Health Economics
C o n s o r t I u m
DEPARTMENT OF HEALTH
Cross Border Healthcare and Patient Mobility: Data and Evidence Gathering
Final Report
KARIN LOWSON, Project Director, YHEC
JAMES MAHON, Senior Associate Consultant
DIANNE WRIGHT, Research Assistant
PAULA LOWSON, Associate Consultant
SOPHI TATLOCK, Research Assistant
STEVEN DUFFY, Research Consultant AUGUST 2010
ÓYHEC
University of York, Market Square, Vanbrugh Way, Heslington, York YO10 5NHTel: 01904 433620 Fax: 01904 433628 Email: http://www.yhec.co.uk
York Health Economics Consortium is a Limited Company
Registered in England and Wales No. 4144762 Registered office as above.
Contents
Page No.
Executive Summary
Acknowledgements
Section 1: Introduction 1
1.1 Background to Study 1
1.2 Processes For Receipt of Health Care Abroad 1
1.3 Planned Healthcare 3
1.4 Current Evidence of Mobility 4
1.5 The Study 4
1.6 The Study Report 5
Section 2: Literature review 7
2.1 Introduction and Methodology 7
2.2 Policy and Legal issues 8
2.3 Data on Cross Border Healthcare in the EU 9
2.4 Patient Choice 10
2.5 Planned Healthcare Initiatives 11
2.6 Medical Tourism 12
Section 3: Collection of Data on Patients Receiving Planned Treatment Abroad Funded by the NHS 14
3.1 Introduction 14
3.2 Analysis of E112 Data 15
3.3 Findings For E112 Analysis 15
3.4 Analysis of EHIC Claims 19
3.5 Analysis of Article 56 Data 19
Section 4: Analysis of the Public Survey 20
4.1 Methodology 20
4.2 FIndings 23
4.3 Summary and discussion 30
4.4 Comparison of Survey Findings with Flashbarometer Findings 33
Section 5: Focus Groups with members of the general public 35
5.1 Introduction 36
5.2 Process for Recruitment and Management 36
5.3 Analysis of Participants 37
5.4 Topics for Discussion 39
5.5 Findings 40
Section 6: Survey of NHS Commissioners 49
6.1 Introduction 50
6.2 Analysis of Responses 51
6.3 Analysis of Data on Patients Who Have Received Treatment Abroad in Mainland Europe 55
Section 7: Case studies of NHS 59
7.1 Introduction 60
7.2 Patient Numbers 60
7.3 Information, Knowledge and Advice 61
7.4 Processes For Considering Planned Treatment Abroad 62
7.5 Barriers To Funding Patients Abroad 64
7.6 Northern Ireland 67
Section 8: Mystery Shopping with NHS Commissioners 69
8.1 Introduction 70
8.2 Methodology 70
8.3 Findings 71
Section 9: Survey of Professional Organisations and Patient Associations 75
9.1 Introduction 75
9.2 Analysis of Responses 76
Section 10: Conclusions and Recommendations 79
10.1 Demand 80
10.2 Processes 81
Bibliography
Appendices:
Appendix A Detailed Costs of E112s
Executive Summary
1. INTRODUCTION
In July, 2008, the European Commission (EC) published a draft Directive on the application of patients' rights in cross-border healthcare, which sought to codify existing ECJ case law on patients' rights and clarify their application. This issue had previously been subject to public consultation by the EC to which the Department of Health (DH) had responded.
The Department of Health (DH) commissioned a targeted research and information gathering study to collect information on public and patient knowledge, attitudes and preferences with regard to the proposed EU Cross-Border Healthcare Directive (EUCBHD), and on patient mobility issues in general. The study had two broad objectives:
· To develop an understanding of the public’s and/or patients’ responses to the Directive, including an assessment of the likely numbers choosing to travel;
· To assess the state of NHS readiness, including a review of current processes and numbers being managed.
Activities undertaken to address these objectives comprised the collection of data from the Department for Work and Pensions (DWP); a large survey and focus groups with members of the public; a survey of, case studies with and mystery shopping of NHS commissioners; and a survey of professional organisations and patient associations. The whole study was underpinned by a literature review and stakeholder interviews It is also believed that patients are increasingly confident about their rights, options and entitlements about their NHS healthcare. Following a number of high profie legal rulings in Europe, many of these rights and entitlements now extend to healthcare accessed in other European countries, as confirmed in the NHS Constitution. Part of the research study investigated how widely people were of their rights in respect of cross border healthcare.
