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Have sickness, must travel - Newspaper Edition - Times Online

Sunday Times Newspaper - 3rd December 2006 - London

Fed up with NHS waiting lists, dirty hospitals and shoddy service, hundreds of British taxpayers are travelling to Europe and beyond for operations — often blowing their life savings. But does it pay off? By Oliver Bennett. Photographs by Kalpesh Lathigra

Anne Richardson, 82, is preparing herself for a journey from her Watford home. Phrase books, French-language tapes, neighbours’ orders for croissants – all part of a long-awaited two-week break in France.



But Richardson is not going on holiday: she is off to the Clinique Sainte Isabelle, on the outskirts of Abbeville, northern France, to have her hip replaced. It started “twingeing” two years ago. “I went to see my doctor, who said, ‘Leave it as long as you can.’ ” Richardson used arnica gel to cope, because she doesn’t like drugs. She aims to live an independent life, and grows her own vegetables. “I’m sure my bad hip must be due to all that digging,” she says.



Why doesn’t Richardson go to her local NHS hospital, where treatment is free? “I don’t want to go in with one thing and come out with another,” she says. Nor did she fancy Bupa. Besides, the French operation was cheaper, although she says the cost – £6,350 – didn’t come into it. So off she is going, lured by French promise and driven by fear of the NHS. Yes, she’s had NHS operations and was happy with them, but Richardson, who has lived 24 years longer than the NHS (she worked in the food-administration office after the second world war, and has outlived her husband), has seen public sentiment wax and wane towards the great British institution. “We thought it was so wonderful, and gradually it deteriorated. Mind you, with age everything deteriorates.”



The doorbell rings. It’s the driver for People Logistics, the Northampton-based medical-tourism firm that is taking Richardson to France. Soon we’re all on the way to Abbeville in a people carrier, picking up others en route.



Richardson is one of a growing number of British “medical tourists”. As I arrive in Abbeville the scale of the trade becomes apparent. Most are first-time, paying patients. “It’s a quarter of our savings gone, but it’s been worth it,” says Judith Collins, 60, from Yorkshire, sitting by her post-operative husband, Jeremy, 66. “I couldn’t wait,” says a hip-replacement patient who wishes to remain anonymous. “The costs are tolerable. It’s a little irksome that you could spend it going on a cruise, but in your mid-seventies it’s about making life bearable. Our friends are all saying, ‘I’d come if I had the money, or if the NHS paid our bills.’ ” Indeed, the place is full of British patients and the talk is of waiting lists (“They say it’s only six months to wait now, under the new Patient Choice system,” says Collins, “but first you’ve got to get on the waiting list, which might take ages”) and of MRSA, of which Britain has one of the highest infection rates in Europe. The latter alone is what has driven Richardson to France: “I’m scared of the dirt.”



They even discuss the friendliness of the French, as opposed to the arrogance of British consultants, the comfort of their surroundings, and the fact they spend two weeks recovering after their operations, not four days. The only thing they don’t like is the food. “It’s the same as hospital food everywhere,” says Vernon Aitkens, 74. “But the aftercare has been great.”



After exchanging bedside pleasantries, I leave with Keith Smith, the director of People Logistics, whose team of drivers constantly shuttles patients from British homes to French hospitals. It’s one of a growing clutch of companies in the medical-tourism sector. “There’s probably less than 10 serious players at the moment,” says Smith, as we drive back to the UK via the Channel tunnel.



Medical tourism has been growing for more than 10 years. It started off with people opting to have cosmetic surgery abroad for reasons of price and anonymity. In America, a fashion began for hotel packages, golf and a health screening, say. Since then, it’s moved inexorably into the non-cosmetic arena. Britons now travel for dentistry, orthopaedic surgery, hernias, cataracts, heart surgery – almost any kind of elective surgery.



Sholto Ramsay of the Edinburgh-based Globe Health Tours, which started with dental implants, has seen reverse vasectomies, gastric bypasses for weight loss and penis enlargements – “the more esoteric procedures”. There’s even a micro-exodus of British couples going to eastern Europe to get IVF treatments at half the price, often

with a higher success rate than in the UK.



