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If NHS waiting times are a pain, you might be tempted to consider going overseas for fast-tracked private treatment. Many of those who do find that cash-starved, overcrowded and grubby hospitals are actually more common in the UK than abroad, writes Mike Lowson Pensioner Yvonne Watts is not the kind of woman you would associate with a mould-breaking campaign. The disabled, frail, 75-year-old grandmother did not set out to change the way healthcare works, but she has done so. Her legacy could affect us all.

Today, the Press and Journal reveals that a north-east firm is offering to help patients beat NHS waiting lists by flying them to Dubai for surgery. Dubai Surgery is the brainchild of Aberdeen businesswoman Sarah Howard and believed to be the first to offer "medical holidays" to the United Arab Emirates.

Ms Howard is tapping into a growing demand for treatment abroad, for which Yvonne Watts was an unlikely pioneer.

Mrs Watts booked a double hip-replacement operation abroad when she found she might have to wait up to a year for an op on the NHS. Her local trust, in Bedfordshire, declined to meet the cost, but the European Court of Justice ruled last month that any EU healthcare system must pay the bill if a patient is obliged to look elsewhere in Europe for treatment because of hold-ups. The waves of that judgment are now lapping at the door of the NHS.

Increasing numbers are following in her footsteps, albeit privately, and travelling abroad to link sightseeing and shopping with medical, dental, and surgical services. Countries such as Mexico, Brazil, Argentina, Costa Rica, Dominican Republic, Peru, Hungary, India, Israel, Jordan, Lithuania, Malaysia, South Africa, Thailand and the Philippines are cashing in.

But if you are sniffy about the risks of being subjected to a medical procedure in a bureaucratic, cash-starved, over-crowded, grubby hospital under a doctor with a poor grasp of basic English, just think - that could describe some NHS hospitals here.

NHS Grampian says medical tourism is not a problem in the north-east, however. There are no ongoing costs because the problem has not arisen, it says.

A spokeswoman said: "We have a different situation here in the north-east from that faced by some other parts of the UK.

"If we needed extra help to cope with a delay problem, then we do have agreements with some private healthcare providers in the area to avoid us having to send anyone abroad for treatment." She added: "It is, of course, a matter of personal choice for anyone who might want to go abroad for treatment, and that is really out of our hands." Direct Health Care International, in London, is one operator now advertising widely. It specialises in organising treatments in Belgium. But why would people have surgery there rather than in Scotland? According to Direct Health Care International: "Belgium tops the list in the quality of its surgery, its clinical standards, its excellent after-care, negligible secondary infection rates, and medical staff speak English." Flexibility in the Belgian hospital system means most patients can be seen almost immediately and waiting times for surgery are often just seven to 14 days. And there is another benefit: "Belgium's spotlessly clean hospitals and theatres have no significant problems of secondary infections, and cases of MRSA are non-existent." The Coventry-based Taj Medical Group, which organises private medical treatment in India - one of the fastest-growing medical tourism destinations - stresses not only the standards of treatment but also the value of idyllic retreats and spas for post-surgery convalescence.

When it was founded in 2003, Taj Medical arranged treatment for a handful of people only, but it now receives more than 200 inquiries a day, many lured by the advertised cost savings. A hip-replacement operation with Bupa in the UK can cost more than GBP7,000, but Taj Medical offers the procedure in India for as little as GBP2,975.

Dr Peter Terry, chairman of the British Medical Association in Scotland, sounds a note of caution over such figures, however.

He said: "Before travelling abroad for treatment, patients should consider all aspects of the service on offer and not base their decision on price alone. Any surgical procedure carries a level of risk and patients should be aware of any potential complications that could arise.

"Patients should find out about the hospital they are going to - is the doctor qualified, is the centre regulated, what is the success rate for procedures and so on." Not all medical tourism is for surgical ailments, however. Other procedures such as cosmetic surgery and infertility treatment are also popular.

Anne McConnell, business manager of the Assisted Conception Unit at Ninewells Hospital, Dundee, has noticed the change, especially since a donor's right to anonymity was removed in the UK last year.

She said: "There has been an increase in patients seeking treatment abroad, mostly in Spain, due to the donor shortage in this country.

"But as these clinics are outwith the UK, they are not regulated by the Human Fertilisation and Embryology Authority (HFEA), we cannot recommend a particular clinic to patients." Dame Suzi Leather, chairwoman of the HFEA, said: "We are concerned that people who choose to have their treatment abroad should know about the potential risks.

"We have heard of some clinics which offer treatment to patients that is so dangerous it has been banned in the UK - for example, implanting five embryos which significantly raises the chance of multiple pregnancy, the biggest risk of IVF for mothers and babies.

