Time to end the political rhetoric on health tourism
BMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h2215 (Published 28 April 2015) Cite this as: BMJ 2015;350:h2215
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As authors of the Department of Health commissioned report on the cost of visitors and short-term migrants to the NHS in England (1), we strongly agree with Schulkind et al. (2) that it is “time to end the political rhetoric” surrounding this issue. However, whilst we commend Schulkind and her colleagues for taking our politicians to task for the misappropriation of information we would like to suggest that her interpretation of our report is also inaccurate. Far from being “absurd” our report was a credible attempt to quantify visitor and short-term migrant use of the NHS in the absence of any statistics directly measuring this. Peer review of our work supported our findings.
When, during the Leaders’ Debate on 2 April 2015, Nigel Farage confused our overall estimate of the costs of the use of the NHS with ‘health tourism’ we were more annoyed than anyone. We were however pleased to see that FullFact (3) for instance used our report to debunk some of the claims made about this. A further positive sign was that when, during the BBC programme “Election 2015: Ask Nigel Farage”, the aforementioned again conflated the normal use of the NHS with health tourism the interviewer (Jo Coburn) used figures from our report to correct him.
Our report was commissioned to estimate the cost of visitors and short-term migrants to the NHS. The analysis is a top down estimate based on the best available data in the public domain at the time of analysis (July and August 2013). This includes data from the 2011 Census, the International Passenger Survey 2012 and other statistics from the Office of National Statistics, the Department of Health and the Home Office. We derived a daily equivalent visitor population i.e. the number of visitors and short-term migrants (mostly staying under a year) present in England on an average day. This was then analysed by age and gender to enable the populations to be associated with the relevant health costs. With a daily equivalent population of just under 2m, the costs of the regular use of the NHS were estimated to be about £1.4billion.
Building out from this analysis, we estimated the cost of irregular migrant use of the NHS to be about a further £330m, based on a Home Office accepted estimate of irregular migrants of 580,000. The uncertainty surrounding these estimates was fully acknowledged.
We also distinguished the normal use of the NHS from ‘health tourism’ and provided a taxonomy of use, of which two groups were our focus: deliberate intent and taking advantage. We highlighted the fact that, as with any irregular activity, the numbers are highly uncertain and our estimates were plausible ranges rather than distinct values. We advised that these numbers should be used with caution. We thought that deliberate use of the NHS lay between £20m-£100m and the taking advantage category was plausibly between £50m and £200m. These are costs over and above the normal use of the NHS.
Instead of dismissing our research it would have been more helpful if Schulkind et al. perhaps had a greater understanding of it. Her letter quotes Doctors of the World who reported that only 1.6% of migrants at their London-based clinic left their country for health reasons, the majority are here to work, study or escape persecution (4). We did not classify these people as ‘health tourists’. If they were legal migrants, they would be included in the main categories of work, study and family. Our report also explained that people receiving treatment for infectious diseases were not included in the figure for recoverable costs as these patients are eligible for free treatment to protect Public Health. We drew no inferences about how much it costs to provide non-UK nationals with treatment for HIV.
Schulkind also states that ‘Evidence of health tourism from the front-line is equally lacking’. We would like to point out that qualitative research (5) commissioned by the Department of Health at the same time as ours provides evidence that this does happen. Our report provides some scale to that problem. At the most optimistic view this is measured in tens of millions of pounds. This is not a big number in the context of the £100bn spent on the NHS in England, but in absolute terms is a substantial amount.
In this context, credit should be given to the Department of Health for using the evidence in the report to shift the emphasis of policy from dealing with alarms over ‘health tourism’, towards the proper application of the rules around the recovery of costs from other EEA states and from individuals who are not ‘ordinarily resident’ and are not entitled to free treatment.
Finally, it is also worth emphasising that our report was based on evidence from empirical research which shows that generally migrants are less likely to use NHS services than UK-born individuals. Our report summarises this evidence. Rather than believing Nigel Farage’s misinterpretation of our report it would have been better if Schulkind and her colleagues had used it to help dispel the hysteria around migrants abusing our health service.
