Globalisation

GlobalisationHow will it affect the NHS?

Patient expectationsThe NHS founding principle ofneeds-based care, largely free at the point of use, still commandswidespread support, but Britishpeople are now much more aware that the quality and availability of care varies betweenand within countries.

Key points

• Knowledge and experience of other healthcare systems mayraise expectations in the UK.

• The expectations of increasinglydiverse populations in the UKmay make it harder to achievehigh levels of satisfaction withthe NHS.

• The likely growth ofinternational patients – bothinward and outward – posesmany challenges to the NHS.

• The NHS needs to think about,and plan for, the health needs of new immigrants.

• EU moves could make it easierfor UK patients to seekhealthcare elsewhere in Europe,funded by the NHS. While some will benefit from theseopportunities, there is a risk thatthis will result in increasedhealth inequalities in the UK.

Globalisation is seen as a major driver of change in the wider economy, but has received less attention in health services. The NHS does not competeinternationally and, like other health systems, has been able to treatglobalisation as if it is of marginal significance. This position is not sustainable,and what the NHS provides and what patients and the public expect will beincreasingly shaped by forces from outside the UK.

The public is increasingly aware of the quality and availability of care in othercountries. Will this raise expectations around quality, access and the speed withwhich new treatments are available more quickly than we can keep up with?

The NHS may face unexpected demands from future immigration, whethercaused by economic choice or war and persecution. Can the NHS meet theneeds of an increasingly diverse population?

This paper looks at what the NHS needs to do to be better prepared for someof the challenges – and opportunities – globalisation will bring.

When the NHS was ‘born’ in 1948,the public was largely unaware ofhow health systems were organisedin other countries. People were morelikely to make comparisons with theprevious fragmented UK system. Thesituation is very different today. Themedia provides news of medicaladvances around the world.

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Furthermore, devolution ofresponsibility for NHS policy to the four UK nations is leading todivergences in health policy whichcould have a profound effect onnational consciousness.

Undermining publicconfidence in the systemSlow response to public concern

In the 1980s, public pride in the NHSbegan to give way to a growing

Futures debate 3 Globalisation

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International organisations such as the World Health Organisation, the Organisation for Economic Co-operation and Development, and the European Commissionpublish country rankings on keyhealthcare indicators. Internetsearches yield information aboutnew treatments, and foreign travel and migration help spread ideas about alternative approaches to healthcare deliveryand entitlements.

sense that health systems in otherwestern countries were providingfaster access and better-quality care,albeit at higher cost. It also becameapparent that UK patients werebeing denied new technologieswhich were available elsewhere.

The Conservatives introducedmarket-based reforms andemphasised responsiveness topatients, but the clamour forincreased spending grew louder.

Migrants and expectations

Ethnic diversity and overall PCT ratings (patient satisfaction)

Source: PCT patient surveys 2003/MORI

Ove

rall

PCT

ratin

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85

80

75

70

65

Ethnic diversity (extent of different ethnicities living in area)

Mid Devon PCT

Bradford CityPCT

Airedale PCT

Preston PCTSouth BirminghamPCT Lambeth PCT

BasildonPCT

ThurrockPCT

Barking andDagenhamPCT

Greenwich PCT

Haringey PCT NewhamPCT

0 20 40 60 80

Ethnic diversity and ratings of inpatient care (patient satisfaction)

Source: NHS acute trust inpatient surveys 2001–02/MORI

Ratin

gs o

f ove

rall

care

Ethnic diversity (extent of different ethnicities living in area)

University Hospitalsof Leicester

North MiddlesexUniversity Hospital

Taunton and SomersetNHS Trust

West MiddlesexUniversity Hospital

MedwayNHS Trust

Sandwell and West Birmingham Hospitals

Newham Healthcare

0 20 40 60 80

Airedale NHS Trust

90

85

80

75

70

65

60

55

In the future, Britain may facegreater levels of migration, andincreasing ethnic and culturaldiversity which may reach parts of the country that have notexperienced it before.

The evidence from patient surveysis that areas which are more diversehave lower levels of satisfactionwith NHS services. This may bebecause they have toaccommodate diverse expectations,not all of which resonate withtraditional NHS values.

Serving a more diverse country will increase pressure to offer more personalised care, but that very diversity may make it harder to do so.

