HEALTH SERVICES AND DELIVERY RESEARCH

HEALTH SERVICES AND DELIVERY RESEARCH VOLUME 2 ISSUE 2 JANUARY 2014 ISSN 2050-4349 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 10.3310/hsdr02020

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: 10.3310/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).

Heath Services and Deivery Research ISSN 2050-4349 (Print) ISSN 2050-4357 (Onine) This journa is a member of and subscribes to the principes of the Committee on Pubication Ethics (COPE) (www.pubicationethics.org/). Editoria contact: nihredit@southampton.ac.uk The fu HS&DR archive is freey avaiabe to view onine at www.journasibrary.nihr.ac.uk/hsdr. Print-on-demand copies can be purchased from the report pages of the NIHR Journas Library website: www.journasibrary.nihr.ac.uk 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 2012. 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: www.netscc.ac.uk/hsdr/ 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 2010. The fina report began editoria review in October 2012 and was accepted for pubication in May 2013. 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 2014. 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 (www.journasibrary.nihr.ac.uk), produced by Prepress Projects Ltd, Perth, Scotand (www.prepress-projects.co.uk).

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: www.journasibrary.nihr.ac.uk/about/editors Editoria contact: nihredit@southampton.ac.uk NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/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 2014. 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

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 www.journasibrary.nihr.ac.uk

DOI: 10.3310/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 1 3 3 5 5 5 5 6 6 7 7 7 7 7 7 9 10 10 11 11 12 12 12 15 15 15 16 16 16 16 17 17 17 18 18 18 19 Queen s Printer and Controer of HMSO 2014. 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

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 19 20 20 20 21 23 23 24 24 24 24 25 25 26 27 27 28 29 31 31 33 34 37 39 39 41 43 45 45 46 47 48 49 51 51 51 52 52 52 53 viii NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/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 55 57 57 59 59 60 60 61 61 62 63 63 64 64 64 66 66 67 69 69 69 72 73 75 75 79 79 81 81 83 84 85 85 85 86 87 89 89 90 90 91 91 92 93 93 Queen s Printer and Controer of HMSO 2014. 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

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 95 97 97 97 98 100 102 104 105 106 106 106 108 109 109 111 112 112 113 115 115 115 117 118 119 119 121 125 127 143 147 159 163 165 167 169 171 x NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/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 2000 10 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 2012 175 179 181 183 187 189 191 195 197 203 207 209 211 215 221 227 229 233 Queen s Printer and Controer of HMSO 2014. 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

DOI: 10.3310/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 2014. 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

DOI: 10.3310/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 2000 10 28 FIGURE 2 Pie chart showing tota outward medica trave by UK residents by destination region over the time period 2000 10 29 FIGURE 3 Map depicting tota numbers of medica traveers from the UK and their destinations over the period 2000 10 30 FIGURE 4 Map depicting tota numbers of medica traveers to the UK and their countries of origin over the period 2000 10 32 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 2000 10 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 2000 10 by region of origin 192 FIGURE 15 Line charts iustrating the nine most popuar destinations of UK residents who traveed for medica treatment in 2000 10 193 FIGURE 16 Line charts iustrating the nine most common countries of origin for those who traveed to the UK for medica treatment in 2000 10 194 Queen s Printer and Controer of HMSO 2014. 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

DOI: 10.3310/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 2014. 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

DOI: 10.3310/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 2014. 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

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 www.nhs.uk/ivewe/treatmentabroad/pages/questionsandanswers.aspx) and information deveoped by the Nationa Trave Heath Network and Centre (NaTHNaC) (see www.nathnac. org/trave/misc/medicatourism_010911.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 www.journasibrary.nihr.ac.uk

DOI: 10.3310/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 178 325M. 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 2014. 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

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 www.journasibrary.nihr.ac.uk

DOI: 10.3310/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 2014. 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

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 Section 1 Background Queen s Printer and Controer of HMSO 2014. 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

DOI: 10.3310/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. 10 12 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. 14 17 Queen s Printer and Controer of HMSO 2014. 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

INTRODUCTION Second, at a European eve, medica tourism may invove exercising citizenship rights to receive medica treatment in another EU member state (better known as cross-border care) and request their nationa purchaser to reimburse the cost of treatment (see European Court of Justice judgments 18 20 ). The European Pariament and the Counci of Ministers formay adopted the patients rights to cross-border heath care directive 1 in March 2011 in an attempt to codify deveopment and carify the situation for EU citizens (see Appendix 1). However, athough current knowedge of the demand and suppy of cross-border heath care is growing at European and nationa eves, 21 24 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. 8 This study therefore contributes to further understanding of patient mobiity and its impications for the NHS. 7,25,26 The study was particuary timey given the current goba financia context and the ikey impications for heath expenditure and nationa heath budgets, 27,28 and aso attempts to encourage NHS institutions to be more outward ooking through the aunch of NHS Goba in 2010: 29 Whie there are aready strong exampes of NHS Trusts and organisations successfuy sharing their ideas and products abroad, we want to create a more systematic approach to this work, and in doing so bring benefits back to the NHS and the UK taxpayer... It is now more important than ever to maximise the internationa potentia of the NHS. NHS foundation trusts wi aso have more opportunity to undertake internationa activities shoud they wish to, incuding treating internationa patients (as inward medica traveers are known). Under the 2012 Heath and Socia Care Act 30 the pre-existing cap on non-nhs income, which varied across foundation trusts, was increased. This aowed a foundation trusts to earn 49% of income from non-nhs work, incuding internationa patient activity within private activities (in force from 1 October 2012). How the increase in private activity impacts on the NHS and its patients is not cear and is dependent on whether or not the particuar foundation trust is operating cose to capacity and whether additiona capacity is generated to treat private patients or existing capacity is used. 31 NHS patients may receive benefits if new or enhanced faciities are shared between private and NHS patients. However, if private patients are of greater priority there wi a things unchanged be a growth in waiting ists and waiting times for NHS patients (Section B155 B156). 31 There is currenty no evidence to judge whether or not this wi be the case. A number of factors have possiby contributed towards the 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 which is a major patform of information for those seeking and providing such treatments. Why do patients choose to trave overseas for treatments when evidence suggests that most patients prefer to be treated coser to home? 32,33 Before this research was conducted, purported reasons to trave were said to incude cost (e.g. dentistry), avaiabiity of treatment, privacy, perceived quaity and for the purposes of combining treatment with an overseas vacation (especiay for diaspora popuations). For instance, UK patients may have to wait to meet NHS criteria on age or circumstance before being offered some treatments, or may be ineigibe according to the current criteria [e.g. in vitro fertiisation (IVF), gender reassignment surgery, rena transpantation], and private treatment in the UK may be costy and not offer the range of preferred techniques and technoogy. Conversey, the reputation of private providers in the UK, and the perceived or actua quaity of care in many countries, mean that in some areas of medica activity there is a desire for foreign nationas to seek treatment in the UK. Having competed the project, the evidence about decision-making and drivers is now on a far firmer footing. Currenty, medica tourism for the UK is imited to the private, out-of-pocket sector. However, there are important impications for a pubicy funded and provided system such as the NHS. For instance, there may be a range of beneficia and detrimenta consequences, such as cost savings from those vountariy seeking care abroad, costs of foow-up care for those who have been treated overseas, and costs and benefits 4 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 associated with patients traveing into the UK for paid treatments. There wi aso be a range of associated heath impacts. Research objectives Media reports and specuation notwithstanding, we knew itte about the historica and ikey future deveopment and impact of medica tourism for the UK NHS. The objectives of our study 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 of medica tourists to and from the UK better understand the information, marketing and advertising practices used in medica tourism, within both the UK and provider countries of Europe and beyond (and the benefits and drawbacks of them) 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) and to coate evidence on the roe of intermediaries and brokers in faciitating medica tourism 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 a egitimate interest in medica tourism (exporing patient and professiona choice, benefit, safety, harm and iabiity) map out the medica tourism industry and chart its deveopment within the UK and assess the ikey future significance for the NHS. Research streams A preiminary scope of the iterature and practica issues identified four streams of evidence that woud inform a better understanding of medica tourism and advise poicy-makers on strategies to capitaise on its benefits and minimise risks it may present: Stream 1: consumerism and patient decision-making We knew itte about how patients made their decisions concerning treatments and destinations and what forms of hard inteigence (performance measures, quaity markers, safety information) and soft inteigence (website information, friends, internet chat rooms) they use. What roe do networks pay in decision-making? How informed are patients when making their choices? 34 Are factors that encourage cross-border exchanges (incuding type of care, reputation of provider, urgency of treatment, gender, age, ocation and socioeconomic status of patient) (e.g. reference 21) simiar to those that shape out-of-pocket exchanges? What is the roe of genera practitioners (GPs) and web-based resources in encouraging or discouraging UK residents considering undertaking medica tourist treatments? Stream 2: quaity, safety and risk Modern heath care is an inherenty risky undertaking with the potentia for cinica errors and medica incompetence and mapractice, particuary in treatment areas that are not reguated by nationa aws and guideines. How do patients understand the eements of risk invoved in undertaking treatment overseas? There are aso potentia ethica, ega and insurance issues, which can infuence the patient decisionmaking procedure. Research was needed to coect evidence on the experiences and outcomes of treatment abroad (benefits, satisfaction, unintended and dysfunctiona cinica consequences). The importance of communication between professionas and aftercare, privacy and confidentiaity vis-à-vis information sharing, the use of information technoogy (IT) information by professionas, and how patient Queen s Printer and Controer of HMSO 2014. 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. 5

INTRODUCTION information fows are a important areas in which data are needed. What attempts are being made to reguate the industries by nationa governments or organisations themseves? What is the use of independent internationa heath-care accreditation in European settings, such as that provided by Joint Commission Internationa (JCI)? Stream 3: economic impications What are the economic impications of medica tourism for the UK NHS? There are no routiney coected data concerning inward and outward fows of medica tourists to and from the UK; however, we sought to expore what information existed [within the Internationa Passenger Survey (IPS) and within foundation trusts themseves] and to examine the impications of such data. Stream 4: medica tourism providers and market deveopment There has been a steady rise in the number of companies and consutancies offering brokerage arrangements for services and providing web-based information for prospective patients about avaiabe services and choices. This can be attributed to the transaction costs associated with medica tourism, which patients woud want to reduce. Typicay brokers and their websites taior surgica packages to individua requirements: fights, treatment, hote and recuperation. Some brokers or concierges offer medica screening. A series of inter-reated questions arose with regard to the precise roe of brokers and intermediaries in arranging overseas surgery. How do organisations determine their market? How do medica tourism faciitators source information, seect providers and subsequenty determine the most appropriate advice? Further, what are the reationships between cinica providers and such intermediaries? What are the impications of the majority of medica tourism websites being commerciay driven and intermediaries reying on advertising revenues and commission? 6 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 Chapter 2 Methods and structure Research approach and methodoogy The study invoved integrating poicy anaysis, desk-based work, economic anaysis and treatment case studies. We used a mixed-method approach of quaitative and quantitative data coection and the study incuded both primary and secondary data coection/anaysis. Activity comprised a preiminary systematic review and broad data coection to address the four research streams. In this chapter we focus on the broad methodoogy, outining why a number of data sources were required to understand medica tourism, and the chaenges of impementing a project of this nature (see Appendix 2 for the study protoco). The research conducted for this project has been ambitious in that it was trying to estabish the eve of current evidence and knowedge in an area in which robust routine data are acking. This required innovative approaches, incuding in the recruitment of patients but aso in obtaining data on inward medica tourism through freedom of information requests. Specific issues with regard to the research process and sampe sizes are addressed in this chapter. The entire research project adopted an iterative approach, with authors reguary reviewing methods for data coection. Data coected were trianguated with other sources to ensure that findings presented are an accurate refection of the data. The NHS fiedwork was undertaken in the Engish NHS [with primary care trusts (PCTs) and foundation trusts] athough the medica tourists that we interviewed were ocated UK-wide (incuding Waes, Scotand and Northern Ireand). The IPS data reate to the UK whereas our trust data for economic costs reate to Engand. A number of the broader issues regarding outward medica trave and patient decision-making, safety and experience are common to the wider UK popuation but there are differences between how the Engish NHS and non-engish NHS are organised (e.g. with regard to foundation trust status and commissioner/provider reationships). The poicy directions on potentiay expanding private care and the directive on NHS Goba do not extend outside of the Engish NHS. Preiminary systematic review activity The study was underpinned by a systematic overview [based on NHS Centre for Reviews and Dissemination (CRD) guideines for systematic review 35 ] of previousy pubished iterature on medica tourism (reported fuy in Chapter 3). Athough the research project overa drew on grey iterature and industry surveys to trianguate findings when required (and as specified), the systematic review focused on pubished iterature. This was to ensure the robustness of findings and to retain feasibiity, given the overwheming quantity of data pubished on the subject. Secondary data anaysis Data provided by the IPS and foundation trusts responses to freedom of information requests were anaysed to understand patient fows and their financia consequences. Desk-based activity Desk-based activity was undertaken to coect both primary and secondary data around patient safety and service quaity ega dimensions, education and information, externa quaity assessment (EQA) and quaity information systems (QISs). The methods and resuts are reported fuy in Chapters 6 8. Interviews We undertook in-depth interviews with a range of key stakehoders and interests invoved with medica tourism (n = 134 pus 23 overseas providers) between March 2011 and August 2012. A interview schedues are provided in Appendix 3. Interviews were conducted with the foowing groups. Queen s Printer and Controer of HMSO 2014. 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. 7

METHODS AND STRUCTURE Professiona associations and stakehoders Individuas representing a range of professiona associations, cinica interests and representative bodies were interviewed. This ranged from the Roya Coeges to bodies concerned with quaity contro and those representing nurses and doctors. Overa, we interviewed 16 individuas across this range of interests, incuding from ega, cosmetic, denta, fertiity, primary care and trave heath services. The project team drew up a ist of key interests and individuas and discussed their coverage. Individuas were invited to be interviewed, either in a persona capacity or as spokespeope of their cinica speciaty or organisation. There was aso an eement of further snowba recruitment. Interviewees were typicay interviewed face to face; interviews asted for between 30 and 60 minutes and were recorded and transcribed. Medica tourism businesses and empoyees Individuas representing the perspectives of businesses and empoyees within medica tourism (incuding faciitators, website operators, insurance providers, private fertiity counseors) were interviewed. The project team drew up a ist of key interests and undertook a review of recent conference speakers, iterature and websites to identify medica trave interest. The recruitment net was cast widey and we sought to understand the wider dynamics, drivers and aspirations of the individuas and companies. Overa, we interviewed 18 individuas across this range of interests, incuding from ega, cosmetic, denta, fertiity and trave heath services. Individuas were interviewed over the teephone or using Skype (Skype Ltd, Rives de Causen, Luxembourg), athough a number were aso interviewed at trade fairs and conventions. There was aso an eement of further snowba recruitment. Interviews asted for between 20 and 60 minutes and were recorded and transcribed. NHS managers We sought to interview individua managers within PCTs and foundation trusts who coud iuminate our understanding of the inward and outward fows of patients and the impact of such fows on the NHS. An eement of snowba and convenience recruitment was used. To access individuas with commissioning insights, the study was pubicised by istservs to those with commissioning knowedge and interest in overseas/cross-border patients. Individuas who had attended a cross-border heath-care seminar at which the research team was present were aso contacted. The NHS Confederation circuated our ca for interviewees to members and, of our 23 NHS interviewees, six hed commissioning roes. For NHS providers, we identified trusts that were seen to have a ongstanding interest in, or aspiration to further deveop, internationa patient work. There is a strong network of interests (particuary around London) focused on private and internationa services by the NHS; individuas were approached to participate. Interviews were conducted face to face and asted for 25 60 minutes. Interviews were usuay recorded and transcribed. The NHS Confederation circuated our ca for interviewees to members. We interviewed 13 NHS providers, which aong with the six commissioners and four reevant practitioners, gave us a tota sampe of 23 NHS interviewees. Patient interviews A tota of 46 peope were categorised to our medica tourist and diaspora sampes across four treatment case studies and other treatment categories. In addition to these respondents, we aso spoke to a tota of 31 individuas as part of our diaspora category (Tabe 1). Not a of these individuas provided interviews, instead opting to take part in a more communa discussion appropriate to the cutura dynamics of the group. Our core sampe of 46 medica tourists was sourced through a variety of means. In the first instance we posted a ca for interviewees on our medica tourism project website as we as triaing an advert in a oca newspaper. The advert was unsuccessfu and over the 18 months of the project our onine contact form yieded four responses. We came to increasingy rey on posts made to onine support or information forums. This proved particuary successfu, especiay in terms of our bariatric and fertiity sampes 8 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 TABLE 1 Medica tourist sampe Treatment type Number of respondents Procedures covered Locations of treatment Fertiity 9 IVF, intracytopasmic sperm injection, egg donation, sperm donation Bariatric 11 Gastric band, gastric bypass, gastric wrap, gastric seeve, duodena switch, pancreatic diversion and duodena bridge Denta 11 Crowns, bridges, routine work and check-ups, fiings, braces, denta pates, impants Cosmetic 9 Faceift, iposuction, tummy tuck, minima access crania suspension faceift, nose, face and eyes Other 6 Nerve surgery, gynaecoogy, utrasound, immunotherapy, shouder stabiisation, neede for Dupuytren's contracture Czech Repubic, Ukraine, Sweden, Spain, Cyprus Begium, France, Czech Repubic Hungary, Germany, Croatia, India, Poand, Itay, Lithuania Begium, Poand, Czech Repubic, Pakistan France, Greece, Begium, Germany, USA Diaspora 31 Diagnostic, denta Germany, India (Appendix 7 detais the range of sites and networks that we utiised for recruitment). In some cases we made contact with those whose stories had been reported esewhere, for exampe in media pubications or as patient testimonias. A sampe of 46 is ceary not a representative sampe, athough the team attempted to source a wide range of trave experiences, incuding major and more minor procedures, a range of treatments and those who perceived themseves as having good and ess successfu outcomes. Attracting respondents proved extremey difficut, especiay the denta sampe as there appeared to be no onine community. Our diaspora sampe consists of individuas from three community groups (two urban Somai groups and one Gujarati group). Access to these groups invoved the support of individuas who acted as informa gatekeepers to the communities, often organising meetings with interviewees, a ocation in which to meet and, in some instances, interpreters. Individuas were approached to participate and interviews were conducted face to face or, when a preference was expressed, by teephone and Skype. Interviews asted for between 30 and 100 minutes and were recorded and transcribed. The interviews expored a range of dimensions incuding drivers, decision-making, treatment experience and postoperative care. They aso asked about the costs that were incurred during trave abroad, incuding for treatment, accommodation, insurance, recuperation and aftercare. Overseas providers A tota of 23 peope were interviewed regarding overseas provision. Here, a range of recruitment and interview techniques was adopted. We undertook five fu interviews by teephone and face to face, but aso used opportunities at trade shows and conferences in the UK and Europe to meet and tak with overseas providers, taking fied notes. These contacts and discussions went far beyond our initia expectation of 10 providers. Interview process As aready described the recruitment of patients evoved and we revised the recruitment strategy severa times. The different kinds of treatments that formed the basis for the case studies deveoped in the anaysis were informed by findings from the initia systematic review of the iterature. This identified Queen s Printer and Controer of HMSO 2014. 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. 9

METHODS AND STRUCTURE bariatric, fertiity, denta and cosmetic treatment and diaspora trave as types of procedures for which patients trave to receive treatment. Initiay, we had anticipated hip and heart patients as a further group of patients traveing for higher-risk and higher-cost procedures but, athough these were targeted in our initia recruitment strategy, they proved much harder to identify. This is a ikey refection of the project s UK focus as patients resident in the UK are unikey to trave for high-cost and compex procedures given that these are avaiabe for free on the NHS. This is opposite to the case in the USA where patients may fee more compeed to trave for treatment for compex procedures given the high costs and much arger associated savings. We made a conscious effort to interview simiar numbers of patients across the different groups to maintain a baance within the findings across different treatment types and ensure that the findings can refect on medica tourism overa, rather than specific conditions. Attempts to identify specificities and commonaities across treatment conditions aso informed the anaysis process described beow. Athough the number of interviews gathered was in part determined by constraints in timing and chaenges faced in recruitment, especiay of patients, we stopped the interviewing process ony once a saturation point was reached and no new themes were emerging from the interviews. Athough the sampe is not representative of a medica tourists, cear commonaities in motivation and experiences of patients emerged across the sampe of interviews. Interview anaysis Both quantitative and quaitative data anaysis invoves the common steps of data reduction (and data ceaning), data organisation and data interpretation. The study interview data were anaysed using the framework method of thematic anaysis. 36,37 This aowed a search for conceptua definitions, typoogies, cassifications, form and nature (process, system, attitudes, behaviours) and expanations. 38 The study had cear research streams and specific questions that it sought to expore. We examined the data for particuar outiers, searching for negative or disconfirming evidence that appeared to be inconsistent with the emerging anaysis. When consent was provided, a interviews were recorded and transcribed (see transcriber confidentiaity agreement in Appendix 4). Transcripts were reviewed by four authors undertaking primary data coection and anaysis (NL, DH, HK, JH). Interviews were grouped into categories defined in the study framework (e.g. professiona associations or patients.). Patient interviews were further grouped into the foowing categories: bariatric, cosmetic, fertiity, denta, diaspora and other tourism. Authors read a transcripts and met to generate initia themes for the anaysis. Themes were specific to groups of transcripts, for exampe themes for the anaysis of fertiity tourists differed from those used for professiona associations. Once themes were agreed, one author took the ead on thematic anaysis of the specific group of interviews and drafting of texts. These were then cross-checked by a second author to ensure accuracy and avoid bias. As a fina step, competed drafts of the texts were reviewed and commented on by a authors. Given the highy sensitive nature of the patient and provider data, we endeavoured to ensure the confidentiaity and anonymity of individuas and organisations when reporting the findings. Case study synthesis The research design incuded treatment case studies that woud aow the team to synthesise findings across the range of data sources (quaitative and, when possibe, quantitative) and to draw together primary and secondary knowedge. Five case studies were deveoped: bariatric, fertiity, denta, cosmetic 10 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 and diaspora (see Section 3). Case study seection was informed by the review of the iterature, which indicated that these areas were ikey to be of vaue in understanding medica trave. This method aows a better understanding of the varying speciaties within medica tourism and the dynamics of patient consumer decision-making, risk-taking, and quaity and safety of particuar treatments. Mutipe case study anaysis aso provides insight over and above that of individua case studies and has advantages over simpy seeing the whoe data set in the round. 39 Each case comprises around 10 interviews with patients to iuminate decision-making processes and treatment experiences (e.g. dentistry or bariatric). Cases incuded quantitative data anaysis where possibe, based on descriptive statistics covering aspects such as expenses incurred. Case studies aso introduced anaysis of reevant website and print advice (commercia and professiona sources) for that particuar speciaism. The case studies drew on interview data from industry and cinica interests with a view to assessing current and emerging deveopments. The case studies heped faciitate understanding of aspects of medica tourism that were treatment specific and those that were common across different types of treatment. This proved particuary vauabe for the anaysis of patient motivation and in the costing work. It aso heped vaidate the data. Ethics We sought NHS ethica approva to interview representatives of NHS purchaser and provider organisations in the ocaities seected (managers and non-cinicians within PCT or foundation trust settings). The fu ethics appication Impications for the NHS of inward and outward medica tourism was submitted to the Sheffied Research Ethics Committee for consideration and approva (11/H1308/3). Loca research and deveopment approva and appropriate etters of access were then gained for each of our fina fiedwork ocations (11 sites in tota). Samping for medica tourism patients did not require access to the NHS, nor patient records or materias. We sought carification with the oca Nationa Institute for Heath Research Research and Design Service and oca NHS research ethics committee and ethics approva for patient recruitment was not required. We recruited medica tourists through networks and snowba recruitment, not through the NHS. Informed consent was a fundamenta part of the study approach. Each interviewee was provided with detais of the study (which they coud retain) and asked to compete a consent form (see Appendices 5 and 6, respectivey, for exampes of these). Fiedwork chaenges The project had a number of chaenges. It incuded data coection in famiiar heath services territory (incuding NHS managers and professiona associations and use of NHS financia information). But it aso required fuer engagement with non-nhs interests and groups (non-nhs patients, commercia interests beyond the NHS). A range of data sources was required for the research team to meet its objectives and offer insight around decision-making, patient safety, economic impications and market and provider deveopment. Sourcing and competing interviews with medica tourists required significant effort, as we as intensive networking, patience and substantia persistence. In some areas of activity (e.g. cosmetic treatment) we recruited in a context in which media outets woud pay hefty fees for patient stories and testimonias. We were aso taking about potentiay sensitive issues across a range of treatment areas. Each strategy, network and site (detaied extensivey in Appendix 7) contributed some part towards meeting our fina sampe target. The project team was supported by an advisory group (see Appendix 8 for advisory group terms of reference and membership). Queen s Printer and Controer of HMSO 2014. 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. 11

METHODS AND STRUCTURE For NHS managers, particuary those on the purchasing side, the impending reorganisation of PCTs provided recruitment obstaces. In two sites where we gained ethics approva, interviewees were unabe or unwiing to participate in the research. Given the number of recruitment sites (up to 15), obtaining oca research and deveopment approvas and access was very time-consuming but necessary under existing governance arrangements. Changes from protoco There were two main departures from the envisaged study design. First, the proposa envisaged undertaking a survey in addition to the in-depth quaitative interviews. This woud coect more detaied demographic and financia information from a arger number of traveers. Athough we were successfu in securing the quaitative interviews, recruitment numbers were not high enough to aow for a survey eement. Some indicative financia information was coected in the detaied patient interviews, some of which is detaied in the treatment pathways (see Appendix 9). Second, we anticipated recruiting 10 inward medica tourists within our overa figure of 50. However, given the typicay high-end treatment focus and government-sponsored nature of these patients, this proved difficut. There were aso no support forums and cear gatekeepers through which such patients coud be accessed. Time constraints did not aow us to buid the necessary reationships with embassies and heath attachés that may have provided these recruitment opportunities. Aside from this we were abe to coect data on the context within which these patients traveed to the UK. These data were coected by taking to a range of managers within the NHS foundation trusts and those working within the independent sector. Tabe 2 summarises our data coection process. The impact of departure from the protoco on findings In ight of the chaenges reported and the obvious further insights that coud be gained by having a greater number of cases or interviews, for exampe of NHS managers, we have been carefu not to overstate the findings and potentia weaknesses resuting. We addressed chaenges in data coection through innovative data coection methods, for exampe the freedom of information requests to fi in the imited information avaiabe on inbound UK tourists. For the subgroups for whom data were coected, a saturation point was reached in the interviews as themes repeated themseves. The ack of interviews with inbound medica tourists to the UK means that research findings do not address motivation and imit the insights offered of their experiences of the NHS. There is aso a need for further research to better understand the effects of inbound medica tourism on the NHS. In addition, a arge-scae survey (had it yieded statisticay significant resuts) may have enabed further quantitative anaysis of medica tourism. However, as the study interviewed the argest sampe of UK medica tourists to date, we fee strongy that it presents the most vaid insights and the most robust data on patient motivation and experience avaiabe to date. We carefuy trianguated a findings and recommendations to ensure the vaidity of the findings stated. Report structure The report is structured as foows. The remainder of Section 1 provides a systematic review of the medica tourism iterature (see Chapter 3), highighting where major gaps in knowedge exist. Chapter 4 provides an introduction to the medica tourism industry. Drawing across a interview data (industry, overseas providers and professiona associations, and medica tourists) it undertakes broader conceptuaising to expore services invoved, the ways in which information is sought, and suppy/provider chains. Chapter 5 provides a critique of existing estimates and extrapoations around medica tourist fows and an anaysis using IPS data provided by the Office for Nationa Statistics (ONS). 12 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 TABLE 2 Summary of data coection Data coection method Description Coected by Research objective Report coverage Interviews Patients (treatment groups n = 46; diaspora n = 31) Treatment groups: cosmetic, denta, bariatric, denta, cutura, other DH, JH, LM, HK, NL Understand decision-making frames, assessments of risk and associated factors; better understand treatment experience, continuity of care and postoperative recovery Chapters 9 14 NHS (n = 23) Purchaser and provider roes NL Eicit the views and perspectives of key stakehoder groups Chapters 9 15 Stakehoders (professiona associations n = 16) Representatives of professiona associations NL/JH Eicit the views and perspectives of key stakehoder groups; map out the medica tourism industry and chart its deveopment Chapters 9 15 Stakehoders (businesses, empoyees n = 18) Individuas working within the private sector of medica tourism LM, DH, JH Map out the medica tourism industry and chart its deveopment Chapter 4 Overseas providers (n = 23) Desk-based work Country strategies JH/DH/NL Map out the medica tourism industry and chart its deveopment Chapter 4 Review of websites 100 sites reviewed, guideine search DH, HK, NL, RS, JH Better understand information, marketing and advertising practices Chapters 6 and 8 Review of quaity and safety accreditation Secondary data anaysis 150 sites reviewed NL/HK Understand decision-making frames, assessments of risk and associated factors Chapters 6 and 8 IPS 2000 11 DH, JH, RS Examine the magnitude of inward and outward medica tourism Chapter 5 Costing Freedom of information requests 28 NHS trusts JH/RS/NL Examine the economic and direct heath-reated consequences of inward and outward medica tourism Chapter 16 Systematic review Review of medica tourism iterature JH/RS Comprehensive documentary review Chapters 3 and 7 Section 2 examines issues reated to patient safety and service quaity incuding the ega and poicy context (see Chapter 6), education (see Chapter 7) and EQA and QISs (see Chapter 8), and synthesises interviews from professiona associations and NHS managers. Section 3 incudes the treatment case studies. This section contains an initia synthesis (see Chapter 9) foowed by five case studies of different treatments (bariatric, fertiity, denta and cosmetic; see Chapters 10 13) and diaspora trave (see Chapter 14). The cases incude patient interview data, wider interview data reevant to the treatment case (professiona, industry, overseas) and materia drawn from earier sections. Section 4 presents the data and discussion on inward patient fows of internationa patients into the NHS (poicy and background, processes and perspectives) (see Chapter 15), outines the economic considerations (see Chapter 16) and draws together the poicy, management and research impications (see Chapter 17). Queen s Printer and Controer of HMSO 2014. 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. 13

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 Chapter 3 Systematic review: what do we know about medica tourism? Introduction Medica tourism peope traveing abroad with the expressed purpose of accessing or receiving medica treatment is a growing phenomenon associated with processes of gobaisation. 40 This incudes cheaper and more widey avaiabe air trave and cross-border communication through the internet, which aows medica providers from one country to market themseves to patients in another. At the same time, increased movement of heath workers for education means greater consistency of care offered in origin and destination countries. This has been couped with an increase in foreign direct investment in heath-care providers in destination countries, incuding by private medica insurance companies. In some instances, US private insurers now aow patients to have treatment abroad. The increasing acceptance of heath-care portabiity is evident in Europe where greater patient mobiity ed to a EU directive 1 on cross-border heath care. Together with a rise in out-of-pocket expenditures for heath in many high-income countries at a time of economic crisis, these factors (trave, communication, consistency of care, cost and an increased acceptance of the portabiity of heath care) conspire to form a perfect storm for medica tourism. As a consequence, even in countries with a universa pubic heath-care system, such as the UK NHS, patients are now traveing abroad to receive medica treatment. Data from the ONS indicate that in 2010 63,000 41 peope traveed abroad for medica treatment. However, understanding of medica trave is imited. Litte is known about which patients choose to trave and why. Detais of the voume of patient fows and resources spent remain uncertain. This has hampered efforts to understand the economic costs to and benefits for countries experiencing infows and outfows of patients. 8 Simiary, the medica tourism industry and the roe of private providers, brokers and marketing remains a back box. 40 Athough interest in the issue has grown over the past decade, the effects on patients and heath systems are not fuy understood. Given the emerging nature of medica trave research, the evidence base is not yet ceary mapped. This review of the iterature aims to outine the current eve of knowedge on medica tourism and to better understand this phenomenon, incuding its impact on the UK NHS. Specific objectives are to better understand patient motivation, the medica tourism industry, the voume of medica trave and the effects of medica tourism on originating heath systems. These objectives informed the search strategy and review criteria set out in Appendix 10. The resuts of the iterature review are reported and discussed with reference to subthemes that emerged; specia attention is devoted to findings directy reevant to the NHS. Concusions are presented on current eves of knowedge, critica gaps and future research priorities on medica trave. Methods The review was conducted between September and December 2011, considering a papers pubished by this date, and adapted the strategy empoyed by Smith et a. 42 The strategy was reviewed and amended by a project advisory board consisting of academics, poicy-makers and practitioners. The search strategy and incusion criteria for the review are provided in Appendix 10 and the Preferred Reporting Items for Systematic Reviews and Meta-Anayses (PRISMA) fow chart is provided in Appendix 11. In tota, 100 papers were seected for incusion in the review. 8,10 12,17,26,40,42 134 Queen s Printer and Controer of HMSO 2014. 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. 15

SYSTEMATIC REVIEW: WHAT DO WE KNOW ABOUT MEDICAL TOURISM? Resuts An increase in medica tourism research is evident from the prominence of the issue. In 2010 and 2011, five journas devoted specia editions to medica tourism: Goba Socia Poicy, Body and Society, Anthropoogy and Medicine, Tourism Review and Signs. A rapidy expanding iterature over the past 5 years (with an exposion in 2010 and 2011) is refected in the pubication dates of papers reviewed, as evident from Appendix 12 (see Figure 9); 73 papers were pubished in 2010 and 2011. 40,42 45,47,50 52,54 57,59 61,64,67 78,80 95,97,99,102 104,107 121,123,125 127,129 133 This underines the increase in medica trave and its importance as an issue in UK heath-care provision. Types of studies reviewed Papers incuded in the review were cassified into the foowing categories: empirica: denoting papers based on primary research, interviews, surveys, anaysis of data sets, or the cacuation of revenue and tourist fows, and case studies of patients reviews: iterature, scoping and systematic reviews of medica tourism websites anaysis: papers that, athough drawing on secondary sources, provide substantive new insights or conceptuaise medica tourism in a new way (a number of papers presented frameworks) overview artices: papers that give an introduction to the issue of medica tourism. The resuts are summarised in Appendix 12 (see Figure 10). In tota, 47 papers 17,43,44,47 49,51,57,62,65,66,68,71,76,78, 81 83,85 87,93,94,96 100,103 106,110 114,116,118 120,124,126,127,132,133 presented findings from empirica research, 25 provided an overview of issues, 10,11,26,46,50,52,53,58 60,63,67,73,79,80,91,97,100,115,120,122,128,130,135,136 15 were cassified as anaysis 8,54,56,61,69,75,84,88,108,109,119,123,125,129,131 and 11 were reviews. 40,42,55,70,72,78,89,90,92,95,133 Of the 47 empirica studies, 19 reported findings from quantitative research 12,17,43,47,76,81,85,93,96,98,99,103 106,110,114,116,124 (in most cases a survey), 15 were quaitative studies, 44,57,62,68,71,74,82,87,94,112,113,116,118,120,132 eight reported case studies of patients 51,66,83,101,102,111,119,127 and a further five 48,49,65,86,93 reported the resuts of an experiment, cost cacuation or evauation of an intervention. In tota, 32 of the empirica findings were pubished between 2010 and 2011, underying the provenance of the issue. Geographica focus Papers were grouped according to which region the research investigated. Papers that provided a genera overview that was not focused on a specific region or country were cassed as goba. A tota of 43 papers fe into this category. 8,10 12,17,26,45 47,52 55,58,59,63,64,67,69,70,72,73,78 81,89,90,92,93,95,107,111,119,121 123,129 133,135 Europe was the focus of 27 papers, 40,42,44,48 50,57,60 62,65,66,75,76,83,84,91,94,98,100 102,104 106,114,126 with 13 expicity focusing on the UK 42,57,62,65,66,76,83,94,98,101,102,104,114 in their study design and a further 11 papers 10,40,43,50,53,90,91,99,105,106,119 from across the entire sampe referring to either UK patients or the NHS. The geographica distribution of papers is summarised in Appendix 12 (see Figure 11). Evidence from studies reviewed suggests a regiona dimension to medica tourism. Japanese companies send their empoyees to Thaiand 10 or to countries in the Guf. 43,116 A study of medica tourists in Tunisia found that these were from neighbouring countries. 85 Thaiand, Singapore, Maaysia 109 and India 8 and others have marketed themseves as medica tourism destinations. Countries are known for specific areas of medicine: Singapore for high-end procedures, 86 Thaiand for cardiac, orthopaedic and gender reassignment surgery, 11 Eastern Europe for denta tourism 108 and Spain for fertiity treatment. 72 Athough some destinations were recognised as being popuar with UK patients, for exampe Budapest for denta treatment, proximity aone does not appear to expain preference for one destination over another. Issues covered Most papers made reference to push and pu factors determining patients decision to trave. These reate to cost, perceived quaity, famiiarity, waiting ists or deays in treatment or the ack of avaiabiity of certain 16 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 treatments in the country of origin. 61 As this ist demonstrates, these are often compex 57 and may vary according to the treatment for which a patient traves. A patient traveing for cosmetic surgery, for exampe, may enjoy the anonymity of a destination far from their country of origin, 53 whereas migrants may prefer to trave to their country of origin to fee more comfortabe with the anguage or type of care provided. 87 A subset of papers reviewed focused on specific types of medica tourism. Diaspora trave A number of studies refer to a group of medica traveers cassified as diaspora traveers. Studies describe this in reation to India, China, Korea and Mexico, with recent migrants returning to their home country to access treatment that is either not avaiabe or perceived to be not avaiabe in their country of residence, or perceived to be more effective in their home country. 43,71,87,94 Ginos et a. 61 deveoped a typoogy for patient motivation (avaiabiity, affordabiity, famiiarity, perceived quaity of care), cross-referenced with whether a patient has funding or not. The authors appied this typoogy to understand patient motivation in a range of case studies from the iterature and found that diaspora patients return because of reasons of famiiarity with the system, as we as affordabiity. Fertiity tourism Reproductive or fertiity tourism is comparativey better documented than other forms of medica tourism. 40 Sixteen papers 44,47,57,59,60,72,74,79,98,100,106,113,114,129,130,132 were identified for incusion in this review; seven 59,74,79,113,129,130,132 focused on equity and ethica issues reating to fertiity tourism, incuding the rights of women in recipient countries. Four papers 57,98,106,114 specificay examined cross-border reproductive care (CBRC) in Europe. Two 106,114 of these papers presented findings of surveys monitoring patient fow and services accessed across Europe and a third paper 98 presented the resuts of the effects of such trave on patients giving birth in a centra London hospita. One 57 provided a quaitative, in-depth study of UK patients and their motivations for traveing abroad. One paper 47 presented findings from an onine survey of prospective and actua tourists. Four papers 44,60,79,100 provided a genera overview of the issues reating to fertiity tourism. Hudson et a. 72 presented a review of the iterature on CBRC. Resuts incuded the consistent gap in empirica research; of 54 papers reviewed ony 15 were based on findings from empirica investigation. The authors note the absence of studies and knowedge about patients backgrounds and factors motivating their trave, and a gap in the research on the industry. Three papers 57,98,114 expicity expore the effects on the NHS. The study by McKevey et a. 98 of mutipe births over the past 11 years found that over one-quarter of high-order pregnancies in a UK foeta medicine unit occurred in patients who had traveed abroad to access fertiity treatment. The quaitative study by Cuey et a. 57 showed the compex motivations for traveing abroad, but concurred with other research that cost of treatment and the greater number of gametes avaiabe abroad or more easiy accessibe gametes payed a part in decision-making. This was echoed by the resuts of a survey 114 in which UK respondents were most ikey to name difficuty in accessing fertiity treatment as motivation for trave. Denta, bariatric and cosmetic tourism A further area of medica tourism is denta tourism. 137 Three papers 101,105,122 focused on the issue of patients traveing for denta treatment. These indicated that this is ikey to be an area of increasing trave by UK residents given the high cost of dentistry in the UK private sector, imited avaiabiity in the pubic sector and the ower cost in Eastern Europe. 101 Some countries, such as Hungary and Poand, have marketed themseves as denta centres of exceence. 137 A survey of denta cinics in Western Hungary and Budapest 105 Queen s Printer and Controer of HMSO 2014. 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. 17

SYSTEMATIC REVIEW: WHAT DO WE KNOW ABOUT MEDICAL TOURISM? showed the argest group of patients (20.2%) originating from the UK, with ower prices being cited as the main motivating factor. Two papers focused in depth on issues surrounding bariatric surgery. One expored the ethica chaenges 117 and the other was a case study of compications experienced by a US patient. 127 Papers by Birch et a. 134 and Miyagi et a. 102 focused on compications from cosmetic tourism in UK patients. A po conducted amongst members of the UK pubic found that 92% woud consider traveing abroad for cosmetic surgery. 104 The possibiity of a arge number of UK patients seeking cosmetic surgery abroad appears to be supported by a survey conducted by the British Association of Pastic, Reconstructive and Aesthetic Surgeons (BAPRAS), 76 which found that 37% of respondents had seen patients in the NHS with compications from overseas surgery. Risks The issue of risks to the patient in terms of heath outcomes was covered in 30 papers. 11,26,40,51,53,55,63,64,66,67, 70,72,76,77,79,83,91,92,99,102,104,107,111,114,115,117,119,127,128,135 Perhaps surprisingy, ony seven of these 51,64,83,91,99,102,111 focused excusivey on the issue; 10 studies 51,55,65,98 101,117,127,132 mentioned onger-term heath outcomes of patients. Four papers 51,66,83,111 reported cases of infection that resuted from patients traveing to receive medica treatment. Three 51,83,111 described the recent outbreak of NDM-1-producing Enterobacteriaceae foowing patients receiving treatment in India, which highighted some of the dangers of medica tourism and microbia resistance. The fourth 66 described an outbreak of hepatitis B in a London hospita traced to a patient recenty returned from surgery in India. Effect on recipient country heath system As summarised in Appendix 12, 36 papers 8,17,42,43,48,49,51,56,65,68,71,74,78,83,85 88,92,94,97,102,103,105,106,108,109, 113 116,120,124,125,128,132 focused on the effects on the recipient country heath system. Issues highighted incude the potentia for medica tourism to resut in the retention of doctors in, or attraction of doctors to, ow- and midde-income countries, thus preventing or reversing a brain drain, and to generate foreign currency. 86 Aso considered is the danger of creating a two-tiered heath system, resuting in increasing inequities in access and quaity of heath care for the oca popuation in destination countries. 78,125 Expanations are twofod: first, a rise in price in countries that do not provide pubic heath services free at the point of use and, second, the potentiay greater concentration of doctors in the private sector. 103 A tota of 34 papers 8,17,42,47 49,56,57,65,66,71,76,77,81,83,87,91,94 96,98 101,104,106 108,114,117,118,127,129,132 focused on potentia effects on the heath system of originating countries. These referred to factors eading to trave by patients, incuding a rise in costs. Studies documented patients returning with compications, 99 incuding to the NHS. 102 Research highighted the need for reguation, the ack of quaity contro of overseas providers and the cost (potentia or rea) arising to the originating country from treating compications. Two papers 94,96 cacuated the potentia cost savings and benefits of sending patients abroad. When papers focused on the effects on the heath system of originating countries, this was mainy on perceived negative consequences. Industry Thirty-nine of the papers reviewed 8,10,11,17,43,44,50,53,56,57,60,62,68,69,71,72,76,81,85,88 92,95,97,98,103,104,106,107,109,113,116,122,124, 128,132,135 focused at east party on providers of medica tourism. Less attention was paid to faciitators (n = 19). 47,50,56,57,59,70,77,81,89 92,104,113,117,118,132,133,135 A subset of 19 papers 8,50,56,62,68,69,76,81,88 90,92,95,107,109,118,124, 132,133 studied the medica tourism industry in a more focused way. This incuded reviews of websites, 90 market anaysis, 82 quaitative anaysis of the roe of medica tourism faciitators 118 and a more genera review, 92 as we as a mode for tourism deveopment. 69 Artices examining communication materias and websites highighted the imited information on foow-up care and redress in case of compications. 79 They aso pointed to an emphasis on testimonies from patients rather than forma accreditation or quaification of cinicians and the great focus on tourism aspects of the destination and offering services as good as at home. 80 In addition, the ow cost of treatment was used as a seing point. 18 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 There were two quaitative studies of medica tourism faciitators (interview sampes incuded nine 118 and 12 82 interviewees, respectivey); faciitators were presented as a heterogeneous group with a range of motivations. Studies tended to mention reguation but ony two 123,130 reviewed this more systematicay; both pointed to a vacuum in reguation. Many studies mentioned individua hospitas or recounted an exampe of a medica tourism provider at the country eve to give a favour of the industry. 53,82 However, ony four studies 85 88 reported findings of a more systematic assessment of the industry and its operations. One study, 40 evauating past experiences of EU cross-border care, examined contracting arrangements and their effects on heath outcomes. Trade in heath services: revenue and voume Medica trave the consumption of heath services abroad is defined as a trade under the Genera Agreement on Trade in Services (GATS) mode 2 and the majority of papers incuded in this review impicity or expicity focused on this form of trade in heath services. 8 A subset of seven papers 75,85,94,103,116,125,128 incuded a detaied discussion of other forms of trade in heath services, incuding cross-border provision of services (GATS mode 1) and movement of heath workers (GATS mode 4). Many overview papers mentioned the investment by US providers in Asian hospita groups without expicity exporing this (GATS mode 3). Four papers 8,46,75,94 anaysed poicy processes and chaenges to trade in heath services. The actua voume of trade (the fow of medica patients) was referred to in many papers but investigated in few. 74,85,105,114,116 Studies by the United Nations Economic and Socia Commission for Asia and the Pacific 124 and Leng 88 a provided further estimates or trends. The studies by Lautier, 85 Siddiqi et a. 116 and NaRanong and NaRanong 103 were the ony ones that cacuated the tota voume of trade in heath services (for 13 countries), incuding the actua costs and effects on recipient country heath systems. For exampe, NaRanong and NaRanong 103 cacuate the contribution of medica tourism to the Thai gross domestic product (GDP) (0.4%), with medica tourists with their higher purchasing power ikey to increase the cost of heath services and essen access in the pubic sector. Most papers cited simiar figures for patient fow but often sources were not accessibe or figures were based on media reports or on other academic papers, which in turn quoted inaccessibe sources. When sources for patient numbers were cited these have been summarised in Appendix 12. One of the most commony cited sources for patient fows was other academic papers. Seven papers 67,81,92,93,108,129,131 referred directy to a report by Deoitte 17 and six 10,40,50,58,67,68 referred to a report by McKinsey; 12 the exact ways in which figures in these reports were cacuated remain uncear. Even when these reports were not referenced, the figures cited suggest that these two reports were used as sources. For exampe, a paper by Nassab et a. 104 cites the Economist, stating that 750,000 US patients traveed abroad for treatment in 2007. This is the figure provided in the report from Deoitte 17 in 2008. Eight papers 85,88,103,105,106,114,116,124 had either generated or coected their own data on patient fows. Discussion Perhaps the most surprising finding was the increase in number of papers presenting findings from primary research a shortfa or gap that had been noted by the earier iterature reviews. 42,55,70 The recent pubication date of many papers confirms the increasing amount of research being carried out on medica trave. Medica tourism is a phenomenon in the private heath-care market, which makes it hard to monitor and reguate patient fows. 137 Despite the rapid increase in number of pubications over the past 2 years, Queen s Printer and Controer of HMSO 2014. 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. 19