Ian Bennett
Director, Prederi
Darren Waite
Senior Consultant, Prederi
Dr Anita Jolly FFPH
Consultant in Public Health Medicine, Prederi
anita.jolly@prederi.com
Sent on behalf of Prederi
References
1. Prederi. Quantitative assessment of visitor and migrant use of the NHS in England: exploring the data. Prederi, London; 2013
2. Schulkind J, Biggart R, Bowsher G. Time to end the political rhetoric on health tourism. BMJ 2015; 350:h2215
3. https://fullfact.org/health/costs_health_tourism-37227 [Accessed 03/05/2015]
4. Shortall, C. The truth about health tourism. Doctors of the World, London; 2014 http://doctorsoftheworld.org.uk/blog/entry/the-truth-about-health-tourism. (accessed Apr 5, 2015)
5. Creative Research. Qualitative Assessment of Visitor and Migrant use of the NHS in England: Observations from the Front Line. Creative Research; London 2013
Competing interests: No competing interests
Obviously there must be some expense inherent in our policy towards health care for visitors and immigrants, both regular and irregular. The NHS has some of the most generous rules in the world, allowing free access to primary care for any visitor to the UK, including tourists, and free access to all NHS care for foreign students and temporary residents. Only NHS hospitals have a statutory duty to charge, and even then, emergency treatment provided in an Accident and Emergency (A&E) unit is free. Your correspondents Schulkind et al (1) argue that the entire premise of health tourism is unfounded. Presumably they mean the premises that people travel to the UK to gain access to our health care system. They dismiss the calculations of “Quantitative Assessment of Visitor and Migrant use of the NHS In England: Exploring the data” completed by Prederi in July to September 2013 as an "absurd theoretical calculation". This unsupported assertion should not be allowed to pass without comment.
We do not have accurate or in many cases any figures on what it costs to provide the generous care policy as defined above, therefore estimates have to be made using available data. That is what Prederi do and state clearly. The partner document to Prederi was the qualitative assessment (Qualitative Assessment of Visitor and Migrant use of the NHS in England Observations from the Front Line, prepared by Creative Research), which runs to 248 pages and gives a real insight into the difficulties in assessing who is or is not eligible for free treatment under the NHS. To say this is not a problem is to simply sweep under the carpet a potentially crippling burden of health care arriving in our country from the whole world.
Everyone wants something for nothing, that is human nature, and some visitors do intend to work the system to their benefit. Some of them will succeed. Health care 'Free at the time of access' (a policy supported by UKIP) is a noble aspiration. But there have to be limits and the government through the department of health has set limits and guidance on implementing them. It remains the case that a visitor to these shores who tests positive for HIV will be eligible for treatment if they meet the eligibility criteria. But it is costly. We need to recognise that fact and include it transparently in the calculation of what our policy on free health care for visitors and migrants, both legal and irregular, actually costs the tax payer.
Competing interests: No competing interests
This is a correction to the author details of this letter.
Gemma Bowsher, last author, is a medical student at Kings College London. The address is:
King's College London
GKT School of Medical Education
Guy's Campus
London
SE1 1UL
Competing interests: No competing interests
Private practice is not unethical.
I do not see the reason why someone should call or even think that private practice is 'unethical'. In my opinion this is a matter of personal choice and circumstances.
Given the fact that private practice has its pros and cons from physicians' perspective, the patients may see it differently. Consultation and receiving medical care from a private practitioner does suit few patients as compared to them seeking the same at a government or public facility. The major advantages are, however, waiting time, cleanliness and personal attention.
Private practice is a different ball game in different parts of the world and it all depends on which part of the world you are practicing in. Having worked in the East, West and now in the Middle East (in a semi-private hospital), I must say private practice is challenging, tasking but enjoyable.
One would, however, need to balance work and life outside work.
I would highly recommend that one should 'taste the flavor' of private practice if the circumstances permit but should not overindulge.
Competing interests: No competing interests