Wednesday, 21 January 2009


By chance I saw two patients from other European countries in my surgery this morning. Both of them irritated me, although I tried very hard not to let this show. And because I was aware of my irritation I also tried to be fair to them.

The first was a young man who has booked an arthroscopy for his knee pain, to be carried out by an eminent orthopaedic surgeon in his home country in just two months time. Since he pays taxes and national insurance in this country he would like the NHS to pay for his operation, and he has found out that he needs an E112 form for this to happen. Guess whom he was advised to see about this? You have guessed correctly - his GP.

At first I was affronted - why should this man come to live here and then expect the NHS to pay for an operation back home? But I could also see his point of view that since he was paying his contributions he was entitled to an operation, and why shouldn't he have it done in his preferred European country? Fortunately I had a fair idea of how the system worked and a quick search on Google confirmed that I was right. The NHS will pay for such an operation provided that an NHS consultant has confirmed that the treatment is necessary and that it is not available “without undue delay” in this country. I think that the local waiting list for knee arthroscopy will not be considered as constituting “undue delay” and so the NHS commissioners will turn down my patient's request. I also suspect that he will run out of time before the decision can be made. In either case he will be faced with the choice of a free operation in the UK or paying for it to be done back home. I told him all this and he asked to be referred to an NHS consultant, which I have done.

The second patient was a woman who has had several miscarriages and is now in the early stages of another pregnancy. I have already referred her to our local experts and she is due to see them in a few days time. However she has just been back to her own country to see her own gynaecologist and has brought back a list of treatments that he wants me to prescribe and blood tests that he wants me to order. She wants the results of those tests to be sent to her gynaecologist so he can continue to monitor the situation.

I can foresee problems here with the patient running between two experts in different countries and expecting me to carry out the wishes of the foreign expert if they differ from those of the local expert. That is really an untenable position for me to hold. And although my patient undoubtedly has great faith in her “home” expert I don't know him from Adam. I do not want to act as his proxy in this country. But of course I understand that my patient will treat his word as gospel and may have little faith in “our” expert. I felt I had to take some sort of stand, and fortunately she has a sufficient supply of the treatments recommended by her expert to last until she sees our expert so I declined to prescribe anything until she sees him. As far as the blood tests are concerned, some of them are routine antenatal bloods which will be done in due course and have no bearing on her problem of recurrent miscarriage. The problem with the other tests is that I would not know how to interpret them if I ordered them. It would not be right for me to order blood tests on behalf of her expert and then take his advice, with all the problems of language barrier (he does not write very comprehensible English) and medico-legal problems of responsibility. I also think it will be a bad thing for my patient to be under the care of two experts. I have tried to explain all this to her, but her command of English is not perfect and I don't speak her language at all.

I hope I have not upset her or appeared rigidly unhelpful. She may yet need my help if things go wrong in the pregnancy despite the best efforts of experts in two countries.


Anonymous said...

as ever you wankers in the nhs running a sub 3rd world service for your own benefit and not the patients

why the fuck should anyone paying taxes in the UK not be entitled to an operation anywhere they dam well choose? especially given the shit and dirt on the walls of the average NHS facility

and why can folk not choose their own consultant across borders? what total bollocks

the sooner GP's need their money from patents paying them directly the better and you fuckers can bend to our will

btw my wife kept alive by advice from various consulants in diabetic medicine in other countries as the NHS only see fit to give her access to a nurse and a typical inner city GP who is fucking useless... thank God for easy international travel I say

what a fucking waste of money the NHS is

Doctor Daedalus said...

You have never experienced healthcare in a third world country, my sweary little friend. If you had, you would have some tiny inkling of just how bad things are there.

For instance, I guarantee that your wife is not kept alive by advice from consultants in diabetic medicine from, for example, Sierra Leone - because there pretty much aren't any.

I do sympathise with her only being allowed to see a nurse; you fail to understand that a majority of doctors also deplore the government's outsourcing of medicine to people who, while extremely good at what their jobs originally were, are not qualified to act as physicians. I don't sympathise with your description of your GP, and if you are the aggressive, stupid, abusive tosser you come across as here with him or her, I hope they throw you out the surgery.

