Budapest: the “dental capital of Europe”

A recent visit to Budapest, the “dental capital of Europe” made me consider the perception of medical travel. Many people think that if you’re travelling abroad for treatment because it is far cheaper, then the standard of services can in no way match what you would expect in your home market. Hungary’s dental treatment providers provide a strong contradiction to this perception. I was speaking at the Business Travel Show in Budapest at a dedicated session on dental tourism, organised by the Association of Leading Hungarian Dental Clinics.

Aware of the number of new entrants into the dental tourism market, Hungarian dentists are keen to maintain their position as market leaders. They are also keen that the Hungarian government and tourism board take note of their success and provide support for the dental tourism sector.

Hungary was one of the first countries to exploit the healthcare needs of neighbouring countries and encourage patients to cross borders for treatment. It became common for German and Austrian patients to travel to Hungary for dental treatment in particular, and Hungarian dental clinics prospered in border villages and towns. When we launched Treatment Abroad five years ago, it was to some extent a response to requests from Hungarian dental clinics to increase their profile in the UK healthcare market. Having succeeded in attracting large numbers of German and Austrian patients, Hungarian clinics were spreading their wings and seeking to promote their expertise in other markets. Now, Hungarian dental clinics and services represent the largest segment of services on Treatment Abroad.

The Hungarian dental tourism market is one of the notable successes in the medical tourism market worldwide. In Budapest, the Association of Leading Hungarian Dental Clinics has been formed. The Association represents the interests of seven significant players in the dental tourism business:

• VitalCenter


• VitalEurope


• Bátorfi Dental Implant Clinic


• ImplantCenter


• Kreativ Dental


• Madenta


• Solydent

The Association has some clearly defined criteria for joining. For example:

• The practice must employ a minimum of ten dentists / oral surgeons.


• The practice must be equipped with a minimum of 5 modern dental medical operating units.


• The practice must place a minimum of 1,000 dental implants a year.


• The practice must provide digital intra-oral and panoramic X-ray.


• The practice must ensure that all practitioners work within industry recognized protocols, including clinical governance and undergo regular internal clinical audits and assessments.

See the full list of Association criteria at ALHDC Code of Practice.

The number of patients from overseas that are going through these seven clinics is staggering. Association members carry out around 75,000 treatment sessions per year. Around 60% of these are for dental tourists. The Implant Center alone inserts around 1,800 dental implants each year. Each clinic has multilingual staff and dedicated cars and drivers for transporting international patients.

Although established markets such as the UK, Ireland and Scandinavia provide the bulk of patients, new opportunities are developing in France, Italy and Russia. I visited three of the facilities - ImplantCenter, Kreativ Dental and Vital Europe. Each has a different approach to marketing its services. Whereas Vital Europe focuses on UK patients and provides both consultation and treatment facilities in London and Manchester, Kreativ relies on its overseas agents to convince patients of their quality of service and flies patients straight to Budapest without prior consultation. ImplantCenter has also dental office in Dublin and London.

The expertise and extent of dental services in each individual clinic is quite something. Each clinic has around eight to ten dentists employed by the clinic, some general dentists and some with areas of specialty such as implantology or orthodontics. All three clinics have extensive dental laboratories on site, owned and operated by the clinics themselves.

There are few private dental clinics in the UK that can match the set up of thes dental facilities in Budapest. The challenge for Hungary is how it maintains its lead in dental tourism. New competitors are entering the market, such as Croatia, Czech Republic and Slovakia, some at even lower prices than those in Hungary. The challenge for these new dental tourism competitors is how they match the standards of the "dental capital of the world".

Practice makes perfect...a message for medical tourism providers and patients

In the largest ever study of hospital mortality rates published in the UK,"death rates for emergency patients jump 6 per cent when newly qualified doctors start work. The Health Services Journal reports that "the traditional first day for NHS doctors is the first Wednesday in August. Researchers found that patients brought into hospital the week before were more likely to survive.....Researchers could not find a definite reason for the higher mortality rate, but said early August was known as an “unsafe period” in hospitals due to the influx of new doctors"

Now, what can we conclude from this?

Might I suggest that doctors with more experience are better than those with less experience? It goes without saying, really.

