Having trained as a surgeon at St George’s Hospital, I was sad to learn that this once proud hospital is in special measures after being rated inadequate by the Care Quality Commission. Its medical school is one of the largest in the UK, and the hospital serves a large, relatively deprived population in South London.
The summary of the hospital’s inadequate performance is disappointing but ,among the gloom, maternity services were rated by the CQC as outstanding.
In this context, St George’s was again in the news a few weeks ago after it was disclosed that the hospital was a hub for maternity health tourism. It was reported that half of the 1783 overseas women who gave birth at St George’s Hospital in 2015-2016 were later found not to be entitled to free NHS care. The hospital conceded that it had been targetted because it didn’t carry out robust eligibility checks. It is highly unlikely that this problem suddenly started in 2015: more likely, it has been endemic at St George’s for years, and has only recently been identified. Either way, the error amounts to gross managerial incompetence, which might explain why, all told, the hospital is now in special measures. The suspicion is that some maternity tourism is widespread and organised, much like a package holiday. Where are the NHS fraud officers?
Maternity tourists present late for antenatal care knowing that airlines are reluctant, or unwilling, to allow pregnant women to travel home within a month of the expected date of delivery. The NHS can charge these patients, but we know from previous research commissioned by the Department of Health that, of invoices raised, only 16 per cent are honoured. We also know that an uncomplicated delivery in the NHS costs £5,000, rising steeply for a Caesarean section and precipitously if neonatal intensive care is required, for example, to manage multiple births.
The driver for maternity tourism is the high infant mortality rate in low-income countries plus the mantra, known worldwide, that the NHS is “free”. In May 2013, The Bill and Melinda Gates Foundation published research entitled “Surviving the first day”. This was published as a World Mother’s Day report by Save the Children, and concluded that of 176 countries investigated, Nigeria ranked the 169th most dangerous place for a child to be born.
This problem of maternity tourism is exacerbated by competitive practices in fertility clinics in low-income countries. In the UK, the Human Fertilisation and Embryology Authority has stipulated that only two fertilised eggs can be returned to the womb in any one menstrual cycle, meaning that a twin pregnancy is the maximum possible. In some countries, multiple fertilised eggs are returned to increase the chance of successful implantation, which explains the higher incidence of multiple births among maternity tourists.
The St George’s hospital solution, backed by the Prime Minister in the Commons last month, is that all new referrals to its maternity unit should present a valid passport, but this alone will not prove entitlement to free NHS care. Furthermore, unless a strict ID policy is applied in all maternity units, health tourists will simply move to a less vigilant hospital.
The total cost of health tourism is unknown because, like the St George’s hospital patients, many patients are not identified and charged. Last February, Lord Bates, then a Home Office Minister, stated in a Lords debate that “the total cost of visitors and temporary migrants accessing NHS services in England alone has been estimated at £2 billion per year at 2013 prices”.
Despite this estimate, the Department of Health’s cost recovery programme has set itself the modest task of recovering only £500 million annually by 2017-2018. Recently, a National Audit Office report, soon to be debated by the Public Accounts Committee, concluded that in 2015-2016, only £289 million was collected and that, by the target year, the goal will be deficient by £150 million. Hit squads of debt collectors are to be sent into hospitals to recover debts.
The NAO has also suggested that more efficiently identification and charging of patients with foreign European Health Insurance Cards (EHIC), who have accessed the NHS, can reduce this deficit. This is unlikely to work because, in other EU countries, patients are not entitled to their “home” EHIC card unless they, or their employer, are contributing to the “home” health system. Most EU migrants to UK are unemployed and seeking a job, and are therefore don’t have an EHIC card from their native country. However, once in the UK and having obtained either am NI or an NHS number, migrants are lawfully and immediately entitled to a UK EHIC, which is valid for five years. They can then use that card for emergency care anywhere in Europe, including their home country. This is one of the reasons why the UK pays £750 million to other EU countries to cover costs of UK EHIC card-holders having treatment abroad, but the UK recovers only £40 million from other EU countries.
It can be concluded that the meagre efforts of the Department of Health have failed to curb health tourism. Until that happens, the British taxpayer will continue to subsidise this abuse of the NHS.
Dr. J Meirion Thomas