HEALTH SERVICES AND DELIVERY RESEARCH

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1 HEALTH SERVICES AND DELIVERY RESEARCH VOLUME 2 ISSUE 2 JANUARY 2014 ISSN Impications for the NHS of inward and outward medica tourism: a poicy and economic anaysis using iterature review and mixed-methods approaches Nei Lunt, Richard D Smith, Russe Mannion, Stephen T Green, Mark Exworthy, Johanna Hanefed, Danie Horsfa, Laura Machin and Hannah King DOI /hsdr02020

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3 Impications for the NHS of inward and outward medica tourism: a poicy and economic anaysis using iterature review and mixed-methods approaches Nei Lunt, 1 * Richard D Smith, 2 Russe Mannion, 3 Stephen T Green, 4 Mark Exworthy, 5 Johanna Hanefed, 2 Danie Horsfa, 1 Laura Machin 6 and Hannah King 1 1 Department of Socia Poicy and Socia Work, University of York, York, UK 2 London Schoo of Hygiene and Tropica Medicine, London, UK 3 Heath Services Management Centre, University of Birmingham, Birmingham, UK 4 Sheffied Teaching Hospitas NHS Foundation Trust, Sheffied, UK 5 Schoo of Management, Roya Hooway, University of London, London, UK 6 The York Management Schoo, University of York, York, UK *Corresponding author Decared competing interests of authors: Stephen T Green is a NHS consutant and director of QHA Trent. QHA Trent is a British company deivering accreditation and consutancy services for hospitas and cinics ocated internationay. Pubished January 2014 DOI: /hsdr02020 This report shoud be referenced as foows: Lunt N, Smith RD, Mannion R, Green ST, Exworthy M, Hanefed J, et a. Impications for the NHS of inward and outward medica tourism: a poicy and economic anaysis using iterature review and mixed-methods approaches. Heath Serv Deiv Res 2014;2(2).

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5 Heath Services and Deivery Research ISSN (Print) ISSN (Onine) This journa is a member of and subscribes to the principes of the Committee on Pubication Ethics (COPE) ( Editoria contact: The fu HS&DR archive is freey avaiabe to view onine at Print-on-demand copies can be purchased from the report pages of the NIHR Journas Library website: Criteria for incusion in the Heath Services and Deivery Research journa Reports are pubished in Heath Services and Deivery Research (HS&DR) if (1) they have resuted from work for the HS&DR programme or programmes which preceded the HS&DR programme, and (2) they are of a sufficienty high scientific quaity as assessed by the reviewers and editors. HS&DR programme The Heath Services and Deivery Research (HS&DR) programme, part of the Nationa Institute for Heath Research (NIHR), was estabished to fund a broad range of research. It combines the strengths and contributions of two previous NIHR research programmes: the Heath Services Research (HSR) programme and the Service Deivery and Organisation (SDO) programme, which were merged in January The HS&DR programme aims to produce rigorous and reevant evidence on the quaity, access and organisation of heath services incuding costs and outcomes, as we as research on impementation. The programme wi enhance the strategic focus on research that matters to the NHS and is keen to support ambitious evauative research to improve heath services. For more information about the HS&DR programme pease visit the website: This report The research reported in this issue of the journa was funded by the HS&DR programme or one of its proceeding programmes as project number 09/2001/21. The contractua start date was in November The fina report began editoria review in October 2012 and was accepted for pubication in May The authors have been whoy responsibe for a data coection, anaysis and interpretation, and for writing up their work. The HS&DR editors and production house have tried to ensure the accuracy of the authors report and woud ike to thank the reviewers for their constructive comments on the fina report document. However, they do not accept iabiity for damages or osses arising from materia pubished in this report. This report presents independent research funded by the Nationa Institute for Heath Research (NIHR). The views and opinions expressed by authors in this pubication are those of the authors and do not necessariy refect those of the NHS, the NIHR, NETSCC, the HS&DR programme or the Department of Heath. If there are verbatim quotations incuded in this pubication the views and opinions expressed by the interviewees are those of the interviewees and do not necessariy refect those of the authors, those of the NHS, the NIHR, NETSCC, the HS&DR programme or the Department of Heath. Queen s Printer and Controer of HMSO This work was produced by Lunt et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. Pubished by the NIHR Journas Library ( produced by Prepress Projects Ltd, Perth, Scotand (

