triplets is only 35 weeks and that premature birth is extremely common with multiples, the cost of neonatal treatment is a major burden for the NHS (NHS15, PA7).

Fertility tourism or CBRC clearly shares some similarities with other forms of medical travel while at the same time standing apart in many ways. Our respondents have shared motivations and experiences that are common with those in other studies, while never engaging with the legal and ethical dimensions that mark much of the academic debate. Our respondents are satisfied on the whole yet some of their stories allude to quite substantial risks faced by those who travel for fertility treatment and the implications of these risks for the NHS. Ultimately, as our professional respondents noted, when a patient travels abroad certain best practices cannot be guaranteed, from the way that donors are treated to the number of embryos that are transferred (NHS17, PA7). Until a degree of global regulation can be guaranteed, which does not seem viable, or provision within the UK meets demand, UK citizens will travel abroad and the associated risks cannot be easily controlled.

Implications for the NHS

We have discussed the broad implications common to all forms of medical tourism but fertility tourism often exacerbates some of the issues common to medical tourism more generally, as well as presenting others:

• Aftercare or the continuation of care is not required in the same sense as with bariatric treatment or even cosmetic treatment; however, the NHS bears the cost of antenatal care, which is expensive, in nearly all cases.

• Furthermore, IVF treatment is, ceteris paribus, more likely than non-assisted fertilisation to result in a multiple pregnancy, which in turn increases the likelihood of premature birth or miscarriage. Neonatal costs are extremely high.

• In addition, not all countries have strict legislation governing the number of embryos that can be transferred. With every additional transfer beyond the UK limit of two, the likelihood of multiple pregnancies/births increases, along with the risk of premature birth and the need for neonatal care.

• Unclear regulatory frameworks overseas mean that patient data may not always be held in the detail expected within the NHS and it is not always possible to retrieve data. When countries have anonymous donor laws this is exacerbated.

The distinctiveness of dental tourism

As with other treatment types, lack of NHS availability can be seen as a primary motivator for seeking overseas dental treatment. However, this was not the case for five of our respondents: unlike for fertility or bariatric treatment, for example, not all of our dental respondents had sought NHS treatment (DT6, DT8, DT10) and, even when they had, it was not necessarily a lack of availability that had prompted overseas treatment (DT2, DT3). Other core reasons cited were a distrust of or scepticism about NHS dentists (DT3, DT8, DT10), a perceived lack of availability (rather than experienced) (DT8), dissatisfaction with NHS dental care received previously (DT3) and cultural reasons (DT5, DT6, DT8, DT10). Similar to studies of other treatment types, the decision to travel abroad for dental treatment was in no case motivated by a single factor but rather a combination of factors.

For some a distrust of the NHS played a key role in looking for private treatment:

I’ve never heard any good stories about UK dentists so I thought if I have to pay here I might just go home and pay there as well.

DT10

I wouldn’t dream of it [using an NHS dentist]. I’ve just seen a colleague, funnily enough a couple of hours ago, who was just about to go to an NHS dentist. She had a provisional crown in one of her front rows of teeth for a proper replacement and it looked so amateurish. No I just wouldn’t dream of it. I’d rather jump on a flight and bear the cost for that.

DT3

Even among those who would at some stage have sought NHS treatment had it been available there was a sense that the standard of care was not as high as they would hope, often drawing on personal experience:

The NHS did the cheapest job they could and for two or three years I’d had problems and the infection spread to my gums and affected other teeth. So in the end I lost more teeth than I should have done. If the NHS had been up to snuff I would never have needed to go.

DT1

Whether our respondents had decided to seek private treatment as a consequence of issues with NHS dental care or because of other factors, the decision to seek this private care abroad was shaped by four issues: a wider distrust of UK dentistry, cost, culture and the opportunity for a holiday.

The distrust of or dissatisfaction with UK private health care was a common theme for those who had been born or who had spent a considerable amount of time outside the UK (DT3, DT6, DT8, DT10). Here, the sense is that British dentistry, private or otherwise, is of a low standard (DT10). One respondent reflected on her experience of private UK treatment: ‘So I actually went to see a private dentist and I always thought I’d get better and prompter treatment and that is just an illusion’ (DT3).

Cultural and familial reasons to travel were not limited to those who returned home; one respondent (DT5) travelled to her partner’s country of origin after a poor personal experience of NHS dental care. As with others who travelled home (as well as five British citizens who travelled to destinations to which they had no previous connections), this respondent located her dental treatment within a holiday. It is perhaps one of the major differences between the motivations of dental tourists and the motivations of other medical travellers; whereas some who travelled for bariatric or fertility treatment may have built a holiday or some sightseeing around the planned treatment, with some dental respondents the holiday was as central as the treatment. In this respect dental and cosmetic tourism perhaps best fit the label of medical tourism. One respondent has even returned to her dental destination for a holiday whereas another scheduled his treatment to coincide with a ‘stag party’:

The places we went were fantastic and it was a good holiday. I think we went back three or four times.

DT1

I’d been wanting to go for ages so when my mate said he was going to do Hungary for the stag I just thought, done.

DT11

Perhaps the most surprising finding from the interviews was that cost was not seen as a key driver by most. Cost was likely to be more important to those with no cultural ties beyond the UK. In our sample only six mentioned cost and in only four cases was cost the most important factor for choosing overseas treatment rather than UK private treatment. In each of these cases, however, the cost savings were felt to be significant by the interviewees and in two cases (DT1, DT7) the perceived savings were > £20,000. Given the media attention that has focused on the cost of dental treatment abroad, it is perhaps surprising that cost was not a factor for more of our respondents. Indeed, when asked what they thought the key motivations for travelling were, our professional association respondents ranked cost as being the only real reason to travel (PA9, PA16).

With regard to the experience of travelling for dental treatment, the organisation of the journey was rather mixed. In some cases our respondents had pretreatment consultations in the UK. Although ‘package’ treatment and holiday offers are readily available on the internet, none of our respondents had travelled on such a deal (although two did have their accommodation organised by the treatment provider). In addition, none of our respondents had used brokers or facilitators. Instead, all organised their journeys direct with the clinic and organised their own flights.

In terms of the experience, for 10 of our 11 respondents it was overwhelmingly positive:

Yeah, the experience we had there was excellent.

DT1

Yeah, wonderful. They said that these were guaranteed for 10 years.

DT2

She [the dentist] was brilliant. I can’t praise her high enough. I’m not being emotional about it. She was very, very good. She listened first and foremost. She didn’t rip me off and she charged very reasonable and at the same time she didn’t cut herself short.

DT9

However, as one of our professional association respondents (PA9) and the wider literature caution,207 problems may not reveal themselves until months or even years down the line.

An unregulated industry

One respondent (DT4) did not have a positive experience. Having travelled for what she called a full restoration of her smile, numerous implants were provided. In fact, the implants were initially placed in the UK before the respondent travelled to Hungary for the subsequent stages of treatment:

Some of my existing teeth which had been filed back too far and therefore caused a lot of pain because the nerves, the pulp was exposed . . . There was no trial of whether they were the right size or the correct whatever. The final work, it ended up that they were all far, far too big for the size of my mouth. They weren’t in the right place of my original teeth. They completely cramped my tongue. I couldn’t speak. I had no room to speak because they were too high. I couldn’t close my mouth. And I was in a considerable amount of pain, which wasn’t taken any notice of at all.

The respondent has subsequently had all of the work redone bringing the total cost to in excess of £40,000 and has suffered for a number of years while the problem was being addressed. This is only one case in our sample but it underscores the potential negative outcomes of dental surgery. Indeed, our professional association respondents (PA9, PA16) suggest that corrective work is commonly requested by those who have travelled abroad. A survey by the Irish Dental Association in 2010208 even suggested that 75% of those who had travelled abroad for dental surgery and then subsequently re-engaged with the Irish dental system required corrective work. Even if these figures are incorrect, the success rate for non-complicated implants ranges between 93% and 98%,207 which means that even when best practice is observed complications will arise. When these have occurred within a different legal and regulatory framework the problems faced by the patient can be difficult to address. One professional association respondent (PA8) stated that he would never feel comfortable referring a patient for treatment overseas as there is too much that cannot be controlled.

A clear issue is the lack of regulation governing dental practice overseas, especially when procedures are considered cosmetic in nature. Not unlike cosmetic tourism, dental tourism is marketed very much as a commodity rather than as a health service. This, as we have seen, has a profound impact on the quality of information that exists and in turn on how well protected potential dental tourists are from issues of risk. That many of the dentists who operate abroad have trained in the UK or been registered with the GDC is clearly of great comfort to many of those who travel for dental treatment. But how reassuring is such registration? Dental tourists are unlikely to look beyond whether a practitioner is registered with the GDC, perhaps to explore clinical memberships beyond the UK and the comprehensiveness of their safeguards. Moreover, it is unrealistic to expect prospective dental tourists to assess the veracity of any claims made regarding memberships. In the UK it is relatively straightforward to ascertain whether or not a dentist is deemed as being in good standing with the GDC. It is extremely unlikely that any professional who has been suspended or deleted from the GDC’s register could practise for long without being dealt with by the GDC. However, this may not be the case abroad. Indeed, one of our professional association interviewees (PA9) points to the case of a celebrated dentist in one country who had actually been suspended from the GDC’s list in the UK. The dentist in question continued to actively market himself to UK customers, even maintaining that he was registered with the GDC when in fact he was suspended.

It is possible to think of dental treatment abroad as reflecting more closely the consumer-driven ideal of choice in medical services and perhaps best befitting the label ‘medical tourism’. But as one respondent noted (DT4), although dental tourism does not necessarily involve life-threatening medical treatment, it most definitely can involve life-changing medical treatment. As in this case, this change will not always be positive.

Implications for the NHS

Although many in the UK undergo private dental treatment, it is clearly possible that people who have had dental work abroad may seek NHS care on their return. As the NHS are unlikely to offer anything beyond the most basic corrective work (if patients are in great pain), dental tourism does still present some implications for the NHS:

• The lack of comprehensive regulation of dentistry outside the UK means that there is a genuine risk of wholly inadequate care being received abroad. Although the NHS is likely to perform emergency treatment only, often with the purpose of relieving pain, there is the potential for a large number of such cases to occur as a consequence of dental tourism.

• Many clinics offering dental treatment, especially in selected locations, also offer what is marketed as minor cosmetic treatment. In many cases it is unclear whether or not they are qualified to do so.

• The key issue relates to the lack of clarity regarding patient records. In particular, when a patient has travelled for treatment, the apparent linguistic ability of clinicians may not be reflected in records. It is entirely possible that continuation of care will take place within the NHS, sometimes in circumstances in which the precise treatment undertaken abroad is unknown.

Distinctive features of cosmetic tourism

Unlike all other forms of treatment, it is unlikely that those who require cosmetic surgery will have had much contact related to their treatment with the NHS. As one NHS commissioner remarked:

We have a very, very tight cosmetic approval process which we’ve had for a number of years. Every GP is aware of it so the numbers of people who actually get referred – we call it IFR, Individual Funding Request – is quite small.

NHS6

As our interviews confirmed, people are generally aware that cosmetic procedures are rarely provided on the NHS and as such there is an understanding from the outset that treatment will be privately funded and provided. There are notable exceptions, for example following bariatric surgery some may hope to have loose skin removed. Likewise, those who use the NHS dental service may assume that cosmetic dentistry can be provided through the NHS. In both of these examples people who seek cosmetic surgery may engage with the NHS in the hope that treatment will be provided, although as the quote above implies such treatment is unlikely to be approved.

The mindset that surrounds cosmetic treatment is perhaps then different to that which surrounds other forms of treatment. It is generally understood that to seek cosmetic treatment is to seek private treatment. Even when it comes to aftercare, our respondents either were turned away by their GP or opted to utilise private facilities from the outset. In one case a respondent discussed visiting their GP for the removal of stitches: ‘I had to go and get my stitches out 15 days later. The doctor that took them out was very unimpressed, very angry, that I’d gone to get four stitches taken out that had been for private treatment’ (CT2).

The consequence of this is that, for those seeking cosmetic surgery, value for money and overall costs appear extremely important. Although one study found that 66% of its respondents would never consider cosmetic surgery abroad and only 4% would consider it for reduced costs,209 a consensus of commercial, professional and academic sources, as well as our sample of medical tourists, suggest that cost is the key driver behind those who travel for cosmetic treatment. ‘The cost generally does seduce you . . . I thought to myself if I’m going to pay £5000 and not get any result at all and be back to stage one why not go to Cyprus and pay £800 and get the same thing’ (CT4).

Patients felt that it was important and useful that prices were upfront and made readily available on websites of foreign providers, in comparison to UK providers at which an enquiry and consultation would first be necessary. Almost half (four out of nine) of the sample opted for multiple procedures as part of a package; this was particularly cost-effective. For example, CT3 explained how the surgeon offered to ‘throw in some extras’ to make it a more attractive package: ‘It was £5000 for my arms alone. In Belgium I paid £6000 for my arms, my tummy and he said because you’re having all that done we’ll do some liposuction and reshape you. So he did that as well’ (CT3).

The cosmetic tourism industry

The value-for-money nature of cosmetic tourism reflects a wider approach from within the industry and combined with intensive marketing, there is a potential for risks to be not only heightened but also misunderstood by those who travel. All of our interviewees, whether they had travelled for treatment, worked in the NHS, represented a professional association or had a commercial interest in cosmetic tourism, presented a picture of a process that is very much marketed as tourism. This is not to say that our medical tourists agreed with the notion of cosmetic treatment being reconcilable with a holiday:

I don’t understand this image that you’re going to have an operation and then go and lie on the beach for a week and have cocktails. Because you’re big swollen and painful – whatever you’ve had done [. . .] so I think it’s naughty for companies to advertise as sort of holiday surgery breaks because it’s not like that.

CT4

Contrasting this point with the image presented by many online sources and verbalised by one interviewee with commercial interests is particularly stark:

It’s not just about going for medical treatment. [Location] is an absolutely stunningly beautiful city so don’t just think about it as going for a quick nip or tuck. Actually take an extra few days out of your diary and actually spend some time doing sightseeing.

IND14

There is clearly an issue with how cosmetic treatment is marketed in general, with the role of television, from reality TV shows to adverts, linked to an increasing prevalence of people deciding to undergo procedures. 210 Although our professional respondents were all keen to underscore the fact that cosmetic surgery is still surgery and as such should be considered as a medical procedure (PA8, PA17), cosmetic surgery, especially abroad, is marketed more as a commodity than a procedure. This has clear consequences for the quality of information that is presented, especially online.

We saw in Chapter 7 that the quality of information that can be found on cosmetic tourism websites is poor. This is perhaps even more problematic given that it is unlikely that potential cosmetic tourists will have discussed their treatment plans with a health-care professional. This lack of quality is exacerbated by the broader consumer rather than medical focus of the cosmetic tourism industry. Interviews with industry professionals demonstrated a level of concern for patients opting to travel abroad for financial reasons, as this can result in patients overlooking more important factors such as qualifications and aftercare.

