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?"

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!

NHS staff numbers reach an all-time high

The UK Department of Health today released it's latest update on NHS staff numbers. It reflects the investment that the UK has been putting into the NHS in recent years, and also has an impact on outbound medical tourism from the UK. NHS shortcomings and waiting times are a significant driver of people seeking elective surgery abroad. In the last couple of years NHS waiting times have come down and there is now an 18 week target which most NHS trusts are meeting.

The number of people working for the NHS has reached an all-time high. After a dip in overall numbers in the previous two years, the annual NHS census showed staffing levels recovered to reach a peak of 1,368,200 in September 2008. This is a 2.8 per cent increase on the previous year and a 27.7 per cent increase compared to 1998.

In September 2008, the NHS employed:

• 408,200 qualified nurses – up 2.1 per cent or 8,600 on 2007 and up 26.2 per cent or 84,700 on 1998.
• 25,700 midwives – up 2.3 per cent or 570 on 2007 and up 12.4 per cent or 2,800 on 1998.
• 34,900 consultants – up 3.7 per cent or 1,200 on 2007 and up 56.4 per cent or 12,600 on 1998.
• 49,200 hospital doctors in training – an increase of 5.1 per cent or 2,400 on 2007 and up 59.4 per cent or 18,300 on 1998.

The number of people in employment in the UK was 31.32 million in December 2008 which means that 4.4% of the UK workforce is employed in the NHS.

The UK unemployment rate has now reached 6.5 per cent. So, the NHS is quite a good place to have a job!

EU Directive on cross border healthcare boosts health tourism

After a six month delay, the EU Proposal for a Directive on patient’s rights in cross border healthcare has finally been released. It provides an added stimulus to the already growing number of medical tourists who seek hospital treatment elsewhere in the European Union. Its aim is to create a formal framework for cross border healthcare and remove the obstacles that patients face if they wish to travel for treatment in other EU countries.


I'll attempt to answer some of the questions that people are asking about this new Directive and its impact.

Why do we need a Directive on cross border healthcare?
The Directive has come about from a desire to create a European market in healthcare, and to some extent as a result of European Court judgements which have upheld the rights of patients to gain reimbursement for treatment in other countries where they have been subject to "undue delay" in their own country.

What does it cover?
The Directive proposes a number of developments in cross border healthcare, including reimbursement of medical tourists, patient safety and quality issues, European cooperation on healthcare, assessment of new medical technology and standards for e-health and transfer of patient information between member states.

How will it affect UK NHS patients?
In April this year, NHS patient choice in the UK was extended, giving patients the right to opt for treatment anywhere in the UK. The Directive, in effect, extends this patient choice to anywhere in the EU, provided that the treatment is available at a cost which is the same or lower than the NHS cost.

Under the Directive, the NHS will be requested to establish a direct payment or reimbursement system. This means that patients will not have to fund the treatment and then claim the cost back from the NHS. They will have to fund their travel and accommodation costs. No prior approval is required from the NHS or the patient's primary care trust.

It doesn't mean that patients in the UK or elsewhere in the EU can opt for treatments overseas that are not covered by the NHS. So, if a new drug or a new procedure is available in another country, the patient cannot obtain payment for this.

How many patients will opt for treatment abroad?
Who knows? Patients may decide to travel abroad because:

• Surgeons and hospitals with better results for their treatment may be available elsewhere in Europe.
• Hospital infection rates may be lower in other European countries.
• Faster treatment may be available elsewhere.

It is worth noting that:

• There is no requirement for the patient to be suffering "undue delay" in treatment.
• The patient will need a referal from a GP.
• Patients cannot jump the waiting list in other countries..... which is one reason why why we will not see large numbers of patients travelling to the UK for treatment. They will join the end of the queue of existing UK patients.
• And since the UK is one of the most expensive healthcare providers in Europe, this will also discourage an inflow of patients from lower cost countries.