So, how does this help the medical tourist who is trying to make a decision about which doctor or specialist overseas to choose for their operation? The problem of patient choice in healthcare whether it is a choice of an overseas surgeon or a domestic surgeon is the "how do I know that he's any good?"issue. In the UK, we're probably ahead of the game in enabling patients to make informed choices about treatment. The NHS web site is has been renamed "NHS Choices" and in recent years there's been a drive to expose data on clinical outcomes and surgeon and hospital performance, and make this freely available to patients.

One of the strengths of the UK healthcare system (and one of its shortcomings!) is that the vast proportion of healthcare is delivered by one healthcare provider - the NHS. This means that data on processes, outcomes, performance and patient satisfaction is fairly standardised, thus enabling valid comparisons to be made between one hospital and another, between one specialist and another.

Let's imagine that I need a knee replacement. Under the NHS, I can choose to go to any hospital in the UK, not just my local hospital. But let's assume that I want to stay fairly local. Here's some of the data I can access about my local hospitals through NHS Choices. For each "quality factor", I have highlighted the best result.

Impressed? Which hospital would you choose? Or which hospital would you rule out of consideration? The above table only scratches the surface of the data that is now being made available to patients. I could also compare the quality of the food, levels of service and so on. And I can also begin to make comparisons between individual surgeons.

Where does this leave the medical tourist? The reality is that there are few countries where this kind of comparative information would be made available to the patient. And the reality is that different healthcare systems often measure things in different ways, so that comparing outcome data from a hospital in Thailand with outcome data from a hospital in India might be very difficult.

So, the medical tourist probably needs to ask some very basic questions about the hospital and specialist. One of which is a fundamental measure of "how do I know that he's any good?” It's "how many times have you done this operation before?" "Practice makes perfect" as the recent study demonstrates. Choose a surgeon with experience in exactly what you require. If you're looking for a knee replacement, choose an orthopaedic surgeon who does knee replacements and virtually nothing else. Don't choose a "general" orthopaedic surgeon who does “everything under the sun" - knees, shoulders, feet, hips etc.

And ask the guy "how many have you done this year?"

Transparency and fraud in health tourism

One of the criticisms of buying services via the web is that you cannot always be sure with whom you are actually dealing. This is especially true in the field of health and medical tourism. When you visit a site about medical tourism:

• How do you know who is behind the site?


• How can you tell what they actually know about health tourism and healthcare in general?


• How do you know if you can trust them?


• How do you know where the patient's money is going?

Next month, I'm speaking at the Annual Conference of the European Healthcare Fraud & Corruption Network (EHFCN) in Edinburgh. The Conference theme is "Cross-Border Healthcare in Europe: A Gateway to Fraud and Corruption?".

The European Healthcare Fraud & Corruption Network (EHFCN) is the only European organisation dedicated to combating fraud and corruption in the healthcare sector across Europe. The network represents 23 member associations in 10 countries, which provide healthcare services to millions of people in Europe.

According to EHFCN, "the healthcare sector appears to be particularly vulnerable to corruption. The large amounts of money involved and the complexities of many healthcare systems play a role as well as the fact that there are many processes with high risks of bribery"

And now it is turning its attention to health tourism.

As a web publishing company in the healthcare sector, it's important that Treatment Abroad is transparent, and that when we're publishing health advice on our various web sites, we ensure that the information is written by qualified medical professionals. We make sure that all of our sites go through the Health On the Net Foundation's certification process. (I recommend that all healthcare sites go through this process.) And our company has a Medical Director to oversee what we do - Dr Nick Plowman from St Bartholomew's Hospital in London.

But in the world of medical tourism, is there a problem with lack of transparency and is there significant potential for fraud?

In researching my presentation for the EHFCN conference, I've taken a look at transparency in medical tourism. I did the usual Google searches and I came across Health-tourism.com for the first time: It states that is "a guide for medical tourism, bringing you reliable, objective and useful information that will help you plan your medical travel".

While I was browsing the site, I came across this:

• Medical Tourism Transparency Award - "we have created the Medical Tourism Transparency Award. This is a badge awarded to websites of medical tourism providers whose website information meet the criteria below."

