NHS bosses grumpy about new EU rights

The Government interrupted its week-long celebration of the NHS yesterday to issue a sharp warning to anyone tempted to desert it. Rather than welcoming a new EU Directive that codifies the rights of patients to travel abroad for treatment, the Department of Health gruffly announced that "health tourism" would not be funded by the NHS. This assertion missed the point so spectacularly that one wonders if anybody was awake in Richmond Terrace, the DoH's headquarters. The new directive - the result of several years of negotiation in which the Government has been fully involved - does not confer any new rights on EU citizens to become health tourists. Nor does it impose any new costs on health systems.

It simply says what is already EU law, though now codified in a far more comprehensive fashion. People have the right to travel and to have treatment abroad. If they do so, they will be reimbursed by the exact amount that their treatment would have cost in their home country. Nobody stands to gain or lose. Suppose a British patient decides he wants his hip implant done in Spain. If the local cost exceeds the NHS price (5,587 pounds for a straightforward cemented implant) he will have to pay the difference. If the cost is less, then the operation will have cost the NHS less than if he had stayed in Britain for it, and he will have reduced the queue by one. What's to worry about?

Now let's imagine the reverse scenario. An EU national, attracted by the paeans lavished this week on the NHS, decides he would like to come here for the same operation. Unlikely, but bear with me. If the NHS cost is higher than the cost in his country of origin, he will have to fund the difference. If it is less, the NHS will be reimbursed its normal tariff cost. The NHS will have to find room for another patient, but it will have been fully reimbursed for treating him. EU officials expect just one in 300 European patients to take advantage of the rules. The great majority will live on the mainland with attractive hospitals just over the border.

With a Channel to cross, the odds are that an even lower proportion of British patients will choose to travel. Anybody hoping to take advantage of a few weeks in a German spa - generously provided by the German healthcare system - will be disappointed. The NHS does not do spas. So it is not obliged to pay for anyone travelling to one. In any case, there is an opt-out clause. Should the numbers of British patients wanting to travel abroad become so large that they threaten the future of a service or a hospital here, they can be required to obtain a "prior authorisation" that would not in those circumstances be granted.

The new directive, it should be made clear, is distinct from the case law established by Yvonne Watts, who won the right to be reimbursed for having a hip operation in France when waiting lists in Britain were long. The judges at the European Court ruled that she was entitled to reimbursement if she had suffered undue delay in treatment. Under the Watts ruling, full costs would be reimbursable, not just the NHS tariff cost. But now that maximum English waiting times for elective operations are down to six months, it is unlikely that anyone would qualify under the Watts criterion - and they would have to go to court to prove undue delay.

The directive seems unlikely to create a flood of patients in either direction. In any case, there is a safeguard. The department's anxiety appears misplaced.

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NYTs Practice Of Medicine

In another one of those long, in this case 4278 words, articles by the New York Times, "Weighing the Costs of a Look Inside the Heart," it again demonstrates its failure to conduct or convey elemental journalistic research. And, again, an agenda appears at work. The result is that certain key facts and distinctions are omitted, which surely could have found space within this long article, that would have conveyed more and important information.

The agenda is rationing of health care. Rationing is inherent in the various schemes for "universal" or "single-payer" or "government-run" or "nationalized" health care. There's no doubt that some degree of rationing already occurs for those relatively few who truly can't afford insurance or co-pays but earn a bit too much to benefit from government programs. But, by shifting their earnings and taxes to the benefit of those few, the schemes would subject everyone else to rationing.

I'm a decades-long participant in HMOs, and even advocate them in areas like mine where their panels are so large and inclusive of the quality providers that there's nothing material to be gained by not being in one. However, most prefer more freedom of choice, as in PPOs, though their premiums are higher, and polls consistently show overwhelming majorities not favoring government-run health care. The fear is tangible and sometimes real that in case of an extreme circumstance or particular set of facts they will be denied covered care.

It's true, as the NYTs article says, that we collectively overuse medical care, and that costs. The problem is that, first, most of that is a personal decision and, second, the only way to drastically cut that cost would be wholesale imposed rationing that would often discriminate against many cases where the extra measure would save lives or make them more salutary. Third, many of the treatments proposed for rationing show demonstrated benefits but are, while not 100% proven - whatever that means, if even possible, discriminated against due to their cost. In that case, it's ironic that those who advocate greater preventive medicine, also advocate against preventive medicine.

The gist of the NYTs article is that overuse of heart CT scans is expensive, deliver large doses of radiation, may be spurred by self-interest profits by some doctor owners of CT machines, and the test and diagnoses not certain. As generalizations, that may be so. But, the NYTs fails to mention there are large-scale, reputable studies of those cases where it is proper and beneficial.

For example, the American Heart Association and American College of Cardiology Foundation in 2007 examined all the literature and studies to reach a "Clinical Expert Consensus Document on Coronary Artery Calcium Scoring By Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients With Chest Pain." Patients who either score low or high (high already evident for additional treatment) on risk predictors are not indicated for the test. Patients who are scored intermediate risks are indicated for the test, as "such patients may be reclassified to a higher risk status based on high CAC score, and subsequent patient management may be modified". Many other peer journal articles affirm this finding. This test, calcium scoring, is - as the NYTs mentions only briefly in passing - "a less extensive form of scanning," but is grouped in with the NYTs negativity toward coronary CT scanning in general.

The NYTs article ends with a quote from an opponent of CT scanning, "We're spending a lot of money on technology of unclear benefit and risk." The NYTs want us to forfeit individual or independent expert judgments to centralized government-run entities whose track-record on cost-benefit analysis is proven repeatedly faulty and causing higher risks. No thank you to a British National Health Service.

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