It is possible that immigration and emigration will drive debatesaround whether eligibility to access NHS treatment should be strengthened and whether there should be ‘earned’ access to treatment.

Ben Page, Ipsos MORI


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The Labour Government was slow to read the public mood until TonyBlair’s pledge in January 2000 tobring NHS spending levels up to theEuropean average.

Expenditure and the pace of reformquickened, but this was not matchedby the UK’s place in the leaguetables. In 2006, the UK made it intothe top ten European countries formale cancer mortality rates, butremained near the bottom for femalecancer mortality.

Comparisons fuelled public concern

An analysis of mortality in 19industrialised countries foundimprovements across the boardbetween 1997 and 2003, but the UKranked 16th with only Ireland,Portugal and the US having worsemortality rates.

This type of comparison served tofuel concern about the quality ofNHS care. Right-wing pressuregroups argued that the time hadcome to replace the tax-funded NHSwith an insurance-based system likethose in Switzerland, France,Germany and the Netherlands.

However, the Commonwealth Fund,a private foundation whichcampaigns to promote a high-performance health system, foundthat dissatisfaction with the systemwas significantly higher in Australia,Germany and the US than in the UK.While there seems to be no clearcorrelation between spending ratesand levels of satisfaction, somecountries have been more successfulat instilling public confidence in theirhealth systems. For example, peoplein the Netherlands are moreconfident of getting high-quality,

safe care than those in the UK, andFrench and Danish peopleconsistently report much higherlevels of satisfaction with healthcarein their countries.

Always important to the public

Of course, satisfaction ratings are animperfect measure of systemperformance and are particularlyprone to the influence of priorexpectations and reporting biases.Ratings may be influenced by thepopularity of the government at thetime of the survey, or by publicconfidence in economic prospects,and they are highly susceptible tomedia influences.

But what is always important to thepublic is the security of knowing thathigh-quality services will be availablewhen they need them. People alsowant to be sure that healthcareresources are equitably distributedand used efficiently. Maintainingconfidence in the system is essentialfor its sustainability, so any healthdepartment that ignores itsperformance in international rankingsdoes so at its peril.

Pressure to change access arrangementsGPs as gatekeepers

Patients in some European countriesand in the US can access specialistcare directly without needing a

referral from a family doctor.Historically, British patients haveaccepted the GP gate-keepingsystem, but this could change ifconcern about waiting times persists.

For example, recent reports thatdelays in referral and diagnosiscontribute to worse cancer treatmentoutcomes in the UK than those inmany other developed countriescould fuel a demand to bypass GPsand go directly to specialists. Healthsystems that rely on GPs to managedemand tend to provide better valuefor money, so a breakdown in thereferral system could haveconsequences for the costs of care.

Waiting times

British patients are much less likely toface financial barriers to accessinghealthcare than those in many otherdeveloped countries. However, the UKdoes not fare so well when it comesto other barriers to access. Waitingtimes for elective admissions are stilllonger in the UK than elsewhere. TheCommonwealth Fund ranked the UKfourth after Germany, New Zealandand Australia in its league table ofaccess indicators, a better result thanfor Canada and the US.

Since 2002, waiting times in primaryand secondary care in England have steadily fallen, but Scotland,Wales and Northern Ireland havelagged behind. If this divergencecontinues, it could lead to anincrease in cross-border flows insearch of the shortest waits.

The impact of legal rulings

Alongside issues such as cost andconvenience of accessing care,waiting times are one of the driversbehind patient mobility withinEurope, with some patients seeking

“Maintaining confidence inthe system is essential for its sustainability, so anyhealth department thatignores its performance ininternational rankings doesso at its peril.“

care in another country to avoid longwaits at home. Yvonne Watts, whowent to France for a hip replacementto avoid a long wait in England,asked her local primary care trust(PCT) to reimburse her costs. Whenher request was refused, she took her case to the courts, ultimatelyreaching the European Court ofJustice. The judgement upheldpatients’ rights to receive medicaltreatment anywhere in the EuropeanUnion (EU) and confirmed that,subject to certain conditions, thecosts, or a proportion of them, must be reimbursed by patients’home country.