Now, let's be clear, the guys at Health-tourism.com may be decent and honest people, with the best interests of medical travelers at heart. But it was their "Medical Tourism Transparency Award" that caught my attention. Health-tourism.com says that "The purpose of this award is to encourage providers to supply necessary information on their web sites - making it easier for you to make an informed decision.

So, I put Health-tourism.com through a "Transparency Test".

I looked all over the site....

• It says that it's run by Find Global Care.I can't tell who they are or what their qualifications are.


• In the lengthy disclaimer it says "the content on this website has not been reviewed or prepared by medical professionals.


• And it says that the "relationship between the visitor/user and FGC shall be governed by the laws of Cyprus". Why Cyprus?


• I can't find any names at all.


• I can't find out who owns the site or the company.


• I can find an address - 1B, Pinetree Boulevard, Old Bridge, New Jersey.

I'm an inquisitive person.....

I did some digging for information on Find Global Care. But all I could find... was another web site - half built at www.findglobalcare.com and an entry on WikiCompany with no information on the company ownership.

So I thought I'd pay a visit to 1 Pine Tree Blvd, Old Bridge, NJ 08857, USA using Google Maps Streetview. (Isn't the web a wonderful thing?). I'm not an expert on US arrchitecture but judging by the Real Estate sigh outside and the building, this looks like an apartment building. But who lives there? And who's behind the business? And what does he or she know about health tourism?

Next, I checked out the domain name. It's registered to Udi Shomer from Illinois. Perhaps he's behind the business? Who is he? I don't know. But it's not a common name, and the web may have some info on him?

There's only ten results for a search for "Udi Shomer" on Google. (Hey, that's close to being a Googlewhack!). Let's take a look at the Udi Shomers on the web:

• There's an Udi Shomer who has an entry in the Lonely Planet guide to Thailand.


• There's a listing page for Tai Chi in Thailand.


• And there's a few references in Israeli job sites (I think).


• And that's it.

There's a clear message here for medical tourists who use the web to research healthcare services.

• Look (very carefully) before you leap.!

And if anyone knows who runs Health-tourism.com, ask them to get in touch, so that I can fill in the gaps.

Dental tourism...Let's work together

The Irish Dental Association is the most recent medical professionals body to publish a "survey" raising doubts about medical tourism.
In a recent press release from the Irish Dental Association, they state that "3 out of every 4 Irish dentists are treating patients for problems arising from treatment abroad. Let's take a look at the background to the survey, and examine some of the real concerns that are raised.
The Consumers’ Association of Ireland has published research about the high costs of dental treatment in Ireland. The Irish Dental Association accepts that Irish dentists are not immune from the wider economy and the bottom line is that Ireland is a high-cost economy. As a result, significant numbers of Irish dental patients travel for treatment to minimise treatment costs. Some of these are cross border dental tourists. Many services carried out in Northern Ireland are between 25% and 45% cheaper than the same services in the Republic, according to the study published in the Consumers’ Association of Ireland’s magazine Consumer Choice. And of course, many Irish patients take advantage of low cost treatment in countries such as Hungary and Poland. Several Budapest dental treatment providers have offices or representatives in the Republic of Ireland.
According to the Irish Dental Association survey, 76% of Irish dentists in private practice [more than 3 out of 4] have had to treat patients for problems linked to the dental treatment they received abroad.
First, we need to examine the basis of this claim.

• There are approximately 1,700 dentists in private practice in Ireland at present.
• 440 Irish dentists responded to the survey.
• 334 said that they are treating problems arising from treatment overseas.
• So.... in fact 334 out of 1,700 said that they were seeing problems which is 20%. Obviously, this assumes that those who didn't bother are not seeing problems.

When reviewing such surveys conducted by on or on behalf of professional associations, we have to bear the following in mind:

• Inbuilt sample bias: People who see a problem are more likely to respond to a survey on that issue, than those who don't. We've seen similar bias built into surveys conducted by a PR agency in behalf of the British Association of Plastic Surgeons.
• Motivation: We always need to remember that professional associations represent the interests of their members. Losing patients to Belfast or Budapest hits the pockets of private dentists.