6 Heath Services and Deivery Research Editor-in-Chief Professor Ray Fitzpatrick Professor of Pubic Heath and Primary Care, University of Oxford, UK NIHR Journas Library Editor-in-Chief Professor Tom Waey Director, NIHR Evauation, Trias and Studies and Director of the HTA Programme, UK NIHR Journas Library Editors Professor Ken Stein Chair of HTA Editoria Board and Professor of Pubic Heath, University of Exeter Medica Schoo, UK Professor Andree Le May Chair of NIHR Journas Library Editoria Group (EME, HS&DR, PGfAR, PHR journas) Dr Martin Ashton-Key Consutant in Pubic Heath Medicine/Consutant Advisor, NETSCC, UK Professor Matthias Beck Chair in Pubic Sector Management and Subject Leader (Management Group), Queen s University Management Schoo, Queen s University Befast, UK Professor Aieen Carke Professor of Heath Sciences, Warwick Medica Schoo, University of Warwick, UK Dr Tessa Criy Director, Crysta Bue Consuting Ltd, UK Dr Peter Davidson Director of NETSCC, HTA, UK Ms Tara Lamont Scientific Advisor, NETSCC, UK Professor Eaine McCo Director, Newcaste Cinica Trias Unit, Institute of Heath and Society, Newcaste University, UK Professor Wiiam McGuire Professor of Chid Heath, Hu York Medica Schoo, University of York, UK Professor Geoffrey Meads Honorary Professor, Business Schoo, Winchester University and Medica Schoo, University of Warwick, UK Professor Jane Norman Professor of Materna and Feta Heath, University of Edinburgh, UK Professor John Powe Consutant Cinica Adviser, Nationa Institute for Heath and Care Exceence (NICE), UK Professor James Raftery Professor of Heath Technoogy Assessment, Wessex Institute, Facuty of Medicine, University of Southampton, UK Dr Rob Riemsma Reviews Manager, Keijnen Systematic Reviews Ltd, UK Professor Heen Roberts Professoria Research Associate, University Coege London, UK Professor Heen Snooks Professor of Heath Services Research, Institute of Life Science, Coege of Medicine, Swansea University, UK Pease visit the website for a ist of members of the NIHR Journas Library Board: Editoria contact: NIHR Journas Library

7 DOI: /hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 Abstract Impications for the NHS of inward and outward medica tourism: a poicy and economic anaysis using iterature review and mixed-methods approaches Nei Lunt, 1 * Richard D Smith, 2 Russe Mannion, 3 Stephen T Green, 4 Mark Exworthy, 5 Johanna Hanefed, 2 Danie Horsfa, 1 Laura Machin 6 and Hannah King 1 1 Department of Socia Poicy and Socia Work, University of York, York, UK 2 London Schoo of Hygiene and Tropica Medicine, London, UK 3 Heath Services Management Centre, University of Birmingham, Birmingham, UK 4 Sheffied Teaching Hospitas NHS Foundation Trust, Sheffied, UK 5 Schoo of Management, Roya Hooway, University of London, London, UK 6 The York Management Schoo, University of York, York, UK *Corresponding author Background: The study examined the impications of inward and outward fows of private patients for the NHS across a range of speciaties and services. Objectives: To generate a comprehensive documentary review; to better understand information, marketing and advertising practices; examine the magnitude and economic and heath-reated consequences of trave; understand decision-making frames and assessments of risk; understand treatment experience; eicit the perspectives of key stakehoder groups; and map out medica tourism deveopment within the UK. Design and participants: The study integrated poicy anaysis, desk-based work, economic anaysis to estimate preiminary costs, savings and NHS revenue, and treatment case studies. The case studies invoved synthesising data sources around bariatric, fertiity, cosmetic, denta and diaspora exampes. Overa, we drew on a mixed-methods approach of quaitative and quantitative data coection. The study was underpinned by a systematic overview and a ega and poicy review. In-depth interviews were carried out with those representing professiona associations, those with cinica interests and representative bodies (n = 16); businesses and empoyees within medica tourism (n = 18); NHS managers (n = 23); and overseas providers. We spoke to outward medica traveers (46 peope across four treatment case studies: bariatric, fertiity, denta and cosmetic) and aso 31 individuas from UK-resident Somai and Gujarati popuations. Resuts: The study found that the past decade has seen an increase in both inward and outward medica trave. Europe is both a key source of traveers to the UK and a destination for UK residents who trave for medica treatment. Inward trave often invoves either expatriates or peope from nations with historic ties to the UK. The economic impications of medica tourism for the NHS are not uniform. The medica tourism industry is amost entirey unreguated and this has potentia risks for those traveing out of the UK. Existing information regarding medica tourism is variabe and there is no authoritative and trustworthy singe source of information. Those who trave for treatment are a heterogeneous group, with peope of a ages spread across a range of sociodemographic groups. Medica tourists do not appear to inform their decision-making with hard information and consequenty often do not consider a risks. They make use of extensive informa networks such as treatment-based or cutura groups. Motivations to trave are in ine Queen s Printer and Controer of HMSO This work was produced by Lunt et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. v

