Care in the community

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First published in ITIJ 98, March 2009

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The United Kingdom is the world's sixth most popular tourist destination, with 32.7 million visitors in 2006 alone. Inevitably, some of these foreign guests will become ill or require emergency treatment when in the UK, so Jane Collingwood asks: what standard of care can they expect, how do they go about receiving it, and how much will it cost them?

Tourists come to the UK from all over the world, particularly from other European countries, the US and Australia. When they require medical help, the public National Health Service (NHS) can be relied upon as their first port of call. It is a relatively high quality service: in total, the UK spends 8.2 per cent of its gross domestic product on health, and is rated 18th in the world for overall health system performance – hospital quality, technology and medical care – by the World Health Organization.

Visitors to the UK who need emergency treatment can call 999 for an ambulance and will be taken to the Accident and Emergency (A&E) department of a public hospital free of charge. The emergency treatment they receive on arrival is also free of charge. However, the patient or their insurers will be required to pay for any further care unless they are defined as ‘ordinarily resident’ in the UK or ‘lawfully living in the UK for a settled purpose as part of the regular order of his or her life for the time being’. The number of people falling into this category is rising: official figures show that 2.3 million migrants have moved to Britain since 1997.

Foreign students studying in the UK for longer than six months are entitled to free healthcare, alongside most visiting Europeans. The European Health Insurance Card (EHIC), which replaced the E111 in 2005, gives anyone from the European Economic Area and Switzerland access to emergency medical treatment in another member state free, or at a reduced cost. But it has some complex restrictions and eligibility requirements, a limited choice of treatment centre, and does not cover evacuation or repatriation back to the patient's home country, so in no way does it render travel insurance obsolete.

"There have been a number of concerns raised over the use of private ambulance firms … patients’ safety is being put in jeopardy by the use of (such) unregulated agencies … the practice [is] a ‘desperate’ response to a crisis in emergency care."

Many other countries have reciprocal healthcare agreements with the UK (see box 1). In return, eligible UK residents can receive free or reduced cost medical treatment whilst visiting these countries. Anyone not eligible for free healthcare in the UK is subject to the National Health Service (Charges to Overseas Visitors) Regulations 1989, and its recent amendments.

gherkinMeeting expectations?

Clinical operations manager at AXA Assistance Pippa Bray believes, "Foreign patients are generally treated very well here in the UK." She explained that assistance companies need medical reports and regular updates from hospitals, but the patient must give written consent for this confidential data to be released. "Data protection gets tighter all the time," she warned. Assistance companies in the country generally report that liaising with hospitals to determine whether or not charges will be made normally goes ‘fairly smoothly’; but says Bray, "Public hospitals are very busy and sometimes do not charge due to administrative issues.” This does vary from place to place, however. A central London hospital with an A&E department (e.g. Middlesex, St Mary's) will treat more foreign patients and so will be more familiar with the process of dealing with patients who speak a different language, and with assistance companies working on behalf of travel or medical insurers, than rural hospitals or those in other parts of the UK.

The NHS is a high-standard health system supported by general tax revenues. Founded in 1948, it provides a comprehensive and free service to 60 million people, has annual spending levels in excess of £100 billion and a staff of 1.3 million. The NHS refers to the four healthcare systems of the UK – England, Northern Ireland, Wales and Scotland. There is no problem when a patient from one UK country needs treatment in another.

In England, the NHS is the responsibility of the Department of Health, overseen by a secretary of state for health, who reports to the Prime Minister. The department is responsible for the ten ‘strategic’ health authorities that supervise and monitor local NHS Trusts. The NHS has a range of trusts in any one area of the UK, responsible for different elements such as hospitals or mental health. The trusts' directors oversee local hospitals, most of which, but not all, have A&E departments.

The NHS is highly regarded for its universal coverage, comprehensive primary care, rigorous regulation and the high degree of skill and professionalism of staff. Across the UK, there are a large number of medical and dental schools and centres offering training for nurses and other staff. The NHS draws on a wide range of resources – government agencies, professional organisations, educational bodies, charities, foundations and private companies.