Even those who engage with an online community find themselves under- or ill-informed. Indeed, there appears much less balance to the online community that surrounds cosmetic tourism than can be found in bariatric or fertility surgery forums. As one respondent noted (CT8), forums on cosmetic surgery provider sites are heavily monitored to remove any negative comments about the treatment received.

Risk

The picture that is painted by those with commercial interests in the cosmetic tourism industry is one that plays up the tourism dimension, attempts to normalise the notion that one would travel to have cosmetic surgery and seriously underplays the risks involved. This has a profound impact on how people view the risks involved and, in turn, through being under- or ill-informed, how they experience risks. The poor quality and lack of regulation of information online is found across all forms of medical tourism; however, a wider lack of regulation surrounds cosmetic tourism, even within the UK. One professional respondent suggested that, within the UK, cosmetic treatment is being offered by people without the necessary qualifications and that this is certainly the case overseas as well (PA8). Turning to overseas cosmetic surgery the same interviewee explained that, as things stand, there was no good clinical reason to travel for treatment:

By and large nobody encourages the principle of people going into a foreign land, not knowing the culture, often not knowing the language and also not knowing how to check on who the surgeon is, what qualifications they have and where they have the surgery whether they have similar standards to those imposed by the Care Quality Commission here in the UK.

PA8

Regulation is quite simply missing. 211 Despite our interviewees from the commercial sector playing down the risks of cosmetic treatment, both in general and abroad, evidence from academic and professional sources suggests that there are numerous clinical risks and examples of quite serious complications arising from cosmetic tourism abroad. 76,102,134,212,213 We can draw examples of quite severe complications even from our cosmetic tourists:

I’d got a pocket full of fluid inside of my face. I’d got infection all round my neck and I’d got this pocket full of fluid.

CT5

I’m left with a hole in my stomach because they just couldn’t be bothered to sort it out properly.

CT8

We should probably note that none of our sample had travelled for cosmetic surgery involving their breasts. A survey of clinicians by BAPRAS212 recorded a higher rate of complications related to such cosmetic surgery than for any other type of surgery.

The reality is that many of the health implications are likely to present after the period that a cosmetic tourist spends abroad (PA8, PA17). It is unlikely that people will be willing or able to travel, perhaps in great pain, to the country in which they underwent treatment and, even if they did, there are no guarantees that the original provider would offer treatment. The recent PIP breast implant scandal underscores the unclear legal and regulatory frameworks that exist around cosmetic tourism as well as the clinical risks faced by those who undergo cosmetic treatment abroad.

An additional issue that is addressed in the literature,213,214 and which was discussed by our professional association interviewees but not by our cosmetic tourists, is that of psychological support. One representative of a professional association stressed that psychological support is woefully lacking in general and even more so abroad. Moreover, in her opinion:

Cosmetic surgery patients are amongst the most vulnerable patients in this society and they can be taken advantage of. Many patients, the vast majority of them, who think about cosmetic surgery, they feel embarrassed to talk about it. They don’t even go and discuss it with their GP.

PA8

This sentiment is echoed by both Bradbury213 and McGrath,214 who discuss the psychological impact of cosmetic surgery and breast implant surgery respectively. Indeed, it is worth reflecting on the fact that cosmetic surgery abroad may often involve vulnerable people who may have little interaction with health-care professionals, who have been exposed to poor-quality information, who travel for possibly life-changing procedures and who do so with no professional psychological support.

Implications for the NHS

Cosmetic tourism involves people leaving a rather weak regulatory framework in the UK to have what can be serious and complex procedures in countries that may offer even fewer safeguards than the UK. This has a number of consequences and presents the following possible implications for the NHS:

• Complications from cosmetic surgery often do not occur immediately. Once patients have returned to the UK it is likely that any serious complications will be addressed by the NHS.

• Perhaps even more than for those who travel for any other form of medical treatment abroad, cosmetic tourists are likely to be exposed to poor-quality information that is not balanced through interaction with health-care professionals.

• The lack of psychological support offered by private providers, especially overseas, leaves many at risk of undergoing inappropriate procedures or procedures that are unlikely to offer outcomes that meet what may be unrealistic expectations. The consequences of this are once again likely to fall on the NHS.

Destination

Within the diaspora category there were several different strands to the diaspora element of patients travelling abroad. The three individuals travelled to familial countries within Europe (France and Germany); two travelled to their country of origin and the third travelled to his wife’s country of origin. They had strong links with family and friends and previous experience of the health-care system. Industry professionals explained that members of specific ethnic communities within their catchment areas would often travel ‘home’ for various treatments and combine this with visiting family and friends.

The Gujarati community travelled to a specific area of Gujarat in India. However, none of the individuals had direct familial links to this city. All of the members had been born or grown up in East Africa and moved to the UK in the 1970s. Although their families originated from Gujarat, there was a specific religious element to their choice of destination. All of the community members follow a certain branch of Hinduism and they have become followers and travel to Gujarat as part of an annual religious pilgrimage. The choice of destination by this group was not primarily determined by any of the considerations evident for other medical tourists interviewed for this research.

Members of the Somali community predominantly travelled to Germany and occasionally to Italy. Research from both Sweden216 and Holland217 demonstrates that members of the Somali communities in these countries also travel to Germany for medical treatment, in particular diagnosis, for similar reasons. German doctors have advertised on Somali television for many years and this has developed as the main medical tourism route for the Somali communities that we spoke with. A minority of the groups have travelled to other European destinations, including Italy and Holland. Community members stay with members of the Somali communities in both of those countries. Holland was a prominent destination for Somali refugees during the 1990s and Italy has a colonial connection with Somalia. Industry professionals also considered this a reason for Somali community travel. Members of the community were keen to highlight that it is commonplace within their nomadic culture to travel, including for health purposes, and therefore this may be specific to Somali diaspora.

Motivation

Motivation for travel differed vastly amongst diaspora travellers in contrast to the motivation for travel for all other outbound medical tourists.

Information and marketing

Contrary to other medical tourism patients, diaspora tourists do not rely heavily on the internet for information. Community and family relationships play a key role in decision-making. Two of the patients travelled to countries that they had a familial relationship with and relied on personal recommendations from their family or friends in that country when seeking treatment.

When patients travel with the primary purpose of treatment this is often combined with a familial visit:

I do go to see my mom from time to time but otherwise I know that there are times where I’m just going specifically. I make phone calls to make appointments and I leave for my checks up. Maybe I take a week where I can just go to all of my doctors in that week and I just go to France.

OT6

Personal recommendations also form the basis of decision-making within the Gujarati community. Interviewees requested recommendations through the religious organisation that they are members of and these are shared within the community. This contrasts with the Somali community, which relies heavily on oral information and mainstream sources, such as the internet. Media and papers are not consulted, leading them to be described as ‘oral communities’. 219 In Manchester community leaders were key in distributing information to the community. Some community members may not be able to access written information, available in different languages, such as leaflets about local NHS services, because of illiteracy. The oral dimension has a significant impact on community members’ decision-making processes and how they view services available for them. For example, all negative experiences of the NHS and GPs are shared within the community, which increases mistrust. 219

Another key source of information is Somali television channels, available by satellite. This helped develop the connection with German clinics and doctors. German clinics are the only ones to advertise on Somali television in Somali and these adverts are usually at peak viewing times, for example before the early evening news. Once one patient has been to visit a doctor this then rapidly spreads through the community through word of mouth. For example, one Somali explained:

We’re a close-knit oral community so if someone comes around and says I’m not well then they might say there’s this doctor I’ve been to. So lots of advice from word of mouth but they’ve got Somali channels now and they do adverts on them. So they’ll have advertisements for hospitals abroad. The doctors out there I think have clued on and they advertise. So people get that if they have satellite TV.

These examples highlight how health information, including information about medical providers abroad, is spread within specific diaspora communities. It is also clear that specific clinics, such as German clinics, market themselves to specific segments of diaspora markets. This was echoed by the Gujarati community interviewed who reported that in Gujarat there are now a number of clinics targeting returning non-resident Indians, who have greater resources than domestic patients.

Language barriers: a key motivation for diaspora travel

The issue of language is a key area of divergence in experience within this diaspora category. For members of the Gujarati community and other diaspora patients, language was not a barrier to accessing or receiving health care in the UK. However, language barriers exist for members of the Somali community in the UK and these are key to their experience of, and interaction with, the NHS. This can prove problematic on a practical level and lead to misunderstandings. For example, one Somali explained:

Sometimes if you’re not feeling well and you go to the GP and sometimes you don’t know the words. They cannot find a way for an interpreter. So it can be a bit difficult and so you have to point to it. Sometimes there’s a misunderstanding.

This frustration expressed by Somali women at language and cultural barriers, including brief and rushed appointments, results in further mistrust, which is also the case for Somali women in other countries. 220

This can also affect the services that patients receive: ‘Sometimes if they know your English is not good they just brush you away’. However, the language barriers between members of the Somali community and their GPs can be seen as one aspect of poor health literacy within the community. 222

In one of our focus group areas, additional funding had been sourced to employ a Somali nurse at the local surgery who acted as the first point of contact for Somali patients. This was extremely well received and successfully ensured that language and cultural differences could be both understood and interpreted in partnership with the GP. However, the majority of patients said that translators were rarely available. This was a key determining factor in their seeking treatment with private Somali doctors in the UK or their choosing to travel abroad. Across the two Somali communities interviewed, accessing a Somali doctor in the UK was their first choice.

The reason they go is because he speaks the same language and you don’t have to look for a translator. You don’t feel like he doesn’t understand you. Sometimes when you go to a GP you feel like they don’t understand you so you always have doubt. But he 100 per cent understands and we understand him as well.

However, this option was significantly more expensive than travelling abroad and therefore was rarely used. Notably, doctors accessed abroad are not necessarily always of Somali origin. For example, some of the most popular German doctors do not speak Somali but provide translators as standard. In contrast, when patients return to a country with familial ties, language does not pose a barrier.

Treatment experience

Patients’ experiences of treatment and care in the clinics abroad were overwhelmingly positive and some compared their experience to their experience of care in the UK. For example, one patient described her experience of diagnosis and tests abroad:

If you see a specialist you usually see them in their private office. It’s a nicer environment. Here you go to the hospital and you’re in a big waiting room, unless you see someone privately. It’s a lot more busy. It feels a lot more like you’re on a conveyor belt.

OT2

Despite this, she went on to say that, ‘With my experience it’s very difficult to compare because it’s not like for like really. I wouldn’t say that care is necessarily better. You get things much quicker in Germany’.

Throughout the Somali and Gujarati communities, members discussed how happy they were with the treatment received abroad. In particular, the sense of value for money compared with private care in the UK is important in this process.

The reasons why diaspora patients travel differ from the motivations observed in other medical tourists. Mainly they lie in cultural ties and connections to the place of treatment, or in opportunistically making use of a ‘holiday’ or a return ‘home’, which could be in part for treatment but may be motivated by other reasons. At the same time the high numbers of patients from specific ethnic groups (in our case the Somali community) who travel to receive treatment in a third country could be indicative of a lack of communication or outreach by the NHS to specific sections of the population, rather than a more general phenomenon of medical tourism.

Regardless of cause, providers have clearly developed to capture this niche, as is evident from German clinics and from the medical industry in India catering for non-resident Indians who return ‘home’ for their medical treatment.

Implications for the NHS

Diaspora patients, especially those of the diaspora Somali community, described cultural and specifically language barriers to accessing the NHS, including local GPs. When services are accessed, the treatment and care received may in some cases not meet patient needs. More needs to be done to address these needs, which act as the main determinant for travel. This includes communication in diaspora languages not limited to print materials and the use of health mediators from diaspora communities in local GP surgeries. It could include health information on diaspora radio and television stations, as well as greater engagement of community leaders to disseminate health information, including information on services provided by the NHS.

Background

The discussion below presents analysis of inward international patient flows to the NHS. Discussion is based on data gathered from seven foundation trusts, based on semistructured interviews with a range of NHS providers (n = 13), and three key stakeholder discussions with individuals who have significant experience of international patients flows, including a Department of Health official and a business consultant with significant experience of the NHS and private activity. Except for one, all foundation trusts were based within London. The roles of interviewees within trusts included the commercial and strategic oversight of activity, contract and business development and managing private and international patient activity.

The focus on inward flows is around the booked and planned admission of international patients treated as private patients within NHS facilities. This could include outpatient admission and day surgery as well as overnight stays. Possible payers for these patients include government-sponsored patients, private/employer insurance, and those funding treatment out of pocket.

The emphasis was on booked and planned admissions for which the foundation trusts could reasonably expect reimbursement (prepaid or through an embassy or insurer ‘letter of guarantee’). Individuals travelling from outside the UK for booked and planned treatment should be distinguished from categories of ‘overseas’ and ‘eligible’ or ‘non-eligible’ patients. For example:

• Individuals might travel to the UK and receive NHS services (as a result of initial admission to A&E or through GP referral) but not be eligible for these services (which could include maternity, dialysis, cancer or human immunodeficiency virus treatments). This links to a pejorative meaning of health tourism,223 in which there is no booked and planned admission with a clear reimbursement pathway.

• Overseas nationals could be admitted to A&E and could then be transferred to private patient facilities if their costs were covered by insurance or self- or embassy guarantee.

• EU nationals who access A&E or planned treatments using their rights as clarified under the EU directive (Directive 2011/24/EU of the European Parliament and of the Council). 1

The background and policy context to international patient activity is detailed in Appendix 25.

Size and scope of international patient activity

Data from the IPS suggest that, overall, international patient flows were in the region of 62,000 in 2010. Within this overall figure, major source countries include Ireland, Spain, Greece, Cyprus and the Middle East.

From the freedom of information requests we submitted it was clear that trusts could not always clearly identify international patients within their pool of private patients because nationality was not recorded: ‘With [international private] patients, a lot of them have an address in England and so that’s the address that will go on the systems. So we may never have a record of where they come from’ (NHS20).

Those whose treatment was funded by foreign embassies were more easily identified, but foreign nationals based/living in the UK may undergo treatment as private NHS patients in the UK, the costs of which are paid by their overseas employer or insurer or are funded out of pocket.

The NHS foundation trusts participating in the study were purposely sampled as we sought to understand the experiences of and ambitions for treating international patients. The London-based foundation trusts had longstanding international patient flows (including single-specialty hospitals as well as those offering a broader range of specialties). Countries identified as sending patients were primarily those from the Middle East (including Kuwait, the United Arab Emirates, Oman and Qatar, with smaller numbers from Saudi Arabia), and there were also strong flows from Cyprus and Greece. Types of treatment centred on complex tertiary procedures (including paediatrics and heart surgery).

Trusts that had delivered care to international patients over a number of years were keen to maintain and consolidate such activity. A number sought to explore opportunities to develop further international patient flows. The one trust based outside London had some limited experience but a growing interest in developing its international activity.