"We would urge patients to think twice and consider the risks and implications before going abroad for treatment." Costs remain a big lure, however. A cycle of IVF treatment costs more than GBP3,000 in the UK, but about GBP2,100 in Warsaw, GBP1,800 in Slovenia and GBP1,700 in Istanbul. One centre in Chania, Greece, even advertises "IVF holiday packages", emphasising stress reduction in achieving a pregnancy.

Those down in the mouth about dental treatment are being wooed by Poltravel, a Scottish-based company specialising in dental treatments in Krakow, Poland. It arranges treatment, accommodation and flights and offers savings on time and treatment costs in Scotland.

One client, Sheila Gordon, who received a week-long treatment at a month's notice, was told by her Polish dentist that salaries and overhead costs were much lower than in the UK, hence the savings.

But increasing numbers looking abroad for a sun, sea and surgery holiday will not create a direct cost to the NHS, says the Scottish Executive.

A spokeswoman said: "Patients have been able to go to other EU countries for elective treatment ever since we joined the EU. However, there is no automatic right to be treated abroad and we would strongly advise any person who is considering such a move to speak to their NHS board first.

"The E112 (certificate authorising treatment abroad) is not available on demand; there is no automatic right to one and it was always intended to be invoked in exceptional circumstances." Peter Terry, of the BMA, says things cannot go on as they are.

He said: "Patients' needs must come first and although we have to accept that in the short term they may have to travel to receive care, in the long term, this cannot be sustained.

"Patients have a right to be treated where they can be supported by family and friends. They have the right to be treated in their own country, where they do not face language barriers on top of the stress of undergoing treatment." "Considering sending patients to a foreign country for treatment just shows how over-stretched the NHS has become." Official NHS figures for acute treatment in Scotland show the average waiting time for a new outpatient appointment was 56 days for the year to March 31, 2005. The average waiting time for patients treated in the same period was 43 days, up two days from the year before and higher in comparison with earlier years.

According to Norwich Union private health insurance, average waiting times in north Scotland are as follows: Procedure/waiting time in days...

Cateract removal 186 Knee replacement 312 Hip replacement 310 Tonsils removal 189 Varicose veins removal 190 Heart bypass 142 Abdominal hernia repair 134 Nose septum repair 220

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Jim Macleod of Canada had not been sure whether he would be cured of a crippling problem in his hips.

After a painful wait for 18 months back home to consult a surgeon, he was waitlisted for another 12 months to undergo a surgery. But perseverance paid.

Mr. Macleod surfed the internet to look for options outside his country; those that would be easy on his purse and end his agony soon.

His search for surgeons for hip resurfacing ended when he read about people from the U.S. undergoing the procedure at Coimbatore.

The Canadian came to know of Sri Ramakrishna Hospital's consultant orthopaedic surgeon G. Balasubramaniam having enabled a patient like him to resume skiing back home at Wyoming in the U.S.

Dr. Balasubramaniam said the Canadian spoke to him a couple of months ago and he and his wife landed in Coimbatore for bilateral (both hips) hip resurfacing with a space of six days between the two surgeries.

In 12 days after the operations, the patient was able to walk without any pain.

Cost of surgery

Judith Lawson of New Mexico in the U.S. said in an e-mail to Dr. Balasubramaniam recently that she was going hiking at a place that was 7,500 ft above mean sea level.

Swimming and sailing were also to be resumed soon. She too learnt about the growing medical tourism in Coimbatore and reached the hospital for resurfacing.

The surgery here cost her around Rs. 2.25 lakh while it was much higher in the U.S., apart from the agonising wait for one's turn for surgery.

Harry Bennewitt (59) from Florida in the U.S. was asked to cough up $ 35,000 (more than Rs.15 lakh) for resurfacing of the right hip.

The real estate agent had been suffering from osteoarthritis that prevented him from doing any exercise.

As a result, his weight touched 120 kg and he was confined to home by the pain in the hip. Mr. Bennewitt underwent resurfacing here in May-end.

Patty Adachi, a U.S. citizen of Italian origin, underwent resurfacing here as the solution offered back in the U.S. was total hip replacement that cost anywhere between $ 30,000 to $ 60,000 (from about Rs. 13 lakh to more than Rs. 25 lakh).

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NEW DELHI: Get a new knee or hip at a discount, take a companion along for free plus pocket some of the money saved on the operation. That's the kind of incentive some US companies are offering employees who travel to India for healthcare.

While individual foreign patients have been coming to India for quite some time now, this pioneering initiative by some small and mid-sized companies who are swamped by rising healthcare costs in the US may just open the floodgates for a new wave of medical tourism.

For companies, however, it's sheer economics at work. Blue Ridge Paper Products, a North Carolina-based manufacturing company which is considering the outsourcing option for its 2,000 employees, is looking to make a substantial saving since cost of treatment in India is 80-90% less than in the US.