2. UNDERSTANDING PUBLIC AND PATIENTS’ ATTITUDES
According to the public survey, 62% stated they would consider seeking planned healthcare abroad in the future with 50% citing avoidance of long waiting lists as the main advantages to going abroad. These findings are reinforced by the findings from the focus groups, where waiting times were a driver to seek healthcare abroad. Disadvantages cited included not having family nearby, not being to speak the language and the costs of travelling.
While we cannot provide strong evidence on the scale of any future demand for planned treatment in the EU, the evidence found does suggest that there is a willingness to consider going abroad in a majority of the population – although many indicated they did not know where to go for information if they were considering overseas treatment.
3. ASSESSMENT OF LIKELY NUMBERS CHOOSING TO TRAVEL
To the year ending 13 November 2009 there were 747 E112s issued by the DWP. 108 of these were non-maternity relating to 64 patients, 47 of whom were British. We estimate the costs of these 108 E112s to be no more than £1.1million or £17,000 per E112. As there were low numbers of E112s issued, it can be deduced that the majority of PCTs did not agree to fund planned healthcare abroad using an E112 in the 12 months analysed.
Taking evidence from the survey, the lack of translation of potential into current demand for overseas treatment could be that supply of healthcare in the UK meets current demand and so people do not need to go overseas. However, given the change in emphasis away from targets around waiting times, increases in waiting times or size of waiting lists may lead to an imbalance in supply and demand and more patients may seek treatment abroad. The new Directive may also increase the demand for overseas treatment amongst people with no intrinsic barrier to treatment outside the UK, perhaps for routine treatment such as dentistry although we found no evidence of this.
Consistent messages from across all EU countries are that whilst many might consider travelling outside their country to receive healthcare, neither our survey, nor the EU survey, suggest that this consideration will necessarily be translated into demand or that the numbers are likely to increase under current supply of healthcare, such as the management of waiting lists. This may change in the future.
4. ASSESSMENT OF NHS READINESS
There is limited evidence that preparations are being made for the introduction of the new directive and strong evidence that many local commissioners are not even aware that a new directive is coming. Whilst the commissioners’ survey found that many PCTs and Health Boards stated that they were looking at future demand for overseas care, this was not found in the case studies. The current system of using panels to assess a request is, in our opinion, unsuitable should numbers increase with the introduction of the new directive - which our research has not discounted.
The clear, consistent message throughout the research is that the concept of patient mobility and the correct application of patients’ extended rights are areas that PCTs find complex and challenging. This has contributed to some PCTs applying criteria by which they make decisions to fund that do not seem to have any basis in current legislation or case law. The NHS is therefore at considerable risk of challenge.
The majority, if not all, PCTs see overseas treatment within the EU as being a low priority area. Knowledge of processes and criteria for NHS funding of treatment abroad does not appear widely known by staff within individual PCTs. Further, the mystery shopping indicated that PCTs do not have the processes or knowledge to deal with queries, and may not be offering helpful or accurate advice.
If anything, the national picture is likely to be much worse than was found through our evidence gathering as it is likely that those PCTs that did choose to engage with the research are areas that do attempt to give this subject some priority. Our strong suspicion is that those PCTs that failed to engage (the vast majority of PCTs) treat this as a very low priority area – with no one locally who is responsible to assess requests or offer correct advice.
Our research shows that commissioners are applying criteria in deciding on whether to fund overseas treatment that appears to run counter to case law. This, coupled with the apparent lack of interest in this area from local commissioners and the potential consequences of failing to allow someone treatment abroad when they had a clear right for funding under legislation and case law, means in our opinion this is a responsibility that would be more appropriately handled nationally.
This recommendation holds if numbers stay low or increase with the new Directive. With low numbers it seems an inefficient use of resources to make each local commissioner have their own set of processes to decide on requests. If numbers increase, a higher likelihood is created that a decision will be challenged and given current local practice the decision found to be in contradiction of legislation and case law.
iii
Acknowledgements
We would like to thank all those working in the NHS and in professional organisations and patients’ associations who completed our surveys, as well as those PCTs who participated in our case studies and mystery shopping.