SYSTEMATIC REVIEW: WHAT DO WE KNOW ABOUT MEDICAL TOURISM? reiabe cacuations of the actua voume of patient fow remain rare. This confirms findings from an earier review, 42 which aso noted the ack of information on how the figures in the reports by Deoitte Consutancy 17 and McKinsey 12 were cacuated. The body of iterature focusing on medica tourism as a trade in heath services indicates that further research investigating eves of such trade is needed. Data on costs and benefits of medica tourism are rare and this imits accurate assessments of its effects to inform poicy decision-making. Studies are aso needed to empiricay observe the effects of medica tourism in practice. The definitions of trade in heath services provided, 8 together with the framework for measuring its eve provided by Siddiqi et a., 116 set out a methodoogy for such research. Understanding of the industry is imited. None of the research-driven papers captured the entire vaue chain of medica tourism. It is not evident how different industry actors (e.g. referring cinician, websites, faciitators, trave agents and receiving cinicians or hospitas) ink together and how their reationships may infuence patient experiences and heath outcomes. Three papers referred to the roe of medica tourism faciitators, drawing on sma sampes, demonstrating the need for further research in this area, especiay to enabe reguation or to address the ethica dimensions discussed in the papers reviewed. 118,131,133 Types of medica tourism The iterature reviewed ceary indicates that medica tourism is no unified phenomenon. Subthemes as distinct areas covered by research were evident from the review, such as diaspora or fertiity trave or trave for bariatric surgery or denta or cosmetic work. The papers on diaspora trave highight that medica tourism and decisions by patients to trave are not simpy guided by cost considerations or even cinica outcomes. Rather, the iterature points to a compex matrix of perceptions of care, waiting times, cost and other factors. The different types of medica trave aow some inferences about patient motivation, for exampe cost or avaiabiity in cosmetic procedures, reguation in the case of fertiity and so on. However, a ack of information about patients characteristics imits a deeper understanding of push and pu factors. Impact on the NHS: ack of studies focusing on ong-term heath outcomes Evidence demonstrates that patients traveing abroad to receive treatment and returning to the UK may face compications or infections requiring foow-up in the pubic sector. Seven papers 65,66,76,83,98,101,102 reported on patients who were treated in the NHS as a resut of compications resuting from treatment abroad. Based on the iterature reviewed, cosmetic procedures appear to be an area of growth for medica trave by UK patients and are ikey to resut in costs to the NHS from resuting compications. This underines the need for further research to ascertain the potentia impact and costs for the NHS arising from medica tourism. In addition, itte is known about the onger-term heath outcomes of medica tourists beyond these incidenta reports of compications. No iterature on inward medica trave and its effects on the NHS was identified, pointing to a gap in knowedge. Concusions This review provides a map of current knowedge on medica tourism and identifies a series of subthemes. The reviewed papers demonstrate the mutidiscipinary nature of medica tourism research. There has been an exposion in research on medica tourism over the past 2 years. This review ceary identifies imits to current knowedge; many papers remain hypothetica and there are many areas in which further research is needed. 20 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 There is sti a ack of information on the background of patients and the numbers of patients traveing abroad for treatment. This imits insights into why some patients trave and others do not and restricts evidence about the possibe costs and benefits of medica trave. The absence of information on patients socia, economic and demographic backgrounds hampers the abiity to understand patient decision-making and determinants of trave. The studies reviewed indicate that motivation is compex. Further information is needed to fuy understand this decision-making process. It is especiay reevant to gain insight into why patients from countries with pubic heath-care systems such as the UK choose to trave abroad. Litte is known about the industry beyond reviews of information materias and websites. Further research, especiay quaitative and survey-based research, is needed to better understand how the sector operates and what its motives are to utimatey understand how it drives or affects trade in heath services and heath outcomes of medica traveers. Athough case studies of patients returning from treatment abroad with compications were reported, these did not quantify the potentia cost of medica trave to the patients home heath systems. Given the evidence of an increase in medica trave such research is urgenty needed. There is no research examining the ong-term heath outcomes of UK medica tourists. Further quaitative and quantitative research, beyond immediate cinica outcomes, is needed to truy understand the effect of medica trave on patients and its cost to the heath system. Impications for the NHS There is a need to coect data on the number of patients who return from treatment abroad and are treated within the NHS. There is a need for additiona surveys and quantitative research to understand more fuy the voume of patients who trave abroad and their socia and economic characteristics. This wi enabe a more accurate understanding of the scae of the issue and factors determining patient trave. These push factors may in themseves hod vauabe essons that refect on the NHS. There is a need for research to assess the ong-term heath outcomes of medica traveers to fuy understand the effects on individua and popuation heath. Queen s Printer and Controer of HMSO 2014. 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. 21

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 Chapter 4 The context of medica tourism This chapter provides an introduction to medica tourism services, processes, providers and countries strategies. Drawing across the composite data set, incuding interview data (encompassing commercia interests, overseas providers, professiona associations and stakehoders, and medica tourists) supported by the desk-based activity (e.g. website review), we seek to conceptuaise and typoogise, unraveing the bigger picture of medica tourism, as viewed through the perspective of respondents. The chapter is structured around four themes: services: highighting the range of treatment and anciary services within medica tourism (offered by providers, marketed on the internet and purchased by patients) information: conceptuaising the ways in which information is made avaiabe cinica provision: outining the range of cinica providers within medica tourism and their suppy chains country strategies: a review of five country strategies aimed at growing medica tourism and their perspectives on UK market opportunities. The chapter summarises the emerging impications for the NHS. Services Medica tourism treatment pathways invove a number of services (both cinica and anciary) that together give an overa experience. Athough not a of these services are integrated in each and every patient journey, the variety of services iustrates the fu range of possibiities: conferences and media activities: for exampe fertiity trade fairs that market, inform and connect potentia traveers with overseas services websites: prospective traveers use the internet to find out about medica trave and to support decision-making, incuding cinic websites, portas (which may contain detais of numerous cinics) and consumer-driven sites such as chat rooms and discussion boards intermediaries: (faciitators and brokers) provide information (web-based and one-to-one) for prospective patients about treatments and services and make arrangements for treatment and services preconsutation: this may take pace in the UK or abroad at a preiminary cinic undertaken by the surgeon or doctor, or screening may be provided by a contractor based within the UK treatment: (provided by cinics and hospitas) may invove outpatient treatment, day surgery or ongerstay hospita admission forms of accreditation: (avaiabe to cinics, hospitas and faciitators) seek to offer assurance around the quaity and safety of products; accreditation is itsef typicay a commercia activity with competing accreditation bodies offering their services financia products: avaiabe to patients to fund the costs of trave and treatment insurance products: deveoped to insure for trave and oss, and seek to cover the costs of further treatments that may be required as a resut of compications and dissatisfaction foowing surgery abroad trave, hote and concierge: fights, accommodation (for accompanying famiy and companions, or for patient recuperation) and support services (e.g. transation) are purchased tourism and weness: for some medica tourist destinations and treatments, attempts are made to promote the cutura, heritage and recreationa opportunities aftercare: may be arranged within the treatment country or within the home country (incuding dressings, stitches, pharmaceutica arrangements, monitoring and foow-up). Queen s Printer and Controer of HMSO 2014. 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. 23

THE CONTEXT OF MEDICAL TOURISM There are particuar stages in the treatment pathway during which issues arise that have a bearing on the NHS. First, can individuas obtain appropriate information to ensure that they are abe to make an informed choice and ensure their safety? For exampe, is non-commercia advice and input avaiabe at trade fairs and on websites, for exampe trave guidance and checkists? Second, what advice shoud the Department of Heath, commissioning bodies and GPs provide to individuas seeking to trave abroad? Finay, are appropriate aftercare arrangements made, given that there may be expectations of receiving NHS care and financia impications if aftercare services are required. Information Searching for information may be time-consuming, confusing and overwheming. Individuas may be uncear how best to go about finding and vaidating trustworthy sources of information. Looking across the range of patient, commercia and stakehoder interviews, anaysis identified three ideaist modes whereby prospective medica tourists gather information and source their destination and provider (see Appendix 13). Mode 1: faciitator-enabed provision A range of intermediaries known as brokers or faciitators arrange services and phases of treatments. Such intermediaries may speciaise in particuar target markets or procedures or destination countries (e.g. from our own interviews these incuded sites focused on fertiity treatment or on a particuar destination for a range of treatments). Faciitators may be physicay ocated in a home country, have a presence overseas or both. As we as e-mai and teephone communication, they may undertake chaperoning and transation functions during the trave and treatment phases. The potentia for intermediaries can be attributed to the transaction costs associated with medica tourism. Mode 2: consumer-driven access to information and provision In the consumer-driven mode individuas use various forms of soft/hard inteigence to inform decisionmaking around medica and anciary products, reying on marketing imagery, or evidence on quaity and outcomes. They take the ead in searching and arranging. Our patient interview data suggest that individuas consut websites to compare costs and to reduce their own transaction costs when putting together a particuar treatment journey (particuary reated to search and information costs). As outined in Section 3, decisions are ikey to vary for different treatments (e.g. fertiity treatments, for which patients are ikey to be heath iterate about success rates and risks). Decisions to be made incude seecting country, cinic and cinician and arranging trave insurance or speciaist insurance, finance, trave, accommodation and concierge, and aftercare. Mode 3: networked access to information and provision The fina type of access to medica trave information reies predominanty on network dynamics. 138 Individuas source information through treatment-based, cutura-based and professiona networks. Cutura- or treatment-based networks invove patients drawing on the advice, reationships and sociaisation infuence of a wider group: Cutura-based networks: for exampe, Section 3 outines how British residents and citizens with cutura and historic ties to Indian and Somai popuations trave to India and Germany, respectivey, for denta treatment and diagnostics based on informa recommendations from cose friends and within the wider community network. Treatment-focused networks incude organised discussion forums and sef-hep groups that cohere around treatments/conditions such as bariatric, fertiity and cosmetic treatment. As Section 3 outines, these networks may aso be enmeshed in deivering treatments themseves, incuding offering services for support and aftercare (e.g. bariatric and fertiity support groups). 24 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 Professiona networks invove professiona ties and connections mediating information and choice: Professiona networks can invove cinicians and professionas advising and inking individuas to cinicians and hospitas across nationa boundaries. For exampe, as detaied in Section 3, some private fertiity cinics have inks to partner cinics overseas (where perhaps wider treatment choices are avaiabe). Cinicians wi aso directy recommend amongst their own networks (refecting education, training and experiences). As Chapter 15 outines, when overseas governments are paying for NHS treatment, the choice of provider is expained by network knowedge and strong ties (e.g. where referring cinicians trained or undertook postquaifying training or where attachés have strong inks). These three network configurations sharpy contrast simpe market reationships of buyer and seer making trade-offs around price/quaity. To reiterate, these three ideaist modes (faciitators, individuas and networks) expain how information is sourced for medica tourism. These three types are ceary evidenced within our patient stories and wider interviews. As idea types they are not mutuay excusive, and patient stories wi contain one or more such sources of information, for exampe there is overap between modes 2 and 3 with regards to consumers engagement with professionas. There are aso cear advantages and disadvantages of such sources of information. In Appendix 13 we deveop an anaysis of the potentia advantages and drawbacks of these three information sources, informed by what medica tourists and commercia interests suggested during interviews. Cinica provision Within medica tourism there is a diversity of participating cinics and providers [as Ackerman 139 suggests, cottage industries and transnationa enterprises (p. 405)]. Providers are primariy from the private sector but are aso drawn from pubic sectors. Reativey sma cinica providers may incude soo practices or dua partnerships, offering a wide range of treatments in areas such as cosmetic surgery. At the other end of the scae are extremey arge medica tourism faciities in which cinica speciaism is the order of the day. Hospitas may be part of arge corporations or wider affiiations of genera and speciaist cinics. Athough there are smaer independent, speciaist cinics, it is these arge compexes that dominate the Spanish industry. Larger cinics and providers have moved to offer a range of services (financia products, insurance, hote, transation, accommodation, aftercare) within a horizontay integrated suppy chain. Services may be more oosey or fuy integrated and emphasise upstream integration (finance, preconsutation, trave), downstream integration (recuperation, aftercare, foow-up) or both. Country strategies A range of nationa government agencies and poicy initiatives (both in Europe and beyond) have sought to stimuate and promote medica tourism in their countries. Many countries see significant economic deveopment potentia in the emergent fied of medica tourism. Before and during our fiedwork period we attended arge internationa trade fairs and conferences supported by the Hungarian, Matese, Croatian and Turkish governments, a of which sought to promote their comparative advantage as medica tourism destinations. In Appendix 14 we present a synopsis of what we assess their strategies and deveopments to be (drawing on provider and wider industry discussions, trade fairs and onine information). Queen s Printer and Controer of HMSO 2014. 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. 25

THE CONTEXT OF MEDICAL TOURISM Impications for the NHS 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. Some European countries and beyond are seeking to expicity market to prospective UK patients. There is strong competition, as we as voatiity and changeabiity within mainand European provision, for some treatments. Medica tourists use a range of information points (intermediaries, direct and networks), which compicates practica attempts to improve information quaity. The European market for medica tourism is dominated by soo practices and sma providers, athough there are some moves to nationa organisation and professiona affiiation in some countries. Monitoring quaity and outcomes across this range of providers (and outside of the arge and pubicy financed institutions) is probematic. 26 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 Chapter 5 Mapping patient inward and outward fows Probems with numbers Authoritative data on numbers and fows of medica tourists between nations and continents are difficut to identify. Athough there is consensus that the medica tourism industry has grown over the past decade, and that there are particuar biatera fows, there remains disagreement as to the current and potentia size of the industry. A key issue is that the primary source of data reating to numbers and fows is the industry stakehoders themseves. Given the possibe scope of what is often a private and confidentia industry in an increasingy borderess word, it is inevitabe that the industry stakehoders are best paced to provide the most reiabe information. The probem of course is that such information may not be reiabe at a; aside from the fact that such stakehoders have a vested interest in presenting a picture of a vibrant and growing industry, those prepared to accuratey record patient numbers, fows and profies face a range of difficuties. Whether estimates are taken from industry stakehoders, the grey iterature or the academy, they are consistent in one respect: a of the numbers cited are either estimates or extrapoations. These estimates of the goba numbers of medica tourists generay ie on a continuum between statistics pubished by the Deoitte management consutancy at one end of the spectrum and a more conservative estimate by McKinsey at the other. Deoitte paced the number of US citizens eaving the country in search of treatment at 750,000 in 2007 and this number was projected to reach somewhere between 3 and 5 miion by 2010. 17,140 Given that US tourists are thought to represent roughy 10% of the goba number of medica tourists, 12 this woud suggest that tota wordwide figures woud ie somewhere between 30 and 50 miion medica tourists traveing for treatment each year. However, anaysts at McKinsey suggest that, athough the potentia for such arge numbers exists, a more accurate wordwide figure woud be between 60,000 and 85,000 medica tourists per year, 12 athough these numbers do appear rather sma and unreaistic. The rea probem when searching for reiabe data is, as mentioned, that it is stakehoders with a vested interest who are providing the data. 141 So successfu have these stakehoders been that their numbers and the numbers offered by Deoitte have transcended commercia iterature, with Deoitte s 750,000 Americans statistic being reproduced not ony on commercia sites but aso in grey iterature as we as peer-reviewed academic iterature. It coud be argued that, by providing the parameters within which the industry is discussed (i.e. huge), Deoitte has managed to normaise the rather grandiose caims of organisations such as Bumrungrad Internationa Hospita as we as countess nationa tourism boards. None of this is probematic of course if Deoitte s statistics are correct, but here we encounter a rea probem. In both Deoitte s origina 2008 pubication 17 as we as in their 2009 updated projections, 140 the numbers cited have not been generated by any scientific method. Indeed, the source of their numbers is simpy an onine artice for India Daiy, 142 which simpy states that 750,000 Americans wi trave in 2007 and that by 2010 the number wi reach 6 miion. No evidence is offered; the figure is an estimate provided with no source of support and there is absoutey no suggestion that the figure has been reached as a consequence of any data coection. Approaching industry estimates with caution may seem ike common sense, but it is important to note that such sources have aso informed the wider grey and academic iteratures, often being repeated in artices within we-respected journas. Queen s Printer and Controer of HMSO 2014. 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. 27

MAPPING PATIENT INWARD AND OUTWARD FLOWS So where shoud we ook for data? Ideay we woud ook to we-designed, unbiased empirica studies from within the academy. Here, though, it is cear that there exists no credibe authoritative data at the goba eve. The empirica work that has been pubished is generay sma-scae and quaitative and these studies often avoid making market estimates. The reaity is that no authoritative, reiabe and unbiased data at the goba eve exist in the pubic domain. Athough this cannot be fuy addressed, the IPS can provide some iumination with regards to the fows into and out of the UK. The survey has some methodoogica faws, especiay in terms of how representative it is, but it is nonetheess an unbiased, quantitative source of data that aows time series anaysis over the ast decade. The IPS, conducted by the ONS, coects information from passengers as they enter or eave the UK. Started in 1961, it aims to coect data on credits and debits in the UK baance of payments; provide information on visitors to the UK to inform tourism poicy; provide data on migration; and coect information to hep aviation and shipping authorities (IPS, J Hanefed, London Schoo of Hygiene and Tropica Medicine, 2012, persona communication). Passengers are randomy seected as they trave through passport contro (entering or eaving) and a brief survey is administered. This incudes basic questions about an individua s age, sex, origin and destination, as we as questions about whether the trave is part of a package, with company or for business, the cass of trave and the ikey ength of stay abroad or in the UK and ikey pattern of expenditure. One of the survey questions asks passengers to define the primary purpose of their trave and medica treatment is one of the possibe answers, thus providing insight into the number of passengers traveing for this reason. The main imitation of these data is the number of passengers samped. In 2007, for exampe, 255,000 interviews were conducted, representing 0.2% of traveers to and from the UK overa. 41 However, given the absence of other reiabe data on numbers of medica tourists, their characteristics and where they trave, the IPS does represent the singe most comprehensive data quantifying medica trave to and from the UK. The IPS data have important imitations, which inhibit nuanced statistica anaysis. As such, a more descriptive anaysis is appropriate and, given the dearth of trustworthy data pertaining to medica tourism, is incrediby vauabe. Data from the Internationa Passenger Survey As Figure 1 shows, the number of peope from the UK traveing to access medica treatment has increased steadiy over the past decade. The number of patients traveing to the UK has hed reasonaby steady over the decade. (The IPS codes a passengers traveing from the Channe Isands and the Ise of Man as 70,000 Number of medica tourists 60,000 50,000 40,000 30,000 20,000 10,000 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Year Inbound Outbound FIGURE 1 Line chart showing the numbers of peope who traveed into or out of the UK for medica treatment during the period 2000 10. 28 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 inbound medica traveers, that is, those coming to the UK to access treatment. As these patients are part of the NHS and are ikey to have been referred for medica treatment to the mainand UK, these have been excuded from the sampe of inbound patients to give an accurate picture of the numbers.) At the time of data anaysis, figures for 2011 were avaiabe ony for three quarters of the year, so are not incuded in the graph (see Appendix 15 for a regiona breakdown). Destination of UK outbound medica traveers For UK residents who trave abroad for medica treatment, Northern, Western and Southern Europe are the most common destination regions, as evident from Figures 2 and 3, with France being the most visited country over the decade. Appendix 15 charts these trends over time. Centra and Eastern Europe are the second most popuar destinations. Appendix 15 (see Figure 15) ceary shows high numbers of traveers visiting Poand, the second most popuar trave destination over the decade, and the most popuar in recent years with approximatey 11,000 and 13,500 traveers in 2009 and 2010 respectivey. It aso indicates the popuarity of medica trave to Hungary since 2006. South Asia (primariy India) attracts arge numbers of UK patients, making it the most frequenty visited non-european region (see Figure 2). The most recent data show the reativey stabe pattern of trave to India, Pakistan and (in much ower numbers) Sri Lanka and Bangadesh. Medica trave to East Asia shows a different pattern to that for South Asia. No medica traveers from the UK to East Asia were recorded by the IPS before 2003, when 1500 peope traveed from the UK to East Asia. In 2010 > 4000 peope made the same journey, which represents an increase of 171%. By 2010, 15% of a UK medica traveers went to East Asia. North America, the Midde East, Africa and Centra and Southern America account for a sma percentage of those undertaking medica trave. As Appendix 15 (see Figure 15) iustrates, France, Poand and India are the most popuar destinations for UK medica tourists, with France hoding reativey steady, India demonstrating a gradua increase and Poand experiencing a rapid increase as of 2007. The French case may be expained as a historica and Africa (2%) North America (4%) Centra and South America (1%) Other (1%) Northern, Western and Southern Europe (43%) Southern Asia (13%) Centra and Eastern Europe (29%) Midde East (3%) East Asia (4%) FIGURE 2 Pie chart showing tota outward medica trave by UK residents by destination region over the time period 2000 10. Queen s Printer and Controer of HMSO 2014. 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. 29

MAPPING PATIENT INWARD AND OUTWARD FLOWS FIGURE 3 Map depicting tota numbers of medica traveers from the UK and their destinations over the period 2000 10. 0 499 500 1499 1500 4999 5000 9999 10,000 14,999 15,000 19,999 20,000 24,999 25,000 29,999 30,000 100,000 30 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 geographica option, with its proximity to the UK proving convenient aongside a famiiarity of British hoidaymakers with France. Simiary, both Begium and Spain can be found in the top 10 destinations across the decade (fifth and eighth, respectivey), perhaps for simiar reasons. Poand has demonstrated the argest surge in popuarity and by 2009 was the most visited destination for medica traveers from the UK. This may refect the fact that the UK is home to a arge popuation of peope with historic and famiia ties to Poand, a popuation that has burgeoned consideraby during the second haf of the ast decade. Athough this is ikey to be the case, the proximity to and accessibiity of Centra and Eastern Europe and the emergence of a reputation for high-quaity cosmetic care (whether this is accurate or not) are aso undoubtedy factors. Hungary, with a reputation as a eader in denta care, is, ike Poand, easiy accessibe by ow-cost airines operating from the UK and is the fourth most visited destination by UK traveers. Simiary, the Czech Repubic is the 12th most visited destination and, ike both Hungary and Poand, has deveoped a reputation for particuar types of treatment and is we served by budget airines. India has proven to be a popuar and increasingy visited destination during the time period anaysed, which, as with Poand, might refect the fact that the UK has a arge popuation with historic ties to India and that trave to this region has become much more accessibe in recent years. Indeed, it may even be that those traveing retain Indian citizenship. Simiary, Pakistan was the 10th most popuar destination for UK medica traveers, once again possiby a refection of a arge popuation of peope in the UK with historic ties to Pakistan. Inward medica trave The argest numbers of inbound medica traveers are from Northern, Western and Southern Europe (Figure 4). Looking at individua countries, the greatest numbers of patients traveing into the UK for treatment are from Ireand and Spain and these two countries aso show a growing trend of patients coming to the UK. In the case of Spanish (and perhaps French) residents, it is highy ikey that a substantia number wi be UK expatriates and it is uncear whether these engage in out-of-pocket medica treatment or whether they use NHS services. The numbers of Greeks and Cypriots traveing into the UK to access treatment rose rapidy in 2009 and 2010. This increase may be the resut of the economic crisis, which in turn has meant severe pubic sector cuts incuding in heath. 143 A significant number of patients aso trave from countries in the Midde East (specificay from the United Arab Emirates and Kuwait, athough visitor numbers dropped sharpy in 2008 and 2009 respectivey). Despite some variation over the years, a stabe inward fow of medica traveers from Nigeria is aso evident over the past decade. Comparing numbers of inbound and outbound medica traveers from 2000 to 2010 (see Appendix 15), a trend in increasing outbound medica trave is visibe. Despite a temporary drop in patients from the UK traveing to access treatment in 2008, the data show that the number of outbound traveers in 2010 exceeded the number of inbound traveers for the first time. Characteristics Most inbound medica tourists are in the age group 35 44 years (22%), with 18% of medica tourists between the ages of 45 and 54 years and 19% between the ages of 55 and 64 years; 16% were aged 65 years. A much smaer number of chidren and young aduts were inbound medica traveers. Interestingy, this differs from the demographic profie of those traveing from the UK to seek treatment abroad. Amost one-third (30%) of a UK patients traveing abroad are aged between 25 and 34 years, 20% are aged between 35 and 44 years and 16% are aged between 45 and 54 years. Overa, Figure 5 shows outbound medica traveers to be comparativey younger than those who trave into the UK to access medica treatment. Queen s Printer and Controer of HMSO 2014. 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. 31

MAPPING PATIENT INWARD AND OUTWARD FLOWS FIGURE 4 Map depicting tota numbers of medica traveers to the UK and their countries of origin over the period 2000 10. 0 499 500 1499 1500 4999 5000 9999 10,000 14,999 15,000 19,999 20,000 24,999 25,000 29,999 30,000 100,000 32 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 35 30 25 Percentage 20 15 10 5 Inbound Outbound 0 0 15 16 24 25 34 35 44 45 54 55 64 65 Age (years) FIGURE 5 Medica traveers by age. There is aso a difference in gender spit between inbound and outbound medica tourists. More women than men trave out of the UK to access medica treatment, whereas a greater number of inbound medica tourists are mae. This appears stabe across the decade when ooking at the average across 2000 10 and considering the ast coupe of years individuay. Discussion Data anaysis highights the characteristics of inbound and outbound UK medica trave. The argest number of patients traveing into the UK are from Ireand and more than haf of a UK patients trave to Europe (both Northern, Western and Southern Europe and Eastern and Centra Europe) to access treatment, with France being the most popuar destination country for UK patients when ooking across the decade (see Appendix 15, Figure 15). This seems to confirm the importance of proximity for patient choice of destination observed in other empirica work. 85,116 It is aso worth highighting the fact that many of those who have traveed into the UK for treatment may be expatriates, especiay those traveing from countries such as France and Spain. It is possibe that this group of peope may be using knowingy or otherwise NHS services when they are not entited to do so. Given that such high numbers of inward traveers are from regions with high concentrations of UK expatriates, this issue deserves further study. Trave to South Asia on the other hand has remained reativey stabe over the past years. Studies that demonstrate the importance of diaspora inkages for medica trave 87,94 may offer a ikey expanation for this. Diaspora inkages coud aso be an expanation in the past for the arge number of inbound medica traveers from Ireand. Data confirm that the UK is a destination for medica traveers, incuding from the Guf States in the Midde East (see Appendix 15, Figure 16). Taken together with the information avaiabe on age groups of inbound medica traveers, it may be ikey that patients from the Midde East are accessing speciaist care in the UK private sector. Demographic factors such as age and sex of outbound medica traveers from the UK comparativey younger and more women coud potentiay indicate that cosmetic and fertiity treatments are key areas of medicine for which patients trave, as has been shown in incidenta reports 102 and recent survey resuts. 104 Queen s Printer and Controer of HMSO 2014. 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. 33

MAPPING PATIENT INWARD AND OUTWARD FLOWS Trends Anaysis over time confirms recent media reports of a growing number of medica traveers to Poand and Hungary. This is ikey to incude patients traveing for cosmetic, denta and fertiity treatment. These were confirmed in our research as areas of medicine for which both countries are marketing themseves. Examining time trends aso shows how medica trave is changing. Notabe in this respect is the growth in medica trave to East Asia. No patients traveed to this region before 2003 yet in 2010 17% of a UK medica traveers visited the region. At the same time, athough the overa voume of patients from the UK seeking treatment abroad grew, a comparativey smaer percentage of these were traveing to Europe. For exampe, in 2009 70% of a UK patients seeking treatment abroad traveed to Europe, whereas in 2010 this had reduced to 58%. This may indicate a changing trend in medica trave from Europe towards ong-hau destinations, athough it shoud be noted that Europe remains the most popuar destination for medica trave and Centra and Eastern Europe have seen a steady increase across the decade. The rapid increase in the number of traveers from Ireand to the UK over the past 3 years coud be an effect of the economic crisis, which has resuted in greater imitations on services avaiabe within the pubic sector in Ireand. This woud then infer that these patients are ikey to access care in the pubic sector. Simiary, the growing number of inbound medica traveers from Greece over the past 2 years may be associated with the effects of the economic crisis there. This is particuary ikey given the documented impact that this has had on heath. 143 The dip in both inbound and outbound medica trave evident in Figure 1 in 2008 may be attributabe to the onset of the crisis. Examining the number of traveers by quarter there was a much ower number of inward and outward medica traveers in quarter 3 of 2008 during the onset of the crisis than during the rest of 2008 or in quarter 3 of 2009. Data confirm an overa rising trend in the number of patients traveing from the UK to access treatment but a stabiisation and decine in numbers of patients traveing into the UK to access medica services. The year 2010, the ast year for which data were anaysed, represented a tipping point at which the UK became a net importer of heath-care services with a greater number of patients traveing out of the UK to access treatment and care than patients seeking services in the UK. Given the age of outbound medica traveers the argest percentage of whom are 25 34 years od this trend seems ikey to continue. This study offers the most extensive anaysis of the most robust data set on inward and outward UK medica trave to date. This data set is not without its imitations. First, the data are usefu ony if passengers have answered the survey questions honesty; as we have encountered throughout this project, many do not wish to discuss heath matters. Second, the samping strategy empoyed by the ONS is not without faws. Third, upscaing raw data regarding destination countries and countries of origin on the basis of an estimate of the proportion of passengers samped is risky. That said, some of the resuts of this anaysis add credence to some of the hypotheses and trends described in the recent academic iterature and show that medica trave is compex and not a uniform phenomenon. Given that the IPS data indicate that 63,000 UK citizens or 0.1% of a popuation of 65 miion trave per annum from a country with a NHS, it may be that the often-touted figure of 500,000 750,000 or 0.2% of Americans traveing abroad is reaistic, athough this wi incude arge numbers of diaspora traveers, especiay to Mexico. We can probaby suggest that the debate shoud be firmy moved on from the estimates provided by McKinsey. 12 A growing number of patients from the UK are traveing abroad to access treatment. The majority of patients trave within Europe but an increasing number are seeking treatment further afied. Findings show a growing trend in UK patients traveing specificay to Poand and Hungary in Centra and Eastern Europe, and a growth in trave to East Asia. Findings aso confirm a sight overa decine in inbound medica trave, but a growth in numbers of traveers from Ireand, Greece and Nigeria. Furthermore, the data support some of the characteristics of medica trave described in the iterature. This incudes the importance of proximity in determining where patients trave to seek medica treatment and the importance of diaspora inkages for patients traveing abroad. Some of the findings appear 34 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 unexpected, such as the recent increase in inbound trave from Nigeria, which coud be an indication of economic growth in the country. At the same time the findings sti provide ony imited demographic information on patients who trave and their conditions and expenditure. Specific further research is required to investigate some of the observations that our anaysis aows. This incudes the decine in numbers of traveers from the Midde East, the effects of the economic crisis on inbound medica trave and the increase in outbound medica trave to East Asia. Further information on these woud aow an even better understanding of why patients trave and the impact of this trade in heath services on the NHS and other heath systems. Based on this data anaysis, incuding the reative youth of patients from the UK, outbound medica tourism ooks set to grow with the UK becoming an importer of heath care. The impact of medica trave on the UK pubic, incuding patients returning with compications or ongoing care needs in the absence of cear and reiabe guidance, ooks set to offer increasing chaenges to poicy-makers in the UK and gobay. More broady, our anaysis highights heath services as a tradabe commodity that behaves just as financia markets do sensitive to externa events. The increase in the number of patients visiting the UK from Greece and Ireand shows the effects of the economic crisis on medica trave. Simiary, the drop in trave observed from some countries and the growth of trave from Nigeria a refect wider deveopments in the goba economy, showing how medica trave acts as an indicator of gobaisation and its effects on heath. Queen s Printer and Controer of HMSO 2014. 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. 35

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 Section 2 Patient safety and service quaity Section 2 focuses on patient safety and service quaity. It draws on two sets of data. The first incudes desk-based materia that was coected to understand the context and practice of patient safety and service quaity in the context of medica tourism. The second incudes interviews with NHS managers (primariy those with commissioning and pubic heath roes) and a range of interested stakehoders representing professiona societies and those with expertise regarding issues such as mapractice and indemnity, heath poicy and trave heath. This part is organised around four themes, refecting the key factors that we perceive as enabing quaity, safety and choice: ega: a review of the ega context and background (see Chapter 6) education: issues reating to informing and educating medica tourists (e.g. regarding website resources and guideines) (see Chapter 7) quaity and safety: expores the roe of EQA (see Chapter 8) performance and outcomes: detais the reevant dimensions of QISs (see Chapter 8). For expanatory purposes these four points can be viewed as a patient safety and service quaity diamond for medica tourism (Figure 6). Lega QIS Patient safety for treatment choices and quaity services Information, education and knowedge EQA FIGURE 6 Medica tourism patient safety and service quaity diamond. Queen s Printer and Controer of HMSO 2014. 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. 37

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 Chapter 6 Lega dimensions of outward medica trave The medica tourist faces uncertain ega difficuties at each point in the treatment process (Figure 7). Heath-care consumers face particuar chaenges in making choices given the often episodic nature of heath care, information asymmetries with providers and probems of measuring and assessing quaity both before and foowing treatment. Particuar probems incude: Initia advertising and search for information. Prospective medica traveers require information and opportunities to identify cinicians and cinics, sometimes using companies that act as intermediaries to faciitate this search. Such information searches, and the associated promotion and advertising of treatments and faciities, present difficuties. Purchasing treatment and anciary services. There are decisions to make about what treatments to purchase, whether or not to use a broker, whether or not to take out trave insurance and opportunities for pretreatment consutation. A combination of services may contribute towards the medica tourist experience at different stages of the process, incuding product advertising, initia internet consutation, brokerage services, the treatment itsef and various combinations of the above. There are a number of uncertainties, incuding who is iabe when there is a deficiency in the quaity of treatment (heath-care professiona, cinic or broker) and the precise coverage of insurance. Seers of insurance products in the UK may themseves be subject to reguation by the Financia Services Authority (FSA). Questions incude who has responsibiity for meeting the additiona costs of compications that arise during, or as a resut of, surgery and how is redress best pursued. Longer-term aftercare. Beyond the immediate treatment, there are questions about a surgeon s and a cinic s ega duty to provide foow-up if the procedure resuts in adverse outcomes for the patient, both immediatey foowing the procedure as we as in the future. Obtaining persona and provider information To begin their treatment journeys, patients (at some point in their decision-making) may seek to obtain their own persona medica (or denta) records and attempt to ensure that they have adequate information about medica treatments avaiabe overseas. Individuas in the UK are entited (under the Data Protection Act 1998 144 ) to have access to their persona heath information, incuding NHS and private heath records hed by a GP, optician or dentist or by a hospita (e.g. denta records and radiographs). An administration fee may be charged depending on whether records are hed eectronicay or in paper format. Under the Data Protection Act, requests for access to records are required to be met within 40 days. However, government guidance for heath-care organisations states that they shoud aim to respond within 21 days. A request may be refused if it is beieved that reeasing the information may cause serious harm to an individua s physica or menta heath or that of another person. With regards to provider information, medica tourism services are marketed and advertised vigorousy and a key driver for such promotion is the high-profie technoogica patform afforded by the internet for consumers to access heath-care information and advertising from anywhere in the word. Within the UK, the advertising of medicines for human use is tighty egisated and is reguated by a unit within the Medicines and Heathcare products Reguatory Agency (MHRA). The advertising of treatment services, incuding medica trave abroad, is outside the MHRA s remit of responsibiity for medicines and devices. Within the UK, heath care has not traditionay been viewed as simpy another product to be advertised. However, the marketing of domestic cosmetic surgery is increasingy commonpace in the UK (incuding biboards) and the Committee of Advertising Practice has reeased guidance on the interpretation of rues in the British Code of Advertising. 145 The Advertising Standards Authority (ASA), which is independent of Queen s Printer and Controer of HMSO 2014. 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. 39

LEGAL DIMENSIONS OF OUTWARD MEDICAL TRAVEL Information Consutation and treatment Aftercare and foow-up Advertising Websites Faciitators Patient records Pre-consutation Post-surgery Purchase treatment (treatment, Longer-term trave, foow-up and recuperation management of and insurance) conditions FIGURE 7 The patient journey. the government and the advertising industry, is the main body responsibe for deaing with compaints in the UK. The ASA investigates compaints and proactivey monitors and takes action against miseading, harmfu or offensive advertisements, saes promotions and direct marketing. 146 If a compaint is uphed, the advertiser must withdraw or amend the advertisement and not use the advertising approach again. The remit of the ASA incudes onine advertising for paid advertisements, marketing messages on a provider s own website and marketing communications in spaces that incude Twitter and Facebook. ASA s coverage is imited, however, to UK websites. The ASA has on occasions rued on domestic advertising of treatment services. For exampe, it rued against advertising that promoted invasive cosmetic surgery as being without risk and safe. It stated that such content was irresponsibe and miseading and breached causes reating to socia responsibiity and truthfuness. 147 The body has aso criticised a biboard advertising campaign that emphasised the speed and costs of cosmetic treatment because, in its judgement, this triviaised cosmetic surgery and conficts with advice esewhere in the advertisement about the need for consutation before surgery. 148 From the standpoint of professiona standards, a major function of the Genera Medica Counci (GMC) 149 is to foster good medica practice. Its good medica practice guideines 150 contain a number of impications for treatment promotion and marketing, noting: 60. If you pubish information about your medica services, you must make sure the information is factua and verifiabe. 61. You must not make unjustifiabe caims about the quaity or outcomes of your services in any information you provide to patients. It must not offer guarantees of cures, nor expoit patients vunerabiity or ack of medica knowedge. 62. You must not put pressure on peope to use a service, for exampe by arousing i-founded fears for their future heath. Reproduced with permission from GMC. Good medica practice 2006. URL: www.gmc-uk.org/ Good_Medica_Practice_Archived.pdf_51772200.pdf (accessed 9 September 2013). GMC. It shoud be noted that the 2006 guideines, quoted here, were withdrawn on 22 Apri 2013 and repaced with an updated set of guideines (see www.gmc-uk.org/gmp for the atest edition). The GMC aso has responsibiity for keeping an up-to-date register of quaified doctors and seeks to dea firmy and fairy with doctors whose fitness to practise is in doubt. The EU E-Commerce Directive (2000/31/EC) 151 has impications for website quaity and requires a companies to dispay ways in which the website can be contacted. The European Court of Justice has rued that this may incude a teephone number and a contact form that is answered within an hour. The ruing impacts on e-businesses operating within the EU and requires that the name of the service provider, the geographica address of the service provider and service provider detais incuding the e-mai address where it may be contacted at short notice must be provided before a contract can be entered into through 40 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 the website. As our own review of websites found, many European sites (but not a) adhere to these requirements and the vast majority carry cear privacy statements on how persona data are protected. Potentia medica tourists face the diemma that there is no guarantee of the veracity or egitimacy of caims made on websites. Treatment outside of jurisdiction poses probems for the effective reguation of advertising and promotion. Athough the ASA wi refer compaints about advertising that originate from outside the UK to the European Advertising Standards Aiance (covering 24 European countries) and to some countries outside of Europe (incuding India), the reach of these is unikey to prevent companies breaking reguations through their internet-based advertisements. The sheer number of websites operating in the medica tourism fied further compicates the issue. Simiary, cross-border compaints against GMC-registered cinicians operating outside of the UK are ess ikey to resut in charges than if such individuas were practicing within the UK. In summary, the rise of medica tourism has been a argey onine phenomenon and it is the internet that provides the arena in which a key stakehoders (from the patients, through the faciitators, to the providers) can interact. In the offine word where such decisions are taken in doctors surgeries and hospitas, there is at east a sense that information is authoritative, impartia and trustworthy. There is a genera appreciation of the existing and potentia probems reated to heath information on the internet, especiay given the increasing quantity of heath-reated websites. Issues of accuracy have ong been a concern, athough perhaps compounded by the burgeoning number of sites whose primary purpose is to market products rather than inform. What is ess cear is how (if at a) the quaity of information provided to medica tourists shoud be reguated, with suggestions beyond egisative contro ranging from codes of conduct to sef-taken quaity abes, user guidance toos and third-party quaity and accreditation abes. Lega redress The ack of an internationay agreed framework to reguate medica tourism or offer ega redress begs a number of difficut questions concerning: the grounds for seeking ega redress who is responsibe the cinic, surgeon or broker? in which jurisdiction to seek redress the time frame to seek ega redress. It is common practice in many countries for a patient to sue for negigence if he or she has suffered avoidabe harm as a resut of poor-quaity medica treatment. Under the aw of tort, a patient may seek compensation if he or she can provide proof of faut. He or she can aso caim under a breach of contract. The grounds for seeking redress vary from country to country. For exampe, in the case of an Austraian citizen, 152 domestic egisation woud provide an additiona third potentia route for redress in the form of action under the misrepresentation of Trade Practices (contracts) Act 1974, 153 which in January 2011 was repaced by the Competition and Consumer Act 2010. 154 In the UK, treatment is considered negigent if the court accepts that a patient has suffered injury and oss as a resut of the negigence, or that the doctor or surgeon is in breach of his or her duty of care to the patient and has faied to act in accordance with the accepted standards of a competent practitioner in his or her area of expertise. 155 However, some foreign companies may insist that medica tourists sign a ega discaimer before their treatment. These may incude causes that seek to imit where a case can be hed, the aw that governs the caim and iabiity imitation, which can reduce potentia options for redress. (An emergent area of speciaist ega services provides cients with the opportunity to seek ega redress for adverse outcomes of medica tourism. Some ega practitioners speciaise in particuar treatments, for exampe fertiity treatment abroad.) In the UK, exemption causes that excude a doctor or cinic from Queen s Printer and Controer of HMSO 2014. 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. 41

LEGAL DIMENSIONS OF OUTWARD MEDICAL TRAVEL iabiity for negigence are not enforceabe and discaimers are subject to egisation governing the fairness and egaity of their contract terms. When attempting to sue for medica mapractice abroad, there are decisions to be made about who the patient shoud sue (cinic, surgeon or faciitator) and the particuar jurisdiction where any ega case woud be heard and the aws and egisation that woud be used. Ordinariy, when both the patient and the cinician are within the EU, the cinician has to be sued in his or her home country. However, as patients are ikey to be considered as consumers, under EU consumer contract rues they can opt to sue in their home country. 155 Cinics outside of the EU woud be subject to the same issues discussed above, for exampe if they advertise in the EU they can be sued in the EU. The case for seeking ega redress in the UK is strengthened if any initia consutations, written consent or the signing of contracts or payment have taken pace within the UK. 155 A cinic that consuted in London and treated in Begium was recenty successfuy pursued using grounds of negigence and breach of contract. 155 The initia consutation was in Engish, the contract was signed and agreed in Engand and payment was made in stering. For itigation purposes it can work in a patient s favour if an overseas cinic has advertised within the UK. Cinics that specificay target UK citizens, for exampe by advertising in the UK, having an office based in the UK or having a.co.uk website address, may become subject to the jurisdiction and aws of the UK, which has impications for itigation. Overseas cinics with a UK base or a UK-targeted advertising campaign may not be fuy aware of the impications. Payment for treatment using a credit card coud aow a case to be brought in the UK against the consumer credit card company under Section 75 of the 1974 Consumer Credit Act. 156 This route has been pursued for the cost of repacing Poy Impant Prosthèse (PIP) impants in cases in which the surgery was undertaken in the UK. Beyond the iabiity of brokers, surgeons and cinics, questions arise with regard to potentia iabiity issues for UK-based heath professionas (e.g. within the fertiity fied). For exampe, when the initia consutation and advice are deivered privatey in the UK but treatment is subsequenty obtained overseas, abeit recommended through the UK faciity, who is iabe? Under such circumstances, shoud UK faciities be expected to accredit physicians within their overseas treatment network (and, if so, how woud they do this)? Are such UK heath professionas ikey to be subject to vicarious iabiity if compications arise from treatment, or is this avoidabe through their cear statement of discaimers? Medica cinics are normay iabe for the faiings of their empoyees, incuding surgeons. A cinic is usuay responsibe for advertising and arranging a patient s treatment and the patient s contract wi be with the cinic. It is therefore the responsibiity of the cinic to pursue itigation against a surgeon if it so wishes. As Vick 155 states: despite offering the package of care to the patient cinics may seek to divert bame to surgeons with whom the patient had no contract (p. 108). Even if the surgeon is registered with the GMC in the UK, his or her indemnity cover [with the Medica Defence Union (MDU) or Medica Protection Society (MPS) in the UK] is unikey to cover treatment undertaken outside the UK. 157 Conversey, the surgeon s insurance may not cover the cinic and thus cinics must aso ensure that they have adequate insurance in pace. If a cinic is not insured for a case brought in the UK, it may not be possibe to enforce a judgement in a UK court and turn the award into financia payment. Once iabiity is estabished, it may be necessary for the patient s ega representative to appy to the court in the cinic s home country for recognition of the UK judgement and permission to enforce it in that jurisdiction. 157 Finay, in some cases the jurisdictions of both the patient and the cinic may be appied. A patient may have to pursue ega action in the country where the operation took pace. This coud resut in the patient having to return to that country and having to instruct a speciaist awyer in that country, a at extra persona expense. If a patient seeks ega action abroad he or she must be prepared to dea with compications reated to anguage, oca cuture and unfamiiar aw and ega traditions. Some argue that there is a particuary high risk of foreign patients not being adequatey protected from mapractice in deveoping countries. 26 Patients shoud be made aware that other countries might have different mapractice aws and ega traditions and that these wi impact on the size of mapractice payouts. 42 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 For exampe, Maaysian standards for proving medica negigence are said to defer to physicians to determine whether the standard of care has been breached, rendering it extremey difficut for foreign patients to successfuy prosecute. 26 In India a civi case coud be brought using the Fata Accidents Act 158 and Section 357 of the Code of Crimina Procedure 159 (or via a consumer route under consumer protection egisation); however, 95% of cases are said to be dismissed because there is not a cuture of professiona critique. 160 Favourabe judgements handed down in an overseas jurisdiction may therefore be very difficut to enforce. Some countries may have a damages cap on the amount of compensation or may not aow compensation, for exampe for oss of earnings or the cost of care. For exampe, in India the eve of compensation is ikey to be extremey modest compared with Western standards. 26 In the UK and many other jurisdictions, for exampe, when a patient is awarded compensation this usuay incudes genera damages for the psychoogica and physica consequences of the negigence and specia damages for past and future financia osses incurred from the negigence. 157 A further issue concerns the time frame within which ega redress may be sought, which varies from country to country. Adverse after-effects arising from a particuar treatment may not occur for severa years, for exampe as has been the case in the recent PIP impant debate. 161 As iustrated by the PIP events, surgeons may be difficut to trace and cinics may no onger be in business. 162 In the UK the deadine for fiing a persona injury caim is 3 years from the treatment or the patient s date of knowedge of compications, but other countries may have shorter time frames for seeking ega redress. Even within the EU the time imit varies, for exampe from 1 year for caims in Spain to 3 years for caims in the UK. 155 In summary, we are entering reativey uncharted and rapidy changing territory with regards to the ega dimensions of outward medica trave, and the increased use of the internet further compicates this ega uncertainty (see Appendix 16 for a discussion of this in reation to fertiity treatment). There is no cear egisative picture or deveoped body of case aw to guide practice in this area. There are cear imitations in the current ega framework that bunt one point of the medica tourism safety and quaity diamond. Athough cases have been successfuy argued (see Appendix 17 for an exampe), patients ooking to rey on the existing UK framework in the event of adverse outcomes shoud be warned: caveat emptor buyer beware. Impications for the NHS Prospective patients may not be aware of the ack of cear avenues for redress shoud treatment abroad give rise to unexpected compications. Lega uncertainty and compexity bedevis a phases of treatment abroad: access to information, preconsutation, treatment itsef, aftercare and foow-up. Longstanding safeguards for UK heath care (e.g. GMC registration) may have itte reevance if treatment is received out of jurisdiction. The need to seek redress and the subsequent ega impications may become apparent many years foowing treatment, when compications have emerged. Queen s Printer and Controer of HMSO 2014. 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. 43

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 Chapter 7 Education and information The second point of the safety and quaity diamond focuses on educating and informing prospective medica traveers and, potentiay, doctors and aied heath professionas in the UK with whom they may consut. To expore education and information, we undertook two empirica reviews: first, we ooked in detai at websites that promote and market treatment services abroad and, second, we reviewed the range of trave guidance and checkist documents around medica tourism that are avaiabe. Website anaysis of outward medica trave A key driver of medica tourism is the patform provided by the internet for consumers to access heath-care information and for advertising. The aim of the foowing discussion is to provide a systematic review of medica tourism websites, describe their range and content and begin to examine their quaity and the impications of this in reation to decision-making. We first present an overview of medica tourism websites and a conceptua framework to understand these. This is foowed by a detaied review of 100 commercia medica tourism websites for denta tourism using checkists adapted from proposed questions that consumers shoud ask, according to a number of nationa-eve bodies. Finay, we present a consideration of the broader impications of these findings. There has been a burgeoning of websites dedicated to providing information for medica tourists in recent years. Athough restricting its coverage to Engish-anguage websites, one scoping study suggests that a usefu typoogy of websites can be drawn: (1) commercia portas (to aid the search for treatments and information about them); (2) media sites (e.g. carrying weeky features and updates); (3) consumer-driven sites (incuding discussion boards and bogs); (4) commerce-reated sites (advertising anciary products such as finance or accommodation); and (5) professiona contributions (from professiona associations, poicy-makers and reguators). 90 Medica tourism websites perform a range of functions. First and foremost the scope of the websites is to introduce and promote services to the consumer. The main functions of the websites can be separated into five main processes: as a gateway to medica and surgica information; to provide connectivity to reated heath services; for the assessment and/or promotion of services; commerciaity; and an opportunity for communication. 90 The range of medica tourism websites and reated content raises famiiar concerns associated with unreguated onine heath information. 163 165 The sites are reativey cheap to set up and run and contributors may post information without being subject to cear quaity contros. A contextua deficit means that seective information may be presented, or information may be presented in a vacuum, ignoring issues such as the need for and avaiabiity of postoperative care and support. There is aso the possibiity of unreiabe products being marketed via the internet: poor-quaity surgery or inadvisabe treatments or unnecessary and even dangerous medica care. Cear evidence from other studies suggests that the quaity of heath information onine is variabe and shoud be used with caution. There have been some suggestions that the quaity of information has been improving as a consequence of the increasing use of peer reviewing of information on increasingy interactive websites; 166 however, it is sti best characterised as being of variabe and suspect quaity. 167 169 In one study concerned with the quaity of information on the internet pertaining to infammatory bowe disease, researchers found that ony 14% of websites offered high-quaity information. 170 A review 171 of patient-oriented methotrexate information on the internet found many of the same issues identified by Bernard et a., 170 especiay that the eve of technica anguage was restrictivey high and so Queen s Printer and Controer of HMSO 2014. 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. 45

