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Sun 1 Apr 2007 02:11 PM

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Suitcase healthcare

Ensuring patient safety as number of patients opting for surgical sojourns rises.

Medical tourism, where patients travel abroad for urgent or elective medical procedures, is on course to become a multi-billion dollar industry within the next ten years. For a growing number of travellers, the lure of high quality, low-cost healthcare when compared to an over-burdened national health service or rocketing private costs, is proving irresistible; and Middle Eastern patients are leading the pack.

While health tourism is a comparatively new trend in the west, tourists from this region have long been on to the combination of sun, sea and surgery. At any one time, between 150 and 200 UAE nationals are receiving medical care abroad and in 2001, the number of Saudi nationals travelling to the US for treatment topped 56,000.

To a degree, this trend has been driven by necessity. Until recently, high-end healthcare was not readily available regionally and the perception that for world-class healthcare you must travel, has lingered. This view, together with the readiness of GCC governments to fund overseas treatment for nationals, has seen the medical tourist become a year-round target for eager health destinations.

"Most patients who choose to go abroad for surgery do so because of psychological reasons, believing that treatment is better," explains Dr Alaa AK Mohammed, consultant surgeon at Um Al Quwain hospital. "If it is funded by the Government, they seize the opportunity."

Traditionally, the UK and US have been favoured by regional travellers seeking state-of-the-art care alongside cultural appeal. But since 9/11, the difficulty in securing visas has seen Arab patients look elsewhere for treatment. Now, thanks to a marketing formula of low treatment prices and high-end care, Asian countries such as Thailand and Malaysia are vying with established healthcare destinations, such as India and Germany, to attract Middle Eastern patients. Concerted promotional campaigns fronted by hospitals and government bodies have helped the continent soak up the overspill from the US. These drives have boosted Thailand's visitor figures by 30% since 2005 and seen the UAE Ministry of Health station full-time representatives in the country to help marshal the swelling numbers of government-funded patients. India is boasting a similar growth pattern, while Singapore has notched up a 20% rise in patients. Recent additions to the table include South Africa's ‘surgery and safari' deals and Eastern Europe is fast developing a booming cosmetic surgery sector.

But the increasing number of international patients seeking care abroad has also led to an explosion in the number of dubiously cheap, surgical deals. Lured by a glossy brochure combining treatment and a luxury holiday, patients can forget that they're signing up for major operations.

"I'm amazed that people go for these deals," says Dr Rajiv Grove, a consultant plastic surgeon and member of the British Association of Aesthetic Plastic Surgeons (BAAPS). "The notion of a holiday dilutes the fact that it's serious surgery. What people forget is that nobody feels like a holiday when they've just had an operation."

When medicine is marketed to unwary consumers, the role of the primary care provider becomes vital. GPs are often overlooked in the medical tourism process, but should play a crucial part in screening potential treatment plans. Dr Jason Jap is director for healthcare services for the Singapore Tourism Board. Singapore hosts some 374,000 ‘health tourists' a year, and Jap firmly believes that overseas treatment should be a shared decision between GP and patient.

"This decision is not to be made lightly," he says. "GPs and patients should research carefully the various options and the GP should give advice on the critical criteria for evaluating healthcare. While the decision is the patient's, it should be made with good advice from his doctor."

So what are the key issues to raise with patients considering care abroad? First and foremost, says Jap, is deciding whether there is really a need to travel at all.

"The first question is whether international travel is even necessary," he explains. "Where there are clinical services accessible to the patient and there is no need to travel, the GP should not recommend healthcare overseas."

Mohammed agrees. "Hospitals in the UAE are fully equipped and highly specialised with skilful surgeons," he says. "GPs should explain this fact to their patients and only make exceptions for very complicated cases."

Should treatment abroad be the only option, however, the most important decision is helping patients select a reputable hospital and surgeon, adds Dr Mohammed. "This is the minimum obligation of the doctor, should the patient insist on going abroad for treatment."

Passage to India

Dr Karum Thakur is director of communications for the JCI-accredited Apollo Group, India's largest medical group. The corporation, at the front of India's health tourism boom, has treated more than 90,000 international patients to date.

India has carved a niche for itself as a specialist medical venue. Promotional campaigns point to the number of medical conferences and breakthroughs India has overseen, working from the stance that it's not just cost but competency that counts. And, according to research analysts McKinsey & Company, the strategy is working. India's medical tourism market is forecast to be a $22 billion business within six years.

Rather than luring patients with post-operation vacations, India's popularity stems from the quality of its healthcare and its competitive pricing structure, particularly for more complex operations. This reputation has led to India winning the tagline ‘First-class healthcare at third-world prices'. For instance, the cost of having a pacemaker fitted is less than US $7,500. In the US, the same operation could cost in excess of $20,000. A large percentage of Indian doctors are US or UK trained and several medical groups are internationally accredited, helping clients feel safe. India's comparatively short-haul flight is also an attraction in complex surgeries, as less air time means less chance of post-operative complications such as DVT.

Thakur, however, is keen to stress the importance of careful sourcing and independent medical advice when choosing any overseas healthcare provider. "It's very easy to put up an internet site," he says. "It doesn't mean a thing. Any recommendation for medical treatment a patient gets from abroad should be vetted by their GP. That one consultation with your doctor can make all the difference. Patients can be easily confused by medical jargon but GPs offer unbiased advice."

Grove goes one step further. "All patients should meet the surgeon and have a relationship with the practitioner, not just the agent selling the package," he says.