But what will make employees travel thousands of miles to a strange land for treatment? "We plan to pay all the travel, lodging, meals, etc for the patient and one family member, plus give them up to 25% of the savings.

The savings will be based on the average cost of the procedure here in the US compared to what it costs in India," says Darrell Douglas, vice-president of human resources.

But before signing on the dotted line, a Blue Ridge team plans to visit hospitals in India later this month to assess their quality of care.

And it won't be the only one. IndUShealth, a medical tourism start-up which has tie-ups with Apollo, Wockhardt and Escorts, has many more visits lined up. "By year-end, several dozen companies will be on board.

Though India's growth story is well-known, many Americans don't know what it translates into in the healthcare space. Inspection of the excellent hospital facilities here will take care of all doubts," says Rajesh Rao, CEO and founder of IndUShealth.

Besides coordinating care between US and Indian doctors, IndUShealth takes care of the logistics and legalities. "We have case managers who ensure seamless care," says Rao, whose firm started off with individual patients before expanding to employer groups.

"Costs of healthcare are rising in the US with the result that providers want to shift part of the burden to consumers. The concept of co-pay where the patient has to foot around 20 to 25% of the surgery bill is becoming common.

In this context, the India option makes financial sense," he points out. For Indian hospitals, meanwhile, health is indeed wealth.

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The University of Sto. Tomas Hospital has earmarked up to P3 billion to upgrade its facilities, for expansion and for its plan to become a medical tourism destination.

In an interview, UST Hospital Medical Director Rolando Cabatu told BusinessWorld that the five-year upgrade and expansion of the hospital is aimed at, among others, enticing foreigners to have their medical needs addressed in the country.

"We are one of the six [private] hospitals that have been accredited for medical tourism. One of the projects that will be part of this is the international wing. This will be finished by 2008. The wing will have 50 to 100 beds and we will be utilizing the suites for medical tourism," he said.

Mr. Cabatu said that UST Hospital will offer a range of services, from cosmetic treatments to cardiac surgery. Other services that will be offered include eye operations and hip transplants.

He also said that their hospital has sufficient medical staff to cater to the needs of foreign visitors.

"We have five teams for cardiac surgery. We have enough doctors and nurses. Our medical staff has grown from 320 to 650," he said.

Mr. Cabatu said that UST Hospital is not looking at getting partners for its plan to venture into medical tourism. He also said that the hospital is just waiting for the government to concretize incentives that it has promised to hospitals that will engage in the sector.

"These are mostly tax incentives. Right now, these are all plans. Nothing has been concretized yet," he said.

Aside from putting a medical tourism component in the hospital, the P3-billion upgrade also includes equipment modernization, which UST Hospital has been implementing in the past two years, Mr. Cabatu said.

He also said that following the upgrade, UST Hospital will increase its number of beds. "It will be converted to 1,200 beds from 800," he said.

He said, however, that the charity ward, which currently has 460 beds, will not be expanded as "it is a cost for us."

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The Philippine Medical Tourism Program, started two years ago to cash in on the growing number of patients worldwide traveling to get cheaper medical treatments, is steadily growing, according to a Philippine news service.

According to Undersecretary Jade del Mundo, head of the Philippine Department of Health's medical tourism program, people are coming because treatment is much cheaper than in their respective countries like the US. Del Mundo said the program has had tourists from South Korea, Japan and China in Asia, and Germany, France and the Netherlands in Europe, as well as the US.

Since available kidneys are scarce in the Philippines foreign patients are asked to "bring your own kidney donor" who is usually a relative or close friend, Del Mundo told news.inq7.net., adding , "We don't want Filipinos to be sacrificed in favor of medical tourism."

There are five government and five private hospitals being marketed by the government as centers for the local medical tourism program. They include Capitol Medical Center, St. Luke's Medical Center, Asian Hospital, Medical City, Makati Medical Center, Lung Center, Philippine Heart Center, National Kidney Institute, Philippine Children's Medical Center and East Avenue Medical Center.

The cost for a kidney transplant is P3 million (about $60,000 US). Lasik surgery on the cornea is about P60,000.

Del Mundo predicted the country will catch up with neighboring countries in the multibillion-dollar global medical tourism industry over the next three years. "It will catapult us to the world stage of medical tourism and will be a dollar earner. At the same time, it will help stem the tide of brain drain in the Philippines," he added.

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Byline: Sujata Dutta Sachdeva

New Delhi: Outsourcing is not the only reason why Americans are unhappy with India. Medical tourism seems to be giving them a heartburn too.

And in order to stem this outflow, American hospitals are going in for aggressive marketing strategies and making patients aware about safety and insurance issues.

