The long-term sustainability of the NHS faces multiple threats from globalisation, the NHS Confederation has warned.

The challenges include satisfying a diversifying population, new patterns of diseases, the ability of patients to go elsewhere for care and increased demand driven by drug advertising and rising expectations.

Confederation deputy policy director Jo Webber said: "This is what people need to be managing when they position themselves as providers or when primary care trusts think about how they put information out to patients."

She said one of the biggest threats was the impending European Union directive - due later this summer - which will spell out patients' right to access healthcare anywhere in the European Union, at their home country's expense.

That could lead to PCTs having to fund the cost of operations done abroad and could "exacerbate" health inequalities, as only those able to afford the travel costs would take advantage of the scheme.

Ms Webber said the best way for the NHS to counter the threat would be to ensure that patients were aware of the vast improvements in NHS quality and waiting times, as this might not be clear to those tempted to travel abroad.

Some NHS providers would be able to exploit the development to their advantage by recruiting more EU patients. But the report also warns that a separate EU development to potentially relax the rules on promoting prescription drugs to patients "could create the pressure for increased prescribing of possibly inappropriate treatments" (news, page 9, 24 April).

The report also highlights the challenge that immigration poses to personalised care. As the population becomes more diverse, personalised services become more necessary but also more difficult.

Research by Ipsos Mori for the confederation suggests the NHS is falling short on personalised services, with hospitals and PCTs in the most diverse areas achieving the lowest levels of satisfaction.