8 ABSTRACT with the findings of other studies. Notaby, cost is never a soe motivator and often not the primary motivation for seeking treatment abroad. Limitations: One major imitation of the study was the abandonment of a survey of medica tourists. We sought to avoid an extremey sma survey, which offers no rea insight. Instead we redirected our resources to a deeper anaysis of quaitative interviews, which proved remarkaby fruitfu. In a simiar vein, the economic anaysis proved more difficut and time consuming than anticipated. Data were incompete and this inhibited the modeing of some important eements. Concusions: In 2010 at east 63,000 residents of the UK traveed abroad for medica treatment and at east 52,000 residents of foreign countries traveed to the UK for treatment. Inward referra and fows of internationa patients are shaped by cinica networks and ongstanding reationships that are fostered between cinicians within sender countries and their NHS counterparts. Our research demonstrated a range of different modes that providers market and by which patients trave to receive treatment. There are ceary ega uncertainties at the interface of these and cinica provision. Patients are now traveing to further or new markets in medica tourism. Future research shoud: seek to better understand the medium- and ong-term heath and socia outcomes of treatment for those who trave from the UK for medica treatment; generate more robust data that better capture the size and fows of medica trave; seek to better understand inward fows of medica traveers; gather a greater eve of information on patients, incuding their origins, procedures and outcomes, to aow for the deveopment of better economic costing; expore further the issues of cinica reationships and networks; and consider the importance of the NHS brand. Funding: The Nationa Institute for Heath Research Heath Services and Deivery Research programme. vi NIHR Journas Library

9 DOI: /hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 Contents List of tabes...xiii List of figures...xv List of abbreviations.... Scientific summary... Section 1 Background Chapter 1 Introduction Background Research objectives Research streams Stream 1: consumerism and patient decision-making Stream 2: quaity, safety and risk Stream 3: economic impications Stream 4: medica tourism providers and market deveopment Chapter 2 Methods and structure Research approach and methodoogy Preiminary systematic review activity Secondary data anaysis Desk-based activity Interviews Interview process Interview anaysis Case study synthesis Ethics Fiedwork chaenges Changes from protoco The impact of departure from the protoco on findings Report structure Chapter 3 Systematic review: what do we know about medica tourism? Introduction Methods Resuts Types of studies reviewed Geographica focus Issues covered Diaspora trave Fertiity tourism Denta, bariatric and cosmetic tourism Risks Effect on recipient country heath system Industry Trade in heath services: revenue and voume xvii xix Queen s Printer and Controer of HMSO This work was produced by Lunt et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. vii

10 CONTENTS Discussion Types of medica tourism Impact on the NHS: ack of studies focusing on ong-term heath outcomes Concusions Impications for the NHS Chapter 4 The context of medica tourism Services Information Mode 1: faciitator-enabed provision Mode 2: consumer-driven access to information and provision Mode 3: networked access to information and provision Cinica provision Country strategies Impications for the NHS Chapter 5 Mapping patient inward and outward fows Probems with numbers Data from the Internationa Passenger Survey Destination of UK outbound medica traveers Inward medica trave Characteristics Discussion Trends Section 2 Patient safety and service quaity Chapter 6 Lega dimensions of outward medica trave Obtaining persona and provider information Lega redress Impications for the NHS Chapter 7 Education and information Website anaysis of outward medica trave Systematic review: sites promoting commercia denta and weight oss surgery Discussion Anaysis of medica tourism trave information, advice and guidance Impications for the NHS Chapter 8 Externa quaity assessment and quaity information systems The importance of externa quaity assessment for medica tourism Denta surgery externa quaity assessment: an empirica review Bariatric surgery externa quaity assessment: an empirica review Cosmetic surgery externa quaity assessment: an empirica review Quaity information systems Impications for the NHS viii NIHR Journas Library

