key: cord-0852376-g0cwny4u authors: Faulkner, Alastair; Harding, Thomas; Miller, Craig; Davies, Peter; McNair, Colin title: Tourism and the Highlands: A cross-sectional study on trauma and orthopaedic service use by tourists in 2017 date: 2020-07-07 journal: Surgeon DOI: 10.1016/j.surge.2020.06.003 sha: 7645f2e7d564e8d0b8bef4ef88a0b460b454859c doc_id: 852376 cord_uid: g0cwny4u BACKGROUND: NHS Highland covers a wide geographical region encompassing the Isle of Skye, and Ben Nevis. Tourism is a significant contributor to the local economy and in 2017 the Highlands welcomed 534,000 visitors. Health services across the region treat tourists in addition to the local population. We investigated how many tourists accessed the Trauma and Orthopaedic (T&O) Department at Raigmore Hospital, Inverness. METHODS: We conducted a cross-sectional study with data collected over one year (2017). The number of tourists referred to T&O including patient demographics, country of origin, type of injury and their clinical outcome were recorded. A freedom of information (FOI) request to NHS Highland was sought to investigate associated costs incurred by tourists. RESULTS: 376 tourists accessed T&O services in 2017. Country of origin: 47 (12.5%) Scotland; 177 (47.1%) rest of UK; 74 (19.7%) EU; 45 (12.0%) non-EU. Highest referral month August (61), lowest referral month November (8). Injuries: 224 (59.6%) fracture; 62 (16.5%) soft tissue injury; 20 (5.3%) laceration. Commonest sites of injury were ankle, distal radius and finger. Outcomes: 28 (7.4%) Virtual clinic; 137 (36.4%) hospital admission; 193 (51.3%) advice to referring team and discharge; 13 (3.5%) direct discharge by T&O; 4 (1.1%) missing. No. of trauma cases booked: tourists 133 (9%), local population 1415 (91%). CONCLUSIONS: Tourists account for fewer than ten percent of the T&O surgical workload over one year with common injuries being fractures affecting the extremities. Seasonal variation was observed with more referrals occurring in the summer months. Just under half of tourists originated from outside the UK and EU. Health boards should consider increasing resources over the summer months to deal with expected increases in tourist numbers and should be able to recover the cost of treatment from the patient or their travel insurance companies directly at point of care. NHS Highland covers a wide geographical region encompassing popular tourist destinations including the Isle of Skye, John O'Groats, Ben Nevis, and Inverness. 1 The region is served by one main district general hospital, Raigmore Hospital with associated small peripheral hospitals including the Belford Hospital, Fort William; Caithness General Hospital, Wick; and MacKinnon Memorial Hospital, Skye. There are also minor injury services present in Aviemore and Invergordon. 1 Health services across the region treat tourists in addition to the local population. (see Fig. 1 ) Tourism is a significant contributor to the local economy and was responsible for over 15,000 jobs and £316.5 million of 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 tax revenue between 2016/2017. 2 In 2018, the Highlands welcomed 13.5 million tourists from the UK and abroad who spent over £1 billion. 2 Tourists visiting the area come from across the world and their country of origin can impact whether they are eligible for National Health Service (NHS) treatment. Domestic tourists from within Scotland and the rest of the United Kingdom are defined under the Scottish Government as "ordinary residents" and are eligible for NHS care. 3 If patients are from the European Union (EU) and European Economic Area (EEA) then their treatment costs would be subject to the Reciprocal Healthcare Agreement under the European Health Insurance Card (EHIC) scheme. 4 Furthermore, the NHS (Charges to Overseas Visitors) (Scotland) Regulations 1989 5 detail the countries or territories outside the EEA with which the United Kingdom has entered reciprocal agreements. 4e6 There is currently a paucity of literature on the impact of tourism on the UK health service as a whole particularly with regards to patient background, number of patients travelling abroad, and the costs and benefits associated with medical travel. 