A patient who is taking multiple medications for hypertension and type-2 diabetes mellitus used to spend three months a year in Spain until his retirement. Now, as he has retired, he is planning to live abroad at least nine months a year and asks for an NHS prescription to cover this period of time.
Both his BP and diabetes have markedly deteriorated recently.
Dr Peter Hill's view
There are two issues here. First, there is the marked deterioration in the patient's BP and blood sugar control. This is complicated by the second issue that the patient plans to live abroad for at least nine months of the year.
The initial thing to do would be to comprehensively review the patient and to elicit why there has been deterioration. Has there been a change in lifestyle since retirement? Is compliance an issue? A lack of routine may mean doses are missed.
After three months overseas, the individual should no longer be registered with a general practice and should be encouraged to seek care abroad. It will help the patient to have enough medication to last him until he finds care in Spain. The NHS accepts responsibility for a prescription of up to three months.
An individual planning to live in a European Economic Area (EEA) for the majority of the year and as a retired UK pensioner would need to obtain an E121. This entitles the patient to the same treatment as a national of that country.
If the patient is an early retiree without a UK state pension, the individual would need to apply for an E106. This may entitle the patient to state healthcare paid for by the UK for up to two-and-a-half years.
It is good practice to provide the patient with a copy of their medical history.
- Dr Hill is on the GP VTS in Gloucestershire
Dr Shuvam Roy's view
This scenario presents two issues that need to be addressed.
First, the clinical issue of recent marked deterioration of both his BP and diabetes. Second, the ethics of providing NHS care to an individual for the period he spends abroad.
This is a rare but not unheard of situation. One needs to establish tactfully the reason behind the recent marked deterioration of both his BP and diabetes. A medication review including the dosage, side-effects and compliance, together with a review of his recent blood tests (renal function, fasting lipids and HbA1c) might shed light on the cause of this deterioration.
Exploring the patient's ideas, concerns and expectations will help formulate a management plan incorporating possible solutions to both issues.
It would be necessary to impress upon the patient the need for closer clinical monitoring given the recent deterioration of his clinical status and the limitations of prescribing for the period he wishes to remain abroad.
One needs to clarify to him that it would be inadvisable to continue taking medications without regular reviews. It would be interesting to find out how he intends to access medical care to monitor his conditions while abroad.
Hopefully by this time, if he were reasonable, he would understand the logic of the GP not being able to comply with his request if no monitoring is involved. If the patient plans to seek local medical input then further management should be arranged abroad.
One could discuss the matter with colleagues or the PCT and seek an opinion, which can then be passed onto the patient if the situation calls for it.
- Dr Roy is a salaried GP in the Wirral
Dr Caroline Gibson's view
There are two issues to be addressed in this consultation: first the clinical issue regarding the patient's deteriorating BP and diabetic control, and second the issue of his eligibility for NHS treatment.
The reasons behind his deteriorating BP and diabetic control should be explored, whether this is due to his recent change in lifestyle since retirement, or a more worrying under- lying cause. A thorough history and examination should be undertaken, and investigations arranged if indicated.
Explore the patient's agenda, and his ideas regarding how his chronic health problems should be managed. He needs to be educated regarding how often his health needs reviewing and why this is important.
NICE guidelines state that in a stable case, patients with hypertension and diabetes should be routinely reviewed six monthly, and more frequently if problems arise.
Explanation of why it is important for him to register with a local doctor in Spain is key; this includes both management of his chronic health problems, but also for dealing with any intercurrent illness that may arise. Explore his ideas and understanding regarding the implications of not controlling his BP and diabetes optimally.
The patient should be informed of the rules and guidelines surrounding eligibility for NHS care: patients are eligible for free primary care treatment in the UK if they are 'ordinarily resident' in the UK. The DoH defines this as expecting to remain in the country for more than six months.
When he returns for less than three months he will be classed as a temporary resident. Alternatively he could be treated privately.
If he needs hospital care in the future, DoH guidelines state that patients in receipt of a UK state pension spending up to but not more than six months per year abroad in an EEA country are entitled to free hospital treatment when in the UK.
If he lives outside the UK for more than six months per year he would have to pay for any hospital treatment when he is here.
The patient can be reassured that any emergency treatment while in the UK will still be free on the NHS, either from a GP or A&E. Also, he can be reassured that if he moved back to the UK permanently, he immediately resumes access to free-at-the-point-of-service care.
- Dr Gibson is a GP registrar in County Durham
- This topic falls under sections 3.3 and 9 of the GP curriculum 'Care of Older Adults' and 'Clinical Ethics and Values-Based Practice', www.healthcarerepublic.com/curriculum
A patient with MS tells you that he has heard about a specific treatment (low-dosage naltrexone), which is used successfully abroad and in some parts of the UK. However, he has learned from the local MS nurse that this is not funded by your PCT. He asks you for help in this apparent and unfair case of 'postcode lottery'. What would you do?
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