The prices are attractive, as are the promise for India Medical Tourism Expo 2006; stands decked with glossy photos of palm trees, white beaches and gleaming ultra-modern hospitals. “We’re booked here for the next 16 years,” beams Prasant Saha, who set up the expo with help from the Indian government, which has created incentives such as a fast-track visa for patients. It was the expo’s second year, boosted by a 2005 report from McKinsey consultants suggesting that medical tourism in India would be a £2 billion business by 2012. Saha thinks India is well placed to capitalise on medical tourism. “In India, English is spoken,” he says. “There’s amazing expertise, and many of the doctors have been educated or have practised in the UK.” There’s a little hindrance on the insurance side – “Only two hospitals in India have an overseas medical-insurance policy” – and he concurs that there remains a “perception problem”.



Among the exhibitors is Jagdish Jethwa of the Taj Medical Group, a former engineer. “We set up three years ago, after my gran broke her hip in the UK. There were complications, and even emergency surgery would have meant waiting several days too long.” India beckoned; his business followed. As a GP in Kenya, Premhar Shah of the Medical Tourist Company used to shuttle patients to South Africa and India. “When I came here [the UK], I read about long waiting lists and thought I should give the business a try,” he says. “People here are frustrated. Even in Kenya, if I wanted a blood test done I could get it in hours. But British patients always ask, ‘How many days will my blood test take?’ ”



India has competition. Thailand, Malaysia, the Philippines, Singapore: all have government-backed medical-tourism programmes. Costa Rica and Mexico offer hospital-and-tourism packages to the US. South Africa is established; Tunisia is snapping at its heels. Turkey, too. Then there are eastern European nations, which offer the lowest prices in Europe. Treatment Abroad, for instance, quotes a Polish cataract removal at £650, as opposed to £2,350 in the UK. And clinics are emerging in transit zones: since 2002, there has been one at Munich international airport; Dubai is scheduled to open the Dubai Healthcare City by the end of the decade.

Air-conditioned transfers, sightseeing programmes, “wellness” facilities: surgery is just one part of the product promise.



On the second floor of the Clinique Saint Isabelle, hardly any French is spoken. At any given time, 15 to 20 British patients sit in the clinic’s beds, having come here to find new hips and knees – the routine orthopaedic surgery they claim they’d have had to wait too long for on the NHS. Richardson, now convalescing, says she’s had “the time of my life. There’s a lovely group of people here. We’ve been taking it in turns to buy cakes. The surgeon was so approachable. And I don’t think a germ could live here”. “It’s very social, like an expats’ club,” says Diana Pavey, 74, from Hertfordshire, whose husband, Doug, 76, has just had a hip replacement. The couple had a pleasant time exploring Abbeville, and brought croissants and claret into the hospital.



Another batch prepares to return home, and they are all going to write to their local trusts, the local papers, and their GPs. The atmosphere is cheery, yet with a disgruntled undertow.



“I’m annoyed,” says Jeremy Miller. “In fact, I’m so annoyed, I’m going to start procedures against the hospital back home. I feel I should get some money back.” Michael Chauffourier, 72, who has a new hip, articulates the mixed feelings: “Three-course meals, a nice environment, a doctor with a good bedside manner: it’s difficult not to make unflattering comparisons with the NHS. Okay, a chunk of my savings has gone and I’ve paid a lot of tax and national insurance for this kind of thing, but what price freedom from pain?”



A constant refrain of health tourists is that they have been driven to it. “From my first visit to my GP to seeing the consultant took eight months,” says Bob Gallagher, 56, who went to India for cardiac ablation. “It was £2,000 rather than £12,000 in the UK.” Gallagher’s ablation became open-heart surgery. “Sitting in India, I thought, ‘Who do I trust?’ Not the NHS. Easy choice.” So he had the surgery and returned home happy. “They discovered a problem that hadn’t even been picked up here,” he says. “The surgeon phoned me at home. Can you see someone from the NHS doing that?” He has now managed to get his operation covered by travel insurance, but maintains he would have tried for reparations from the NHS. “They need to be embarrassed.” Seething beneath almost every British medical tourist’s story is a resentment towards the NHS for its lack of provision in the hour of need. According to Richardson, it is unreasonable: “It’s not as if everyone milks the NHS, is it? I’ve been very pleased with it, but I think that hospitals are getting worse.”