International patients

Citizens of one country seekinghealthcare abroad have, to date,

been largely limited in the UK to self-payers such as those seekingcosmetic surgery, dental work ortreatments unavailable at home.However, in other developedcountries there has been interest in a wider range of healthcare,including major surgery. This comesnot just from individuals paying for their own care, but also from US insurance companieswanting to reduce costs. Somecountries see increasing the numberof international patients as a priorityfor their economies. Improvingstandards in some hospitals indeveloping countries, includinginternational accreditation and linkswith educational facilities in the UKand US, together with low costs,have helped this process.

Increased demand for new treatmentsCommercial pressures andincreased information

Commercial pressures frommultinational companies caninfluence attitudes to, and demandfor, healthcare. Direct-to-consumeradvertising of prescription medicinesis allowed in the US and NewZealand, but not in the EU.

Nevertheless, drug companies haveshown themselves to be adept atgetting publicity for their products by encouraging press coverage. A 1990 article about Prozac in USmagazine Newsweek resulted inwidespread publicity in manyEuropean news media and adramatic increase in sales of thedrug. Similarly, anti-impotence drug Viagra became a newssensation throughout the world and sales soared.

The explosion of health informationon the internet exacerbates thistrend and is much harder to regulatethan print media. Many healthwebsites are sponsored bycommercial companies whose maininterest is to market their productsand many drugs can now be boughtonline without a prescription.

Patients’ requests for medicines are a powerful driver of prescribingdecisions. Many pharmaceuticalcompanies have teamed up withpatient groups to raise awareness ofconditions that they claim are under-diagnosed and under-treated.These so-called disease awarenessprogrammes – dubbed ‘diseasemongering’ by their critics – are legalin the UK as long as they do notmention specific products.


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Travelling for treatmentThe Yvonne Watts ruling raised fundamental questions about patients’ rights to cross-border healthcare which are important for all EU states. The European Commission has said it will issue a draft Directive, due forpublication this summer, designed to clarify the legal position and establishthe principles and entitlements that should apply. This is likely to confirmNHS patients’ rights, subject to certain conditions, to seek reimbursementfor treatment elsewhere in the EU which would have been available on theNHS, up to the cost of their NHS care.

This could result in increased health inequalities in the UK as those with themeans to pay for travel and to fund payment in advance would be able toaccess treatment abroad, potentially avoiding waiting lists at home. Thosewithout the funds to do this – or who were unwilling or unable to travel toaccess treatment – would remain on the waiting list in the UK. PCTs in theUK could also face uncertainty about the costs they face as a result ofpatients exercising this right.

The draft Directive is also likely to call for EU residents who seek treatmentabroad to receive ‘equal treatment’ to residents of the EU country wheretreatment takes place. If large numbers of overseas patients unexpectedlysought treatment in the NHS, there could be an impact in terms of capacityplanning and increased waiting lists for UK patients.

Commercial promotion of diseasesor treatments can encourage healthy people to think they needmedical attention. This increases the likelihood that demand will be distorted and resources will be diverted away from thosewho really need them. It alsoundermines the efforts of theNational Institute for Health andClinical Excellence (NICE) and othersto promote rational, evidence-basedprescribing. This is why direct toconsumer advertising is banned in Europe.

Prescription only medicines

Striking the right balance betweenmaximising patients’ access to health information, includingprescription only medicines, andregulatory safeguards to ensure thatinformation does not stray intoadvertising, has been the subject of long-running discussions in theEU. This recently prompted the European Commission to undertakea public consultation on ideas forreviewing the rules governing theinformation that pharmaceuticalcompanies can provide to patientsand the public. Among the ideasconsidered was the possibility of pharmaceutical companiescommunicating information about their products directly to consumers via television and radio.

If adopted, this proposal could createthe pressure for increased prescribingof possibly inappropriate treatments,with negative consequences both forthe patients concerned and in termsof NHS resources. An appropriateregulatory framework for overseeinginformation to patients will thereforebe essential to prevent suchdistorting effects.


Persistent pressure from industrylobbyists has recently prompted theEuropean Commission to issue adraft proposal which would allowpharmaceutical companies tocommunicate information abouttheir products directly to consumers,including via television and radio.

This could add to the pressure forincreased prescribing of possiblyinappropriate treatments. Rigorousregulation of industry’s promotionalefforts will be essential to counterthese distorting effects and to ensureequitable distribution of the publicresources spent on healthcare.