However, it is also frequently criticised for high bed occupancy rates, ‘rationing’ drugs that it judges too expensive, bowing to political pressure, forcing those who pay for private healthcare to ‘pay twice’ via taxation, lengthy waiting lists (despite recent efforts), and the so-called ‘postcode lottery’ of care standards. Persistent outbreaks of antibiotic-resistant superbugs such as Methicillin-Resistant Staphylococcus Aureus (MRSA) and Clostridium difficile (C.diff) in NHS hospitals also raise hygiene concerns, and have prompted a report by independent regulator the Healthcare Commission, which at the end of 2008 stated that 60 per cent of hospitals in England are failing to deal with superbug infections effectively. In response to the report, the Royal College of Surgeons blamed consistent overcrowding on NHS hospital wards for the ‘uncontrollable spread of superbugs and other forms of infection’.

"Data protection gets tighter all the time … [but] … liaising with hospitals to determine whether or not charges will be made normally goes ‘fairly smoothly’"

Overall, however, the NHS delivers some aspects of healthcare very well. In the case of emergencies relating to foreigners, it will normally cope and patients won't need to move to the private sector or to a different country in order to access better care.

Nevertheless, Dr Charles Levinson, chief executive of the private Doctorcall Medical Services Group, feels that primary care through the NHS ‘is not tailored for access by or ease of use by foreign nationals’. The reason for this, he believes, is its lack of experience and lack of systems for dealing with foreign patients. Anyone who has been a UK resident for three months, regardless of nationality, can theoretically register with GPs surgery, but getting access can be a major hurdle and then the wait for an appointment can be slow.

Furthermore, there is a risk of communication difficulties in treating foreign patients, but most assistance companies, some private hospitals, such as London's Portland Hospital and London Bridge Hospital, as well as larger NHS or public hospitals, such as Great Ormond Street Hospital for Children, make special provision for international patients. This can include anything from offering translators to interpret between patients, consultants and ward staff, to providing a range of menu, television and newspaper choices to cater to different nationalities and cultural sensitivities.

For drug prescriptions, there is a standard charge – currently £7.10 – but some residents can obtain free prescriptions: children, full-time students, the elderly, and those on state benefits. Visitors to the UK can obtain prescription and non-prescription drugs at pharmacies, recognisable by a green cross in the window. Pharmacists are highly trained professionals who can give medical advice but cannot distribute drugs without a doctor's prescription. Boots and Lloyds are major chains of UK pharmacies.

There are some health areas for which referral by an NHS GP is not necessary, such as physiotherapy, health screening, cosmetic surgery and dentistry. On the topic of dentists, it can be hard to find an NHS dental practice that accepts new patients; and the quality of the products and technology used may not be as high as those at private clinics. Optical treatment tends to be provided by high street opticians who are approached and paid directly.

The NHS has a helpline, NHS Direct (0845 46 47 from the UK), for healthcare advice, as well as 90 walk-in centres located around England at which NHS nurses give advice, information and treatment for minor injuries and illnesses with no appointment needed. The centres are available to overseas visitors, but a charge may be made for some services.

The NHS has recently seen an increase in the number of Foundation Trusts – trusts that have gained a degree of independence from the Department of Health and their local NHS strategic health authority. Foundation Trusts give local communities more decision-making power, and are monitored by an independent regulator who then reports to central government. In January this year, the English NHS published a constitution that outlines what staff and patients can expect, explaining the purpose, principles and values of the NHS, patient rights and staff responsibilities. 

ambulances1Private vs public

Running in parallel to the NHS is a thriving private healthcare market. It is used by eight to 12 per cent of the population, often as a ‘top-up’ to NHS services, and is generally ‘fast and responsive’, according to Dr Charlie Easmon of London's private clinic, Number One Health.

There are approximately 250 private hospitals in the UK, mostly in larger cities. BMI Healthcare, Spire Healthcare and the Nuffield Hospital groups are some of the leading operators around the country. Additionally, HCA Hospitals operates six private hospitals in London, including The Wellington Hospital, the UK's largest independent hospital, and London Bridge Hospital and The Princess Grace Hospital, which accept emergency patients.

"60 per cent of hospitals in England are failing to deal with superbug infections effectively"

The private sector is regulated by the Healthcare Commission, which was set up in 2004. In fact, any UK organisation that provides healthcare must register with the Healthcare Commission, which carries out inspections and ensures medical establishments meet government standards. It also provides performance ratings for every hospital in the country, accessible via its website.

Most of the staff working in the private sector will have some experience of working in the NHS, and many work in both. In fact, the government's health agenda increasingly relies on the private sector. Since April 2008, UK patients in England can choose where to receive non-urgent treatment from a range of NHS or sometimes private health units. About 3,500 patients every month have private treatment paid for by the NHS. As a result, the NHS reportedly spends £7.6m in fees with private hospitals each year.