EDUCATION AND INFORMATION not easiy understandabe by prospective consumers. However, this study did note that there were some exampes of extremey high-quaity information that were not ony avaiabe but aso presented on the first page of the Googe search engine returns. One of the issues that they identified was not that information suppied by websites was erroneous but rather that some of the information that experts woud expect to be provided was simpy missing. 165 It is of course possibe that missing information simpy refects the specific focus of a website or perhaps is even a refection of frequenty asked questions (FAQs) posed of a site. However, there is aso the scope to provide misinformation simpy through the omission of important information. Mason and Wright 95 suggest that this is a very rea concern where medica tourism websites are concerned. Their review of 66 medica tourism websites noted a distinct overseing of the positive aspects of medica tourism and a significant downpaying of the risks. Systematic review: sites promoting commercia denta and weight oss surgery Two sampes of commercia websites, the first offering treatment services abroad in the fied of denta surgery and the second offering weight oss surgery abroad, were identified in the first instance (Tabe 3). Buiding on pubished methodoogies, 163,165,169 171 50 sites were seected by interrogation of the Googe search engine with ay terms for both treatment types. Athough there is variation in the precise methodoogy adopted, the iterature is repete with exampes of studies adopting this broad approach. TABLE 3 Destinations promoted by the websites in the website review Country ocation of dentist/cinic Number of sites in denta sampe Number of sites in weight oss sampe Tota number of sites Hungary (mosty Budapest) 25 1 26 Mutipe ocations 10 7 17 Begium 0 13 13 Czech Repubic 1 9 10 Spain/Tenerife 2 3 5 Poand 3 1 4 Turkey 2 1 3 Mexico 0 3 3 India 0 3 3 Ukraine 2 0 2 Lithuania 0 2 2 USA 0 2 2 Itay 0 1 1 Tunisia 0 1 1 France 1 0 1 Sovenia 1 0 1 Switzerand 1 0 1 Germany 1 0 1 Tota 49 (pus 1 with broken ink) 47 (pus 3 with broken ink) 100 (incuding 4 with broken ink) 46 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 We beieve that our sampes are an accurate refection of the type of sites that consumers are presented with when searching the internet. The major assessment of the sites then invoved the utiisation of two simiar, athough not identica, cinica checkists (see Appendix 18 for methods and protocos). A detaied anaysis of the websites is provided in Appendix 19. Discussion The rise of medica tourism has been a argey onine phenomenon and it is the internet that provides the arena in which a of the key stakehoders (from the patients through to the faciitators to the providers) are connecting. But it is not necessariy a safe arena; in the offine word where such decisions are taken in doctors surgeries and hospitas there is at east a sense that information is authoritative, impartia and trustworthy. The internet does not offer this and it is hard not to see the marketing interests behind even the most reassuring information found on the internet. With regard to the websites that we reviewed, there were many affirmations of integrity, quaity and caring services. There was an abundance of guarantees of professionaism, safety and a continuation of care. However, there can be no assurance that such guarantees are anything but empty promises. How we reconcie the potentia of the internet, its endowment of individuas with ever-increasing eves of choice, with the risks inherent with an unreguated and uncontroabe content in a way that empowers patients is uncear and undoubtedy not straightforward. Evidence shows that heath-care consumers increasingy use the internet to access both information and heath-care products and that an even greater proportion of peope woud consider doing so. 172 This incudes peope who are using, or woud consider using, the internet to organise treatment abroad. 173 It is evident that information is often confusing, overwheming and even contradictory a fact that is acknowedged by many heath-care reguatory bodies. 137 Medica tourism is a consumer industry primariy marketed onine and as such there are serious potentia issues facing those considering traveing abroad for treatment. Issues of accuracy are ongstanding, athough perhaps compounded by the burgeoning number of websites whose primary purpose is marketing products, as is the case with websites that promote medica tourism. It is common to identify misinformation, unsubstantiated scientific caims, fear-provoking threats and a ack of information on the uncertainties and the risks of particuar services. On the whoe, websites do not mention ong-term risks or probems, imiting themseves to acknowedging that further treatment may be necessary as a consequence of hitherto unknown circumstance. 95,174 Whether or not it is possibe to guarantee a universa minimum standard for the quaity of medica tourism information is uncear. To this end, suggestions range from the deveopment of codes of conduct, user guidance toos and third-party quaity and accreditation abes, 166 to educating users and assisting those wishing to search for information. 164,165,169 However, a arge and ever-increasing number of quaity measurement toos (many of which represent commercia ventures) exist, which makes seecting an authoritative too impractica. Moreover, many of these systems are not accessibe to a ay audience. 175,176 Some studies aso recommend that prospective e-patients or e-heath consumers shoud be educated by their offine medica professiona. Lawrentschuck et a. 169 go as far as to suggest that professionas shoud take the time to provide a steer to ethica, accurate, readabe and accessibe websites. This is echoed by Scuard et a. 165 and both studies make the recommendation that, if heath-care professionas can direct patients to government websites or other such reputabe sources of information, patients wi be abe to minimise risk. There are of course severa probems with this approach. First, patients are motivated on the basis of what they find on the internet, rather than from having visited a heath-care professiona offine. Second, even when potentia e-patients/consumers have visited heath-care professionas it is not necessariy the case that these professionas wi be aware of reputabe sites beyond perhaps the broad and often genera sites such as NHS Direct. Third, some of the sites assumed to conform to quaity-based expectations do indeed fa short. Queen s Printer and Controer of HMSO 2014. 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. 47

EDUCATION AND INFORMATION Others argue that debates over the quaity of information shoud simpy move on. 166 The new features of many websites brought about by the advent of Web 2.0 have, they insist, inspired a heath 2.0 to emerge. They argue that the increased interactivity through the use of bogs, wikis and podcasts, often provided by not just heath-care professionas but aso researchers and the genera pubic, has heped formuate a new e-heath era that is taiored to the needs of those who access it. Cruciay, this bottom-up approach invoves a process that is anaogous to peer reviewing, drawing on rea-ife experiences, but aways ensuring that an expert source is nearby. However, the findings of our study, aongside with other findings mentioned in this discussion, suggest that, at east for those new to searching the internet for heath information, there is a ot of poor-quaity information that is ikey to be found, and discerning what is usefu and what is not is no easy task. It is perhaps easy, abeit miseading, to think of the reationship between patients and heath-care providers having fundamentay and irrevocaby changed as a consequence of the internet. Even now there is a feeing that word of mouth is sti the main driver behind new patients registering with denta practices 177 and that this reationship of trust between professiona and patient may hod the key to how the internet can be best harnessed for patients, with trusted professionas paying a arger roe in providing heath-care information onine. Anaysis of medica tourism trave information, advice and guidance Given that web-based resources have cear commercia interests, prospective medica tourists may seek to ook towards more objective impartia advice. Trave for medica treatment combines both the potentia uncertainty of trave arrangements (trave deays and canceations, risks to persona safety) and the risks inherent in receiving medica treatment. We sought to understand the range and nature of trave advice that prospective medica tourists coud access to assist them in making informed decisions about overseas trave for treatments. An internet-based search was conducted to determine where potentia medica tourists are abe to find information, advice and guidance and what that may incude. The research team identified and discussed the potentia professiona, reguatory and poicy organisations in which there were cear impications of medica tourism or that had commented, pubished or spoken about medica tourism. These sites, aongside those suggested by a broader search of keyword combinations ( guidance, guideines, advice, checkists, trave, treatment, surgery abroad, medica tourism ), contributed towards the corpus. We aso expored the sites of consumer/advocacy organisations and during our website review (see Appendix 20) recorded sites on which guidance and advice was offered by commercia providers and entities. When repetition was evident within these searches, and eads did not provide additiona sites to investigate, we took this to signa that data saturation had been achieved. A tota of 30 websites were identified as potentia sources of information, advice and guidance; these were reviewed for their content about medica trave. The sites can be grouped into four different types: professiona, reguatory, consumer and commercia. Tabe 4 detais a sma, non-exhaustive seection of organisations that offer information, advice and guidance regarding medica tourism. These are grouped based on the primary roe of the organisation, athough there is ikey to be some overap, especiay between professiona and reguatory organisations. Haf of the professiona sites did not contain information, advice or guidance about medica treatment, medica trave or medica tourism. Regarding the information, advice and guidance that was avaiabe to medica tourists (in particuar from professiona and reguatory bodies), such materia was often difficut to find, requiring specific searches within organisation websites, and was rarey signposted from industry sites. Information, advice and guidance were in a number of formats and the depth and quaity of advice varied consideraby. Information and checkists are the most common formats across a types of sites, but 48 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 TABLE 4 Exampes of sources of avaiabe information, advice and guidance for outward trave Primary roe of organisation Professiona Reguatory Consumer or advocacy Commercia Exampes British Association of Aesthetic Pastic Surgeons, BAPRAS, Foreign & Commonweath Office, Nationa Trave Heath Network and Centre (NaTHNaC), NHS Choices, Department of Heath Human Fertiisation and Embryoogy Authority, Genera Denta Counci, GMC Which?, Infertiity Network UK, British Obesity Surgery Patient Association Medica Tourism Association, Internationa Medica Trave Journa, JCI a few sites from across the types incude guideines or FAQs sections. A tota of 14 sites provided detaied information, advice and guidance specificay reated to traveing abroad for treatment. The FAQs across the websites vary from focusing on practica questions that prospective patients are ikey to ask, such as how do I know if the cinic is cean and safe?, 178 to more generic ones about the industry, such as what types of treatment do peope trave for? 179 Guideines often take the form of information provision, such as the British Association of Aesthetic Pastic Surgeons consumer safety guideines. 180 Checkists and questions to ask are tick box exercises that attempt to ensure that patients have a of the information, advice and guidance that they need. A more detaied anaysis of the advice, information and guidance can be found in Appendix 20. Impications for the NHS There remain doubts about whether or not website information faciitates treatment choice which ensures that care is effective, persona and safe. The risks of treatments are not fuy detaied; unsurprisingy, there exists an imbaance of information and marketing materia. A range of UK advice exists for prospective traveers; typicay, this focuses on treatment decisions and does not ceary identity the ack of a cear framework for redress and that patients may be personay iabe for treatment costs that do not fa within NHS entitements. The onus is on prospective medica tourists to ocate guidance and advice. Queen s Printer and Controer of HMSO 2014. 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. 49

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 Chapter 8 Externa quaity assessment and quaity information systems There are many definitions of quaity in heath care, with the US Institute of Medicine s being probaby the most infuentia, with heath-care quaity defined as the extent to which heath services provided to individuas and patient popuations improve desired heath outcomes. In this sense care shoud be based on the most robust cinica evidence and provided in a technicay and cuturay competent manner with good communication and shared decision-making. Important dimensions of quaity commony associated with heath care incude effectiveness, efficiency, safety, equity, appropriateness, timeiness, acceptabiity, patient responsiveness, satisfaction, heath improvement and continuity of care. The measurement and assessment of heath-care quaity is beset by confusion, with different reguatory bodies promoting different processes and no way to reconcie common standards across borders [Chares Shaw and Pau Stennett, independent accreditation expert and Chief Executive, United Kingdom Accreditation Service (UKAS), 2012, persona communication]. Some have suggested that the ack of transparency with regard to quaity prevents the medica tourism market from fourishing. 12 Indeed, the ack of robust cinica governance arrangements and quaity assurance procedures in provider organisations has ed to concerns over the quaity and safety of some overseas providers. 181 EQA has the capacity for improving cinica effectiveness, quaity and safety and ensuring pubic accountabiity, 182 athough such processes themseves face cas for greater transparency in the evidence base on which they are reiant. 183 The most common EQA modes are statutory inspection, pubic sector education programmes for training and testing private providers, industry-based assessments such as Internationa Organization for Standardization (ISO) certification, and heath care-based assessment through peer review. 182 A more detaied discussion of EQA is provided in Appendix 21. The importance of externa quaity assessment for medica tourism There is a diverse range of different types of EQA and reguation empoyed by organisations (for a fu review see Appendix 22) and consumers are therefore ikey to fee confused and anxious when trying to assess which cinic to access. When making a decision about which cinic and surgeon to seect, medica tourists are ikey to expect safe treatment as a minimum and are aso ikey to be motivated by considerations incuding quaity and cost. How best to judge quaity and safety is one of the most difficut issues for a prospective medica tourist to address in their decision-making process. In searching for providers, there is a pethora of abes and symbos (on website and marketing materias) professing some form of accreditation, certification or professiona registration. However, few woud understand the bewidering array of EQA and badges used by different companies and countries. With a ack of internationa reguation or egisation governing this fied, providers and patients aike may ook to accreditation and certification to prove their standards and inform their decisions respectivey. As part of our investigation into this area, empirica research was undertaken to examine the roe of accreditation and certification used by providers. A systematic review of websites for denta, bariatric and cosmetic surgery was undertaken to understand how they reported their EQA and registration status. Denta surgery externa quaity assessment: an empirica review Foowing our review of 50 websites advertising denta treatment abroad, the same sampe was used to further investigate the forms of (1) accreditation, (2) certification and (3) professiona registration that they Queen s Printer and Controer of HMSO 2014. 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. 51

EXTERNAL QUALITY ASSESSMENT AND QUALITY INFORMATION SYSTEMS ay caim to. Of the 49 websites with working inks, 24 dispayed a range of different forms of accreditation and professiona registration. However, none provided detais on precisey what these meant or an expanation of whether they were a form of accreditation or professiona registration. Bariatric surgery externa quaity assessment: an empirica review Using the bariatric surgery website data set, 50 sites were further systematicay investigated for forms of accreditation, certification and nationa reguation. Of the 49 sites that were accessibe, 25 sites dispayed some form of EQA, athough the amount of detai varied consideraby. Cosmetic surgery externa quaity assessment: an empirica review Finay, 50 sites used by Lunt and Carrera 184 in their discussion of patient advice and sources of information for decision-making were revisited and anaysed for EQA. Simiar to the bariatric surgery review, a arge range of bodies was cited, 46 in tota. However, ony 18 websites provided any detais of accreditation, certification or reguation. Further detais of these three sets of findings may be found in Appendix 22. Quaity information systems The pubic reease of information on the absoute and reative performances of heath-care providers may improve the quaity of care and promote transparency and accountabiity among heath-care consumers and payers. 185,186 There is a range of information systems reporting on the quaity or performance of providers of heath care ( quaity information systems ) that coud, pausiby, be of vaue to prospective medica traveers. Quaity information systems may have mutipe aims and objectives incuding faciitating patient choice, improving quaity by changing provider behaviour and systems, and providing greater carity and accountabiity for provider commissioner reationships. However, deveopment of such systems is patchy, particuary among those countries that are ower-cost destinations. 185 Aside from the avaiabiity of such information, evidence suggests that there is a ow uptake of pubished information, it does not sufficienty meet patients information needs and it is not easiy understood. 187 189 With regard to the UK context, for exampe, there are a range of dimensions for the pubicy funded system (Tabe 5). However, it woud appear that reativey few systems exist that are pubicy avaiabe and accessibe for the prospective medica tourist and faciitators seeking to arrange trave to other EU and non-eu countries. For exampe: Thaiand. There are no cear information portas or sources that gather/compare heath-care providers for purposes of statutory reporting requirements. Beyond a site provided by the Tourism Authority of Thaiand that ists hospitas and other providers of medica services, there is itte avaiabe information. There are numerous privatey owned websites, but information is descriptive with regard to the services, treatments and faciities that are avaiabe. Information is not routiney coected/pubished for key indicators by nationa or regiona agencies and so meaningfu comparison across faciities is difficut (e.g. infection, outcomes, adverse effects). Spain. There are numerous commercia sites providing detais of hospitas and faciities, which may incude statements about the quaity standards that are hed by institutions. The Ministry of Heath website provides information on the Spanish NHS system; however, there does not appear to be a soid information system on quaity. There are extensive reports on accreditation and quaity in terms of patient safety but there are no comparisons between providers. India. Athough it is possibe to identify > 5500 hospitas by region, there are no cear quaity assessment resuts. There are commercia search engines but no QIS data that woud faciitate an informed choice. The Ministry of Heath and Famiy Wefare, the governmenta body that ooks after quaity contro in hospitas and cinics, is said to be estabishing minimum quaity standards to reassure patients seeking treatment abroad. 52 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 TABLE 5 Sources of QIS advice avaiabe in the UK Organisation NHS Choices Dr Foster Inteigence a Care Quaity Commission b Patient-reported outcome measure (PROM) c Monitor d Source of quaity information Trust quaity accounts provide information on quaity of care, specific cinics, treatments and staff information. Key performance indicators are examined; resuts are coour coded and graded 1 10. Patient feedback is avaiabe incuding patient survey scores. Incudes indicators that stress underachievers and ow quaity Provides information on NHS mortaity rates, patients discharged within 56 days and waiting times Reports whether or not trusts meet standards set by the Commission. Exampes incude treating patients with respect, providing care that meets peope's needs, patient safety, staffing and quaity, and the suitabiity of management. Summary of assessment provided. Latest inspection reports avaiabe for review PROMs cacuate heath gain after surgica treatment using pre- and postoperative surveys for four procedures: hip repacement, knee repacement, hernia and varicose veins Information mainy on financia and risk indicators a http://drfosterinteigence.co.uk/. b www.cqc.org.uk/. c www.nhs.uk/nhsengand/thenhs/records/proms/pages/aboutproms.aspx. d www.monitor-nhsft.gov.uk/. Cyprus. Most arge heath-care providers are owned by the pubic sector and there are no cear comparisons between them. On the Ministry of Heath website there is a section that is supposed to provide statistica information on hospitas but it does not work in either Engish or Greek. Again, most of the websites that ist providers are internationa ones for promotiona purposes. Poand. Nothing was identified that detais information on quaity or aows comparison between providers. Impications for the NHS There is a pethora of EQA and registration detais dispayed on websites. There are no cear patterns in take-up of different EQA forms, perhaps refecting that European cinics within the medica tourism market are reativey sma. How EQA and registration detais are presented assumes significant heath iteracy by website users. EQA does not fufi the function of providing reevant signposting to patients. As part of the research, 16 representatives of professiona associations and agencies (incuding Roya Coege and Cinicians Associations representatives) were seected in a purposefu sampe based on their knowedge and experience of the possibe impact or consequences of medica trave to and from the UK and were interviewed. We aso interviewed individuas within NHS commissioning organisations to expore issues and impications for the NHS arising from UK popuations traveing abroad for treatment. These incuded six NHS managers based in PCTs and strategic heath authorities (roes incuded director of pubic heath, head of commissioning and community partnerships). Further, we spoke to a sma number of NHS cinicians who wished to share their insights on specific issues arising from medica tourism (in bariatric surgery, hepatoogy). Overa, the aim was to better understand the impact of medica trave on the UK NHS incuding considerations around the patient safety and service quaity diamond: ega, education, EQA and QIS dimensions. The detaied data are provided in Appendix 23. In summary: Queen s Printer and Controer of HMSO 2014. 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. 53

EXTERNAL QUALITY ASSESSMENT AND QUALITY INFORMATION SYSTEMS Speciaists (often in the private sector), dentists and cosmetic cinics are ikey to see a greater number of compications and foow-up cases after treatment abroad, whereas GPs or NHS cinicians are ikey to interact with a comparativey smaer number of patients. The recent PIP breast impant scanda is an exampe of how there can be a significant deay in compications, making it harder for patients and doctors to contact the origina treating physician. Adequate mechanisms to coect information about the ongoing costs of medica tourism are required to sampe GPs, private cinics, dentists, accident and emergency (A&E) departments, NHS surgica faciities and infectious disease faciities. There is a need to carify the roe of the new strategic NHS Commissioning Board and cinica commissioning groups in providing information, advice and support with regard to medica tourism. There is a need to carify the roe of the Care Quaity Commission (CQC) with regard to uphoding the quaity and safety of care provided to outward medica tourists. 54 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 Section 3 Treatment group case studies Queen s Printer and Controer of HMSO 2014. 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. 55

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 Chapter 9 Common themes within experiences of medica tourism In this section we draw on in-depth interview data to provide a discussion of the genera experience of being a medica tourist, before outining the pecuiarities of different forms of medica tourism. In both the genera overview and our treatment case studies, the interview data coected from our medica tourist respondents pay a key roe in shaping the discussion. However, a wider context is provided by interviews with NHS staff, professiona associations and other reated stakehoders, and respondents from the wider industry, which incudes those with a commercia interest in medica tourism. Further depth is provided by engagement with the wider academic iterature. This chapter seeks to detai what can tentativey be referred to as a typica medica tourism journey. In reaity there is no typica process, even among those who trave to the same pace for the same procedure. However, we have found that certain issues are common to many of our medica tourist respondents, even if the reative importance of such issues differs between individua patients or various forms of medica tourism. This chapter draws on some iterature and interviews with professiona or industry respondents, but is primariy shaped by the responses of our medica tourist sampe. Tabe 6 gives an overview of this sampe and further detais of the individua respondents and their treatment pathways can be found in Appendix 9. Chapters 10 14 provide a series of case studies focusing on different types of medica tourism. In these case studies we present a more focused account of denta, bariatric, cosmetic and fertiity surgery tourism, as we as a discussion around those who trave for famiia or cutura reasons or reasons inked to diaspora. Again, we draw on medica tourists interview data, especiay when highighting the pecuiarities of each case study; however, greater emphasis is paced on professiona interviews and the wider iterature. These case studies wi aso refect on issues such as quaity, safety, risk, ega uncertainties and reguation, as identified earier in this report. Combining the genera discussion of common traits with more focused case studies wi enabe us to highight some of the broad impications of medica trave that are perhaps easy to conceptuaise, with more compex impications reated to the types of treatment for which peope trave. Athough there were most certainy different stories being tod by our respondents, a discussed their experience of the NHS, motivations for traveing for treatment, the process of traveing and their experiences of care abroad. Within these four themes there were aso many common issues addressed and these are discussed within the broader themes. The NHS Across each treatment type our respondents a had something to say about the NHS. Their responses (whether positive or not) usuay refected whether or not they had got what they wanted out of the NHS. Of course, given that we have samped ony those who have traveed abroad for treatment, opinions wi be skewed towards those who did not get what they wanted. Despite this, discussion around the NHS was not whoy negative. Indeed, there are many exampes of peope praising the support of NHS staff throughout their treatment journey, even if they had been initiay disappointed to earn that their treatment coud not be provided on the NHS: I have an extremey, extremey ovey doctor and she gave me a my medication for free. I ve been abe to consut with her a the way through from the very beginning. She s the best doctor that I ve ever had. FT3 Queen s Printer and Controer of HMSO 2014. 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. 57

COMMON THEMES WITHIN EXPERIENCES OF MEDICAL TOURISM TABLE 6 Medica tourist sampe Treatment type Number of respondents Procedures covered Locations Fertiity 9 IVF, intracytopasmic sperm injection, egg donation, sperm donation Bariatric 11 Gastric band, gastric bypass, gastric wrap, gastric seeve, duodena switch, pancreatic diversion and duodena bridge Denta 11 Crowns, bridges, routine work and check-ups, fiings, braces, denta pates, impants Cosmetic 9 Faceift, iposuction, tummy tuck, minima access crania suspension faceift, nose, face and eyes Other 6 Nerve surgery, gynaecoogy, utrasound, immunotherapy, shouder stabiisation, neede for Dupuytren's contracture Czech Repubic, Ukraine, Sweden, Spain, Cyprus Begium, France, Czech Repubic Hungary, Germany, Croatia, India, Poand, Itay, Lithuania Begium, Poand, Czech Repubic, Pakistan France, Greece, Begium, Germany, USA Cutura 31 Diagnostic, denta Germany, India When I came back I tod him I d had the surgery and what had taken pace and he has been very supportive since that. Yeah, I ve spoken to my GP about it. I do get a ot of hep from my GP and he does give me tabets to try and counter my weight probems. CT6 Discussion of the NHS oosey fe into three subthemes: avaiabiity, distrust or dissatisfaction, and aftercare. We wi discuss in more detai the issue of avaiabiity in the section on motivations but, in brief, the overwheming majority of our sampe traveed abroad mainy because they coud not access their desired treatment in the UK. However, even within this common theme there exists much variance: for some, treatment was simpy not practised or not commony practised within the NHS (most notaby with bariatric surgery) whereas, for others, the treatment was avaiabe but they were not eigibe. In many cases issues of eigibiity and whether the procedures were reguary performed within the NHS were ess prominent than the waiting times to access treatment. Here, we encounter yet more variance, with some suggesting that the ong waiting times had been conveyed by professionas, others hearing from friends, some reaching this concusion having read pubished figures and others appearing to have simpy assumed ong waiting times: With regard to the egg donation I was tod [by a friend] there s a five year waiting ist at that time for eggs. I then had to wait a ong time on the waiting ist. I woud phone up the secretary and see where I was on the waiting ist to be pretty much tod there are peope with cancer out there and you re not a priority [...] I d been tod that I was going to be done in the January and then in January I was tod June and I thought I don t think I can hang on ti June. BT8 The second subtheme that emerges ceary from our interview data reated to the NHS is that of distrust or dissatisfaction with previous treatment. Interestingy, those who hed such views were often those who had cutura or famiia ties to other heath systems (e.g. OT2). This was aso inked with treatments for which there is no NHS eigibiity/provision, such as cosmetic surgery or cosmetic denta treatment, rather BT6 FT4 58 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 than fertiity or bariatric surgery. Indeed, this distrust was not confined to the NHS, with many of those who taked of distrust or dissatisfaction extending that feeing to private provision in the UK as we: So I actuay went to see a private dentist and I aways thought I d get better and prompter treatment and that is just an iusion (DT3). The issue of aftercare in the NHS was aso discussed, sometimes at ength, by a range of respondents. Again, those who had traveed for procedures that they may have hoped or even expected to have been provided on the NHS, such as bariatric or fertiity services, generay had some form of interaction with the NHS on their return as part of some ongoing care. In many cases this was care that woud not have been needed (athough other care may have been needed at some stage) and can be described as a pressure on NHS resources entirey as a consequence of medica trave. How NHS staff were described as responding to this desire for post-trave care seems to differ depending on what type of treatment our respondents accessed abroad. Those who traveed for cosmetic or denta work were ess ikey to seek NHS aftercare, but those who did were ess ikey to be provided with aftercare than those who had traveed for bariatric or fertiity treatment. The response to bariatric traveers was much more varied than the response to those who had traveed for fertiity treatment. In their entirety, our fertiity sampe a accessed NHS antenata care and in many cases neonata care. In each case, irrespective of any previous frustrations with NHS rationing, respondents were whoy positive of the antenata and, when reevant, neonata care that they received. There was a sense from both cosmetic and bariatric traveers that there was unwiingness on the part of individua GPs to engage with them after they had traveed for treatment. Whether this was genuiney the case or simpy perceived is hard to ascertain; however, as the iterature suggests, some GPs may be mindfu of assuming responsibiity, and perhaps even couding issues of iabiity, by providing aftercare. 190 On the other hand, some of our respondents simpy never visited their GPs on their return. I went to a private doctor at a skin cinic and got antibiotics and just paid 20 for them rather than go to the NHS. Mainy because of my pride reay. I don t want a GP waving his finger and going you shoudn t have done it and I tod you so. CT4 Interestingy, no respondents who traveed for fertiity treatment mentioned any exampes of unwiingness on the part of the NHS to provide continuation of care that had, in essence, begun overseas. Motivations for traveing Avaiabiity As auded to above, a ack of avaiabiity on the NHS is a key motivator for those who trave abroad. Ony a coupe of our medica tourists had no engagement with the NHS before their decision to seek treatment outside the UK. Athough the reasons for traveing abroad varied (from required procedures not being covered to patients being ineigibe, or from a perceived ack of quaity or expertise in the NHS to ong waiting times), the inabiity or unwiingness to access NHS care can be seen in most cases as a primary motivator for seeking private treatment, which with our sampe saw them eave the UK. In the iterature there is reference to this being best termed a form of medica exiing rather than tourism. 191 However, that term may not be whoy appropriate in the UK because in many cases care was avaiabe and our respondents traveed to avoid waiting times or for what they perceived as better care. That said, among our sampe, statements such as the foowing were not uncommon: We, the NHS woudn t even consider us. It was just a non-starter. No [there was no chance of treatment on the NHS], because of my age. FT5 FT1 Queen s Printer and Controer of HMSO 2014. 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. 59

COMMON THEMES WITHIN EXPERIENCES OF MEDICAL TOURISM But basicay she said I just woudn t get funded to have it done on the NHS. BT9 If the inabiity or unwiingness to access NHS care provided the primary motivation for our sampe to seek private treatment, it was a combination of secondary motivations that saw these private treatment journeys trave overseas. In particuar, issues of cost, the experience of overseas practitioners, the distance that peope woud need to trave, tourism, and cutura or famiia inks to destinations were prominent within our interview data. Cost Cost was discussed by a of our respondents and in amost a cases was an important motivator for trave abroad. Commercia iterature ceary cites cost as the key seing point of medica tourism, and this sentiment is shared by a range of the professiona interviewees who spoke to us (e.g. NHS15). Indeed, cost is important, with many speaking of considerabe savings avaiabe abroad. Cost payed a particuary strong roe among our cosmetic tourists and denta tourists who had no cutura or famiia ties to the destinations to which they traveed. Athough cost was important to our bariatric respondents, it did not take precedence to the same extent, rather being a contributing factor, abeit an important one, aongside others. The story was much more mixed among our fertiity and cutura sampes. Simiary, cost was discussed ony feetingy by those who traveed for treatment not covered by our case studies (OT1 6), such as our respondent who traveed to the USA for pioneering nerve surgery. Indeed, athough some who traveed for fertiity treatment cite cost savings as having payed some roe, many were aware that cost savings were unikey. Simiary, many of our cutura respondents actuay spent a considerabe amount to simpy access diagnostic treatment abroad and one of our other respondents who sought experimenta, high-end treatment abroad has incurred considerabe expense. What is uncear is the degree to which cost in the UK was prohibitive to our sampe. It ceary was in some cases, but on the whoe there was a sense that peope were simpy driven by a perception of better vaue for money overseas. Expertise Our respondents often used terms such as experience and success rates as we as expertise. Here, perhaps more than with any other motivator, we see a cear distinction between those who have traveed for fertiity treatment and those who have undertaken different forms of treatment. For those who sought cosmetic, bariatric and, to a esser degree, denta treatment, expertise seemed bound to the desire to obtain vaue for money; if our respondents were not going to access NHS treatment, why spend more money in the UK, especiay when the surgeons abroad were seen to have more experience of carrying out the surgery? Indeed, both bariatric and cosmetic tourists mentioned that they had traveed to specific ocations and cinics either as the procedure that they desired had been pioneered there or the cinician was accaimed. Of particuar interest is the fact that perceived expertise binds our bariatric, cosmetic and denta tourists to many of the cutura medica tourists as we as those who traveed for procedures not captured in our case studies. As with the pioneering cosmetic and bariatric surgery, our respondents who traveed for other procedures were motivated first by a ack of NHS provision and second by a pu towards areas of expertise. In one case our respondent has maintained his connection to a French cinic even though the treatment that he requires is now avaiabe on the NHS, as he sees his French surgeon as best quaified. With the diaspora group there is again a sense that expertise pays an important roe in motivating trave, athough in many cases this may be more a refection of a ack of confidence in the services that they receive from UK heath care. One of our professiona respondents (PA5) answered this charge by stating that there was often a tendency to ink perceived action with expertise, when often action is not required. Despite the cear discussion of expertise, respondents were often vague as to how they had assessed such expertise and by what criteria they had judged their cinicians or the faciities to which they decided to 60 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 trave. When success rates were mentioned, they were not criticay assessed in comparison with UK data. As one professiona noted (PA12), irrespective of their discussion of expertise, a nicey branded website was as ikey to shape the choice of cinic as hard data on success rates. Athough this appears to be sound anaysis in the main, some of our bariatric sampe had noted the number of procedures that a surgeon had performed. Cutura/famiia We interviewed members of the Somai and Gujarati communities regarding their experiences of traveing for medica treatment; here, the issue of diaspora was prominent, but these were not the ony interviews to touch on this subject. An abiity to speak a certain anguage, the existence of famiy members in the vicinity of the heath-care faciity or, in the case of some of those who traveed for fertiity treatment, phenotypica simiarities with ikey donors were a important motivators for trave and, most importanty, for determining where to trave. Such considerations were not confined to a particuar treatment type and undoubtedy refected the sampe who we recruited. Figure 8 provides a graphica representation of the various motivations cited by our sampe and the reative importance of each within our bariatric, fertiity, cosmetic and denta sampes. This underscores the point raised that many of the motivations were common to a treatment types; however, the reative importance varied between our treatment case studies. The graphic represents the importance of the motivations on a 0 5 scae with 0 (at the centre) indicative of a motivation that was not of import within our sampe. Some motivations register scores of 0 in each of our case studies but have been incuded as they have been highighted as important in other studies. Individua motivation whees for each treatment case study can be found in Appendix 24. The medica tourism process In this section we ook at how peope found their information regarding the faciities that they eventuay visited, how they then organised their care and the process of traveing for care. Avaiabiity (push and pu) Diaspora or famiia Cost Confidentiaity/anonymity Dissatisfaction with UK private options Expertise abroad Tourism Fertiity Bariatric Cosmetic Denta Negative experience of NHS care Distance Lega considerations FIGURE 8 Motivation whee depicting the reative importance of various motivations in the four treatment case studies. Queen s Printer and Controer of HMSO 2014. 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. 61

COMMON THEMES WITHIN EXPERIENCES OF MEDICAL TOURISM Information gathering We have noted in this report that the internet pays a pivota roe within the medica tourism industry. This suggests that, with the exception of entrenched trade patterns, medica tourism is very much an onine phenomenon. With that comes a series of issues reating to the quaity of information onine, the reguation of services onine and, in turn, risk onine. With ony a very sma number of exceptions, our sampe had made some use of the internet to gather information regarding medica tourism abroad. For some, internet searching payed a roe in determining what treatment they wanted as we as where they woud trave for that treatment. Indeed, in some cases it was through this informationa search for the treatment sought that our respondents became aware of medica tourism as a possibiity. Very few of our respondents mentioned, et aone appeared to have assessed, issues of risk, iabiity or even aftercare. Many of our respondents seem to conform to the expectations of the professiona interviewee mentioned earier: a we-presented and cear website and, more importanty, a feeing that peope were receiving a personaised service were deemed much more important than hard information such as success rates. Some respondents did suggest that they found it reassuring to see that their chosen cinician was a member of a body such as the GMC or the Genera Denta Counci (GDC). However, none of our respondents mentioned checking whether or not such memberships were sti vaid. Neither had any of our interviewees expored the quaifications and overseas memberships of the cinicians to whom they entrusted their care. It is worth noting that there is very itte to stop a person who has been suspended or banned from practising in the UK from setting up in another country and, athough they shoud not dispay suspended or deeted credentias, there is itte oversight. Athough cinics that boast GDC- or GMC-registered staff, or profess to meet Human Fertiisation and Embryoogy Authority (HFEA) guideines, are required to do very itte to justify such caims, our respondents were either unaware of this or were simpy ess interested in this hard information. One respondent neaty underines the ack of knowedge that some we woud argue many medica tourists possess with regard to quaity, safety and risk in their discussion of accreditation. This respondent was one of the ony interviewees we spoke to who seemed to have ent the issue much thought: The firm we went to are caed [company name] and I ooked at their website and it gives the CVs of the two dentists. I ooked at their accreditations on there and I then went to the university they said they were accredited with. I foowed those through as far as I coud and they ooked bona fide. You don t know if they ve got that accreditation but they had an honest ook about them and I then aso got on to other peope who had been with them who said it was a comfortabe experience. That was what I was mainy concerned about. DT1 Interestingy, a website having a sea of approva from a commercia organisation seemed to provide an equa eve of reassurance as being abe to view curricuum vitaes (CVs) and professiona memberships: When you get something ike the [medica tourism] website thing they woud tend to give you the estabished practitioners. If you re just ooking at somebody s website, I coud set you up a website that made you ook the most fantastic dentist in York. You ve got no idea what you re going to get and from that point of view having an organisation ike [medica tourism website] gives a itte bit of credence to it. DT1 In cinica terms, being accredited by a commercia organisation, especiay one with a commercia interest in encouraging growth within the medica tourism market, is worth nothing. Yet we have seen from a range of medica tourists as we as professiona respondents that a neat and tidy website, which presents information that comforts readers irrespective of the eve of protection it affords them, is extremey powerfu. When peope have aready competed offine a arge degree of research into the type of treatment that they are seeking, perhaps with support from heath-care professionas in the UK, the onine risk is confined to the choice that is made regarding ocation. This can sti be extremey significant; 62 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 however, the potentia for greater misinformation is increased for those who combine the onine gathering of information about a procedure with onine information gathering with regard to the ocation and cinic. Here, one of the major probems is that, as our website review highighted, even the most professionaooking websites are ceary paying down the risks associated with treatment. Our interviews underscore just how risky this can be with some suggesting that they had carried out very itte research and others beieving themseves we informed as a consequence of the research that they had carried out onine before their treatment. The respondents who seemed most informed and aware of the issues of risk were those who had spent time engaging with NHS care. Primariy we are referring here to our fertiity traveers and, to a esser extent, our bariatric sampe. As our fertiity sampe had neary a engaged with NHS care reated to their fertiity probems, many were aware of exacty what treatment they desired and the associated chances of success and risks. Indeed, for this group the internet payed a sti significant but perhaps reativey smaer roe in information gathering. Here, a wider network of information, from heath-care professionas to support forums and onine sources, was utiised. It has been reported that in some countries, especiay Itay, this represents the most common form of information gathering. 114 That is not to say that our fertiity traveers represent a group of super-informed risk minimisers ; it was cear that some of this sampe had engaged ony partiay with information that auded to risk, perhaps because of the eve of determination and optimism that these respondents had about their ast chance. In particuar, issues around donation were addressed with ony minima discussion and seemingy itte critica appraisa. Wider issues such as how donors are treated were discussed at ength by professiona interviewees but ony feetingy by those who traveed for fertiity treatment. Booking The wider networks mentioned above were aso evident in discussions around the procedure that our sampe engaged with when organising their treatment. Some visited cinics on the recommendation of others, incuding friends or reatives, peope in onine support forums or heath-care professionas. Generay, booking fe into one of two categories with peope either booking direct with the provider or using some form of intermediary such as a broker or faciitator. In the vast majority of cases, our sampe organised their treatment with the provider. In some instances, accommodation and fights were aso organised in this fashion. Some respondents had used a faciitator or broker, either to make the process easier or because the broker represented a gatekeeper to services as in the case of one of our fertiity traveers who required egg donation. In a sma seection of cases our respondents had deat directy with a private cinic in the UK that then organised treatment with a partner cinic overseas. In such cases it was uncear where our respondents woud seek recourse shoud any compications arise. The iterature is repete with suggestions that faciitators and brokers pay an important roe in the goba medica tourism industry; 118,192 however, our sampe made rather mixed use of such services. This perhaps refects a sense of agency and responsibiity that emerged from the interviews with many of our respondents. One respondent stated: Maybe some peope need some hand-hoding and for that handhoding a coupe of hundred quid and you might have swaowed it (FT8). This came through most in the interviews with bariatric traveers, many of whom spoke at ength about taking contro of their heath care, to a certain extent by engaging in medica treatment. Whether respondents deat with their provider directy or through an intermediary, what exacty the service covered ranged from treatment aone at one end of the spectrum to pretreatment tests, treatment, drugs, fights and accommodation at the other end. Most respondents sorted at east some part of their journey in isoation from their treatment provider. Traveing abroad In neary every case our respondents traveed with a companion. When they had traveed as part of a package, the companion was an extra cost rather than incuded in the price. Those who eaborated expained that the abiity to trave with a companion was extremey important, suggesting that without a Queen s Printer and Controer of HMSO 2014. 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. 63

COMMON THEMES WITHIN EXPERIENCES OF MEDICAL TOURISM companion the journey woud have been too daunting. It is uncear whether this was not the case for those who did not discuss their companions at ength or whether they simpy took for granted that they woud trave with their partner or friend. In more than one case a respondent discussed the confict between their desire to keep their treatment pans secret and their need for companionship and support. With regard to how ong peope traveed abroad for, this argey depended on whether or not they were traveing for particuary invasive procedures and whether or not they had famiy in or near their destination country. For most of our sampe, treatment dictated that they woud stay for at east 2 days but coud, shoud they wish, trave home soon after. None of our sampe taked of getting off the pane, having treatment and then returning on the same day. The most common approach was to trave to the country, have pretreatment checks and perhaps treatment on day 1, either recover on day 2 or have treatment foowed by a day of recovery and then journey home. Tourism The popuar conception within the medica tourism promotiona iterature, which echoes the views of some of those we have interviewed from a commercia background, is that the hoiday pays an important roe in medica tourism. Many have criticised the abe medica tourism as underpaying the process of traveing abroad to access heath care, most notaby when discussing fertiity tourism or potentiay ife-saving treatment. 57,72 The notion of tourism is increasingy being appied to denta and cosmetic treatment; however, this is perhaps not an accurate refection of the process. Within our sampe it was cear that tourism payed a periphera roe in the decision-making process. With the exception of those who traveed to see famiy and decided to fit in a trip to the GP or dentist, decisions were taken first and foremost for heath-care reasons. Even in cases in which our respondents stayed and enjoyed their destination country for a coupe of weeks after treatment, traveing abroad was motivated by the need for treatment not the desire for tourism. This is not to say that some of our sampe did not engage in tourist pursuits, of course; a reasonabe number did. The popuar notion of sun, sea, sand and surgery 10 was not, however, one that many of our respondents shared. This may of course be a refection of our sampe and it is important to note that we samped the same number of cosmetic tourists as bariatric tourists. In reaity, cosmetic tourism is ikey to account for much more of the medica tourism market than fertiity and bariatric treatment combined. It shoud aso be acknowedged that recruiting sampes proved extremey compex, in particuar those undergoing forms of treatment that are seen as ess invasive. We did not, for exampe, manage to recruit those who are often referred to as tweakenders, who do pop abroad for the weekend to have minor cosmetic work, or rather fit such minor treatments into a uxury hoiday. We did not interview anybody who had traveed for breast augmentation or reated surgery apparenty a common medica tourism procedure. It may very we be that we have oversamped the medica and undersamped the tourists, but in our sampe tourism was ceary not a priority. The medica tourism experience In this section we discuss how our respondents found their experience, their satisfaction eves with regard to the process and, to a certain extent, the cinica outcomes (athough this is rather imited as it was not the focus of our study), their feeings about the eve of aftercare that they received and the ongoing support that they were given. Satisfaction and dissatisfaction It is easy to regard the patient testimonies on commercia websites with much scepticism, and addressing this potentia imbaance in our knowedge of the medica tourism process is crucia. However, it woud be possibe to use the transcripts of neary a of our interviews across a treatment types to produce the kinds of quotes that furnish these very websites. The overwheming message that we received was one of 64 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 satisfaction, even if the respondents had not achieved the cinica outcome that they desired. Typica statements were: This is the best thing I ve ever done. It was amazing. It s not a country I d ever been to. It s very European cosmopoitan, ovey cafes. It was beautifu weather because it was the summertime. FT9 FT4 Very hepfu, very friendy it s just unfortunate it s so far away that you can t have the treatments you coud have if you ived there. It was a very positive experience it s just unfortunatey it didn t turn out good for me. BT3 It was commony observed that the faciities were cean, often being compared favouraby to NHS faciities, and that anguage barriers were very rarey an issue. In ony a sma number of cases did any of our respondents suggest that their experience was negative and neary a insisted that they woud recommend the process to others. However, the impications of this finding are not straightforward. First, once again the sampe we have recruited is undoubtedy skewed for a number of reasons. For exampe, recruitment of a sampe is difficut as it is uncear where best to target communicationa iterature. Much success came from contacting onine forums and it is ikey that many of these hosted a number of peope wishing to share their experiences. It is perhaps the case that it is easier to share positive experiences than negative and as such it may be that we had easier access to success stories. This was definitey apparent in a coupe of cases in which prospective medica tourists agreed to take part in our study ony to change their mind after not achieving a successfu outcome. Of course, there is the possibiity that peope who have received particuary poor treatment woud be motivated to share their story; however, we encountered ony one exampe of this. It may aso be that those using onine forums are part of a supportive and possiby we-informed network and as such our respondents had been abe to avoid many of the potentia risks associated with medica tourism. In our fertiity sampe a had conceived, either as a resut of their treatment or subsequent to it. It woud have been usefu to hear from those who had not, athough this woud undoubtedy be a very difficut experience to share. Another issue is that we may have to question some of the positivity that our sampe shared. In particuar, our bariatric sampe consisted of many peope for whom treatment had not worked particuary we. In some cases our respondents were in a rather serious state of i heath, requiring constant care. And yet these very respondents were extremey positive about their experience, being very quick to defend both their decision to seek treatment and the surgeons who conducted the treatment. It may be that this refects a cear sense of agency that emerged from our bariatric sampe. Our bariatric surgery respondents seemed to use their organising and traveing for treatment as a form of exerting contro over a hitherto uncontroabe part of their ives. Indeed, as researchers it was often quite difficut to reconcie the cear divide between the ack of cinica success and the eves of positivity with which our respondents regarded their treatment. As our purpose was to understand how our respondents fet and sti fee about their treatment rather than report cinica outcomes, we must restate that the overwheming sense was one of satisfaction. However, it is important to note that there was ceary a vested interest among our respondents in presenting a positive experience. Even with our fertiity sampe, a of whom it can be argued had experienced a successfu procedure, there were ceary ess positive issues that were pushed to the periphery of our conversations. Respondents discussed not feeing whoy prepared and feeing uneasy about the donation process, and at times unsupported, yet a of this was ceary deemed insignificant in the wider context of a successfu pregnancy. Queen s Printer and Controer of HMSO 2014. 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. 65

COMMON THEMES WITHIN EXPERIENCES OF MEDICAL TOURISM Support In particuar, it was uncear from many interviews what support our respondents had received, especiay from their treatment providers. Often our respondents were keen to stress that their friendy cinician had reassured them that they coud pop back shoud any issues arise. Whether a return journey woud have been physicay or financiay possibe is not cear. As highighted, a arge proportion of our bariatric and fertiity surgery sampes were critica of the NHS support that they had received before and after organising treatment. But it is difficut to identify any obvious support being offered by the overseas treatment providers. It woud appear in many cases that the NHS was seen as unsupportive because the respondents were unabe to access NHS care, whereas the overseas providers, by giving the desired care, were viewed as supportive. The fact that this care had been bought rather than provided free of charge as it woud have been on the NHS seems ost in many interviewees discussions. Some did mention a degree of support being forthcoming throughout their journey, with some providers or faciitators providing practica advice in a patient and warm manner. This ranged from providing advice regarding pretreatment drugs to practica support with regard to the organisation of trave and accommodation. What can be thought of as more cinica support, especiay psychoogica support, is argey missing from our respondents stories. When it is discussed it is seen as a deficiency in the process, with two respondents directy highighting a ack of, or inappropriate, psychoogica support as particuary upsetting. The issue of psychoogica support is picked up by three professiona interviewees (NHS17, NHS18, IND18) who note that the ack of psychoogica support, especiay beyond impicationa counseing, is a key concern regarding overseas treatment. Most patients reied on onine or face-to-face support groups for this, athough the high number of patients reporting membership in a support group may be the resut of a sampe bias. Simiary, famiy and friends, especiay the companions who accompanied our respondents on their journeys, were ceary an invauabe form of support, even when our respondents wished to keep their treatment a secret from most. Aftercare Support extends beyond the concusion of treatment and, as noted, support forums are ceary an important source of such support. However, it is important to highight that, as we as support, care aso continues after treatment. This can vary from check-ups and minor adjustments to corrective or further treatment. Even with dentistry, perhaps seen as the east invasive and traumatic treatment accessed by our sampe, care is ongoing. At the most obvious, impants often need readjusting as sweing settes and the mouth changes shape. In addition, pain reief may be an issue for some and, most importanty, teeth, veneers and impants a have to be maintained; a trip abroad does not represent the end of treatment. However, returning to the pace of treatment is not aways possibe, no matter how wecoming the cinician is and how prepared the cinician is to offer aftercare free of charge. What is cear from our interviews is that the continuation of care occurred primariy in the UK, often within the NHS. The immediate aftercare whie our respondents were sti in their destination country was usuay provided by the cinician or cinic and often the medication or toos required for aftercare were provided. However, when the overseas cinic provided drugs or required bood sampes, our respondents were responsibe for ensuring that medication was taken or that bood sampes were provided. In some cases respondents woud use syringes provided by the cinic and then post them from the UK. When aftercare for dentistry or cosmetic treatment was needed, most sought private care or reported being refused NHS care. One respondent even caimed to have removed his own stitches rather than ask his GP to remove them. It is cear that, had any of our bariatric or cosmetic surgery traveers required emergency treatment, the NHS woud have been their chosen provider and it is ikey that the burden woud have faen there. Indeed, as our bariatric case study outines, the NHS is ikey to pay a key roe in providing aftercare for bariatric patients, many of whom were ceary not fuy aware that there woud indeed be a continuation of care required. Even with our fertiity sampe, for whom traditiona conceptions of aftercare were not required, the resuting pregnancies, which have a higher ikeihood of mutipe births and premature births, 98,193 were 66 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 supported through the NHS. With both antenata care and neonata care (much more ikey to be required as a consequence of IVF pregnancies) being extremey expensive, this is sure to be of concern. Impications for the NHS We have seen that medica tourism, irrespective of the treatment that is being sought, invoves much that is simiar across a patients. It is cear that accessing the required treatment in the desired time frame is the primary motivator for trave, but that issues of cost, cuture and even to a esser degree tourism a pay a roe. We have aso seen that the internet, as we as networks both onine and offine, pay an important roe in informing prospective medica tourists, but that on the whoe it does not appear that those who trave are truy informed, especiay with regard to the risks invoved. Despite this, our respondents have neary a registered satisfaction with their experience and woud trave again, or recommend the process to others. The positives must be set in a wider context that is at east cautious. Our sampe is undoubtedy skewed towards those who are satisfied with their experience and yet even here we can see quite profound exampes of i heath, poor cinica outcomes and what are ikey to be ong and expensive requirements for ongoing care. Ceary, with some of our respondents this must be offset against the i heath and need for care that was aready being experienced, but it important to note that treatment abroad represents no panacea, either for those who trave or for the NHS. Subsequent chapters detai the nuances of particuar forms of medica tourism and their impications. At the broader eve we can say that medica tourism presents the foowing potentia impications for the NHS: Medica tourists are unikey to be fuy informed or understanding of a associated cinica risks. Medica tourists pay more heed to soft information than hard cinica information. There is itte effective reguation of information, hard or soft, onine or overseas. Patients traveing overseas eave the reguatory safety of the UK and the NHS. Athough patients may not ever be fuy informed or understanding, if they access care within the NHS then heath-care professionas wi have payed an important roe in ensuring that appropriate treatment is being administered. This cannot be guaranteed abroad. 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, even by those who in the end do sti seek treatment abroad. Even when medica tourists trave to professiona, reputabe cinics, returning for aftercare or continued support is not usuay viabe. Aftercare in some form is usuay required. Aftercare or ongoing care can be extremey intensive. The NHS wi pay some roe in providing ongoing care for many of those who trave for treatment. This can be expensive and can continue through the ife course. It may be that the treatment that has been accessed overseas was risky or inappropriate and aternatives in the UK coud have been offered. Interviews with professiona stakehoders ceary identify the need for guidance and information for patients and staff working within the NHS. Our anaysis points to a vacuum in poicy guidance. It highights the need for information and guidance about quaity and safety issues that patients may wish to consider before traveing. Carification is needed in reation to the roes and responsibiities of the NHS in pre and post care and this shoud be communicated effectivey to those who may engage in medica tourism. Further Department of Heath guidance for NHS providers and patients on what to request from foreign providers may go some way to address the chaenges in continuity of care described. Queen s Printer and Controer of HMSO 2014. 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. 67