11 DOI: /hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 Section 3 Treatment group case studies Chapter 9 Common themes within experiences of medica tourism The NHS Motivations for traveing Avaiabiity Cost Expertise Cutura/famiia The medica tourism process Information gathering Booking Traveing abroad Tourism The medica tourism experience Satisfaction and dissatisfaction Support Aftercare Impications for the NHS Chapter 10 Bariatric surgery case study Findings from bariatric surgery patients Motivation for traveing abroad for bariatric surgery: an emerging fied of expertise in the UK Nationa Heath Service Impications for the NHS Chapter 11 Fertiity surgery case study Distinctive features of fertiity tourism Mutipe births Impications for the NHS Chapter 12 Denta surgery case study The distinctiveness of denta tourism An unreguated industry Impications for the NHS Chapter 13 Cosmetic surgery case study Distinctive features of cosmetic tourism The cosmetic tourism industry Risk Impications for the NHS Chapter 14 Diaspora case study Destination Motivation Expertise Cost Information and marketing Language barriers: a key motivation for diaspora trave Treatment experience Impications for the NHS Queen s Printer and Controer of HMSO This work was produced by Lunt et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. ix

12 CONTENTS Section 4 Inward trave, costings and concusions Chapter 15 Internationa patients and associated activities within the NHS Background Size and scope of internationa patient activity Strategic and commercia considerations Referra and treatment pathways Market deveopment Impications for the NHS Chapter 16 The financia vaue associated with medica tourism Income generated by inbound medica traveers Tourism revenue from inbound medica traveers Heath-care revenue from inbound medica traveers The UK private heath-care sector as a destination Costs to the UK NHS resuting from outbound medica trave Fertiity tourism Cosmetic tourism Savings (or not) from outbound medica tourism Bariatric surgery Impications for the NHS Chapter 17 Concusions and research recommendations Patient decision-making Information, guidance and risk The size and economic impact of the medica tourism market The industry: providers and market deveopment The missing ink: patients heath Research agenda Chapter 18 Synopsis Acknowedgements References 127 Appendix 1 The impementation of the EU directive on cross-border heath care: potentia reevance for medica tourism Appendix 2 Protoco Appendix 3 Exampe interview questions Appendix 4 Confidentiaity agreement for transcriber Appendix 5 Research participation information sheet Appendix 6 Consent form Appendix 7 Recruitment networks and cas for information Appendix 8 Advisory group terms of reference and membership x NIHR Journas Library

13 DOI: /hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 Appendix 9 Treatment pathways for medica tourists interviewed as part of the study Appendix 10 Search strategy for systematic review Appendix 11 Preferred Reporting Items for Systematic Reviews and Meta-Anayses fow diagram for iterature review of medica tourism Appendix 12 Resuts of the iterature search Appendix 13 Modes of information and their advantages and disadvantages Appendix 14 Country strategies: case exampes Appendix 15 Line charts iustrating inward and outward medica trave trends from the Internationa Passenger Survey Appendix 16 Fertiity treatment abroad and the wider ega and reguatory compexities Appendix 17 The peris of cosmetic surgery/medica tourism by Laurence Vick Appendix 18 Detaied methods for website review and checkists for denta and bariatric surgery websites Appendix 19 Detaied anaysis of website review data Appendix 20 Anaysis of guidance avaiabe for medica tourism Appendix 21 Background context for externa quaity assessment Appendix 22 Anaysis of externa quaity assessment statements on websites Appendix 23 Interviewee perspectives on patient safety and service quaity Appendix 24 Motivation whees: bariatric, fertiity, denta and cosmetic treatment Appendix 25 Internationa patients and associated activities: background and poicy context Appendix 26 Resuts of freedom of information requests to NHS trusts Queen s Printer and Controer of HMSO This work was produced by Lunt et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. xi

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15 DOI: /hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 List of tabes TABLE 1 Medica tourist sampe 9 TABLE 2 Summary of data coection 13 TABLE 3 Destinations promoted by the websites in the website review 46 TABLE 4 Exampes of sources of avaiabe information, advice and guidance for outward trave 49 TABLE 5 Sources of QIS advice avaiabe in the UK 53 TABLE 6 Medica tourist sampe 58 TABLE 7 Cacuation of additiona spend by incoming medica tourists and their trave companions 107 TABLE 8 Annua cost to the NHS of mutipe births resuting from cross-border reproductive trave 110 TABLE 9 Annua cost to the NHS of compications in returning cosmetic tourists 111 TABLE 10 Resuts of the iterature search 183 TABLE 11 Issues covered in the 100 papers incuded in the review 183 TABLE 12 Industry categories covered in the 100 papers incuded in the review 184 Queen s Printer and Controer of HMSO This work was produced by Lunt et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. xiii