Reiterating BAAPS' guidelines to surgery abroad, he underlines the importance of not being swayed by cost. "Cheap can be expensive if something goes wrong," he adds.

Dr Richard Dawood, director of the Fleet Street Travel Clinic in London, also emphasises the importance of considering the worst-case scenario. "All surgery carries an element of risk," he explains. "It is not enough that a surgeon or hospital facility is adequate for the operation; they must be proficient enough to cope with worse-case complications as well, and be able to offer swift access to state-of-the-art intensive care as and when required."

Check local standards, he continues, pointing to the risk of counterfeit drugs. He also recommends researching the safety of the blood supply, warning "blood loss is a routine surgical risk."

When it comes to medical tourism, air travel is another. As the most overlooked aspect of health tourism, the question of how and when a patient should return home postoperatively should be high on the agenda. As Grove explains: "A lot of operations increase the ability of blood to clot and are therefore more likely to cause thrombosis when flying - especially in the ten days to two week period after the operation. This is NOT the time to be flying anywhere."

Robert Gluck is the director of ADAC Ambulance Service. Based in Germany, the company provides a fleet of air ambulances that carry out patient transfers worldwide. "Most people are happy to spend a lot of money on treatment, but they don't think about travel," he says. "Commercial airlines are not always a suitable form of transport for patients who have recently undergone an operation."

And an incident on a commercial flight, adds Darwood, could prove costly in the long-run. "Emergencies in the air are more likely, and difficult to deal with, on long-haul flights," he warns. "The circumstances on a flight are very different to the circumstances on the ground," Gluck adds. "Post-operatively, many patients have problems with landing and take-off; the difference in cabin pressure can be an issue."

While Gluck stresses that he is not suggesting every patient requires the use of an air ambulance, he does believe doctors should involve themselves in travel arrangements. He recalls the shock of seeing a coma patient unloaded in Munich, after travelling with a commercial Arab airline and a complete absence of medical supervision. "I couldn't believe it. He had been loaded on a stretcher and flown without any medical staff," he says. "Although the majority of patients won't need an air ambulance aircraft, don't just think about the treatment; think about the travel."

Counting the cost

For the majority of GPs, the primary drawback to medical tourism starts once the patient is back on firm ground. The issue of liability crops up regularly among wary doctors, as justification for giving health tourism a large berth. Internationally, the industry is unregulated and popular healthcare destinations are often countries with weak malpractice laws. Insurance companies don't yet offer medical tourism policies, raising the question of, should something go wrong during the operation or even once the patient has returned home, who is legally responsible? Doctors should advise patients to discuss these issues fully with their healthcare provider before committing to treatment.

Patients should also be aware that their travel agent is unlikely to be of help in the event of a problem. Many UK and US travel firms, where the market is more mature, negate the problem by ensuring patients agree contracts directly with the treating hospital. Dr Jagdish Jethwa, co-founder of the UK-based Taj Medical Group, describes his company as an intermediary between the hospital and patient, organising flights, transfers, accommodation and treatment quotes, but not care.

"We're just the brokerage and we don't give medical advice," Jethwa says. "The patient's contract is with the hospital, so it is the patient's risk. We're only putting them in touch, thought these are reputable hospitals.

Mohammed acknowledges that the issue of continuing care is the biggest concern for physicians when referring patients.

"Improper or insufficient aftercare is frequently the reason for complications, as opposed to improper surgical practice," he says. "At the very least medical reports, operative notes, results of imaging, biochemical and histopathological tests should all be provided to the patient so that follow-ups can be conducted elsewhere, if need be."

Incomplete medical records, poor details of care and a lack of accountability are all mentioned as areas for concern. "Should you have a problem, you can't nip back for a quick check-up with your surgeon if he is thousands of miles away," adds Darwood. "If anything goes badly wrong, costs can escalate. Insurance cover may not apply and legal liability can be impossible to resolve."

While Apollo's Thakur concedes that insurance cover can be a problem ("It's an area that concerns us. There are issues on international legislation that need to be thrashed out."), he argues that good overseas providers are perfectly capable of providing adequate follow-up care. "It's is an issue that concerns our doctors too," he explains, "They want to see how their patients are."

The Apollo Group, he explains, have referral centres in the Middle East that concerned patients can visit. The Group is also in the process of setting up tele-consults, which will enable doctors in India to assess their patients once they've returned home. "Like a webcam, the tele-consults will happen in real time. The doctors can send their reports back to the primary healthcare provider, and offer an accompanying consultation."

But for less high-tech hospitals, Thakur is realistic about the limitations of follow-up care. "Ultimately, when you go abroad, you go for treatment," he explains. "The chances of you seeing the doctor again are remote, unless it is a chronic procedure. The GP is the human element and the most important part of the treatment; once you come home the surgeon will not be there."

As a result, he says, patients should view overseas care as a joint effort between their referring doctor and the receiving hospitals to offer them the best care. "It seems like it's us versus them, but it should be a collaboration. The treatment is a joint effort to find what's best for the patient," he concludes.

The facts; questions every patient should ask

Before finalising a treatment contract, advise patients to secure replies to these questions in writing.

• Who will be operating?

• What medical qualifications and experience do they have?

• How many of these operations have needed unplanned follow-up treatments?

• What internationally agreed standards does the hospital meet and are there inspection reports available?

• What nursing support is available before and after treatment?

• What exactly will the treatment package include; e.g. recovery accommodation, access to specialist care if needed?

• Will there be extra costs for a travel companion?

• What happens if treatment is unsuccessful?

• Who will pay if a follow-up visit is required?

• What liability will the hospital assume in the case of accidents or negligence?

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