As we note in Chapter 16, the size of international private patient flows across trusts and foundation trusts varies. Similarly, across the seven trusts within our sample, activity ranged from being relatively marginal to being one-third of their total private work. The great majority of international patient treatment and payment pathways were organised by embassies and national institutional links. Very few patients within the NHS private system were reported to be out-of-pocket payers.

Respondents suggested that sender countries’ governments valued the NHS brand:

Overseas, it’s a great brand.

NHS16

A lot of those countries feel it’s quite politically supportive to actually send their patients through to NHS facilities rather than to direct private facilities.

NHS3

As we note below, these views regarding brand perception and reputation were also associated with individual NHS providers.

Strategic and commercial considerations

Respondents emphasised strongly that international patient flows must be seen within a wider picture of pressure on NHS resources, broader international activities and linkages and the lifting of the cap on private income earned by foundation trusts.

First, broader commercial imperatives facing the NHS were highlighted by interviewees, and treating international patients was seen as a means to an end (improving services for NHS patients and developing NHS facilities). The current financial climate for the NHS was viewed as a major challenge, and commercial income, private patient income and international income were seen as possible routes to ameliorating pressure on stretched NHS resources: ‘I think going forward all NHS organisations are financially challenged in some way or other . . . . Our best chance is actually by growing income from the private sector which will be used to subsidise the NHS’ (NHS15).

However, any commercial imperatives were balanced with strong statements regarding the core NHS role, centred on NHS services and prioritising NHS patient care:

Why else would we be having a commercial operation if it wasn’t to deliver a surplus that we can then reinvest on the NHS side?

NHS19

You have to balance. You cannot compromise our NHS responsibility. That is number one responsibility of the hospital. What we’re trying to do in these difficult times is manage the whole element of trying to achieve the overheads and costs that we have and manage that in a way that we at least generate some additional monies.

NHS3

We’re in the business of making a profit after we have done our core job which is making people better.

NHS5

It helps us launch services or buy kit that we couldn’t buy otherwise and employ people that we may not be able to employ.

NHS16

International patients were seen as an opportunity, as was domestic private activity. Both domestic and international activities provided opportunities to utilise spare capacity, particularly operating theatre time that was available out of hours. The NHS was viewed as having excellent back-up facilities, particularly in intensive care units. A common view was that, if not carried out at NHS sites, private work would be undertaken elsewhere and that there was an advantage in retaining clinicians on-site because they could be accessed by NHS patients.

There was little interest in actively accessing other patient flows (e.g. EU cross-border flows) given that tariff rates were not perceived as particularly attractive. One trust, for which one-third of its private work is international, directly commented on the advantage of international patients (funded by governments) being on higher tariffs than patients from domestic insurance companies: ‘So to be honest they [embassies] were paying more than insurance companies in this country, we had limited capacity, so why not for the NHS gain as much as we can and put back into the NHS?’ (NHS16).

For one commercial director, the board’s interest in and enthusiasm for exploring commercial opportunities required expectation management with regard to international patient opportunities: ‘What is really uncertain is what are the procedures people will travel for and what countries are they in’ (NHS5).

Such issues of non-NHS activity were invariably contentious. As the Department of Health policy manager stated: ‘It’s a very sensitive issue to the public about how much of the NHS is retained in its original format or how much of it change to opening up a more commercial approach’ (PA15).

Local and national political sensitivities of engaging in private patient and international activity were recognised. Indeed, one commercial manager spoke of the importance of being able to ‘Demonstrate that you’re doing it with additional capacity and it’s not making NHS patients wait and you’re doing it in a way that generates additional income which then goes to benefit patients’ (NHS1).

Second, established traditions and practices of having wider international clinical linkages and exchange were correlated with international patient activity. Institutions had longstanding international consultancy arrangements, collaborations and linkages and harboured ambitions to see these develop and flourish. Some were organisationally driven whereas some lay outside the hands of individual trusts:

So lots of our consultants go overseas to do lots of things. Some of it is charitable, some if it is rather more formal than that but that’s not the same as the organisation doing it . . . It gets quite complicated that in the NHS you’ve got an organisation that may or may not choose to do something but that organisation is made up of a load of clinical staff who will go off and do their own thing anyway.

NHS19

As discussed below, these activities raised the profile of consultants and hospitals and contributed significantly towards international patient referrals.

Third, closely linked to private patients (and thereby international private flows) was the cap limiting earnings from private activity. Fieldwork interviews were conducted during the passage of the Health and Social Care Act 2012. 30 The lifting of the cap was broadly welcomed within the trusts, although differing views were expressed regarding how, and whether, it would make an immediate difference. An interviewee from one trust stated that:

It’s a really very important constraint for us given our location and given the low level of the cap at the moment relative to other organisations . . . an expected policy move to lift the cap will be very important for the future of this organisation.

NHS15

This particular trust pointed to major difficulties with the measurement of the private cap contribution whereby billing counted towards private income (even if unpaid) and treatments that were not necessarily planned and booked were included in the count. One example provided was a treatment bill of £200,000 that was unlikely to be collected but which was nevertheless set against the cap of this particular trust. For some trusts the impact of the cap was dependent on location and also capacity:

I think for some hospitals it’s just a non-starter because of the area they’re in but for us in an area like this . . . it’s very international and affluent. You stand a far better chance of being run over by a Bentley or a Porsche than you do by a normal car out here.

NHS15

Thus, this trust intended to explore opportunities with embassies from a range of countries (e.g. getting on embassy ‘lists’ of preferred providers) once the cap was lifted. Another trust identified how the changes were absolutely vital to its future growth and development; this particular trust had developed two business models for the upcoming year, premised on the cap being lifted at different points in time. For another trust, however, although its earnings were close to the cap, when it was raised capacity issues would continue to constrain any growth of private/international income.

Referral and treatment pathways

There are distinct processes of referral and patient management for international patients. Two central considerations are organisational reputation and ongoing relationships.

First, beyond a broad view of ‘the NHS’, the reputations of individual trusts and hospitals were identified as crucial:

We’ve got a certain brand, particularly around the Middle East.

NHS2

Patients just want to come here . . . to be honest, the trouble we have is the capacity to fit international patients in.

NHS1

We’re actually very protective of that brand so we tend not to formally partner with people overseas.

NHS19

The international patient activity that was referred to NHS facilities was viewed as specialist and typically not possible to treat locally because of relatively small volumes and the complex nature of the treatment required.

Second, relationships, primarily clinical ones, were paramount in maintaining flows of international patients. Patient flows were perceived to develop from clinical relationships, including training links resulting from overseas referring doctors training within the UK or spending time alongside receiving consultants. One individual spoke of their trust’s experience of treating international patients as ‘a clinically convenient relationship presented a commercial opportunity to make a profit’ (NHS5). Another individual suggested that ‘we shouldn’t forget that we have lots of doctors who have come from overseas to train here who then go back to their own countries’ (NHS20).

Some trusts continuously developed and consolidated such links by offering clinical training to overseas consultants and staff exchange and educational programmes. ‘Show and tell days’, either locally or in locations where individual clinicians travelled overseas, were also identified:

The number one factor is the super-specialised doctors we have in London Teaching Hospitals having these links with the referring doctors in Kuwait, or the Emirates or Saudi Arabia.

NHS1

A lot of the international work we do now comes from a variety of sources but a lot of it is to do with our own consultants who have an international reputation.

NHS20

Having clinicians at the centre of relationship building was not without its problems, given that such activity was time-consuming:

I guess the key way of doing it is around getting clinician out there actually and spending a bit of time on the ground with the local clinicians to build up their links . . . providing education, assistance with research, maybe going over and doing some operating lists . . . the problem is really around getting access to these clinicians’ time in a busy NHS hospital.

NHS2

Alongside clinician links there were also cultural preferences that favoured specific London hospitals. For example, Middle East nationals were said to prefer particular London localities for treatment; similarly, a strong connection was identified between some parts of London and Greek and Cypriot populations. ‘I think the patients feel at home in London. Their relatives will come over and get a flat on [name of road] and go buy cuisine they’re familiar with in that area’ (NHS1).

Embassies and health attachés of sender countries were seen to occupy central roles in the market for international patients. A referral typically began with doctors at the local hospital board identifying a patient for overseas treatment and suggesting a particular country and doctor. This recommendation moves forward to an overseas treatment board with responsibility for all hospitals for approval. The decision would be passed to an overseas health department where locally based health attachés may have their own recommendation on choice of consultant/institution. The local health attaché takes responsibility for ongoing clinical liaison.

Embassies generate ‘letters of guarantee’ to provide reimbursement assurance for a trust for what may be a very expensive programme of treatment. Detailed patient records may not always accompany the travelling patient and so detailed checks and diagnostics are undertaken on arrival. Complex cases and lengthy stays will necessarily generate very large bills and sometimes payment is a drawn-out process. Line-by-line billing was the norm, with each item being detailed, rather than packages (self-funders are expected to pay upfront for treatments and are seen as financially riskier propositions given that they lack institutional surety). Staff who we interviewed from NHS trusts offered various forms of patient liaison (which may be 24/7), but not hotel-type concierge services. Translation services were either provided through individual patient liaison (e.g. fluent Arabic speakers) or sourced through NHS lists. There was no door-to-door service; return travel arrangements, for example, were typically made by embassies.

Personal relations and trust were perceived as key in fostering embassy and government institutional links (including military and health departments). One trust identified having 15 different embassy-type relationships and thus potential referral points for international government-sponsored patients. A great deal of institutional marketing centred on embassies and there were fairly regular visits to embassies and discussions to better understand their needs.

There were downsides of such activity, however. Income was not subject to contracts, unlike more continuous PCT income. Business could be volatile – ‘lucrative and transient’ suggested one patient manager (NHS12) – and referrals could dry up relatively quickly from embassy sources without a clear rationale. The role of attachés was central: ‘If they change you might get different favourites [places for referral]. It depends on where they trained, who they trained with, who they think is good. You can get a sudden change in referral patterns if that happens’ (NHS1).

Some interviewees perceived that there was greater competition among London teaching hospitals for referrals and that embassies were likely to explore options and be price sensitive: ‘I think there’s more competition between trusts now to attract international patients. And I don’t think that the pool has grown particularly’ (NHS2).

Some referral sources were said to be shrinking. One trust, for example, outlined that Cyprus was sending only very complex cases for treatment, and as countries developed expertise in particular procedures these were performed locally.

There were instances of facilitators and intermediaries approaching trusts offering to broker work between trusts and embassies. Such offers were often declined by trusts, and individuals involved in embassy liaison and patient support were trust employees (i.e. we did not identify instances of commission-type incentives for individuals bringing business). Specialty had a bearing on the overall pattern of referrals. When opportunities existed for patient self-referral, it meant that embassy referral was only one of a number of sources and website presence could be more significant for trusts.

Market development

All staff interviewed in the trusts perceived their international work as significant and were intending to maintain – or expand – such activity (unsurprising given our purposive sample). There was a distinction between those undertaking some (albeit limited) marketing outside of the UK activities, including attendance at large international trade shows and the use of brochures, and those not undertaking any marketing. Some viewpoints suggested that although such trade shows did not lead directly to additional business they were important for profile raising. There had been some attempts to share the costs of publicity, for example joint marketing of seven of the London specialist hospitals, including a brochure and a hotline. NHS private providers also meet regularly within London.

There was a view that to leverage greater opportunities would require fuller attention to marketing and customer care, and these were challenges in the current NHS environment. Two main points emerged.

First, the private health sector was perceived to have certain advantages, including marketing expertise derived from longstanding involvement. Some arguments were made that large international private health-care organisations were able to undertake general surgical marketing far more effectively given their experience of negotiating with insurance companies and were able to offer a dedicated marketing approach (and a greater customer care focus). One commercial manager perceived opportunities presented by possible private NHS activity being partnered with private health care: ‘If you travel first class your safety risk is the same but you just get a nicer experience. And we do the safe thing well, we don’t do the nice experience that well’ (NHS1).

Foundation trusts were seen as being particularly hampered by not having a commercial team, alongside having limited marketing budgets and also potential internal perceptions about private work:

I think to really leverage that sort of thing the organisation would need to become much better at managing [arrangements]. Because at the high end you are dealing with the sort of people who will want a number of other things.

NHS15

Like anything we’ve got limited budgets so we want to make sure we also use it for the biggest bang for our buck.

NHS16

We’re an NHS facility and the monies that we make through private patient activity feed into the trust so there isn’t a lot of that to enable us to go and do the sort of things that perhaps would generate additional monies.

NHS3

One interviewee argued that customer-focused processes required further attention within the NHS: ‘London has rested on its laurels a bit and sort of got away with it because people want to come and because the clinical standards are good’ (NHS1).

Traditionally, the NHS orientation was a passive one whereas private and international activity may involve more marketing and proactivity engaging overseas markets.

The second point to emerge was the need to manage both internal and local stakeholder views of such NHS commercial developments. One trust was explicitly developing an internal communications strategy that emphasised the contribution of private income to its NHS facilities. ‘The whole point of being a Foundation Trust Hospital is you make choices about how you’re going to generate your money and where you’re going to spend it’ (NHS5).

There were image issues (both internal and external) and a number of managers identified public misunderstanding around the role of NHS private patient activity. Sometimes these perceptions were linked to the pejorative notion of ‘health tourists’.

A number spoke of the benefits of ‘collaboration’. However, balancing the promotion of a NHS ‘brand’ against the interests of individual institutions presented a dilemma:

We should be trying to do it [collaborate] and share the costs. But then obviously I want the business to come to me. That’s what the trust employs me for. But getting the NHS brand out there is certainly going to help me and if we can share it great and if people want to ride on the back of that it’s up to them.

NHS16

A senior Department of Health policy manager commented (speaking some months before the launch of Healthcare UK): ‘So there are related functions across government that sometimes work together and sometimes don’t necessarily work effectively but [are] in the same sort of territory’ (PA15).

A number of trusts were keen for UK Trade and Investment (T&I) and NHS Global to help gain access to markets and foster activity overseas. Some expressed a lack of clarity of roles between T&I and NHS Global at the current time. They were unclear how an organisation that aimed to broker NHS international activities will be structured and located, for example whether it would be a closed subscription body or would be for all NHS trusts: ‘I’m not sure what NHS Global has actually managed to achieve’ (NHS19).

Market competition was seen as both national (including public and private) and international: ‘There’s a lot of competition within the NHS, within the private and that’s before you even start looking at Belgium, Germany, Paris’ (NHS16). For example, hospital consultants may receive a referral and have a choice where to undertake the work (privately or in the NHS), or be invited to operate overseas. ‘We have a number of competitors in London. Largely private hospitals . . . They are competitors but a lot of our own consultants also work in those hospitals’ (NHS20).

Germany was seen as competing for Middle Eastern activity, as well as a number of international developments within the Gulf region itself (although some Gulf developments were said to face challenges of consultant and nurse recruitment and volumes of activity).

Implications for the NHS

• International patient income was identified as significant within a number of trusts, particularly within the London area. Other parts of the country may hardly benefit from international patients.

• The lifting of the private income cap has stimulated further activity in search of international patients.