Nevertheless..... the Irish Dental Association has made some valid points. Are there concerns for dental patients who travel for treatment? Yes. Are the problems as big as the Irish Dental Association suggests. No.

At the end of the day, the Irish Dental Association also has the best interests of Irish dental patients at heart. Dr Donal Blackwell of the Irish Dental Association says that that one of the problems is that when considering travelling abroad for dental treatment, patients tended to focus on short term, aesthetic results rather than the long term quality of the care they receive and suggests that people travelling abroad for dental treatment actually don't know what they need when they enquire about costs. He's certainly right in some cases.

So, what's the solution and what's in the best interests of dentists and patients?

I'd like to see the following:

1. The Irish Dental Association issuing guidance for dentists and patients when considering dental tourism. See the UK General Dental Council's Dental Tourism Checklist on Treatment Abroad.
2. Irish dentists providing assessment and follow up of patients who travel abroad for treatment.
3. Irish dentists visiting some overseas dentists to get an understanding of how they work and their clinical skills and quality.
4. Irish dentists forming partnerships with overseas dentists, so that patients who need extensive treatment but can't afford Irish treatment have access to the treatment they need under the supervision of their own dentist.
5. Overseas dentists communicating with the patient's Irish dentist when a patient turns up in Budapest or Krakow - informing the patient's Irish dentist what work is to be undertaken, and providing post treatment reports on the work that has been carried out.

Common sense really. So, let's work together!

Increase in IVF tourism in Europe

At Treatment Abroad, we've seen increasing interest from IVF clinics abroad that are experiencing significant growth in patient numbers from the UK and other European countries.

The latest report from the European Society for Human Reproduction and Embryology confirms an increase in IVF treatment abroad, The report surveys infertility clinics in Belgium, the Czech Republic, Denmark, Slovenia, Spain and Switzerland and is based on a sample of 1,230 patients visiting these infertlity clinics. See details of the report in the Guardian.

Lack of access to IVF services in the home country for the over 40's and legal restrictions on infertility treatment are the prime drivers. Italy was the biggest source of IVF "medical tourists" accounting for 32% of the patients in the survey. Next was Germany (14%), followed by the Netherlands (12%), France (9%) and the UK (5%). The average age was over 37 but 63.5% of the British patients were over 40.

According to study coordinator, Dr Francoise Shenfield from University College Hospital in London, "Spain and the Czech Republic are popular destinations for oocyte donation; Swedes travel to Denmark for insemination, and the French to Belgium." She also highlighted the significant numbers of Italians who travel abroad to receive treatment that was rendered illegal in their home country under recent legislation or because they believe they will receive better quality care.Extrapolating the data, EHSRE estimates that 20,000 to 25,000 cross-border fertility treatments are carried out each year.IVF related medical tourism is a relatively new but growing trend in the UK, as couples delay having children into their 40's and then discover that they have a problem.

IVF treatment is available within the National Health Service in the UK, but access to treatment can be a problem.

• Age and waiting lists can be a barrier to treatment.


• Overweight women are excluded from NHS treatment.


• Demand for egg donation exceeds supply. ( The right of anononymity for egg donors was removed in 2005)

Obviously, private IVF treatment is available in the UK but this may be expensive and the same legal restrictions will apply.

Whereas some areas of medical tourism may be feeling the effects of the recession and the resulting impact on people’s pockets, IVF treatment abroad is an opportunity worth pursuing for those IVF clinics abroad that can demonstrate impressive results and cater for the needs of the “fertility tourist”.

Medical tourism and a medical city ...a lesson from history

Back in the mid 1990's, before someone, somewhere coined the term medical tourism, I was a UK Marketing Director with an American owned hospital company. We were big in medical tourism.... but in those days, it was known as the international patient business. One day, I got a call from a head-hunter, promising big money for an opportunity that surely I wouldn't want to miss....