7 The aims of this project were to investigate how many tourists accessed the Trauma and Orthopaedic (T&O) Department at Raigmore Hospital, Inverness and the costs associated with treating them. We conducted a cross-sectional study from the 1st January 2017e31st December 2017 in a secondary care setting at the Department of Trauma and Orthopaedics, Raigmore Hospital, Inverness. Patient demographics including age, sex, country of origin, and type of injury were recorded from A&E or minor injury records and were anonymised. Tourists were identified as having an address outside the NHS Highland Health Board catchment area. The method of referral was recorded and was defined as a referral from a peripheral hospital (Skye/Fort William/Wick), referral from within hospital (Inverness) or referral from accident and emergency within hospital (A&E). Treatment outcomes were recorded as virtual clinic, hospital admission, advice given to the referring team with or without an intervention (e.g. application of cast) and discharged and direct discharge by T&O. Two primary authors were responsible for overall data collection to minimise bias and the study size was determined by the number of tourists identified in 2017. Missing data was recorded and taken into account in the data analysis. A freedom of information (FOI) request to NHS Highland was made to investigate associated costs incurred by tourists using T&O services. A response from the Scottish Government was sought regarding the position of treating EU-nationals post-Brexit. Types of injury: 224 (59.6%) fracture; 62 (16.5%) soft tissue injury; 20 (5.3%) laceration; 2 (0.5%) ligamentous injury; 31 (8.2%) joint dislocation, 6 (1.6%) tendon rupture; 13 (3.5%) polytrauma; 18 (4.8%) missing; The most common site of injury was 70 ankle, followed by 43 distal radius, 31 finger, 23 hip and 22 knee. Outcomes: 28 (7.4%) Virtual clinic; 137 (36.4%) hospital admission; 193 (51.3%) advice to referring team and discharge; 13 (3.5%) direct discharge by T&O; 4 (1.1%) missing. Mean length of hospital stay for tourists was 4.1 days (0e92). Highest referral month August 2017 (61), lowest referral month November 2017 (8) . No. of trauma cases booked in 2017 tourists 133 (9%), local 1415 (91%). Costs associated to treating tourists is summarised in Table 1 . Treatment outcomes broken down by country are summarised in Table 2 . List of treatment interventions for hospital admissions is summarised in Table 3 . Domestic and international tourists accounted for 9% of the trauma and orthopaedic surgical workload over one year and approximately one-fifth of all tourists originated from outside the UK and EEA. The most common injuries were fractures mainly affecting the extremities. There is an observed variation in the number of referrals per month with greater referrals to T&O generated over the period from June to September which is expected for an area with a high amount of summer tourism. Furthermore, the Highlands are accessed by the A9 road connecting Perth to Thurso which accounted for 25 accidents and 13 deaths in 2018. 8 There are several limitations to this study. The FOI requested did not have a clear breakdown of expenditure or reasons accounting for the overall net loss which has implications on its accuracy and record keeping. Several patients were unaccounted for due to missing data including several tourists who were polytrauma patients who may have had initial emergency treatment in NHS Highland and subsequently transferred elsewhere for specialist procedures. Furthermore, we do not have any comparative data from other health boards within Scotland. For example, Edinburgh, the capital city of Scotland, received 34.6 million tourists in 2018, 2 which is more than double than that of the Highlands. This study focused on one department in a secondary care setting within one health board and thus we do not have the data on tourist use of services of primary care, accident and emergency visits without T&O involvement and the use of other secondary care departments such as internal medicine or general surgery. The impact of tourism on local health services within NHS Highland in a wider context needs to be examined. There is currently a dearth of literature on the impact of tourists specifically affecting the UK Health System and their respective devolved nations. A recent literature review concluded that there was a lack of evidence on incoming tourists with few studies able to quantify patient flow or calculate the effect on recipient health systems and the economy. 7 There is an apparent discrepancy between expenditure and reimbursement for the treatment of tourists within NHS Highland and the reasons for this are unclear. The NHS (Charges to Overseas Visitors) (Scotland) Regulations 1989 5 states that certain charges are exempt for all tourists including emergency care without inpatient stay, treatment of certain communicable diseases, patients detained under the Mental Health (Scotland) Act 1984 and accessing sexual health services however the breakdown of cost for these services was unavailable. The Scottish Government states that under existing legislation it is incumbent on the health boards to ensure that funds are sought from appropriate individuals. 