The NHS has long been held in high regard around the world, with institutions keen to access UK expertise in order to develop their own healthcare. Healthcare exports have many benefits for the NHS, including tackling our own domestic challenges.
Over the past five years I’ve been involved with activities to build commercial relationships between the UK and other countries. It’s been instructive to see the high regard in which UK healthcare is held.
Many countries want their medical, nursing and allied health professionals to receive post-graduate training in the UK. They also want their institutions to access UK expertise to help develop and improve their healthcare.
Healthcare exports aren’t new.
‘Many countries want their healthcare staff to receive post-graduate training in the UK’
In 1976 the Department of Health issued a circular entitled Exporting the NHS, encouraging NHS organisations to respond to opportunities overseas.
In the 1980s NHS Overseas Enterprises was established to provide training and consultancy services abroad, while in the 1990s British Healthcare was established to encourage public and private sector health exports.
Since its establishment in 2012, Healthcare UK - a body jointly funded by DH, NHS England and UK Trade & Investment - has sought to bring a more strategic approach by focusing on the high growth, emerging markets of China, India, Middle East and Brazil in order to increase healthcare export levels.
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This follows a pattern set by some OECD countries that recognise their highly developed healthcare systems can play a part in economic growth while providing high quality care domestically.
I interviewed six public sector leaders who are actively and successfully working internationally to capture the lessons they have learned.
The projects are wide ranging and span the set up and management of new facilities: Moorfields Eye Hospital in Dubai and King’s College Hospital Clinics in Abu Dhabi.
‘Projects are wide ranging and span the set up and management of new facilities’
There are unique partnerships to improve cancer care which span training and clinical improvement between Leeds Teaching Hospitals and Malta, as well as the King Hussein Cancer Center in Amman, Jordan.
Initiatives to create a step-change in diabetes prevention and treatment between the University of Dundee, NHS Tayside, Aridhia Informatics, the Dasman Diabetes Institute and the Ministry of Health in Kuwait. Some organisations have international relationships going back many years.
In addition to the Middle East, international working includes partnerships formed in China by Royal Free London Foundation Trust, and the work of Public Health England across Europe and in the US.
New funding streams
With the challenges facing many NHS organisations apparent from the pages of the HSJ, some will question whether an expanded horizon is a priority.
It’s a fair question to ask, though my interviews suggest that domestic sustainability is at the heart of international expansion plans.
As Chris Canning, a clinical director for Moorfields, put it: “Exporting changes your own mindset. We are in a global community and we underplay the degree of expertise we have. We take for granted our policies and procedures. These things are superb.”
‘We are in a global community and we underplay the degree of expertise we have’
Predictably the ability to access new funding streams is cited as a core benefit. Some organisations such as PHE rely on external funding (including international work) to cover around one third of their operating costs. Other organisations seek to generate income by training students from other countries.
More directly, some organisations generate revenue by treating patients who travel to the UK to access healthcare privately.
In some cases they open outlets in other countries to treat patients or manage a facility in another country.
Historically some countries have relied on the ability to place patients in nations with well regarded healthcare services. Surpluses generated from additional revenue streams are re-invested.
Many globally renowned institutions consider an international footprint an essential part of their offer. As one put it: “It is a statement about your place in the world”.
Major US tertiary hospitals - whether for profit or not for profit - operate facilities or run programmes in other parts of the world. For some in the UK, matching this is a priority to maintain the reputation and reach of the institution.
A stellar reputation attracts the best clinicians and researchers from around the world, with a commensurate knock-on in terms of teaching and clinical practice here.
The NHS has a fabulous reputation, yet it is the individual institution, its high profile clinicians, its skills, heritage and track record that are prized elsewhere.
‘The NHS’s high profile clinicians, its skills, heritage and track record are prized elsewhere’
Attracting research grants, developing wider catchments of patients are equally important. Clearly research is a key income stream for major institutions and the ability to operate internationally and build partnerships is additive to applications.
