The recent global economic down turn has forced many countries governments to prioritise spending, with the United Kingdom supporting a National Health Service these cuts have also been reflected in the budgets received by Primary Care Trust from the Department of Health. This has subsequently resulted in an unacceptable postcode lottery when considering the need and implementation of Laparoscopic Band or Gastric Bypass Surgery.  Despite the clinical guidelines from Central Government agencies remaining the same, many surgeons are “rationing”  treatment and creating a landscape that is “inconsistent, unethical and completely dependent upon geographical location.”    In 2009 in the UK less than 4300 bariatric surgical procedures were carried out against a back drop of increasing obesity figures being logged with the National Health Services own information centre. This situation has resulted in a burgeoning medical tourism trade of both qualifying and non-qualifying patients heading out of the UK on one of the many ‘weight loss surgery’ package holidays being widely advertised on the web.  This practice gives rise to a number of separate ethical issues ranging from the credibility of the surgeon, facility, aftercare package whilst notwithstanding the overarching ethical consideration of taking what is considered to be elective surgery.

There are a number of ethical, political, economic considerations and implications of the burgeoning medical tourism trade. The UK are currently a major exporter in this industry unlike countries such as India, Hungary, Bulgaria, Thailand and Spain who are some of the largest benefactors from such practices. Bulgaria for example undercuts the UK by approx 66% for hip resurfacing operations and in many dentistry procedures, whilst a Coronary Artery Bypass Graft (heart bypass) is over £10000 cheaper in India as opposed to the UK.   Many of these procedures are likely to be available on the National Health Service  within the UK, with the obvious exception of the dental work which may be available on the NHS but is not free at the point of service, which was considered the ethos of the NHS by Aneurin Bevan in 1948.   It is policy decisions such as the unique classification of dentistry within the NHS and the Government’s decision to regulate NHS treatment to patients who fit into pre determined boxes, which has seen a huge escalation in individuals taking their treatment and potentially health and welfare into their own hands by engaging in the phenomena that is medical tourism.

In pure economic terms the UK’s position as a key exporter of medical tourism, this has an interesting effect on the UK’s economy as there are obvious areas of savings which not only include the cost of surgery, but if the surgery is a procedure to correct a medical condition for which the NHS is already supporting through drug therapy or some other form of rehabilitation then savings are already being made.  This, though compared with purely cosmetic or elective surgery, where there is no pure economic benefit to the UK, but there may be a huge cost if the procedure fails and the cost to rectify these errors may fall under the home jurisdiction and health services.

I believe that the UK Government, through the chain of hierarchy through the Department for Health down to the Strategic Health Authority and finally the Primary Care Trust, are both upholding and positively encouraging the practice of medical tourism by acting outside of their own guidelines and not providing treatment on the NHS, to patients who quite obviously fit into the required criteria, to either save financial resources or to prevent a “flood gates” effect.  This is true of many Primary Care Trusts with respect to Bariatric Surgery where a post code lottery has again ensued resulting in further health inequality in a system that was designed to alleviate such inequality.  As I have already noted, despite the clinical guidelines  from Central Government agencies remaining the same many surgeons, albeit typically vicariously through Primary Care Trusts and administrators, are refusing to offer surgical bariatric treatment procedures to a number of patients who clearly fit the criteria laid down by the Government agency.  The 2006 National Institute of Clinical Excellence’s 2006 guidelines recommend that surgery be available if the patient has

• A BMI of 40 kg/m2 or more, or between 35 and 40kg/m2and other significant co-mobility factor such as type II diabetes, high blood pressure or heart disease, that could be improved if they lost weight
• Tried all appropriate non surgical measures to achieve and maintain clinically beneficial weight loss for six months, and these interventions have failed
• Been receiving intensive management from a specialist obesity specialist service
• Been passed as fit for anaesthesia and surgery
• Committed to the need for long term follow up

As previously mentioned, in 2009 in the UK less than only 4220 bariatric surgical procedures were carried out against a back drop of increasing obesity figures. The UK 2010 figures  show that 60% of the adult population are seen as overweight or obese.  Overweight is defined as a Body Mass Index (BMI) between 25 and 30 kg/m2 and Obese is defined as a BMI of Over 30kg/m2.  This position is typified by Oxfordshire Primary Care Trust who set their criteria at a Body Mass Index of greater than 50 kg/m2 with co-morbidity rather than the national guidelines of a BMI of greater than 35kg/m2 with co-morbidity or a BMI of over 40kg/m2 without the presence of a co-morbidity factor.   This demonstrates a huge disparity in policy and practice, or even policy and policy.

This domestic uncertainty has opened up a growing market in all forms of obesity surgery, though the lap band appears to be the procedure of choice for medical tourists due to this procedure being less invasive and requiring a shorter recovery period.  Whilst this may appear to alleviating a potential burden on the NHS it is necessary to factor in remedial surgery when these practices unfortunately go wrong. Anecdotal evidence shows that for every satisfied medical tourist there is another who is either merely unsatisfied or requires surgery in the UK, on the NHS, to rectify a post surgical complication.

References

  Daily Telegraph 21st January 2010 viewed at http://www.telegraph.co.uk/health/healthnews/7035013/NHS-rations-obesity-surgery-to-save-money.html viewed on 25/03/2010
  Taken from the 2009 Royal College of Surgeons Annual Conference
  Lunt N, Carrera P. Medical Tourism: Assessing the Evidence Abroad, Maturitas 66 (2010) 27-32
  From here on referred to as the NHS
  A message to the medical profession from the Minister of Health. Lancet (1948)  2: 24
  http://www.oxha.org/knowledge/publications/uk_nice_guidelineonobesity_dec06.pdf
  NHS Information Centre Statistics on Obesity, Physical Activity and Diet: England 2101
  www.oxfordduppergi.org.uk

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	Healthcare Rhetoric and the Medical Tourist. pdf