There are potential problems with medical tourism. There is the quality issue with blood donations and the slim chance of being in an unscrupulous clinic that uses counterfeit drugs. Long journeys may be counter-indicated, as some believe surgery increases the risk of deep-vein thrombosis on long-haul flights, a claim denied by the Indian and Far Eastern providers. There may be different medical protocols. The British Transplantation Society recently warned potential transplant tourists going to China that they might be receiving the organs of executed prisoners. Medical terminology might differ, and suffer mistranslations. More prosaically, if surgery does not go smoothly, you might have to extend your trip at extra cost, although some companies offer a fixed fee, regardless of the time spent.



“The key point is caveat emptor, particularly in terms of accountability,” says Dr Borman. “If the NHS gets something wrong, you know where to go with your complaint, as the NHS has financial and civil liability. Going abroad, you might have these glossy documents, but can you go back if something goes wrong?”



There appear to have been few problems thus far, although the specialist clinical-negligence solicitors Linder Myers have seen cases in the cosmetic-surgery sector. Peter Walsh of the Action for Victims of Medical Accidents has come across only a few cases. “We saw one patient who chose to go abroad to get her hip done,” he says. “Complications ensued, and she had a very difficult job trying to find out if she had any legal redress. That seems to be the key problem: you’re dealing with an entirely different jurisdiction.” Two years ago, Peter Wood from Heavitree in Devon became infected after a knee replacement in Belgium. “I am angry about what happened and would warn other people against going abroad and risking the same thing,” he said at the time. “We’ve done about 40 hours of surgery on him since the problem occurred,” says his surgeon, Keith, of the Princess Elizabeth Orthopaedic Centre, Exeter. “In that time, we could have done 14 joint replacements. It’s a big burden on the NHS to have to patch up operations. It’s not like buying a fridge on the internet. It’s your health; you need to have the highest level of control.”



None of this seems to be shaking the increasingly competitive medical-tourism industry. “People are looking at the UK as a real business opportunity,” says Dr Borman. “There are regulations here against doctors advertising, but I think we’ll start to see people testing those limits.” Indeed, Pollard of Treatment Abroad thinks that the industry now needs consumer guidance. His company has just published a “price watch” chart, which claims to be “the ultimate guide to pricing medical tourism”.



British patients are at a crossroads – should they pay, or can they get the NHS to pay? Can they claim the money back after the operation? Some already go abroad on the NHS, and this is going to increase. The DoH says there is likely to be more NHS outsourcing to other EU states – something that has been happening since 2001, when the then secretary of state for health, Alan Milburn, allowed health authorities and primary care trusts (PCTs) to legally commission services from other European countries so as to reduce NHS waiting times. Plus there is the E112 form, set up to refer NHS patients to state-aided service overseas for specific treatments that are difficult to provide in the UK. Trouble is, they have to be authorised by the DoH. Keith Smith, whose patients have managed to claim only twice on this system, says: “E112s are as rare as rocking-horse manure.” It seems as if the system is in abeyance, awaiting judgments due to follow the Yvonne Watts case.



One scenario, believed by many health tourists and their providers, is that the NHS is being downgraded into a skeletal firefighting service, wherein action will only be taken on emergencies and mortal diseases such as cancers. “The long-term trend is for people to rely on the NHS less and less,” says James Bartholomew, author of The Welfare State We’re In. “When the NHS started, only about 1% used private health care. Now it’s about a quarter.” Many Britons, he adds, would rather not even use the NHS for emergency care but have no choice.



However, patients flitting abroad should beware a counter-militancy, and Dr Borman says that NHS attitudes are hardening. “Currently, if something goes wrong, then the NHS will pick it up and you can still sue,” he says. “But at the PCTs I know that people are saying, ‘We’re not here to pick up the tab for anyone all of the time.’ People are beginning to voice that issue.”



“There is a real problem of perception out there,” says Joe Farrington-Douglas, now of the Institute for Public Policy Research. “While the quality of service has been going up, the perception has been going down. It keeps No 10 awake at night.” It’s at the point, he says, where patients commonly think that the NHS is a poor organisation; a negative perception that drives patients to Abbeville, Delhi, Liege, Manila – anywhere but their local hospital, with its rude consultants, filthy wards and inability to offer patients basic treatments within a decent time span. “A lifetime’s tax,” muses a post-operative gentleman in Abbeville, who prefers to remain anonymous, “and this is where we end up. Paying for ourselves, in France.”