ConclusionNo healthcare system can operate asan island, assuming public ignoranceof what happens elsewhere. Britishpatients’ expectations, though stillrelatively modest, are rising inresponse to increased awareness of what is, or should be, possible –fast access to effective treatmentsprovided by well-trained, responsiveprofessionals.

The travelling public knows thatfacilities may be better and waitingtimes shorter in neighbouringcountries like France, Germany, theNetherlands and the Scandinavian

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Travel, immigration and disease

Greater movement of people around the globe may lead to the spread of some diseases into areas where they have never existed or are thought tohave been eradicated. Although this is easy to overemphasise, it could leadto extra demands on the NHS – as with drug-resistant TB.

Economic migrants may come from relatively well-off sections of their owncommunities and may be less likely to suffer from some diseases than thoseforced to move – asylum seekers and refugees.

However, they may have lifestyle factors which can affect their risk ofdeveloping diseases. For example, many Eastern European countries havehigher rates of smoking than the UK. If migrants continue to smoke in thesenumbers, there will be ramifications for the UK health system in the longerterm. In the shorter term, there is also the need for culturally-sensitive healthpromotion.

Globalisation has also contributed to the speed with which diseases cantravel around the world, and therefore also the time available to prepare forthem. Air travel, in particular, may lead to the rapid spread of diseases suchas pandemic flu.

But very often there is simply a mismatch between expectations based onone country’s health system and what is encountered elsewhere. For example,many eastern Europeans are used to a system in which family doctors have adifferent status and role: if adequate information is not made available in theUK, they may not be able to make best use of the services that are available.

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countries. Comparable or betterhealth outcomes are often achievedin these countries.

In the healthcare context, patient andpublic expectations are often seen asproblematic. For example, patients aresometimes accused of havingunrealistic expectations of services ortreatment efficacy. Policymakers’difficulties in reconciling demand withresource availability are frequentlyattributed to rising expectations, withthe implication that these are in someway unreasonable.

But it should not be viewed asunreasonable to expect high standardsof care. Higher public expectationscould be just the driver that is neededto stimulate improvements.

The NHS can provide high standardsof care, but it is struggling to catchup with countries that haveexperienced longer periods ofrelatively high investment in theirhealth systems. Knowing that otherEuropean countries manage toachieve better health outcomesprovides the NHS with anopportunity to learn from others andshould act as a spur to do better.

Greater public awareness shouldhelp to strengthen political resolve to

redistribute resources to ensure thatgood health and social care isavailable to all who need it. We havemuch to learn from our Europeanneighbours. Surely it is time to endthe obsession with the US and turnour attention to seeking good-practice examples in countries thatachieve better results.

Developments in Europe increasingly impact on, andinfluence, the NHS. In particular,forthcoming proposals on cross-border healthcare will have far-reaching implications. Patients willalso be able to access much morehealth-related information in thefuture – both on options forobtaining treatment abroad and onavailable treatments, includingpharmaceuticals. It is important toensure that such developments donot widen health inequalities.

Finally, we should attempt to learnfrom the experiment taking place inour own backyard. Studiescomparing patients’ experience inthe four UK nations are remarkablyscarce and statistics are rarelypublished in a comparable form, yetthese studies are an unprecedentedopportunity to learn what happenswhen policy approaches diverge – anopportunity not to be missed.

Join the debate

• Is the effect of the globalisationof healthcare overstated?

• Are there opportunities for theNHS to benefit from this?

• What do we need to do in the face of rising patientexpectations?

• Could globalisation underminethe consensus underpinningthe NHS?

• In an increasingly diversesociety, how can we ensure care is provided in a way inwhich everyone’s satisfaction is maximised?

• Are European rules allowingpatients to be treated abroad a threat to the NHS?

• Are there other effects whichwe have not covered?

Have your say now in our forumat www.debatepapers.org.uk

The debates will feed into theNHS Confederation’s annualconference and exhibition,Delivering the future today, inManchester from 18 to 20 June. Visit www.nhsconfed.org/2008

The content of this paper does not represent the views of the NHS Confederation. The NHS Confederation is grateful to Angela Coulter, chief executive, Picker Institute Europe, for writing it, with contributions from Ben Page,managing director, Ipsos MORI Public Affairs, and Alison Moore, journalist.

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Globalisation