• Foundation trusts do not always fully distinguish between domestic and international private income. New reporting requirements (under the Health and Social Care Act 201230) and a wish to further promote activities abroad may sharpen this distinction (for trust boards and Monitor).

• Foundation trusts vary in their ability to compete for further international activity and in what is the appropriate role of health care.

• Our study did not focus on accounting systems and how tariffs are determined for international patients who receive treatment within the NHS, or controls to limit costs of private treatment being cross-subsidised by the NHS; research activity is required on these topics.

• Given the ongoing global financial instability, are there greater risks to trusts from international bad debts?

• Trusts were cautious in balancing their NHS responsibilities with the opportunities presented for income generation from international patients.

• Given the importance of referral networks, will changes to UK education and training opportunities facing non-EU medics (because of an EU focus and visas restrictions) impact on referrals over the medium term?

Income generated by inbound medical travellers

Costs to the UK NHS resulting from outbound medical travel

Based on the case studies of different types of medical travel identified by this research and further described in Chapter 7, we sought to identify the likely costs to and savings for the UK NHS from medical travel. In one case there also appeared to be additional savings for wider social services as a result of overseas travel.

Savings (or not) from outbound medical tourism

Implications for the NHS

• Both inbound and outbound medical tourism have the potential for cost savings and, in the case of inbound tourism, for additional income to be generated for the NHS.

• Given the level of complications experienced in the three areas of medical travel explored in this research, guidance to the public is urgently needed to ensure that patients travelling abroad pay greater attention to issues of patient safety. This will minimise costs to the NHS and patients resulting from outbound medical tourism.

• For bariatric and fertility treatment, the long-term costs (and potential savings) for health and social services associated with the procedures and outcomes far outweigh those in the short term. To fully assess the cost of medical tourism to health and social services it is therefore important to understand the differences between the long-term health and social effects resulting from treatment received abroad and those resulting from treatment received in the UK. For bariatric surgery this is currently not known. Research examining long-term outcomes between UK patients and medical tourists to enable a full understanding of the costs and savings of bariatric surgery is required.

• For fertility treatment there is a strong rationale to address the determinants (including regulation) of people travelling and provide greater information and sensitisation on this issue. Studies suggest that the incidence of multiple births is significantly higher (we estimated 20%, as set out earlier) as a result of people having sought and received treatment abroad. This is not a result of ‘different’ treatment but rather of differences in regulation, with other countries allowing different numbers of embryos to be transferred. Thus, any cost to the NHS as a result of multiples born in the UK will increase as a result of medical tourism (because of the increase in incidence of multiples born to couples who have travelled abroad to receive fertility treatment).

• Greater guidance and regulation of the cosmetic surgery sector is needed. The rate of complications for cosmetic surgery observed by others102 may also give an indication of the level and cost of complications in the largely private cosmetic sector in the UK. In many cases complications may not be reported as patients simply return to the original clinic. Our research further indicates that patients are likely to significantly under-report cosmetic procedures and complications. Therefore, the true level of complications resulting from cosmetic surgery is not known. Although the cost of cosmetic tourism to the NHS overall may seem low, all estimates presented here would increase substantively should outbound medical tourism further expand in the absence of clearer regulation and guidelines.

• Unified data collection among NHS hospital trusts with regard to private patients, including whether or not these are from the UK, is needed. This will enable the NHS nationally and individual trusts to plan for and assess this market. This seems to be a particular oversight in light of the changing patient caps within the NHS (Health and Social Care Act 201230).

• The current level of income from inbound medical tourists highlights the potential of this market, in particular for specialist hospitals that have a particular ‘brand’ to market.

• Finally, in terms of bariatric surgery, the balance of costs and savings for health and social services suggests that the NHS might ‘encourage’ people to go abroad for this procedure, but also provide guidelines on what to look for, as it represents a net saving to the NHS and the social security system. This is especially important as complications resulting from bariatric procedures appear to be particularly severe.

Patient decision-making

Eligibility for access to domestic health-care services is a strong influence on the decision to seek medical care overseas. Patients are prepared to travel abroad when a treatment is not available within the NHS, when they do not meet strict eligibility requirements or when they have exhausted their entitlement (e.g. for IVF treatment). Individuals choose to pay for treatment abroad rather than domestically primarily for reasons of cost but also because of the perceived expertise of clinicians overseas; family or cultural connections with overseas destinations are also contributing factors.

Outward medical tourism involves a range of medical and ancillary services and typically a range of small-scale providers and clinics. We identify an emerging trend for patients to travel beyond Europe for treatment, but also the key role of diaspora networks and relations in shaping the favoured travel destinations of medical tourists.

Information, guidance and risk

Decision-making around outward medical travel involves a range of information sources; the internet plays a key role in addition to information from informal networks of friends and peers. It would appear that medical tourists often pay more attention to soft information than hard clinical information and there is little effective regulation of information (be it hard or soft) online or overseas. Because prospective travellers source information from intermediaries, direct from websites and internet marketing, and among networks, it complicates practical attempts to improve the quality of information provided to medical tourists.

A broad range of advice, information and guidance exists for prospective travellers, including the NHS Choices website235 and information developed by the National Travel Health Network and Centre (NaTHNaC) (see www.nathnac.org/travel/misc/medicaltourism_010911.htm). 236 Although potentially valuable, the onus is on prospective medical tourists to seek out such information; presently there is little evidence that they routinely do this. There is clearly scope for health-care professionals within the NHS to become part of the networks of information and support that can be accessed by potential medical tourists.

Our review of the legal framework attests that individuals are willing to travel for treatment to locations that are not regulated by national laws and guidelines. It is apparent that patients do not fully understand the scale and nature of the risk associated with seeking treatment overseas, including the difficulties relating to redress when something goes wrong. This uncertainty bedevils all phases of treatment decision-making, including access to information, preconsultation, treatment itself, aftercare and follow-up.

The wide range of clinical, ancillary and support services involved in medical tourism complicates efforts to inform and educate medical tourists, or to regulate aspects of the industry. It is clear that across many websites of facilitators, clinics and hospitals, treatment risks are underplayed, and there exists an imbalance of objective information and promotion and advertising used for marketing purposes.

Although there has been a recent proliferation of systems of EQA and audit, these, along with the registration details displayed on websites, do not always make for better-informed patients.

It is clear that safeguards for UK health care (e.g. GMC registration) have little relevance if treatment is received out of the national jurisdiction. The need to seek redress and subsequent legal implications may occur many years after treatment and once complications have emerged. Although advice, information and guidance do exist for travellers, it must have appropriate coverage and be widely accessed. To provide sufficient safeguards from risk, guidance needs to be proactively available. Currently, the onus is on prospective medical tourists to locate this information.

Beyond generic travel advice for medical tourists, the need for clearer guidance on bariatric surgery, or for patients considering bariatric surgery, is evident. Patients lacked consistent information on possible complications and also on the long-term consequences of surgery and the ongoing aftercare. Equally, greater information for and training of GPs is needed to enable them to advise patients and to deal with the possible negative consequences associated with weight-loss surgery.

For fertility the situation is particularly complex. IVF treatment is, ceteris paribus, more likely than non-assisted fertilisation to result in multiple births, which are in turn associated with higher risks than single births. UK legislation is geared towards reducing the likelihood of multiple births, in particular governing the number of embryos that can be transferred. However, such legislation varies cross-nationally. Furthermore, unclear regulatory frameworks overseas mean that patient data may not always be held in the detail expected within the NHS and it is not always possible to retrieve data; these issues are exacerbated when countries have anonymous donor laws. With diaspora travel, we have seen that many of the issues outlined here can be further compounded and complicated by wider misunderstandings and often unrealistic culturally rooted expectations about a wide range of issues related to NHS care.

The size and economic impact of the medical tourism market

Individuals travelling for medical treatment are often ill-informed or under-informed and this heightens the risks associated with medical travel. The most robust data available clearly show that this affects many UK residents. Although the limitations of the IPS mean that we cannot banish all uncertainty that surrounds market estimates, the data show that, in 2010, at least 63,000 UK residents travelled abroad for medical treatment and at least 52,000 residents of foreign countries travelled to the UK for treatment. These are likely to be conservative estimates but even these numbers underscore that medical tourism is a very real phenomenon.

To better understand the collective risk faced by medical travellers it is imperative that robust, reliable data are collected that not only map the size of the medical tourism market but also provide useful information about who travels when and for what purpose.

It is also important to better understand the similarities and differences between inward and outward medical travel. We have seen that inward medical travel to the UK occurs across a range of clinics and providers, including to private facilities within the NHS and the independent sector. These inward referrals and flows of international patients are shaped by clinical networks and longstanding relationships that are fostered between clinicians within sender countries and their NHS counterparts; in this sense they may be different to outward flows. Those travelling to the UK for treatment as NHS international patients are more likely to receive complex and expensive treatment underwritten by their national governments, in sharp contrast to outward medical travel from the UK.

Despite important caveats, our calculations show that there are costs and benefits to the UK economy and the NHS resulting from inward and outward medical travel. Our estimates show that inward medical travellers and their companions contribute in the region of £219M per annum to the UK economy in additional tourism spends. We also found spending on medical treatment in the range of £178–325M. Together this amounts to a contribution of between £397M and £544M per annum to the UK economy.

In addition, our research revealed costs and savings resulting from UK residents travelling abroad to seek treatment. When complications occur and these are dealt with by the NHS, or when surgery undertaken will require lifelong maintenance, this represents additional expenditure for the NHS. Although the costs of such complications can be comparatively small (e.g. an infection following cosmetic surgery that requires a GP visit and a course of antibiotics), they can also be very high (e.g. in the case of failed bariatric surgery patients may need full-time care and may be, or continue to be, unable to work). The costs of corrective surgery and ongoing care can be extremely high.

Our research demonstrates equally that, when people opt to travel abroad to access treatment and this is successful and they return to work, savings may be substantial for domestic health and social services. Most importantly, if medical travel increases, so will these costs and savings.

The industry: providers and market development

We are now better able to understand the nature of medical travel providers and ancillary services, including the role of intermediaries. Our research demonstrated a range of different models marketed by providers and by which patients travel to receive treatment. There are clearly legal uncertainties at the interface of these and clinical provision.

Our research reveals a picture of a complex market; surprisingly few of the patients interviewed were using brokerage or facilitator arrangements unless these were built in by the clinic itself. Models also differed by type of medical tourism and clinical procedure for which travel occurred. For example, bariatric patients may have had consultations before and after overseas treatment with a representative of the clinic in London, whereas fertility patients appeared to undertake pretreatment tests privately in the UK in advance of travel, but at the request of the overseas provider.

Findings, including interviews with patients and providers, also highlight recent industry development. Patients are now travelling to further or ‘new’ markets in medical tourism, highlighting development and diversification within the market, with higher-end and lower-end destinations emerging.

International patient income generated for NHS trust hospitals, particularly in London, is significant. Although the analysis of data on patient flows shows a change in origin of travellers from the Middle East towards a greater number of Europeans, this market appears stable. Many NHS trusts do not always fully distinguish between domestic and international private income earned. This has some bearing on the ability to identify and further target particular overseas market segments. It is therefore not possible at the moment to gain a full picture of the types of procedures that incoming patients access, nor the specific hospitals that they target. Nonetheless, our research findings clearly underline the power of the brand that large NHS hospitals have, the extent to which this attracts foreign capital and the potential for generating further income. In light of the lifting of the cap on private income, some specialist providers may wish to market themselves more aggressively.

New reporting requirements under the Health and Social Care Act 2012,30 and a wish to further promote activities abroad, may focus greater attention on the distinction between private domestic and international income, both within trust boards and by regulators. A more accurate national picture of the inbound patient flow could allow targeted marketing of NHS facilities.

Given the importance of clinician networks in attracting referrals of international patients, there are uncertainties about how changes to UK education and training opportunities for non-EU health-care professionals (because of an EU focus and visa restrictions) will change the shape and dynamics of international networks and linkages, thereby impacting on referrals over the medium to long term.

The missing link: patients’ health

A key limitation across the areas of medical tourism information, activity, income and industry is the current lack of evidence on medium- and long-term health outcomes of patients travelling to receive treatment abroad. This includes how these may differ from the outcomes of those patients receiving treatment in the NHS.

A review of the literature reveals that there is currently no long-term comparative evidence of clinical outcomes in medical travellers and clinical outcomes in those who have been treated at home. This restricts the ability to estimate long-term costs and to fully understand the effects of medical travel, as well as its potential for savings and better patient care.

Our sample of patients highlights that medical travel is rarely without complications or costs to the individual. Although some people have minor or no problems following treatment abroad, others face severe health problems that in some cases are exacerbated by an inability to ensure continuity of care or obtain patient records to address their needs. This research did not set out to assess long-term clinical outcomes of medical tourists. However, our findings did reveal that, although the scale of the issue may (arguably) not as yet be overwhelming, the effect on individual patients can in some cases be catastrophic. This raises a number of related ethical questions and issues. These aside it poses a limitation on the ability to fully weigh up the benefits and costs of treatment abroad compared with domestic treatment.

Research agenda

This study has addressed many of the key questions relating to recent developments in medical tourism and the implications of these for the NHS. To obtain an even more complete understanding of the costs and benefits of medical tourism and to move the debate beyond discussing its potential to a stage at which we can understand its impact better, further research needs to be undertaken.

Future research should:

• Seek to better understand the medium- and long-term health and social outcomes of treatment for those who travel from the UK for medical treatment. Specifically, comparative research is needed with patients undergoing similar treatment within the UK. This will enable a direct comparison between the costs and benefits of domestic treatment and those of treatment abroad. There are likely to be not only costs and benefits to the NHS but also costs and benefits to social services. Such research is of particular value as our findings demonstrate that medical treatment has medium- and long-term outcomes that may be evident only in later stages as complications or unintended consequences of medical tourism arise. Routinely recording and analysing the ongoing care needs of those who have travelled abroad for treatment will also enable professionals to provide guidance to patients who are considering treatment abroad. Furthermore, a greater understanding of the clinical outcomes of medical travellers that extends beyond the short term will enable a more robust and nuanced understanding of the costs to the NHS of outward medical tourism.

• Generate more robust data that better capture the amount of activity and the flows of medical travel. This is needed to provide a deeper understanding of why UK residents seek treatment abroad. It will also enable further work on costs and savings to the NHS, to other social services and to the UK economy as a whole that may result from inward and outward medical tourism. Such data should also include sociodemographic data as well as information about what procedures patients are travelling for to better understand patient motivation for travel.

• Aim to better understand inward flows of medical travellers. This includes data on where patients travel to, the procedures they undergo, the price of these and their sources of funding. Data show that the UK’s immediate neighbours are the source of many medical travellers to the UK, but so are many Middle Eastern nations. Do these represent very different medical tourists? Are we correct in assuming that many of the travellers from the Middle East are those requiring ‘high-end’, complex and expensive treatment? Is this conducted within the NHS and without? Are those residents of France and Spain actually expats? If so, how are they funding their treatment?

