Dilemma: Treating an overseas patient
Your busy city practice cares for a small number of international students.
At graduation time one of them attends with their 55-year-old mother from Mexico, who is visiting for a month. The mother has not brought any of her hypertension medication with her from Mexico.
They ask you for a month-long prescription, and in passing mention a rash which the mother says appeared before she left her home country. It is blistering, crusting and painful, covering her back. You are worried this could be pemphigus. What would you do next?
As a pragmatist, I would probably give her a private prescription for her hypertension medication
Three questions cross my mind. Firstly, is there a healthcare agreement with Mexico and how do I find out? Secondly, is the possible diagnosis of pemphigus life threatening? Lastly does my compassion for this woman override the need to do the ‘right’ thing?
If the answer to any of those questions is ‘yes’, or if in fact the mother told me she had decided to stay in the UK for three months, then I would have no hesitation in treating her on the NHS.
As a pragmatist, I would probably give her a private prescription for her hypertension medication and use an online translation tool to explain what likely diagnosis and how serious it could be. I’d hope to give her the option of potentially costly investigations in the UK (is there a health agreement with Mexico?) or blind treatment with steroids and a letter for her doctor.
Dr Samir Dawlatly is a GP in Birmingham.
I would pick up the phone and talk to a dermatologist
This situation highlights a common occurence created by ease of travel. In addition to the clinical problems, it presents manifold social problems.
As a visitor to the UK, the mother´s entitlement to free NHS care is only for emergency situations. NHS managers would not consider either treating her high blood pressure - which she had before she left Mexico - or treating her rash, again which she had before she left for England as emergency conditions. Giving a prescription for blood pressure medication and some rash cream would in all probability go unnoticed, but this rash does not look like a simple rash.
Most visitors have some sort of medical/travel insurance but whether such preexisting conditions are covered would depend upon the specific policy. At the same time, most visitors having heard about the NHS would expect to get treatment for free. Some travellers without any insurance may or may not be able to fund private treatment.
What my approach would be if this patient did not have an insurance to cover her treatment in the country and no funds is, I would pick up the phone and talk to a dermatologist. I have two in my practice who are ‘old fashioned’ with lot of professional pride and believe in professional courtesy. After their guidance and advice, I would issue the appropriate prescription and keep my fingers crossed.
Dr Vijay Abrol is a GP in Birmingham
The possible diagnosis of pemphigus could require a referral for hospital care
GPs have the discretion to accept overseas visitors as fully registered NHS patients, or as temporary residents if they are only in the area for three months or less, according to Department of Health guidance.1 Doctors also have a contractual duty to provide immediately necessary treatment as well as an ethical duty to treat in an emergency, regardless of whether the person is an overseas visitor or registered with the practice.
It would be up the GP to decide whether to accept the mother as a patient and to provide her with a prescription for her hypertension medication. Any decision not to accept an application from an overseas visitor for inclusion on the practice list must be based on reasonable grounds and not discriminatory.2 If accepting the woman as a patient, the GP will not have access to her records so it is important to take a full medical history, including any underlying health conditions, allergies, medication regimes and dosages.
The possible diagnosis of pemphigus is potentially a more urgent problem and could require a referral for hospital care. If, after further assessment, the GP feels the woman needs to be referred, he will need to explain to her (via an interpreter or her daughter, if the mother doesn’t speak English) that being registered with the practice, or having an NHS number, does not give her automatic entitlement to access free NHS hospital treatment. The GP will need to make it clear in the referral letter that the patient is visiting from overseas so that the Overseas Visitors Manager at the hospital can check whether she is entitled to free hospital care. The DH guidance recommends displaying posters in the practice explaining the restrictions on entitlement to free hospital treatment.
Dr Phil Zack is a medico-legal advisor at the MDU.
1 Department of Health, Implementing the Overseas Visitors Hospital Charging Regulations, October 2012
2 NHS GMS contract 2004 paragraphs 15-17 www.legislation.gov.uk