Health tourism: don't forget your toothbrush…

What medical treatment have you had abroad? An emergency trip to hospital for a holiday illness? Or are you one of the rising number of Britons who have travelled overseas specifically to get treatment?

Medical tourism is a growing trend in the developed world. Some estimates put the number of Britons who will travel abroad for planned treatment this year as high as 150,000. Figures from the international passenger survey, which samples people leaving the UK, suggests 77,000 left for medical treatment in 2006.

These figures are dwarfed by the numbers of US citizens who go abroad for treatment, often to get it cheaper than they could at home - sometimes with the support of their health insurers. In 2007, 750,000 are believed to have sought treatment abroad, with some predicting this to rise to 10 million by 2012.

It is a trend that has been helped by the use of the internet to look for overseas care and the improving reputation of some hospitals outside the US and Europe. Increasingly, Asian hospitals are being recognised as centres of excellence and are receiving international accreditation. Bumrungrad International Hospital in Thailand, for example, now treats more than 400,000 overseas patients a year.

The biggest market for UK residents is thought to be in dental work, often in Eastern European countries. Cosmetic surgery, fertility treatment and elective procedures are also common, according to a survey for website Treatment Abroad.

At the moment much of this is funded by the patient, although health insurers do occasionally pay for treatment abroad, for example when a pioneering treatment is not available at home.

Cheaper treatment

A major reason for seeking treatments overseas is lower cost for those not provided or not fully funded by the NHS - such as cosmetic surgery, weight reduction surgery or dental work. Savings compared with paying for private work in the UK are often as much as 50 per cent, even allowing for travel and accommodation costs.

Other patients want to get treatment that is not available in the UK or that would be denied them because of their personal circumstances. Infertility treatment clinics abroad may be cheaper and offer easier access to private treatment than here, where availability of IVF and other fertility treatments is often dictated by where patients live.

"The reason they are being driven abroad is because they should be funded by the NHS [but aren't]," says Laurence Shaw, consultant at the Bridge Clinic in London and spokesman for the British Fertility Society.

Patients may seek fertility treatment which is not available to them in the UK, such as infertility treatment for women in their late fifties and sixties or selecting embryos for non-medical reasons - such as the desire to have a child of a certain sex - which is not permitted in the UK but can be done in some other countries.

Mr Shaw identifies the shortage of donor sperm and eggs as one factor driving patients abroad. This may be to get an ethnic match between patient and donor, or because the removal of anonymity for donors has affected their availability. Other patients may be trying to access new techniques or treatments that are only performed at a few centres or have yet to reach the UK, such as some stem cell treatments.

But a minority of patients will be travelling abroad to pay for elective treatment they could get on the NHS here.

"I really do think people have misconceptions that waiting times are long for everything in the UK, whereas we will be better than many countries in Europe for waiting times," says King's Fund fellow in health policy Tony Harrison.

"There are still people who are not prepared to wait and are happy to pay to go somewhere else," says Keith Pollard, managing director of the firm that runs Treatment Abroad.

And concerns about infection control in the UK can play a factor in patients' decisions to go abroad.

"We had a guy ring up the other day who only wanted to go to Scandinavia or Holland because of their low MRSA rates. A lot of it is Daily Mail driven perception of how bad the NHS is," says Mr Pollard.

But does this increased travel affect the NHS? One obvious impact is patients suffering side-effects or complications of treatment abroad once they return home. It is hard to be specific about how widespread this is (particularly given the difficulty in establishing how many people are receiving treatment abroad) and whether these complications are more common or severe than would be expected from any cohort of patients having these treatments.

The British Association of Plastic, Reconstructive and Aesthetic Surgeons has called for clearer guidance to the NHS on when to treat patients who have problems such as infections and wound breakdowns following cosmetic surgery overseas. It says in 2007 more than 200 patients were seen in NHS hospitals after surgery overseas, of whom three quarters had complications and, of those, 26 per cent needed emergency surgery and a third needed further elective surgery to rectify the problem.

British Association of Aesthetic Plastic Surgery spokesman Patrick Mallucci points to some of the difficulties patients travelling abroad can face, such as finding out about the people who will treat them, language barriers and issues about continuity of care. As some patients are travelling abroad for surgery that will need regular follow-up care, an added complication can be how much information is available about what treatment they have received.

And British Obesity and Metabolic Surgery Society president John Baxter says that although surgery for weight loss is often very good, patients are reluctant to travel again for the aftercare, leading them to turn to the NHS.

Another potential impact on the NHS is from fertility treatment abroad. Women undergoing embryo implantation in the UK are increasingly implanted with just one or two embryos, to avoid multiple births. But some overseas clinics are more willing to transplant up to four, potentially leaving the NHS to cope with the consequences of multiple births, which include greater use of special care baby units and put babies at greater risk of long term health problems.

"Triplet, quadruplet and higher order multiple pregnancies are very challenging high risk pregnancies. National regulatory bodies can be sidestepped by couples desperate for a baby and the myriad of tempting offers of fertility treatments can lead them to serious adverse consequences," says Alastair McKelvey, fellow in materno-fetal medicine at University College London Hospitals foundation trust.