• Gather a greater level of information on patients, including their origins, procedures undertaken and outcomes, to allow for the development of better economic costings. This could include costs and revenue experienced by the NHS as well as the wider economic and social costs and benefits, which may be both public and private.

• Explore further the issues of clinical relationships and networks. Our research suggests that clinical relationships and networks explain the dynamics and patterns of international patient referrals into the NHS. Linkages are generated through education, training, consultancy and research collaborations. However, further studies are required to understand the precise shape and nature of these networks, including how they may be fostered and the impact of policy and broader social developments on their expansion. For example, visa requirements, increased costs of studying and the emergence of alternative training destinations may weaken established networks in the medium and longer term.

• Consider the importance of the NHS brand. Recent policy initiatives are promoting the notion of a NHS brand. Research to explore this brand perception internationally would allow better communication and targeting of activities. It would also identify where potential opportunities, if any, exist for promoting the UK as a destination for medical tourists.

Contribution of authors

Dr Neil Lunt was Principal Investigator and had overall responsibility for the design, data collection, analysis, research governance and preparation of the final document. He undertook data collection (including interviews and website analysis) and contributed towards the policy context and background. He gave final approval of the report to be published.

Professor Richard D Smith was a co-applicant. He conducted the analysis of costings, oversaw the systematic review and was involved in the overall planning and preparation of the final document. He gave final approval of the report to be published.

Professor Russell Mannion was a co-applicant. He contributed towards the background context and analysis of patient safety and service quality and advised on the final write-up. He gave final approval of the report to be published.

Professor Stephen T Green was a co-applicant. He contributed towards the background context and analysis of patient safety and service quality. He gave final approval of the report to be published.

Professor Mark Exworthy was a co-applicant. He contributed towards the background context and analysis of NHS policy and advised on the final write-up. He gave final approval of the report to be published.

Dr Johanna Hanefeld conducted the interviews and analysis and the analysis of the costing work and the IPS. She was responsible for the preparation of the final document. She gave final approval of the report to be published.

Dr Daniel Horsfall was responsible for the day-to-day planning and administration of the project. He conducted the interviews and analysis and the analysis of the IPS. He was responsible for the preparation of the final document. He gave final approval of the report to be published.

Dr Laura Machin was responsible for the project start-up, led on the initial ethics applications and governance and conducted the interviews. She gave final approval of the report to be published.

Dr Hannah King conducted the interviews and analysis and provided background context on patient safety. She gave final approval of the report to be published.

Disclaimers

This report presents independent research funded by the National Institute for Health Research (NIHR). The views and opinions expressed by authors in this publication are those of the authors and do not necessarily reflect those of the NHS, the NIHR, NETSCC, the HS&DR programme or the Department of Health. If there are verbatim quotations included in this publication the views and opinions expressed by the interviewees are those of the interviewees and do not necessarily reflect those of the authors, those of the NHS, the NIHR, NETSCC, the HS&DR programme or the Department of Health.

Publication

Lunt N, Machin L, Mannion R, Green S. Are there implications for quality of care for patients who participate in international medical tourism? Expert Rev Pharmacoecon Outcomes Res 2011;11:133–6.

Introduction and background

European Union directives outline end results to be achieved by every member state. National authorities must adapt their laws to meet these goals but have the freedom to decide how this is done. In 2006 the European Parliament voted for the exclusion of health services from the scope of the Services Directive 2006/123/EC, designed to increase internal service trade within the European zone. The directive relevant to cross-border health care was proposed, which treats health with these specificities. Under this directive, which came into force in 2013, EU patients are able to access health care across borders as a right – under certain conditions.

Health care that falls outside of the directive includes:

• long-term care

• organ transplants

• vaccination programmes.

This summary assesses the implementation of the directive and comments on/highlights potential points of relevance for medical tourism within the UK context. The points of focus are:

• entitlements and authorisation

• care while abroad and continuity of care

• patient information

• regulation of advertising.

Throughout this discussion the ‘state of affiliation’ refers to the state that is competent to offer the patient authorisation to travel under the directive. The ‘state of treatment’ refers to the member state on whose territory health care is provided to the patient. Cross-border health care refers to health care provided or prescribed in a member state other than the member state of affiliation (under the directive).

Entitlements and authorisation

Relevance for medical tourism

In the UK context of cross-border care, patients are typically reimbursed specifically for the health care received. However, if NHS patient eligibility for domestic travel benefits were expanded to include cross-border travel this would have implications (see www.nhs.uk/NHSEngland/Healthcosts/Pages/Travelcosts.aspx). Any expansion to the NHS Low Income Scheme would remove potential cost barriers for lower-income groups to access care under the directive. Those that fall outside the scheme would still need to meet their costs of travel (for further information on the travel costs scheme see http://www.nhs.uk/NHSEngland/Healthcosts/Pages/Travelcosts.aspx).

Under the directive patients’ needs must be considered on a case-by-case basis, which includes medical need and the ability to carry out professional activity. This requirement will complicate the possibility of issuing clear statements of eligibility for both GPs and patients.

If GPs become the route to prior authorisation, this may impact on those travellers who are seeking a service abroad that they could be expected to receive within the primary care setting. This will therefore require GPs to be educated and sensitised should they become gatekeepers for cross-border travel.

Care while abroad and continuity of care

In the UK, when patients make the choice to travel abroad (for both out-of-pocket and cross-border care) it is up to them to make sure that they are insured and that they are aware of what NHS entitlements will cover. The directive stipulates that:

Member states should ensure that mechanisms for the protection of patients and for seeking remedies in the event of harm are in place for healthcare provided on their territory and that they are appropriate to the nature and extent of the risk. However, it should be for the Member State to determine the nature and modalities of such a mechanism.

Article 24

Medical travellers who pay out of pocket may benefit from clarification being developed around cross-border care. A reinstatement of NHS eligibility and responsibility may allow the opportunity to clarify a range of patient circumstances, including what aftercare will be given and aspects of care that are the patient’s own responsibility and when the NHS will not assume liability.

Continuity of care is another aspect for which there may be spillover effects for medical tourism that result from clarifying cross-border rights. The directive outlines that patients who have received care in another state are entitled to a written or electronic medical record of such treatment [Article 4(f)]. In addition, when a patient has received cross-border health care and medical follow-up proves necessary, the same medical follow-up is available as would have been if that health care had been provided on the patient’s territory [Article 5(c)].

However, matters are complicated concerning redress. Under the directive, the NHS is required to treat the patient only in relation to medical need. Outside of this, redress would need to be followed up in the state of treatment, which may incur further travel and accommodation costs to the patient.

Patient information

The means of carrying out the objectives of the directive are largely left to the individual member states. Under the directive, member states will be required to have national contact points that aim to facilitate the exchange of information. A certain amount of information must be provided by these contact points and is likely to be put forward voluntarily. All information made available through national contact points must be easily accessible and shall be made available by electronic means and in formats accessible to people with disabilities, as appropriate (Chapter 2, Article 6.5). Member states will also be able to decide on the number of national contact points and these can be designed to be built into pre-existing information centres (Article 49). Medical tourism may receive some spillover benefits from the provision of information by contact points.

The contact points will play differing roles when acting as treatment states or states of affiliation. When acting as the treatment state, the contact point must make available information on quality and safety standards and guidelines, patient rights, redress mechanisms and complaints procedures. States of treatment are required to provide, on request, relevant information on standards and guidelines. This includes information on the provisions for supervision and assessment of health-care providers; which health-care providers are subject to these standards and guidelines; and the accessibility of hospitals for persons with disabilities [Chapter 2, Article 4(a)]. The contact points must also provide information on the legal and administrative options available to help patients settle disputes, including in the event of harm arising from cross-border health care (Chapter 2, Article 6.3). Medical tourists may use such information to inform their own out-of-pocket treatment decisions.

A state of affiliation must make available on request information on patient rights and entitlements in that member state relating to receiving cross-border health care, in particular regarding the terms and conditions for reimbursement of costs, and procedures for accessing and determining those entitlements and for appeal and redress if patients consider that their rights have not been respected [Article 5(b)].

In addition to the national contact points, health-care providers will also need to provide relevant information for a patient to make an informed choice about treatment and the availability, quality and safety of the health care provided in the state of treatment. They must also provide clear invoices and clear information on prices [Chapter 2, Article 4(b)]. This should already be provided to domestic patients. These requirements may again have spillover effects for medical travellers who seek treatment outside of the directive. Greater transparency around quality and safety and invoicing may inform the treatment decisions of outward medical travellers. The requirement for NHS facilities to provide further information on tariffs may have implications for international patients’ decision-making as they look across NHS providers and make comparisons with the private sector and facilities elsewhere in Europe and further afield.

Although the directive outlines that member states must make information available, there is likely to be great variation in the way in which this information is received.

Irrespective of how much information about rights is provided by countries under the directive, the decision to travel will remain that for the individual to make. Patients are to be informed about what is available to them, yet this should be without the intention of promoting the services abroad. Accurate and transparent reporting on use of the directive and its implementation, including when complications may arise, will require some form of oversight body.

Regulation of advertising

In addition to the directive, treatment providers must adhere to general provider guidelines in European directives designed to increase internal service trade within the European zone. These include making information available with regard to informed choice, treatment options and risks. Health-care providers will need to provide relevant information, including on the availability, quality and safety of the health care that they provide in the state of treatment, so that patients can make an informed choice about treatment options. They must also provide clear invoices and clear information on prices [Chapter 2, Article 4(b)]. Such requirements will have a bearing on advertising practices. Given that information may be sourced through a number of ways (internet, by word of mouth, community television), marketing is more complex to regulate.

Example interview questions for medical tourists

• What treatment/s have you gone overseas for? Where did you go?

• Why did you not have the treatment in the UK?

• How did you first find out that it was possible to have treatment overseas? From whom?

• Did you ask anyone or look for advice on how to go about having treatment overseas?

• How did you choose which agency/hospitals/clinician to have your treatment with? What factors were a priority when choosing?

• What additional services were you made aware of by the agency/hospital when planning your treatment?

• Did you take out any travel insurance for your trip/treatment?

• Did you require any pretreatment checks? Who carried these out and where?

• Did anyone travel/stay with you when going overseas for treatment?

• How was your experience of accessing treatment overseas? How could it have been improved? Would you say you are satisfied with the outcome of your treatment abroad?

• Was the language barrier between you and the hospital staff a concern for you?

• How were you made aware of any risks associated with the treatment before it began?

• Did you have any postoperative care requirements? How were these met? By whom?

• What responsibility does the NHS have to those people who travel overseas for treatment?

• How do you feel about people travelling to the UK to have treatment on the NHS?

• Would you recommend going overseas for treatment to others?

Example interview questions for industry

• Tell me about the work you do here/your role.

• How did you get into this business?

• What services does your business offer? Insurance? Sightseeing, transfer of medical records, transport?

• Can you identify your closest competition?

• How do you attract customers to use your services that don’t rely on/use/have access to the internet?

• Can you explain the process after someone contacts your agency/views your website and wishes to go overseas for treatment (telephone, e-mail, face to face?)

• Is your advice sought after by potential medical tourists? Do you see that as part of your role – to draw on your experience?

• How do you and medical tourists overcome the language barriers that arise from accessing treatment overseas?

• How do you choose which hospitals/clinics to work with? Are they chosen by the customer already or do you advertise particular venues/experts?

• Have you any insights into how your customers handle the postop care arrangements? Does your business deal with the recovery needs of the customers?

• How do you deal with customers reporting bad experiences to you? What are the ramifications for your company? The hospital and surgeon?

• Are there aspects of the medical tourism industry that you don’t yet provide or conduct that you wish to in the future? Particular groups of customers that you wish to attract?

• What is needed for the medical tourism industry to grow? What could hinder the future growth of the medical tourism industry?

Example interview questions for NHS commercial/international/private patient managers

Example interview questions for NHS managers (commissioning)

• Tell me about the work you do here/your role.

• How did you get into this role?

• Why do you believe that people pay for medical treatment overseas?

• Do you view people accessing treatment overseas as patients, customers or consumers? Does your perception vary according to which treatment is being sought after?

• Do you foresee any risks with opting to pay for treatment overseas?

• How can we make accessing treatment overseas safer?

• In your opinion, are there aspects of the medial tourism process that bring up ethical or legal dilemmas?

• Are there particular treatments that you believe should not be available through medical tourism agencies?

• What impact does medical tourism have on the NHS? Its staff? Budget? Its public perception? In the long and short term?

• Can medical tourism provide opportunities for the NHS?

• Are you aware of people travelling to the UK to access treatment through the NHS or private clinics? What do you believe are the issues that arise from this travel and care?

• Have you any insight into how medical tourists handle the postop care arrangements? Are you aware of hospitals that have dealt with the recovery needs of medical tourists?

• Whose responsibility is it to deal with any complications that arise after medical treatment paid for overseas?

• In the current economic climate, what does the future hold for the medical tourism industry?

Example interview questions for professional associations

• Tell me about your role within the association.

• What role does the association provide to its members?

• Does the association have a role within wider society? Within government?

• Is it the role and responsibility of the association to provide advice or guidelines to potential medical tourists? Those working within the medical field?

• Why do you believe that people pay for medical treatment overseas?

• Is there enough regulation around the medical tourism industry?

• Do you foresee any risks with opting to pay for treatment overseas?

• How can we make accessing treatment overseas safer?

• In your opinion, are there aspects of the medial tourism process that bring up ethical or legal dilemmas?

• Are there particular treatments that you believe should not be available through medical tourism agencies?

• Do you see/hear about medical tourism having implications for your members? Your profession?

• Have you any insight into how medical tourists handle the postop care arrangements? Are you aware of hospitals that have dealt with the recovery needs of medical tourists?

• Whose responsibility is it to deal with any complications that arise after medical treatment paid for overseas?

• Are you aware of people travelling to the UK to access treatment through the NHS or private clinics? What do you believe are the issues that arise from this travel and care?

• In the current economic climate, what does the future hold for the medical tourism industry?

Example interview questions for overseas providers

• Numbers of international tourists (type of treatment, country, age/gender, etc.) and types of services offered/utilised.

• Trends – which areas above are growing/declining? Where are they seeking to develop?

• How services are marketed to different groups:

  • marketing strategies (including websites), word of mouth, clinician referral, brokers.

• Treatment pathways:

  • preconsultations

  • use of brokers.

• Competitors for specific treatments/patient groups:

  • national

  • international.

• Observations on quality of care.

• Do you foresee any risks with opting to pay for treatment overseas?

• How can we make accessing treatment overseas safer?

  • role of accreditation

  • role of national/international guidance/legislation.

• Aftercare and follow-up – whose responsibility is it to deal with any complications that arise after medical treatment paid for overseas?

• Ethics and legal – in your opinion, are there aspects of the medial tourism process that bring up ethical or legal dilemmas?

• Plans for the future – any possible problems/barriers with regard to developing services?

Online channels through which recruitment was attempted

Beauty in Prague Forum.

Big Matters.

Cosmedia.