Richardson leaves the clinic, limping a little. It’s been a successful operation, plus she managed to have a wander around Abbeville and liked it so much she’s planning a holiday there with her sister. “I’m full of optimism,” she says. “But I’m tired. I had been hoping to walk into my doctor’s surgery without a stick, but I’m not sure I’ll do that, this week at any rate.” We drive back from the Channel tunnel and eventually reach Watford, where she alights carefully and goes back home to make her phone calls, distribute croissants, adjust to her new hip and sleep.



Like the many other Britons who go abroad for medical treatment each year, Richardson has not experienced a miracle. A month on, she is still finding mobility difficult, has a few unexpected aches and pains, and hasn’t yet managed to tend her beloved garden: “The surgeon told me it’ll be another six months before I’m allowed to do that, I’m afraid. And nobody’s as good a gardener as me.”



She has made an appointment to see her doctor this month for a general recap on her condition, and is seeing an osteopath about something else. There’s no cure for age, not even for a fit, independent woman like Richardson. But the hip doesn’t hurt any more, and she is pleased about that. “Maybe I’ll get the second one done,” she jokes. “It’s a big thing, to be pain-free, and I’ve got a lot of living to do yet.”

This is the complete text of the Washington Times, reprinted as newspaper websites tend to lose their old articles.



Under the knife overseas — The Washington Times

Growing numbers of Americans are traveling abroad to undergo medical and dental procedures that are much less expensive than they are in this country — and sometimes not available in the United States at all.
These so-called “medical tourists” have a vacation in an exotic place where they can soak up the sun, visit a few golden temples or other landmarks and end up with a new hip or knee, a healthy heart — or a robot-controlled joint replacement, a procedure that has not yet been approved in this country.
In addition, “they return with a lot more money left in their pockets — sometimes 70 [percent] to 80 percent more than if they’d been treated in the United States,” said Diana M. Ernst, a public-policy fellow in Health Care Studies for the Pacific Research Institute (PRI).
No organization tracks the number of Americans who travel abroad for surgery, according to Consumer Reports. But PlanetHospital, which arranges medical trips to eight foreign countries, said it receives more than 4,000 inquiries a month.
“In a recent month, we arranged 81 surgeries, and 47 patients were from the United States,” said Rudy Rupak, founder and president of the Calabasas, Calif.-based company.
Uwe Reinhardt, a health economist at Princeton University, said he has not heard “one horror story” involving a medical tourist.
“If there had been, you could be sure the medical establishment would have amplified it,” Mr. Reinhardt said.
But Consumer Reports warns that people “should know the risks” involved in having surgery in a foreign country, such as “uncertain regulation, lack of background information on surgeons, lack of follow-up care and difficulty suing” a foreign physician or hospital.
However, it does acknowledge that going abroad might be the only way to afford surgery or dental work for those without health insurance or for those whose policies do not cover the procedures they need.
“The health care situation in the United States today is causing people to go bankrupt and is forcing companies to decide if they will have to lay off people in order to provide health care benefits,” said Tom Kesling, president of Raleigh, N.C.-based IndUShealth, which sends Americans to India for various medical procedures.
The American Medical Association has not yet taken a position on medical tourism, although it is expected to do so in the future, a spokeswoman said.
“But we don’t think medical tourism is a policy for uninsured Americans,” she said.