Anonymous said...

I don't see why anyone should expect the NHS to pay over the odds for treatment. If someone wants more expensive treatment elsewhere, then it is open to them to pay for it. If they want it on the NHS, then they have to accept that it has a duty to the taxpayers who fund it to spend its money as cost-effectively as possible.

If a PCT pays extra for one patient to go jetting off to the country of their choice, they have to provide less treatment to another patient.

If people want luxury treatment, let them buy health insurance or go and live in a country where they pay a fortune for their healthcare.

What I want from the NHS is fairness, and that isn't about indulging the whims of a few at the expense of others.

Anonymous said...

Hi Dr Brown

This is an interesting post. I read some months ago that the EU plan to allow all European patients to travel cross-border for treatments in the EU.

I wondered what would happen in terms of liability if this plan went ahead. For example, if you prescribed medication for the miscarrying woman on the foreign consultant's say-so, would you be liable or would the consultant? In fact, if an NHS consultant recommends medication and you prescribe it, are you liable or the NHS consultant?

Is the liability problem mainly to do with communication issues? I suppose in the future if the EU does go ahead with the plan, we will see more of these scenarios.

I'm glad you're posting again. I've always thought that your posts would be good enough to publish as a book. Also, it seems you've come to the attention of No-one - he always posts everywhere about his wife's treatment. Don't take it personally. (-;

Jellyhead said...

Dr B, this is an interesting post. I agree completely that you cannot just do as you are bid by overseas specialists, without knowing whether their treatment is in accordance with the guidelines and recommendations of your country. You wouldn't feel confident you were doing right by the patient, and if things went wrong, you would most certainly be at least partially legally liable.

But as for your second last sentence, 'I hope I haven't upset her...' - I think we as medicos just have to accept that, in making the best decisions we can for our patients and their care, we will never be able to please everyone. So, unfortunately, if that lady is upset with you, that's too bad. Of course, it's easy for me to say this in regard to your patient, but I still get that uncomfortable feeling when I know I've annoyed a patient of mine. What can I say? I do the best I can & you do likewise.

Hope you have a relaxing weekend Dr B!

Anonymous said...

Hi Dr. Brown,

I don't like the post of the first "anonymous" here; and I'm sorry that it poluted your blog.

About the test results from the bloodtest of the second patient... the interpretation also for some tests varies per laboratory; in that their measurement systems vary and therefore the outcomes. So even if you would perform the tests and relay the results to the gynaecologist; he might misinterprete them because he's used to his own lab and not yours.

Also, I'm wondering about the recurrent miscarriages: in the Netherlands one is entitled to have genetic testing after two miscarriages. The lady or her partner might be carrying a balanced translocation, causing an unbalanced translocation in the fetus, that might be lethal to it.
What's that like in the UK?

This is my little part of knowledge :-)

Best wishes, have a nice weekend


Dr Andrew Brown said...

Anonymous 13.01: We are always responsible for our own actions. If a patient consults a specialist and the specialist recommends a course of action, we do not have to follow that course of action if we think it is wrong. Indeed, we could be held to account if the course of action was wrong and we should have known it was wrong (specialists can make mistakes too). Normally we refer to specialists that we know, so there is room for plenty of trouble if the patient sees a specialist we don't know in another country, particularly if there is a language barrier. The same thing applies to prescriptions. We are responsible for the prescriptions that we sign. If the patient comes to harm we would have to justify writing the prescription. We could use the consultant's opinion in our defence, but we couldn't just pass the buck and say "it's the consultant's fault, not mine".

Petra: Usually I delete posts with swearing, but in this case Dr Daedalus had already answered, so I let it stand. In the UK we usually start to investigate after three miscarriages, on the grounds that two miscarriages may occur through nothing more than bad luck in 1:25 cases. But that's just the NHS being parsimonious.

Anonymous said...

Aha, OK. Maybe it's 3 in the Netherlands too. I'm not completely sure.
Hopefully for your patient it doesn't get to that point.
It's a terrible thing if you want to have children to go through a miscarriage. Some people can handle it, others can't that well...

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