Health tourism

No one should condone any fraudulent use of the NHS. However, following a consultation focused on the need to close perceived “loop-holes that are open to abuse” by “health tourists,” the government's announcement of its response also raised fundamental concerns regarding the balance between the potential responsibilities of doctors as employees and their ethical responsibilities to their patients.¹ Questions have also been asked regarding the actual extent of the problem of “health tourism.” To date no serious quantitative study seems to have been made of this issue. The only figures available are anecdotal or based on extrapolation, and they vary considerably around the country. Further concerns relate to the applicability of suggested solutions and the public health implications of some of these.

Other than in the case of certain exemptions, specific regulations require NHS trusts to charge for health care that is provided to anyone who is “not ordinarily resident in the UK.”² While this should be performed by overseas patient managers, pursuit of payment seems variably to have been achieved, with anecdotal reports suggesting various forms of abuse. Some examples cited in the government's consultation involve free hospital care for the dependants of people exempt from charges and for visiting business people or their dependants.

Analysis of the responses to the government's consultation shows that respondents differed markedly on how certain key issues should be addressed.³ Though there is a risk of overgeneralising, these may be categorised according to their emphasis on costs or on the rights of the patient, thus providing another illustration of this dichotomy in a health service where both costs and rights are emphasised more than ever before.

This tension is exacerbated by the environment within which all healthcare professionals—whether clinicians or managers—work and are increasingly held accountable. Specifically, doctors are bound by the ethical code that underpins the patient-doctor relationship, which is based on trust, confidentiality, and the primacy of patient needs, and these are also required by their regulatory body.⁴ In its response to the government's consultation the British Medical Association clearly highlighted, and the government accepted, these ethical concerns, which effectively indicated an absolute requirement for any decision regarding eligibility for care to occur outside the context of the clinical consultation.⁵

Ethical problems regarding eligibility for treatment are most profoundly shown by the issue of the proposed withdrawal of free non-emergency hospital care for asylum seekers whose applications to the Home Office have been rejected. A group with understandably high healthcare needs, they still may face long periods in the United Kingdom without financial support before being deported. The BMA cited ethical, clinical, and humanitarian grounds for not supporting this proposal. Similar considerations were felt to apply to the ongoing treatment of HIV positive patients (currently only testing is free), where as an added reason even cost effectiveness can be invoked. It is hoped that when legislation is prepared—it is scheduled to come into effect on 1 April 2004—it will reflect a more compassionate side of British society than some public statements on these issues thus far suggest.

The government must be credited with maintaining free emergency treatment for visitors and for free continuing treatment for certain infectious diseases such as tuberculosis, thus reducing the public health risk and the chances of drug resistance. But the latter decision emphasises the questionable nature of its decision on “non-ordinary residents” who are infected with HIV.

Contention surrounds the means by which the government may envisage these proposals being implemented. Despite the existing regulations it would seem that some trusts either may not pursue reimbursement or are not able to. Responses to the consultation vary in their recognition of the implications of more actively requiring patients to confirm their residency status—from potentially discouraging them from seeking medical attention, to being accused of racial discrimination, to acting as a stimulus for a mandatory NHS patient card. When existing mechanisms may not have been applied adequately, rather than having failed, should not there be greater emphasis on these before more wide ranging legislation is enacted?

Clearly there is an urgent need to address the gap in essential knowledge about the size and nature of the problem and to suggest more specific solutions. Good governance, like good medicine, should be evidence based and proportionate.