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17 DOI: /hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 List of figures FIGURE 1 Line chart showing the numbers of peope who traveed into or out of the UK for medica treatment during the period FIGURE 2 Pie chart showing tota outward medica trave by UK residents by destination region over the time period FIGURE 3 Map depicting tota numbers of medica traveers from the UK and their destinations over the period FIGURE 4 Map depicting tota numbers of medica traveers to the UK and their countries of origin over the period FIGURE 5 Medica traveers by age 33 FIGURE 6 Medica tourism patient safety and service quaity diamond 37 FIGURE 7 The patient journey 40 FIGURE 8 Motivation whee depicting the reative importance of various motivations in the four treatment case studies 61 FIGURE 9 Number of pubications by year of pubication 184 FIGURE 10 Types of studies incuded in the review 184 FIGURE 11 Geographic focus of studies incuded in the review 185 FIGURE 12 Data sources for patient numbers quoted in studies incuded in the review 185 FIGURE 13 Line charts iustrating the numbers of UK residents who traveed for medica treatment in by destination region 191 FIGURE 14 Line charts iustrating the numbers of peope who are resident outside the UK and who traveed to the UK for medica treatment in by region of origin 192 FIGURE 15 Line charts iustrating the nine most popuar destinations of UK residents who traveed for medica treatment in FIGURE 16 Line charts iustrating the nine most common countries of origin for those who traveed to the UK for medica treatment in Queen s Printer and Controer of HMSO This work was produced by Lunt et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. xv

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19 DOI: /hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 List of abbreviations A&E accident and emergency IPS Internationa Passenger Survey ART ASA BAPRAS assisted reproductive technoogy Advertising Standards Authority British Association of Pastic, Reconstructive and Aesthetic Surgeons ISO ISQau IVF Internationa Organization for Standardization Internationa Society for Quaity in Heathcare in vitro fertiisation BME back and minority ethnic JCI Joint Commission Internationa BMI CBRC CQC EQA EU body mass index cross-border reproductive care Care Quaity Commission externa quaity assessment European Union MHRA NaTHNaC NICE Medicines and Heathcare products Reguatory Agency Nationa Trave Heath Network and Centre Nationa Institute for Heath and Care Exceence FAQ frequenty asked question ONS Office for Nationa Statistics GATS GDC GDP GMC GP HCA HFEA HON Genera Agreement on Trade in Services Genera Denta Counci gross domestic product Genera Medica Counci genera practitioner Hospita Corporation of America Human Fertiisation and Embryoogy Authority Heath on the Net PCT PIP PROM QALY QIS T&I TÜV UCLH primary care trust Poy Impant Prosthèse patient-reported outcome measure quaity-adjusted ife-year quaity information system UK Trade and Investment Technica Inspection Association University Coege London Hospitas NHS Foundation Trust ICSI intracytopasmic sperm injection Queen s Printer and Controer of HMSO This work was produced by Lunt et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. xvii

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21 DOI: /hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 Scientific summary Background Medica tourism is a type of patient or consumer mobiity whereby individuas trave outside their own country of residence with the primary intention of receiving medica (usuay eective surgery) treatment, incurring out-of-pocket and third-party payments. A number of factors have possiby contributed towards a growth in outward medica tourism. These incude improved disposabe incomes, increased wiingness of individuas to trave for heath services, ower-cost air trave and the expansion of internet marketing. However, athough current knowedge of the demand and suppy of wider patient mobiity is growing at European and nationa eves, there are no comprehensive data on inward and outward out-of-pocket and third party-funded fows (incuding government-sponsored), and their heath and economic impact for the NHS. This study was particuary timey given the current goba financia context and the ikey impications for heath expenditure and nationa heath budgets. The study examined the impications of such outward fows for the NHS across a range of speciaties and services incuding dentistry, bariatric surgery, fertiity services and cosmetic surgery. The study excuded state-funded cross-border care avaiabe under the European Union (EU) directive. The study aso focused on inward fows of internationa patients being treated within NHS private faciities. It focused on booked and panned treatments for which trusts had expectations of reimbursement (with pre-payment or a etter of guarantee from an embassy or insurer). Objectives To address the gap in knowedge we examined four inter-reated themes: patient decision-making; quaity, safety and risk (incuding in the cinica context); economic impications; and provider and market deveopment. The study objectives were to: generate a comprehensive documentary review of (1) reevant poicy and egisation and (2) professiona guidance and ega frameworks governing inward and outward fows better understand information, marketing and advertising practices, within both the UK and provider countries of Europe and beyond examine the magnitude and economic and direct heath-reated consequences of inward and outward medica tourism for the NHS understand how decision-making frames, assessments of risk and associated factors shape heath treatments for patients, incuding how prospective medica tourists assess provider reputation and risk better understand treatment experience, continuity of care and postoperative recovery for inward and outward fows of patients eicit the views and perspectives of professionas and key stakehoder groups and organisations with an interest in medica tourism map out medica tourism deveopment within the UK and assess the ikey future significance for the NHS. Queen s Printer and Controer of HMSO This work was produced by Lunt et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. xix