9 For EEA citizens this is through the devolved nation, in this case NHS Scotland, submitting reports to the UK Government Department Work and Pensions (DWP) and UK Department of Health (DoH) who manage cost recovery from their respective countries of origin. 4 In 2018, NHS Scotland recovered £1.25 million through reporting schemes of which £223,791 was reimbursed directly to NHS Highland. 10 We were unable to confirm with the health board whether tourists are being charged service at 3 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 cost price, or if a blanket fee for services is charged. Furthermore, it is unclear what proportion of this relates to total cost recovery for EEA citizens in Scotland as a whole. Finally, this process is inefficient, relying on a number of sequential Government departments to be responsible for overall cost recovery for a specific health board. It is also within the remit of local health boards in Scotland to recover the cost of treating non-EEA citizens. The discrepancy found between expenditure and reimbursement again may be due to certain charges being exempt as per the NHS (Charges to Overseas Tourists) (Scotland) 1989 but the breakdown of such costs was not provided by the FOI. Additionally, several non-EEA countries such as Australia, and New Zealand have reciprocal healthcare arrangements with the UK. 5,6,11 Although we have data on the countries of origin for these tourists, it is unclear how much was recovered from these countries specifically. Recent changes in NHS England has a system under the Cost Recovery Programme where overseas non-EEA citizens are charged 150% of the national tariff for the services they receive to minimise medical tourism however a recent estimate indicates only 65% of charges from non-EEA citizens was recovered in 2018. 4 It is estimated that the UK Government could recoup an additional £290 million from EEA countries and Switzerland however this would constitute only a small percentage towards the overall NHS budget. 6 An independent review on the Cost Recovery Programme commissioned by the Department of Health in England concluded that substantial variation exists between trusts on amount recovered and that many outstanding debts are still to be obtained. 12 A number of factors contributing to this include a lack of appropriate staff to administer cost recovery, lack of standardised processes, and a need to significantly change the workforce culture. Health services across Scotland and the rest of the UK should be prepared to meet the demands of the tourist sector. It is difficult to predict how the tourism and hospitality industries will recover following the impact of Coronavirus (COVID-19) in 2020 however this presents an opportune time once the initial crisis has passed, for devolved and national governments at Holyrood and Westminster to review existing legislation to ensure the health service is appropriately reimbursed for treating future international tourists within the EEA and rest of the world. This can be achieved through ongoing negotiations with the EU regarding the EHIC in this Brexit transition period and by reviewing and amending the arguably antiquated NHS (Charges to Overseas Tourists) (Scotland) 1989 legislation which was devised at a time before mass cheap air travel. Furthermore, as there is evidence of seasonal variation in tourist numbers, local health boards should consider increasing resources over the summer months to deal with expected increases in tourist numbers in terms of medical staffing, theatre capacity and administrative staff to deal with cost recovery. Standardised processes of cost recovery across Scotland should be streamlined and local health boards should be able to recover the cost of treatment from the patient or their travel insurance companies directly at point of care. t h e s u r g e o n x x x ( x x x x ) x x x 4 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 Insight department: Highland factsheet 2018. Visit Scotland NHS Inform e Healthcare for overseas visitors Briefing: reciprocal healthcare between the UK and EU. British Medical Association The national health service (charges to overseas visitors) (Scotland) Regulations 1989 (UK) Full Fact e How much does the UK recover in health costs from the EU What do we know about medical tourism? A review of the literature with discussion of its implications for the UK National Health Service as an example of a public health system A9 is the worst for fatal accidents. The Times The Scottish government. Personal communication Freedom of information Act request reference 6877 Overseas visitor and migrant NHS cost recovery Programme. Final report