Cosmetic Compare.

Cosmetic Surgery Forums.

Donor Conception Network.

eHealth Forum.

Fertility Friends.

Gay Family Web.

Infertility Network UK.

Linda Briggs forum.

Look Your Best.

Michelmores.

MoneySave Supermarket.

National Gamete Donation Trust.

Patient Opinion.

PlacidWay.

RealSelf.

Secret Surgery.

So feminine.

Surgery Overseas Forum.

Treatment Abroad.

Weight Loss Surgery Information and Support [site and Facebook (Facebook, Inc., Menlo Park, CA, USA)].

Journals which carried article about the study and recruitment

International Medical Travel Journal (IMTJ) and The Probe Magazine.

Network gatekeepers assisting with sample recruitment

Martin Rathfelder, Somali Adult Social Services, Nina Lakhani and Ubah Egal.

Project website

www.medicaltourismresearch.co.uk

Bariatric surgery

Fertility surgery

Dental surgery

Cosmetic surgery

Other medical tourists

Review criteria

The initial selection of papers was undertaken following a review of titles that had a general focus on medical tourism. The following were excluded: papers on well-being or travel for assisted suicide, news items, commentaries, laws or directives and conference proceedings. One exception was made in the case of a news report published in the Lancet. Only articles published in English and German were included.

Following a review of titles and abstracts, 425 papers remained. Out of this sample a further 21 papers focusing on stem cell tourism and 29 papers focusing on transplant tourism were excluded as these are distinct areas of tourism with specific ethical issues. In addition, one guideline from the American Medical Association was excluded, leaving 374 papers.

Of the 374 remaining papers, the abstract or entire paper for each was reviewed to determine whether or not to include it in the review. In addition, references of the papers identified through the review of the literature were further examined to ensure that all relevant papers were included.

In line with the overall research objectives, papers were selected to see how much they could contribute to understanding medical tourism as an industry, as a trade in health services and from a patient perspective.

Emphasis was on papers published in peer-reviewed journals that had a global focus on medical tourism or a focus specific to the UK (i.e. the review excluded papers that focused exclusively on medical tourism to one country or the effects of medical tourism on one country, for example the USA, unless there was a specific UK link) or to dental, fertility, cosmetic, bariatric or diaspora tourism, which form specific case studies within the overall research project. Articles were included when primary research had been conducted in one country but the framework, conclusions and discussion demonstrated that findings were transferable.

The research project is also undertaking a review of websites to better understand the industry and providers. Given this emphasis, papers focusing on medical tourism provider websites were included. Papers that focused from an industry perspective on the management or organisational issues (e.g. on how to lead virtual teams working within the medical tourism industry) were excluded when these did not draw wider conclusions on the issue of medical tourism as a whole.

There is a body of literature examining issues relating to medical tourism, including issues of transplant, stem cell and surrogacy tourism, from an ethical and philosophical perspective. This literature has not been considered here.

A number of studies explored the impact of medical tourism on the health-care system and professionals within a specific country; these have not been included in this review of the literature unless their findings shed light on the wider phenomenon of medical tourism. Papers focusing exclusively on the implementation of the EC directive on cross-border patient care (e.g. Hawkins et al. 234) were also excluded.

On the basis of these criteria 276 papers were excluded. Following the review of the papers, four additional studies were included that had not emerged from the initial literature searches. Two papers were not accessible and were therefore excluded. Based on these criteria 100 papers8,10–12,17,26,40,42–134 were included in this review.

Review process

Two authors independently reviewed the papers and then met to compare results. A third author tested a sample of papers. The initial results of the review were presented to the study advisory board and following input a further search term of ‘cross-border care’ was run. However, this did not yield any additional papers that had not already been included in the original search.

What do we know about medical tourism? A review of the literature

FIGURE 9.

Number of publications by year of publication.

FIGURE 10.

Types of studies included in the review.

FIGURE 11.

Geographic focus of studies included in the review. Numbers denote the number of papers investigating each region. Papers could fall into more than one category, and some comparative papers focused on two regions or countries from within two regions.

FIGURE 12.

Data sources for patient numbers quoted in studies included in the review.

Belgium

Medical tourism in Belgium is dominated by small independent clinics often specialising in one broad treatment area, the most common being bariatric surgery, cosmetic surgery and fertility surgery. These smaller clinics do market themselves to European, including UK, trade; however, word-of-mouth recommendations are increasingly important in capturing UK tourists. Although cheaper costs available in Belgium are a draw for citizens of other European countries, many clinics are also able to boast pioneering or field-leading surgeons, especially in terms of cosmetic and bariatric surgery. UK citizens who have travelled to Belgium have noted that the cost of travel to and accommodation within Belgium is often cheaper than for London, where the UK alternatives are usually located.

Spain

The Spanish medical tourism industry has a long history built on low costs and an active wider tourism industry. For Britons it has historically not been uncommon to combine low-level medical treatment such as dentistry with conventional tourism to Spain; however, Spain’s medical tourism industry primarily serves continental Europe rather than the UK. Indeed, a senior consultant at one of Spain’s large health-care institutions suggested that UK medical tourists made up only an insignificant proportion of medical tourists to the organisation. The only exception to this is fertility tourism, which brings a large number of UK citizens to Spain.

Medical tourism in Spain is primarily hosted within large multipurpose clinics or hospitals that often deal with a range of treatments. For example, an organisation such as the Barcelona Medical Centre actually represents an affiliation of a number of general and specialist clinics. Much private treatment also occurs within public hospitals. Although there are smaller independent, specialist clinics, it is these large complexes that dominate the industry. The main exception to this is the case of fertility clinics, with a number of smaller clinics attracting medical tourists alongside the larger clinics.

Turkey

The Turkish medical tourism industry is an increasingly national project with small and large clinics soliciting business alongside governmental and quasi-governmental bodies. Although small clinics offering a narrow range of treatments are common, it is larger clinics that are driving the Turkish medical tourism industry. These clinics are usually ‘hotel like’ in their front-of-house appearance, whilst marketing state-of-the-art medical facilities. Such clinics are frequently ‘one-stop’ clinics where a wide range of procedures are performed. Although Turkish providers are happy to court the UK market, UK travellers to Turkey have historically travelled for less complex and lower-cost treatment (often cosmetic). As one provider noted, although this is useful, it does not represent a stable foundation for a viable business model. Clinics are actively courting ‘en masse’ those requiring higher-end procedures. To this end, Turkish clinics are actively seeking partnerships with medical insurance companies, both in Europe and in the Middle East. Although individual clinics are in competition, there is a degree of unity behind what appears to be a national programme aimed at establishing Turkey as medical tourism hotspot ‘where East meets West’. Organisations such as Health in Turkey (an association of the Foreign Economic Relations Board and the Health Tourism Business Council) and the Turkish Healthcare Development Council represent a loose alliance of Turkish medical tourism providers who agree to support certain ventures with the aim of benefitting the wider medical tourism industry in Turkey. These organisations are linked at arm’s length to the Turkish government’s Ministry of Tourism and Culture.

Hungary

The Hungarian Ministry of Health is actively pursuing a medical tourism strategy and is keen to market the country as a destination for patients from abroad. The UK is clearly considered a market for this strategy as the Ministry of Health recently financed its first medical tourism symposium in London. The country is recognised for its expertise in dentistry and has excess capacity in dentistry. Within Hungary, specific regions attract patients from different countries based on proximity and accessibility. Many of the Hungarian dentists catering to UK clients appear to have facilitators in the UK who are the first point of call for patients.

Cosmetic surgery and non-surgical cosmetic procedures are areas targeted at patients abroad with providers from Hungary marketing themselves to UK patients and patients of neighbouring countries. Fertility tourism appears to be an area of growth in Hungary. Cost aside, regulations governing IVF in Hungary (which allow for four embryos to be implanted) were cited as a pull factor for patients. Hungary has the highest European concentration of spas and thermal waters and the Hungarian Ministry of Health and the country’s tourist association are keen to attract a greater number of UK tourists to its spas for medical purposes.

The Hungarian Minister of Health clearly outlined that the government sees the connection between the good reputation of the country’s medical education and the growth in its medical tourism industry. In 2009, concern among the more established larger clinics that medical tourism might risk the reputation of Hungarian dentistry internationally led to the formation of the Association of Leading Hungarian Dental Clinics. This includes a number of clinics that commit themselves to follow a code of practice on professional ethics and quality assurance.

Thailand

Thailand is one of the main medical tourism destinations in Asia and the country has invested in its infrastructure to market itself as a medical tourism centre. Thailand has provided medical services for foreign patients including medical tourists and foreigners working in the country. The country has also targeted regional medical tourists with expatriates from neighbouring countries visiting Thailand for treatment. Thai consuls provide information on treatment and prices and the country provides a specific visa for medical tourism. Most patients, originating mainly from the USA, the UK and Japan, are treated in three hospitals in Bangkok. Thai hospitals generally have also attracted foreign investment, with 24 hospitals part privately owned in 2001.

Dental tourism websites

Bariatric tourism websites

Clinician details

Websites were interrogated whether or not they provided details regarding the experience, qualifications and professional memberships of clinicians. The bariatric surgery websites were also investigated to assess whether a preoperative consultation was possible. Of the dental sites, 35 (70%) provided varying degrees of information about the clinicians employed within surgeries. Of these, all named the dental practitioners and 31 gave details of the dentists’ qualifications, often a full curriculum vitae of qualifications and experience. These numbers were lower in the bariatric surgery sample, with 25 (50%) sites giving some clinician information, mostly pertaining to how long a clinician had been practising and his or her qualifications. However, in both samples the provision of information was not uniform. Some sites simply stated the institution and year of qualification; in comparison, other sites provide extensive details on clinicians’ credentials, including certification and current membership of professional bodies. Many websites (31 in total) enabled potential clients to ascertain whether a dentist is a specialist and, if so, in what area, whereas only 12 weight loss sites allowed viewers to establish how many and what type of procedures clinicians had undertaken and only one site reported the treatment success rate of an individual clinician. In addition, only nine sites displayed any information pertaining to the possibility of preoperative consultation for bariatric treatment. As Exworthy et al. 186 note, for public health care the named clinician is not always the person who does the procedure; however, it should signify that he or she supervises junior staff performing much of the routine work.

Clinics

The majority of websites include photographs of the staff and the clinic, along with videos and even virtual tours of the facilities available. However, a number of the photographs appeared somewhat random and unrelated to dentistry or bariatric surgery and many were duplicated in different sections of the site or even on different websites (perhaps reflecting the interests of website builders). There were few sites giving exact details on the number of dentists employed or the number of treatment rooms. For some, UK media coverage that they had received was seen as a major asset. The most sophisticated websites belonged to large ‘one-stop’ clinics that provided dental, cosmetic and weight loss treatments amongst others. Most dental websites were aesthetically strong; however, many websites for small weight loss clinics in Western Europe were little more than an electronic flyer hosted on the internet.

Assessing whether English was spoken at the clinics, either by the clinicians or by the support staff, was not straightforward. Of our dental sample, 29 (58%) stated that their clinicians speak English and often other languages (mostly German and French), whereas only 16 (32%) weight loss sites made the same claim. However, all of the websites accessed were written in English and there was an implicit suggestion that, when information was presented in English, clients could assume that communication would not be a problem. That said, the grammar and spelling were poor on a number of sites, which is unlikely to reassure potential patients of the clinic that clinicians have the ability to communicate proficiently in English. Roughly half of all sites quoted prices, although these ranged from a sample ‘offer’ price to a full breakdown of prices for all services. However, all sites did carry a caveat that the final price would depend on personal circumstances and treatment plan.

Very few websites acknowledge the possibility of something going wrong during treatment and it is therefore unsurprising that only two of the 50 dental websites explicitly said that their clinic was equipped for medical emergencies. Although weight loss sites were generally better at discussing possible side effects and risks, only 21 of the 47 working sites addressed the issue of risk and only four sites had any statistics pertaining to success rates. When risk was addressed it was often downplayed and, despite many forms of bariatric surgery involving complicated, risk-laden procedures, only three weight loss sites provided details of what would happen should anything go wrong. Although it may be unsurprising that only two dental clinics advertised their access or proximity to emergency facilities, only four weight loss clinics advertised such facilities, which seems remarkably low. It can also be extremely difficult for a prospective client to work out who would be held responsible if something does go wrong, with only three weight loss sites discussing who would be responsible for any clinical failures and their costs.

The issue of responsibility and guarantees highlights a major difference between the dental sites and the bariatric sites. Although none of the websites explicitly state that they will be responsible for clinical failures and any associated costs, 31 dental sites provide some form of guarantee for the dental treatment that their clinic or dentist provides. These guarantees vary for different types of treatment and are often tied to the marketing of a particular ‘brand’. Although all guarantees are replete with an extensive list of conditions and exemption clauses, the existence of such guarantees is a potential source of comfort to prospective dental tourists that is not offered by any weight loss site.

Regulation and quality

There are also substantial differences between the two samples with regard to the issue of regulation. In total, 17 dental sites mentioned a regulatory body either that their practitioners are registered with or whose standards they adhere to; however, no weight loss sites provided such details. Similarly, no weight loss sites provided information regarding medical indemnity to cover cases in which complications arise. Although dental sites did have more information regarding regulation, it is undoubtedly difficult for a lay audience to assess what the varied forms of regulation mean and how rigorous the standards are. Interestingly, even when a number of clinics operate in the same country, they cite different regulatory bodies and authorities. Dental sites frequently make statements pertaining to being regulated but do not clarify the precise details. For example, one website states that it is a ‘fully accredited British Dental Practice Abroad’, whereas another claims to ‘conform to and often exceed all the most stringent of EU regulations and requirements’. There were also 10 websites which declared that they comply with ISO standards and two mention adhering to a commercial provider’s Code of Practice.

Aftercare and follow-up

On the whole, websites provide very little detail about any aftercare services that may be required following the initial treatment. Twelve dental websites made some form of reference to aftercare; for eight of these it is simply to state that check-ups are available in their London clinic at extra cost. Only six weight loss websites directly address issues of aftercare and continuation of advice and care, although when advice was offered it was often detailed. One website even offered an ‘aftercare only’ package in the UK for those who had travelled for weight loss surgery abroad.

The lack of discussion regarding aftercare is perhaps unsurprising given the rather meagre discussion of risks, side effects and complications. Overall, sites sought to convey a sense of ‘popping overseas’ for a treatment holiday, something one site referred to as ‘tweakending’.

Professional and consumer

A number of different professional and consumer organisations provide information, advice and guidance for prospective medical tourists. For both of these types of organisations there were overlaps concerning advice about choosing a private provider in the UK and generic travel advice. The Royal Colleges did not appear to provide any form of information, advice and guidance on aspects of medical tourism. How thorough the websites were in covering the core issues varied considerably. Common across all types of organisation and information, advice and guidance was the need to inform patients about the normal risks associated with treatment, especially surgery, and the potential heightened risks if travelling abroad, including issues such as complications arising from the actual travel. There was also an emphasis on standards abroad differing from those in the UK and the potential risks from infection and transmission of disease. Patients are also consistently advised to find out certain information from the medical tourism provider before travelling, such as the qualifications and experience of staff; success, infection and mortality rates; and aftercare arrangements.