22 SCIENTIFIC SUMMARY Methods The study integrated poicy anaysis, desk-based work, economic anaysis and treatment case studies and drew on a mixed-methods approach of quaitative and quantitative data coection. The study was underpinned by a systematic overview of previousy pubished iterature on medica tourism and a ega and poicy review. Data provided by the Internationa Passenger Survey (IPS) and foundation trusts responses to freedom of information requests were anaysed to understand patient fows and their financia consequences. Desk-based activity incuded a review of websites to assess information quaity, understand information, advice and guidance and examine quaity and safety accreditation. We undertook in-depth interviews with key stakehoders incuding those representing a range of professiona associations, cinica interests and representative bodies (n = 16); businesses and empoyees within medica tourism (n = 18); individua managers within primary care trusts (PCTs) and foundation trusts (n = 23); and overseas providers. We spoke to outward medica traveers a tota of 46 peope across four treatment case studies (bariatric, fertiity, denta and cosmetic) and our other treatment categories. We aso spoke with 31 individuas from UK-resident Somai and Gujarati popuations. Patient decision-making Eigibiity for access to domestic heath-care services is a strong infuence on the decision to seek medica care overseas. Patients are prepared to trave abroad when a treatment is not avaiabe within the NHS, when they do not meet strict eigibiity requirements or when they have exhausted their entitement [such as in vitro fertiisation (IVF) treatment episodes]. Individuas choose to pay for treatment abroad rather than domesticay primariy for reasons of cost, but the perceived expertise of cinicians overseas and famiy or cutura connections with overseas destinations are aso contributing factors. We identify an emerging trend for patients to trave beyond Europe for treatment, but aso the key roe of diaspora networks and reations in shaping the favoured trave destinations of medica tourists. Information, guidance and risk Decision-making around outward medica trave invoves a range of information sources; the internet pays a key roe in addition to information from informa networks of friends and peers. It woud appear that medica tourists often pay more attention to soft information than hard cinica information, and there is itte effective reguation of information, be it hard or soft, onine or overseas. Because prospective traveers source information from intermediaries, direct from websites and internet marketing, and among networks, it compicates practica attempts to improve the quaity of information provided to medica tourists. A broad range of advice, information and guidance exists for prospective traveers, incuding the NHS Choices website (see and information deveoped by the Nationa Trave Heath Network and Centre (NaTHNaC) (see org/trave/misc/medicatourism_ htm). Athough potentiay vauabe, the onus is on prospective medica tourists to seek out such information; presenty there is itte evidence that they routiney do this. There is ceary scope for heath-care professionas within the NHS to become part of the networks of information and support that can be accessed by potentia medica tourists. It is apparent that patients do not fuy understand the scae and nature of risk associated with seeking treatment overseas, incuding the difficuties reating to redress when something goes wrong. xx NIHR Journas Library

