First published in ITIJ 133, February 2012
Tourism to the Canary Islands is booming. Robin Gauldie looks at the high standard of medical services in the region, and talks to doctors and hospital staff about the overloaded public sector and claims of over-treatment in the private sector
Scattered over a wide swathe of the Atlantic, and closer to Africa than to mainland Europe, the Canary Islands archipelago has become one of Europe’s most popular sun and sea destinations, with a sunny, sub-tropical climate that attracts around 12 million visitors each year. Bucking the recessionary trend, visitor numbers were up by almost 20 per cent in the first 10 months of 2011, possibly driven by visitors from the islands’ main markets trading down from more expensive destinations. In addition, a variety of tax concessions on consumer goods – including alcoholic drinks – make the Canary Islands significantly cheaper for holidaymakers than many rival destinations in the eurozone, including mainland Spain.
A mellow climate – with average highs of around 20°C in January and around 27°C in August – also gives the islands a competitive edge over more highly seasonal Mediterranean destinations such as Greece and Turkey. The islands are spread over around 480 kilometres, in a roughly east-west direction, and are grouped quite closely together, with no more than 80 kilometres of open sea separating any two islands. Gran Canaria, the group’s second largest island, which houses the autonomous community of the Canary Islands’ capital – Las Palmas de Gran Canaria, occupies a position midway along the chain.
The Canaries have formed part of Spain since the arrival of Castilian adventurers at the very beginning of the European ‘age of discovery’. At the time, they believed that El Hierro, westernmost of the islands, was at the very edge of the world. The first Spanish expedition was followed by a 90-year process of conquest and genocide that culminated in the extinction of the indigenous Guanche people and their culture.
Lying roughly 1,800 kilometres southwest of the Spanish mainland, the islands have a population of just over two million and are represented by regional government based in the cities of Las Palmas de Gran Canaria and Santa Cruz de Tenerife, on the two largest islands. In turn, each of the seven major islands has its own local council or cabildo insular.
Tenerife is the largest island in the group, followed by Gran Canaria, Lanzarote, Fuerteventura, La Palma, La Gomera, and El Hierro. La Graciosa, with a population fewer than 1,000 people, is the smallest inhabited island in the group. In addition to native Canarians, the islands also have an expatriate resident population of some 300,000, including around 40,000 Germans and 38,000 Britons. Significant numbers of these are relatively elderly retirees, and this has some implications for the health sector.
“The national health system is overcrowded”
Tenerife, Gran Canaria, Lanzarote and Fuerteventura are the most popular holiday islands, offering a classic mainstream mixture of sunshine, sand, and affordable food, drink and accommodation, mainly in large resort hotels and apartment complexes. The UK is the leading tourism source, with British visitors accounting for almost 30 per cent of the total, ahead of non-resident Spaniards (around 22 per cent) and Germans (around 21 per cent). There are airports on all seven main islands, with Gran Canaria and two airports on Tenerife handling the lion’s share of international traffic. Lanzarote, Fuerteventura and La Palma also have international airports, while La Gomera and El Hierro have smaller airports handling flights that connect them with their larger neighbours. The vast majority of visitors arrive by air, but the islands also receive substantial numbers of cruise vessels.
Two local airlines, Binter Canarias and Islas, operate inter-island flights and the islands are also connected by at least five local passenger ferry lines. Road networks are generally good, with well-surfaced roads connecting communities on all the islands, and major highways linking the larger towns on the biggest isles.
The region is regarded as having public and private health provision on a par with any of Spain’s regions, providing medical services that compare well with any mainland European Union (EU) nation. An extensive public sector comprises major and specialist hospitals as well as local clinics, which provide a range of front-line services. As in mainland Spain, pharmacies may provide a number of medications over the counter (such as antibiotics) that are normally available only with a doctor’s prescription in the US, the UK and a number of other EU countries. As a region of an EU country, public health providers in the Canary Islands offer visitors holding the European Health Insurance Card (EHIC) the same level of health services as is available to Spanish nationals, including emergency treatment in the major public Hospital Universitario de Santa Cruz de Tenerife.
Elsewhere, hospitals include the Hospital de Gran Canaria Dr Negrin, in Las Palmas and Hospital Universitario Insular, also on Gran Canaria; Hospital General, Hospital Insular and Hospital Lanzarote, on Lanzarote; and Hospital General on Fuerteventura.