A number of NHS hospitals also have private units, including Hammersmith Hospitals NHS Trust and the Oxford Radcliffe Hospitals. The NHS is currently setting up Independent Sector Treatment Centres, which are contracted within the NHS and normally located in NHS hospitals.

Needless to say, when it comes to treating foreign nationals, the private sector in the UK is only used by self-pay patients or those with medical insurance. Regarding non-emergency care, Dr Levinson says, “Most overseas insurance companies we deal with will prefer us to refer into the private sector.” The NHS, he commented, has ‘issues with communication and lack of experience’.

Is it worth foreign visitors paying to go private if they can afford it? On the one hand, NHS supporters would argue that although private hospitals may have lower infection rates, there is little difference in the cleaning systems they use, and most consultants work in both the public and private sectors, so expertise is the same. NHS hospitals are generally larger, though, have a significantly lower nurse-to-patient ratio, and aren’t as uniformly equipped with modern technology and equipment as the private sector. Private hospitals also offer some medical services that are not available or have limited availability on the NHS, such as some fertility treatments, complementary therapies, and some cosmetic procedures; but they do not generally house intensive care units.

londoncallingCare on demand

Private ambulance services are becoming more common in the UK, performing a number of roles including patient transport, with many NHS trusts and hospitals choosing to use a private company rather than NHS ambulances. On the whole, private companies are used when there is a shortage of NHS ambulances available, or when the private company is cheaper. There have been a number of concerns raised over the use of private ambulance firms, however. As was reported in an article in The Telegraph newspaper in February, the College of Emergency Medicine has warned that patients’ safety is being put in jeopardy by the use of (such) unregulated agencies, which it says ‘use inexperienced or inadequately-trained staff’, while paramedics said the practice was a ‘desperate’ response to a crisis in emergency care.

Separately, aircraft and medics providing evacuation and repatriation are widely available in the UK to fly foreign patients home. Assistance companies operating in the UK (such as Europ Assistance, AXA Assistance, Mondial Assistance, International SOS, First Assist, Healix International, Worldwide Assistance, Medex and On-Call International) usually do not own their own aircraft, so there is quite a bit of overlap in the use of providers. Cega is the only UK assistance company to own its own fleet. Several global air ambulance firms also service the UK, and large commercial airlines such as British Airways, Delta, Continental and Virgin also offer medical evacuation from the UK.

But it’s not all one-way traffic. Medical tourism to the UK is a growing industry, and is especially popular with patients from the US. Explains Treatment Abroad director Keith Pollard: “The UK is more expensive than Malaysia or Singapore but it’s not double the cost, and is still way cheaper than the US.”

"Private hospitals also offer some medical services that are not available or have limited availability on the NHS … but they do not generally house intensive care units"

There are now many companies offering competitively priced services for international patients, typically including joint replacement, cardiac, dental and cosmetic surgeries. Most providers are accredited by groups such as the Trent International Accreditation Scheme, although both NHS and private hospitals with good international reputations are being sought after and even actively marketing themselves to potential international patients, as is the case, for example, with the Great Ormond Street Hospital for Children. As might be expected, a wide range of travel and medical insurance options are available to cover visitors to the UK, as well as those normally resident in the country. Major companies providing private medical insurance in the UK include PruHealth, Norwich Union Healthcare, Saga, Boots, AXA PPP Healthcare, Standard Life Healthcare and Bupa. There are many more providers operating in the UK however, and most banks and building societies now also offer cover.

In 2007, total net premiums for Accident & Health (i.e. Personal Accident and Private Medical Insurance) in the UK came to £4.6bn. Claims came to £3.1bn. In order to compete, UK private medical insurers are increasingly offering preventative medicine, general practitioner (GP) and nurse helplines, health screening, fitness and health advice, and even discounts at health clubs and gyms. Furthermore, shrinking margins are currently driving change in the medical insurance market, according to the latest Health & Care Cover - UK Market Report by Laing & Buisson. Although there was a 4.4-per-cent rise in the number of people covered through corporate medical insurance schemes in 2006, sales of individual policies fell by 2.2 per cent. Insurers' profit as a percentage of gross written premiums also fell, from three per cent in 2005 to 2.3 per cent in 2006. These sales figures and tight margins have resulted in increased consolidation, and the medical insurance market is feeling the pinch of the faltering economic climate, concludes the report.