‘One player among others’
MedRetreat, a Vernon Hills, Ill.-based medical-tourism firm with offices in Fulton, Md., said it arranged surgeries in foreign countries for more than 200 Americans last year and more than 350 this year.
MedRetreat spokesman Patrick Marsek said he has not heard any dire stories about Americans taking part in medical-tourism programs.
But he cited a case that occurred last February, when Joshua Goldberg, 23, a California man who went to Thailand to be ordained as a Buddhist monk, died at Bumrungrad Hospital in Bangkok after being bitten by a snake.
Reports indicated Mr. Goldberg was “simultaneously administered … six contraindicated and lethal medications,” despite warnings to doctors from his father about his allergies to certain drugs.
“Bumrungrad Hospital is supposed to be the world’s leader in attracting foreign patients,” Mr. Marsek said. It is the only hospital in Thailand accredited by the U.S.-based Joint Commission on International Accreditation.
But Mr. Reinhardt cited a report in 1999 by the Institute of Medicine that found nearly 100,000 people die accidentally in U.S. hospitals each year.
“With a track record like that, the medical industry in this country cannot sit in a glass house and throw stones,” he said.
In fact, Mr. Reinhardt said: “A lot of research shows we are just one player among others. A lot of surgery is just plumbing that requires skill. Given circumstances today, it’s much harder to run a hospital in Los Angeles than in India. And while things could go wrong in a hospital in India or another Asian country, they would probably turn out just as well there as here.”

A cheap fix
MedRetreat said the low cost of medical treatment in the seven foreign countries with which it has arrangements — Argentina, Brazil, India, Malaysia, South Africa, Thailand and Turkey — allows a U.S. patient to fly there, enjoy a vacation, get treated, “recover in a four- or five-star resort” and then fly home, “having spent less than the procedure alone in the United States.”
For example, Mr. Marsek said: “In Malaysia or Thailand, an American can get a complete face-lift and neck-lift for under $3,000. But the price will be $6,000 to $12,000 or even higher in the United States.”
However, he acknowledged it is not financially wise to go abroad for a procedure that would cost $6,000 in the United States. Even if the same procedure costs only $1,500 in a foreign country, “you’ll probably only break even,” when you add in the costs of airfare and hotel accommodations, he said.
MedRetreat’s price for a trip to Thailand for a hip replacement is $12,000, including $8,000 or $9,000 for the procedure, he said. Also included is round-trip airfare for two; a one-week stay in the hospital; and a two-week stay in a five-star hotel. In the United States, the price of the hip replacement alone is at least $40,000, Mr. Marsek said.
Mr. Rupak — whose firm sends patients to Argentina, Belgium, Costa Rica, El Salvador, India, Panama, Singapore and Thailand — said a patient would spend $36,000 for coronary arterial-bypass grafting and $55,000 for a heart-valve replacement in the United States. But in some foreign countries, the same operations are available for as little as $11,000 and $13,000 respectively, including airfare and hotel.
A person who undergoes cancer surgery in India or Thailand could expect to pay $14,000, including airfare and hotel, he said. In this country, the surgery alone would cost about $65,000.
Explaining why the cost of medical treatment is so much lower in other countries, Ms. Ernst said, “The American dollar is more valuable in many undeveloped, foreign countries, where the pay scale is low and the number of patients high.”
One of the main reasons American surgeons and hospitals are starting to lose out to competitors in foreign countries is that “medical malpractice is not nearly so ruthless” overseas as it is in the United States, she said in her report in PRI’s newsletter, Health Policy Prescriptions.
In such foreign destinations, “doctors can pay as little as $4,000 a year for malpractice insurance. American doctors can pay 25 times that amount every year,” Ms. Ernst said.
In addition, foreign hospitals involved in medical tourism do not have to worry about the “bad debts” that plague so many facilities in the United States, Mr. Marsek said.
“Hospitals involved in medical tourism don’t take you unless you pay. When you go overseas for medical tourism, you present your credit card, and that’s that,” he said.