Standards of medical care in public and private hospitals are similar, with public hospitals providing higher levels of specialised services such as neurosurgery, cardiac surgery and nuclear magnetic resonance scanning. Foreign visitors holding an EHIC may be directed to a public health facility, but in 90 per cent of cases they are referred directly to a private hospital if they have adequate travel insurance cover, says Dr Gerhard Mueller, head of operations, medical, health and travel assistance at Allianz Global Assistance (AGA) Deutschland.
In the public sector, some medical services cost significantly less than in some of the destination’s markets, such as Germany and the UK, but in the private sector prices are higher than the EU average. Dr Klaus Schafer, network manager at the German aeromedical organisation ADAC, says the private healthcare sector is ‘markedly more expensive than treatment in any western European country except Switzerland’. AGA’s Gerhard Mueller warns that over-diagnosis and over-treatment are not uncommon. “Extensive diagnostic procedures and scientific medicine are used even for tourists who stay only seven to 12 days,” said Dr Mueller.
Meanwhile, all is not entirely well with the Canary Islands’ public health services. “On Tenerife, the national health system is so overcrowded that it is practically impossible to be treated,” claims Dr Ingo Putsch, of the private German Medical Center, “Highly qualified outpatient medicine is rare.”
“Nobody who can afford private care would ever go to a public hospital”
ADAC’s Klaus Schafer concurs. “Our experience is that nobody who can afford private care would ever go to a public hospital apart from very urgent cases that might contact Hospital Universitario de Canarias in Santa Cruz de Tenerife,” he says.
Gerhard Mueller is even more critical. “Public hospitals are increasingly well equipped, but with more or less chaotic organisation and medical staff and doctors who are not very co-operative and friendly,” he comments.
In November 2011, doctors and other health workers took part in a 24-hour strike to protest at the regional government’s plans to implement cuts that trade unionists said would result in the loss of as many as 2,000 health sector jobs – a claim that has been denied by the local government. The planned measures are just the latest in a series of cuts over the last two years, and include pay cuts, longer working hours and redundancies as the regional government tries to slash €32 million from its health budget. Unions representing public health sector workers say the austerity programme will lead to longer waiting lists, force more people to use private healthcare, and fear that it is just the beginning of a broader privatisation of state-provided healthcare.
Reflecting the islands’ multi-national tourist clientele, operators handling calls to the central 112 emergency number are trained to respond in languages including English, German and Italian as well as Spanish, and most senior medical staff are likely to speak at least one European language in addition to Spanish. Many front-line medical staff in the public sector are not fluent in foreign languages, but a number of private clinics cater specifically for foreign residents and visitors.
In 2009, Dr James Harris opened The British Surgery in Playa de Las Americas in southern Tenerife, and the practice has since expanded to provide two further medical centres in the Costa Adeje resort area. “The British Surgery has developed an excellent rapport with all the travel insurance companies including AXA and the (UK) Post Office, major UK banks and supermarket chains that provide travel insurance, and major tour operators including Thomas Cook, Thomson and First Choice,” said Dr Harris.
The British Medical Clinic, based in the major resort of Puerto Rico on Gran Canaria, also serves English-speaking residents and visitors, as does the British Surgery of Lanzarote, in Puerto del Carmen, which also has its own private ambulance service. Mary Beresford-Jones of the British Medical Clinic says that as a smaller, outpatient facility, charges to patients are often below the patient’s policy excess, so patients are normally asked to pay up-front for treatment. She says: “We have found that if we try and deal directly with the insurers we cannot get an immediate guarantee of payment from them.”
Private hospitals often ask for a pre-treatment deposit of up to €2,000 by credit card while the hospital waits for confirmation of payment from the patient’s insurer. “We have heard that some other clinics and hospitals have outstanding bills with various insurers awaiting payment. Apparently, UK insurers are more reluctant to pay out than other countries,” added Beresford-Jones.
Dr Miguel Valdivieso, general director of aeromedical evacuation services provider Aeromedica Canaria, disagrees that payment and over-treatment are problem areas. “I don’t believe assistance companies experience any ongoing problems with over-charging or over-treatment,” he says. “I worked for 20 years in a touristic hospital, and never asked patients for advance payment. Normally, the patient or relatives show the travel insurance documents and doctors or clinics simply contact the companies to confirm payment.”