How will it affect the NHS?
It depends on how many UK patients opt for treatment abroad. If the NHS can prove that the number could be so large that it would affect the planning and funding of healthcare facilities in the UK, then it can make an application to set up a "Prior Approval" system which means that a patient would have to apply for treatment abroad. This is unlikely, I believe. It would be an admission of failure by the Government that the NHS cannot compete in a competitive European marketplace.

Overall the Directive has to be a good thing for both the NHS and UK patients. It could reduce the burden on NHS waiting lists, and offer cost savings where cheaper treatment is available elsewhere in the EU. It would also mean that NHS hospitals would face increased competition and would have to improve their performance relative to other European healthcare providers.

What else is covered by the Directive?
In addition to clarifying the position regarding medical tourism within the EU, the Directive also embraces:

• The establishment of common principles in terms of guaranteeing patient safety and ensuring quality and continuity of care.
• Stimulating greater European cooperation on healthcare including the establishment of “European Reference Networks” which would create a concentration of expertise, training and resources for specific diseases and health issues.
• Establishment of a European network for the assessment of new medical technology.
• Establishment of standards for e-health, in particular the transfer of patient information and treatment records between member states.

When will it take effect?
It's a draft directive, so it has to go through the EU mechanisms to be officially adopted as policy. But it's a part of a consultation process that's been going on for three years, so it's likely to become reality.

Good news or bad news for the medical tourism industry?
Undoubtedly, good news! It will add to the credibility of medical tourism, and will mean that people become more familiar with and confident about travelling for treatment. It will also reinforce the need for an improvement in standards and business practices in the industry. (See the Treatment Abroad Code of Practice for Medical Tourism).

Ultimately, it will result in greater patient choice and more people will choose to travel for treatment abroad.

For patients seeking treatment now who can't wait until the Directive comes into force, they can download Treatment Abroad's Guide to Medical Tourism or visit Treatment Abroad.

British patient wins NHS payment for treatment abroad

Another British patient has succeeded in recouping the cost of treatment abroad from the NHS.

Ann Belshaw of Suffolk took the Suffolk Primary Care Trust to court to pay for a scan at a private clinic in Germany. The NHS originally told her that she would have to wait a year for a scan on her back at the Addenbrookes Hospital in Cambridge.

A three-year legal battle then ensued to force her local NHS Health Trust to pay for her private treatment abroad. The Trust has now agreed to pay the £350 cost of the scan and Mrs Belshaw's legal costs , just as the the case was to go before London's High Court. Had it gone to the High Court, there is little doubt that the European Court of Justice ruling on cross border treatment (the Yvonne Watts case) would have applied.

This legal precedent combined with the forthcoming EU proposals on cross-border healthcare could lead to significant growth in medical tourism from the UK.

New health index means good news for medical tourism companies

The recently published Euro Health Consumer Index provides some interesting insights into the state of the UK health services and some encouragement for those who see the UK as a developing market for outbound medical tourists. The Index rates the public healthcare systems in 29 European countries on many factors such as clinical outcomes, quality of care, access to health services and patient information.

Austria emerges as the 2007 winner of the Euro Health Consumer Index, followed by the Netherlands, France, Switzerland and Germany.

The UK comes a very disappointing 17th out of the 29 countries; its score is dragged down by waiting lists and uneven quality performance. Medical tourism destinations such as France, Belgium, Estonia, Cyprus, Spain and the Czech Republic all outscore the UK.

As a separate exercise, the Euro Health Consumer Index 2007 included a value for money adjusted score, the "Bang-For-the-Buck adjusted score", which attempts to measure the value for money which the consumer gets from the healthcare system allowing for the spend on public healthcare in the country.

More bad news for the UK National Health Service.....

The UK sinks to 26th out of 29. Only Bulgaria, Poland and Latvia do worse.

Despite the efforts of successive UK governments, the NHS continues to deliver value for money to UK health consumers.

And that's probably good news for medical tourism companies!