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 Chapter 10 Bariatric surgery case study An area that has seen rapid growth in the numbers of patients traveing abroad, as we as patients in the UK undergoing surgery, is bariatric or weight oss surgery. 194 The UK, ike many other countries gobay, has seen a rapid increase in the numbers of overweight and obese patients, with the Department of Heath estimating that one-quarter of the UK popuation is now cinicay obese, that is, with a body mass index (BMI) of 30 kg/m 2. 195 Obesity has severa ong-term heath effects incuding an increased incidence of diabetes and cardiovascuar disease. In addition to behavioura interventions such as exercise, counseing and pharmacoogica interventions (appetite suppressants), severa surgica procedures are avaiabe to assist weight oss. The two most common procedures are a gastric band and a gastric bypass. A band is the ess invasive procedure. It imits food intake by pacing a restrictive string around the top end of the stomach. This band has to be reguary adjusted to aow patients to consume food whie maintaining weight oss. When a band is too tight it can prevent patients from eating, whereas a oose band means that patients can eat as much as they wish. The bypass is a much more invasive procedure in which part of the patient s stomach is partitioned and his or her capacity to absorb food is imited. As a resut of a bypass, patients need to monitor their food intake carefuy to ensure that they receive the nutrition that they require. Given the body s reduced capacity to absorb nutrients and specific vitamins and mineras, suppements have to be taken by patients for the rest of their ives to ensure adequate nutrition. 196 In the UK, bariatric surgery is a reativey new fied of surgery. It is avaiabe as treatment on the NHS and Nationa Institute for Heath and Care Exceence (NICE) guideines 197 recommend or make avaiabe bariatric surgery in individuas with a BMI > 40 kg/m 2. However, the impementation and interpretation of the guideines depend on the PCT and on the assessment by a GP. Research has indicated a reuctance by GPs to prescribe such surgery. 195 In this research, 13 in-depth interviews were conducted with patients who traveed abroad for bariatric surgery. These discussed the themes expored in the patient interviews described in Chapter 9, for exampe patients experiences of the NHS before and after treatment, and how they identified the treatment provider abroad. In addition, three professionas from organisations working in bariatric surgery in the UK were interviewed to gain further understanding. Findings from bariatric surgery patients Athough many issues identified across our sampe of patients were common to bariatric patients motivation to trave (such as issues reating to distance and eigibiity), there were aso cear differences within each subtheme identified that were specific to bariatric tourism. These hod important essons when trying to understand and address the specific factors determining bariatric patients trave and foow-up needs. Motivation for traveing abroad for bariatric surgery: an emerging fied of expertise in the UK As with many other medica tourists, bariatric surgery patients were keen to stress that cost had not been the ony factor in them choosing to trave for surgery, and ony 2 of the 13 patients interviewed cited this as their soe motivation. More than for any other group interviewed, expertise (in bariatric surgery) was the biggest pu factor. In tota, 11 out of the 13 had traveed to Begium, which was perceived to be more advanced in the fied of bariatric surgery at the time that the patients interviewed had undertaken treatment (between 2004 and 2009). In severa cases patients specificay described how the surgery that they had opted for had not been avaiabe to them within the NHS, or that surgeons in the UK had conducted ony a sma number of procedures, or that there was ony imited expertise in these areas. Queen s Printer and Controer of HMSO 2014. 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. 69

BARIATRIC SURGERY CASE STUDY Of the 13 patients interviewed, haf reported that the surgeon having conducted the procedure many times before was a key factor in their decision-making. The experience of the surgeon was contrasted in some cases with a genera distrust of the NHS: [My motivation for trave was] mainy the cost but aso because the surgeon was very highy recommended. Aso in genera a-round the whoe experience. I mean, there s quite a big issue with MRSA [methiciin-resistant Staphyococcus aureus] which they didn t have at a abroad. BT4 Avaiabiity Severa issues reating to the avaiabiity of treatment were factors in the decision of where to seek treatment. This reates to bariatric surgery specificay, as it is a comparativey new fied in the UK (see aso p. 69). For exampe, two patients from Northern Ireand reported that, at the time of their surgery, it was not avaiabe in the province and surgery woud have required them to trave (to mainand Britain) in any case. Simiary, a patient from Scotand reported that she woud have had to trave to Engand to receive the procedure under the NHS. Patients aso mentioned that they had seen a NHS doctor and had been judged eigibe but that the waiting time for the operation had put them off having it done on the NHS. In some cases this appeared to be the actua reported waiting times; in others it was uncear if the patient had just anticipated the ong wait. Eigibiity on the NHS: a postcode ottery? As in other cases, such as fertiity surgery, severa patients reported that they had been found to be ineigibe for treatment on the NHS. Athough NICE guideines exist that recommend or make avaiabe bariatric surgery for individuas with a BMI > 40 kg/m 2, 197 the impementation and interpretation of these guideines depends on the PCT and on assessment by the GP. Severa patients interviewed referred to the resuting inequities and the sense of a postcode ottery. In some cases this was because peope were deemed to have a BMI considered too ow to quaify for surgery, or patients were considered heathy despite having a very high BMI and fearing for their ong-term heath. This may in part be the resut of GPs ooking at bariatric surgery as a ast resort and an expense rather than a cost-saving treatment. A recent survey of GPs conducted by the Office of Heath Economics 195 found that the vast majority try to avoid prescribing surgery for obesity, regardess of BMI. Distance: Begium, a perceived centre of expertise As with other patients, distance payed a key roe in decision-making. Specific to bariatric patients was that Begium, as a centre of expertise in bariatric surgery at the time that interviewees had traveed (between 2004 and 2009), was easiy accessibe via Eurostar. Ten of the 13 peope interviewed had traveed to Begium: severa mentioned its proximity, incuding specificay the ease of access by Eurostar. This has particuar reevance for weight oss surgery, as some patients are cautioned against fying foowing the procedure. Based on this anaysis, the decision by patients to trave for weight oss surgery was rarey the resut of a singe motivating factor; rather, it was a combination of cost, expertise, avaiabiity and distance, with different patients giving different weight to each of these. Unique to this group was the specific emphasis given to the experience of the surgeon. This was a direct resut of bariatric surgery being a newer fied of investigation in the UK; as expertise grows in the UK it is ikey that these differences wi disappear or become ess pronounced. A representative of a Roya Coege working on these issues highighted that bariatric surgery had been a very new fied in the UK in 2004, but that the fied was rapidy growing now with increasing expertise in the UK. 70 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 Treatment pathway and experience: high rate of compications The treatment pathway for bariatric patients did not vary greaty from the genera mode set out in Chapter 9, with most patients describing the use of the internet to identify and research providers. What did set the experience of bariatric patients somewhat apart from the genera experience was the eve of compications and aftercare required for most procedures. Of the 13 patients interviewed, four experienced compications directy reating to the surgery and had to be resubmitted to hospita for additiona surgery whie sti abroad. Many of the patients interviewed experienced ong-term heath probems reating to the surgery undertaken or the onger-term care needs resuting from these. However, what resonated across accounts of immediate compications and onger-term issues was the responsibiity that patients took for the heath outcomes of their procedures. This again seemed to be specific to bariatric patients in the study sampe. Foow-up and aftercare The most common procedures for which patients traveed abroad, gastric banding and gastric bypass, both require ifeong foow-up care and maintenance. In the case of a gastric band, this has to be adjusted to ensure that patients continue to ose weight whie being abe to consume enough food to obtain the nutrition that they require to survive. The gastric band is an eastic band fied with fuid that can be adjusted to tighten or oosen it. Peope with a gastric band are required to have the band adjusted at reguar intervas. In the case of a gastric bypass, athough the procedures may vary, a part of a person s gut is removed and his or her capacity to absorb mineras and vitamins is imited. Therefore, patients who have undergone a gastric bypass have to rey on suppements to avoid manutrition and patients have to undergo reguar bood tests to monitor this. A professiona interviewed for this research referred to the maintenance that patients require foowing bariatric surgery and how this is a ifeong condition. Aftercare and foow-up from bariatric surgery can be divided into the needs immediatey foowing surgery and the ongoing maintenance of the resuts achieved from the procedure. Severa patients reported compications with their bands. One patient had a fauty band emptied and removed because of the probems that she experienced with it; this interviewee reported that the repacement was aso probematic. Two patients reported more severe ong-term heath consequences. One (who had had a gastric bypass) reported having been hospitaised for 2 years foowing a ife-threatening compication and was sti unabe to work. Athough the patient had returned to the origina surgeon abroad to have the compication deat with, she was now unabe to afford further foow-up visits to him. Despite the compication arising from the origina surgery, the patient retained a greater trust in the origina surgeon s abiities than in the NHS as he had been abe to resove the issue whereas the NHS had been unabe to: Now, unfortunatey two years down the ine and I m sti not 100 per cent. I m sti on morphine every day and I m sti underweight. So I sti have ong-term probems so I don t know if that wi ever be sorted out. BT6 The other described how the ong-term consequences of a bypass had ed to severe heath issues, incuding tears and fistuas. Continuity of care emerged as a cear chaenge for a patients. However, in bariatric surgery this differed between the compications resuting from the surgery and the ong-term care needs resuting from the surgery. Some of the compications experienced were severey debiitating, whie the need for aftercare Queen s Printer and Controer of HMSO 2014. 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. 71

BARIATRIC SURGERY CASE STUDY and maintenance of a gastric band make continuity of care more important than for some of the other areas of surgery for which peope traveed and which are reviewed here. The specific cinica requirements of aftercare for bariatric treatment aso ed to specificities in the industry modes. Many of the Begian providers offered aftercare services to Engish patients (such as the fiing of bands) in London or other UK ocations at an additiona cost. This was specific to providers of bariatric services. Nationa Heath Service Unike other groups of patients, a patients interviewed had been in contact with the NHS (specificay their GP) in reation to their weight before and after the surgery. Six patients specificay recounted the refusa by their GP to refer them for surgery; two of these expicity mentioned that they were eigibe for the surgery according to NICE guideines but that their GP had tod them that no funding was avaiabe. Overa, the vast majority of patients reported imited support from GPs. This was more common than in other groups of patients interviewed. In many cases patients reported that this may be based on imited knowedge. One interviewee summed it up as foows: The GP that was here just used to ook at me bank if I mentioned my obesity. They didn t offer anything at a, no support whatsoever [...] It s not that they re not supportive they just don t know what to do. They don t know anything about them. BT7 Interviewees aso reported a difference in attitude between surgeons and GPs, which they fet was mainy due to surgeons greater knowedge of bariatric surgery. Moreover, a patients interviewed reported that insufficient services were provided within the remit of the NHS for overweight and obese patients. There was a cear sense that the approach by NHS staff had been cautious in reation to surgery and that as a resut the patients interviewed for the research fet that the treatment that they required was unavaiabe to them. Compared with the overa sampe of medica tourists, there were severa distinct aspects to bariatric tourism. Three key factors were uncommon compared with other patients experiences. First, a bariatric patients interviewed had been in contact with the NHS before making their decision to trave for treatment. Second, the ack of expertise within the NHS was a greater factor for motivating bariatric patients than for motivating other medica tourists. Third, the need for aftercare and the high eve of compications experienced by bariatric surgery patients set this group apart. It underines the need for better information and a fu understanding of risk amongst this group of medica tourists before they trave. This has aso ed to specific industry deveopments by providers, with foow-up consutations in London, and equay specific requirements of the NHS when maintenance is not provided by the origina cinic. Bariatric surgery outcomes have ong-term consequences; as this is a comparativey young fied some of these and the effects of treatment abroad wi ikey emerge ony in the future. The SurgiCa Obesity Treatment Study (SCOTS) at the University of Gasgow (a ongitudina study of bariatric surgery patients) 198 wi in the future provide important resuts in this respect. Across the interviews there was a sense that patients fet that they acked the entitement for surgery on the NHS as their weight was a resut of their own behaviour. Some of the patients addressed this expicity and described how their interactions with the NHS had eft them feeing this way; most patients had had some contact with the NHS about weight oss and fet abandoned, with the NHS not recognising the vaue of weight oss surgery. Even when patients described this negative experience as an exampe of poicy that had to change, they were equay keen to convey a sense of responsibiity that they had taken 72 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 on through their actions, that is, choosing to trave and have surgery to address a heath issue, which a of them fet woud have become worse otherwise. In addition, even in cases in which weight oss surgery may be inadvisabe from a medica perspective, the fact that patients fet compeed to trave indicated that current approaches to overweight and obesity by the NHS are not working. Many patients reported a sense of frustration as they fet that they had saved the NHS substantive future heath-care expenditure reated to being overweight and obese. Patients had a sense of being judged for being overweight or obese. Impications for the NHS The need for cearer guidance on bariatric surgery or for patients considering bariatric surgery is evident. Patients acked consistent information on possibe compications, but aso on the ong-term consequences of surgery and the maintenance requirements, whether they were traveing abroad or seeking treatment in the UK. Equay, greater information for and education of GPs is needed to enabe them to educate patients and to dea with the possibe consequences of weight oss surgery. Our data suggest that, even when patients trave abroad to access treatment for obesity, they are ikey to consut their GP. This presents the opportunity to provide guidance and information either on procedures or on medica trave or both. Queen s Printer and Controer of HMSO 2014. 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. 73

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 Chapter 11 Fertiity surgery case study The rationae for adopting the phrase medica tourism throughout this report has aready been discussed. The imitations of the term are perhaps most stark when discussing fertiity tourism. Indeed, the term fertiity tourism is not common among the academic iterature with the exception of noting its ack of suitabiity. Instead, a rather extensive and diverse range of terms, from cross-border fertiity treatment to transnationa reproduction, is adopted. 47,72,114 The most frequenty used and seemingy acceptabe term appears to be cross-border reproductive care, which is adopted widey and most notaby in the works of Hudson et a., 72 Cuey et a. 57 and Shenfied et a. 114 However it is abeed, fertiity tourism or CBRC appears to be on the rise (PA7, PA11, NHS15, Hudson et a. 72 ). With this comes a range of potentia issues. Many of these, such as patient safety and risk, ega uncertainties and ong-term care, are simiar (athough not identica) to those that arise from a forms of medica tourism. However, there are often additiona mora and ethica debates surrounding CBRC. 199 201 Distinctive features of fertiity tourism Athough there are many simiarities between traveing for fertiity treatment and traveing for other forms of medica treatment, there is much that sets fertiity tourism apart. Discussion here is informed by interviews with NHS professionas, representatives of professiona associations and those who pay a roe (be it commercia or otherwise) in overseas treatment, as we as those who have traveed for some form of what can be termed fertiity treatment abroad. The purpose here is to highight the differences between fertiity treatment abroad and other forms of medica tourism, and attempt to expain such differences. As with the findings of other studies, the avaiabiity of treatment in the UK was the singe biggest motivator to trave abroad for fertiity treatment. A respondents discussed their ineigibiity for pubicy funded treatment, which again was the consequence of a range of factors: some were outwith the age criterion, others were deemed as having an extremey ow chance of success, one had exhausted her pubicy funded opportunities and one, athough eigibe, coud not access the treatment in a time scae that she fet was reasonabe. Typica comments were: We, the NHS woudn t even consider us. It was just a non-starter. No [there was no chance of treatment on the NHS], because of my age. FT5 FT1 Despite this, a respondents reported positive experiences of the NHS. For some, frustration or disappointment regarding a ack of eigibiity was baanced by high eves of support from their GP or other NHS staff throughout their treatment journey, in terms of both hep received with organising tests and accessing required fertiity drugs before treatment and the antenata care accessed after pregnancy was successfuy achieved. When respondents were ess positive regarding the support that they had received pretreatment abroad, they were unanimous in their satisfaction with subsequent NHS antenata care. Perhaps surprisingy, not a were frustrated with their ineigibiity for pubicy funded fertiity treatment, with one respondent remarking: It s my choice in a way that I m this age wanting to have a famiy [...] so in a way I think it was my ifestye choice and I knew that that coud be a potentia issue in the future so I m not sure heath-care systems shoud have to pay for my ifestye choice. FT1 Queen s Printer and Controer of HMSO 2014. 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. 75

FERTILITY SURGERY CASE STUDY An interesting finding from our interviews was that support from NHS staff for those who had undertaken private treatment varied. In some instances NHS staff aided patients in accessing necessary pretreatment scans and tests free through the NHS, whereas others woud provide no such access to drugs and scans: She ooked at the ist and she said I can make an excuse to have that one done for you and that one and that one and that one. So she did absoutey as many as she coud on the NHS, which was fantastic of her. FT5 I tried to go to my GP to get the bood tests done but he woudn t do it. It depends on your GP. He tod me to go to my oca GUM [genitourinary medicine] cinic and pretend I d sept with a waiter on hoiday to get a test for HIV [human immunodeficiency virus] and Hep and stuff. FT8 Here, it is ikey that a compex range of considerations has informed a GP s decision whether or not to provide NHS resources, from a desire to hep at the most human eve perhaps to a fear of vicarious iabiity at the other end of the spectrum. As one NHS respondent noted (NHS18), some NHS staff may worry about paying a roe in faciitating the overseas journey of a patient to a country with different ethica and ega principes of medicine. The main reason cited by our respondents for traveing abroad for fertiity treatment was waiting times; even privatey in the UK, the wait for egg donors in particuar can fee prohibitive for those seeking fertiity treatment: With regard to the egg donation I was tod there s a five year waiting ist at that time for eggs. This woud have been in about 2002/03. So I thought about it and I thought we I m 40 so if I wait five years I m going to be 45, my son is going to be eight, I don t think I can wait that ong. FT4 Athough there is the hope that recent egisative changes aowing greater remuneration for sperm and egg donors wi increase suppy, numbers are sti ow (PA7). In tota, five of our respondents required egg donation (sometimes aongside other procedures) and for a the ack of avaiabiity both pubicy and privatey in the UK precipitated their decision to trave. Other studies suggest that a high proportion of those traveing gobay for fertiity treatment are receiving some form of egg donation. Shenfied et a. 114 suggest figures of roughy 45% Europe-wide and Cuey et a. 57 report figures of 59% in a sma study of UK fertiity traveers. The figure is even higher for patients from Germany where there is a shortage of donors. 202 It was not ony the avaiabiity of donor eggs that motivated our respondents to trave; in one case concerns were raised regarding the quaity of UK-sourced eggs (FT8). A review of the iterature suggests three other common motivations for seeking CBRC: success rates, ega restrictions and issues of anonymity. 72 In our sampe, as with other UK-focused studies, 57 there was no discussion of ega restrictions. With regards to anonymity, ony one respondent (FT2) suggested that this had payed a roe in traveing abroad and even here it was a minor consideration. On the contrary, other respondents who did mention anonymity professed to find the anonymity offered to donors abroad to be a concern (FT1). This was ceary the case for one respondent (FT9) who strugged to access vita information when her offspring was being tested for certain genetic conditions. This is perhaps surprising in the context of the interviews we conducted with professionas and stakehoders, as we as the wider iterature. Here the suggestion seems to be that anonymity is a key motivator for those who seek fertiity treatment abroad (NHS17, NHS56). Perhaps equay surprising was the fact that ony two respondents (FT6, FT8) directy addressed the issue of success rates and in ony one case (FT6) did this seem to be a key (athough sti not the soe) motivator. One NHS professiona (NHS15) did remark that it was unikey that overseas cinics coud actuay offer better success rates than are avaiabe in the UK, or innovative procedures that are unavaiabe in the UK. 76 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 Unike other forms of medica tourism, information gathering on the internet was imited to searching for cinics, rather than information about procedures. GPs and other NHS staff represented the main source of information regarding the procedures that our sampe traveed for. The internet was simpy a ocation in which the cinics offering the required treatment coud be identified. The websites of cinics were not the ony source of information that respondents engaged with. Most had some contact with an onine fertiity support group or forum, which proved usefu in terms of both gaining information about the experiences of others and obtaining specific cinician reviews: I went to [support forum] website and through there I started ooking at cinics. And I saw simiar probems to mine so I contacted the [cinic] and went for a consutation. FT2 So I had heard from peope on [support forum] website about the cinic in the Czech Repubic and they had been successfu there and they just said it s a wonderfu cinic. FT2 The roe payed by support forums is ceary substantia here, with one respondent from a support organisation presenting extremey arge membership figures (IND2). Moreover, they acknowedge the power that a post on such trusted sites can have, with visitors to sites happy to take the recommendations of others based on a cinic or cinician being nice over hard evidence regarding success rates (PA12). Athough the internet payed an extremey important roe in identifying and seecting overseas cinics, it woud appear that it payed a much more minor roe, if any, in gathering information regarding the conditions that peope suffer from and possibe treatment options. Rather, a had engaged with the NHS (or the French nationa heath system in one case) and diagnosis had occurred here. Further diagnosis may have occurred at private cinics, but regardess of the pubic or private setting much of the information gathering regarding the procedures that our sampe traveed for was undertaken as part of the diagnosis procedure. As such, it can be argued that the fertiity patients in our sampe coud have been considered as having expertise beyond that of ay persons when searching the internet for foreign cinics. As one professiona association respondent noted (PA12), a had a cear idea of what procedure was needed and the questions they woud need answering. With regards to how fertiity traveers organise their treatment, the picture was mixed. At one end of the spectrum we heard from somebody who paid a fat fee to a private UK cinic, which then organised a pretreatment tests, fights, accommodation, treatment and foow-ups: It s a incuded. They basicay arrange it on different budgets. So there s an expensive hote in [city], there s a cheaper hote in [city]. I think you get a your meas. It s very, very we organised. They te you what fights you can have. You re quite imited on your fights [...] I took my son with me because we didn t have a babysitter reay and he was about eight at the time. So they arranged everything. FT4 At the other end of the spectrum respondents had contacted cinics directy, had organised their own fights and accommodation and had responsibiity for organising any pretreatment scans and drugs. In the most extreme case there was no guidance offered as to which drugs, tests and scans were needed and when they were needed: Queen s Printer and Controer of HMSO 2014. 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. 77

FERTILITY SURGERY CASE STUDY That was the ony thing about having treatment abroad is that they don t te you that you have to have anything prior to going out there. I was using my own eggs so therefore I had to take a these drugs prior to going out to [destination]. But having done four cyces in the UK I knew the procedure [...] so I organised those scans privatey in a private hospita in [UK city]. FT3 As with other types of treatment most potted a journey in between these two extremes, with parts of the process packaged with the treatment. What is hard to te is whether our respondents opted for a more or ess comprehensive package as a refection of a desire to reinquish or take contro. Even in cases in which our respondents have an increased eve of responsibiity, say for organising tests, scans and drugs, they are foowing an extremey prescriptive and strict pan. Other studies have highighted the importance of agency and the feeing that fertiity traveers were their own project manager (p. 577). 203 We have certainy witnessed this with other treatment types, notaby bariatric treatment; however, the tone of our interviews does not seem to suggest that the process has been engaged with as a form of exerting contro over a part of ife that is out of the respondents contro. Athough the fertiity issues are ceary out of the respondents contro, there appears in our interviews to be a sense of this being a ast chance rather than a means to assert contro. Indeed, when the issue of contro is addressed it is an admission that the process does not endow the person seeking treatment with any contro: If peope wanted compete and utter contro over it then that s fata. You don t have contro over the process (FT7). What is particuary interesting is that, even with regard to the organising of tests, scans and drugs, for which respondents have responsibiity if ony a itte contro, most had at east attempted to source these through the NHS. Overa, the experiences of our traveers mirror those that our professiona interviewees have come across and those that have been discussed in pubished studies inasmuch as they are argey positive. 72 There is undoubtedy a samping issue here as a of our interviewees had been successfu in achieving pregnancy. Indeed, potentia respondents have withdrawn their participation as a consequence of treatment being unsuccessfu. A mentioned that cinica staff were proficient in the Engish anguage athough quite often nurses had itte command of Engish. Communication was not seen as an issue by any of the respondents, athough it had been a concern in advance of traveing for some. Interestingy, amost a of the respondents seemed at pains to highight how cean the overseas cinics were, with some contrasting the cean, cear and un-hospita-ike nature of the overseas cinics with conditions in UK cinics and hospitas (FT1, FT4). In contrast to other treatment types, such as bariatric or cosmetic surgery, there was itte to probe with regard to aftercare and compications. As auded to earier, for a the majority of aftercare was deat with on the NHS as with any traditiona pregnancy. A respondents mentioned that they received foow-up communications from their private cinic and some attended a first scan and bood test post impantation at their private cinic, athough this was usuay for those who had traveed abroad through a UK cinic. However, there was no detaied or continuous care or communication. None of the respondents seemed to expect this and seemed happy to engage with NHS antenata services. In ony one case did a respondent discuss a compication from the treatment that she had received, expressing frustration that the apparenty we-known risk of such a compication was not communicated to her (FT4). Here, the intracytopasmic sperm injection (ICSI) procedure precipitated a twin pregnancy that resuted in a premature birth at 29 weeks and subsequent intensive treatment. 78 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 Mutipe births Athough others do not speak directy of compications, a number of respondents had mutipe births as a consequence of their fertiity treatment abroad. In a cases, whether we consider mutipe births as a compication or not, these outcomes of fertiity treatment abroad were addressed in the UK within the NHS. One professiona respondent (NHS15) suggests that compications are extremey rare, with the outcome simpy being pregnancy or non-pregnancy. Others were keen to stress the seriousness of mutipe births, with regard to not ony the chance that a pregnancy woud ast unti term, but aso compications such as disabiities that might not manifest or present themseves unti months after the birth (PA7, PA12). Mutipe births have ong been seen as more ikey after assisted reproductive technoogy (ART) than after spontaneous conception, 98,193 but evidence aso suggests that the ikeihood is even higher when patients undergo ART abroad. 98 This is amost certainy a consequence of higher numbers of embryo transfers being permitted in some countries than in the UK (PA7). In our sampe, one respondent even speaks of having four embryos transferred (FT3). This is particuary worrying if we consider the impications of fertiity tourism or CBRC for the NHS. As both professiona association and NHS respondents are keen to stress, the cost of care during and after mutipe pregnancies is consideraby higher than that for singeton pregnancies (NHS15, NHS17, PA7, PA11). Neonata care is itsef an expensive process, which, within the NHS, is subsidised in part by private income generated from other procedures. Simpy increasing the number of births is a probem but, given that the average ength of pregnancy for a carrier of tripets is ony 35 weeks and that premature birth is extremey common with mutipes, the cost of neonata treatment is a major burden for the NHS (NHS15, PA7). Fertiity tourism or CBRC ceary shares some simiarities with other forms of medica trave whie at the same time standing apart in many ways. Our respondents have shared motivations and experiences that are common with those in other studies, whie never engaging with the ega and ethica dimensions that mark much of the academic debate. Our respondents are satisfied on the whoe yet some of their stories aude to quite substantia risks faced by those who trave for fertiity treatment and the impications of these risks for the NHS. Utimatey, as our professiona respondents noted, when a patient traves abroad certain best practices cannot be guaranteed, from the way that donors are treated to the number of embryos that are transferred (NHS17, PA7). Unti a degree of goba reguation can be guaranteed, which does not seem viabe, or provision within the UK meets demand, UK citizens wi trave abroad and the associated risks cannot be easiy controed. Impications for the NHS We have discussed the broad impications common to a forms of medica tourism but fertiity tourism often exacerbates some of the issues common to medica tourism more generay, as we as presenting others: Aftercare or the continuation of care is not required in the same sense as with bariatric treatment or even cosmetic treatment; however, the NHS bears the cost of antenata care, which is expensive, in neary a cases. Furthermore, IVF treatment is, ceteris paribus, more ikey than non-assisted fertiisation to resut in a mutipe pregnancy, which in turn increases the ikeihood of premature birth or miscarriage. Neonata costs are extremey high. In addition, not a countries have strict egisation governing the number of embryos that can be transferred. With every additiona transfer beyond the UK imit of two, the ikeihood of mutipe pregnancies/births increases, aong with the risk of premature birth and the need for neonata care. Uncear reguatory frameworks overseas mean that patient data may not aways be hed in the detai expected within the NHS and it is not aways possibe to retrieve data. When countries have anonymous donor aws this is exacerbated. Queen s Printer and Controer of HMSO 2014. 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. 79

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 Chapter 12 Denta surgery case study Athough commercia sources have undoubtedy taked up the numbers traveing for a forms of medica tourism, it is cear that denta tourists represent a arge proportion of whatever the goba figure is for medica tourists. One commercia survey suggests that denta tourism represents 32% of a medica tourism 204 and this is echoed by the consumer watchdog Which? s survey, 179 which finds that denta treatment is the most popuar form of medica tourism among its sampe of UK-based medica tourists. In addition, media sources both in the UK and beyond have reported the denta tourism phenomenon for over a decade, and in the UK denta tourists have often been tied to commentary on a perceived crisis within NHS provision. Countess newspapers artices and BBC news reports have highighted the difficuties of registering with a NHS denta practice. Once British patients have accepted this they wi rationay seek cheaper treatment offered abroad. 205,206 This case study centres on interviews with 11 peope who have traveed for some form of denta care, with responses from NHS professionas, professiona associations and other stakehoders in the denta tourism industry (aongside a rather scant iterature base) providing a wider context. There are many differences between denta tourism and other forms of treatment abroad. Not east is the fact that the very term denta tourism appears much more paatabe than other treatment tourisms such as fertiity tourism. Indeed, as we discuss, many of our respondents pace their treatment journey within a tourism context, refecting the portraya of denta treatment abroad that is commony found onine. The distinctiveness of denta tourism As with other treatment types, ack of NHS avaiabiity can be seen as a primary motivator for seeking overseas denta treatment. However, this was not the case for five of our respondents: unike for fertiity or bariatric treatment, for exampe, not a of our denta respondents had sought NHS treatment (DT6, DT8, DT10) and, even when they had, it was not necessariy a ack of avaiabiity that had prompted overseas treatment (DT2, DT3). Other core reasons cited were a distrust of or scepticism about NHS dentists (DT3, DT8, DT10), a perceived ack of avaiabiity (rather than experienced) (DT8), dissatisfaction with NHS denta care received previousy (DT3) and cutura reasons (DT5, DT6, DT8, DT10). Simiar to studies of other treatment types, the decision to trave abroad for denta treatment was in no case motivated by a singe factor but rather a combination of factors. For some a distrust of the NHS payed a key roe in ooking for private treatment: I ve never heard any good stories about UK dentists so I thought if I have to pay here I might just go home and pay there as we. DT10 I woudn t dream of it [using an NHS dentist]. I ve just seen a coeague, funniy enough a coupe of hours ago, who was just about to go to an NHS dentist. She had a provisiona crown in one of her front rows of teeth for a proper repacement and it ooked so amateurish. No I just woudn t dream of it. I d rather jump on a fight and bear the cost for that. DT3 Queen s Printer and Controer of HMSO 2014. 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. 81

DENTAL SURGERY CASE STUDY Even among those who woud at some stage have sought NHS treatment had it been avaiabe there was a sense that the standard of care was not as high as they woud hope, often drawing on persona experience: The NHS did the cheapest job they coud and for two or three years I d had probems and the infection spread to my gums and affected other teeth. So in the end I ost more teeth than I shoud have done. If the NHS had been up to snuff I woud never have needed to go. DT1 Whether our respondents had decided to seek private treatment as a consequence of issues with NHS denta care or because of other factors, the decision to seek this private care abroad was shaped by four issues: a wider distrust of UK dentistry, cost, cuture and the opportunity for a hoiday. The distrust of or dissatisfaction with UK private heath care was a common theme for those who had been born or who had spent a considerabe amount of time outside the UK (DT3, DT6, DT8, DT10). Here, the sense is that British dentistry, private or otherwise, is of a ow standard (DT10). One respondent refected on her experience of private UK treatment: So I actuay went to see a private dentist and I aways thought I d get better and prompter treatment and that is just an iusion (DT3). Cutura and famiia reasons to trave were not imited to those who returned home; one respondent (DT5) traveed to her partner s country of origin after a poor persona experience of NHS denta care. As with others who traveed home (as we as five British citizens who traveed to destinations to which they had no previous connections), this respondent ocated her denta treatment within a hoiday. It is perhaps one of the major differences between the motivations of denta tourists and the motivations of other medica traveers; whereas some who traveed for bariatric or fertiity treatment may have buit a hoiday or some sightseeing around the panned treatment, with some denta respondents the hoiday was as centra as the treatment. In this respect denta and cosmetic tourism perhaps best fit the abe of medica tourism. One respondent has even returned to her denta destination for a hoiday whereas another schedued his treatment to coincide with a stag party : The paces we went were fantastic and it was a good hoiday. I think we went back three or four times. DT1 I d been wanting to go for ages so when my mate said he was going to do Hungary for the stag I just thought, done. DT11 Perhaps the most surprising finding from the interviews was that cost was not seen as a key driver by most. Cost was ikey to be more important to those with no cutura ties beyond the UK. In our sampe ony six mentioned cost and in ony four cases was cost the most important factor for choosing overseas treatment rather than UK private treatment. In each of these cases, however, the cost savings were fet to be significant by the interviewees and in two cases (DT1, DT7) the perceived savings were > 20,000. Given the media attention that has focused on the cost of denta treatment abroad, it is perhaps surprising that cost was not a factor for more of our respondents. Indeed, when asked what they thought the key motivations for traveing were, our professiona association respondents ranked cost as being the ony rea reason to trave (PA9, PA16). With regard to the experience of traveing for denta treatment, the organisation of the journey was rather mixed. In some cases our respondents had pretreatment consutations in the UK. Athough package treatment and hoiday offers are readiy avaiabe on the internet, none of our respondents had traveed on such a dea (athough two did have their accommodation organised by the treatment provider). 82 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 In addition, none of our respondents had used brokers or faciitators. Instead, a organised their journeys direct with the cinic and organised their own fights. In terms of the experience, for 10 of our 11 respondents it was overwhemingy positive: Yeah, the experience we had there was exceent. Yeah, wonderfu. They said that these were guaranteed for 10 years. DT1 DT2 She [the dentist] was briiant. I can t praise her high enough. I m not being emotiona about it. She was very, very good. She istened first and foremost. She didn t rip me off and she charged very reasonabe and at the same time she didn t cut hersef short. DT9 However, as one of our professiona association respondents (PA9) and the wider iterature caution, 207 probems may not revea themseves unti months or even years down the ine. An unreguated industry One respondent (DT4) did not have a positive experience. Having traveed for what she caed a fu restoration of her smie, numerous impants were provided. In fact, the impants were initiay paced in the UK before the respondent traveed to Hungary for the subsequent stages of treatment: Some of my existing teeth which had been fied back too far and therefore caused a ot of pain because the nerves, the pup was exposed... There was no tria of whether they were the right size or the correct whatever. The fina work, it ended up that they were a far, far too big for the size of my mouth. They weren t in the right pace of my origina teeth. They competey cramped my tongue. I coudn t speak. I had no room to speak because they were too high. I coudn t cose my mouth. And I was in a considerabe amount of pain, which wasn t taken any notice of at a. The respondent has subsequenty had a of the work redone bringing the tota cost to in excess of 40,000 and has suffered for a number of years whie the probem was being addressed. This is ony one case in our sampe but it underscores the potentia negative outcomes of denta surgery. Indeed, our professiona association respondents (PA9, PA16) suggest that corrective work is commony requested by those who have traveed abroad. A survey by the Irish Denta Association in 2010 208 even suggested that 75% of those who had traveed abroad for denta surgery and then subsequenty re-engaged with the Irish denta system required corrective work. Even if these figures are incorrect, the success rate for non-compicated impants ranges between 93% and 98%, 207 which means that even when best practice is observed compications wi arise. When these have occurred within a different ega and reguatory framework the probems faced by the patient can be difficut to address. One professiona association respondent (PA8) stated that he woud never fee comfortabe referring a patient for treatment overseas as there is too much that cannot be controed. A cear issue is the ack of reguation governing denta practice overseas, especiay when procedures are considered cosmetic in nature. Not unike cosmetic tourism, denta tourism is marketed very much as a commodity rather than as a heath service. This, as we have seen, has a profound impact on the quaity of information that exists and in turn on how we protected potentia denta tourists are from issues of risk. That many of the dentists who operate abroad have trained in the UK or been registered with the GDC is ceary of great comfort to many of those who trave for denta treatment. But how reassuring is such registration? Denta tourists are unikey to ook beyond whether a practitioner is registered with the GDC, Queen s Printer and Controer of HMSO 2014. 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. 83

DENTAL SURGERY CASE STUDY perhaps to expore cinica memberships beyond the UK and the comprehensiveness of their safeguards. Moreover, it is unreaistic to expect prospective denta tourists to assess the veracity of any caims made regarding memberships. In the UK it is reativey straightforward to ascertain whether or not a dentist is deemed as being in good standing with the GDC. It is extremey unikey that any professiona who has been suspended or deeted from the GDC s register coud practise for ong without being deat with by the GDC. However, this may not be the case abroad. Indeed, one of our professiona association interviewees (PA9) points to the case of a ceebrated dentist in one country who had actuay been suspended from the GDC s ist in the UK. The dentist in question continued to activey market himsef to UK customers, even maintaining that he was registered with the GDC when in fact he was suspended. It is possibe to think of denta treatment abroad as refecting more cosey the consumer-driven idea of choice in medica services and perhaps best befitting the abe medica tourism. But as one respondent noted (DT4), athough denta tourism does not necessariy invove ife-threatening medica treatment, it most definitey can invove ife-changing medica treatment. As in this case, this change wi not aways be positive. Impications for the NHS Athough many in the UK undergo private denta treatment, it is ceary possibe that peope who have had denta work abroad may seek NHS care on their return. As the NHS are unikey to offer anything beyond the most basic corrective work (if patients are in great pain), denta tourism does sti present some impications for the NHS: The ack of comprehensive reguation of dentistry outside the UK means that there is a genuine risk of whoy inadequate care being received abroad. Athough the NHS is ikey to perform emergency treatment ony, often with the purpose of reieving pain, there is the potentia for a arge number of such cases to occur as a consequence of denta tourism. Many cinics offering denta treatment, especiay in seected ocations, aso offer what is marketed as minor cosmetic treatment. In many cases it is uncear whether or not they are quaified to do so. The key issue reates to the ack of carity regarding patient records. In particuar, when a patient has traveed for treatment, the apparent inguistic abiity of cinicians may not be refected in records. It is entirey possibe that continuation of care wi take pace within the NHS, sometimes in circumstances in which the precise treatment undertaken abroad is unknown. 84 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 Chapter 13 Cosmetic surgery case study Distinctive features of cosmetic tourism Unike a other forms of treatment, it is unikey that those who require cosmetic surgery wi have had much contact reated to their treatment with the NHS. As one NHS commissioner remarked: We have a very, very tight cosmetic approva process which we ve had for a number of years. Every GP is aware of it so the numbers of peope who actuay get referred we ca it IFR, Individua Funding Request is quite sma. NHS6 As our interviews confirmed, peope are generay aware that cosmetic procedures are rarey provided on the NHS and as such there is an understanding from the outset that treatment wi be privatey funded and provided. There are notabe exceptions, for exampe foowing bariatric surgery some may hope to have oose skin removed. Likewise, those who use the NHS denta service may assume that cosmetic dentistry can be provided through the NHS. In both of these exampes peope who seek cosmetic surgery may engage with the NHS in the hope that treatment wi be provided, athough as the quote above impies such treatment is unikey to be approved. The mindset that surrounds cosmetic treatment is perhaps then different to that which surrounds other forms of treatment. It is generay understood that to seek cosmetic treatment is to seek private treatment. Even when it comes to aftercare, our respondents either were turned away by their GP or opted to utiise private faciities from the outset. In one case a respondent discussed visiting their GP for the remova of stitches: I had to go and get my stitches out 15 days ater. The doctor that took them out was very unimpressed, very angry, that I d gone to get four stitches taken out that had been for private treatment (CT2). The consequence of this is that, for those seeking cosmetic surgery, vaue for money and overa costs appear extremey important. Athough one study found that 66% of its respondents woud never consider cosmetic surgery abroad and ony 4% woud consider it for reduced costs, 209 a consensus of commercia, professiona and academic sources, as we as our sampe of medica tourists, suggest that cost is the key driver behind those who trave for cosmetic treatment. The cost generay does seduce you... I thought to mysef if I m going to pay 5000 and not get any resut at a and be back to stage one why not go to Cyprus and pay 800 and get the same thing (CT4). Patients fet that it was important and usefu that prices were upfront and made readiy avaiabe on websites of foreign providers, in comparison to UK providers at which an enquiry and consutation woud first be necessary. Amost haf (four out of nine) of the sampe opted for mutipe procedures as part of a package; this was particuary cost-effective. For exampe, CT3 expained how the surgeon offered to throw in some extras to make it a more attractive package: It was 5000 for my arms aone. In Begium I paid 6000 for my arms, my tummy and he said because you re having a that done we do some iposuction and reshape you. So he did that as we (CT3). The cosmetic tourism industry The vaue-for-money nature of cosmetic tourism refects a wider approach from within the industry and combined with intensive marketing, there is a potentia for risks to be not ony heightened but aso misunderstood by those who trave. A of our interviewees, whether they had traveed for treatment, Queen s Printer and Controer of HMSO 2014. 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. 85

COSMETIC SURGERY CASE STUDY worked in the NHS, represented a professiona association or had a commercia interest in cosmetic tourism, presented a picture of a process that is very much marketed as tourism. This is not to say that our medica tourists agreed with the notion of cosmetic treatment being reconciabe with a hoiday: I don t understand this image that you re going to have an operation and then go and ie on the beach for a week and have cocktais. Because you re big swoen and painfu whatever you ve had done [...] so I think it s naughty for companies to advertise as sort of hoiday surgery breaks because it s not ike that. CT4 Contrasting this point with the image presented by many onine sources and verbaised by one interviewee with commercia interests is particuary stark: It s not just about going for medica treatment. [Location] is an absoutey stunningy beautifu city so don t just think about it as going for a quick nip or tuck. Actuay take an extra few days out of your diary and actuay spend some time doing sightseeing. IND14 There is ceary an issue with how cosmetic treatment is marketed in genera, with the roe of teevision, from reaity TV shows to adverts, inked to an increasing prevaence of peope deciding to undergo procedures. 210 Athough our professiona respondents were a keen to underscore the fact that cosmetic surgery is sti surgery and as such shoud be considered as a medica procedure (PA8, PA17), cosmetic surgery, especiay abroad, is marketed more as a commodity than a procedure. This has cear consequences for the quaity of information that is presented, especiay onine. We saw in Chapter 7 that the quaity of information that can be found on cosmetic tourism websites is poor. This is perhaps even more probematic given that it is unikey that potentia cosmetic tourists wi have discussed their treatment pans with a heath-care professiona. This ack of quaity is exacerbated by the broader consumer rather than medica focus of the cosmetic tourism industry. Interviews with industry professionas demonstrated a eve of concern for patients opting to trave abroad for financia reasons, as this can resut in patients overooking more important factors such as quaifications and aftercare. Even those who engage with an onine community find themseves under- or i-informed. Indeed, there appears much ess baance to the onine community that surrounds cosmetic tourism than can be found in bariatric or fertiity surgery forums. As one respondent noted (CT8), forums on cosmetic surgery provider sites are heaviy monitored to remove any negative comments about the treatment received. Risk The picture that is painted by those with commercia interests in the cosmetic tourism industry is one that pays up the tourism dimension, attempts to normaise the notion that one woud trave to have cosmetic surgery and seriousy underpays the risks invoved. This has a profound impact on how peope view the risks invoved and, in turn, through being under- or i-informed, how they experience risks. The poor quaity and ack of reguation of information onine is found across a forms of medica tourism; however, a wider ack of reguation surrounds cosmetic tourism, even within the UK. One professiona respondent suggested that, within the UK, cosmetic treatment is being offered by peope without the necessary quaifications and that this is certainy the case overseas as we (PA8). Turning to overseas cosmetic surgery the same interviewee expained that, as things stand, there was no good cinica reason to trave for treatment: By and arge nobody encourages the principe of peope going into a foreign and, not knowing the cuture, often not knowing the anguage and aso not knowing how to check on who the surgeon is, 86 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 what quaifications they have and where they have the surgery whether they have simiar standards to those imposed by the Care Quaity Commission here in the UK. PA8 Reguation is quite simpy missing. 211 Despite our interviewees from the commercia sector paying down the risks of cosmetic treatment, both in genera and abroad, evidence from academic and professiona sources suggests that there are numerous cinica risks and exampes of quite serious compications arising from cosmetic tourism abroad. 76,102,134,212,213 We can draw exampes of quite severe compications even from our cosmetic tourists: I d got a pocket fu of fuid inside of my face. I d got infection a round my neck and I d got this pocket fu of fuid. I m eft with a hoe in my stomach because they just coudn t be bothered to sort it out propery. CT5 CT8 We shoud probaby note that none of our sampe had traveed for cosmetic surgery invoving their breasts. A survey of cinicians by BAPRAS 212 recorded a higher rate of compications reated to such cosmetic surgery than for any other type of surgery. The reaity is that many of the heath impications are ikey to present after the period that a cosmetic tourist spends abroad (PA8, PA17). It is unikey that peope wi be wiing or abe to trave, perhaps in great pain, to the country in which they underwent treatment and, even if they did, there are no guarantees that the origina provider woud offer treatment. The recent PIP breast impant scanda underscores the uncear ega and reguatory frameworks that exist around cosmetic tourism as we as the cinica risks faced by those who undergo cosmetic treatment abroad. An additiona issue that is addressed in the iterature, 213,214 and which was discussed by our professiona association interviewees but not by our cosmetic tourists, is that of psychoogica support. One representative of a professiona association stressed that psychoogica support is woefuy acking in genera and even more so abroad. Moreover, in her opinion: Cosmetic surgery patients are amongst the most vunerabe patients in this society and they can be taken advantage of. Many patients, the vast majority of them, who think about cosmetic surgery, they fee embarrassed to tak about it. They don t even go and discuss it with their GP. PA8 This sentiment is echoed by both Bradbury 213 and McGrath, 214 who discuss the psychoogica impact of cosmetic surgery and breast impant surgery respectivey. Indeed, it is worth refecting on the fact that cosmetic surgery abroad may often invove vunerabe peope who may have itte interaction with heathcare professionas, who have been exposed to poor-quaity information, who trave for possiby ifechanging procedures and who do so with no professiona psychoogica support. Impications for the NHS Cosmetic tourism invoves peope eaving a rather weak reguatory framework in the UK to have what can be serious and compex procedures in countries that may offer even fewer safeguards than the UK. This has a number of consequences and presents the foowing possibe impications for the NHS: Compications from cosmetic surgery often do not occur immediatey. Once patients have returned to the UK it is ikey that any serious compications wi be addressed by the NHS. Queen s Printer and Controer of HMSO 2014. 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. 87