In the Playa de Las Americas resort on Tenerife, the German Medical Center, founded in 1999, now has a team of 13 including seven doctors, provides a day clinic service primarily for German-speaking residents and visitors and also works with the German medevac organisations ADAC and Deutsche Luftrettung (DRF).
Crime rates throughout the archipelago are relatively low, and no special immunisations are required. That said, the volume of tourism means that local emergency services are kept busy. Incidents in 2011 included the beheading of an English woman, the drowning of two tourists at a major beach resort, the evacuation of a group of 52 hikers trapped in the Tiede National Park by heavy rains and flooding, and a gas explosion at a major resort hotel that killed one guest and injured 23, two of whom, with severe burns, required medical evacuation to a specialist hospital in Seville. The islands are also popular with yacht sailors, and search and rescue services are not infrequently called on to aid yachts in trouble.
Chance for trouble
The vast majority of visitors to the Canaries seek little more than a relaxing stay in the sun, but the remarkably diverse geography of the islands also offers opportunities for more active holidaymakers and concomitant challenges for emergency rescue services. Scuba enthusiasts are attracted by dive sites clustered close around the coasts of Gran Canaria, Lanzarote and Tenerife, and for emergency decompression cases there is a hyperbaric chamber at the Hospital Universitario at La Laguna on Tenerife.
Above the surface, El Teide, the highest summit in Spain at 3,718m, dominates the landscape of Tenerife and is surrounded by a national park that attracts walkers and nature-lovers. In sharp contrast to the archipelago’s generally mild climate, thick snow and ice are usual on the higher slopes in the coldest months of the year (January to March) and put ill-prepared walkers at risk. For less energetic sightseers, a cable car goes all the way to the top, presenting an unusual risk for divers, who are not always aware of the risk of decompression illness if they take this trip too soon after a dive.
El Teide is an inactive volcanic cone, but the whole island chain is the result of vulcanism and not all its volcanoes are extinct. In October-November 2011, a series of earth tremors shook El Hierro, the smallest of the major islands, to be followed by marine upwellings of steam and magma that revealed the existence of an active undersea volcano close to the island’s shores. A red alert was declared for part of the island, and residents of La Restinga, the community closest to the eruption, were briefly evacuated from their homes by the island council. As of mid-December 2011, seismic activity appeared to be less severe, but alerts remained in place.
“Over-diagnosis is not uncommon”
On land, Ayuda en Emergencias Anaga (AEA), a partly volunteer organisation operating under the remit of the regional government, provides ambulance and mountain rescue services and also has teams specialising in cave and sub-aqua rescue.
The regional government’s airborne emergency rescue organisation, founded by the regional government in 2000 as Grupo de Intervencion de Emergencias (GIE) and reconstituted in 2007 as Grupo de Emergencias y Salvamento (GES), operates a fleet of five Bell 412 helicopters from bases at Tenerife Sur, Gran Canaria, La Palma, Fuerteventura and El Hierro airports, each with a standard crew of two pilots and one winchman.
The five major airports are capable of handling large passenger jets. El Hierro and La Gomera, with their shorter runways, can service smaller turbo-prop aircraft but cannot handle medium to long-haul passenger jets. Both, however, can accept most air ambulance types.
Full aeromedical service is provided by local CAMTS/EURAMI accredited specialist Aeromedica Canaria, the regional government’s official medical air transport provider. Based at Gran Canaria airport, Aeromedica’s flights are operated by CanaryFly, using a fleet of two Fairchild SA-227 aircraft, one SA-226 and one ATR-42-320. All are equipped with a life support unit, fitted with an oxygen source, compressed air and vacuum system, 12-24-220V electrical supply, Oxylog 3000 emergency ventilator, Zoll M series defibrillator, with 12 lead ECG, external pacemaker, pulse oximetry, capnography and invasive and non-invasive arterial tension monitoring, perfusion pumps, Dräger 5000 transport incubator with pediatric ventilator, circulatory and ventilatory support equipment, immobilisation equipment and material for surgery and traumatology. Most of mainland Spain is comfortably within the SA-227’s range of just over 2,000 kilometres.
Overall, travel insurers, medical service providers and aeromedical operators seem to agree that the Canary Islands scores reasonably highly in terms of emergency medical provision – but that the public sector needs to address problems with long waiting lists and poor organisation, while private hospitals should take a concerted look at potential issues of over-treatment and over-diagnosis.