Head To Head

Will expansion of the NHS abroad benefit UK patients? Yes

BMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.e8493 (Published 02 January 2013) Cite this as: BMJ 2013;346:e8493
  1. Philip Leonard, director
  1. 1Healthcare, Ernst and Young, London SE1 2AF, UK
  1. pleonard{at}uk.ey.com

The new NHS mandate calls for hospitals to set up more profit making branches abroad. Philip Leonard says this will bring new revenue to the cash strapped service, but Allyson Pollock (doi:10.1136/bmj.e8496) says that promoting trade in healthcare over universal access benefits no one

One of the quirkier parts of the opening ceremony of the 2012 London Olympic games featured dancers dressed as doctors, nurses, and patients in NHS hospitals. It was met with baffled responses from some of the press, which saw it as celebrating Britain’s socialist heritage. Others expressed concern that it marked a new era of entrepreneurism: the NHS was now open for business and was preparing to export its national treasures to rich foreigners. Inevitably, concerns have been raised that this will be done at great cost to NHS patients because the best of the service will seek foreign gold and UK patients will be left with second rate healthcare.

These worries are misplaced. For a start, investors abroad are really interested in importing services from only the NHS’s mega-brands. These are specialist centres such as Great Ormond Street, Moorfields, the Christie, and some of the larger teaching hospitals, such as Guy’s and St Thomas’s, which already have a profile outside the UK. So the majority of UK patients will never be exposed to the risks (nor sadly gain the benefits) of being treated in hospitals that invest abroad. In possession of such powerful brands, any decent NHS hospital would be in dereliction of its duty not to seek new streams of funding for their core missions.

Consider, for example, options for delivery of elective care in the Middle East—a diverse market with few publicly available data on quality. NHS organisations have a huge advantage because for many years they have had to publish performance data. They have readily available evidence on the quality of their care that can be shown to prospective patients, investors, and business partners. Of course, there are many things to consider before making the foray abroad. But for a number of NHS organisations, the prospects are quite compelling. It’s unlikely, in the short term, that they will earn enough money to replace the huge savings being demanded by the Nicholson challenge. The NHS budget is enormous compared with the prospective income from overseas business. But that is because NHS Trusts are not yet experienced and resourced to pursue and deliver large deals. In time a number of NHS organisations will mature and gain the confidence to consider large, complex and well rewarded projects. For some specialist centres, it’s not inconceivable that 20% or more of their income could be generated with overseas clients, providing them with financial stability that liberates them to continue the delivery of world class medicine to NHS patients.

Secrets of success

Firstly, NHS organisations have to be clear about what they want to do. There are many options: joint ventures, working with dormant partners, direct delivery of services, training and development arrangements, and so on. Organisations need to be sensitive about how they operate abroad so as not to devalue the brand. A local partner may want to work in a different way from that adopted by NHS organisations at home. That is fine when the partner is providing helpful, practical advice about how to win work in the market but not when it wishes to cut corners on quality. It is tempting when operating in regulatory environments that are less rigorous than the NHS and where there is pressure on cost, to follow competitors by reducing price and quality. That’s not to say that NHS organisations must not do it, but it must be a part of planned strategy not mere opportunism.

Secondly, it is a fallacy that there is easy money to be made in wealthy oil states or emerging economies. NHS organisations need to work hard for it. Many foreign markets have some tough negotiators, who have for many years been wise to foreign organisations after a quick buck. The NHS will have to show its long term commitment to its hosts and make plans to stay in markets for years rather than a few weeks or months.

Finally, if NHS organisations intend to sell the services of doctors, researchers, and other staff abroad they need to recruit so that they have capacity and NHS patients are not let down. They will need to employ commercial specialists with the skills to develop relationships, design services for clients, assess risk, win contracts, and most importantly deliver abroad.

If the NHS does these things well, and there is every reason to think that it will, international markets offer great opportunity for the service to extend itself, offer its skills to the world, and secure foreign money that does the opposite of short changing UK patients. Indeed, those whose services are in potential demand have a moral obligation to serve their NHS patients by exploring overseas opportunities that will secure the future of their organisations and their world class treatment and research.


Cite this as: BMJ 2012;345:e8493


  • Competing interests: The author has completed the ICMJE unified disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declares no support from any organisation for the submitted work; Ernst & Young is a global professional services firm with a large portfolio of healthcare clients. It provides services to NHS organisations including support in developing propositions in overseas markets.

  • Provenance and peer review: Commissioned; not externally peer reviewed.