However, Mr Shaw cautions against the view that healthcare abroad is automatically going to be substandard to the UK. The Euro health consumer index recently rated the UK just 13th out of 31 European countries for healthcare and one of the reasons seeking treatment overseas has grown in popularity is because of some people's good experiences. But it is unlikely that paying foreigners will see the worst bits of a country's health service. Their experience may give a false impression of what is available to locals or outside a major city, especially in the developing world.

Easy jet

An EU directive on cross-border care published in July last year will make it easier for patients to travel abroad for planned treatment and get the NHS to pay for this, so long as the cost is up to what it would cost in the UK. The move will force the service to set up mechanisms for this. Some health service organisations may offer free information about how much they will reimburse. Approval in advance will only be needed for treatment involving an overnight stay and where planning or financing in the UK would be undermined.

But many believe only a few patients are likely to look much further afield than their local hospitals for care. Outgoing Picker Institute director Angela Coulter believes numbers travelling abroad will be relatively few, especially if waiting times in the UK remain low, although she stresses that flow between Northern and Southern Ireland is important. But there is concern that the well educated and well off will travel for better or quicker treatment, while the poor and badly educated will stay at home - which could worsen health inequalities.

Ms Coulter believes the emphasis on providing information means an ability to compare quality will be the major impact of the directive.

"Things like the international cancer survival rates help to concentrate the minds of politicians and policy makers," she says.

Major issues for the NHS will be how bureaucratic the process will be and how trusts will be paid for work carried out on EU nationals - as well as how they can be slotted into the UK system. The Department of Health says it will not issue any additional guidance on this until the directive is finalised, which will not happen until after it has been approved by individual governments and the European Parliament.

But the directive could also be a challenge for primary care trusts that will need to sort out funding systems and assess how it could affect demand for services in the UK.

It could also lead to more pan-European centres of excellence for rare conditions, such as some childhood cancers.

"My fear is that hospitals in places like Austria and Germany will do better at this, but if we don't compete these centres will end up elsewhere in Europe. Patients with rare diseases will travel," says Mr Pollard.

Pay or stay?

To some extent, the UK has been isolated from cross-border healthcare because it is an island with a mainly state funded healthcare system. But a handful of people are funded for treatment abroad.

The Department of Health says 552 people were granted approval for treatment elsewhere in the EU in 2007 but it has no numbers for those who were treated further afield at NHS expense.

A number of pilot projects have previously sent patients abroad in significant numbers, mainly in response to long waiting times. Around 1,000 people from London went to Belgium for surgery under a scheme which ended in 2005. And in 2002, 190 people from the South East were sent to hospitals in France and Germany as the NHS battled to bring waiting times down.

A later evaluation of the South East programme found a generally high level of satisfaction among patients, especially with the clinical care they received. Concerns were more often about travel and non-clinical aspects of their care. The project had been time consuming to arrange, with limited buy-in from some NHS organisations and clinicians.

But the evaluation team was able to devise a model for future commissioning which could reduce some of these problems and could be used to commission more operations abroad.

Could it happen again? Robert McCafferty, who recently organised a health tourism show in London that drew 30 overseas exhibitors, says he is surprised no NHS organisations were present.

"I half expected to see people from the NHS who wanted to get 500 hip replacements done and thought their local trusts would cost too much. It makes good financial sense [to go overseas]. Almost all of the hospitals who came along to this show were accredited by international medical accreditation bodies, which can't be said for the vast majority of British hospitals."

Return fare: UK tourism

Global tourism is a two way process: travel into the UK for healthcare has existed for many years, often concentrated around trusts with an international reputation.

Some of this is within the NHS - often tertiary centres in London - but some private hospitals actively seek out international patients, whether self-funded, insured or paid for by their governments.

Treatment Abroad director Keith Pollard thinks there is room for further expansion in this area in the UK.

"The UK is more expensive than Malaysia or Singapore but it's not double the cost and is still way cheaper than the US. It could be a really attractive opportunity for trusts."

Trusts could exploit this either by attracting US self-payers or through offering services to US insurers. However, there would be ethical considerations for trusts, such as ensuring no NHS patients were disadvantaged in taking overseas paying patients and whether this was an appropriate direction for an NHS organisation to take - not to mention how it would be treated under rules that limit hospitals' private income.

Some trusts have already seen opportunities abroad. Moorfields Eye Hospital foundation trust has a clinic in Dubai which saw nearly 2,000 patients in its first year. It uses consultants trained at and employed by Moorfields, thereby preserving the value of its brand. Profits come back into the NHS.

Great Ormond Street Hospital for Children trust is also looking to grow its international business - both from Europe and further afield - over the next few years. But a spokesperson points out that referrals from the UK are also expected to increase substantially and its capacity is not unlimited.

Other trusts seem to be at a very early stage of looking at the possibilities, even when they are geographically well placed to benefit from the EU directive.

A Foundation Trust Network spokeswoman says that the EU directive is very much on foundation trusts' radars.

"It's an opportunity. Where foundation trusts are offering really high quality services that they want to expand, they could potentially see themselves as the treatment destination of choice for people in England and beyond," she says.

But it is currently uncertain whether those patients would be seen as private - which could count under the private patient cap - or not.