23 DOI: /hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 The wide range of cinica, anciary and support services invoved in medica tourism compicates efforts to inform and educate medica tourists, or to reguate aspects of the industry. It is cear that, across many websites of faciitators, cinics and hospitas, treatment risks are underpayed. Athough there has been a recent proiferation of systems of externa quaity assurance and audit, these (aong with the registration detais dispayed on websites) do not aways make for better-informed patients. Beyond generic trave advice for medica tourists, the need for cearer guidance on bariatric surgery, or for patients considering bariatric surgery, is evident. For fertiity, the situation is particuary compex. UK egisation is geared towards reducing the ikeihood of mutipe births, in particuar governing the number of embryos that can be transferred, but such egisation varies cross-nationay. Furthermore, uncear reguatory frameworks overseas mean that patient data may not aways be hed in the detai expected within the NHS. When diaspora trave occurs, we have seen that many of the issues outined here can be further compounded and compicated by wider misunderstandings and often unreaistic cuturay rooted expectations about a wide range of issues reated to NHS care. The size and economic impact of the medica tourism market Individuas traveing for medica treatment are often i-informed or underinformed and this heightens the risks associated with medica trave. The most robust data avaiabe ceary show that this affects many UK residents. Athough the imitations of the IPS mean that we cannot banish a uncertainty that surrounds market estimates, the data show that in 2010 at east 63,000 residents of the UK traveed abroad for medica treatment, and at east 52,000 residents of foreign countries traveed to the UK for treatment. These are ikey to be conservative estimates, but even these numbers underscore that medica tourism is a very rea phenomenon. Inward referra and fows of internationa patients are shaped by cinica networks and ongstanding reationships that are fostered between cinicians within sender countries and their NHS counterparts; in this sense they may be different to outward fows. Those traveing to the UK for treatment as NHS internationa patients are more ikey to receive compex and expensive treatment underwritten by their nationa governments a sharp contrast with outward medica trave from the UK. Despite important caveats, our cacuations show that there are costs and benefits for the UK economy and the NHS resuting from inward and outward medica trave. Our estimates show that inward medica traveers and their companions contribute in the region of 219M pounds to the UK economy in additiona tourism spends per annum. We aso found spending on medica treatment in the range of M. Together this amounts to between 397M and 544M per annum. In addition, our research reveaed costs and savings resuting from UK residents traveing abroad to seek treatment. When compications occur and these are deat with by the NHS, or when surgery undertaken wi require ifeong maintenance, this represents additiona expenditure for the NHS. Athough the actua current costs of such compications seem comparativey sma at the moment [e.g. when an infection foowing cosmetic surgery requires a genera practitioner (GP) visit and a course of antibiotics], these can equay be very high (e.g. as a resut of faied bariatric surgery patients needing fu-time care and possiby being, or continuing to be, unabe to work). The costs of corrective surgery and ongoing care can be extremey high. Our research aso demonstrates that, when peope opt to trave abroad to access treatment and this is successfu and they return to work, savings may be substantia to domestic heath and to socia services. Most importanty, if medica trave increases, so wi these costs and savings. Queen s Printer and Controer of HMSO This work was produced by Lunt et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. xxi

24 SCIENTIFIC SUMMARY The industry: providers and market deveopment Our research demonstrated a range of different modes that providers market and by which patients trave to receive treatment. There are ceary ega uncertainties at the interface of these and cinica provision. Modes aso differed by type of medica tourism and cinica procedure for which trave occurred. Patients are now traveing to further or new markets in medica tourism, highighting a deveopment and diversification within the market in medica tourists, with higher-end and ower-end destinations emerging. Internationa patient income generated for NHS trust hospitas, particuary in London, is significant. Athough the anaysis of data on patient fows shows a change in the profie and origin of traveers, from the Midde East towards a greater number of Europeans, this market appears stabe. Many NHS trusts do not aways fuy distinguish between domestic and internationa private income earned. Our research findings ceary underine the power of the brand that arge NHS hospitas have, the extent to which this attracts foreign capita and the potentia for generating further income. In ight of the ifting of the cap on private income, some speciaist providers may wish to market themseves more aggressivey. Given the importance of cinician networks in attracting referras of internationa patients, there are uncertainties about how changes to UK education and training opportunities for non-eu heath-care professionas (because of the EU focus and visa restrictions) wi change the shape and dynamics of internationa networks and inkages, thereby impacting on referras over the medium to ong term. The missing ink: patients heath Our sampe of patients highights that medica trave is rarey without compications or costs to the individua. Athough some peope have minor or no probems foowing treatment abroad, others face severe heath probems, which in some cases are then exacerbated by an inabiity to ensure continuity of care or obtain patient records to address patient needs. This research did not set out to assess ong-term cinica outcomes of medica tourists. Yet our findings did revea that, athough the scae of the issue may (arguaby) not yet be overwheming, the effect on individua patients can in some cases be catastrophic. Impications for practice Our research has a number of possibe impications for practice: Information and advice avaiabe to potentia medica tourists shoud highight the ack of a cear framework for redress in many countries shoud compications arise from treatment abroad. Potentia traveers shoud be made fuy aware of current NHS eigibiity and commissioning rues, and costs for which patients may be personay iabe, incuding non-emergency care to rectify any poor outcomes of treatments received overseas. Information for potentia medica tourists needs to be packaged and disseminated in such a way that it wi reach prospective medica tourists, who may not consut their GP, or indeed a speciaist website, before traveing. GPs need support and training to enabe them to advise patients not ony on the broad consequences of medica tourism but aso on the impications of specific forms of treatment that may present particuar concerns. Specific attention is needed to ensure that information is provided in a manner accessibe to a; this incudes taiored information to ethnic or inguistic minorities. It is important that a fee that they can trust the information that is provided. xxii NIHR Journas Library