This is roughly how the conversation went:

Head-hunter: "We've got these American investors who are planning to spend $500 million on a brand new 260 bed state of the art private hospital in the UK. They plan to attract international patients from all over the world. It's going to be called "Health Care International."
KP: "Sounds interesting. Where are they going to build it?"
Head-hunter: "On Clydebank. It's going to be massive."
KP: "Clydebank..... You mean Clydebank.... in Scotland....near Glasgow."
Head-hunter: "Yes, that's right. It'll be close to the airport so people will be able to fly in from all over the world. Labour costs for hospital workers in Scotland are much lower than they are in America"
KP: "Are you serious?" "Or is this a bad joke?"
Head-hunter: "I'm serious. It's backed by some American guys who are ex-Harvard Medical School and a US medical ventures company. They're going to create a medical city. They know what they're doing. They want someone to run it who knows the business inside out. You come highly recommended. Are you interested?"

I think my response was something along the lines of, "Not in your wildest dreams".

So...what happened?
Health Care International was one of the biggest disasters of all time in terms of a hospital development. They built the Clydebank hospital....... patients didn't come. Surprise, surprise, they failed to fill its 240 beds, 21 operating theatres and neighbouring five-star hotel. By 1995, it was going bust.

Unperturbed by this unmitigated failure, in walked a group of Middle Eastern investors from Abu Dhabi with a plan to "develop the hospital as a centre of international medical excellence". It grew to 540 beds. And in 2002, it went bust again. In walked the National Health Service who picked up a state of the art hospital and all the equipment for around $50 million!

It's still there. It's now part of the NHS National Waiting Times Centre and is known as the Golden Jubilee National Hospital.

And there's not a medical tourist in sight!

History repeats itself...
It was the poet and philosopher, George Santayana, who said, "Those who do not study history are doomed to repeat it."
At the core of the Health Care International debacle was a failure to understand marketing and a failure to understand the market.

• The Americans involved had little real grasp of the international patient business.
• The Abu Dhabi investors who bought it out had even less.

But they both had a vision of a booming medical tourism market and it cost them millions and millions of dollars.

Around the medical tourism world today, I see history repeating itself. Investors getting involved who may have little real grasp of the international patient business, being guided by others who may have even less.

So, my suggestion to the investors and medical tourism pundits is "Get your history books out".

Or buy a decent marketing text book. It might save you a few million!

NHS Patient Choice - Lessons for medical tourism

In the UK, "patient choice" is one of the driving forces in healthcare. Since April 2008, patient choice has been extended in the UK. Patients can choose which hospital they are treated in....anywhere in the country. Patients can choose the time of their hospital appointment. In some cases, patients can choose the individual consultant they see. The NHS Choices website lists information about all NHS hospitals, such as their MRSA rates, facilities and ratings and reviews by patients which means that patients can make an informed choice.
The NHS Choose and Book web site enables people to make their choices.
In reality, the patient choice initiative has been a bit of a disappointment. One problem is that not enough patients are actually aware that they have a choice. The Report of the National Patient Choice Survey, England - December 2008 has analysed uptake of patient choice so far.
The key findings:

• The percentage of patients recalling being offered a choice of hospital for their first outpatient appointment was 46% in December 2008, the same as in September but up from 30% in the first survey (May/June 2006)
• 50% of patients were aware before they visited their GP that they had a choice of hospitals for their first appointment, up from 48% in September and 29% in the May/June 2006 survey.

The factors influencing choice

• Hospital cleanliness and low infection rates were given most often (by 74% of patients) as an important factor when choosing a hospital.
• The other five are quality of care (given by 64% of patients), waiting times (63%), the friendliness of staff (57%), the reputation of the hospital (55%) and location or transport considerations (54%).

So what can medical tourism businesses learn from this?

If UK patients can compare NHS hospitals on MRSA rates, post operative infection rates and outcomes, why can't they do this for overseas hospitals? Or perhaps, why is it difficult if not impossible to find a hospital treating medical tourists that publishs such data or makes it freely available on their web site?

Many people in the UK have the right under EU law to travel abroad for treatment. The EU Directive sets up a framework around this. but the basic right of free movement already exists. So, why aren't people taking advantage of this?

• They don't know they have the right.
• They don't "trust" overseas hospitals.
• They would rather wait for treatment on the NHS in their local area.

Awareness of overseas treatment options can be generated by the providers themselves. One of the best tools to consider is the use of patient stories to create local press coverage and thus raise awareness. See this story in the Scotsman. Let's see more of them!