Anything to save their turf. Richard Merli, managing editor, Health Care Insider, KPMG, recently wrote in his weekly health analysis: "American hospitals may dismiss those patients as low or middle-income consumers who lack health insurance and might not get the procedure done in the US.

But industry observers say that the exotic locales and prospect of a vacation is attracting many wealthy patients to have elective surgeries done abroad." Last year alone, around 1.5 lakh medical tourists visited India.

According to CII, their numbers are growing at 15% per annum and by 2012, medical tourism will generate $2.3 billion annually.

In fact, the allure of low-cost medical procedures has tempted many Americans to make a trip to India. No wonder US hospitals are raking up safety issues to limit the outflow.

Merli argues that foreign hospitals often require medical tourists to sign contracts waiving their right to sue the institution/physician for malpractice.

Patients may have little recourse for a botched-up procedure, or may face costly complications once they return to the US.

Adds Saul Helman, Pharmaceuticals Practice, MD, KPMG, "All the protection afforded by the US health care system - board-certified physicians, the FDA and a legal system that supports patient rights - are void as soon as one steps out of the (country).

A patient runs the risk of being exposed to a physician not trained to the level expected in the US. They may also be exposed to non-FDA-approved medication and devices or techniques."

Indian hospitals however feel this is a knee-jerk reaction. Anne Marie Moncure, MD, Indraprastha Apollo Hospital, says, "Every year, 98,000 patients die in US hospitals due to medical negligence and three to four times that number is left permanently-disabled.

Clearly, American hospitals are on the defensive. This is a typical case of American protectionism. Patients are looking elsewhere simply because the US has not done enough to cut costs."

As for FDA-approved techniques and devices, they're used by all hospitals that attract medical tourists. "At Apollo, Delhi, the 64 slice CT angio machine manufactured by Toshiba is the same as that used at John Hopkins Hospital, New York. Stents too are FDA-approved, so where's the difference?" Moncure asks.

There are also nearly 41,000 doctors of Indian origin working in the US presently. In fact, physicians from India are considered among the best in the world.

Dr Anupam Sibal, group medical director, Apollo Group asks, "Why would anybody want to travel outside if they get the same quality at lesser cost.

Surely, we are giving them a better alternative. Also, many of the elective procedures they come for are not covered by insurance in the US."

Interestingly, in a bit of reverse marketing, Cedars-Sinai Medical Center in Los Angeles is reaching out to patients outside the US who may wish to get complicated surgical procedures done there.

An influx of foreign patients, they feel, will offset American patients who opt to go overseas. The long-term solution, says Harpal Singh, chairman and MD, Fortis Healthcare, lies in partnerships. "It'll be mutually beneficial for both them and us."

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MUMBAI: The recent floods in Mumbai proved it. Hurricane Katrina's devastation in New Orleans underlined it. Ignore the public healthcare system and people pay the price.

This formed the gist of the discussion at a public meeting called by rights activists on Friday to highlight the systematic erosion of the public healthcare initiative by government bodies, driven by the privatisation mantra.

The public sector's privatisation mantra and the private enterprise's medical tourism dreams will put healthcare beyond the reach of the poor and middle-class population, said human rights activists.

The meeting, called by the Lokshahi Hakk Sanghatana, also decried a move by the Wadia Maternity Hospital's management to establish a modern 100-bed speciality facility and a mall within the complex.

"We have conducted a detailed study about existing moves to privatise the public healthcare set-up and concluded that even partial privatisation can cannibalise the existing set-up," said the Sanghatana's Hutokshi Rustomfram.

In other words, in any hospital that operates as a partially public and partially private set-up, poor patients will be told to pay their way if they want instant treatment. "They will be told that if you want immediate scan or surgery, pay up or wait indefinitely," she explained.

The report looked at six city hospitals-Marol Cancer Hospital, Cooper Hospital, Siddharth Hospital, V N Desai Hospital, BSES Hospital and Nowrosjee Wadia Maternity Hospital. In each instance, the report noted that the state machinery was trying to wash its hands off healthcare.

For instance, in the plan to set up a hospital in Marol. While Seven Hills, a private firm, will build and operate it, the BMC will get Rs 10.42 crore each year (to be increased by 10 % every year) for 60 years.

"BMC absolves itself from maintenance and running expenses, gains a few crores each year and shrugs off responsibility in return of a paltry 20% of the facilities reserved for its patients," it noted. The main problem with the public-private mantra is that "the right to health is reduced to a scarce handout".

While promoting medical tourism, the activists noted that entrepreneurs would only concentrate on building super-speciality of, say, 100 beds in place of huge hospitals and cater mainly to paying tourists.

"Not just the poor who depend on the public healthcare system, even the large middle class will be affected by this phenomenon," said Anthony Samy of the Sanghatana.