25 DOI: /hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 Separatey recorded private income from domestic and internationa sources wi enabe trusts to have a more accurate picture of their income. This wi aso provide a more accurate picture of inward medica fows and aow for better panning and decision-making in this area. Future research Seek to better understand the medium- and ong-term heath and socia outcomes of treatment for those who trave from the UK for medica treatment. Specificay, comparative research is needed with patients undergoing simiar treatment within the UK. This wi enabe a direct comparison of the costs and benefits of domestic treatment and treatment abroad. Furthermore, a greater understanding of the cinica outcomes of medica traveers that extends beyond the short term wi enabe a more robust and nuanced understanding of the costs to the NHS of outward medica tourism. Generate more robust data that better capture the amount of internationa patient activity and fows of medica trave. This is needed to provide a deeper understanding of why UK residents seek treatment abroad. Such data shoud aso incude sociodemographic data as we as information about what procedures patients are traveing for, to better understand patient motivation for trave. Better understand inward fows of medica traveers. This incudes data on where patients trave to, the procedures they use, the cost of these and their sources of funding. Gather a greater eve of information on patients, incuding their origins, procedures and outcomes, to aow for the deveopment of better economic costing. This coud incude costs and revenue experienced by the NHS as we as the wider economic and socia costs and benefits, which may be both pubic and private. Expore further the issues of cinica reationships and networks. Our research suggests that cinica reationships and networks expain the dynamics and patterns of internationa patient referras into the NHS. Consider the importance of the NHS brand. Recent poicy initiatives are promoting the notion of a NHS brand. Research to expore this brand perception internationay woud aow better communication and targeting of activities. Funding The Nationa Institute for Heath Research Heath Services and Deivery Research programme. Queen s Printer and Controer of HMSO This work was produced by Lunt et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. xxiii

26

27 DOI: /hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 Section 1 Background Queen s Printer and Controer of HMSO This work was produced by Lunt et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. 1

28

29 DOI: /hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 Chapter 1 Introduction This study expores the roe and impact of medica tourism, defined here as trave by patients to non-oca providers incurring out-of-pocket and third-party payments for medica treatments but excuding state-funded cross-border care avaiabe under the European Union (EU) directive. 1 Our focus is on both inward and outward fows of medica tourists seeking treatments to and from the UK. The study examines the impications of medica tourism for the NHS across a range of speciaties and services incuding dentistry, bariatric surgery, fertiity services and cosmetic surgery. The mutidiscipinary research team worked across four anaytica streams of activity to examine: consumerism and patient decision-making quaity, safety and risk (incuding in the cinica context) economic impications medica tourism provider and market deveopment. Beyond anecdota reports and media specuation, reativey itte is known about the impications for the NHS of inward or outward out-of-pocket medica tourism. This is despite an estimated 50,000 UK patients traveing overseas for treatment annuay 2 and significant numbers of overseas patients using UK NHS private and independent sector faciities. The study sought to understand these fows in greater detai and to expore the opportunities and risks. The study provides insights for NHS poicy-makers, managers, reguators, commissioners, providers, cinicians and consumer interest groups. The study contributes to a better understanding of macro and oca factors: costs; quaity and safety; administrative and ega dimensions; decision-making; and unintended and unforeseen consequences for the NHS of inward and outward medica tourists. Background The impact of gobaisation in heath and heath care has paraeed emerging trends towards increased reiance on individuaised heath-care provision and consumer -ed access to heath-reated information. Wider system deveopments incude the growth of the cross-border suppy of heath-reated goods and services, greater overseas investment in domestic provision and increased movement of professionas and heath providers, as we as trends towards consumption of heath care abroad and discounted trave incentives incuded as part of medica assessment and treatment packages. 3 8 One increasingy popuar form of consumer expenditure is what has become commony known as medica tourism, a type of patient or consumer mobiity in which individuas trave outside their country of residence for the consumption of heath-care services abroad. 9 Medica tourism takes pace when individuas opt to trave overseas with the primary intention of receiving medica (usuay eective surgery) treatment. These journeys may be ong distance and intercontinenta, for exampe from Europe and North America to Asia, and cover a range of treatments incuding denta care, cosmetic surgery, bariatric surgery and fertiity treatment Some specuate that medica tourism is a US$60B industry internationay. 13 A medica tourist may be defined in two ways depending on the type of heath system and how it is funded. First, there are medica tourists who can be categorised as consumers because they use purchasing power expressed through the market to access a range of denta, cosmetic and eective medica treatment. There are reated questions about access to insurance, the portabiity of insurance and whether or not vountary insurance systems extend to the choice of overseas services. Within the USA, for exampe, severa domestic private insurers have ooked towards purchasing services overseas. In addition, there are increasing numbers of underinsured consumers who need to pay out of pocket for treatments Queen s Printer and Controer of HMSO This work was produced by Lunt et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. 3

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