However, beyond this the information, advice and guidance varies and there are a number of issues that are covered by only a few websites. For example, only one website specifically addresses the legal situation in terms of redress if things go wrong (Which?). Consequently, unless a potential medical tourist has consulted this site, they may be unlikely to have considered, or be aware of, the inherent challenges in seeking redress. The Which? site also advises of the need to exercise caution over money transactions, who you arrange your treatment with and their liability to you (the clinic or broker). Furthermore, only three websites advise about the difficulties of securing travel and medical insurance covering treatment abroad. Communication problems, especially language differences, are also mentioned rarely.

One of the most dependable sources of information, advice and guidance is the NHS Choices website, which has distinct sections for different types of treatment and a very useful ‘Questions to ask the Surgeon or Dentist’ section. Along with a number of other agencies, such as the NaTHNaC, the website emphasises the importance of consulting with your local GP or dentist first. The importance of researching your chosen treatment, clinic and surgeon and having a consultation before deciding on treatment are stressed across the sectors. A number of websites point out that, although outlay costs for treatment abroad may be cheaper than those for treatment in the UK, the patient is responsible for covering costs if things go wrong, which could be substantially more. Generally, warnings about regulatory differences are not easy to find, with only vague inferences on sites that ‘things may be different abroad’. Related to this, it appears that only NaTHNaC mentions EQA in a list provided of international accreditation schemes.

Sector-specific information, advice and guidance

As well as generic information, advice and guidance for medical travel overseas, there is also more specialist treatment provision advice. This is particularly the case for fertility treatment with the regulatory body in the UK (the HFEA) providing very thorough information, advice and guidance and a checklist for prospective fertility tourists, along with the guidelines that they adhere to. The HFEA covers a number of issues, including multiple birth rates; legislation and legal, social and ethical implications; donor and surrogacy issues; counselling and support; and the management of patient data. As a result, those travellers who consult the website are more likely to be better informed and to ask the right questions of the provider. However, this is not the case for other forms of treatment, including cosmetic and dental treatment. These other sectors provide generic information, advice and guidance that is pertinent to all medical tourists. Professional bodies specialising in cosmetic surgery do emphasise consumer safety, in particular warning against the holiday sell and ‘tweakender’ rhetoric, highlighting that all surgery carries risks, is likely to be painful afterwards and requires some form of aftercare.

Terminology

There is a great deal of complexity when exploring EQA, including terminology. For example, the term ‘accreditation’ has a number of different meanings. Historically, the original use of the term ‘accreditation’ in health care related to training programmes. More recently, it has come to be accepted as meaning the recognition of competent assessors, such as the ISO and the EU. 247 However, in the vocabulary of the ISO, hospital accreditation is actually called certification. This in turn would mean that a hospital had met defined requirements, verified by an independent auditor (Charles Shaw and Paul Stennett, 2012;personal communication).

Lack of standardisation

A second complication arises with the lack of standardisation across accreditors. 248 Although standards are reasonably considered to be a level of achievement, a benchmark for comparison or a requirement of regulation, they vary both across and within countries. An American organisation, ISO is also regulated in Europe and provides standards for organisations to be measured against for accreditation or certification purposes. Originally focusing on quality management systems for manufacturing, the ISO 9000 series of standards has been extended to assess hospitals and other medical providers. Standards that materialise at a national level can be incorporated at regional levels, but unless adopted by government they carry no legal weight. For example, the British Standard (BS) 5750 on quality systems was adopted as European Norm (EN) 29000 and then internationally as ISO 9000 (Charles Shaw and Paul Stennett, 2012; personal communication). Although ISO 9001:2000 is considered to be an excellent health-care quality management tool, it differs from hospital accreditation, which tends to have a strong clinical dimension. 182

The International Society for Quality in Healthcare (ISQua) also plays a key role in this area, assessing external health-care organisations against published standards. In addition, it promotes and benchmarks health-care standards and organisations. Here, health-care accreditation of a provider organisation (termed ‘certification’ by the ISO) includes peer review assessment against these standards, which have been specifically designed. 249 In 2010 there were 46 national health-care accreditation organisations operating around the world. 250 EQA thus varies across and within countries, with a range of badges being used and no consistency in terms of standards, assessment or regulation.

Selective coverage

A third complication is that hospital accreditation is by no means universal across Europe (or more globally) and there is a very unequal distribution of take-up across countries. For example, 100% of eligible hospitals in France (780 hospitals) participate in nationally available programmes in comparison to < 15% in Spain (four hospitals). There are also questions about the motivations of institutions for pursuing accreditation. Shaw et al. 250 found that, although ‘quality improvement’ was identified by schemes as the key motivator for hospitals to seek accreditation, there were also a number of other incentives. Medical tourism was an incentive for > 27% of accrediting organisations, along with marketing for 50% and as a legal requirement for 34%. The question thus arises as to what and whose interests do forms of EQA serve.

Value of forms of external quality assessment

There are debates about the precise value of accreditation/certification. 183,251 In their investigation of accreditation and ISO certification in Europe, Shaw et al. 247 found that, of the participating hospitals, those with either accreditation or certification were safer and better than those with neither. However, they also found that accredited hospitals consistently appeared to score higher on measures of hospital management, patient safety and clinical organisation and practice than hospitals with ISO certification. Despite this, there is some debate over the value of accreditation and the evidence to support claims of its importance as an EQA method. As Braithwaite et al. 252 have highlighted, ‘empirical evidence to sustain many claims about the benefits of accreditation is currently lacking’ (p. 8). Indeed, in a later systematic review of health sector accreditation research, Greenfield and Braithwaite253 concluded that accreditation was consistently having a positive impact in only 2 of 10 categories (promoting change and professional development).

Cost and affordability

A further challenge facing accreditation is how internationally accessible and affordable it is. Accreditation schemes often come with an expensive price tag, often prohibitively so for providers in developing countries, especially smaller ones. In addition, the commercial aims of the scheme may overshadow the purpose of the process. Very few accreditation schemes openly publish information about their charges and associated expenses on their websites. The 2003 study by Mihalik et al. ,254 which analysed the costs of the National Committee for Quality Assurance accreditation process, estimated an annual cost of around £400,000 a year for participation in the accreditation process for a typical, medium-sized US-based organisation.

The USA’s JCI publishes an average accreditation survey cost of £29,700, and an explanation of additional costs, including onsite costs for the team (travel, accommodation, food), preparation and other consultations. 255 With members in over 70 countries, the JCI is one organisation accredited by ISQua. 253 Research undertaken in July 2011 found that the JCI had conducted 90% of all international accreditations, with the total number of JCI hospitals reaching 329. 256

Non-enforceable standards and guidance

A number of other organisations internationally issue standards and guidance, although without clear methods of enforcement. For example, the World Health Organization issues both general guidance on health care and also documents on specific issues such as safe surgery. 252 Within Europe there are a number of examples of attempts to harmonise standards in the medical field by the EU, including for professional training and clinical practice. Despite there being no standardised system for quality and safety, efforts have been made to share best practice, such as through the European network for Health Technology Assessment (EUnetHTA) and the European Network for Patient Safety (EUNetPaS) project. 249

Voluntary and commercial initiatives

Outside of formal EQA and accreditation, voluntary and commercial schemes exist in which providers sign up to ‘codes of practice’ or become ‘partners’ of other organisations. Many medical tourism facilities and facilitators state that they adhere to commercial ‘codes of practice’. Claiming to be a partner of another organisation is also common, although this is also a grey area in terms of how this ‘partnership’ helps ensure the quality and safety of the actual provider.

Statutory regulation

In addition to accreditation and certification, all countries have some form of inspectorate for health services that provides a minimum level of regulation for both public and private sector providers. In the UK, the CQC regulates facilities whereas the GMC regulates standards for the practice of medicine. In addition, there are a number of bodies that provide and promote standards and training within specialist areas, such as the Royal Colleges (Surgeons, Psychiatrists, GPs). A RAND185 study found that the structure, remit and values of medical regulation vary significantly between different countries. For example, some countries have a unitary state-authorised regulator (such as the UK in medicine and dentistry), whereas others have decentralised polycentric systems, such as Spain, where different bodies and processes exist depending on the region.

The Health & Care Professions Council (the UK body responsible for keeping a register of health and care professionals) hosts a searchable online database of health regulators and professional bodies for health professionals (see www.hpc-uk.org/). A wide range of countries and specialisms are included with links referring individuals to (typically non-English) websites.

Dental clinics external quality assessment

The different credentials can be categorised into:

• ISO standards, e.g. ISO 9001

• national regulations, e.g. GDC (UK)

• domestic professional associations, e.g. British Academy of Cosmetic Dentistry

• accreditation organisations/companies, e.g. Technical Inspection Association (TÜV)

• voluntary associations and codes of practice

• those remaining, as other.

Ten websites identified some form of ISO certification, usually ISO 9001, although not all displayed details. Only one other accrediting body was mentioned, TÜV, with two sites claiming accreditation.

The majority of websites detailed some form of national regulation. Unsurprisingly, given the proliferation of Hungarian dental providers, the most commonly cited were the Hungarian Chamber of Dentists and the Hungarian Medical Chamber, which incidentally oversees the former. The UK GDC was also mentioned by two websites in recognition of the need to be registered (with the GDC) to hold consultations in the UK. However, no explanation is given to highlight that its regulation extends only to those practising on British soil. Other national regulatory bodies included the Romanian Dental Council and the Ministry of Health of the Czech Republic.

Websites also claimed some form of affiliation to a domestic professional association within the home country, usually some form of Hungarian Dental Academy (although these claims are typically inaccessible for consumers who search in English). Four websites claimed some form of British registration, although this ranged from credible (GDC) to unverifiable through online English searches (‘British Dental Practice Abroad’). Further non-verifiable claims included being a member of the ‘Cosmetic Dentistry Guide’. Two further European voluntary associations were also mentioned by single websites: the European Dental Association and the European Association of Cosmetic Dentistry. A further two displayed ‘Treatment Abroad Code of Practice’ labels but with no detail as to what this involved (see full list in table below).

The lack of explanation for prospective tourists about the differences between accreditation, certification and national regulation, and the failure to provide any details of what any of these mean, render assessment of a dental clinic’s credentials particularly difficult.

Bariatric clinics external quality assessment

Overall, 23 different types of credentials were mentioned. However, seven of those were US specific and were on one American website. Here, extensive details of the seven credentials were provided with a brief explanation and some links to the source of the accreditation [e.g. the American College of Surgeons: Level 1A Accredited Bariatric Center, Adult and Pediatric (15 years and above)].

Once again, ISO certification was strongly evident, with nine providers claiming to meet one of their standards, including ISO 9001, ISO 15189, ISO 14001 and ISO 13001. Five websites claimed either certification or partnership with Treatment Abroad or the Medical Tourism Association. Two websites claimed HON certification; however, HON no longer offers certification for medical tourism sites. A further two displayed a Better Business Bureau rating.

Five clinics displayed a connection with domestic professional associations, including the Czech Obesity Society and the Indian Association of Gastrointestinal Endosurgeons. Three websites claimed professional registration with the GMC, the national regulating body in the UK, but again failed to highlight that the GMC’s regulation extends only as far as the British borders.

A large number of clinics claimed some form of professional allegiance to or partnerships with institutions including Apollo Hospitals, Harvard Medical School and Worldwide Medical Partners. It was rare for precise details of the arrangements to be provided beyond a symbol demonstrating the affiliation.

Other individually cited memberships included the ‘GLC’ and the ‘FEQH’ (Forum for Enhancement of Quality in Healthcare) quality certificates, neither of which are traceable through English-based internet searches. Further unverifiable statements found on some bariatric sites included ‘licensed health care hospital’ and ‘Our company is British and so we adhere to the regulations of the British Government’, with no further detail on what these regulations may be (for full list see table).

Cosmetic clinics external quality assessment

Finally, 50 sites analysed by Lunt and Carrera89 in their discussion of patient advice and sources of information for decision-making were revisited and analysed for EQA. Similar to the bariatric review, a large range of bodies was cited (46 in total); however, only 18 websites provided any details of accreditation, certification or regulation.

As with both the dental and bariatric reviews, ISO certification was identified, with five provider websites citing ISO 9001:2000 and two citing ISO 14001. Membership of domestic professional associations was most frequently cited, although rarely were links provided to these associations’ websites. Twenty-one different domestic professional associations were highlighted by the websites, with the Polish Society of Plastic and Reconstructive Surgery the most frequently cited (by four sites), along with the American Society for Aesthetic Plastic Surgery (three sites) and the Spanish Society of Plastic, Reconstructive and Aesthetic Surgery (two sites).

Membership of international voluntary associations was also evident, with four websites claiming membership of the International Society of Aesthetic Plastic Surgery and three claiming allegiance with the International Confederation for Plastic, Reconstructive and Aesthetic Surgery. National regulation through domestic medical councils or chambers was cited infrequently, with two mentioning the UK GMC.

As with both other reviews, a number of other forms of accreditation or certification were claimed with no explanation as to their meaning or why they had been awarded. For example, one website claimed that it had received a ‘Slovak Gold Exclusive’ award and displayed a gold medal symbol. However, it proved impossible to verify through English-language internet searches what this was (for full list see table).

Background

Stakeholders interviewed differed markedly in their areas of expertise and in their roles with regard to medical travellers. They ranged from GPs who had dealt with returning patients’ medical problems in their surgery to policy-makers developing guidance on patient safety. Despite these differences, a set of key themes and perspectives emerged clearly from the interviews.

A number of interviewees based in PCTs identified drivers that encouraged individuals to travel to overseas destinations. These included the tightening of eligibility for services (e.g. the general unavailability of cosmetic breast surgery paid for by PCTs), a broader consumer orientation and the influence of advertising: ‘They are seeing what’s available on the shelves and deciding that there’s actually more available on the shelves of different country’ (NHS13).

Primary care trusts reported receiving a number of treatment requests that were outside their eligibility criteria and which may prompt private (including overseas) treatment as a result: ‘[We receive] a lot of requests for what we would consider cosmetic or plastic procedures. Endless requests for breast augmentation or reductions or nips and tucks and abdominal plastics and so forth’ (NHS9).

Across the different groups of actors interviewed, the absence of reliable data on the scale of outbound medical tourism and on the costs and any problems was highlighted.

You really come up against a lot of industry based information but very limited and fast facts about the numbers of people trying to access healthcare abroad. And obviously there are discrepancies between industry sources and figures for the UK, for instance, when you look at the international passenger survey data. [. . .] frustrated not being able to find good information or reliable information.

PA11

At the same time there was a sense that medical travel and any resulting complications posed potentially serious issues and were worthy of further attention but that this was not an overwhelming challenge either for the organisations that the interviewees were representing or for the NHS as a whole. A representative from one of the Royal Colleges summarised:

[It] doesn’t happen too much I think in the UK. Not that much because actually most people don’t speak languages. Most people don’t want to go abroad to have treatment, to be honest. [. . .] They want to be treated at their local hospital.