We are extremely grateful to everyone in the Department of Work and Pensions, Overseas Healthcare Division, especially Judith Pharoah and her team who assisted us with our collection and analysis of data on E112s.
We would like to thank Adrea Begley at DHSSPS for providing the data on E112s for Northern Ireland.
We are also grateful to Magda Rosenmoller from IESE Business School at the University of Navarra and Neil Lunt from York Management School at the University of York, who gave advice and offered material to the study, including work that they had undertaken, and to Keith Pollard from Treatment Abroad, who offered useful information and advice and who generously allowed us to use their Survey.
Finally, we would like to thank the team at the Department of Health, including Rob Dickman, Paul Whitbourn, Mark Wilson and Amy Everton, who commissioned the study, and who offered useful advice and comments throughout the project life.
Section 1: Introduction
1.1 Background to Study
Whilst most people receive their health care in the country in which they reside, patients may travel to other countries to receive healthcare. However, evidence suggests that the number of people who obtain care in another country is low, accounting for around 1% of total health care expenditure. Rules for receiving cross-border healthcare and for the reimbursement of costs are not always clear, although case law has been established by the European Court of Justice (ECJ). In July, 2008, the European Commission (EC) published a draft Directive on the application of patients' rights in cross-border healthcare, which sought to codify existing ECJ case law on patients' rights and clarify their application. This issue had previously been subject to public consultation by the EC to which the Department of Health (DH) had responded.
The DH carried out consultation on the proposed Directive in the autumn of 2008. The purpose of this consultation was to help inform the UK Government’s negotiating position on the draft Directive and begin data collection to aid assessment of the impact that the proposed Directive could have on the UK.
It is also believed that patients are increasingly confident about their rights, options and entitlements about their NHS healthcare, following a number of high profile legal rulings in Europe, many of these rights and entitlements now extend to healthcare accessed in other European countries, as confirmed in the NHS Constitution. Part of the research study investigated how widely people were of their rights in respect of cross border healthcare.
Against this backdrop, the DH commissioned a targeted research and information gathering study to collect information on public and patient knowledge, attitudes and preferences with regard to the proposed EU Cross-Border Healthcare Directive (EUCBHD), and on patient mobility issues in general.
1.2 Processes For Receipt of Health Care Abroad
1.2.1 Overview of patient mobility
Legido –Quigley[1] and her colleagues devised a useful typology to describe patient mobility, summarised in Box 1, and believe that the data available seriously underestimates the numbers seeking these routes.
Box 1.1 Broad categories of patient mobility
CategoryTemporary visitors abroad
People retiring to other countries
People in border regions
People sent abroad by their home systems
People going abroad on their own initiative
Of particular interest are those in the latter two categories. Examples of schemes in which people are sent abroad by their system include a pilot project established by the DH in 2001, under which patients from the south-east and south-west received care in French and German hospitals for orthopaedic and ophthalmic conditions, evaluated by YHEC[2]; the Norwegian Medical Treatment Abroad project which was used to reduce waiting lists for elective surgery; and longer term schemes under which small countries lacking specialised treatment options send patients abroad.
Rosenmoller, under the Europe4patients work, has developed a useful patient mobility typology, examining the relationship between types of patient flows, and types of arrangements, as shown in figure 1.
Figure 1 Typology of patient mobility[3]
Types of arrangementsTypes of patient flows / Reg 1408/71 / Institutionally arranged care / Self managed
care
Abroad when
in need of
care / Short term
Double residence
Long-term
Going abroad
for care / Familiarity
Availability
Financial costs
Perceived quality
(bio)ethical legislation
1.2.2 Healthcare Tourism
The number of patients seeking treatment abroad under their own initiative appears to have increased reflecting ‘healthcare tourism’. Examples include receipt of dental care from Hungary, and surgery in South Africa. Intermediary companies exist which assist patients in choosing health care organisations, and arranging their care. Under this category are patients seeking treatment which may not be available in their home country, for example abortions, or fertility treatment.