COSMETIC SURGERY CASE STUDY Perhaps even more than for those who trave for any other form of medica treatment abroad, cosmetic tourists are ikey to be exposed to poor-quaity information that is not baanced through interaction with heath-care professionas. The ack of psychoogica support offered by private providers, especiay overseas, eaves many at risk of undergoing inappropriate procedures or procedures that are unikey to offer outcomes that meet what may be unreaistic expectations. The consequences of this are once again ikey to fa on the NHS. 88 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 Chapter 14 Diaspora case study Of particuar interest to this project is the experience of diaspora patients who choose to trave abroad, to their countries of origin or to a third country, for medica treatment. There are a number of reasons why these patients choose to trave, in particuar the desire to access primary care, which is freey avaiabe in the UK. Research demonstrates that back and minority ethnic (BME) and migrant communities often encounter difficuties when accessing heath care in the UK, and this is aso often the case in other countries. 215 Three individuas were interviewed regarding their experiences of traveing abroad to a country that they had a famiia connection with for medica treatment. In addition, focus groups were conducted with members of the Somai communities in Manchester and Camden and the Gujarati community in Leicester. Here it has been necessary to deviate from the hitherto-used method of interviewee identification, in which individua identifiers have been attached to verbatim quotes. Given that the diaspora groups were often interviewed within a group setting, sometimes with the faciitation of a cutura gatekeeper, it was not possibe to give individuas unique identifier abes. Athough patients traveed for a range of treatments, diagnostics was the predominant reason. Despite representing different ethnic communities, there were a number of commonaities across a patients that marked this as a distinct group within our patient sampe, with specific characteristics differing from those of the genera medica tourism experience. This incuded patients motivation for trave and their use of information and awareness. Destination Within the diaspora category there were severa different strands to the diaspora eement of patients traveing abroad. The three individuas traveed to famiia countries within Europe (France and Germany); two traveed to their country of origin and the third traveed to his wife s country of origin. They had strong inks with famiy and friends and previous experience of the heath-care system. Industry professionas expained that members of specific ethnic communities within their catchment areas woud often trave home for various treatments and combine this with visiting famiy and friends. The Gujarati community traveed to a specific area of Gujarat in India. However, none of the individuas had direct famiia inks to this city. A of the members had been born or grown up in East Africa and moved to the UK in the 1970s. Athough their famiies originated from Gujarat, there was a specific reigious eement to their choice of destination. A of the community members foow a certain branch of Hinduism and they have become foowers and trave to Gujarat as part of an annua reigious pigrimage. The choice of destination by this group was not primariy determined by any of the considerations evident for other medica tourists interviewed for this research. Members of the Somai community predominanty traveed to Germany and occasionay to Itay. Research from both Sweden 216 and Hoand 217 demonstrates that members of the Somai communities in these countries aso trave to Germany for medica treatment, in particuar diagnosis, for simiar reasons. German doctors have advertised on Somai teevision for many years and this has deveoped as the main medica tourism route for the Somai communities that we spoke with. A minority of the groups have traveed to other European destinations, incuding Itay and Hoand. Community members stay with members of the Somai communities in both of those countries. Hoand was a prominent destination for Somai refugees during the 1990s and Itay has a coonia connection with Somaia. Industry professionas aso considered this a reason for Somai community trave. Members of the community were keen to highight that it is commonpace within their nomadic cuture to trave, incuding for heath purposes, and therefore this may be specific to Somai diaspora. Queen s Printer and Controer of HMSO 2014. 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. 89

DIASPORA CASE STUDY Motivation Motivation for trave differed vasty amongst diaspora traveers in contrast to the motivation for trave for a other outbound medica tourists. Expertise The overwheming motivating factor for the mixed and Somai diaspora groups was their desire to seek a quick and thorough diagnosis. This was paired with a wiingness to trave and pay out of pocket for services normay avaiabe on the NHS. Athough the Gujarati community aso dispayed such wiingness, cost took precedence for these patients. The wiingness to trave and seek a quick diagnosis is combined with a ack of confidence in the UK system and in some cases not having a fu awareness of a services offered. Tiiikainen and Koehn 218 found that a key motivation for Somai patients to trave is a negative perception of the host nation s heath-care system, incuding a ack of understanding of the system and a ack of trust in the diagnosis given. However, for both the Somai and the Gujarati communities, cost was aso an infuencing factor as they were abe to access diagnostics more cheapy abroad than in the UK. Across the board, patients were generay unhappy with the diagnostics that they receive from their GPs. For exampe, OT6 expained: I don t ike to go to doctors and have the feeing that right from the get go the examination or even the way the diagnosis is being formuated, I don t ike to have the impression that I m going to have to come back or see another doctor. Patients expressed the beief that a GP shoud undertake a thorough diagnostics process, incuding any necessary testing (e.g. bood tests), during the first visit and be abe to prescribe treatment or medication as appropriate. They often fet that their GPs went through a process of vague questioning and prescribing of either paracetamo or antibiotics with the proviso that if their compaint did not improve they shoud return in a month or so. This ed members of the Somai communities to refer to their oca GPs as Dr Paracetamo, demonstrating their dissatisfaction. This has been corroborated by other studies. 219 The Somai focus groups reveaed that Somai patients te their GP their probems and expect tests and a diagnosis immediatey, rather than having to return for tests or resuts at a ater date. One individua said: Somais fee that their GPs don t care about peope they provide no diagnosis, no resuts and no evidence and so, peope trave. Research has found this to be the case in America as we, where Somai patients expect to receive immediate resuts and a diagnosis, in some cases causing tension for patients and physicians. 220 The expectation to be diagnosed immediatey has aso been reported in other Somai diaspora communities. 216 Warfa et a. 221 found that some Somai patients seek treatment in A&E departments to bypass their GP, which was corroborated by our focus group discussion. A report for the Department of Heath into BME experiences of heath care in the UK found that there is a mismatch between the heath needs and requirements of BME and the services on offer, eading to dissatisfaction and unmet need (p. 5). 215 Many patients reported a ack of faith in GPs. Having had an unsatisfactory experience a number of years ago and rectified the situation through private treatment in her country of origin, one interviewee continues to trave for check-ups and any necessary diagnoses or treatment with the same provider abroad: I don t know why but for some reason when I go to UK doctors I just don t fee I don t have a ot of confidence in their diagnostics. I don t know why they don t make me fee ike I can trust what they re teing me. And often if I don t go for a check-up but go for a specific probem the medicine they give me doesn t work and end up having to go and see another doctor. OT6 90 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 For two individuas, access to treatment in the UK was further compicated by a ack of avaiabiity of their chosen treatment on the NHS. Athough the treatment for his rare condition is now avaiabe in the UK, one individua prefers to continue to trave to France because of the expertise there and because he can combine this with visiting his in-aws. The other interviewee traves home for utrasound, which athough avaiabe through the NHS is not avaiabe for her condition. In Germany, this is freey avaiabe without a referra and is cheap compared with the cost in the UK. Cost As for a medica tourists interviewed, cost is a factor in deciding to be treated abroad. A patients were abe to receive a diagnosis and treatment abroad for significanty ess than in the UK. Members of the Gujarati community seek denta treatment in particuar during their trips to India. For exampe, patients were quoted 3000 5000 for denta impants in the UK compared with 110 in India. The price of denta treatment in the UK is prohibitivey high for them. This is aso the case for the Somai community. In addition, both diaspora communities perceived private heath care in the UK to be out of their means. Patients interviewed described that they are not weathy but that a person s heath is considered paramount and that therefore the community wi chip in to ensure that they are abe to trave for diagnostics in serious cases. One Somai said: Cuturay and reigiousy we re cose-knit so what generay tends to happen is we hep each other. So if peope know that somebody is in a reay bad way and they need treatment or they need money to be coected to get them something then that s what we do. It s ike an obigation as a community to do it. Even peope when they have nothing wi find a way to hep. And that s kind of how peope survive. So it s not that peope have this disposabe income it s just they find a way if it s reay serious. If peope are so sick that peope are worried then they do something. What is distinct to diaspora patients is that the choice of destination is not determined by cost but rather by cutura or persona affinity or a perception that members of their community are ikey to receive a better service abroad. In many cases, such as in the Gujarati community, treatment is not the primary motivation for trave but rather trave provides an opportunity for treatment. Information and marketing Contrary to other medica tourism patients, diaspora tourists do not rey heaviy on the internet for information. Community and famiy reationships pay a key roe in decision-making. Two of the patients traveed to countries that they had a famiia reationship with and reied on persona recommendations from their famiy or friends in that country when seeking treatment. When patients trave with the primary purpose of treatment this is often combined with a famiia visit: I do go to see my mom from time to time but otherwise I know that there are times where I m just going specificay. I make phone cas to make appointments and I eave for my checks up. Maybe I take a week where I can just go to a of my doctors in that week and I just go to France. OT6 Persona recommendations aso form the basis of decision-making within the Gujarati community. Interviewees requested recommendations through the reigious organisation that they are members of and these are shared within the community. This contrasts with the Somai community, which reies heaviy on ora information and mainstream sources, such as the internet. Media and papers are not consuted, eading them to be described as ora communities. 219 In Manchester community eaders were key in distributing information to the community. Some community members may not be abe to access written information, avaiabe in different anguages, such as eafets about oca NHS services, because of iiteracy. The ora dimension has a significant impact on community members decision-making processes and how Queen s Printer and Controer of HMSO 2014. 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. 91

DIASPORA CASE STUDY they view services avaiabe for them. For exampe, a negative experiences of the NHS and GPs are shared within the community, which increases mistrust. 219 Another key source of information is Somai teevision channes, avaiabe by sateite. This heped deveop the connection with German cinics and doctors. German cinics are the ony ones to advertise on Somai teevision in Somai and these adverts are usuay at peak viewing times, for exampe before the eary evening news. Once one patient has been to visit a doctor this then rapidy spreads through the community through word of mouth. For exampe, one Somai expained: We re a cose-knit ora community so if someone comes around and says I m not we then they might say there s this doctor I ve been to. So ots of advice from word of mouth but they ve got Somai channes now and they do adverts on them. So they have advertisements for hospitas abroad. The doctors out there I think have cued on and they advertise. So peope get that if they have sateite TV. These exampes highight how heath information, incuding information about medica providers abroad, is spread within specific diaspora communities. It is aso cear that specific cinics, such as German cinics, market themseves to specific segments of diaspora markets. This was echoed by the Gujarati community interviewed who reported that in Gujarat there are now a number of cinics targeting returning non-resident Indians, who have greater resources than domestic patients. Language barriers: a key motivation for diaspora trave The issue of anguage is a key area of divergence in experience within this diaspora category. For members of the Gujarati community and other diaspora patients, anguage was not a barrier to accessing or receiving heath care in the UK. However, anguage barriers exist for members of the Somai community in the UK and these are key to their experience of, and interaction with, the NHS. This can prove probematic on a practica eve and ead to misunderstandings. For exampe, one Somai expained: Sometimes if you re not feeing we and you go to the GP and sometimes you don t know the words. They cannot find a way for an interpreter. So it can be a bit difficut and so you have to point to it. Sometimes there s a misunderstanding. This frustration expressed by Somai women at anguage and cutura barriers, incuding brief and rushed appointments, resuts in further mistrust, which is aso the case for Somai women in other countries. 220 This can aso affect the services that patients receive: Sometimes if they know your Engish is not good they just brush you away. However, the anguage barriers between members of the Somai community and their GPs can be seen as one aspect of poor heath iteracy within the community. 222 In one of our focus group areas, additiona funding had been sourced to empoy a Somai nurse at the oca surgery who acted as the first point of contact for Somai patients. This was extremey we received and successfuy ensured that anguage and cutura differences coud be both understood and interpreted in partnership with the GP. However, the majority of patients said that transators were rarey avaiabe. This was a key determining factor in their seeking treatment with private Somai doctors in the UK or their choosing to trave abroad. Across the two Somai communities interviewed, accessing a Somai doctor in the UK was their first choice. The reason they go is because he speaks the same anguage and you don t have to ook for a transator. You don t fee ike he doesn t understand you. Sometimes when you go to a GP you fee ike they don t understand you so you aways have doubt. But he 100 per cent understands and we understand him as we. 92 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 However, this option was significanty more expensive than traveing abroad and therefore was rarey used. Notaby, doctors accessed abroad are not necessariy aways of Somai origin. For exampe, some of the most popuar German doctors do not speak Somai but provide transators as standard. In contrast, when patients return to a country with famiia ties, anguage does not pose a barrier. Treatment experience Patients experiences of treatment and care in the cinics abroad were overwhemingy positive and some compared their experience to their experience of care in the UK. For exampe, one patient described her experience of diagnosis and tests abroad: If you see a speciaist you usuay see them in their private office. It s a nicer environment. Here you go to the hospita and you re in a big waiting room, uness you see someone privatey. It s a ot more busy. It fees a ot more ike you re on a conveyor bet. OT2 Despite this, she went on to say that, With my experience it s very difficut to compare because it s not ike for ike reay. I woudn t say that care is necessariy better. You get things much quicker in Germany. Throughout the Somai and Gujarati communities, members discussed how happy they were with the treatment received abroad. In particuar, the sense of vaue for money compared with private care in the UK is important in this process. The reasons why diaspora patients trave differ from the motivations observed in other medica tourists. Mainy they ie in cutura ties and connections to the pace of treatment, or in opportunisticay making use of a hoiday or a return home, which coud be in part for treatment but may be motivated by other reasons. At the same time the high numbers of patients from specific ethnic groups (in our case the Somai community) who trave to receive treatment in a third country coud be indicative of a ack of communication or outreach by the NHS to specific sections of the popuation, rather than a more genera phenomenon of medica tourism. Regardess of cause, providers have ceary deveoped to capture this niche, as is evident from German cinics and from the medica industry in India catering for non-resident Indians who return home for their medica treatment. Impications for the NHS Diaspora patients, especiay those of the diaspora Somai community, described cutura and specificay anguage barriers to accessing the NHS, incuding oca GPs. When services are accessed, the treatment and care received may in some cases not meet patient needs. More needs to be done to address these needs, which act as the main determinant for trave. This incudes communication in diaspora anguages not imited to print materias and the use of heath mediators from diaspora communities in oca GP surgeries. It coud incude heath information on diaspora radio and teevision stations, as we as greater engagement of community eaders to disseminate heath information, incuding information on services provided by the NHS. Queen s Printer and Controer of HMSO 2014. 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. 93

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 Section 4 Inward trave, costings and concusions Queen s Printer and Controer of HMSO 2014. 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. 95

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 Chapter 15 Internationa patients and associated activities within the NHS Background The discussion beow presents anaysis of inward internationa patient fows to the NHS. Discussion is based on data gathered from seven foundation trusts, based on semistructured interviews with a range of NHS providers (n = 13), and three key stakehoder discussions with individuas who have significant experience of internationa patients fows, incuding a Department of Heath officia and a business consutant with significant experience of the NHS and private activity. Except for one, a foundation trusts were based within London. The roes of interviewees within trusts incuded the commercia and strategic oversight of activity, contract and business deveopment and managing private and internationa patient activity. The focus on inward fows is around the booked and panned admission of internationa patients treated as private patients within NHS faciities. This coud incude outpatient admission and day surgery as we as overnight stays. Possibe payers for these patients incude government-sponsored patients, private/empoyer insurance, and those funding treatment out of pocket. The emphasis was on booked and panned admissions for which the foundation trusts coud reasonaby expect reimbursement (prepaid or through an embassy or insurer etter of guarantee ). Individuas traveing from outside the UK for booked and panned treatment shoud be distinguished from categories of overseas and eigibe or non-eigibe patients. For exampe: Individuas might trave to the UK and receive NHS services (as a resut of initia admission to A&E or through GP referra) but not be eigibe for these services (which coud incude maternity, diaysis, cancer or human immunodeficiency virus treatments). This inks to a pejorative meaning of heath tourism, 223 in which there is no booked and panned admission with a cear reimbursement pathway. Overseas nationas coud be admitted to A&E and coud then be transferred to private patient faciities if their costs were covered by insurance or sef- or embassy guarantee. EU nationas who access A&E or panned treatments using their rights as carified under the EU directive (Directive 2011/24/EU of the European Pariament and of the Counci). 1 The background and poicy context to internationa patient activity is detaied in Appendix 25. Size and scope of internationa patient activity Data from the IPS suggest that, overa, internationa patient fows were in the region of 62,000 in 2010. Within this overa figure, major source countries incude Ireand, Spain, Greece, Cyprus and the Midde East. From the freedom of information requests we submitted it was cear that trusts coud not aways ceary identify internationa patients within their poo of private patients because nationaity was not recorded: With [internationa private] patients, a ot of them have an address in Engand and so that s the address that wi go on the systems. So we may never have a record of where they come from (NHS20). Queen s Printer and Controer of HMSO 2014. 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. 97

INTERNATIONAL PATIENTS AND ASSOCIATED ACTIVITIES WITHIN THE NHS Those whose treatment was funded by foreign embassies were more easiy identified, but foreign nationas based/iving in the UK may undergo treatment as private NHS patients in the UK, the costs of which are paid by their overseas empoyer or insurer or are funded out of pocket. The NHS foundation trusts participating in the study were purposey samped as we sought to understand the experiences of and ambitions for treating internationa patients. The London-based foundation trusts had ongstanding internationa patient fows (incuding singe-speciaty hospitas as we as those offering a broader range of speciaties). Countries identified as sending patients were primariy those from the Midde East (incuding Kuwait, the United Arab Emirates, Oman and Qatar, with smaer numbers from Saudi Arabia), and there were aso strong fows from Cyprus and Greece. Types of treatment centred on compex tertiary procedures (incuding paediatrics and heart surgery). Trusts that had deivered care to internationa patients over a number of years were keen to maintain and consoidate such activity. A number sought to expore opportunities to deveop further internationa patient fows. The one trust based outside London had some imited experience but a growing interest in deveoping its internationa activity. As we note in Chapter 16, the size of internationa private patient fows across trusts and foundation trusts varies. Simiary, across the seven trusts within our sampe, activity ranged from being reativey margina to being one-third of their tota private work. The great majority of internationa patient treatment and payment pathways were organised by embassies and nationa institutiona inks. Very few patients within the NHS private system were reported to be out-of-pocket payers. Respondents suggested that sender countries governments vaued the NHS brand: Overseas, it s a great brand. NHS16 A ot of those countries fee it s quite poiticay supportive to actuay send their patients through to NHS faciities rather than to direct private faciities. NHS3 As we note beow, these views regarding brand perception and reputation were aso associated with individua NHS providers. Strategic and commercia considerations Respondents emphasised strongy that internationa patient fows must be seen within a wider picture of pressure on NHS resources, broader internationa activities and inkages and the ifting of the cap on private income earned by foundation trusts. First, broader commercia imperatives facing the NHS were highighted by interviewees, and treating internationa patients was seen as a means to an end (improving services for NHS patients and deveoping NHS faciities). The current financia cimate for the NHS was viewed as a major chaenge, and commercia income, private patient income and internationa income were seen as possibe routes to ameiorating pressure on stretched NHS resources: I think going forward a NHS organisations are financiay chaenged in some way or other.... Our best chance is actuay by growing income from the private sector which wi be used to subsidise the NHS (NHS15). However, any commercia imperatives were baanced with strong statements regarding the core NHS roe, centred on NHS services and prioritising NHS patient care: 98 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 Why ese woud we be having a commercia operation if it wasn t to deiver a surpus that we can then reinvest on the NHS side? NHS19 You have to baance. You cannot compromise our NHS responsibiity. That is number one responsibiity of the hospita. What we re trying to do in these difficut times is manage the whoe eement of trying to achieve the overheads and costs that we have and manage that in a way that we at east generate some additiona monies. NHS3 We re in the business of making a profit after we have done our core job which is making peope better. NHS5 It heps us aunch services or buy kit that we coudn t buy otherwise and empoy peope that we may not be abe to empoy. NHS16 Internationa patients were seen as an opportunity, as was domestic private activity. Both domestic and internationa activities provided opportunities to utiise spare capacity, particuary operating theatre time that was avaiabe out of hours. The NHS was viewed as having exceent back-up faciities, particuary in intensive care units. A common view was that, if not carried out at NHS sites, private work woud be undertaken esewhere and that there was an advantage in retaining cinicians on-site because they coud be accessed by NHS patients. There was itte interest in activey accessing other patient fows (e.g. EU cross-border fows) given that tariff rates were not perceived as particuary attractive. One trust, for which one-third of its private work is internationa, directy commented on the advantage of internationa patients (funded by governments) being on higher tariffs than patients from domestic insurance companies: So to be honest they [embassies] were paying more than insurance companies in this country, we had imited capacity, so why not for the NHS gain as much as we can and put back into the NHS? (NHS16). For one commercia director, the board s interest in and enthusiasm for exporing commercia opportunities required expectation management with regard to internationa patient opportunities: What is reay uncertain is what are the procedures peope wi trave for and what countries are they in (NHS5). Such issues of non-nhs activity were invariaby contentious. As the Department of Heath poicy manager stated: It s a very sensitive issue to the pubic about how much of the NHS is retained in its origina format or how much of it change to opening up a more commercia approach (PA15). Loca and nationa poitica sensitivities of engaging in private patient and internationa activity were recognised. Indeed, one commercia manager spoke of the importance of being abe to Demonstrate that you re doing it with additiona capacity and it s not making NHS patients wait and you re doing it in a way that generates additiona income which then goes to benefit patients (NHS1). Second, estabished traditions and practices of having wider internationa cinica inkages and exchange were correated with internationa patient activity. Institutions had ongstanding internationa consutancy arrangements, coaborations and inkages and harboured ambitions to see these deveop and fourish. Some were organisationay driven whereas some ay outside the hands of individua trusts: So ots of our consutants go overseas to do ots of things. Some of it is charitabe, some if it is rather more forma than that but that s not the same as the organisation doing it... It gets quite compicated that in the NHS you ve got an organisation that may or may not choose to do something Queen s Printer and Controer of HMSO 2014. 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. 99

INTERNATIONAL PATIENTS AND ASSOCIATED ACTIVITIES WITHIN THE NHS but that organisation is made up of a oad of cinica staff who wi go off and do their own thing anyway. NHS19 As discussed beow, these activities raised the profie of consutants and hospitas and contributed significanty towards internationa patient referras. Third, cosey inked to private patients (and thereby internationa private fows) was the cap imiting earnings from private activity. Fiedwork interviews were conducted during the passage of the Heath and Socia Care Act 2012. 30 The ifting of the cap was broady wecomed within the trusts, athough differing views were expressed regarding how, and whether, it woud make an immediate difference. An interviewee from one trust stated that: It s a reay very important constraint for us given our ocation and given the ow eve of the cap at the moment reative to other organisations... an expected poicy move to ift the cap wi be very important for the future of this organisation. NHS15 This particuar trust pointed to major difficuties with the measurement of the private cap contribution whereby biing counted towards private income (even if unpaid) and treatments that were not necessariy panned and booked were incuded in the count. One exampe provided was a treatment bi of 200,000 that was unikey to be coected but which was nevertheess set against the cap of this particuar trust. For some trusts the impact of the cap was dependent on ocation and aso capacity: I think for some hospitas it s just a non-starter because of the area they re in but for us in an area ike this... it s very internationa and affuent. You stand a far better chance of being run over by a Bentey or a Porsche than you do by a norma car out here. NHS15 Thus, this trust intended to expore opportunities with embassies from a range of countries (e.g. getting on embassy ists of preferred providers) once the cap was ifted. Another trust identified how the changes were absoutey vita to its future growth and deveopment; this particuar trust had deveoped two business modes for the upcoming year, premised on the cap being ifted at different points in time. For another trust, however, athough its earnings were cose to the cap, when it was raised capacity issues woud continue to constrain any growth of private/internationa income. Referra and treatment pathways There are distinct processes of referra and patient management for internationa patients. Two centra considerations are organisationa reputation and ongoing reationships. First, beyond a broad view of the NHS, the reputations of individua trusts and hospitas were identified as crucia: We ve got a certain brand, particuary around the Midde East. Patients just want to come here... to be honest, the troube we have is the capacity to fit internationa patients in. NHS2 NHS1 100 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 We re actuay very protective of that brand so we tend not to formay partner with peope overseas. NHS19 The internationa patient activity that was referred to NHS faciities was viewed as speciaist and typicay not possibe to treat ocay because of reativey sma voumes and the compex nature of the treatment required. Second, reationships, primariy cinica ones, were paramount in maintaining fows of internationa patients. Patient fows were perceived to deveop from cinica reationships, incuding training inks resuting from overseas referring doctors training within the UK or spending time aongside receiving consutants. One individua spoke of their trust s experience of treating internationa patients as a cinicay convenient reationship presented a commercia opportunity to make a profit (NHS5). Another individua suggested that we shoudn t forget that we have ots of doctors who have come from overseas to train here who then go back to their own countries (NHS20). Some trusts continuousy deveoped and consoidated such inks by offering cinica training to overseas consutants and staff exchange and educationa programmes. Show and te days, either ocay or in ocations where individua cinicians traveed overseas, were aso identified: The number one factor is the super-speciaised doctors we have in London Teaching Hospitas having these inks with the referring doctors in Kuwait, or the Emirates or Saudi Arabia. NHS1 A ot of the internationa work we do now comes from a variety of sources but a ot of it is to do with our own consutants who have an internationa reputation. NHS20 Having cinicians at the centre of reationship buiding was not without its probems, given that such activity was time-consuming: I guess the key way of doing it is around getting cinician out there actuay and spending a bit of time on the ground with the oca cinicians to buid up their inks... providing education, assistance with research, maybe going over and doing some operating ists... the probem is reay around getting access to these cinicians time in a busy NHS hospita. NHS2 Aongside cinician inks there were aso cutura preferences that favoured specific London hospitas. For exampe, Midde East nationas were said to prefer particuar London ocaities for treatment; simiary, a strong connection was identified between some parts of London and Greek and Cypriot popuations. I think the patients fee at home in London. Their reatives wi come over and get a fat on [name of road] and go buy cuisine they re famiiar with in that area (NHS1). Embassies and heath attachés of sender countries were seen to occupy centra roes in the market for internationa patients. A referra typicay began with doctors at the oca hospita board identifying a patient for overseas treatment and suggesting a particuar country and doctor. This recommendation moves forward to an overseas treatment board with responsibiity for a hospitas for approva. The decision woud be passed to an overseas heath department where ocay based heath attachés may have their own recommendation on choice of consutant/institution. The oca heath attaché takes responsibiity for ongoing cinica iaison. Embassies generate etters of guarantee to provide reimbursement assurance for a trust for what may be a very expensive programme of treatment. Detaied patient records may not aways accompany the traveing patient and so detaied checks and diagnostics are undertaken on arriva. Compex cases and Queen s Printer and Controer of HMSO 2014. 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. 101

INTERNATIONAL PATIENTS AND ASSOCIATED ACTIVITIES WITHIN THE NHS engthy stays wi necessariy generate very arge bis and sometimes payment is a drawn-out process. Line-by-ine biing was the norm, with each item being detaied, rather than packages (sef-funders are expected to pay upfront for treatments and are seen as financiay riskier propositions given that they ack institutiona surety). Staff who we interviewed from NHS trusts offered various forms of patient iaison (which may be 24/7), but not hote-type concierge services. Transation services were either provided through individua patient iaison (e.g. fuent Arabic speakers) or sourced through NHS ists. There was no door-to-door service; return trave arrangements, for exampe, were typicay made by embassies. Persona reations and trust were perceived as key in fostering embassy and government institutiona inks (incuding miitary and heath departments). One trust identified having 15 different embassy-type reationships and thus potentia referra points for internationa government-sponsored patients. A great dea of institutiona marketing centred on embassies and there were fairy reguar visits to embassies and discussions to better understand their needs. There were downsides of such activity, however. Income was not subject to contracts, unike more continuous PCT income. Business coud be voatie ucrative and transient suggested one patient manager (NHS12) and referras coud dry up reativey quicky from embassy sources without a cear rationae. The roe of attachés was centra: If they change you might get different favourites [paces for referra]. It depends on where they trained, who they trained with, who they think is good. You can get a sudden change in referra patterns if that happens (NHS1). Some interviewees perceived that there was greater competition among London teaching hospitas for referras and that embassies were ikey to expore options and be price sensitive: I think there s more competition between trusts now to attract internationa patients. And I don t think that the poo has grown particuary (NHS2). Some referra sources were said to be shrinking. One trust, for exampe, outined that Cyprus was sending ony very compex cases for treatment, and as countries deveoped expertise in particuar procedures these were performed ocay. There were instances of faciitators and intermediaries approaching trusts offering to broker work between trusts and embassies. Such offers were often decined by trusts, and individuas invoved in embassy iaison and patient support were trust empoyees (i.e. we did not identify instances of commission-type incentives for individuas bringing business). Speciaty had a bearing on the overa pattern of referras. When opportunities existed for patient sef-referra, it meant that embassy referra was ony one of a number of sources and website presence coud be more significant for trusts. Market deveopment A staff interviewed in the trusts perceived their internationa work as significant and were intending to maintain or expand such activity (unsurprising given our purposive sampe). There was a distinction between those undertaking some (abeit imited) marketing outside of the UK activities, incuding attendance at arge internationa trade shows and the use of brochures, and those not undertaking any marketing. Some viewpoints suggested that athough such trade shows did not ead directy to additiona business they were important for profie raising. There had been some attempts to share the costs of pubicity, for exampe joint marketing of seven of the London speciaist hospitas, incuding a brochure and a hotine. NHS private providers aso meet reguary within London. There was a view that to everage greater opportunities woud require fuer attention to marketing and customer care, and these were chaenges in the current NHS environment. Two main points emerged. 102 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 First, the private heath sector was perceived to have certain advantages, incuding marketing expertise derived from ongstanding invovement. Some arguments were made that arge internationa private heath-care organisations were abe to undertake genera surgica marketing far more effectivey given their experience of negotiating with insurance companies and were abe to offer a dedicated marketing approach (and a greater customer care focus). One commercia manager perceived opportunities presented by possibe private NHS activity being partnered with private heath care: If you trave first cass your safety risk is the same but you just get a nicer experience. And we do the safe thing we, we don t do the nice experience that we (NHS1). Foundation trusts were seen as being particuary hampered by not having a commercia team, aongside having imited marketing budgets and aso potentia interna perceptions about private work: I think to reay everage that sort of thing the organisation woud need to become much better at managing [arrangements]. Because at the high end you are deaing with the sort of peope who wi want a number of other things. NHS15 Like anything we ve got imited budgets so we want to make sure we aso use it for the biggest bang for our buck. NHS16 We re an NHS faciity and the monies that we make through private patient activity feed into the trust so there isn t a ot of that to enabe us to go and do the sort of things that perhaps woud generate additiona monies. NHS3 One interviewee argued that customer-focused processes required further attention within the NHS: London has rested on its aures a bit and sort of got away with it because peope want to come and because the cinica standards are good (NHS1). Traditionay, the NHS orientation was a passive one whereas private and internationa activity may invove more marketing and proactivity engaging overseas markets. The second point to emerge was the need to manage both interna and oca stakehoder views of such NHS commercia deveopments. One trust was expicity deveoping an interna communications strategy that emphasised the contribution of private income to its NHS faciities. The whoe point of being a Foundation Trust Hospita is you make choices about how you re going to generate your money and where you re going to spend it (NHS5). There were image issues (both interna and externa) and a number of managers identified pubic misunderstanding around the roe of NHS private patient activity. Sometimes these perceptions were inked to the pejorative notion of heath tourists. A number spoke of the benefits of coaboration. However, baancing the promotion of a NHS brand against the interests of individua institutions presented a diemma: We shoud be trying to do it [coaborate] and share the costs. But then obviousy I want the business to come to me. That s what the trust empoys me for. But getting the NHS brand out there is certainy going to hep me and if we can share it great and if peope want to ride on the back of that it s up to them. NHS16 Queen s Printer and Controer of HMSO 2014. 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. 103

INTERNATIONAL PATIENTS AND ASSOCIATED ACTIVITIES WITHIN THE NHS A senior Department of Heath poicy manager commented (speaking some months before the aunch of Heathcare UK): So there are reated functions across government that sometimes work together and sometimes don t necessariy work effectivey but [are] in the same sort of territory (PA15). A number of trusts were keen for UK Trade and Investment (T&I) and NHS Goba to hep gain access to markets and foster activity overseas. Some expressed a ack of carity of roes between T&I and NHS Goba at the current time. They were uncear how an organisation that aimed to broker NHS internationa activities wi be structured and ocated, for exampe whether it woud be a cosed subscription body or woud be for a NHS trusts: I m not sure what NHS Goba has actuay managed to achieve (NHS19). Market competition was seen as both nationa (incuding pubic and private) and internationa: There s a ot of competition within the NHS, within the private and that s before you even start ooking at Begium, Germany, Paris (NHS16). For exampe, hospita consutants may receive a referra and have a choice where to undertake the work (privatey or in the NHS), or be invited to operate overseas. We have a number of competitors in London. Largey private hospitas... They are competitors but a ot of our own consutants aso work in those hospitas (NHS20). Germany was seen as competing for Midde Eastern activity, as we as a number of internationa deveopments within the Guf region itsef (athough some Guf deveopments were said to face chaenges of consutant and nurse recruitment and voumes of activity). Impications for the NHS Internationa patient income was identified as significant within a number of trusts, particuary within the London area. Other parts of the country may hardy benefit from internationa patients. The ifting of the private income cap has stimuated further activity in search of internationa patients. Foundation trusts do not aways fuy distinguish between domestic and internationa private income. New reporting requirements (under the Heath and Socia Care Act 2012 30 ) and a wish to further promote activities abroad may sharpen this distinction (for trust boards and Monitor). Foundation trusts vary in their abiity to compete for further internationa activity and in what is the appropriate roe of heath care. Our study did not focus on accounting systems and how tariffs are determined for internationa patients who receive treatment within the NHS, or contros to imit costs of private treatment being cross-subsidised by the NHS; research activity is required on these topics. Given the ongoing goba financia instabiity, are there greater risks to trusts from internationa bad debts? Trusts were cautious in baancing their NHS responsibiities with the opportunities presented for income generation from internationa patients. Given the importance of referra networks, wi changes to UK education and training opportunities facing non-eu medics (because of an EU focus and visas restrictions) impact on referras over the medium term? 104 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 Chapter 16 The financia vaue associated with medica tourism Many estimates of the potentia vaue of the medica tourism industry are reported in the media, athough these are mosty based on industry reports in which there is often an incentive to exaggerate the possibe income streams coming from medica tourism. For exampe, the vaue of the Indian medica tourism sector is often cited as being worth some US$1B by 2012, which originates, as does much in the iterature, from the McKinsey report 12 (see discussion in Chapter 5). A report by the industry research company Tourism Research & Marketing (TRAM) 224 puts the overa vaue of the medica tourism industry in 2006 at US$20B, predicting this to doube by 2010. However, it is not cear how either of these figures were cacuated or whether current estimates vaidate these predictions. One of the few empirica studies reported in the academic iterature investigating the revenue generated by medica tourism was carried out in Thaiand. 103 Drawing on survey data, the Thai market was estimated to be worth between 59 and 110 biion baht (between 1.1B and 2B) in 2012, contributing a tota of 0.4% of the Thai GDP. In another empirica study, Johnson and Garman 225 estimated the number of inbound and outbound medica traveers to and from the USA to cacuate the voume of trade in heath services. They estimated that the vaue of inbound trave for medica care was between US$491M and US$1.2B, whereas the oss to the US economy from medica fees paid to foreign providers ranged from US$87M to US$209M, eading them to concude a surpus of between US$404M and US$1B for the US economy. Both of these studies are based on extensive data sets of inbound and outbound medica tourists obtained from their nationa Ministries of Heath. However, there are no such studies concerned with the vaue of medica tourism for the UK. We therefore set out to estimate the financia vaue that may be associated with medica tourism from the UK perspective, considering the income generated by inbound medica traveers, the savings to the NHS resuting from peope traveing abroad to receive treatment that they may be eigibe for on the NHS and the costs arising to the NHS from possibe compications and foow-up care. Within the scope of this research project we focused on the avaiabe data and the anaysis and insights that these aowed. There is imited avaiabiity of reiabe data and further primary research emerged as a key recommendation from this work. The anaysis in this chapter presents a first picture of some of the economic impications on the basis of the data currenty avaiabe. Despite this caveat it represents the cearest indication to date of the economic impact of medica tourism on the UK (NHS, genera economy and socia services). Athough the overa focus is on costs incurred or averted by the NHS, when direct costs reating to socia services were ceary avoided, as in the case of bariatric patients, socia services expenditure was considered. The costings incuded here consider scenarios in which there is an additiona cost to the NHS from returning medica tourists who require foow-up treatment as a resut of procedures that woud not have been covered by the NHS. When patients opt to receive treatment abroad that they woud have been entited to under the NHS, this represents a saving to the NHS (but not a source of revenue), uness these patients experience compications. In addition to the actua costs of the treatment incurred, future heath and socia security spending averted are considered in one case for which reiabe modes for costing were avaiabe. We focused specificay on three areas of treatment (fertiity, cosmetic and bariatric), incuded among the case studies for this research and in which we interviewed a number of patients. Queen s Printer and Controer of HMSO 2014. 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. 105

THE FINANCIAL VALUE ASSOCIATED WITH MEDICAL TOURISM Income generated by inbound medica traveers Tourism revenue from inbound medica traveers We cacuated the economic contribution from medica traveers to the UK per annum based on avaiabe data from the IPS, based on the most recent data set for inbound medica tourists (2010), excuding the Channe Isands and the Ise of Man (as expained in Chapter 3) (J Hanefed, London Schoo of Hygiene and Tropica Medicine, 2012, persona communication). As respondents in the IPS survey specificay state that they are visiting for heath care, we have assumed that this is their main purpose and that they woud not have otherwise been visiting the UK and thus are an addition to visitor/tourist numbers to the UK. Hence, any spending woud be seen to be a net benefit not otherwise coming to the UK. Based on hospita data for the average patient (both medica tourists and UK patients) treated within NHS hospitas, we assumed that 20% of inbound medica traveers receive treatment as inpatients and the remainder undergo day-case procedures. We cacuated the expenditure of patients staying in the UK for a number of different scenarios, ranging from those who stay for 4 days to receive outpatient treatment to those who receive inpatient treatment for 10 days and stay a further 2 weeks for foow-up (Tabe 7). These assumptions were based on data that we coected and on an average hospita stay for inpatients (not ony medica tourists) in 2010 11 from the NHS Hospita Episode Statistics. 226 We assumed that patients woud ikey arrive some days before treatment and remain for additiona days to fuy recuperate or to take the opportunity for additiona tourism activities. Based on our research findings reported in Chapter 15 (corroborated by an earier survey by Which? magazine 179 ), we assumed that peope trave with one companion, apart from those traveers from the Midde East who we assumed to trave with two companions. Data obtained from interviews indicated that patients themseves are in many cases reuctant to report that they trave for treatment. We therefore assume that accompanying traveers do not identify themseves as traveing for treatment, that is, figures for inbound traveers captured by the IPS are soey those for patients (not their companions). According to the IPS, 21% of inbound medica patients were from the Midde East. Moreover, we assumed that the majority of these patients traveed to the UK for more compex inpatient procedures, given the cost and the initia ength of trave. We assumed an average cost of 80 per night for accommodation and 100 per day as spending for patients and their trave companions when they were not in hospita. Based on these assumptions, our cacuations, summarised in Tabe 7, suggest that, even without taking the cost of the actua medica treatment into account, medica traveers for fertiity, denta and cosmetic procedures contribute around 219M in additiona tourism spending to the UK economy per year. Heath-care revenue from inbound medica traveers To estimate as accuratey as possibe the spend on medica procedures in NHS faciities by inbound medica tourists we submitted freedom of information requests for data on income from private patients in NHS hospitas, incuding UK and non-uk patients, to 28 NHS foundation hospitas (see ist in Appendix 26). These 28 hospitas reported a combined income from private patients of around 195M. Of these hospitas, 18 were abe to provide data on the percentage of income that resuted from non-uk resident patients. The remainder were unabe to differentiate between private UK and non-uk resident patients. Those who were abe to provide differentiated data indicated that 42M of the tota income was from non-uk resident patients; ooking across these 18 hospitas, cose to 25% of the income was from incoming medica tourists. Athough our sampe of hospitas was weighted towards arge London-based 106 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 TABLE 7 Cacuation of additiona spend by incoming medica tourists and their trave companions Inbound medica traveers Number Nights in hote Cost of hote ( ) Expenditure ( ) Tota expenditure ( ) Tota 52,000 Inpatients 10,400 Hospita for 10 days (75%) (75% from Midde East) Hospita for 5 days (25%) (5% from Midde East) 7800 14 8,736,000 10,920,000 19,656,000 2600 7 1,456,000 1,820,000 3,276,000 Subtota inpatients 10,192,000 12,740,000 22,932,000 Accompanying persons inpatients 16,380 Hospita for 10 days (75%) (75% from Midde East) Hospita for 5 days (25%) (5% from Midde East) 13,650 24 26,208,000 32,760,000 58,968,000 2730 12 2,620,800 3,276,000 5,896,800 Subtota accompanying persons 28,828,800 36,036,000 64,864,800 Tota inpatient and accompanying 39,020,800 48,776,000 87,796,800 Outpatients 41,600 4-day stay (25%) 10,400 4 3,328,000 4,160,000 7,488,000 7-day stay (40%) (2.75% from Midde East) 14-day stay (35%) (2% from Midde East) 16,640 7 9,318,400 11,648,000 20,966,400 14,560 14 16,307,200 20,384,000 36,691,200 Subtota outpatients 28,953,600 36,192,000 65,145,600 Accompanying persons outpatients 41,600 4-day stay (25%) 10,400 4 3,328,000 4,160,000 7,488,000 7-day stay (40%) (2.75% from Midde East) 14-day stay (35%) (2% from Midde East) Subtota accompanying persons outpatients 17,098 7 9,574,880 11,968,600 21,543,480 14,809 14 16,586,080 20,732,600 37,318,680 42,307 29,488,960 36,861,200 66,350,160 Tota outpatient and accompanying 131,495,760 Tota 219,292,560 faciities that may experience a higher number of medica tourists, income ranged vasty between the hospitas surveyed: from > 20M to just 2466, with a mean of 2.47M. Those hospitas that were abe to provide numbers of patients reported a tota of 6722 patients from abroad out of a tota of 88,775 private patients counted, that is, 7% of private patients were inbound medica tourists. It might therefore appear that medica tourists are especiay profitabe, yieding amost a quarter of revenue from ony 7% of voume. However, it is ikey that these figures are an underestimate as, for exampe, one of the hospitas was abe to suppy a figure ony for private patients reimbursed by foreign embassies and this aone was responsibe Queen s Printer and Controer of HMSO 2014. 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. 107

THE FINANCIAL VALUE ASSOCIATED WITH MEDICAL TOURISM for 7% of its private patients. There was aso great variation between hospitas with regard to numbers of patients treated, ranging from one non-uk resident patient to > 1880 patients, with the median being 147 patients per hospita. Unsurprisingy, the argest numbers of inbound medica tourists were treated in the arge hospitas that are internationay known for their speciaism; foremost among these was Great Ormond Street Hospita, which reported income of > 20M from 656 patients. We excuded Moorfieds Eye Hospita as a review of the data across different hospitas indicated that this was an outier. Given the focus on eye medicine, it has a very arge number of patients visiting for outpatient procedures at a very ow cost. These data aso demonstrate the range of procedures carried out and the average income per patient. Whereas Great Ormond Street Hospita has a high average cost of treatment per patient (approximatey 31,600), University Coege London Hospitas NHS Foundation Trust (UCLH), despite seeing more than doube the number of private non-uk resident patients (n = 1881), has an income of ony 1.53M from these patients (a very ow average treatment cost of 813), indicating the differences in the cost of procedures as we as the chaenges in estimating the tota market vaue given these variations. The ow treatment cost per patient at UCLH was somewhat of an outier but we chose to incude this to highight the range of costs paid by inbound medica traveers and because UCLH covers a broader spectrum of treatment than Moorfieds Eye Hospita. Data summarised in Appendix 26 aso highight the variation in the percentage of income that non-uk resident patients represent for hospitas; to some, especiay the arge hospitas in London, it marks a significant part or even the majority of the private patient income whereas for others it contributes a very sma percentage of funding. Despite the variations in numbers of patients visiting different hospitas and income per patient, the number of medica tourists was comparativey smaer than the percentage of income generated by them (7% of patients generating cose to 25% of private income). This indicates that spending by private non-uk residents per procedure was much higher than spending by private UK residents. These figures suggest that non-uk residents traveing to the UK for medica treatment seek high-end speciaist and expensive procedures. Drawing on our data to gain a picture of inbound medica tourists more generay, we cacuated that the average income per non-uk patient across the 18 hospitas was 6252. If we scae up the average cost per incoming patient using data from the IPS, medica tourists coming to the UK spend a tota of 325M per annum on heath services. To further trianguate this figure we used the median earned per patient across the hospitas samped (a ower figure of 3402 per patient) and scaed this up to the tota number of inbound medica tourists to give a tota spend of 178M per annum. We concude that expenditure by inbound medica tourists on heath services is in the range of 178 325M per annum. Athough we recognise that our sampe of hospitas is biased towards London and other ocations that attract inbound medica tourists, it is ikey that the majority of inbound medica traveers wi visit these centres. The UK private heath-care sector as a destination From the avaiabe data it is not known what percentage of the tota number of incoming medica tourists estimated by the IPS access treatment in the NHS and what percentage access treatment in the private medica sector. Given the internationa reputation and proific nature of Harey Street medicine, it is fair to assume that a significant number of inbound medica tourists wi access treatment in the private sector. Because the cost per procedure in the private sector may be higher, it is probabe that patients undertaking serious and more compex procedures wi be more ikey to have these carried out within the NHS (as highighted in the previous chapter). A 2012 report by the Office for Fair Trading investigating the private heath-care sector in the UK 227 concuded that in 2009 the market was worth 5B in tota and that 2.4% of this was income generated by foreign patients (i.e. 120M was generated by medica tourists). Based on the avaiabe data and the assumptions made and set out earier, tota spending by incoming medica tourists (i.e. taking together spending on medica treatment and additiona tourism spend ) ranges from 397M to 544M per annum. Athough this does represent a sizabe market and one that obviousy 108 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 coud grow, this represents < 0.5% of the projected government spend on the NHS of 130B in 2012 13. However, as refected in our samping of NHS hospitas, we consider it ikey that the majority of inbound medica traveers wi visit London and seect other urban medica centres in the UK. Considering the tourism and heath expenditure by medica tourists as concentrated more in these ocations, this may represent a very significant stream of income in specific areas. Given the revenue estimated earier it is ikey that medica tourists may represent a usefu stream of income to some arge trusts but at present not a significant market segment. Of course, as the caps on private patients are raised there is the potentia for expansion of this market, athough it is hard to imagine (given the greater eve of competition with the private sector) that this it become anything other than a niche area, athough with possiby ucrative margins. An additiona benefit from having a greater number of inward medica tourists undergoing speciaist treatments within NHS hospitas may ie in the abiity of doctors to further deveop a speciaism, for exampe in reation to surgica earning curves. Costs to the UK NHS resuting from outbound medica trave Based on the case studies of different types of medica trave identified by this research and further described in Chapter 7, we sought to identify the ikey costs to and savings for the UK NHS from medica trave. In one case there aso appeared to be additiona savings for wider socia services as a resut of overseas trave. Fertiity tourism Mutipe pregnancy is associated with increased risks for the mother and babies. The mother is at increased risk of hypertensive disorders, anaemia, gestationa diabetes, haemorrhage, preterm abour and operative deivery (incuding caesarean section). Risks to babies incude ow birth weight and immaturity needing admission to a neonata intensive care unit, congenita maformations, cerebra pasy, and impaired physica and cognitive deveopment. Reproduced with permission from NICE. Fertiity: assessment and management (update). London: NICE; 2012 (p. 1). 228 For updated documentation see www.nice.org.uk/nicemedia/ive/14078/62770/62770.pdf Athough it is cear that mutipe births can present compications for the mother and the chid, in the anaysis presented in this report we are concerned with the costs arising to the NHS associated with the medica tourist. In this case, once the chid is born (and of course obtains its own unique NHS patient identifier) then it is a NHS patient who is not a medica tourist. Therefore, in our anaysis we have not been concerned with possibe impications for the chid but ony the mother, in the same way that we are concerned with effects for the patient undergoing bariatric surgery or cosmetic surgery. If we undertake to cost the impications for those other than the medica tourist then this generates discussion of the breadth of effects to cover. This aso moves us, for instance, to consider ethica issues such as those associated with organ donation and transpantation (e.g. when the organ donor is not a medica tourist but the recipient is, it is not cear whether the costs of compications in the donor are incorporated in the cost exercise or not). We accept that in many ways this means that the cost of fertiity treatment may be underestimated compared with if these costs for the chid were taken into account. We have pointed to the iterature that discusses the costs incurred through compications reated to the chid, 229,230 but this issue needs further discussion. For instance, even when the chid is totay heathy there are arguaby sti costs stemming from them simpy existing. Therefore, shoud this perfecty heathy chid be seen as a cost of infertiity treatment? Or is their productive future a benefit? Is a chid itsef a compication of the treatment? Queen s Printer and Controer of HMSO 2014. 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. 109