Exploring options
Jeanne Bennett, 49, of Raleigh, N.C., received national attention for a trip she made to Chennai, India, where she underwent hip resurfacing to eliminate arthritis pain.
Hip resurfacing is a long-lasting therapy that is less invasive than hip replacement and is usually recommended for younger patients, such as Mrs. Bennett, who have endured years of debilitating pain.
While commonly performed in Europe and Asia, hip resurfacing remained an experimental therapy in the United States until the Food and Drug Administration approved it May 10.
Mrs. Bennett said she first learned of the procedure and its low-cost availability in India from a report last spring on “60 Minutes.”
In June 2005, she and her husband, John, cashed in frequent-flyer miles and flew to India, where Dr. Vijay C. Bose resurfaced Mrs. Bennett’s arthritic right hip for $5,600, including all hospital fees.
“My experience could not have been any better,” she said. “I had lived with chronic pain for 10 years, and I walked with a severe limp. My leg would lock up at night, and I couldn’t sleep. But today I sleep without problems. I can walk again, and there’s no pain. I play tennis, and there is no pain.”
When Mrs. Bennett first learned about hip resurfacing, the technique was being tested at Duke University Medical Center and several other U.S. hospitals. But because it had not yet been approved by the FDA, Mrs. Bennett would have had to pay $40,000 to have the procedure done at Duke — and her health insurance would not cover it.
Mrs. Bennett said she had confidence in Dr. Bose because he helped develop the special prosthesis that’s now in her right hip.
“In fact, I sent two other people over there after I got back home,” she said.
Mrs. Bennett had her hip resurfaced at facilities operated by Apollo Hospital Enterprises, the largest company in India serving medical tourists. Like other companies aggressively seeking those willing to travel for health care, Apollo Hospitals usually provides Western patients with a package that includes round-trip flights, hotels, medical treatment and even a postoperative vacation.
The Apollo Hospital in Chennai and two other Apollo hospitals are among five facilities in India accredited by the Joint Commission.
“To sweeten the attraction, many [foreign] hospitals promote their services like a resort, offering private, air-conditioned rooms with on-site spas, pools and Internet access,” Consumer Reports said.
The phenomenon of medical tourism is a role reversal for those accustomed to having foreigners travel to the United States for high-quality health care, if they can afford it.
“But if you don’t have insurance, and you are in pain like I was, you’ll do whatever you have to,” Mrs. Bennett said.

Overcoming roadblocks
While some Americans are heading to Asia for low-cost medical services, others are bound for Poland for dental work.
Dental Travel Poland (DTP) said it organizes “money-saving dental trips” to Warsaw, the nation’s capital, where foreign patients visit “top dental clinics” and receive “a wide range of high-quality services at one-third of the prices” charged in England and the United States.
The deal also includes accommodations at some of Warsaw’s “best” hotels plus sightseeing and transportation in the city. DTP provides advice on flight arrangements, but airfare is not included in its treatment packages.
In an e-mail message, DTP said its prices are “very competitive, especially for major work.” For example, its fee for a dental implant is $980. The price in the United States is about $3,400.
Given that a round-trip flight from Washington to Warsaw can be as low as $350 at certain times of the year, going to Poland for major dental services can still be cost effective, especially if multiple repairs are made, said Marek Purowski, a spokesman for the Polish Embassy in Washington.
“The prices for dental care in the United States are unbelievable, ridiculous,” he said.
In Latin America and South Korea, the big draws are plastic surgery and dental work.
“South Korea is the world’s capital for plastic surgery,” Mr. Reinhardt said. “They do it round the clock. Getting plastic surgery in South Korea is like getting your hair done in the United States.”
A State Department official said medical tourism is also a “big industry” in Tijuana, Mexico. The official, who spoke on the condition of anonymity, said Americans usually seek dental work or cosmetic surgery.
Those same services are also in demand in Costa Rica, Mr. Rupak said. “And believe it or not, El Salvador also has amazing [medical] facilities, particularly for hysterectomies, tubal ligations or reverse tubal ligations,” he said.
However, there are still some roadblocks to a groundswell of U.S. support for medical tourism. For example, a North Carolina paper-products company interested in sending an employee to India for shoulder and gallbladder surgery and giving him the $10,000 it expected to save ran into difficulties with a union that represented some of its employees.
“Large American insurance companies have not fully jumped aboard the medical-tourism bandwagon, so the number of medical tourists remains paltry compared to the millions of surgeries performed in the U.S. every year,” Ms. Ernst said.
But Mr. Reinhardt said medical tourism will only grow in the coming years.
“And if it is used a lot, this has the potential of doing to the U.S. health care system what the Japanese auto industry did to American carmakers,” he said.



Researchers Amy Baskerville and John Sopko contributed to this article.

Under the knife overseas Report Washington Times, America’s Newspaper



Long and researched article on the impact of medical tourism on the US consumer and potentially the US healthcare system.



Will it do to US healthcare what the Japanese Auto business did to the US auto business or will it stay always on the periphery?