On a more tactical level, international presence is a recruiting siren for healthcare workers. Training links create lifelong connections for the country as well as the institution in question.
In a healthcare environment where an adequate workforce establishment is essential to maintain quality standards, international links are ever more important.
A lack of funding will put budgets under pressure, but a lack of trained staff has a more profound impact.
In the case of PHE, having international projects creates a surge capacity which is invaluable for emergencies and which could not be justified on a standing basis domestically.
The final benefit, reciprocity, is important but easier to ignore.
It’s clear from the experiences of some that there is much to be learned by working in other health systems. The application of UK expertise in a different culture can result in unexpected innovations that can be re-applied in the UK. Equally, observed behaviours from other health systems can be adopted to good effect in the UK.
Realising these benefits isn’t plain sailing, as my interviewees were keen to point out.
Developing relationships in a new country takes time (often longer than expected), dedicated investment and commitment. Delivering services in most countries requires face to face engagement from managers and clinicians.
Leadership alignment, a clear plan and drive from board level are essential.
‘Leadership alignment, a clear plan and drive from board level are essential’
An ambition to deliver post-graduate training programmes is different from a commitment to manage a new hospital.
Embarking on philanthropic activities in developing nations calls for a different approach to taking on commercial contracts.
Institutions need a high level of self-awareness to identify genuine strengths that others would envy and be willing to pay for. The service needs to be robust enough to accommodate growth.
Equally, some models are more portable than others; require less expensive equipment or capital investment.
Dr Canning illustrates this very eloquently in relation to ophthalmology. “The eye may be a small structure, measuring 23mm in length, but there are 13 sub-specialties within ophthalmology and 12 per cent of all hospital outpatients appointments are ophthalmic,” he says.
“The cost per [quality-adjusted life year] is high, length of stay is measured in hours not days, and treatment doesn’t rely on expensive acute care facilities. Allied with Moorfields reputation, it is a business model that is highly amenable to export.”
Getting started is particularly hard and raising the necessary investment can be difficult.
Organisations with existing private patient income can reinvest the proceeds in their international plans. Some interviewees have sought to work in partnership with others, either other public sector bodies or commercial organisations to reduce their own upfront investment, access new capabilities or share risk.
It’s clear from discussions with Healthcare UK that international demand exists for a range of healthcare services delivered by UK organisations and that organisations can draw upon active support from government to help them succeed.
‘Looking outwards is an important means to tackle domestic challenges’
What I draw from this small sample of interviews is that organisations with the capacity to invest for the long term in a high quality offering can realise a range of benefits, both financial and non-financial.
In a period where healthcare is changing, where inflation in the cost of healthcare outstrips economic growth and the hunt for talent is ever more global, I tend to the view that looking outwards is important as a means to tackle domestic challenges.
As David Berridge, deputy chief medical officer of Leeds Teaching Hospitals put it: “The NHS is a major GDP contributor. We are becoming alive to the opportunities to punch our weight nationally and internationally.”
John Myatt is strategic development director for Serco Healthcare
- David Berridge deputy chief medical officer of Leeds Teaching Hospitals Trust;
- Chris Canning a clinical director for Moorfields Eye Hospital FT;
- Alison Shutt commercial and international development director for Royal Free London FT;
- Simon Taylor chief financial officer at King’s College Hospital FT;
- David Rhodes deputy director and head of business development at Public Health England; and
- Mairi Scott professor of general practice and medical education at University of Dundee.
- Department of Health and Social Care (DHSC)
- KING'S COLLEGE HOSPITAL NHS FT
- LEEDS TEACHING HOSPITALS NHS TRUST
- MOORFIELDS EYE HOSPITAL NHS FOUNDATION TRUST
- NHS England (Commissioning Board)
- Public Health England
- Royal Free London NHS Foundation Trust
- Yorkshire and the Humber