THE FINANCIAL VALUE ASSOCIATED WITH MEDICAL TOURISM These profound ethica issues cannot be addressed here and hence we have simpy restricted ourseves to issues surrounding the heath and care of the mother. Here we focus on costs to the NHS of mutipe pregnancies and births rather than onger-term heath outcomes of the chid, but note that the mode on which these cacuations are based considers chid heath for up to 1 year in its costings. As indicated, mutipe births can present severe compications. Infertiity treatment, incuding IVF, has been shown to increase the chances of mutipe births. To cacuate the ikey number of mutipe births and costs to the NHS resuting from fertiity trave we draw on a ongitudina study by consutants in obstetrics and gynaecoogy at University Coege London who observed that mutipe births submitted to their ward were often the resut of women having received fertiity treatment overseas (incuding IVF and intrauterine insemination). 98 The authors studied a mutipe births over a period of 10 years and found that more than one-quarter were as a resut of patients having traveed overseas to receive fertiity treatment. A patients interviewed by us traveed abroad for IVF and none of these was eigibe for further treatment on the NHS (some had exhausted their free rounds on the NHS). We trianguated findings from our interviews by drawing on the iterature reating to CBRC, incuding the findings by Shenfied et a. 114 reporting on a six-country study of cross-border fertiity care and in-depth quaitative work conducted by Cuey et a., 57 in which a arge sampe of fertiity tourists was interviewed. We assumed that patients seeking CBRC woud not be eigibe for fertiity treatment on the NHS and thus did not represent a saving for the NHS. We drew on ONS data 231 on mutipe births in the UK for the atest avaiabe year. In 2010, 11,053 women gave birth to twins, 169 to tripets and six to quads and above in Engand and Waes, giving a tota of 11,228 mutipe births. We further assumed that the cohort studied by McKevey et a. 98 was sighty swayed towards medica tourists as it was based in an urban popuation in centra London. Therefore, we assumed that 20% of mutipe births (a tota of 2246 women giving birth to mutipes) were as a resut of fertiity treatment received abroad. This is supported by our anaysis of data from the IPS in which a comparativey arger number of women between the ages of 24 and 45 years trave abroad to access fertiity treatment. Women with mutipe pregnancies require increased and more compex monitoring, which is sometimes not avaiabe in the routine NHS setting. Women with mutipe pregnancies aso require a greater number of antenata visits. However, their exact needs are highy variabe. We therefore drew on an earier study by the Cost of Mutipe Births Study Group, 193 which cacuated the expense of mutipe births compared with singeton pregnancies in 2006 and reported costs of 3313 for the birth of a singeton, 9122 for twins and 32,354 for tripets. We estimated that these costs had increased by 3% per year between 2006 and 2010 and then cacuated the additiona cost of a twin or tripet pregnancy over that of a singeton birth (Tabe 8). This gave an estimate of 15.5M for the cost of mutipe births resuting from fertiity trave in 2010. The ong-term costs resuting from assisted reproductive technoogies, incuding cases of mutipe pregnancies, wi not differ between medica tourists and fertiity patients who received care in the UK. TABLE 8 Annua cost to the NHS of mutipe births resuting from cross-border reproductive trave Type of mutipe birth Number of births Resuting from fertiity treatment abroad Additiona cost ( ) Cost resuting from fertiity treatment abroad ( ) Twins 11,053 2210.6 6506 14,382,164 Tripets 169 33.8 32,526 1,099,379 Tota 15,481,542 110 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 However, our research indicates that patients wi trave in search of reproductive care to countries with reguations that wi aow fertiity treatment ikey to resut in a higher number of mutipe births. Any effort to address the rise in mutipe births in the UK therefore needs to take account of medica trave and invove specific targeted information to be effective. Cosmetic tourism A comparativey greater focus in reation to the costs and compications of medica tourism faing on the UK NHS has been on cosmetic tourism. As observed in the review of the iterature in Chapter 3, there are reports highighting compications arising from cosmetic treatment received abroad, 134 incuding survey resuts indicating the percentage of doctors who have treated compications within the NHS (37%) as a resut of cosmetic tourism. 76 In addition, a recent study by Miyagi et a. 102 described a cohort of patients seen in a tertiary faciity who reported with probems arising from cosmetic surgery abroad over a period of 3 years. The authors cacuated the cost of treatment provided within the NHS for compications, highighted the reimbursement received by the hospita from the PCT (which was ess than the expenditure of the hospita) and provided a mean cost per patient (this incuded patients who were seen but who did not receive foow-up treatment) of 6360. However, as can be expected, costs varied widey, ranging from 114 to 57,968. Based on IPS data on age and gender of outbound traveers we estimated that 30% (18,300) of patients who traveed abroad for medica treatment traveed for cosmetic surgery. We trianguated this with the survey conducted by Which? magazine, 179 which found that 28% of medica tourists traveed for cosmetic procedures, recent survey findings that 95% of a peope considering cosmetic surgery woud trave abroad for this 104 and the survey resuts of medica doctors reported above. 76 This makes it ikey that the estimate of 30% of patients traveing for cosmetic surgery is at the ower end of the spectrum. Based on our interview findings and the survey resuts reported by Jeevan et a., 76 we estimated that 10% of those who trave abroad for cosmetic treatment wi require some form of aftercare, even if this is imited to deaing with an infection or removing stitching. However, drawing on Miyagi et a. 102 we assumed a great variation in the eve of aftercare required, with some compications (such as infections or the remova of stitches) being resoved at the GP surgery eve, for exampe through one consutation and a course of antibiotics. Based on our interview sampe and cases reported in the iterature, we assumed that 20% of compications in those traveing for cosmetic surgery woud require a visit to a tertiary faciity, either as an emergency or through referra. For this we used the average cost of the four higher-cost cases described by Miyagi et a. 102 We assumed that other compications woud be resoved at a much ower cost (for this we used the average cost of the two owest-cost cases described in Miyagi et a. s study) and woud ikey require ony one GP visit to remove stitches with more compex cases deat with at primary care eve. Based on these assumptions and drawing on the mean costs provided by Miyagi et a. 102 we cacuated that, in 2010, 1890 patients woud seek foow-up care (some major, some minor) from the NHS, at a cost of 8.2M (Tabe 9). The cost incurred by the NHS for patients who have traveed abroad for cosmetic procedures may give an indication of the eve of compications that occur in the cosmetic surgery sector in the UK. Athough there TABLE 9 Annua cost to the NHS of compications in returning cosmetic tourists Tota Severe compications Minor compications Number of cosmetic tourists 18,900 Number with compications 1890 378 1512 Cost ( ) 8,251,740 7,867,692 384,048 Queen s Printer and Controer of HMSO 2014. 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. 111

THE FINANCIAL VALUE ASSOCIATED WITH MEDICAL TOURISM are no reiabe figures for the size of the sector in the UK, the recent PIP breast impant scanda gave an indication of just how sizeabe this market is. The UK NHS estimated that 45,000 women had been fitted with the impant, with ony 900 of these as NHS patients and the rest in the private medica sector. 232 Given the size of this market in the UK and the compications experienced by returning medica traveers, it appears opportune to address this gap in reguation. The government aunched a consutation process to this effect in August 2012 and findings from our research underine the need for this. Savings (or not) from outbound medica tourism Bariatric surgery With 25% of the UK popuation cassified as cinicay obese, there has been some focus on the costs of obesity and how to tacking obesity in a cost-effective way. The financia impact on the NHS of obesity is cacuated by the Department of Heath to be 4.3B. 195 The Nationa Institute for Heath and Care Exceence has deveoped a cost guide 197 aongside its 2009 obesity guideines. 195 This modeed a reduction in cost to the NHS of 16M per year through prescription of medications and surgery. This saving was primariy based on saved GP contacts as a resut of these prescriptions. Moreover, a study by the Nationa Audit Office in 2001 233 estimated that 18 miion working days were ost as a resut of obesity. A study by Hawkins et a. 234 in 2007 demonstrated that in a cohort of 59 bariatric patients there was a 32% increase in the number of patients in paid work after surgery. Given the goba rise in obesity a number of cost-effectiveness studies and systematic reviews summarising the evidence concerning bariatric surgery have been pubished (e.g. see Picot et a. 196 ). A study in Heath Technoogy Assessment from 2009 196 found that, for morbid obesity, incrementa cost-effectiveness ratios (base case) ranged between 2000 and 4000 per quaity-adjusted ife-year (QALY) gained. The authors reported that this was both at a ower cost per QALY than non-surgica interventions and within the cost range deemed efficient by NICE. Taking this as a starting point, a recent study by the Office of Heath Economics 195 focused specificay on the cost-effectiveness of bariatric surgery in the UK. The author estimated that between 11,000 and 140,000 peope woud have quaified for bariatric surgery in 2009/10 but ony 3607 were given surgery on the NHS. The range of 11,000 140,000 patients is based on the assumption that between 1% and 25% of patients eigibe for bariatric surgery wi choose to undergo this. The authors then cacuate savings to the UK economy by deducting the cost of the surgica intervention from workdays gained and savings in socia benefits, incuding unempoyment, disabiity and housing benefits. Based on this range, additiona income is estimated at 46 578M per year and the savings in benefit payments are estimated in the range of 10 151M per year. These cacuations expicity excude any costs of compications or foow-up care. Further research is currenty under way to examine the ong-term effects of obesity surgery, specificay the SurgiCa Obesity Treatment Study (SCOTS) at the University of Gasgow. 198 For our sampe we used the nationa tariff costs for a gastric band and gastric bypass obtained through a freedom of information request to cacuate the cost savings for patients who we interviewed who had opted to trave abroad to have bariatric surgery. The cost of procedures saved by the NHS was a tota of 58,816 for the 13 patients interviewed. If we use the mode empoyed by the Office of Heath Economics both savings in heath and socia services and additiona income (incuding through taxation on additiona days worked) the tota savings and additiona income woud rise to 112,506. Even if this was a high estimate, the key point remains that patients traveing abroad to receive bariatric surgery are ikey to represent a sizeabe saving to the NHS and socia services. At the same time the imited knowedge of ong-term costs and effectiveness of bariatric surgery beyond the immediate cinica outcomes remains a major imitation of the research. 112 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 To fuy understand the costs of and savings from bariatric surgery for both heath and socia services, further research is required incuding into the ong-term medica and socia outcomes of such surgery, incuding a comparison of outcomes in medica tourists and patients who have received this treatment in the UK. Based on the patient histories coected for this research, the iterature on bariatric surgery seems highy optimistic. Ony one of the bariatric tourists had not experienced any compications and a 13 required ongoing treatment and care. This echoes the findings from a systematic review of the cost-effectiveness of bariatric surgery conducted in 2009. 196 This research found that a studies reviewed reported bariatric surgery to be cost-effective but equay found faws in a of the modes and studies. Picot et a. 196 use the methodoogica insights from studies reviewed to further deveop a mode for economic evauation and aso find bariatric surgery to be cost-effective. The review of the cost-effectiveness iterature stresses the need to consider a onger (minimum of 5 years) time frame to understand morbidity and compications associated with weight-oss surgery. This seems to be corroborated by our research findings. In reation to medica tourism, our findings highight that, first, the compications ikey to occur as a resut of bariatric surgery received abroad wi happen at a time when the patient may be unabe to return abroad or caim compensation from a cinician or cinic abroad. Second, the cost of the surgery incurred by patients when they trave abroad is negigibe compared with the potentia future savings in heath and socia services to the state or in heath-care costs (to either the patient or the heath-care worker) that may resut from the procedure. Our research indicates that, when compications occur, these may be catastrophic in the ong term with no savings and high costs to the individua and a pubicy funded heath-care system. Impications for the NHS Both inbound and outbound medica tourism have the potentia for cost savings and, in the case of inbound tourism, for additiona income to be generated for the NHS. Given the eve of compications experienced in the three areas of medica trave expored in this research, guidance to the pubic is urgenty needed to ensure that patients traveing abroad pay greater attention to issues of patient safety. This wi minimise costs to the NHS and patients resuting from outbound medica tourism. For bariatric and fertiity treatment, the ong-term costs (and potentia savings) for heath and socia services associated with the procedures and outcomes far outweigh those in the short term. To fuy assess the cost of medica tourism to heath and socia services it is therefore important to understand the differences between the ong-term heath and socia effects resuting from treatment received abroad and those resuting from treatment received in the UK. For bariatric surgery this is currenty not known. Research examining ong-term outcomes between UK patients and medica tourists to enabe a fu understanding of the costs and savings of bariatric surgery is required. For fertiity treatment there is a strong rationae to address the determinants (incuding reguation) of peope traveing and provide greater information and sensitisation on this issue. Studies suggest that the incidence of mutipe births is significanty higher (we estimated 20%, as set out earier) as a resut of peope having sought and received treatment abroad. This is not a resut of different treatment but rather of differences in reguation, with other countries aowing different numbers of embryos to be transferred. Thus, any cost to the NHS as a resut of mutipes born in the UK wi increase as a resut of medica tourism (because of the increase in incidence of mutipes born to coupes who have traveed abroad to receive fertiity treatment). Greater guidance and reguation of the cosmetic surgery sector is needed. The rate of compications for cosmetic surgery observed by others 102 may aso give an indication of the eve and cost of compications in the argey private cosmetic sector in the UK. In many cases compications may not be reported as patients simpy return to the origina cinic. Our research further indicates that patients are ikey to significanty under-report cosmetic procedures and compications. Therefore, the true eve of Queen s Printer and Controer of HMSO 2014. 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. 113

THE FINANCIAL VALUE ASSOCIATED WITH MEDICAL TOURISM compications resuting from cosmetic surgery is not known. Athough the cost of cosmetic tourism to the NHS overa may seem ow, a estimates presented here woud increase substantivey shoud outbound medica tourism further expand in the absence of cearer reguation and guideines. Unified data coection among NHS hospita trusts with regard to private patients, incuding whether or not these are from the UK, is needed. This wi enabe the NHS nationay and individua trusts to pan for and assess this market. This seems to be a particuar oversight in ight of the changing patient caps within the NHS (Heath and Socia Care Act 2012 30 ). The current eve of income from inbound medica tourists highights the potentia of this market, in particuar for speciaist hospitas that have a particuar brand to market. Finay, in terms of bariatric surgery, the baance of costs and savings for heath and socia services suggests that the NHS might encourage peope to go abroad for this procedure, but aso provide guideines on what to ook for, as it represents a net saving to the NHS and the socia security system. This is especiay important as compications resuting from bariatric procedures appear to be particuary severe. 114 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 Chapter 17 Concusions and research recommendations The premise for undertaking this study was that itte was known about the inward and outward fows of patients and the impications for the NHS of these fows were not we understood. Our study focused on combining a wide range of evidence about the nature and scae of internationa patient fows, incuding: an understanding of egisation, poicy and practice with regard to medica tourism sources of information and marketing and advertising practices with regard to medica tourism the infuences on and shapers of medica tourism decision-making treatment processes and experiences of using medica tourism services professionas and key stakehoder group perspectives on medica tourism the magnitude of fows of inward and outward medica tourism and the economic and direct heath-reated consequences of this for the NHS. In this chapter we interpret our findings, highight the key impications for poicy and practice in the NHS and ook forward at the emerging research agenda in this area. The practica impications for the NHS are detaied in a series of text boxes. 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 (e.g. for IVF treatment). Individuas choose to pay for treatment abroad rather than domesticay primariy for reasons of cost but aso because of the perceived expertise of cinicians overseas; famiy or cutura connections with overseas destinations are aso contributing factors. Outward medica tourism invoves a range of medica and anciary services and typicay a range of sma-scae providers and cinics. 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 235 and information deveoped by the Nationa Trave Heath Network and Centre (NaTHNaC) (see www.nathnac.org/trave/misc/medicatourism_010911.htm). 236 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 Queen s Printer and Controer of HMSO 2014. 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. 115

CONCLUSIONS AND RESEARCH RECOMMENDATIONS to become part of the networks of information and support that can be accessed by potentia medica tourists. Concusion 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. Our review of the ega framework attests that individuas are wiing to trave for treatment to ocations that are not reguated by nationa aws and guideines. It is apparent that patients do not fuy understand the scae and nature of the risk associated with seeking treatment overseas, incuding the difficuties reating to redress when something goes wrong. This uncertainty bedevis a phases of treatment decision-making, incuding access to information, preconsutation, treatment itsef, aftercare and foow-up. 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, and there exists an imbaance of objective information and promotion and advertising used for marketing purposes. Athough there has been a recent proiferation of systems of EQA and audit, these, aong with the registration detais dispayed on websites, do not aways make for better-informed patients. Concusion Information for potentia medica tourists needs to be packaged and disseminated in such a way that it wi reach them, some of whom may not consut their GP or indeed a speciaist website before traveing. It is cear that safeguards for UK heath care (e.g. GMC registration) have itte reevance if treatment is received out of the nationa jurisdiction. The need to seek redress and subsequent ega impications may occur many years after treatment and once compications have emerged. Athough advice, information and guidance do exist for traveers, it must have appropriate coverage and be widey accessed. To provide sufficient safeguards from risk, guidance needs to be proactivey avaiabe. Currenty, the onus is on prospective medica tourists to ocate this information. Beyond generic trave advice for medica tourists, the need for cearer guidance on bariatric surgery, or for patients considering bariatric surgery, is evident. Patients acked consistent information on possibe compications and aso on the ong-term consequences of surgery and the ongoing aftercare. Equay, greater information for and training of GPs is needed to enabe them to advise patients and to dea with the possibe negative consequences associated with weight-oss surgery. Concusion 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. 116 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 For fertiity the situation is particuary compex. IVF treatment is, ceteris paribus, more ikey than non-assisted fertiisation to resut in mutipe births, which are in turn associated with higher risks than singe births. UK egisation is geared towards reducing the ikeihood of mutipe births, in particuar governing the number of embryos that can be transferred. However, 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 and it is not aways possibe to retrieve data; these issues are exacerbated when countries have anonymous donor aws. With diaspora trave, 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. Concusion Specific attention is needed to ensure that information is provided in a manner that is accessibe to a; this incudes taiored information for ethnic or inguistic minorities. It is important that a fee that they can trust the information that is provided. The size and economic impact of the medica tourism market Individuas traveing for medica treatment are often i-informed or under-informed 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 UK residents 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. To better understand the coective risk faced by medica traveers it is imperative that robust, reiabe data are coected that not ony map the size of the medica tourism market but aso provide usefu information about who traves when and for what purpose. It is aso important to better understand the simiarities and differences between inward and outward medica trave. We have seen that inward medica trave to the UK occurs across a range of cinics and providers, incuding to private faciities within the NHS and the independent sector. These inward referras 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, in sharp contrast to outward medica trave from the UK. Despite important caveats, our cacuations show that there are costs and benefits to 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 per annum to the UK economy in additiona tourism spends. We aso found spending on medica treatment in the range of 178 325M. Together this amounts to a contribution of between 397M and 544M per annum to the UK economy. 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 costs of Queen s Printer and Controer of HMSO 2014. 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. 117

CONCLUSIONS AND RESEARCH RECOMMENDATIONS such compications can be comparativey sma (e.g. an infection foowing cosmetic surgery that requires a GP visit and a course of antibiotics), they can aso be very high (e.g. in the case of faied bariatric surgery patients may need fu-time care and may be, or continue to be, unabe to work). The costs of corrective surgery and ongoing care can be extremey high. Our research demonstrates equay that, when peope opt to trave abroad to access treatment and this is successfu and they return to work, savings may be substantia for domestic heath and socia services. Most importanty, if medica trave increases, so wi these costs and savings. The industry: providers and market deveopment We are now better abe to understand the nature of medica trave providers and anciary services, incuding the roe of intermediaries. Our research demonstrated a range of different modes marketed by providers and by which patients trave to receive treatment. There are ceary ega uncertainties at the interface of these and cinica provision. Our research reveas a picture of a compex market; surprisingy few of the patients interviewed were using brokerage or faciitator arrangements uness these were buit in by the cinic itsef. Modes aso differed by type of medica tourism and cinica procedure for which trave occurred. For exampe, bariatric patients may have had consutations before and after overseas treatment with a representative of the cinic in London, whereas fertiity patients appeared to undertake pretreatment tests privatey in the UK in advance of trave, but at the request of the overseas provider. Findings, incuding interviews with patients and providers, aso highight recent industry deveopment. Patients are now traveing to further or new markets in medica tourism, highighting deveopment and diversification within the market, 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 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. This has some bearing on the abiity to identify and further target particuar overseas market segments. It is therefore not possibe at the moment to gain a fu picture of the types of procedures that incoming patients access, nor the specific hospitas that they target. Nonetheess, 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. Concusion Separatey recorded private income from domestic and internationa sources wi enabe trusts to have a more accurate picture of their income. It wi aso provide a more accurate picture of inward medica fows and aow for better panning and decision-making in this area. New reporting requirements under the Heath and Socia Care Act 2012, 30 and a wish to further promote activities abroad, may focus greater attention on the distinction between private domestic and internationa income, both within trust boards and by reguators. A more accurate nationa picture of the inbound patient fow coud aow targeted marketing of NHS faciities. 118 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 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 an 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 A key imitation across the areas of medica tourism information, activity, income and industry is the current ack of evidence on medium- and ong-term heath outcomes of patients traveing to receive treatment abroad. This incudes how these may differ from the outcomes of those patients receiving treatment in the NHS. A review of the iterature reveas that there is currenty no ong-term comparative evidence of cinica outcomes in medica traveers and cinica outcomes in those who have been treated at home. This restricts the abiity to estimate ong-term costs and to fuy understand the effects of medica trave, as we as its potentia for savings and better patient care. 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 that in some cases are exacerbated by an inabiity to ensure continuity of care or obtain patient records to address their needs. This research did not set out to assess ong-term cinica outcomes of medica tourists. However, our findings did revea that, athough the scae of the issue may (arguaby) not as yet be overwheming, the effect on individua patients can in some cases be catastrophic. This raises a number of reated ethica questions and issues. These aside it poses a imitation on the abiity to fuy weigh up the benefits and costs of treatment abroad compared with domestic treatment. Research agenda This study has addressed many of the key questions reating to recent deveopments in medica tourism and the impications of these for the NHS. To obtain an even more compete understanding of the costs and benefits of medica tourism and to move the debate beyond discussing its potentia to a stage at which we can understand its impact better, further research needs to be undertaken. 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. Specificay, comparative research is needed with patients undergoing simiar treatment within the UK. This wi enabe a direct comparison between the costs and benefits of domestic treatment and those of treatment abroad. There are ikey to be not ony costs and benefits to the NHS but aso costs and benefits to socia services. Such research is of particuar vaue as our findings demonstrate that medica treatment has medium- and ong-term outcomes that may be evident ony in ater stages as compications or unintended consequences of medica tourism arise. Routiney recording and anaysing the ongoing care needs of those who have traveed abroad for treatment wi aso enabe professionas to provide guidance to patients who are considering 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 activity and the fows of medica trave. This is needed to provide a deeper understanding of why UK residents seek treatment abroad. It wi aso enabe further work on costs and savings to the NHS, to other socia services and to the UK economy as a whoe that may resut from inward and outward medica tourism. Such data shoud aso Queen s Printer and Controer of HMSO 2014. 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. 119

CONCLUSIONS AND RESEARCH RECOMMENDATIONS incude sociodemographic data as we as information about what procedures patients are traveing for to better understand patient motivation for trave. Aim to better understand inward fows of medica traveers. This incudes data on where patients trave to, the procedures they undergo, the price of these and their sources of funding. Data show that the UK s immediate neighbours are the source of many medica traveers to the UK, but so are many Midde Eastern nations. Do these represent very different medica tourists? Are we correct in assuming that many of the traveers from the Midde East are those requiring high-end, compex and expensive treatment? Is this conducted within the NHS and without? Are those residents of France and Spain actuay expats? If so, how are they funding their treatment? Gather a greater eve of information on patients, incuding their origins, procedures undertaken and outcomes, to aow for the deveopment of better economic costings. 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. Linkages are generated through education, training, consutancy and research coaborations. However, further studies are required to understand the precise shape and nature of these networks, incuding how they may be fostered and the impact of poicy and broader socia deveopments on their expansion. For exampe, visa requirements, increased costs of studying and the emergence of aternative training destinations may weaken estabished networks in the medium and onger term. 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. It woud aso identify where potentia opportunities, if any, exist for promoting the UK as a destination for medica tourists. 120 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 Chapter 18 Synopsis This project set out to increase our understanding of medica tourism, both as a process undertaken by patients and as a broader commercia activity and industry. Given the private nature of treatment as we as the range of commerciay focused treatment providers and anciary services, it woud be unreaistic to expect to capture the whoe picture. However, using an innovative appication of a mixture of methods, our understanding of both the overseas treatment process and the wider suppy-side effects has been enriched. We have produced the first, high-quaity study of the phenomenon of patients paying out of pocket for treatment abroad. In short, we can say with confidence that medica tourism invoving traveers to and from the UK is on the increase, that the motivations behind such trave are varied and compex, that the economic impications of medica tourism are diverse and that there are opportunities for savings for the NHS as we as costs, that these depend argey on future deveopments and that there are wide-ranging risks and uncertainties for patients with regard to a number of aspects of medica tourism. We are now we positioned to deveop the wider theoretica and conceptua debate that is ceary of importance. As with any project of this size, there are a number of imitations. Largey these stem from unexpected barriers, which created difficuties accessing information that we had reasonaby fet woud be forthcoming. In particuar, one major deviation from the protoco invoved the abandonment of a survey of medica tourists. It was fet that, athough the survey woud have been usefu, we woud not have been confident of achieving a sufficient sampe size and a high-quaity survey without better access to potentia samping frames hed by a range of commercia organisations. We sought to avoid an extremey sma n survey, which offers no rea insights. Instead, we redirected our resources to a deeper anaysis of the quaitative interviews, which proved remarkaby fruitfu. A cear finding regarding inward medica trave that may assist future panning of such a survey is that many of those traveing to the UK are either expatriates or those who utiise existing networks of support, such as embassies, to access treatment in the UK. In a simiar vein, the economic anaysis proved more difficut and time-consuming than anticipated. Given that many foundation trusts empoyed an internationa patient manager (or simiar), it was anticipated that hospitas woud routiney coect data pertaining to inward medica traveers who booked and panned treatment in the UK. This proved not to be the case there are difficuties in distinguishing amongst the broader private patient group for whom cear data were avaiabe. Data were incompete and this inhibited the modeing of some important eements. However, there was sufficient evidence to support a tentative estimate ikey to be an underestimate of the economic impications for the NHS and the wider UK economy of inward medica traveers. Given the fraities of the data, we have adopted a precautionary principe and present estimates when we are confident that these describe an accurate trend. We envisage this as a basis for future research. Given that the scope of the study was argey imited to an exporation of out-of-pocket payments for treatment, we chose not to focus expicity on the EU directive on cross-border heath care. 1 Athough we acknowedge that such patients are ikey to represent a different type of medica traveer and merit further study, they are distinct from the type of private medica trave researched as part of this project. It is important to note that, despite incuding a arge sampe of medica tourism interviewees, this was not a representative sampe. Not a questions have been fuy answered (we woud wish to understand more about the costs and the ongoing heath impications of treatment abroad), even some of those that had appeared to be straightforward at the outset. Despite these imitations the study has generated new evidence and insights into severa aspects of medica tourism; contrary to the pubic image presented in the media, medica tourism is sti a sensitive issue. Those who have traveed or who are considering traveing are reuctant to discuss their experiences. Queen s Printer and Controer of HMSO 2014. 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. 121

SYNOPSIS This presented chaenges in terms of our recruitment of medica tourists. Equay, the industry is argey suspicious of academic interest and those within the NHS do not seem to have a consistent strategy for deaing with medica tourism, whether inward or outward. Indeed, it is cear that in many areas within the NHS this is a rather unknown and not widey understood phenomenon. By utiising a mixed-methods approach, which was often innovative, we uncovered the processes of referra of internationa patients traveing into the UK. Simiary, we identified a confusing array of accreditation, registration and icensing that exists internationay. This is important if, as our study demonstrates, medica tourism is a process that carries inherent and often serious risks and is on the increase. In spite of the imitations of our study, we have advanced the evidence base on medica tourism, as we as confirming insights from other studies. Resuts from this research demonstrate reiaby for the first time that a growing number of patients trave for treatment. Athough many of the numbers presented by commercia sources are indeed overestimates, arge numbers of UK residents are engaging in medica tourism and an equay sizeabe number of overseas residents are traveing to the UK for treatment as internationa patients within the NHS and the independent sector. The impications of this depend on severa factors, incuding where patients trave to or from and what types of procedures they trave for, as we as a range of demographic and socioeconomic factors. Contrary to previous assumptions, outward medica trave appears to invove ower-cost procedures within Europe, with fewer tourists traveing further afied or accessing more compex procedures abroad. This study has identified two streams within inward medica tourism: the first invoves expatriates and the second is driven by nationas of countries with which the UK has ongstanding ties. Both groups merit further study. It may aso be that the previousy muted impact of the EU directive 1 wi yied a very different type of medica tourist and that further study wi be required as the directive becomes more frequenty utiised. Our evidence demonstrates that medica tourism represents potentia income for some trusts. The estimates presented in this report are based on the avaiabe evidence but equay the imited data suggest that these figures may be underestimates and may be set to grow. There may be potentia savings in future heath and socia services spending averted when patients trave abroad for treatment. This is cosey inked to specific procedures and of course reies on quaity contro. Without a detaied study of the direct and wider costs associated with procedures such as bariatric surgery it is uncear what eve such cost savings coud conceivaby reach and as such further study is essentia. Our study provides cearer evidence on how prospective medica tourists gather information about destinations and treatment. This incudes greater information on individua internet searches, the roe of faciitators and the pace of networks based around treatments and cuture, and aso infuenced by the knowedge and preferences of referring cinicians. Providers are primariy from the private sector but pubic sectors are aso constituents of these emerging treatment reationships. Private activity may incude sma cinica partnerships offering a wide range of treatments and extremey arge medica tourism faciities where cinica speciaism is the order of the day. Larger cinics and providers overseas have moved to offer a range of anciary products and services. The precise requirements of domestic reguation and the roe of accreditation schemes are typicay confusing and uncear to medica traveers. Much treatment activity does not have cear reguation in pace. Our findings aso aow us to question some of the assumptions within the medica tourism fied. This incudes making reaistic estimates of how much medica tourism activity countries may expect to attract. Pre-existing networks, history and reationships may provide insights into medica tourist fows and the success of particuar destinations in attracting patients. Confirming that medica tourism is indeed a rea phenomenon affecting a cross-section of society, a phenomenon that occurs in a diverse industry without reguation or even a cear sense of direction, requires consideration of how patients can be safeguarded. We interviewed individuas with serious and 122 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 compex heath needs. Whether these can genuiney not be met within the NHS or, rather, these individuas simpy perceive that their needs woud be better met esewhere, we can say with confidence that > 60,000 UK residents each year make the decision to trave abroad for treatment. In so doing they eave behind the reguatory framework and reative safety of the NHS. Patients often have information that is at best incompete and at worst incorrect. They often trave for inappropriate procedures, deivered with ower standards of care than are guaranteed in the NHS, and do not consider continuity of care. Quite simpy they are often at risk and are rarey fuy aware of such risks. Perhaps the most important finding of this report is that in some instances reativey minor changes to practice can severey minimise these risks. Queen s Printer and Controer of HMSO 2014. 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. 123

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 Acknowedgements The project team acknowedges the support and advice of the advisory group; individuay and coectivey they made a huge contribution during the ife of the project. Thank you. We thank our many interviewees. We are very gratefu for their time, their wiingness to take part and their honesty. Particuar thanks go to Nina Lakhani, Martin Rathfeder, Ubah Ega and Ken Care for their assistance with recruitment. A number of individuas provided research support during the project: Gavrii Tsoos, Lauren Hutchinson and Chris Carke. Thanks go to Dr Chares Shaw, Eizabeth Boutbee and Lia Skountridaki for providing context and materias. Aicia Wooding and Athoynne Lonsdae assisted in the fina preparation of the manuscript. Many professionas and cinicians provided background context and carification during the project: Evangeos Efthimiou, Dimitrios Pournaras, Ashey Brown, Aneez Esmai, Simon Kay, Aex Miosevic, Jacqueine Joyce, Aaana Woods and Suzanne Wynne-Jones. The views and concusions outined in this report remain the soe responsibiity of the authors. Contribution of authors Dr Nei Lunt was Principa Investigator and had overa responsibiity for the design, data coection, anaysis, research governance and preparation of the fina document. He undertook data coection (incuding interviews and website anaysis) and contributed towards the poicy context and background. He gave fina approva of the report to be pubished. Professor Richard D Smith was a co-appicant. He conducted the anaysis of costings, oversaw the systematic review and was invoved in the overa panning and preparation of the fina document. He gave fina approva of the report to be pubished. Professor Russe Mannion was a co-appicant. He contributed towards the background context and anaysis of patient safety and service quaity and advised on the fina write-up. He gave fina approva of the report to be pubished. Professor Stephen T Green was a co-appicant. He contributed towards the background context and anaysis of patient safety and service quaity. He gave fina approva of the report to be pubished. Professor Mark Exworthy was a co-appicant. He contributed towards the background context and anaysis of NHS poicy and advised on the fina write-up. He gave fina approva of the report to be pubished. Queen s Printer and Controer of HMSO 2014. 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. 125

ACKNOWLEDGEMENTS Dr Johanna Hanefed conducted the interviews and anaysis and the anaysis of the costing work and the IPS. She was responsibe for the preparation of the fina document. She gave fina approva of the report to be pubished. Dr Danie Horsfa was responsibe for the day-to-day panning and administration of the project. He conducted the interviews and anaysis and the anaysis of the IPS. He was responsibe for the preparation of the fina document. He gave fina approva of the report to be pubished. Dr Laura Machin was responsibe for the project start-up, ed on the initia ethics appications and governance and conducted the interviews. She gave fina approva of the report to be pubished. Dr Hannah King conducted the interviews and anaysis and provided background context on patient safety. She gave fina approva of the report to be pubished. Pubication Lunt N, Machin L, Mannion R, Green S. Are there impications for quaity of care for patients who participate in internationa medica tourism? Expert Rev Pharmacoecon Outcomes Res 2011;11:133 6. 126 NIHR Journas Library www.journasibrary.nihr.ac.uk

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DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 Appendix 1 The impementation of the EU directive on cross-border heath care: potentia reevance for medica tourism Introduction and background European Union directives outine end resuts to be achieved by every member state. Nationa authorities must adapt their aws to meet these goas but have the freedom to decide how this is done. In 2006 the European Pariament voted for the excusion of heath services from the scope of the Services Directive 2006/123/EC, designed to increase interna service trade within the European zone. The directive reevant to cross-border heath care was proposed, which treats heath with these specificities. Under this directive, which came into force in 2013, EU patients are abe to access heath care across borders as a right under certain conditions. Heath care that fas outside of the directive incudes: ong-term care organ transpants vaccination programmes. This summary assesses the impementation of the directive and comments on/highights potentia points of reevance for medica tourism within the UK context. The points of focus are: entitements and authorisation care whie abroad and continuity of care patient information reguation of advertising. Throughout this discussion the state of affiiation refers to the state that is competent to offer the patient authorisation to trave under the directive. The state of treatment refers to the member state on whose territory heath care is provided to the patient. Cross-border heath care refers to heath care provided or prescribed in a member state other than the member state of affiiation (under the directive). Entitements and authorisation What treatments are patients entited to cross borders for under the directive? Patients may receive treatment in another EU country under the directive for treatments to which they are entited in their state/country of affiiation. 1,237 In addition, the treatment must be unavaiabe within a reasonabe time frame in the country of affiiation, that is, the directive expicity aims to address undue deay for treatment found to be offered esewhere in the EU in a shorter time period. The state of affiiation (not state of treatment) determines whether at a oca or nationa eve the patient is entited to the heath care (Chapter III, Artice 7.3). Under the carified rights there are ony certain circumstances under which heath care can be refused. Do patients need to obtain authorisation? There are certain circumstances under which patients must acquire prior authorisation before choosing to cross a border for heath care. These incude when the treatment invoves overnight hospita Queen s Printer and Controer of HMSO 2014. 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. 143

APPENDIX 1 accommodation for at east one night; requires the use of highy speciaised cost-intensive medica infrastructure or equipment; invoves treatment that has the potentia to pose a particuar risk to the patient (or popuation); or when there coud be serious concerns about quaity and safety of care (Artice 8, Part 2). The state of affiiation may object if the heath care offered by a provider raises serious and specific concerns reating to quaity of care and patient safety. Authorisation can aso be rejected if the heath care can be provided on the member state s own territory within a time imit that is medicay justifiabe, taking into account the current state of heath and the probabe course of iness of each patient concerned [Artice 8, Section 6(d)]. Under the directive, member states organise their own method of administrative formaities for reimbursement of heath care. For exampe, a member state may require that patients receive a referra from a GP before receiving hospita care. If a member state does introduce prior authorisation, then this must be identified and made pubicy avaiabe (Artice 42). The directive aso advises that this must be carried out in a transparent manner and shoud not impose any additiona burden on patients seeking heathcare in another member state in comparison to patients being treated in their State of affiiation, and that decisions shoud be made as quicky as possibe (Artice 37). States of treatment may object to treating foreign patients in certain circumstances, the main reason being if a patient s request for treatment woud interfere with panned nationa heath systems, for exampe if the treatment centre did not have the capacity to treat non-domestic patients. The directive outines that foreign patients must not be favoured over domestic patients. How are patients reimbursed? Under the directive, reimbursement for treatment is based on the rate of the treatment state and reimbursement to the patient is determined by the rate of the state of affiiation. The treatment providers are not aowed to charge incoming patients at a different rate from their domestic patients. Patients wi be reimbursed ony up to the amount that it woud cost in their state of affiiation. Member states are required to reimburse specificay for the heath care received as a minimum. In addition to this, the state of affiiation may decide to reimburse other costs such as accommodation and trave, or extra costs which persons with disabiities might incur due to one or more disabiities when receiving cross-border heathcare. This wi be in accordance with nationa egisation and there must be sufficient documentation setting out these costs (Chapter III, Artice 7.4). Reevance for medica tourism In the UK context of cross-border care, patients are typicay reimbursed specificay for the heath care received. However, if NHS patient eigibiity for domestic trave benefits were expanded to incude cross-border trave this woud have impications (see www.nhs.uk/nhsengand/heathcosts/pages/ Travecosts.aspx). Any expansion to the NHS Low Income Scheme woud remove potentia cost barriers for ower-income groups to access care under the directive. Those that fa outside the scheme woud sti need to meet their costs of trave (for further information on the trave costs scheme see http://www.nhs. uk/nhsengand/heathcosts/pages/travecosts.aspx). Under the directive patients needs must be considered on a case-by-case basis, which incudes medica need and the abiity to carry out professiona activity. This requirement wi compicate the possibiity of issuing cear statements of eigibiity for both GPs and patients. If GPs become the route to prior authorisation, this may impact on those traveers who are seeking a service abroad that they coud be expected to receive within the primary care setting. This wi therefore require GPs to be educated and sensitised shoud they become gatekeepers for cross-border trave. 144 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 Care whie abroad and continuity of care In the UK, when patients make the choice to trave abroad (for both out-of-pocket and cross-border care) it is up to them to make sure that they are insured and that they are aware of what NHS entitements wi cover. The directive stipuates that: Member states shoud ensure that mechanisms for the protection of patients and for seeking remedies in the event of harm are in pace for heathcare provided on their territory and that they are appropriate to the nature and extent of the risk. However, it shoud be for the Member State to determine the nature and modaities of such a mechanism. Artice 24 Medica traveers who pay out of pocket may benefit from carification being deveoped around cross-border care. A reinstatement of NHS eigibiity and responsibiity may aow the opportunity to carify a range of patient circumstances, incuding what aftercare wi be given and aspects of care that are the patient s own responsibiity and when the NHS wi not assume iabiity. Continuity of care is another aspect for which there may be spiover effects for medica tourism that resut from carifying cross-border rights. The directive outines that patients who have received care in another state are entited to a written or eectronic medica record of such treatment [Artice 4(f)]. In addition, when a patient has received cross-border heath care and medica foow-up proves necessary, the same medica foow-up is avaiabe as woud have been if that heath care had been provided on the patient s territory [Artice 5(c)]. However, matters are compicated concerning redress. Under the directive, the NHS is required to treat the patient ony in reation to medica need. Outside of this, redress woud need to be foowed up in the state of treatment, which may incur further trave and accommodation costs to the patient. Patient information The means of carrying out the objectives of the directive are argey eft to the individua member states. Under the directive, member states wi be required to have nationa contact points that aim to faciitate the exchange of information. A certain amount of information must be provided by these contact points and is ikey to be put forward vountariy. A information made avaiabe through nationa contact points must be easiy accessibe and sha be made avaiabe by eectronic means and in formats accessibe to peope with disabiities, as appropriate (Chapter 2, Artice 6.5). Member states wi aso be abe to decide on the number of nationa contact points and these can be designed to be buit into pre-existing information centres (Artice 49). Medica tourism may receive some spiover benefits from the provision of information by contact points. The contact points wi pay differing roes when acting as treatment states or states of affiiation. When acting as the treatment state, the contact point must make avaiabe information on quaity and safety standards and guideines, patient rights, redress mechanisms and compaints procedures. States of treatment are required to provide, on request, reevant information on standards and guideines. This incudes information on the provisions for supervision and assessment of heath-care providers; which heath-care providers are subject to these standards and guideines; and the accessibiity of hospitas for persons with disabiities [Chapter 2, Artice 4(a)]. The contact points must aso provide information on the ega and administrative options avaiabe to hep patients sette disputes, incuding in the event of harm arising from cross-border heath care (Chapter 2, Artice 6.3). Medica tourists may use such information to inform their own out-of-pocket treatment decisions. Queen s Printer and Controer of HMSO 2014. 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. 145

APPENDIX 1 A state of affiiation must make avaiabe on request information on patient rights and entitements in that member state reating to receiving cross-border heath care, in particuar regarding the terms and conditions for reimbursement of costs, and procedures for accessing and determining those entitements and for appea and redress if patients consider that their rights have not been respected [Artice 5(b)]. In addition to the nationa contact points, heath-care providers wi aso need to provide reevant information for a patient to make an informed choice about treatment and the avaiabiity, quaity and safety of the heath care provided in the state of treatment. They must aso provide cear invoices and cear information on prices [Chapter 2, Artice 4(b)]. This shoud aready be provided to domestic patients. These requirements may again have spiover effects for medica traveers who seek treatment outside of the directive. Greater transparency around quaity and safety and invoicing may inform the treatment decisions of outward medica traveers. The requirement for NHS faciities to provide further information on tariffs may have impications for internationa patients decision-making as they ook across NHS providers and make comparisons with the private sector and faciities esewhere in Europe and further afied. Athough the directive outines that member states must make information avaiabe, there is ikey to be great variation in the way in which this information is received. Irrespective of how much information about rights is provided by countries under the directive, the decision to trave wi remain that for the individua to make. Patients are to be informed about what is avaiabe to them, yet this shoud be without the intention of promoting the services abroad. Accurate and transparent reporting on use of the directive and its impementation, incuding when compications may arise, wi require some form of oversight body. Reguation of advertising In addition to the directive, treatment providers must adhere to genera provider guideines in European directives designed to increase interna service trade within the European zone. These incude making information avaiabe with regard to informed choice, treatment options and risks. Heath-care providers wi need to provide reevant information, incuding on the avaiabiity, quaity and safety of the heath care that they provide in the state of treatment, so that patients can make an informed choice about treatment options. They must aso provide cear invoices and cear information on prices [Chapter 2, Artice 4(b)]. Such requirements wi have a bearing on advertising practices. Given that information may be sourced through a number of ways (internet, by word of mouth, community teevision), marketing is more compex to reguate. 146 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 Appendix 2 Protoco Queen s Printer and Controer of HMSO 2014. 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. 147

APPENDIX 2 148 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 Queen s Printer and Controer of HMSO 2014. 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. 149

APPENDIX 2 150 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 Queen s Printer and Controer of HMSO 2014. 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. 151

APPENDIX 2 152 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 Queen s Printer and Controer of HMSO 2014. 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. 153

APPENDIX 2 154 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 Queen s Printer and Controer of HMSO 2014. 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. 155

APPENDIX 2 156 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 Queen s Printer and Controer of HMSO 2014. 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. 157

APPENDIX 2 158 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 Appendix 3 Exampe interview questions Exampe interview questions for medica tourists What treatment/s have you gone overseas for? Where did you go? Why did you not have the treatment in the UK? How did you first find out that it was possibe to have treatment overseas? From whom? Did you ask anyone or ook for advice on how to go about having treatment overseas? How did you choose which agency/hospitas/cinician to have your treatment with? What factors were a priority when choosing? What additiona services were you made aware of by the agency/hospita when panning your treatment? Did you take out any trave insurance for your trip/treatment? Did you require any pretreatment checks? Who carried these out and where? Did anyone trave/stay with you when going overseas for treatment? How was your experience of accessing treatment overseas? How coud it have been improved? Woud you say you are satisfied with the outcome of your treatment abroad? Was the anguage barrier between you and the hospita staff a concern for you? How were you made aware of any risks associated with the treatment before it began? Did you have any postoperative care requirements? How were these met? By whom? What responsibiity does the NHS have to those peope who trave overseas for treatment? How do you fee about peope traveing to the UK to have treatment on the NHS? Woud you recommend going overseas for treatment to others? Costs Trave/accommodation/transfers. Sef/accompanied. How ong stay. Aftercare/after-service: which/what hote/recuperation pharmacy bandages/dressings, etc. remova of sutures, etc. foow-up appointments/consutations. Tourism/visiting, etc. Other costs (visa, insurance). Exampe interview questions for industry Te me about the work you do here/your roe. How did you get into this business? What services does your business offer? Insurance? Sightseeing, transfer of medica records, transport? Can you identify your cosest competition? How do you attract customers to use your services that don t rey on/use/have access to the internet? Can you expain the process after someone contacts your agency/views your website and wishes to go overseas for treatment (teephone, e-mai, face to face?) Queen s Printer and Controer of HMSO 2014. 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. 159

APPENDIX 3 Is your advice sought after by potentia medica tourists? Do you see that as part of your roe to draw on your experience? How do you and medica tourists overcome the anguage barriers that arise from accessing treatment overseas? How do you choose which hospitas/cinics to work with? Are they chosen by the customer aready or do you advertise particuar venues/experts? Have you any insights into how your customers hande the postop care arrangements? Does your business dea with the recovery needs of the customers? How do you dea with customers reporting bad experiences to you? What are the ramifications for your company? The hospita and surgeon? Are there aspects of the medica tourism industry that you don t yet provide or conduct that you wish to in the future? Particuar groups of customers that you wish to attract? What is needed for the medica tourism industry to grow? What coud hinder the future growth of the medica tourism industry? Exampe interview questions for NHS commercia/internationa/ private patient managers Background Numbers of internationa tourists (type of treatment, country, age/gender, etc.). Where is funding from? Out of pocket, centra government, third-party insurers? Reasons for patient traveing cost, quaity, etc. Trends which areas in above are growing/decining? How services are marketed to different groups. Which patients generate most revenue/profit? Price easticity of treatment how sensitive are different patient groups/treatments to increasing/ower prices? Deveopment Impications of ifting private patient cap on recruiting internationa patient groups above. Marketing strategies (incuding websites) used for different potentia patient groups branding, etc. Probems with entry (e.g. visas) and suggestions for overcoming barriers to entry. Competitors for specific treatments/patient groups: nationa internationa. Wider poicy considerations Compications and unintended consequences of internationa patients. Any knock-on costs for the UK? Centra government support and enterprise support for deveoping services trade missions, etc. Pans for the future. Exampe interview questions for NHS managers (commissioning) Te me about the work you do here/your roe. How did you get into this roe? Why do you beieve that peope pay for medica treatment overseas? 160

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 Do you view peope accessing treatment overseas as patients, customers or consumers? Does your perception vary according to which treatment is being sought after? Do you foresee any risks with opting to pay for treatment overseas? How can we make accessing treatment overseas safer? In your opinion, are there aspects of the media tourism process that bring up ethica or ega diemmas? Are there particuar treatments that you beieve shoud not be avaiabe through medica tourism agencies? What impact does medica tourism have on the NHS? Its staff? Budget? Its pubic perception? In the ong and short term? Can medica tourism provide opportunities for the NHS? Are you aware of peope traveing to the UK to access treatment through the NHS or private cinics? What do you beieve are the issues that arise from this trave and care? Have you any insight into how medica tourists hande the postop care arrangements? Are you aware of hospitas that have deat with the recovery needs of medica tourists? Whose responsibiity is it to dea with any compications that arise after medica treatment paid for overseas? In the current economic cimate, what does the future hod for the medica tourism industry? Exampe interview questions for professiona associations Te me about your roe within the association. What roe does the association provide to its members? Does the association have a roe within wider society? Within government? Is it the roe and responsibiity of the association to provide advice or guideines to potentia medica tourists? Those working within the medica fied? Why do you beieve that peope pay for medica treatment overseas? Is there enough reguation around the medica tourism industry? Do you foresee any risks with opting to pay for treatment overseas? How can we make accessing treatment overseas safer? In your opinion, are there aspects of the media tourism process that bring up ethica or ega diemmas? Are there particuar treatments that you beieve shoud not be avaiabe through medica tourism agencies? Do you see/hear about medica tourism having impications for your members? Your profession? Have you any insight into how medica tourists hande the postop care arrangements? Are you aware of hospitas that have deat with the recovery needs of medica tourists? Whose responsibiity is it to dea with any compications that arise after medica treatment paid for overseas? Are you aware of peope traveing to the UK to access treatment through the NHS or private cinics? What do you beieve are the issues that arise from this trave and care? In the current economic cimate, what does the future hod for the medica tourism industry? Queen s Printer and Controer of HMSO 2014. 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. 161

APPENDIX 3 Exampe interview questions for overseas providers Numbers of internationa tourists (type of treatment, country, age/gender, etc.) and types of services offered/utiised. Trends which areas above are growing/decining? Where are they seeking to deveop? How services are marketed to different groups: marketing strategies (incuding websites), word of mouth, cinician referra, brokers. Treatment pathways: preconsutations use of brokers. Competitors for specific treatments/patient groups: nationa internationa. Observations on quaity of care. Do you foresee any risks with opting to pay for treatment overseas? How can we make accessing treatment overseas safer? roe of accreditation roe of nationa/internationa guidance/egisation. Aftercare and foow-up whose responsibiity is it to dea with any compications that arise after medica treatment paid for overseas? Ethics and ega in your opinion, are there aspects of the media tourism process that bring up ethica or ega diemmas? Pans for the future any possibe probems/barriers with regard to deveoping services? 162 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 Appendix 4 Confidentiaity agreement for transcriber Queen s Printer and Controer of HMSO 2014. 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. 163

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 Appendix 5 Research participation information sheet Queen s Printer and Controer of HMSO 2014. 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. 165

APPENDIX 5 166 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 Appendix 6 Consent form Queen s Printer and Controer of HMSO 2014. 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. 167

