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Dilemma: Should you treat an overseas visitor?

A patient brings her father to your clinic for a same-day appointment. He tells you he’s visiting the UK from South Africa ‘to get his health sorted out’. He has multiple medical problems including COPD, diabetes, ‘kidney problems’ and ischaemic heart disease – but he has no medical notes or record of what medication he is on. What should you do?

This patient is not eligible for NHS treatment for pre-existing conditions

Dr Richard Van Mellaerts - LMCs conference 2013 - online

In a global society, issues of this kind present with increasing regularity. Health inequalities around the world remain wide, and ‘health tourism’ is a favourite hobby horse of the national press, although the scale of the problem is probably far smaller than feared by some.

This gentleman has a number of pre-existing conditions that have all developed prior to coming to the UK. If he were to need emergency care while here he would be able to access it, but he is not ordinarily resident in the UK and so is not entitled to register with a GP as an NHS patient. Equally, South Africa does not have a reciprocal care arrangement with the UK and so he does not qualify for treatment in this way either.

He is not entitled to be seen as an NHS patient for these pre-existing conditions, so you are left with the option of offering a private consultation or signposting him to alternative non-NHS services.

Without access to his medical records or even his medication notes, there are considerable difficulties in advancing his care, and the limits of your position would need to be made clear.

The medicolegal risk of consulting without adequate medical history may be exacerbated by medical defence bodies being unable to provide cover for proceedings taking place outside the UK.

Eligibility for NHS care is complex. You need to explain this to him and his daughter, and offer potential solutions to allow him to ‘get sorted out’ in a way that complies with NHS regulations.

Dr Richard van Mellaerts is a GP in Kingston, Surrey, and a GPC member

GPs do have discretion to accept overseas visitors as NHS patients

Dr Rachel Birch - online

GPs have a duty to provide immediate and necessary treatment to any patient, regardless of whether that patient is entitled to NHS healthcare.1 You have discretion to accept overseas visitors as fully registered NHS patients or you can accept them as temporary residents if their stay is between 24 hours and three months.2

It is impossible to address all of the issues in a short appointment – therefore take time to establish and treat the most pressing symptoms. Make a plan to address the other concerns and book follow-up appointments. Ask the practice nurse to obtain some baseline bloods, blood pressure and spirometry readings.

The patient doesn’t appear to know what medication he is on. Ask him to bring in all his medications, so that you can identify them and arrange for ongoing prescriptions and any necessary monitoring. Seek his consent to contact his doctor in South Africa so that you can obtain relevant information.

You should also be impartial about his care in South Africa. Listen to his concerns but do not express any negative views. He is likely to return to South Africa, and you don’t want to undermine his trust in its healthcare system.

Refer him to secondary care if this
is clinically indicated. Avoid making judgments about the likelihood that he will be charged as it is the responsibility of the trust to decide this.  

Dr Rachel Birch is a medicolegal consultant at the Medical Protection Society

Make the likely costs clear and clarify the daughter’s role

Dr John Canning online

This is not an unusual situation for a GP. There are at least three dilemmas to resolve here: first, whether he is entitled to NHS care; second, how you should treat him (using NHS resources or his own money); and third, what his daughter’s role is in his attendance.

This patient is here for less than six months, has no settled purpose in the UK and is therefore not entitled to NHS care unless he has an immediate need or an infectious disease (which does not appear to be the case).

While you can treat him as an NHS patient there is no obligation to do so and you may wish to consult with him privately. 

If you do this you should make the costs clear to him and that these will include your consultation fees, the cost of all investigations and drugs.

He should also be made aware that any hospital treatment beyond A&E is likely to be chargeable or require private referral. I would advise you to put this in writing, with details of your fees.

Ensure he understands the financial consequences and has sufficient resources to pay.

Finally there is the position of the daughter. Does he want her involved? If she is a patient of yours already, is there going to be a difficulty in that relationship?

You must make it clear to her that her role – unless her father is in agreement or she has power of attorney – is that of a concerned relative, and no more.

Dr John Canning is secretary of Cleveland LMC and a GP in Middlesbrough