Cosmetic tourism and the burden on the NHS

7th February 2013

 

The past decade has seen dramatic changes in the workload of UK plastic surgeons, with increasing awareness and demand for aesthetic surgery among the general public. Globalisation has led to an increased acceptance of outsourcing in the provision of key goods and services to the UK population as a whole. In parallel, the increased availability of cheap flights abroad has removed a key financial barrier for those seeking aesthetic surgery abroad, a phenomenon labelled as ‘cosmetic tourism.More and more patients travel abroad to undertake such procedures, in many cases assisted by agencies that offer ‘package’ deals to a multitude of destinations.

Inadequate arrangements for follow-up care mean that patients routinely present to local plastic surgeons with post-operative complications or concerns that arise after their return to the UK. While few have issues with such patients presenting to surgeons in the independent sector for advice or treatment, the availability of a National Health Service (NHS) free at the point of use creates a significant potential for abuse. The tacit ‘under-writing’ of cosmetic surgery abroad by the NHS may also contribute to the cost differential for such procedures between the UK and overseas providers.

BAPRAS commissioned research to describe the overall burden placed on NHS plastic surgery teams by patients presenting with concerns, or complications requiring intervention, following private cosmetic surgery undertaken outside of the United Kingdom. By doing so, we aim to build on work undertaken by colleagues who attempted to quantify this phenomenon at the regional level, better
inform those commissioning and providing care to these patients, and encourage the development of clear national guidelines for their management. 

An initial screening e-mail was sent to all UK Consultant members of BAPRAS. After an introductory statement, this asked a single question:

'In 2007, did you or any of your team see patients with complications or concerns related to cosmetic procedures performed outside of the United Kingdom?'

All 326 UK consultant members of BAPRAS were contacted during the survey, and 203 (62%) of them responded. Of the 203 respondents, 76 (37%) had seen patients in the NHS during 2007 who presented with complications or concerns related to cosmetic procedures abroad. 63 (83%) consultants proceeded to complete the remainder of the questionnaire. During 2007, 215 patients presented to these 63 consultants (mean 3.4, range 1 to 15). The most popular procedures were: breast augmentation, abdominoplasty, breast reduction and face/necklift. The great majority (76%) of patients underwent surgery within Eastern and Western Europe or Asia and none were reported as travelling as far as Australia.

The majority of patients (88%) were referred by NHS Primary Care and Emergency Department colleagues, with the remainder referred by other NHS and private sector consultants. A quarter required emergency surgery and a very small proportion in-patient non-surgical treatment (e.g. intravenous antibiotic therapy). The great majority required treatment provided in an outpatient setting or elective revisional surgery e it is likely that such treatments would be for simple wound management or involve revision for cosmetic reasons. Most consultants felt that his problem was increasing with more patients presenting to the NHS with cosmetic tourism complications year on year. Further, they felt that the increasing number of patients undergoing such procedures abroad would have a significant impact on their service with ramifications for the emergency and elective NHS services provided for plastic surgery teams around the UK.

The perceived benefits of cosmetic tourism by patients include reduced cost, increased accessibility and reduced waiting times. However, such patients are unlikely to see their surgeon or discuss procedures with them prior to travelling out for their surgery. They are also usually required to pay for a ‘package’ deal prior to travel. Having travelled to a distant location for this purpose, there is significant financial and psychological pressure to proceed with surgery. The widely accepted principle of informed consent may be superseded by the decision to ‘package’ and pay for both travel and treatment prior to an initial surgical consultation, with significant financial implications if a patient changes their mind about a particular procedure.

Irrespective of these concerns, cosmetic tourism continues to thrive, and is regularly reported in the mainstream media. The limited nature of pre-operative counselling in such cases becomes particularly important as these procedures carry significant risks of major and minor complications and the unrealistic expectations engendered may also lead to dissatisfaction with the clinical and cosmetic outcomes attained.

In addition there are clinical concerns related to air travel very soon after major surgery. Normally such patients fly back to the UK shortly after their procedure is carried out with a significantly increased risk of deep vein thrombosis and pulmonary embolism.

An expected increase in cosmetic tourism in the coming years will impact on plastic surgery waiting times in the NHS for oncology, trauma and elective procedures if patients use their local plastic surgery departments as a safety net should their cosmetic overseas experience lead to complications.

At the present time there is no clear or consistent policy across NHS providers or commissioners for the treatment of such patients presenting with acute complications of their surgery or, in the longer term, for elective revision procedures. Such procedures would not normally be funded by the NHS and the question is therefore raised as to who should fund treatment of complications following overseas private cosmetic surgery.

As a result of this research, BAPRAS will seek to establish national guidance for the treatment of patients referred to NHS teams following cosmetic tourism.

Anthony Armstrong (Full Member of BAPRAS) and Ranjeet Jeevan

Read our patient information guide on cosmetic tourism

 

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