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 Appendix 7 Recruitment networks and cas for information Onine channes through which recruitment was attempted Beauty in Prague Forum. Big Matters. Cosmedia. Cosmetic Compare. Cosmetic Surgery Forums. Donor Conception Network. eheath Forum. Fertiity Friends. Gay Famiy Web. Infertiity Network UK. Linda Briggs forum. Look Your Best. Michemores. MoneySave Supermarket. Nationa Gamete Donation Trust. Patient Opinion. PacidWay. ReaSef. Secret Surgery. So feminine. Surgery Overseas Forum. Treatment Abroad. Weight Loss Surgery Information and Support [site and Facebook (Facebook, Inc., Meno Park, CA, USA)]. Journas which carried artice about the study and recruitment Internationa Medica Trave Journa (IMTJ) and The Probe Magazine. Network gatekeepers assisting with sampe recruitment Martin Rathfeder, Somai Adut Socia Services, Nina Lakhani and Ubah Ega. Project website www.medicatourismresearch.co.uk Queen s Printer and Controer of HMSO 2014. 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. 169

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 Appendix 8 Advisory group terms of reference and membership Queen s Printer and Controer of HMSO 2014. 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. 171

APPENDIX 8 172 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 Queen s Printer and Controer of HMSO 2014. 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. 173

APPENDIX 8 174 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 Appendix 9 Treatment pathways for medica tourists interviewed as part of the study Bariatric surgery Patient Procedure Destination Motivation BT1 Gastric band Begium Experience, distance, cost BT2 Gastric band France Recommendations, NHS Gastric bypass Poand waiting ist, mortaity rate Treatment pathway a Mode 5, internet, onine patient forum Media, persona contact Cost savings ( ) b 7000 3500 BT3 Gastric wrap Prague, Czech Repubic Cost Onine patient forum, booked through faciitator 1000 BT4 Gastric band Bruges, Begium Cost, surgeon experience Internet 4000 BT5 Gastric band Begium NHS criteria not met, distance, cost Onine patient forum, internet 7000 BT6 Gastric bypass Bruges, Begium Treatment not avaiabe, experience, cost Web forum 5000 BT7 Gastric band, tummy tuck Begium NHS criteria, cost, no wait Internet, faciitator, preconsutation in London 8000 BT8 Duodena switch Begium Waiting ist, experience, treatment not avaiabe at the time Onine patient forum 7000 BT9 Gastric band Brusses, Begium NHS said no, agency, cost Onine patient forum 5400 BT11 Pancreatic diversion and duodena bridge Begium NHS criteria, experience Persona recommendation 5000 BT12 Gastric band Begium Cost Internet, London contact 10,000 for both patients BT13 Abdominopasty and iposuction Poand Cost Internet 2300 a Treatment pathway focuses on how surgeon was identified. b Cost savings were sef-reported. Patients were asked about cost in the UK and the cost of the procedure, trave and accommodation reated to trave overseas. Savings were cacuated based on information provided and erred on the ow side. Queen s Printer and Controer of HMSO 2014. 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. 175

APPENDIX 9 Fertiity surgery Patient Procedure Destination Motivation Outcomes/ compication Cost (and savings) FT1 IVF/egg donation Brno, Czech Repubic Needed donor eggs/time, not eigibe on NHS (age) Pregnancy/mutipe births None, cost 10,000 14,000 FT2 IVF Czech Repubic Low ikeihood of success meant not avaiabe free on NHS, cost and experience of UK private treatment No pregnancy foowed up with egg donation in Dubin Cost 2400 compared with 7500 in the UK FT3 IVF/ICSI Cyprus (North) Exhausted free NHS cyces, cost of private treatment Pregnancy Cost 3650 excuding fights and premedication, but incusive of a other treatment and accommodation. Meds cost 800 (athough this was not paid). This is compared with 6000 in Edinburgh FT4 IVF/egg donation/ ICSI Kiev, Ukraine Eary menopause, no provision on the NHS, donor needed Pregnancy/twins, eary pregnancy Cost 20,000 FT5 IVF/egg donation Kiev, Ukraine No provision on the NHS, mutipe miscarriages and extremey high risk of Down syndrome, donor Pregnancy (third cyce) Cost 22,000 FT6 IVF Sweden NHS waiting time exacerbated by ong diagnosis time of endometriosis, didn t ike private UK treatment Pregnancy (three chidren from two cyces) Cost roughy 8000 (reading between ines). Represented a 2000 saving (ish) but this was offset by trave and taking time off work FT7 IVF Czech Repubic NHS waiting time, private costs and desire for ignorance No pregnancy despite four cyces 1000 for treatment compared with 3500 in the UK. Medication 500 (sourced in the Czech Repubic) compared with 1000 in the UK. With fights and accommodation tota cost 3000, so roughy a 1500 saving FT8 IVF/egg donation (prospective) Madrid Not eigibe on NHS, waiting times, private costs Prospective Hard to te, a in it appears to be 12,000, which FT8 seems to beieve is a major saving FT9 IVF/sperm donation/ egg donation Aicante, Spain Not eigibe on NHS or French SS Two faied cyces in the UK and one successfu in Aicante, pregnancy to term 7000 for treatment in Aicante but a tota of > 21,000 for a treatment 176 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 Denta surgery Patient Procedure Destination Motivation Outcomes/ compication Cost (and savings) DT1 Crowns and bridges for mutipes Croatia No NHS treatment and then cost. Cost the motivator for overseas treatment rather than UK private treatment Satisfied Cost 4000 saving of 36,000? DT2 Impants Hungary Cost, experience of dentist Satisfied Saving DT3 Emergency and cosmetic Germany Bad UK private experience Satisfied Minima DT4 Restoration? 11 impants Hungary Word of mouth Work had to be redone Cost 40,000 to have rectified DT5 Brace to bottom jaw Poand Lack of NHS treatment waiting times and cost, boyfriend speaks Poish, word of mouth, hoiday Satisfied Even incuding the cost of fights, the tota cost was ess than haf DT6 Routine India Cutura Satisfied No saving DT7 Bridge and pate Croatia No NHS treatment and then cost. Cost the motivator for overseas treatment rather than UK private treatment Satisfied Estimated anywhere between 15,000 and 35,000 DT8 Routine Itay Cutura Satisfied No costs incurred DT9 Crowns and fiings Lithuania Cost Satisfied Cost 5200 incuding fights compared with 18,000 DT10 Routine Germany Distrust of NHS and cutura reasons Satisfied No cost saving DT11 Impant Hungary Cost and hoiday Satisfied Cost 400 pus fights; perceived a-in saving of 200 (cost for treatment in UK 1200) Queen s Printer and Controer of HMSO 2014. 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. 177

APPENDIX 9 Cosmetic surgery Patient Procedure Destination Motivation CT1 Faceift Prague Price, previous experience Outcomes/ compication Cost ( ) Satisfied 3300 CT2 Thigh iposuction Prague Price, expertise 1200 + CT3 Tummy tuck, iposuction, arm ift Begium Price 6600 CT4 Minima access crania suspension ift Brusses, Begium Price, expertise Satisfied 2000 CT5 Faceift Prague, Czech Repubic Price 4000 CT6 Abdominopasty, iposuction Poand Price Satisfied 3500 CT7 Face and neck ift Lahore, Pakistan Price Satisfied 3800 CT8 Caesarean section tummy tuck Prague Price Major infection 2600 CT9 Nose, face, eyes Poand Price Compication 5000 Other medica tourists Patient Procedure Destination Motivation Outcomes/ compication Cost ( ) OT1 Buttock/nerve surgery Los Angees, Caifornia Pain, expertise, ack of NHS avaiabiity Needed second operation but hasn t worked 78,000 OT2 Utrasound Germany Lack of NHS avaiabiity Ongoing visits 0 150 OT3 Shouder stabiisation Begium Poor NHS response, pain/ack of faith Some restriction of movement 2500 OT4 Neede for Dupuytren s contracture France Lack of NHS avaiabiity Ongoing treatment 30 OT5 Immunotherapy for breast cancer Athens, Greece Lack of NHS avaiabiity In remission but ongoing treatment Free treatment (trave) OT6 Check-ups (GP/gynaecoogy/eyes/ dermatoogy) Paris, France Lack of faith in NHS Ongoing visits Free treatment (trave) 178 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 Appendix 10 Search strategy for systematic review The systematic review of the iterature foowed a number of strategies. Key papers in journas and other researchers working on the issue of medica tourism were identified, incuding through the interviews. Foow-up with severa academics was conducted to ensure that additiona research and emerging pubications woud be considered as part of the review. A review of key iterature databases was conducted in October and December 2011 using the terms medica tourism, heath tourism, tourism AND medicine and tourism AND heath. No restrictions in terms of pubication dates were made. The foowing tabe ists the databases searched, the search terms used and the exact number of hits achieved for each database. Database No. of hits Search terms MEDLINE 360 heath tourism, medica tourism, medicine, tourism AND heath, tourism AND medicine ISI Web of Science 878 medica tourism, heath tourism, tourism AND medicine, tourism AND heath EMBASE 546 heath tourism, medica tourism, medicine, tourism AND heath, tourism AND medicine Goba Heath 514 medica tourism, heath tourism, tourism AND medicine, and tourism AND heath Heath Management Information Consortium (HMIC) 77 heath tourism, overseas treatment, overseas patients, heath tourism EconLit 280 medica tourism, heath tourism, tourism AND medicine, tourism AND heath Note: For keywords tites and abstracts were searched. Search terms indicated were used individuay and in combination a, indicates OR. In tota, 2295 papers (incuding dupicates) were identified through the database searching. Two papers were aso incuded based on recommendations from peope interviewed as part of the research project. 91,102 Review criteria The initia seection of papers was undertaken foowing a review of tites that had a genera focus on medica tourism. The foowing were excuded: papers on we-being or trave for assisted suicide, news items, commentaries, aws or directives and conference proceedings. One exception was made in the case of a news report pubished in the Lancet. Ony artices pubished in Engish and German were incuded. Foowing a review of tites and abstracts, 425 papers remained. Out of this sampe a further 21 papers focusing on stem ce tourism and 29 papers focusing on transpant tourism were excuded as these are distinct areas of tourism with specific ethica issues. In addition, one guideine from the American Medica Association was excuded, eaving 374 papers. Queen s Printer and Controer of HMSO 2014. 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. 179

APPENDIX 10 Of the 374 remaining papers, the abstract or entire paper for each was reviewed to determine whether or not to incude it in the review. In addition, references of the papers identified through the review of the iterature were further examined to ensure that a reevant papers were incuded. In ine with the overa research objectives, papers were seected to see how much they coud contribute to understanding medica tourism as an industry, as a trade in heath services and from a patient perspective. Emphasis was on papers pubished in peer-reviewed journas that had a goba focus on medica tourism or a focus specific to the UK (i.e. the review excuded papers that focused excusivey on medica tourism to one country or the effects of medica tourism on one country, for exampe the USA, uness there was a specific UK ink) or to denta, fertiity, cosmetic, bariatric or diaspora tourism, which form specific case studies within the overa research project. Artices were incuded when primary research had been conducted in one country but the framework, concusions and discussion demonstrated that findings were transferabe. The research project is aso undertaking a review of websites to better understand the industry and providers. Given this emphasis, papers focusing on medica tourism provider websites were incuded. Papers that focused from an industry perspective on the management or organisationa issues (e.g. on how to ead virtua teams working within the medica tourism industry) were excuded when these did not draw wider concusions on the issue of medica tourism as a whoe. There is a body of iterature examining issues reating to medica tourism, incuding issues of transpant, stem ce and surrogacy tourism, from an ethica and phiosophica perspective. This iterature has not been considered here. A number of studies expored the impact of medica tourism on the heath-care system and professionas within a specific country; these have not been incuded in this review of the iterature uness their findings shed ight on the wider phenomenon of medica tourism. Papers focusing excusivey on the impementation of the EC directive on cross-border patient care (e.g. Hawkins et a. 234 ) were aso excuded. On the basis of these criteria 276 papers were excuded. Foowing the review of the papers, four additiona studies were incuded that had not emerged from the initia iterature searches. Two papers were not accessibe and were therefore excuded. Based on these criteria 100 papers 8,10 12,17,26,40,42 134 were incuded in this review. Review process Two authors independenty reviewed the papers and then met to compare resuts. A third author tested a sampe of papers. The initia resuts of the review were presented to the study advisory board and foowing input a further search term of cross-border care was run. However, this did not yied any additiona papers that had not aready been incuded in the origina search. 180 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 Appendix 11 Preferred Reporting Items for Systematic Reviews and Meta-Anayses fow diagram for iterature review of medica tourism Incuded Eigibiity Screening Identification Papers incuded foowing review of references (n = 4) Papers identified through database searching (n = 2295) Papers after dupicates removed (n = 2127) Papers after tites reviewed (n = 425) Abstracts or, where needed, fu papers reviewed for eigibiity (n = 374) Papers incuded in review (n = 100) Papers identified through other sources (n = 2) Papers excuded after review of tite (n = 1702) Papers excuded as focused on stem ce or transpant (n = 51) Papers excuded after abstract or fu-text reviews, based on criteria defined (n = 276) Papers not accessibe (n = 2) Queen s Printer and Controer of HMSO 2014. 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. 181

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 Appendix 12 Resuts of the iterature search What do we know about medica tourism? A review of the iterature TABLE 10 Resuts of the iterature search Database searched No. of hits MEDLINE 360 ISI Web of Science 878 EMBASE 546 Goba Heath 514 Heath Management Information Consortium (HMIC) 77 EconLit 280 TABLE 11 Issues covered in the 100 papers incuded in the review Issue No. of papers a Fertiity 16 Cosmetic 5 Denta 3 Diaspora 5 Bariatric 2 Risks in heath outcomes 29 Focus on recipient country heath system 37 Focus on originating country heath system 34 a Papers coud fa into more than one category. Queen s Printer and Controer of HMSO 2014. 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. 183

APPENDIX 12 TABLE 12 Industry categories covered in the 100 papers incuded in the review Industry category No. of papers a Providers 41 Tourism faciitators 19 Focused on industry a 22 Website review 5 Market review 4 Communication 4 Mode 1 Faciitators 3 Reguation 2 At country eve 4 Contracts 1 a Papers coud fa into more than one category. 45 40 Number of pubications 35 30 25 20 15 10 5 0 2002 2003 2004 2005 2006 2007 Year 2008 2009 2010 2011 FIGURE 9 Number of pubications by year of pubication. 60 50 Number of papers 40 30 20 10 Anaysis Empirica Overview Review 0 FIGURE 10 Types of studies incuded in the review. Type of study 184 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 16 1 4 18 43 Goba Europe Asia Midde East Africa America 29 FIGURE 11 Geographic focus of studies incuded in the review. Numbers denote the number of papers investigating each region. Papers coud fa into more than one category, and some comparative papers focused on two regions or countries from within two regions. 10 9 Number of papers 8 7 6 5 4 3 2 1 0 Treatment Abroad survey for UK Own research findings Deoitte McKinsey UNESCAP Media Other Other academic papers Data source FIGURE 12 Data sources for patient numbers quoted in studies incuded in the review. Queen s Printer and Controer of HMSO 2014. 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. 185

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 Appendix 13 Modes of information and their advantages and disadvantages Key features Advantages Disadvantages Faciitator-enabed provision 1. Arrange services and treatment phases 2. Location and business modes may vary 3. Incude treatment, insurance, finance, trave and accommodation and aftercare Faciitator reassurance for prospective and traveing patients, particuary if they have oca/speciaist knowedge Faciitators offer support and customer care throughout the treatment experience, from departure to return home, incuding aftercare and foow-up Potentia to reduce transaction costs for individuas seeking to combine a range of services within a treatment journey Faciitators may achieve economies of scae and negotiate improved tariffs for patient treatment, aftercare and anciary services (e.g. accommodation) Range of faciitator motivations: medica and professiona insights; others share persona experience of treatment abroad and can personaise for patient Range of faciitator motivations. For some, faciitation purey a commercia opportunity Uncear how faciitators target markets, source information, seect provider/s and give appropriate advice Commission arrangements contribute towards suboptima outcomes skew referra or provide incentive to overse (e.g. additiona diagnostic tests) Possibiities for underseing (e.g. a-incusive price, negecting to incude fu recuperation and foow-up costs) Lega situation remains uncear: faciitators unreguated and consumers have potentiay misaigned interests Consumer-driven mode 1. Search, seect and purchase components of treatment 2. Roe of websites centra Eevates choice and ess encumbered by faciitator interests and suppier-induced demand Internet reduces transaction costs (search/contract) and aows individuas to appraise risk Within fee-for-service approach, strong conception of individuas framed as consumers rather than patients Veracity and commercia bias of website information. Few objective sources of advice on risk. Information may confuse, overwhem and contradict Individuas sti subject to risk, discontinuity amongst services and impartia advice Preferred suppy chains may not be possibe (e.g. private aftercare services may refuse individuas treated abroad) Network provision 1. Interconnection of socia and professiona networks 2. Treatment, cutura and professiona networks Networks mediate market reationships and aow trust to be buit, e.g. encave networks without centra authority, based on shared commitment Sharing of information/ideas among professionas. So-caed hierarchica networks may fit cutura dynamics Individua patient receives support through network connections Informa information exchange and continuity of care and support. Issues of information reiabiity Not a network reationships equa in terms of power and contro Queen s Printer and Controer of HMSO 2014. 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. 187

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 Appendix 14 Country strategies: case exampes Begium Medica tourism in Begium is dominated by sma independent cinics often speciaising in one broad treatment area, the most common being bariatric surgery, cosmetic surgery and fertiity surgery. These smaer cinics do market themseves to European, incuding UK, trade; however, word-of-mouth recommendations are increasingy important in capturing UK tourists. Athough cheaper costs avaiabe in Begium are a draw for citizens of other European countries, many cinics are aso abe to boast pioneering or fied-eading surgeons, especiay in terms of cosmetic and bariatric surgery. UK citizens who have traveed to Begium have noted that the cost of trave to and accommodation within Begium is often cheaper than for London, where the UK aternatives are usuay ocated. Spain The Spanish medica tourism industry has a ong history buit on ow costs and an active wider tourism industry. For Britons it has historicay not been uncommon to combine ow-eve medica treatment such as dentistry with conventiona tourism to Spain; however, Spain s medica tourism industry primariy serves continenta Europe rather than the UK. Indeed, a senior consutant at one of Spain s arge heath-care institutions suggested that UK medica tourists made up ony an insignificant proportion of medica tourists to the organisation. The ony exception to this is fertiity tourism, which brings a arge number of UK citizens to Spain. Medica tourism in Spain is primariy hosted within arge mutipurpose cinics or hospitas that often dea with a range of treatments. For exampe, an organisation such as the Barceona Medica Centre actuay represents an affiiation of a number of genera and speciaist cinics. Much private treatment aso occurs within pubic hospitas. Athough there are smaer independent, speciaist cinics, it is these arge compexes that dominate the industry. The main exception to this is the case of fertiity cinics, with a number of smaer cinics attracting medica tourists aongside the arger cinics. Turkey The Turkish medica tourism industry is an increasingy nationa project with sma and arge cinics soiciting business aongside governmenta and quasi-governmenta bodies. Athough sma cinics offering a narrow range of treatments are common, it is arger cinics that are driving the Turkish medica tourism industry. These cinics are usuay hote ike in their front-of-house appearance, whist marketing state-of-the-art medica faciities. Such cinics are frequenty one-stop cinics where a wide range of procedures are performed. Athough Turkish providers are happy to court the UK market, UK traveers to Turkey have historicay traveed for ess compex and ower-cost treatment (often cosmetic). As one provider noted, athough this is usefu, it does not represent a stabe foundation for a viabe business mode. Cinics are activey courting en masse those requiring higher-end procedures. To this end, Turkish cinics are activey seeking partnerships with medica insurance companies, both in Europe and in the Midde East. Athough individua cinics are in competition, there is a degree of unity behind what appears to be a nationa programme aimed at estabishing Turkey as medica tourism hotspot where East meets West. Organisations such as Heath in Turkey (an association of the Foreign Economic Reations Board and the Heath Tourism Business Counci) and the Turkish Heathcare Deveopment Counci represent a oose aiance of Turkish medica tourism providers who agree to support certain ventures with the aim of benefitting the wider medica tourism industry in Turkey. These organisations are inked at arm s ength to the Turkish government s Ministry of Tourism and Cuture. Queen s Printer and Controer of HMSO 2014. 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. 189

APPENDIX 14 Hungary The Hungarian Ministry of Heath is activey pursuing a medica tourism strategy and is keen to market the country as a destination for patients from abroad. The UK is ceary considered a market for this strategy as the Ministry of Heath recenty financed its first medica tourism symposium in London. The country is recognised for its expertise in dentistry and has excess capacity in dentistry. Within Hungary, specific regions attract patients from different countries based on proximity and accessibiity. Many of the Hungarian dentists catering to UK cients appear to have faciitators in the UK who are the first point of ca for patients. Cosmetic surgery and non-surgica cosmetic procedures are areas targeted at patients abroad with providers from Hungary marketing themseves to UK patients and patients of neighbouring countries. Fertiity tourism appears to be an area of growth in Hungary. Cost aside, reguations governing IVF in Hungary (which aow for four embryos to be impanted) were cited as a pu factor for patients. Hungary has the highest European concentration of spas and therma waters and the Hungarian Ministry of Heath and the country s tourist association are keen to attract a greater number of UK tourists to its spas for medica purposes. The Hungarian Minister of Heath ceary outined that the government sees the connection between the good reputation of the country s medica education and the growth in its medica tourism industry. In 2009, concern among the more estabished arger cinics that medica tourism might risk the reputation of Hungarian dentistry internationay ed to the formation of the Association of Leading Hungarian Denta Cinics. This incudes a number of cinics that commit themseves to foow a code of practice on professiona ethics and quaity assurance. Thaiand Thaiand is one of the main medica tourism destinations in Asia and the country has invested in its infrastructure to market itsef as a medica tourism centre. Thaiand has provided medica services for foreign patients incuding medica tourists and foreigners working in the country. The country has aso targeted regiona medica tourists with expatriates from neighbouring countries visiting Thaiand for treatment. Thai consus provide information on treatment and prices and the country provides a specific visa for medica tourism. Most patients, originating mainy from the USA, the UK and Japan, are treated in three hospitas in Bangkok. Thai hospitas generay have aso attracted foreign investment, with 24 hospitas part privatey owned in 2001. 190 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 Appendix 15 Line charts iustrating inward and outward medica trave trends from the Internationa Passenger Survey 2000 10 (a) 12,000 Number of traveers 10,000 8000 6000 4000 2000 Africa Southern Asia East Asia 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Year (b) 30,000 Number of traveers 25,000 20,000 15,000 10,000 5000 Midde East Centra and Eastern Europe Northern, Western and Southern Europe 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Year (c) 2500 Number of traveers 2000 1500 1000 500 North America Centra and South America Other 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Year FIGURE 13 Line charts iustrating the numbers of UK residents who traveed for medica treatment in 2000 10 by destination region. (a) Africa, Southern Asia and East Asia; (b) the Midde East, Centra and Eastern Europe and Northern, Western and Southern Europe; and (c) North America, Centra and South America and other regions. Queen s Printer and Controer of HMSO 2014. 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. 191

APPENDIX 15 (a) Number of traveers 8000 7000 6000 5000 4000 3000 2000 1000 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Year Africa Southern Asia East Asia (b) 35,000 Number of traveers 30,000 25,000 20,000 15,000 10,000 5000 Midde East Northern, Western and Southern Europe Centra and Eastern Europe 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Year (c) Number of traveers 4500 4000 3500 3000 2500 2000 1500 1000 500 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Year North America Centra and South America Other 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 2000 10 by region of origin. (a) Africa, Southern Asia and East Asia; (b) the Midde East, Northern, Western and Southern Europe and Centra and Eastern Europe; and (c) North America, Centra and South America and other regions. 192 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 (a) 16,000 Number of traveers 14,000 12,000 10,000 8000 6000 4000 2000 France Poand India 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Year (b) Number of traveers 5000 4500 4000 3500 3000 2500 2000 1500 1000 500 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Year Hungary Begium Germany (c) Number of traveers 3500 3000 2500 2000 1500 1000 500 USA Spain Turkey 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Year FIGURE 15 Line charts iustrating the nine most popuar destinations of UK residents who traveed for medica treatment in 2000 10. (a) France, Poand and India; (b) Hungary, Begium and Germany; and (c) USA, Spain and Turkey. Queen s Printer and Controer of HMSO 2014. 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. 193

APPENDIX 15 (a) Number of traveers 8000 7000 6000 5000 4000 3000 2000 1000 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Year Ireand Spain United Arab Emirates (b) Number of traveers 5000 4500 4000 3500 3000 2500 2000 1500 1000 500 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Year Kuwait Nigeria Greece (c) Number of traveers 4000 3500 3000 2500 2000 1500 1000 500 France Cyprus Portuga 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Year FIGURE 16 Line charts iustrating the nine most common countries of origin for those who traveed to the UK for medica treatment in 2000 10. (a) Ireand, Spain and the United Arab Emirates; (b) Kuwait, Nigeria and Greece; and (c) France, Cyprus and Portuga. 194 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 Appendix 16 Fertiity treatment abroad and the wider ega and reguatory compexities Aongside the pioneering techniques and continued innovation in fertiity treatment, the UK has advanced reguatory and ega frameworks overseen by the HFEA, which governs assisted reproduction standards. The Human Fertiisation and Embryoogy Act 238 estabished the HFEA and since 1990 it has icensed and monitored UK fertiity cinics, reguated research and fertiity procedures, maintained a register of donors, treatments and any resuting births, pubished a code of practice, provided advice to cinics and patients and advised the appropriate Secretaries of State on issues reated to fertiity. Athough it is uncear whether the HFEA wi continue in its current form or whether some or a of its functions wi be transferred to bodies such as the CQC, 239,240 the HFEA currenty ensures that: A fertiity cinics in the UK receive a icense through the HFEA for which they are periodicay inspected. Detais of their services, faciities and success rates are avaiabe through the HFEA and in that sense are transparent and independenty vaidated. Fertiity cinics transfer a maximum of two embryos (ony increased in exceptiona circumstances), thus reducing the risk of mutipe births. Counseing is provided to a those who seek fertiity treatment. Donors receive a set payment and their heath and we-being is considered throughout. Faciities do not breach ega or ethica codes in advertising donor services or recruiting donors. A register is maintained of a procedures carried out by registered UK cinics. Sperm and egg donors are identifiabe to a chid once they reach the age of 18 years. A maximum of 10 famiies are created per donor. Research on embryos is stricty controed. By traveing abroad for fertiity treatment, patients remove themseves from a system with the above guarantees and safeguards. In many countries there are frameworks covering ART; however, there is a arge degree of variance with regard to what is addressed by such frameworks. Moreover, the principes enshrined in one may run contrary to those guaranteed by others. 114 It is difficut to state that patients traveing abroad for fertiity treatment present cear ega difficuties. However, there is much to be considered simpy by removing the guarantees isted above. The interviews conducted in this study aone have highighted instances in which the guarantees above were absent or may have been absent and in each case it has been detrimenta to the immediate and future we-being of the patient and offspring. Of particuar concern is that the transfer of embryos is not reguated in some countries or higher imits are set. 241 Higher transfer eves are directy reated to an increased risk of mutipe births and with that comes a raft of reated risks and costs, which as we have seen are being borne by the NHS irrespective of where fertiity treatment occurs. 98,193 Legisation and, perhaps more importanty, record keeping surrounding donation abroad are ceary variabe. Beyond the wider ethica impications of ower or a ack of standards regarding the commerciaisation of donation abroad, the anonymity of donors presents two major points for consideration. First, especiay if combined with an inconsistent or not particuary thorough record-keeping system, the information that patients receive about donors is at best unreiabe. Second, when unexpained or suspected genetic conditions present in offspring, information can be difficut to retrieve. Queen s Printer and Controer of HMSO 2014. 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. 195

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 Appendix 17 The peris of cosmetic surgery/medica tourism by Laurence Vick This artice has been reproduced with permission from AvMA Medica & Lega Journa 2012;18:106 9. 155 Queen s Printer and Controer of HMSO 2014. 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. 197

APPENDIX 17 The peris of cosmetic surgery/medica tourism Laurence Vick Abstract The artice discusses a case invoving negigent aesthetic surgery. The surgery took pace in a Begian cinic and was performed by an Itaian surgeon. MR V DR VALERIO BADIALI (D1) ELYZEA COSMETIC SURGERY GROUP (D2) Background The Caimant then aged 38 underwent Biatera Faceift and Biatera upper and ower eyeid surgery performed by an Itaian surgeon (D1) at D2 s cinic in Brusses in June 2005 after initia discussions with D1 at D2 s Harey Street premises. She had seen D2 s website and promotiona materia in Engand (D2 advertises widey in Engand and their website has a co.uk suffix); she signed the contract in Engish and paid for her surgery in Stering after the initia meeting with D1. D2 s iterature asserted that Eyzea s pastic surgeons who provide consutations are fuy registered with the British GMC and most of them are isted on the Speciaist Register for Pastic Surgery. No adequate medica records were discosed by either Defendant but it was inferred from the Caimant s injuries that she had suffered compications during her surgery, specificay a beed within her eft cheek which caused a buid-up of pressure. She suffered damage to the infraorbita and greater auricuar nerves, damage to her eft upper ip and damage to the skin of her face atera to both eyeids and to the front and behind both ears. D1 agreed to undertake further surgery in October 2006 to improve the appearance of the scarring to her face and to remove a retained suture from her right cheek. This faied to improve the Caimant s scarring. The Caimant was given no warning by D1 or D2 as to the risk of nerve damage or of any injury simiar to that which she suffered. After the unsuccessfu corrective surgery D1 faied to respond to the Caimant s emais and teephone cas and D2 maintained the position they had hed throughout that they were not responsibe and that under Begium aw any itigation must be directed to the surgeon. It ater transpired that D1 faced compaints from numerous dissatisfied patients and he returned to Itay after D2 were assumed to have terminated their reationship with him. Instructions were received from the Caimant in May 2008 and we agreed to enter into a CFA. A correspondence sent on behaf of the Caimant incuding Letters of Caim were ignored by D1 and D2. Laurence Vick, Michemores LLP, Woodwater House Pynes Hi Exeter EX2 5WR, United Kingdom Emai: aurence.vick@michemores.com Proceedings Once it became apparent that the Itaian surgeon D1 was untraceabe, on the basis that the Caimant had entered into a contract with the cinic to provide the package of care the decision was taken to focus on D2. The Caimant peaded that D1 was either an empoyee or agent of D2 for whom they were vicariousy iabe. A communications to D2 were sent to their London premises and Brusses head office. D2 chose not to obtain ega representation throughout the proceedings (save for the penutimate hearing for the assessment of damages). Proceedings were issued on a protective basis in June 2008 and the Court subsequenty agreed to extend time for service of proceedings and granted permission under CPR 6.33 to serve on D1 and D2 outside the jurisdiction. Proceedings were served on D2 at their London premises in February 2009. The Court granted further extensions of time to attempt service on D1 in Itay to Apri and Juy 2009. In the absence of any response from D2 Judgment was entered in defaut in Apri 2009 for damages to be assessed. As it had been impossibe to serve directy on D1, deemed service was carried out under Artice 140 of the Itaian Code of Civi Procedure. A correspondence to D2was ignored and the ony contact was two teephone cas from Brusses to the Caimant s soicitors. D2 faied to comprehend that they had been found to be iabe and that Judgment had been entered against them. In these teephone cas they insisted that the Caimant had sued the wrong party and that under Begian aw iabiity ay with the surgeon. They admitted that they had themseves been attempting to trace D1 in Itay because of probems with his surgery carried out on other dissatisfied patients. The Caimant s expert medica evidence confirmed that she was suffering from numbness of the eft side of her face, ack of symmetry of the eft side of her face, abnormaity of movement of the eft upper ip, prominent scarring of the face atera to the eyeids on the eft and right and in front and behind the ears on the eft and right and a papabe firm area within the subcutaneous tissues of the eft cheek. The numbness, ack of symmetry and abnormaity of movement were due to nerve damage which was ikey to be permanent and it was unikey that any further treatment woud improve the symptoms. Simiary, the papabe area to the eft cheek and scarring were ikey to remain permanent features. The Caimant s psychiatric expert confirmed that she was suffering a chronic adjustment disorder secondary to the operation and its physica effects, that the condition was ikey to be DOI: 10.1258/cr.2012.012017 198 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 amenabe to improvement with cognitive behavioura therapy and was ikey to remain with some eve of ow mood, anhedonia (the inabiity to experience peasure from activities) and sensitivity towards other peope in the foreseeabe future. The Caimant s iabiity expert, a Consutant Reconstructive and Aesthetic Pastic Surgeon, confirmed that D1 had paced scars inappropriatey at a site where the risk of hypertrophy had eventuated, the scars behind the ears were of poor quaity and were hypertrophic, suggesting that he had faied to ensure that the wounds at the site were cosed without tension either at the primary or revision procedure; one or more of the termina branches of the greater auricuar nerve destined for the cheek was damaged during the face ift surgery, suggesting that the pane of dissection was inappropriatey deep at this point. Assessment of Damages An initia hearing took pace before the Recorder in June 2011 in the absence of D2 when he insisted that the assessment be adjourned for the Caimant to obtain further expert evidence estabishing the causation of her injuries in addition to the condition and prognosis evidence aready discosed. A further hearing before a Circuit Judge in September 2011 was adjourned after A Begian awyer appied by etter so they coud instruct soicitors to commission their own expert evidence. The Judge agreed to this adjournment on condition that D2 make a payment on account of the Caimant s damages of 45,000.00 and pay a sum on account of costs within 28 days. No payment was made by D2 and a fina hearing took pace before the Circuit Judge on 2 March 2012, with no attendance from D2, and damages were assessed. The award of 113,148.96 comprised 30,000 genera damages, interest on those damages of 1,669.53, 71,671.06 specia damages pus interest of 8,808.37. The Caimant s soicitors costs were aso assessed with the incusion of a 100% success fee. Steps are now being taken to enforce those damages and costs against D2. Choice of Jurisdiction The decision was taken to seek jurisdiction in Engand and Waes. There were no jurisdiction or choice of aw/appicabe aw causes in the contract with D2 and no written agreement or documentation between the Caimant and D1. Neither of the Defendants chaenged jurisdiction. The Order granting permission to serve outside the jurisdiction under CPR 6.33 was made on the Caimant s without notice appication in which she reied on the fact that proposed Defendant D1 an Itaian nationa domicied in an EU Member State and proposed Defendant D2 carried on business in Begium and London, both EU Member States, where the caim was one in which the court had power to determine the case under the Judgments Reguation. In the without notice appication the Caimant reied on the fact that D2 advertises and soicits business and hods cinics in this country; the contract was written in Engish and concuded in Engand and payment for surgery was made in Stering. Additionay D2 promoted the fact that D1 was one of their GMC registered surgeons performing operations at their cinic, many of whom were isted on the Speciaist Register for Pastic Surgery. The caim was peaded in contract and tort. Taking the two European Conventions to which the UK is party, the Brusses and Lugano Conventions, there are presumptions first, that a Defendant shoud be sued in the State where a tort occurred and second, that he shoud be sued in his own Member State. Whereas RTAs and other accidents abroad may be caught by this, medica tourists wi normay have entered into a contract with the foreign cinic and under EU consumer contract rues can eect to sue in their home court rather than in the country where the surgery was carried out. As we as the absence of a jurisdiction cause the Defendants had made no reference to appicabe aw in any choice of aw cause by which many foreign cinics stipuate that the aw of their home country is to be appied in determining any caim against them. We peaded that Engish Law shoud be appied and this was not chaenged. Had this been contested the Private Internationa Law (Misceaneous Provisions) Act 1995 woud have been reevant for the purposes of deciding appicabe aw. This estabishes the genera rue under Section 11 of the Act that the appicabe aw wi be that of the country in which the events constituting the tort occured. Where eements of those events occur in different countries the appicabe aw in a persona injury action is taken to be the aw of the country where the individua was when he suffered his injury. The genera rue as to choice of appicabe aw may be dispaced in accordance with Section 12 if it can be estabished in a the circumstances that it is substantiay more appropriate for the appicabe aw to be the aw of, in this context, the patient s home country. This invoves identifying factors connecting the tort to Engand and comparing the significance of the factors pointing either way (substantiay more appropriate). Had the Defendants sought to argue these issues the Caimant was assisted by the fact that she coud rey on the EU consumer contract provisions. D2 did not seek to chaenge the Order granting permission to serve outside the jurisdiction and we did not face any forum non conveniens arguments proposing Begium as a more appropriate aternative forum. Summary Genera Damages: 30,000 pus interest 113,148.96 Specia Damages: 71,671.06 pus interest 8,808.37 Date of Assessment: 2 March 2012 Tota Award: 113,148.96 Negigent Biatera Faceift and Biatera upper and ower eyeid surgery carried out by D1 at D2 s Brusses cinic. Medica tourism (or Medica Trave) Medica tourism, where patients trave for medica treatment from their home or source country to another, the destination country, has become a rapidy growing goba phenomenon but remains a itte understood sector, certainy in the UK. It is not a new phenomenon. Footbaers and other top athetes in the UK have traveed abroad for many years to see AvMA Medica & Lega Journa, Voume 18 Number 3, May 2012 by SAGE Pubications Ltd, A rights reserved. Laurence Vick 199

APPENDIX 17 eading surgeons to keep their careers on track. Patients are now traveing abroad for a much wider range of treatment. With an estimated 49 miion Americans disenfranchised by their heathcare system and many forms of treatment excuded from cover much of the iterature and data comes from the US where medica tourism is big business. This is changing here. Medica journas have been pubishing papers on the topic and more is being done to understand the impact of medica tourism on the heathcare services of both home and destination countries. Many countries across the word, supported by their governments, promote the avaiabiity of a wide range of eective, often compex, forms of medica treatment incuding cosmetic, denta, bariatric, infertiity, stem ce therapy, ophthamic, cardiac, orthopaedic and other surgery to overseas patients attracted by ow costs and the high standards of care described in promotiona materia and websites. The term medica tourism does not accuratey refect the intentions of most patients or the sophisticated medica treatment avaiabe in these destinations; the recreationa vaue of traveing abroad is of imited importance to patients with compex medica probems - medica trave is the term preferred by many commentators incuding the WHO. A government-funded NIHR University of York-ed study into medica tourism and the economic impications of inward and outward medica tourism for the NHS is due to report ater this year after an 18 month investigation. The other side of the coin is that the NHS receives significant sums from in-bound medica tourists traveing to the UK for treatment at our eading hospitas. This is ikey to increase when the current 2% cap on the amount NHS trusts are permitted to receive from treating private patients is increased to 49%. This study wi aso gain a deeper understanding of the cost to the NHS of rectifying faied surgery carried out at foreign cinics Because of the way in which cinics and agents market their services there is a tendency to down-pay the risks of surgery in their promotiona materia which is aimed to persuade the woud-be medica tourist. Many patients, particuary those seeking cosmetic surgery or weight-oss surgery have unreaistic expectations and may aow the prospect of undergoing treatment in a sunny foreign ocation overcome their judgment. Athough this is stating the obvious, care needs to be taken by cinics to manage these expectations and ensure that patients understand the nature of the treatment they are undergoing and the risks they face. When these operations go wrong they have the potentia to go very wrong and the experience can be deepy traumatic for the patient. Medica tourism patients cross internationa boundaries and the jurisdiction issues can be a minefied for the patient s awyer. Foreign cinics may not appreciate that if they target patients in other countries they can be sued in the patient s jurisdiction. No two countries appear to have the same aws and procedures - time imits are different, some countries have damages caps or award damages on a tariff basis. Securing jurisdiction in the patients home country has obvious advantages for the patient but any judgment sti has to be enforced and turned in to cash within the cinic s jurisdiction. Aternativey, if proceedings are brought in Engand, the cinic s iabiity insurance - if it has any - must cover what to the cinic is a judgment from a foreign jurisdiction. Issues over the system of aw to be appied to the case even if jurisdiction is secured in the patient s home jurisdiction adds to the compications. Care needs to be taken because of the different imitation periods throughout the EU. When deciding appicabe aw our Courts wi generay appy the aw of the foreign cinic s country to the substantive eements of the case but our own aw to the procedura eements. The duty of care and standard of care are unikey to differ greaty from one country to another but our Court may decide that the foreign aw governs the imitation period to be appied. Many countries have shorter imitation periods than our 3 years: Spain one year, Sovakia Cyprus Poand and Denmark 2 years and some countries do not recognise the concept of a continuing tort or do not extend the commencement of the running of time to refect date of knowedge. Few EU countries appear to have the equivaent of a Section 33 discretion procedure to disappy their imitation periods. If in doubt on the reevant period and whether time runs from the initia surgery or any subsequent treatment the patient may have no option but to pursue a caim in the foreign cinic s jurisdiction. The cacuation of damages and heads of caim under which damages can be caimed wi generay be regarded as procedura and our own aw wi appy. This is going to be reevant if the foreign jurisdiction (the Caimant is seeking to avoid) awards damages on a tariff basis or if damage awards in that jurisdiction are subject to a cap. It may be necessary to seek advice from a cinica negigence awyer in the foreign jurisdiction to be sure of the imitation position and how the foreign jurisdiction deas with date of knowedge and continuing tort. Despite offering the package of care to the patient cinics may seek to divert bame to surgeons with whom the patient had no contract. Key issues raised by medica tourism Accreditation Estabishing the record of a surgeon, hospita unit or cinic is difficut enough in the UK, NHS or private. Ten years post-kennedy the record of our paediatric cardiac units can ony be obtained by means of FOI appications and morbidity resuts for many NHS operations are impossibe to obtain. Researching the record of a surgeon or cinic operating in a foreign country s private heath sector is even more difficut. Much of the treatment avaiabe at foreign cinics is going to be of a high standard. The fundamenta probem is that foreign cinics market their services with great ski and it is difficut to test these advertisements and estabish the record of a cinic and the surgeons they empoy or sub-contract. Foreign cinics have gone some way to address this by means of accreditation schemes. Over 400 hospitas in 39 countries have been accredited by the US JCI body (Joint Commission Internationa), a ten-fod increase over the numbers in 2004. Accreditation is not a famiiar concept in the 200 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 UK but we may see simiar schemes when private heath companies seek to demonstrate their abiity to deiver safe heathcare as the current fragmentation of the NHS continues. Reguatory issues There is a ack of any uniform internationa approach to the reguation and approva of medica devices that might be used by foreign cinics and medica tourists are vunerabe to the different regimes in destination countries with ess stringent reguation. The recent scanda over PIP breast impants where the manufacturers used industria instead of medica-grade siicone to cut costs has demonstrated that reguatory standards in the UK and esewhere in Europe are ower than in the US where the FDA generay imposes stringent requirements for the approva of medica devices. The German reguator faied to uncover the probems at the PIP factory in France. There has been imited coection of data on impants and medica devices across Europe. The scanda over DePuy Articuar Surface Repacement (ASR) bone-on-bone hip impants has aso highighted varying approaches between different countries. Ethics Medica tourism raises many difficut ethica as we as compex ega issues. The impact of medica tourism on the heathcare services of destination countries is an important issue and the concern is that countries keen to attract medica tourists may provide a better service or better faciities to medica traveers than to their own nationas and doctors may be ured away from oca hospitas to state of the art hospitas buit for weathy foreign patients. A major patient-protection concern is that some forms of treatment may be unproven or regarded as experimenta or even, in the case of femae genita surgery for exampe, iega in the UK but readiy avaiabe in certain medica tourism destinations. Stem ce treatment has no goba reguatory framework or agreed internationa framework but many forms of treatment are avaiabe at foreign cinics. Reproductive or fertiity tourism - traveing abroad for assisted conception - is becoming increasingy common and increasing numbers of coupes trave abroad to access assisted reproductive technoogy and surrogacy programmes. In addition to the highy compex ega issues there are significant risks associated with internationa surrogacy. Commercia surrogacy is prohibited in the UK on poicy grounds. The Hague Conference on Private Internationa Chidren Law has identified surrogacy as a pressing socioega probem and is investigating ways of reguating surrogacy internationay. Medica tourists traveing abroad are at risk of infections and may present a pubic heath threat on their return. The effect of reports in 2011 of the NDM-1 and other superbugs resistant to antibiotics is not known but this is aso a potentia hazard faced by the medica tourist. Medica tourism can have a distincty ugy side. There is reported to be a booming market in human organs from iving and dead donors for transpant surgery. Goba demand for organs far exceeds the avaiabe suppy. 50 100,000 Americans are said to be on waiting ists for various organs in the US where ess than 15,000 donors are found each year. China is reported to carry out 10,000 organ transpants annuay. Unti recenty this was unreguated and the Chinese government has admitted that in the past some organs have come from executed prisoners. EU The EU Directive on Cross Border Heathcare Europe, in pace by 2013, wi see patients reimbursed by their home State for the cost of treatment received in other EU countries. The Directive requires that a EU Member States provide transparency about their range of services, prices and quaity of treatment. The jurisdictiona aspects of overseas medica treatment are highy compex. The cinic may have inserted jurisdiction and appicabe aw causes in their contracts. Barriers to caiming compensation may be insurmountabe. These ega hurdes and the difficuties faced by patients needing corrective treatment and continuity of care - with a cear route to obtain redress if things go wrong - must be resoved if medica tourism is to expand and truy form an additiona tier in the provision of heathcare avaiabe to patients in the UK. Concusion Medica tourism may we be anathema to Caimant awyers and patient support groups but some patients wi trave abroad to take advantage of ow costs and exercise freedom of choice whatever the risks invoved. Can we bame a patient who traves abroad for gastric band surgery currenty advertised for just over 3000 incuding 2 nights hote accommodation for patient and companion and the option of foow-up care (at extra cost) on return to the UK - compared with 7 8,000 at a private cinic in the UK? This operation might be subject to a 2 3 year NHS waiting ist or coud be unavaiabe on the NHS because their BMI criteria have not been met. Or coupes who seek fertiity procedures unavaiabe in the UK at overseas cinics promoting the fact that they compy with ESHRE (European Society of Human Reproduction and Embryoogy) cross-border reproductive care standards? It is essentia for the medica tourist to take out a medica trave insurance poicy avaiabe from a speciaist provider even if it does not cover a conceivabe eventuaities and consequences. Gaining an accurate understanding of the extent of the current medica tourism market in the UK is not easy but this is an industry that is amost certainy going to expand here, if not at the highy optimistic eves predicted by some commentators. AvMA Medica & Lega Journa, Voume 18 Number 3, May 2012 by SAGE Pubications Ltd, A rights reserved. Laurence Vick 201

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 Appendix 18 Detaied methods for website review and checkists for denta and bariatric surgery websites Drawing on previous studies we used (on 20 January 2012) the most popuar search engine, Googe 165,242 to search for both denta and weight oss surgery offered abroad. Evidence suggests that interested searchers are unikey to trave beyond the first page of a search engine. 165,170,242 As such, we imited the search to the first three pages of returns for what we identified as our major search terms; additiona terms were searched to the first page ony. We aso foowed the sponsored advertisements that appear at the top of a Googe search page as we as any advertisement banners that appear on the right-hand-side of the search return page. In addition, we foowed a sampe of inks from any porta website that appeared in the first page of returns. Our search of denta websites consisted of the foowing major search terms: denta surgery, denta surgery abroad and dentist abroad. These returned a high number of reevant sites athough there was much overap. We suppemented these terms with further ay searches such as denta impant, denta impant abroad, crowns abroad and teeth whitening as we as perhaps more technica searches such as veneers, cosmetic dentistry and cosmetic dentistry prices. With regard to weight oss websites we searched using the foowing major ay search terms: weight oss surgery, obesity surgery and bariatric surgery. These ay terms produced a high number of returns and these, aongside our informed understanding of the onine community surrounding weight oss treatment, ed us to suppement these ay terms with a sma number of more technica searches. These were gastric bypass, ap band, gastric band, VSG (vertica seeve gastrectomy) and gastric baoon. For both topics search terms were entered as isted here and then subsequenty with the terms abroad, Asia and Europe after each term. This approach mirrored previous studies that focused on the quaity of information on the web pertaining to cosmetic surgery 89 and oncoogy information. 169 Sites that were returned were incuded in our two 50-site sampes if they satisfied the criteria of being active (had been updated recenty), offering surgery abroad directy through the website and not being an extension of a website that had aready been incuded. This means that we have used portas to access other websites but that the portas have not formed part of our sampe. As a fina check regarding the robustness of our samping strategy the major search terms were entered into the search engines Bing, Yahoo and Ata Vista ; we found that the majority of our sites, incuding a those that appeared on page 1 in Googe, were found in the first three pages of these aternative search engines returns. Overa, our denta sampe consisted of four sites that were accessed through portas returned by the Googe search, eight that were not returned in the Googe search but which were foowed through the banners on the right-hand side of the page and three that were simiary accessed through adverts at the top of the Googe return. The remaining 35 sites were isted in the Googe returns athough there were a sma number of these that aso appeared either in a porta or as a banner. Of the 50 websites searched, ony one did not work, dispaying a home page with broken inks. For the 49 remaining websites, four were found to provide answers to two or ess of the questions used to interrogate the sites. Our bariatric sampe consisted of 28 sites returned by the Googe search, 13 sites soey from portas that were returned by Googe, six sites that were accessed soey by foowing right-hand banners and three sites that were advertised at the top of the Googe returns pages. A sma number of the 28 sites coud aso be found as adverts, banners or through portas. Three sites were no onger working when they came to be reviewed. In our combined sampe a wide range of destinations was covered, athough Hungary was easiy the most frequenty advertised denta destination and Begium was advertised by the argest number of weight oss tourism sites. The overa visua impact and content of sites varied widey. Most were professiona, Queen s Printer and Controer of HMSO 2014. 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. 203

