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.”
