The consequences of patient export

1
The consequences of patient export

• Jullien GAER
• Royal Brompton Harefield Hospitals
• Bio City Development Company

2
Reasons for exporting patients

• Innovative therapies
• Rationalisation of resources to reflect
  demand/population size
• Lack of facilities/expertise locally
• Lack of confidence in local facilities/expertise

3
Innovation

• Thoracic transplantation in the UK in 1980s
• No lung transplant programme in other countries
  of EEC
• EEC nationals entitled to seek treatment
  elsewhere in EEC if treatment not available in
  country of origin

4
Lack of local facilities/expertise

• Patients travelling to other countries for
  treatment
• state funded
• privately funded
• Failure of investment in UK NHS leading to long
  waiting lists

5
Lack of confidence in local facilities/expertise

• Lack of confidence is a direct consequence of
  patient export not vice versa
• Demoralisation of personnel institutions

6
The vicious circle
7
The virtuous circle
8
Creating centres of excellence on a shoestring

• Institut du Coeur, Ho Chi Minh City, Viet Nam
• Political will
• Individual drive
• Progressive reduction in foreign involvement
• Now financially clinically autonomous

9
Why is this happening?

• All professions are conspiracies against the
  laity.
• The Doctors Dilemma,George Bernard Shaw, 1906
• 1st doctor What did you charge him?
• 2nd doctor 200.
• 1st doctor What had he got?
• 2nd Doctor 200!

10
We all like the feel of a fat wallet

• Adam Smith (1723-1790)
• It is not from the benevolence of the butcher,
  the brewer and the baker, that we expect our
  dinner, but from their regard to their own
  self-interest. We address ourselves, not to
  their humanity but to their self-love.. (The
  Wealth of Nations, 1776)

11
Duty

• Those general rules of conduct ... are of great
  use in correcting the misrepresentations of self
  love ... The regard of those general rules of
  conduct is what is properly called a sense of
  duty, a principle of greatest consequence in
  human life, and the only principle by which the
  bulk of mankind are capable of directing their
  actions
• (The Theory of Moral Sentiments, 1757)

12
Openness

• Risk stratified publication of mortality data and
  other outcome measures in lay press

13
Quality maintenance

• Anyanwu Treasure Unrealistic expectations
  arising from mortality data reported in the
  cardiothoracic journals. J Thorac Cardiovasc
  Surg 200212316-20
• Compared the mortality data in papers published
  in leading cardiac journals with national
  databases
• Mortality for major cardiac procedures
  approximately half that recorded in national
  databases

14
Evidence based practice

• National Institute for Clinical Excellence
• a statutory body whose goal is to assess the
  clinical efficacy cost effectiveness of both
  new and existing therapies devices

15
Personality cults
16
Personality cults

• Personality cults are the result of
  corrupt/inadequate medical systems
• NB no one asks the name of the pilot before
  getting on a plane, we should be aiming for the
  same in medicine
• The system/brand is what guarantees the quality
• When trust breaks down personality cults replace
  system/brand quality

17
Achieving the virtuous circle

• Political will and vision to realise that
  investment in research training will reap
  enormous rewards
• National training bodies and accreditation of
  professionals
• Evidence based best practice

18
Achieving the virtuous circle

• If you need outside help choose an operator who
  isnt just making you pay his marketing costs
• Discourage the social and financial elite from
  seeking treatment abroad
• Withhold state funding for treatment overseas if
  same is available locally