APPENDIX 18 attractive and we designed with auring images of beauty, heath and vitaity; a sma number, however, were extremey basic and did not refect advanced web design and marketing techniques and practices. The major assessment invoved the utiisation of two simiar, athough not identica, cinica checkists. The checkists were adapted from a series of simiar checkists aimed at assessing the quaity of information pertaining to other cinica areas such as cosmetic surgery (NaTHNaC, 236 NHS Choices, 235 GDC 243 ) before being finaised with the hep of denta and bariatric experts. We aso suppemented these cinica checkists with a quaitative assessment of the non-cinica quaity of the websites. Here, the HONcode [Heath on the Net (HON) Code of Conduct for Medica and Heath Web sites] 244 was extremey usefu, providing us with a patform to assess how accessibe, accurate and authoritative the websites are (see Meric et a., 245 Lunt and Carrera 89 and Khazaa et a. 246 ). Athough the checkists differed sighty for our two treatment types, both sought to estabish the quaity of information pertaining to four main categories: the cinicians, the cinic, reguation and aftercare. Having deveoped the respective ists of criteria against which to judge our sampes of sites, roes were divided within the five-person research team. Two members of the team performed the initia assessment of the denta websites against our checkist whie at the same time noting any interesting features of the websites according to the HONcode and broader quaitative refections. This process was aso undertaken for our weight oss sites by two other members of the research team. After competion, the two research teams swapped sampes and as part of a moderation exercise any variations were expored. As a fina check, a fifth member of the research team assessed a random sampe of the sites and, again, any disparities were discussed and addressed. Such procedures extend those adopted in simiar methodoogies 165,171 in an attempt to avoid many of the imitations acknowedged by Meric et a. 245 Denta tourism websites Cinicians I. Is the denta practitioner named? II. Are denta quaifications isted? III. Is the denta practitioner a speciaist? Cinic IV. Does the practitioner speak Engish/have transation? V. Is the cinic equipped for medica emergencies? VI. Are there any side effects or risks associated with the procedure? VII. Who wi be responsibe for any cinica faiures and their costs? Reguation VIII. Who is the practitioner s reguatory body? IX. Does both the practitioner and the cinic have professiona indemnity cover? X. Does the cinic have a compaints procedure? Aftercare XI. Wi I be given a copy of my denta records on competion? XII. What continuing care wi be required? XIII. What is the overa cost of the procedure? 204 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 Bariatric tourism websites Cinicians I. How many years practising? II. Experience of performing procedure (number given)? III. Opportunity of preoperative consutation (UK)? IV. Quaifications/organisations isted? Cinic V. Engish-speaking surgeon/cinic (medica notes)? VI. Faciities and back-up (e.g. how woud the cinic dea with an emergency if serious compications were to arise during the procedure)? VII. Are there any side effects or risks associated with the procedure? VIII. What are the rates of success, compications and infection? IX. Who wi sort out compications (and pay, etc.)? Reguation X. Is there a body that reguates the cinic or practice? XI. Does the cinic/operator have the correct medica indemnity in pace shoud anything go wrong with the procedure? Aftercare XII. What type of care wi I need after the treatment? Who wi provide check-ups in the UK? XIII. Who can I contact for advice once I m back in the UK? XIV. Overa cost of the treatment? Queen s Printer and Controer of HMSO 2014. 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. 205

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 Appendix 19 Detaied anaysis of website review data Cinician detais Websites were interrogated whether or not they provided detais regarding the experience, quaifications and professiona memberships of cinicians. The bariatric surgery websites were aso investigated to assess whether a preoperative consutation was possibe. Of the denta sites, 35 (70%) provided varying degrees of information about the cinicians empoyed within surgeries. Of these, a named the denta practitioners and 31 gave detais of the dentists quaifications, often a fu curricuum vitae of quaifications and experience. These numbers were ower in the bariatric surgery sampe, with 25 (50%) sites giving some cinician information, mosty pertaining to how ong a cinician had been practising and his or her quaifications. However, in both sampes the provision of information was not uniform. Some sites simpy stated the institution and year of quaification; in comparison, other sites provide extensive detais on cinicians credentias, incuding certification and current membership of professiona bodies. Many websites (31 in tota) enabed potentia cients to ascertain whether a dentist is a speciaist and, if so, in what area, whereas ony 12 weight oss sites aowed viewers to estabish how many and what type of procedures cinicians had undertaken and ony one site reported the treatment success rate of an individua cinician. In addition, ony nine sites dispayed any information pertaining to the possibiity of preoperative consutation for bariatric treatment. As Exworthy et a. 186 note, for pubic heath care the named cinician is not aways the person who does the procedure; however, it shoud signify that he or she supervises junior staff performing much of the routine work. Cinics The majority of websites incude photographs of the staff and the cinic, aong with videos and even virtua tours of the faciities avaiabe. However, a number of the photographs appeared somewhat random and unreated to dentistry or bariatric surgery and many were dupicated in different sections of the site or even on different websites (perhaps refecting the interests of website buiders). There were few sites giving exact detais on the number of dentists empoyed or the number of treatment rooms. For some, UK media coverage that they had received was seen as a major asset. The most sophisticated websites beonged to arge one-stop cinics that provided denta, cosmetic and weight oss treatments amongst others. Most denta websites were aestheticay strong; however, many websites for sma weight oss cinics in Western Europe were itte more than an eectronic fyer hosted on the internet. Assessing whether Engish was spoken at the cinics, either by the cinicians or by the support staff, was not straightforward. Of our denta sampe, 29 (58%) stated that their cinicians speak Engish and often other anguages (mosty German and French), whereas ony 16 (32%) weight oss sites made the same caim. However, a of the websites accessed were written in Engish and there was an impicit suggestion that, when information was presented in Engish, cients coud assume that communication woud not be a probem. That said, the grammar and speing were poor on a number of sites, which is unikey to reassure potentia patients of the cinic that cinicians have the abiity to communicate proficienty in Engish. Roughy haf of a sites quoted prices, athough these ranged from a sampe offer price to a fu breakdown of prices for a services. However, a sites did carry a caveat that the fina price woud depend on persona circumstances and treatment pan. Very few websites acknowedge the possibiity of something going wrong during treatment and it is therefore unsurprising that ony two of the 50 denta websites expicity said that their cinic was equipped for medica emergencies. Athough weight oss sites were generay better at discussing possibe side Queen s Printer and Controer of HMSO 2014. 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. 207

APPENDIX 19 effects and risks, ony 21 of the 47 working sites addressed the issue of risk and ony four sites had any statistics pertaining to success rates. When risk was addressed it was often downpayed and, despite many forms of bariatric surgery invoving compicated, risk-aden procedures, ony three weight oss sites provided detais of what woud happen shoud anything go wrong. Athough it may be unsurprising that ony two denta cinics advertised their access or proximity to emergency faciities, ony four weight oss cinics advertised such faciities, which seems remarkaby ow. It can aso be extremey difficut for a prospective cient to work out who woud be hed responsibe if something does go wrong, with ony three weight oss sites discussing who woud be responsibe for any cinica faiures and their costs. The issue of responsibiity and guarantees highights a major difference between the denta sites and the bariatric sites. Athough none of the websites expicity state that they wi be responsibe for cinica faiures and any associated costs, 31 denta sites provide some form of guarantee for the denta treatment that their cinic or dentist provides. These guarantees vary for different types of treatment and are often tied to the marketing of a particuar brand. Athough a guarantees are repete with an extensive ist of conditions and exemption causes, the existence of such guarantees is a potentia source of comfort to prospective denta tourists that is not offered by any weight oss site. Reguation and quaity There are aso substantia differences between the two sampes with regard to the issue of reguation. In tota, 17 denta sites mentioned a reguatory body either that their practitioners are registered with or whose standards they adhere to; however, no weight oss sites provided such detais. Simiary, no weight oss sites provided information regarding medica indemnity to cover cases in which compications arise. Athough denta sites did have more information regarding reguation, it is undoubtedy difficut for a ay audience to assess what the varied forms of reguation mean and how rigorous the standards are. Interestingy, even when a number of cinics operate in the same country, they cite different reguatory bodies and authorities. Denta sites frequenty make statements pertaining to being reguated but do not carify the precise detais. For exampe, one website states that it is a fuy accredited British Denta Practice Abroad, whereas another caims to conform to and often exceed a the most stringent of EU reguations and requirements. There were aso 10 websites which decared that they compy with ISO standards and two mention adhering to a commercia provider s Code of Practice. Aftercare and foow-up On the whoe, websites provide very itte detai about any aftercare services that may be required foowing the initia treatment. Tweve denta websites made some form of reference to aftercare; for eight of these it is simpy to state that check-ups are avaiabe in their London cinic at extra cost. Ony six weight oss websites directy address issues of aftercare and continuation of advice and care, athough when advice was offered it was often detaied. One website even offered an aftercare ony package in the UK for those who had traveed for weight oss surgery abroad. The ack of discussion regarding aftercare is perhaps unsurprising given the rather meagre discussion of risks, side effects and compications. Overa, sites sought to convey a sense of popping overseas for a treatment hoiday, something one site referred to as tweakending. 208 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 Appendix 20 Anaysis of guidance avaiabe for medica tourism Professiona and consumer A number of different professiona and consumer organisations provide information, advice and guidance for prospective medica tourists. For both of these types of organisations there were overaps concerning advice about choosing a private provider in the UK and generic trave advice. The Roya Coeges did not appear to provide any form of information, advice and guidance on aspects of medica tourism. How thorough the websites were in covering the core issues varied consideraby. Common across a types of organisation and information, advice and guidance was the need to inform patients about the norma risks associated with treatment, especiay surgery, and the potentia heightened risks if traveing abroad, incuding issues such as compications arising from the actua trave. There was aso an emphasis on standards abroad differing from those in the UK and the potentia risks from infection and transmission of disease. Patients are aso consistenty advised to find out certain information from the medica tourism provider before traveing, such as the quaifications and experience of staff; success, infection and mortaity rates; and aftercare arrangements. However, beyond this the information, advice and guidance varies and there are a number of issues that are covered by ony a few websites. For exampe, ony one website specificay addresses the ega situation in terms of redress if things go wrong (Which?). Consequenty, uness a potentia medica tourist has consuted this site, they may be unikey to have considered, or be aware of, the inherent chaenges in seeking redress. The Which? site aso advises of the need to exercise caution over money transactions, who you arrange your treatment with and their iabiity to you (the cinic or broker). Furthermore, ony three websites advise about the difficuties of securing trave and medica insurance covering treatment abroad. Communication probems, especiay anguage differences, are aso mentioned rarey. One of the most dependabe sources of information, advice and guidance is the NHS Choices website, which has distinct sections for different types of treatment and a very usefu Questions to ask the Surgeon or Dentist section. Aong with a number of other agencies, such as the NaTHNaC, the website emphasises the importance of consuting with your oca GP or dentist first. The importance of researching your chosen treatment, cinic and surgeon and having a consutation before deciding on treatment are stressed across the sectors. A number of websites point out that, athough outay costs for treatment abroad may be cheaper than those for treatment in the UK, the patient is responsibe for covering costs if things go wrong, which coud be substantiay more. Generay, warnings about reguatory differences are not easy to find, with ony vague inferences on sites that things may be different abroad. Reated to this, it appears that ony NaTHNaC mentions EQA in a ist provided of internationa accreditation schemes. Sector-specific information, advice and guidance As we as generic information, advice and guidance for medica trave overseas, there is aso more speciaist treatment provision advice. This is particuary the case for fertiity treatment with the reguatory body in the UK (the HFEA) providing very thorough information, advice and guidance and a checkist for prospective fertiity tourists, aong with the guideines that they adhere to. The HFEA covers a number of issues, incuding mutipe birth rates; egisation and ega, socia and ethica impications; donor and surrogacy issues; counseing and support; and the management of patient data. As a resut, those Queen s Printer and Controer of HMSO 2014. 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. 209

APPENDIX 20 traveers who consut the website are more ikey to be better informed and to ask the right questions of the provider. However, this is not the case for other forms of treatment, incuding cosmetic and denta treatment. These other sectors provide generic information, advice and guidance that is pertinent to a medica tourists. Professiona bodies speciaising in cosmetic surgery do emphasise consumer safety, in particuar warning against the hoiday se and tweakender rhetoric, highighting that a surgery carries risks, is ikey to be painfu afterwards and requires some form of aftercare. 210 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 Appendix 21 Background context for externa quaity assessment Terminoogy There is a great dea of compexity when exporing EQA, incuding terminoogy. For exampe, the term accreditation has a number of different meanings. Historicay, the origina use of the term accreditation in heath care reated to training programmes. More recenty, it has come to be accepted as meaning the recognition of competent assessors, such as the ISO and the EU. 247 However, in the vocabuary of the ISO, hospita accreditation is actuay caed certification. This in turn woud mean that a hospita had met defined requirements, verified by an independent auditor (Chares Shaw and Pau Stennett, 2012; persona communication). Lack of standardisation A second compication arises with the ack of standardisation across accreditors. 248 Athough standards are reasonaby considered to be a eve of achievement, a benchmark for comparison or a requirement of reguation, they vary both across and within countries. An American organisation, ISO is aso reguated in Europe and provides standards for organisations to be measured against for accreditation or certification purposes. Originay focusing on quaity management systems for manufacturing, the ISO 9000 series of standards has been extended to assess hospitas and other medica providers. Standards that materiaise at a nationa eve can be incorporated at regiona eves, but uness adopted by government they carry no ega weight. For exampe, the British Standard (BS) 5750 on quaity systems was adopted as European Norm (EN) 29000 and then internationay as ISO 9000 (Chares Shaw and Pau Stennett, 2012; persona communication). Athough ISO 9001:2000 is considered to be an exceent heath-care quaity management too, it differs from hospita accreditation, which tends to have a strong cinica dimension. 182 The Internationa Society for Quaity in Heathcare (ISQua) aso pays a key roe in this area, assessing externa heath-care organisations against pubished standards. In addition, it promotes and benchmarks heath-care standards and organisations. Here, heath-care accreditation of a provider organisation (termed certification by the ISO) incudes peer review assessment against these standards, which have been specificay designed. 249 In 2010 there were 46 nationa heath-care accreditation organisations operating around the word. 250 EQA thus varies across and within countries, with a range of badges being used and no consistency in terms of standards, assessment or reguation. Seective coverage A third compication is that hospita accreditation is by no means universa across Europe (or more gobay) and there is a very unequa distribution of take-up across countries. For exampe, 100% of eigibe hospitas in France (780 hospitas) participate in nationay avaiabe programmes in comparison to < 15% in Spain (four hospitas). There are aso questions about the motivations of institutions for pursuing accreditation. Shaw et a. 250 found that, athough quaity improvement was identified by schemes as the key motivator for hospitas to seek accreditation, there were aso a number of other incentives. Medica tourism was an incentive for > 27% of accrediting organisations, aong with marketing for 50% and as a ega requirement for 34%. The question thus arises as to what and whose interests do forms of EQA serve. Queen s Printer and Controer of HMSO 2014. 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. 211

APPENDIX 21 Vaue of forms of externa quaity assessment There are debates about the precise vaue of accreditation/certification. 183,251 In their investigation of accreditation and ISO certification in Europe, Shaw et a. 247 found that, of the participating hospitas, those with either accreditation or certification were safer and better than those with neither. However, they aso found that accredited hospitas consistenty appeared to score higher on measures of hospita management, patient safety and cinica organisation and practice than hospitas with ISO certification. Despite this, there is some debate over the vaue of accreditation and the evidence to support caims of its importance as an EQA method. As Braithwaite et a. 252 have highighted, empirica evidence to sustain many caims about the benefits of accreditation is currenty acking (p. 8). Indeed, in a ater systematic review of heath sector accreditation research, Greenfied and Braithwaite 253 concuded that accreditation was consistenty having a positive impact in ony 2 of 10 categories (promoting change and professiona deveopment). Cost and affordabiity A further chaenge facing accreditation is how internationay accessibe and affordabe it is. Accreditation schemes often come with an expensive price tag, often prohibitivey so for providers in deveoping countries, especiay smaer ones. In addition, the commercia aims of the scheme may overshadow the purpose of the process. Very few accreditation schemes openy pubish information about their charges and associated expenses on their websites. The 2003 study by Mihaik et a., 254 which anaysed the costs of the Nationa Committee for Quaity Assurance accreditation process, estimated an annua cost of around 400,000 a year for participation in the accreditation process for a typica, medium-sized US-based organisation. The USA s JCI pubishes an average accreditation survey cost of 29,700, and an expanation of additiona costs, incuding onsite costs for the team (trave, accommodation, food), preparation and other consutations. 255 With members in over 70 countries, the JCI is one organisation accredited by ISQua. 253 Research undertaken in Juy 2011 found that the JCI had conducted 90% of a internationa accreditations, with the tota number of JCI hospitas reaching 329. 256 Non-enforceabe standards and guidance A number of other organisations internationay issue standards and guidance, athough without cear methods of enforcement. For exampe, the Word Heath Organization issues both genera guidance on heath care and aso documents on specific issues such as safe surgery. 252 Within Europe there are a number of exampes of attempts to harmonise standards in the medica fied by the EU, incuding for professiona training and cinica practice. Despite there being no standardised system for quaity and safety, efforts have been made to share best practice, such as through the European network for Heath Technoogy Assessment (EUnetHTA) and the European Network for Patient Safety (EUNetPaS) project. 249 Vountary and commercia initiatives Outside of forma EQA and accreditation, vountary and commercia schemes exist in which providers sign up to codes of practice or become partners of other organisations. Many medica tourism faciities and faciitators state that they adhere to commercia codes of practice. Caiming to be a partner of another organisation is aso common, athough this is aso a grey area in terms of how this partnership heps ensure the quaity and safety of the actua provider. 212 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 Statutory reguation In addition to accreditation and certification, a countries have some form of inspectorate for heath services that provides a minimum eve of reguation for both pubic and private sector providers. In the UK, the CQC reguates faciities whereas the GMC reguates standards for the practice of medicine. In addition, there are a number of bodies that provide and promote standards and training within speciaist areas, such as the Roya Coeges (Surgeons, Psychiatrists, GPs). A RAND 185 study found that the structure, remit and vaues of medica reguation vary significanty between different countries. For exampe, some countries have a unitary state-authorised reguator (such as the UK in medicine and dentistry), whereas others have decentraised poycentric systems, such as Spain, where different bodies and processes exist depending on the region. The Heath & Care Professions Counci (the UK body responsibe for keeping a register of heath and care professionas) hosts a searchabe onine database of heath reguators and professiona bodies for heath professionas (see www.hpc-uk.org/). A wide range of countries and speciaisms are incuded with inks referring individuas to (typicay non-engish) websites. Queen s Printer and Controer of HMSO 2014. 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. 213

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 Appendix 22 Anaysis of externa quaity assessment statements on websites Denta cinics externa quaity assessment The different credentias can be categorised into: ISO standards, e.g. ISO 9001 nationa reguations, e.g. GDC (UK) domestic professiona associations, e.g. British Academy of Cosmetic Dentistry accreditation organisations/companies, e.g. Technica Inspection Association (TÜV) vountary associations and codes of practice those remaining, as other. Ten websites identified some form of ISO certification, usuay ISO 9001, athough not a dispayed detais. Ony one other accrediting body was mentioned, TÜV, with two sites caiming accreditation. The majority of websites detaied some form of nationa reguation. Unsurprisingy, given the proiferation of Hungarian denta providers, the most commony cited were the Hungarian Chamber of Dentists and the Hungarian Medica Chamber, which incidentay oversees the former. The UK GDC was aso mentioned by two websites in recognition of the need to be registered (with the GDC) to hod consutations in the UK. However, no expanation is given to highight that its reguation extends ony to those practising on British soi. Other nationa reguatory bodies incuded the Romanian Denta Counci and the Ministry of Heath of the Czech Repubic. Websites aso caimed some form of affiiation to a domestic professiona association within the home country, usuay some form of Hungarian Denta Academy (athough these caims are typicay inaccessibe for consumers who search in Engish). Four websites caimed some form of British registration, athough this ranged from credibe (GDC) to unverifiabe through onine Engish searches ( British Denta Practice Abroad ). Further non-verifiabe caims incuded being a member of the Cosmetic Dentistry Guide. Two further European vountary associations were aso mentioned by singe websites: the European Denta Association and the European Association of Cosmetic Dentistry. A further two dispayed Treatment Abroad Code of Practice abes but with no detai as to what this invoved (see fu ist in tabe beow). The ack of expanation for prospective tourists about the differences between accreditation, certification and nationa reguation, and the faiure to provide any detais of what any of these mean, render assessment of a denta cinic s credentias particuary difficut. Queen s Printer and Controer of HMSO 2014. 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. 215

APPENDIX 22 ISO standards Domestic professiona associations Vountary associations (Europe and other) Nationa reguation Accreditation organisation/ company Other ISO 9001 ISO 9001:2000 Academy of Leading Hungarian Denta Cinics British Academy of Cosmetic Dentistry Hungarian Academy of Aesthetic Dentistry Treatment Abroad Code of Practice European Association of Cosmetic Dentistry European Denta Association Romanian Denta Counci Ministry of Heath of the Czech Repubic Hungarian Chamber of Dentists Hungarian Medica Chamber UK GDC TÜV German, aso certificates ISO British Denta Practice Abroad not found onine Genera Medica Office not found onine GDC of Hungary not found onine Bariatric cinics externa quaity assessment Overa, 23 different types of credentias were mentioned. However, seven of those were US specific and were on one American website. Here, extensive detais of the seven credentias were provided with a brief expanation and some inks to the source of the accreditation [e.g. the American Coege of Surgeons: Leve 1A Accredited Bariatric Center, Adut and Pediatric (15 years and above)]. Once again, ISO certification was strongy evident, with nine providers caiming to meet one of their standards, incuding ISO 9001, ISO 15189, ISO 14001 and ISO 13001. Five websites caimed either certification or partnership with Treatment Abroad or the Medica Tourism Association. Two websites caimed HON certification; however, HON no onger offers certification for medica tourism sites. A further two dispayed a Better Business Bureau rating. Five cinics dispayed a connection with domestic professiona associations, incuding the Czech Obesity Society and the Indian Association of Gastrointestina Endosurgeons. Three websites caimed professiona registration with the GMC, the nationa reguating body in the UK, but again faied to highight that the GMC s reguation extends ony as far as the British borders. A arge number of cinics caimed some form of professiona aegiance to or partnerships with institutions incuding Apoo Hospitas, Harvard Medica Schoo and Wordwide Medica Partners. It was rare for precise detais of the arrangements to be provided beyond a symbo demonstrating the affiiation. Other individuay cited memberships incuded the GLC and the FEQH (Forum for Enhancement of Quaity in Heathcare) quaity certificates, neither of which are traceabe through Engish-based internet searches. Further unverifiabe statements found on some bariatric sites incuded icensed heath care hospita and Our company is British and so we adhere to the reguations of the British Government, with no further detai on what these reguations may be (for fu ist see tabe). 216 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 ISO standards Domestic professiona associations Vountary associations (Europe and other) Nationa reguation Accreditation organisation/ company Other ISO 9001 ISO 13001 ISO 14001 ISO 15189 Czech Obesity Society Czech Bariatric Chapter Association of Gastrointestina Endosurgeons American Society for Bariatric Surgery: Center of Exceence American Coege of Surgeons [Leve 1A Accredited Bariatric Center, Adut and Pediatric (15 years and above)] Internationa Federation for the Surgery of Obesity Anthem Bue Cross and Bue Shied: Bue Distinction Program, Center of Exceence for Bariatric Services Aetna: Aetna Preferred Bariatric Center Network Medica Mutua of Ohio: Medica Mutua of Ohio Center of Exceence for Bariatric Surgery Cigna: Center of Exceence Program for Bariatric Surgery UK GMC Occupationa Heath and Safety Advisory Services (OHSAS 18001) HON code certified 2009/10 Better Business Bureau rating Medica Tourism Association membership Onine Medica Tourism Partner Medica tourism certificate issued by the State of Baja Caifornia FEQH quaity certificate Treatment Abroad member/partner GLC quaity certificate Cosmetic cinics externa quaity assessment Finay, 50 sites anaysed by Lunt and Carrera 89 in their discussion of patient advice and sources of information for decision-making were revisited and anaysed for EQA. Simiar to the bariatric review, a arge range of bodies was cited (46 in tota); however, ony 18 websites provided any detais of accreditation, certification or reguation. As with both the denta and bariatric reviews, ISO certification was identified, with five provider websites citing ISO 9001:2000 and two citing ISO 14001. Membership of domestic professiona associations was most frequenty cited, athough rarey were inks provided to these associations websites. Twenty-one different domestic professiona associations were highighted by the websites, with the Poish Society of Pastic and Reconstructive Surgery the most frequenty cited (by four sites), aong with the American Society for Aesthetic Pastic Surgery (three sites) and the Spanish Society of Pastic, Reconstructive and Aesthetic Surgery (two sites). Membership of internationa vountary associations was aso evident, with four websites caiming membership of the Internationa Society of Aesthetic Pastic Surgery and three caiming aegiance with the Internationa Confederation for Pastic, Reconstructive and Aesthetic Surgery. Nationa reguation through domestic medica councis or chambers was cited infrequenty, with two mentioning the UK GMC. As with both other reviews, a number of other forms of accreditation or certification were caimed with no expanation as to their meaning or why they had been awarded. For exampe, one website caimed that it had received a Sovak God Excusive award and dispayed a god meda symbo. However, it proved impossibe to verify through Engish-anguage internet searches what this was (for fu ist see tabe). Queen s Printer and Controer of HMSO 2014. 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. 217

APPENDIX 22 ISO standards Domestic professiona associations Vountary associations (Europe and other) Nationa reguation Accreditation organisation/ company ISO 9001:2000 ISO 14001 PN-N-18001:2004 Occupationa Heath and Safety Management Certificate ÁNTSZ Hungarian Nationa Pubic Heath and Medica Officer Service MPHEST Hungarian Society for Pastic, Reconstructive and Aesthetic Surgery Poish Society of Pastic and Reconstructive Surgery SSPES Sovak Society of Pastic and Aesthetic Surgery Begian Society for Pastic Surgery Netherands Society for Aesthetic Pastic Surgery French Society for Lipopasty Internationa Confederation for Pastic, Reconstructive and Aesthetic Surgery Internationa society of Aesthetic Pastic Surgery European Academy of Cosmetic Surgery Internationa Federation for Adipose Therapeutics And Science Word Society of Anti-Ageing Medicine American Society for Aesthetic Pastic Surgery European Society of Pastic, Reconstructive and Aesthetic Surgery Czech Repubic Medica Chamber UK GMC Sovak Medica Chamber French Society for Cosmetic Surgery HON code PN-N-18001:2004 Occupationa Heath and Safety Management Certificate Heath Care Surveiance Authority SOF-CPRE French Society of Pastic Reconstructive and Aesthetic Society SETGRA Spanish Society of Fat Transfer Appications European Academy of Facia Pastic Surgery Internationa Coege of Surgeons (Pastic Surgeons) SECPRE Spanish Society of Pastic, Reconstructive and Aesthetic Surgeons SEMAL Spanish Society of Anti-aging Medicine AECEP Spanish Association of Aesthetic Pastic Surgery Croatian Society for Pastic, Reconstructive and Aesthetic Surgery Society of German Otorhinoaryngoogists Society of Croatian Otorhinoaryngoogists Roya Coege of Surgeons of Thaiand (Pastic Surgeons) 218 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 ISO standards Domestic professiona associations Society of Aesthetic Pastic Surgeons of Thaiand Vountary associations (Europe and other) Nationa reguation Accreditation organisation/ company Society of Pastic and Reconstructive Surgeons of Thaiand Thai Society of Cosmetic Dermatoogy and Surgery Internationa member of American Society of Pastic Surgeons Queen s Printer and Controer of HMSO 2014. 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. 219

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 Appendix 23 Interviewee perspectives on patient safety and service quaity Background Stakehoders interviewed differed markedy in their areas of expertise and in their roes with regard to medica traveers. They ranged from GPs who had deat with returning patients medica probems in their surgery to poicy-makers deveoping guidance on patient safety. Despite these differences, a set of key themes and perspectives emerged ceary from the interviews. A number of interviewees based in PCTs identified drivers that encouraged individuas to trave to overseas destinations. These incuded the tightening of eigibiity for services (e.g. the genera unavaiabiity of cosmetic breast surgery paid for by PCTs), a broader consumer orientation and the infuence of advertising: They are seeing what s avaiabe on the sheves and deciding that there s actuay more avaiabe on the sheves of different country (NHS13). Primary care trusts reported receiving a number of treatment requests that were outside their eigibiity criteria and which may prompt private (incuding overseas) treatment as a resut: [We receive] a ot of requests for what we woud consider cosmetic or pastic procedures. Endess requests for breast augmentation or reductions or nips and tucks and abdomina pastics and so forth (NHS9). Across the different groups of actors interviewed, the absence of reiabe data on the scae of outbound medica tourism and on the costs and any probems was highighted. You reay come up against a ot of industry based information but very imited and fast facts about the numbers of peope trying to access heathcare abroad. And obviousy there are discrepancies between industry sources and figures for the UK, for instance, when you ook at the internationa passenger survey data. [...] frustrated not being abe to find good information or reiabe information. PA11 At the same time there was a sense that medica trave and any resuting compications posed potentiay serious issues and were worthy of further attention but that this was not an overwheming chaenge either for the organisations that the interviewees were representing or for the NHS as a whoe. A representative from one of the Roya Coeges summarised: [It] doesn t happen too much I think in the UK. Not that much because actuay most peope don t speak anguages. Most peope don t want to go abroad to have treatment, to be honest. [...] They want to be treated at their oca hospita. PA5 The experience of the NHS in the eary 2000s, which provided patients on waiting ists with the option of traveing under a NHS contract to another European country, was aso cited as reevant to understanding the eve of outbound medica trave and the motivation for it. Queen s Printer and Controer of HMSO 2014. 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. 221

APPENDIX 23 Primary care trust interviewees reported exampes of compications that had occurred after medica tourists returned back to the UK: So we re not infrequenty getting requests from peope to go abroad for surgery or other things. Not infrequenty getting peope coming back from having gone abroad with probems. NHS7 Peope have gone and had a gastric band fitted in Hoand and then come back and had probems and expect the NHS to either pay for that care or to pick up the foow-up care which they re not entited to do NHS6 There were aso said to be subsequent requests for cosmetic surgery to remove excess skin foowing overseas bariatric surgery. However, athough exampes were given (a coupe of bariatric cases in one PCT, a bariatric case and gender reassignment in another), the scae was not overwheming when viewed in the context of PCT activity. A director of pubic heath suggested: The totaity of a this, at east in terms of the stuff that comes back in our direction, is very sma (NHS7). Medica tourists returning with diagnostics was aso mentioned in the case of some minority ethnic cutura groups: I ve heard of ots of peope that are turning up with fies an inch or two thick with ridicuousy over detaied packs of diagnostics for essentiay a dermatoogy condition. Or something which woud be an endoscopy and you ve had fu body scan. NHS6 Many peope trave for treatments that are not avaiabe on the NHS. This was the case for many of the patients interviewed for this research (see Section 3) and aso heps expain the seemingy greater number of providers of eective procedures (especiay denta treatment and cosmetic surgery) and fertiity treatment. A difference in perception of the scae of the issue between professionas working in different medica sectors was ceary evident from the interviews. However, athough compications were not identified as significant (abeit within the sma number of PCTs that we spoke to), what was aso cear was the absence of a cear mechanism for recording such compications (e.g. to identify patterns): Nobody woud come back [to the PCT] because that woud be taken care of in primary care generay or even if it need[ed] secondary care, they woudn t reay have a way to feed that back to us (NHS9). Education and information Many professionas pointed to the absence of cear guidance (and reated reguation), both for patients traveing abroad and for those returning with compications. Interviewees highighted the need for greater guidance for patients traveing abroad for medica treatment incuding what the minimum standards for providers and overseas treatment shoud be. This reates cosey to how information is packaged, how it is provided and by whom. Many of the interviewees offered ideas on how information coud be better provided, either through GPs or the Roya Coeges, but aso through greater pubic awareness of these issues. Providing reiabe independent information on medica trave was seen as a key chaenge and an important step in addressing issues of patient safety, to imit some of the ikey negative consequences of medica tourism (incuding compications and insufficient aftercare). One of the main probems with the current provision of information is that it is often provided by agents: 222 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 At the moment if you ook at the information sources out there they appear to be so swayed towards internet sites that have a vested interest in getting peope on panes and abroad and having treatment we reay need to have a thing that is free from commercia interest. PA5 Interviewees referred to information in the media being sensationaist, with individua stories of compications being reported or stories generay having negative undertones. This eads to medica tourism overa having negative connotations, which in turn imits open discussion and accurate debate of the issues invoved. Actors highighted the need to get reiabe institutions invoved in providing information but aso the need to make this easiy accessibe to patients. Representatives of the Department of Heath interviewed for the research pointed to the need for greater patient information and highighted that such advice and guidance woud be deveoped as part of the impementation of the EU directive on cross-border care. 1 PCTs did identify NHS Choices and the Department of Heath as porta points where prospective medica tourists coud be directed. Those professionas working on issues reating to cosmetic treatments highighted that patients often did not speak to a doctor or their GP in the UK before seeking treatment abroad: Cosmetic surgery patients are amongst the most vunerabe. The vast majority of them who think about cosmetic surgery fee embarrassed to tak about it. They do not even go and discuss it with their GP. They quiety go away (PA8). Doctors working within the NHS, especiay GPs, were seen as centra to the provision of information and in guiding medica patients as they contempate traveing abroad for medica treatment. In this respect, severa professionas interviewed highighted the importance of GPs being open to patients discussing their pans for medica trave with them and providing a safe space for advice. Externa quaity assessment and quaity information systems A interviewees commented on the vast variety of standards of treatment and procedures undertaken abroad. There was a genera recognition that this depended entirey on the provider and that peope traveing abroad may receive exceent heath care but equay may receive very poor treatment. One of the cinicians working for a professiona organisation observed: Some of the work I see from oversees is exceent and some of the work I see from my peers in the UK is not aways great. So I think it depends on who you see (PA16). However, given the very arge variation in providers and quaity, patient safety was mentioned as a key concern by a professiona actors interviewed. The absence of reiabe universa benchmarking or quaity contro mechanisms was described as a key imitation for patient safety and a critica issue to address. One of the actors interviewed highighted that in the absence of the CQC or its equivaent many patients trave into the unknown: The vast majority of peope who go on hoiday woud not dream of going to a hairdresser abroad [...]. Yet they go abroad and they trust their body, their heath, their webeing to somebody they have no idea who he or she is and in circumstances where you do not know whether they meet the necessary requirements of safety. PA8 Producing guidance or guideines woud not be a straightforward task. An interviewee from a professiona association suggested: In order to have guideines you need to have evidence and facts... what are the outcomes not ony of operations abroad but of operations in this country. I m afraid they re sady acking at the moment (PA2). Queen s Printer and Controer of HMSO 2014. 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. 223

APPENDIX 23 Fertiity trave, in which many patients trave to have access to treatment not aowed by UK reguations, poses specific threats to patient safety. Professionas working in reproductive care repeatedy mentioned the resuting increase in risk of compications incuding mutipe births. A representative from an organisation working in reproductive care (PA12) commented that the desire for a chid is so a-consuming, it takes over rationaity on occasions. Interviewees aso referred to accreditation as a way of ensuring greater patient safety. Internationa accreditation schemes, such as JCI, offer greater credibiity but come at a higher cost. This wi be refected in the price of the treatment as these costs have to be passed on to the patient. It is therefore more ikey that patients who search for the cheapest possibe treatment wi have inadvertenty compromised on safety standards. Professionas noted that cosmetic surgery is referred to as the Wid West as no quaity standards exist. Continuity of care was seen as a particuar concern. A of the professionas interviewed referred to foow-up care and compications as an issue. Athough the scae of medica tourism did not seem overwheming, a interviewees were aware of (or had treated) compications arising from treatment abroad. The greatest chaenges experienced were due to a ack of continuity of care provided to the patient, incuding chaenges faced by doctors in the UK providing aftercare. Severa issues were highighted in this respect. Professionas aso reported that it was not uncommon to see patients who had been to one or more providers, having aready seen a number of different cinicians, often adding to the confusion over the treatments carried out. Contributing to the ack in continuity of care was that compications and the need for aftercare often arise much ater than the origina treatment. In many cases patients woud experience probems years after the surgica procedures had been carried out. Of the medica professionas interviewed, severa referred to the ack of reiabe patient records as a key chaenge to providing foow-up care to patients who may experience compications. Either records do not exist or they may be in a different anguage. A senior representative of the professiona denta community described severa negative experiences in terms of record keeping. He described a ong deay in receiving patient records from the overseas provider, which in many cases are in a different anguage and therefore need to be transated to be of any vaue, but aso how these are often meaningess. Lega considerations and NHS entitement Medica insurance providers and quaity contro agencies highighted different eves of indemnity cover across countries. Many providers do not offer this and this was noted as a concern for patients if things go wrong. Specific industry modes were aso reported as being particuary imiting to patients abiity to assure quaity. Patients who pay up front for treatment, especiay when they pay a broker without having seen the cinician or doctor, raised concerns with professionas about the consent to medica treatment and safeguarding this principe. Certainy, amongst the sampe of patients interviewed for this research were some who had not fuy understood the procedure that they were receiving and consenting to. Representatives from the Department of Heath were very cear on NHS responsibiity for deaing with compications and foow-up care resuting from medica trave: It comes back to the fact that the NHS is a universa heathcare service therefore if you ive in this country those services are avaiabe to you. Whether you ve been deat with bady in another country and if you re iving here you have the right to access the NHS and that extends to putting right treatments. PA14 224 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 This no faut treatment issue was captured by another provider viewpoint that those trusts with A&E faciities face key issues that PCTs must dea with: We take everybody in and then ony get to decide whether you pay or not and if you don t wish to pay we there s ony so much we can do about it. So I think from an acute side its very much a routes ead into us from whether it s a private hospita to us when it goes wrong, whether it s done overseas that treatment has gone wrong, or whether it s GPs saying I didn t check the status because it s not my probem. NHS10 Interviewees conveyed that, athough compications woud be deat with, this may not necessariy invove onger-term management of patients foow-up care and needs. Professiona associations of NHS doctors described patients requests for pretreatment tests and investigations as a diemma, especiay at a time of imited resources. One GP described how prospective medica tourists were deat with using the same principe as for those seeking treatment in the private sector in the UK and consuting their GP in advance. However, when the tests required by patients woud be part of a NHS treatment pan, the surgery woud provide these for patients seeking to trave abroad or receive treatment in the private sector. When these are different from or are additiona to what the NHS prescribes they are not provided. A number suggested that outward medica trave shoud simpy be seen within the wider context of private care: We have received cases of patients who have had a private operation and then want to come back within the NHS (NHS8). The NHS as a treatment faciity was viewed as the eventua recipient of a patients with compications that coud not be rectified in the private sector: If you were an overseas provider you woud just give peope the advice that our private sector providers down the road give their patients. If you ve got any probems go to your oca NHS hospita, which is what they do. The private sector doesn t take a particuary pastora approach to the management of some of the compications. NHS15 Overa, among the different professiona stakehoders there appeared to be a ack of carity on NHS responsibiity to provide information, dea with compications and provide foow-up care. Given the overa remit of the NHS there was a sense that in a ikeihood a compications woud be deat with in the NHS. Those interviewed pointed to the government s responsibiity, specificay the Department of Heath, to provide cear information and guidance on the responsibiity of the NHS both to NHS doctors and to patients. Queen s Printer and Controer of HMSO 2014. 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. 225

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 Appendix 24 Motivation whees: bariatric, fertiity, denta and cosmetic treatment Bariatric treatment Avaiabiity (push and pu) Diaspora or famiia Cost Confidentiaity/anonymity Expertise abroad Dissatisfaction with UK private options Tourism Negative experience of NHS care Distance Lega considerations Fertiity treatment Diaspora or famiia Avaiabiity (push and pu) Cost Confidentiaity/anonymity Expertise abroad Dissatisfaction with UK private options Tourism Negative experience of NHS care Distance Lega considerations Queen s Printer and Controer of HMSO 2014. 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. 227

APPENDIX 24 Denta treatment Avaiabiity (push and pu) Diaspora or famiia Cost Confidentiaity/anonymity Expertise abroad Dissatisfaction with UK private options Tourism Negative experience of NHS care Distance Lega considerations Cosmetic treatment Diaspora or famiia Avaiabiity (push and pu) Cost Confidentiaity/anonymity Expertise abroad Dissatisfaction with UK private options Tourism Negative experience of NHS care Distance Lega considerations 228 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 Appendix 25 Internationa patients and associated activities: background and poicy context Speciaist NHS faciities have a ong tradition of treating internationa patients; there are aso estabished coaborative cinician networks and programmes with regard to training, education and consutancy. NHS trusts adopt a range of commercia modes and approaches to the organisation of services and their deivery to internationa patients. First, some foundation trusts partner private commercia interests. For exampe, Hospita Corporation of America (HCA) NHS Ventures has a number of partnership arrangements with NHS trusts whereby patients are treated excusivey in private settings. 257 HCA s first such venture was the 2006 partnership arrangement with UCLH. This was to deveop Harey Street at UCLH (a compex cancer centre faciity). This has resuted in HCA taking over the hospita s private patient wing, easing space and paying for services and sharing profits from private patients with the hospita. 258 A 2010 partnership with Christie NHS Foundation Trust in Manchester ed to the Christie Cinic, a new trust/hca joint venture. Second, some speciaist London hospitas have opened branches in the Midde East or partnered with commercia interests and heath-care deveopments in the region. Imperia Coege London Diabetes Centre opened its Abu Dhabi faciity in 2006, speciaising in diabetes treatments, research and training. The Guf region in particuar has a significant British and Western expatriate popuation. Great Ormond Street Hospita opened a regiona office at Dubai Heathcare City in 2006 aiming to: improve the quaity of services provided to chidren and famiies referred to Great Ormond Street Hospita from the Guf region deveop the internationa business of the hospita through service improvement and deveopment maintain and deveop the profie of Great Ormond Street Hospita as a provider of heath care for chidren. Great Ormond Street Hospita s Guf office averages 300 patient contacts annuay. It offers support to patients and famiies traveing from the region to London that paraes support undertaken by faciitators within the wider medica trave industry: advice on investigations and pretreatment; information and assistance with accommodation and transport to the hospita and information on services and London; and assistance obtaining visas. On return to the Guf, the office caims to provide medica records and adequate information for the referring hospita/doctor, continuity of care with regard to equipment or medication, and ongoing contact with famiies and communication with cinicians at Great Ormond Street Hospita. 259 In 2007 Moorfieds Eye Hospita opened a faciity in Dubai Heathcare City that operates as an overseas arm of the hospita. Its doctors have typicay undergone training at Moorfieds and are based in Dubai permanenty rather than rotating between London and Dubai. 260 The hospita treats around 11,000 patients per year at its purpose-buit campus, with around 70% coming from the Emirati and expat Arab communities. 261 The hospita has estabished 18 insurance affiiations and many of the patients are covered by insurance, the number of insured patients rising strongy as a proportion of the tota patient base. 262 In March 2011, Moorfieds Eye Hospita NHS Foundation Trust took the decision not to expand its Dubai faciities. 263 There is aso emerging internationa competition within the region, with the US-owned and run Ceveand Cinic schedued to open in Abu Dhabi in 2013. A number of the speciaist teaching hospitas have cose cinica reationships with hospitas in Midde Eastern countries and offer cinica training, education and ongoing support, which may be more or ess formaised (at hospita or nationa eve). Great Ormond Street Hospita activity, for exampe, is undertaken through partnerships with the Dubai Heath Authority. This provides a visiting consutant programme to the main government hospitas. 259 Simiary, a Queen s Printer and Controer of HMSO 2014. 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. 229

APPENDIX 25 programme of education and training for paediatric services is run in partnership with the Kuwaiti Ministry of Heath to enhance deivery of its government hospitas. Third, within the NHS, private services are offered to patients (incuding private patients from abroad) within both integrated and standaone faciities. Integrated faciities invove the use of shared theatres and treatments; activities are co-ocated because of the need for intensive care units and speciaist support (e.g. shared theatres with private wards for private maternity patients). For some treatments there may be dedicated faciities with private operating theatre space and ward faciities. Private patient income cap A imit on the amount of income that hospitas can raise from private activities was introduced by the Labour government in 2003 as part of the egisation to estabish NHS foundation trusts (Heath and Socia Care Act 2003 264 ). The cap for foundation trusts was fixed at that existing in the 2002 3 base financia year and so varied from hospita to hospita. As we as private patient income, the percentage coud incude income from externa business ventures such as commerciaisation of research and deveopment, training and consutancy. Athough typicay the cap on hospita income from private activity was around 2%, for a sma number of speciaist faciities it was much higher. The Roya Marsden, for exampe, had a 30% cap on income from private activity The cap imited hospitas from increasing the amount of private work and income beyond their base-year proportion and foundation trusts were monitored to ensure compiance. There were reported cases of singe expensive treatments taking foundation trusts over their cap. The Heath Service Journa (6 October 2011) 265 reported Guy s Hospita breaching its private patient cap by 700,000 because of treatment reating to one set of overseas twins. Non-NHS trusts were not subject to the cap and a number had private patient income far in excess of that of many foundation trusts. Since the cap was introduced, severa NHS foundation trusts have estabished charity, joint venture or other arrangements with private sector interests to raise additiona income or protect existing sources of income raised from private patients. There ensued considerabe discussion about the cap and the merits or otherwise of its remova. The White Paper Equity and Exceence: Liberating the NHS 266 argued for Aboishing the arbitrary cap on the amount of income foundation trusts may earn from other sources to reinvest in their services and aowing a broader scope, for exampe to provide heath and care services (Section 4.22). The NHS Confederation and the Foundation Trust Network both backed the ifting of the cap. Additiona private sector income was expicity identified in the Heath and Socia Care Bi 31 in the form of additiona non-eea overseas private patients who under previous arrangements coud not be treated in the NHS if trusts were cose to their cap. The chief executive of Great Ormond Street Hospita suggested that The ifting of the private patient cap woud aow us, as a Foundation Trust, to treat more private patients but aso, through reinvestment, to hep more NHS patients as we. 267 Advocates of egisation foresaw opportunities to secure greater numbers of patients traveing from overseas for treatment as part of wider commercia deveopments. Critics pointed to the further privatisation of the NHS. These non-uk patients wi potentiay be sponsored by governments, funded by insurers or paying out of pocket. Under the Heath and Socia Care Act 2012 30 the cap for foundation trusts was increased and now 49% of income can be earned from non-nhs work (in force since 1 October 2012). However, the core ega duty of foundation trusts remains unchanged (that of caring for NHS patients and deivering authorised services). How the increase in private activity wi impact on the NHS and its patients is not cear and is dependent on whether a particuar foundation trust is operating cose to capacity and whether additiona capacity is generated to treat private patients or existing capacity is used. 31 NHS patients may receive benefits if new or enhanced faciities are shared between private and NHS patients. However, if private patients have greater priority there wi a things unchanged be a growth in waiting ists and waiting times for NHS patients (Section B155 B156). 31 There is no evidence to judge this. 230 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 The fina egisation passed in March 2012 made key provisos with respect to the impact of private income on NHS services: Each annua report prepared by an NHS foundation trust must give information on the impact that income received by the trust otherwise than from the provision of goods and services for the purposes of the heath service in Engand has had on the provision by the trust of goods and services for those purposes. Chapter 7, Part 4, Section 164, 3A 31 Any major increases in private sector income require governance approva at board eve: An NHS foundation trust which proposes to increase by 5% or more the proportion of its tota income in any financia year attributabe to activities other than the provision of goods and services for the purposes of the heath service in Engand may impement the proposa ony if more than haf of the members of the counci of governors of the trust voting approve its impementation. Chapter 7, Part 4, Section 164, 3D 31 The NHS brand Since 2010 there have been cear attempts to support internationa activities of NHS trusts and organisations. NHS Goba was aunched in 2010 by the chief executive of the NHS: 29 Whie there are aready strong exampes of NHS Trusts and organisations successfuy sharing their ideas and products abroad, we want to create a more systematic approach to this work, and in doing so bring benefits back to the NHS and the UK taxpayer... It is now more important than ever to maximise the internationa potentia of the NHS. The 2010 White Paper 266 aso highighted the potentia of the NHS to expoit the power of its internationa reputation and financiay gain from the NHS brand when marketing NHS services to overseas patients. 31 To date, however foundation trusts have often been unwiing or unabe to take fu advantage of a of their apparent freedoms. 268 NHS Goba is hosted outside the Department of Heath by the NHS Institute for Innovation and Improvement. Its stated aims incude identifying commercia opportunities, generating demand, brokering partnerships and advising on egaities and risks. The Treasury has an expressed interest in these deveopments. As the Pan for Growth 269 outined: The Government wi work with the NHS and industry to design and estabish a proactive entrepreneuria NHS Goba to make the most of the brand internationay and to offer support and advice to NHS Trusts. In eary August 2012 the Heathcare UK scheme was aunched, supported by the Department of Heath and T&I. The aim is to further promote and encourage overseas investment and activities from within the NHS with the aim of providing profit streams for reinvestment in core NHS services. Queen s Printer and Controer of HMSO 2014. 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. 231

DOI: 10.3310/hsdr02020 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 2 Appendix 26 Resuts of freedom of information requests to NHS trusts 2012 Queen s Printer and Controer of HMSO 2014. 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. 233

APPENDIX 26 234 NIHR Journas Library www.journasibrary.nihr.ac.uk

EME HS&DR HTA PGfAR PHR Part of the NIHR Journas Library www.journasibrary.nihr.ac.uk This report presents independent research funded by the Nationa Institute for Heath Research (NIHR). The views expressed are those of the author(s) and not necessariy those of the NHS, the NIHR or the Department of Heath Pubished by the NIHR Journas Library