Patients having treatment abroad

A GRADUAL easing of travel restrictions with the fall in serious Covid-19 cases is welcome news to many but it does present challenges for the NHS when patients seek medical/dental treatment abroad and then present for follow-up back in the UK.

In April this year, an audit by The British Association of Aesthetic Plastic Surgeons revealed that the number of patients being treated for serious complications following cosmetic surgery abroad in the last four years rose by 44 per cent in 2021. Many of the complications involved systemic infection following abdominoplasty.

Recent reports in the media have also highlighted patients travelling abroad to access transgender care or to have bariatric surgery, which is either currently unavailable in some parts of the UK or has been significantly affected by Covid-19 pressures. Dental patients attending for treatment failure after restorative procedures abroad is also a perennial problem for dentists, now made worse by pandemic backlogs.

MDDUS advisers have noted a recent increase in the number of doctors and dentists across the UK asking what their responsibilities are when patients present seeking follow-up and support after treatment in another country, where there are no specific commissioning arrangements in place.

Specific issues being raised include:

• An expectation from returning patients and foreign care providers that GPs will provide post-procedure phlebotomy testing. Some GPs have reported that discharge information simply states ‘phlebotomy’ without providing specific test requirements.
• Requests for GPs to undertake tests that they have not been commissioned to do, particularly relating to procedures where they have no specific knowledge of indicative tests and their frequency.
• Concerns around ongoing monitoring of a patient’s condition, with no specialist secondary care support available to the primary care GP.
• Whether a GP can simply signpost patients to the private sector in the UK if the treatment obtained abroad was undertaken privately.
• Patients presenting with records of treatment abroad in another language and questions over responsibility for translating.
• Dental patients presenting with poor marginal fit after restorative treatment abroad and seeking corrective work.

Current NHS advice urges patients to understand the conditions under which they will be treated abroad along with the associated risks, and how aftercare will be provided on returning home. Patients are encouraged to discuss their plans with a doctor or dentist in the UK before making any final decisions about travel or medical arrangements – but this can still lead to a feeling of unfairness among health professionals that the NHS may be expected to simply ‘pick up the tab’ for aftercare, or be responsible for providing advice and care in the event of a botched surgery.

Clinical monitoring

It is important for any clinician who is the initial point of contact for a patient returning from abroad to seek advice from appropriate colleagues before providing follow-up treatment or support, for example gastroenterologists or upper GI surgeons in the case of bariatric surgery.

A key point here is that no clinician is obliged to undertake any care which is contrary to their clinical judgement or beyond their expertise. However, given the potential impact of surgery on a patient's health, a GP (for example) should consider whether specific clinical monitoring should be undertaken. This is similar to the circumstances where patients are obtaining illicit anabolic steroids and have set monitoring that they want to undergo. In this scenario, there may be specific tests that a GP feels are warranted, to address patient safety.

Prescribing

Primary and secondary care clinicians should also not feel pressurised into prescribing unfamiliar drugs when dealing with the aftercare of patients who have received treatment abroad. Some medications may not be licensed in the UK and such requests should be treated in the same way as recommendations from a UK specialist.

Each prescriber must take responsibility for any prescriptions they issue and be prepared to explain and justify their decisions and actions in prescribing, administering and managing medicines. Doctors and dentists should familiarise themselves with current regulatory guidance on this important issue if in any doubt.

• Good practice in prescribing and managing medicines and devices. GMC
• Guidance on prescribing medicines. GDC

Translating treatment records

Doctors and dentists are under no obligation to translate treatment records provided in a foreign language by a patient returning from abroad. Any costs associated with translation should in most circumstances be met by the patient.

Dental issues

An estimated 20 to 35 thousand patients travel abroad each year for cheaper and more accessible dental cosmetic treatment and that number is rising. Some UK dentists are encountering significant challenges with patients who have undergone extensive dental work abroad, including implants. Complications include gingival inflammation, caries or infection, poor marginal fit and occlusal issues.

Most dentists feel a degree of empathy with patients in these circumstances, but practices are not required to bear any of the costs of remedial work. In fact, correcting unsuccessful dentistry is often more complex and risky than carrying out the initial treatment. Practitioners must not, through some misplaced sense of obligation, involve themselves in work that is beyond their expertise, and consideration should be given to further referral for specialist treatment if necessary.

If the practitioner does agree to provide remedial treatment, the presenting condition should be carefully assessed and scrupulously recorded, making use of photographs and radiographs where applicable, before a written estimate is given for work judged to be beneficial. At this stage, it is up to the patient to decide whether to proceed on this basis or return to the dentist who provided the original treatment.

There is no requirement to undertake remedial work on the NHS contract except for assessment and appropriate pain relief. It is also clear that by agreeing to treat a patient under these circumstances, the dentist is not taking responsibility for the whole case or the unfortunate consequences of their dental treatment abroad.

Key points

• Advise patients of the risks of undertaking treatment abroad, considering factors such as language barriers and follow-up care in the UK.
• When asked to provide follow-up/after care, be careful not to overstep your own expertise and consider appropriate referrals where necessary.
• Resist pressure to prescribe drugs/provide treatments that are unlicensed or beyond your expertise.
• Clinicians are under no obligation to translate treatment records provided in a foreign language.

Alan Frame, risk adviser, MDDUS