Patients seeking treatment abroadBMJ 2010; 341 doi: https://doi.org/10.1136/bmj.c5769 (Published 18 October 2010) Cite this as: BMJ 2010;341:c5769
All rapid responses
The editorial by Legido-Quigley and McKee (BMJ 2010;341:c5769) raises
some of the truly thorny issues that health care authorities must manage
when dealing with the growing trend of patients seeking medical care
outside of their country of residence.
The reception of patients exercising their right to seek treatment
abroad has become a challenge for health care providing organisations that
has been further accentuated by the recent enlargement of the European
Union. As with countless other children's hospitals throughout the
continent, our centre, the largest public tertiary paediatric facility in
Italy, is progressively coming to grips with this new emergency.
Particularly relevant are the numbers of children coming from former
Soviet bloc states, where health care standards are still often sub-par
and cannot guarantee adequate early diagnosis and advanced treatment (1-
3). Survival curves aptly demonstrate this sad reality (2).
Without even considering the medical issues, the migration of
patients entails a myriad of difficulties (financial, administrative,
logistical, psychological) and involves the efforts of scores of
individuals, both inside and outside the hospital (embassies, patient
organizations, NGOs). At the outset of this decade our hospital witnessed
a dramatic rise in the arrival of foreign inpatients, with the number of
non-Italian nationals exceeding 800 in the year 2004. This trend, at its
origins driven by families directly and by patient charities, has since
then essentially levelled off, thanks chiefly to intervention by foreign
governments that must now authorize hospitalizations (and reimburse
medical costs) for seriously ill children only. But there's the rub:
although we now see fewer foreign children (slightly more than 500
patients in 2008), the severity and complexity of the cases that still
reach us demand the commitment of highly specialised staff and costly
resources. Moreover, the severity of conditions with which these patients
present inevitably requires prolonged stays of weeks, if not months.
Particularly burdensome in this context are the communication and
understanding difficulties that often arise during interactions with
patients and their families (5). And as if this were not enough, waiting
lists for especially complex procedures, e.g., blood and marrow
transplantation, continue to grow.
Indeed, further discussion and exchange on measures for the
sustainable management of migrating patients are needed and most welcome.
1. Ibrahim SA: Health inequities: a global concern. A. J Public
2. Senior K: Disparities in cancer survival and cancer care across
Europe. Lancet Oncol. 2009;10:214-5.
3. Senior K Health migration and childhood cancer. Lancet Oncol
4. Roberts JH: The impact of global inequities on health professional
migration. Policy Polit Nurs Pract 2008,9:323-327.
5. Shein A., Gatard R, Dhami S: Consultations for people from
minority groups. BMJ 2008; 337:273.
Competing interests: No competing interests
Sir, we welcome the article by Legido-Quigley and McKee on patients
seeking treatment abroad for at least two reasons: one reason is, because
of the inevitability of an aging population across Europe and a second
reason is, because of aspects of lifestyle which have changed in the past
20 years across Europe in the adult working-age group populations.
The article clearly describes lessons learnt from cases already
seeking care elsewhere and their difficulties in meeting the deserved
reimbursement. Ten years ago some colleagues challenged the
idea of cross-border healthcare, justifying it as 'unfair' for richer
European countries to provide a needed care for migrants from other parts
of Europe, not necessarily of the world. They obviously were not
acquainted with Bismarck's principle of solidarity in social health
insurance or with the "healthy worker" effect.
In protecting the public's health two other things spring to mind:
prevention services and quality of care.
Sexual health, unlike other aspects of physical health, remains a
"tabu" subject, yet as humans we are all touched by stories in the media
regarding human trafficking. The phenomenon has been with us since very
old times: whatever area of life it covers, sexual or other, human
trafficking is exploitation.
In 2000, the Dutch legalised brothels. This was a leap after 88
years, as the new law lifted the 1912 ban on brothels, to bring in "safer
sex". Added to the problem was that about 40 per cent of the prostitutes
were illegal immigrants who did not officially exist. Many were from
Eastern Europe and also other parts of the world, such as African
countries, as media reported at the time. The Dutch went on to review the
law in 2007 considering that activities have not been controlled as
previously thought and that many lessons were already learnt as a result
of the legalisation.
A similar approach was taken by Germany in 2005 (around the World
Cup) and by 2009, this legalised activity has turned to market forces in
terms of supply and demand with media sources quoting price cuts in
services and even an introduction of 'loyalty cards', something of which
we only normally hear around super- and chain stores.
In Spain, brothels were legalised in 2006 and again, quoting the
media, brothel-owners themselves claim that prostitution, and its spin-
offs, are now an Euro 18bn (GBP12.4bn) business sector - equivalent to
half of Spain's education budget. Prostitutes come from 15 developing
world and eastern European countries. Furthermore, at the time Spain's
National Statistics Institute reported in 2003 that more than 27% of
Spanish men under 49 had had sex with a prostitute during their lives, and
one in 15 over the previous year - "noticeably higher than those in other
surveys in Europe". This makes the phenomenon not exactly a rare one and
the health of both self-employed women and clients alike remains at stake.
Now, four years after the latest EU enlargement the Spanish commune
La Jonquera, at the border with France, will host Europe's largest brothel
and will be in direct competition with a neighbouring facility in a
similar small population. These are communities of around 3,000 "static"
populations yet benefit from the passing by of 6,000 trucks or "dynamic"
population, mostly male.
I have more questions than answers to many of the issues arising as
all of a sudden things become very complex:
What does this all mean? What have the Dutch, the Germans and the
Spanish learnt and what can they share with the rest of Europe's or the
world's public health communities?
Should migrant populations as well as the local static ones fear
emerging or even existing sexually transmitted communicable diseases?
Do these establishments benefit from appropriate health facilities?
Have they got health policies?
Are languages a barrier or is communication ensured to meet the cross-
border health care needs in all these areas?
What about the self-employed women of working age who come from as
far as other continents, who ensures their equal access to health care?
How does the wider EU cross-border healthcare right, as a basic human
right, cover them, too?
Whereas chronic diseases and surgical acts may involve health
planning and where time is of essence, too, in this area of health a
different type of organised cross-border healthcare needs to be promoted.
It will be a case where the EHIC may not be sufficient as one once
Competing interests: No competing interests