PA5

The experience of the NHS in the early 2000s, which provided patients on waiting lists with the option of travelling under a NHS contract to another European country, was also cited as relevant to understanding the level of outbound medical travel and the motivation for it.

Primary care trust interviewees reported examples of complications that had occurred after medical tourists returned back to the UK:

So we’re not infrequently getting requests from people to go abroad for surgery or other things. Not infrequently getting people coming back from having gone abroad with problems.

NHS7

People have gone and had a gastric band fitted in Holland and then come back and had problems and expect the NHS to either pay for that care or to pick up the follow-up care which they’re not entitled to do

NHS6

There were also said to be subsequent requests for cosmetic surgery to remove excess skin following overseas bariatric surgery. However, although examples were given (a couple of bariatric cases in one PCT, a bariatric case and gender reassignment in another), the scale was not overwhelming when viewed in the context of PCT activity. A director of public health suggested: ‘The totality of all this, at least in terms of the stuff that comes back in our direction, is very small’ (NHS7).

Medical tourists returning with diagnostics was also mentioned in the case of some minority ethnic cultural groups:

I’ve heard of lots of people that are turning up with files an inch or two thick with ridiculously over detailed packs of diagnostics for essentially a dermatology condition. Or something which would be an endoscopy and you’ve had full body scan.

NHS6

Many people travel for treatments that are not available on the NHS. This was the case for many of the patients interviewed for this research (see Section 3) and also helps explain the seemingly greater number of providers of elective procedures (especially dental treatment and cosmetic surgery) and fertility treatment. A difference in perception of the scale of the issue between professionals working in different medical sectors was clearly evident from the interviews. However, although complications were not identified as significant (albeit within the small number of PCTs that we spoke to), what was also clear was the absence of a clear mechanism for recording such complications (e.g. to identify patterns): ‘Nobody would come back [to the PCT] because that would be taken care of in primary care generally or even if it need[ed] secondary care, they wouldn’t really have a way to feed that back to us’ (NHS9).

Education and information

Many professionals pointed to the absence of clear guidance (and related regulation), both for patients travelling abroad and for those returning with complications. Interviewees highlighted the need for greater guidance for patients travelling abroad for medical treatment including what the minimum standards for providers and overseas treatment should be. This relates closely to how information is packaged, how it is provided and by whom. Many of the interviewees offered ideas on how information could be better provided, either through GPs or the Royal Colleges, but also through greater public awareness of these issues.

Providing reliable independent information on medical travel was seen as a key challenge and an important step in addressing issues of patient safety, to limit some of the likely negative consequences of medical tourism (including complications and insufficient aftercare). One of the main problems with the current provision of information is that it is often provided by agents:

At the moment if you look at the information sources out there they appear to be so swayed towards internet sites that have a vested interest in getting people on planes and abroad and having treatment we really need to have a thing that is free from commercial interest.

PA5

Interviewees referred to information in the media being sensationalist, with individual stories of complications being reported or stories generally having negative undertones. This leads to medical tourism overall having negative connotations, which in turn limits open discussion and accurate debate of the issues involved. Actors highlighted the need to get reliable institutions involved in providing information but also the need to make this easily accessible to patients.

Representatives of the Department of Health interviewed for the research pointed to the need for greater patient information and highlighted that such advice and guidance would be developed as part of the implementation of the EU directive on cross-border care. 1 PCTs did identify NHS Choices and the Department of Health as portal points where prospective medical tourists could be directed.

Those professionals working on issues relating to cosmetic treatments highlighted that patients often did not speak to a doctor or their GP in the UK before seeking treatment abroad: ‘Cosmetic surgery patients are amongst the most vulnerable. The vast majority of them who think about cosmetic surgery feel embarrassed to talk about it. They do not even go and discuss it with their GP. They quietly go away’ (PA8).

Doctors working within the NHS, especially GPs, were seen as central to the provision of information and in guiding medical patients as they contemplate travelling abroad for medical treatment. In this respect, several professionals interviewed highlighted the importance of GPs being open to patients discussing their plans for medical travel with them and providing a safe space for advice.

External quality assessment and quality information systems

All interviewees commented on the vast variety of standards of treatment and procedures undertaken abroad. There was a general recognition that this depended entirely on the provider and that people travelling abroad may receive excellent health care but equally may receive very poor treatment. One of the clinicians working for a professional organisation observed: ‘Some of the work I see from oversees is excellent and some of the work I see from my peers in the UK is not always great. So I think it depends on who you see’ (PA16).

However, given the very large variation in providers and quality, patient safety was mentioned as a key concern by all professional actors interviewed. The absence of reliable universal benchmarking or quality control mechanisms was described as a key limitation for patient safety and a critical issue to address. One of the actors interviewed highlighted that in the absence of the CQC or its equivalent many patients travel into the unknown:

The vast majority of people who go on holiday would not dream of going to a hairdresser abroad [. . .]. Yet they go abroad and they trust their body, their health, their wellbeing to somebody they have no idea who he or she is and in circumstances where you do not know whether they meet the necessary requirements of safety.

PA8

Producing guidance or guidelines would not be a straightforward task. An interviewee from a professional association suggested: ‘In order to have guidelines you need to have evidence and facts . . . what are the outcomes not only of operations abroad but of operations in this country. I’m afraid they’re sadly lacking at the moment ‘ (PA2).

Fertility travel, in which many patients travel to have access to treatment not allowed by UK regulations, poses specific threats to patient safety. Professionals working in reproductive care repeatedly mentioned the resulting increase in risk of complications including multiple births. A representative from an organisation working in reproductive care (PA12) commented that ‘the desire for a child is so all-consuming, it takes over rationality on occasions’.

Interviewees also referred to accreditation as a way of ensuring greater patient safety. International accreditation schemes, such as JCI, offer greater credibility but come at a higher cost. This will be reflected in the price of the treatment as these costs have to be passed on to the patient. It is therefore more likely that patients who search for the cheapest possible treatment will have inadvertently compromised on safety standards. Professionals noted that cosmetic surgery is referred to as the ‘Wild West’ as no quality standards exist.

Continuity of care was seen as a particular concern. All of the professionals interviewed referred to follow-up care and complications as an issue. Although the scale of medical tourism did not seem overwhelming, all interviewees were aware of (or had treated) complications arising from treatment abroad. The greatest challenges experienced were due to a lack of continuity of care provided to the patient, including challenges faced by doctors in the UK providing aftercare. Several issues were highlighted in this respect.

Professionals also reported that it was not uncommon to see patients who had been to one or more providers, having already seen a number of different clinicians, often adding to the confusion over the treatments carried out. Contributing to the lack in continuity of care was that complications and the need for aftercare often arise much later than the original treatment. In many cases patients would experience problems years after the surgical procedures had been carried out.

Of the medical professionals interviewed, several referred to the lack of reliable patient records as a key challenge to providing follow-up care to patients who may experience complications. Either records do not exist or they may be in a different language. A senior representative of the professional dental community described several negative experiences in terms of record keeping. He described a long delay in receiving patient records from the overseas provider, which in many cases are in a different language and therefore need to be translated to be of any value, but also how these are often meaningless.

Legal considerations and NHS entitlement

Medical insurance providers and quality control agencies highlighted different levels of indemnity cover across countries. Many providers do not offer this and this was noted as a concern for patients if things go wrong. Specific industry models were also reported as being particularly limiting to patients’ ability to assure quality. Patients who pay up front for treatment, especially when they pay a broker without having seen the clinician or doctor, raised concerns with professionals about the consent to medical treatment and safeguarding this principle. Certainly, amongst the sample of patients interviewed for this research were some who had not fully understood the procedure that they were receiving and consenting to.

Representatives from the Department of Health were very clear on NHS responsibility for dealing with complications and follow-up care resulting from medical travel:

It comes back to the fact that the NHS is a universal healthcare service therefore if you live in this country those services are available to you. Whether you’ve been dealt with badly in another country and if you’re living here you have the right to access the NHS and that extends to putting right treatments.

PA14

This ‘no fault’ treatment issue was captured by another provider viewpoint that those trusts with A&E facilities face key issues that PCTs must deal with:

We take everybody in and then only get to decide whether you pay or not and if you don’t wish to pay well there’s only so much we can do about it. So I think from an acute side its very much all routes lead into us from whether it’s a private hospital to us when it goes wrong, whether it’s done overseas that treatment has gone wrong, or whether it’s GPs saying I didn’t check the status because it’s not my problem.

NHS10

Interviewees conveyed that, although complications would be dealt with, this may not necessarily involve longer-term management of patients’ follow-up care and needs.

Professional associations of NHS doctors described patients’ requests for pretreatment tests and investigations as a dilemma, especially at a time of limited resources. One GP described how prospective medical tourists were dealt with using the same principle as for those seeking treatment in the private sector in the UK and consulting their GP in advance. However, when the tests required by patients would be part of a NHS treatment plan, the surgery would provide these for patients seeking to travel abroad or receive treatment in the private sector. When these are different from or are additional to what the NHS prescribes they are not provided.

A number suggested that outward medical travel should simply be seen within the wider context of private care: ‘We have received cases of patients who have had a private operation and then want to come back within the NHS’ (NHS8).

The NHS as a treatment facility was viewed as the eventual recipient of all patients with complications that could not be rectified in the private sector:

If you were an overseas provider you would just give people the advice that our private sector providers down the road give their patients. If you’ve got any problems go to your local NHS hospital, which is what they do. The private sector doesn’t take a particularly pastoral approach to the management of some of the complications.

NHS15

Overall, among the different professional stakeholders there appeared to be a lack of clarity on NHS responsibility to provide information, deal with complications and provide follow-up care. Given the overall remit of the NHS there was a sense that in all likelihood all complications would be dealt with in the NHS. Those interviewed pointed to the government’s responsibility, specifically the Department of Health, to provide clear information and guidance on the responsibility of the NHS both to NHS doctors and to patients.

Bariatric treatment

Fertility treatment

Dental treatment

Cosmetic treatment

Private patient income cap

A limit on the amount of income that hospitals can raise from private activities was introduced by the Labour government in 2003 as part of the legislation to establish NHS foundation trusts (Health and Social Care Act 2003264). The cap for foundation trusts was fixed at that existing in the 2002–3 base financial year and so varied from hospital to hospital. As well as private patient income, the percentage could include income from external business ventures such as commercialisation of research and development, training and consultancy. Although typically the cap on hospital income from private activity was around 2%, for a small number of specialist facilities it was much higher. The Royal Marsden, for example, had a 30% cap on income from private activity The cap limited hospitals from increasing the amount of private work and income beyond their base-year proportion and foundation trusts were monitored to ensure compliance. There were reported cases of single expensive treatments taking foundation trusts over their cap. The Health Service Journal (6 October 2011)265 reported Guy’s Hospital breaching its private patient cap by £700,000 because of treatment relating to one set of overseas twins. Non-NHS trusts were not subject to the cap and a number had private patient income far in excess of that of many foundation trusts. Since the cap was introduced, several NHS foundation trusts have established charity, joint venture or other arrangements with private sector interests to raise additional income or protect existing sources of income raised from private patients.

There ensued considerable discussion about the cap and the merits or otherwise of its removal. The White Paper Equity and Excellence: Liberating the NHS266 argued for ‘Abolishing the arbitrary cap on the amount of income foundation trusts may earn from other sources to reinvest in their services and allowing a broader scope, for example to provide health and care services’ (Section 4.22).

The NHS Confederation and the Foundation Trust Network both backed the lifting of the cap. Additional private sector income was explicitly identified in the Health and Social Care Bill31 in the form of ‘additional non-EEA overseas private patients’ who under previous arrangements could not be treated in the NHS if trusts were close to their cap. The chief executive of Great Ormond Street Hospital suggested that ‘The lifting of the “private patient cap” would allow us, as a Foundation Trust, to treat more private patients but also, through reinvestment, to help more NHS patients as well’. 267 Advocates of legislation foresaw opportunities to secure greater numbers of patients travelling from overseas for treatment as part of wider commercial developments. Critics pointed to the further privatisation of the NHS. These non-UK patients will potentially be sponsored by governments, funded by insurers or paying out of pocket. Under the Health and Social Care Act 201230 the cap for foundation trusts was increased and now 49% of income can be earned from non-NHS work (in force since 1 October 2012). However, the core legal duty of foundation trusts remains unchanged (that of caring for NHS patients and delivering authorised services).

How the increase in private activity will impact on the NHS and its patients is not clear and is dependent on whether a particular foundation trust is operating close to capacity and whether additional capacity is generated to treat private patients or existing capacity is used. 31 NHS patients may receive benefits if new or enhanced facilities are shared between private and NHS patients. However, if private patients have greater priority there will – all things unchanged – be a growth in waiting lists and waiting times for NHS patients (Section B155–B156). 31 There is no evidence to judge this.

The final legislation passed in March 2012 made key provisos with respect to the impact of private income on NHS services:

Each annual report prepared by an NHS foundation trust must give information on the impact that income received by the trust otherwise than from the provision of goods and services for the purposes of the health service in England has had on the provision by the trust of goods and services for those purposes.

Chapter 7, Part 4, Section 164, 3A31

Any major increases in private sector income require governance approval at board level:

An NHS foundation trust which proposes to increase by 5% or more the proportion of its total income in any financial year attributable to activities other than the provision of goods and services for the purposes of the health service in England may implement the proposal only if more than half of the members of the council of governors of the trust voting approve its implementation.

Chapter 7, Part 4, Section 164, 3D31

The NHS ‘brand’

Since 2010 there have been clear attempts to support international activities of NHS trusts and organisations. NHS Global was launched in 2010 by the chief executive of the NHS:29

While there are already strong examples of NHS Trusts and organisations successfully sharing their ideas and products abroad, we want to create a more systematic approach to this work, and in doing so bring benefits back to the NHS and the UK taxpayer . . . It is now more important than ever to maximise the international potential of the NHS.

The 2010 White Paper266 also highlighted the potential of the NHS to exploit the power of its international reputation and financially gain from the NHS ‘brand’ when marketing NHS services to overseas patients. 31 To date, however foundation trusts have often been unwilling or unable to take full advantage of all of their ‘apparent freedoms’. 268

NHS Global is hosted outside the Department of Health by the NHS Institute for Innovation and Improvement. Its stated aims include identifying commercial opportunities, generating demand, brokering partnerships and advising on legalities and risks. The Treasury has an expressed interest in these developments. As the Plan for Growth269 outlined: ‘The Government will work with the NHS and industry to design and establish a proactive entrepreneurial NHS Global to make the most of the brand internationally and to offer support and advice to NHS Trusts’.

In early August 2012 the Healthcare UK scheme was launched, supported by the Department of Health and T&I. The aim is to further promote and encourage overseas investment and activities from within the NHS with the aim of providing profit streams for reinvestment in core NHS services.