The Covid-19 pandemic is the latest example of a truly global health crisis. International collaboration – or protectionism on the part of some jurisdictions – has been seen in the sharing of intelligence to understand and combat coronavirus, including in the development and rollout of vaccines. But long before the pandemic, the internationalisation of healthcare was already taking place. Hamza Drabu assesses the keys to successful cross-border provision of healthcare.
From a UK perspective, the healthcare sector has long been a jewel in the country’s crown. The NHS has been a prominent point of national pride for decades, and healthcare provision in the round has ranked alongside political and socio-economic stability, and the quality of the legal landscape, as markers of the nation’s international standing and reputation.
With such a reputation comes overseas interest and intrigue. An interest to observe potential best practice, and a desire to replicate it where appropriate. Alongside resultant efforts to export the NHS brand to other jurisdictions based on foreign appetite, there is interest in pursuing win-win scenarios as overseas interest provides the opportunity to tap into new funding streams around the world.
This interest is longstanding. The UK has the largest integrated health system in the world, and its expertise is in demand globally. International interest is piqued by both the public and private provision of healthcare in the UK. Over many years, London’s Harley Street has become synonymous with high quality healthcare service providers, and many foreign nationals routinely fly into the UK for medical treatment. In more recent years, the concept of taking the UK’s offer abroad has gained more traction.
“Even under previous UK governments, there was this argument for the NHS going global,” says Hassan Chaudhury, digital health sector specialist for Healthcare UK, a joint initiative of the Department for International Trade, Department of Health and Social Care, NHS England and NHS Improvement which launched in 2013 to strengthen the NHS and improve global healthcare.
From an NHS funding perspective, it remains an attractive avenue to explore given there are limits on revenues from other sources such as taxation or public borrowing.
“Those routes aren’t possible, and the model is built on the principle of not charging for client care. That’s why every hospital has to have paid-for parking, along with a Boots or a Costa,” says Chaudhury. “The export idea is part of NHS trusts looking elsewhere to help solve funding conundrums.”
While the interest and the appetite from both sides is strong, the difficulty comes in crystallising a product that can be properly packaged and exported around the world. There are lessons that could be learned from the large consumer brands in this regard.
“Starbucks is very good at what you might call ‘proposition development’. You walk in and you know what you’re getting. So a challenge for the NHS has been to improve how it packages its offer,” says Chaudhury.
Pastures new
One example of a UK healthcare institution launching overseas is Moorfields Eye Hospital, which has a presence in both Dubai and Abu Dhabi. Moorfields Dubai opened in 2007 and operates in the Dubai free trade zone as a private commercial hospital which is wholly owned by Moorfields London. It operates as a circular model whereby profits generated in Dubai can be returned to the parent entity and invested in Moorfields’ NHS services.
The Abu Dhabi model is slightly different, having been built in partnership with an Emirati company, United Eastern. Moorfields holds a 51% stake of the partnership, and the Abu Dhabi venture carries Moorfields branding and hosts Moorfields clinicians.
“Wherever Moorfields’ name is associated with something, we viewed it as important that Moorfields had control on clinical governance, clinical care, clinical staff appointments and so on,” says David Probert, former CEO of Moorfields Eye Hospital NHS Foundation Trust and current CEO at University College London Hospitals NHS Foundation Trust. “While these are private, commercial hospitals, we always wanted to run them with the same Moorfields values and ethos, which includes encouraging and valuing education and research.”
When it comes to expanding overseas, geographical location has to make sense. Due diligence and scoping exercises must be completed before any decision to start building can be made. For Moorfields, Dubai and Abu Dhabi made sense for a number of reasons. Many patients based in the Middle East region would previously visit London for treatments, so the hospital had an existing consumer base and demand for its services, while the locations also provide further growth potential via access to the North African and Indian subcontinent markets.
“It’s a good model, and Moorfields underwent structural changes to ensure the right level of care, as well as profitability, was being delivered,” says Probert. “Everybody worked hard to ensure that those hospitals were self-sufficient, as well as benefitting from Moorfields specialists in London – including via technology.”
The different models used for Dubai and Abu Dhabi are testament to the flexibility of the expansion and exporting model. But Moorfields isn’t necessarily eyeing further expansion right now.
“Pre-pandemic, we were receiving enquiries every other month from jurisdictions interested in discussing the possibility of Moorfields setting up there,” Probert says. “We didn’t pursue those models. At the end of the day, Moorfields is an NHS body. So expansion wasn’t at the forefront of our minds. It could be a distraction, and the primary focus was on being a very good NHS hospital.”
Another, lower-risk exporting model involves the provision of consultancy and advice to other jurisdictions. Moorfields has also pursued such opportunities, which provide a strategic injection for those overseas, while also offering interesting extra-curricular options for Moorfields staff.
“It has to be strategic. There has to be a market-driven business case with commercial support,” says Probert. “Ultimately you want to operate in a low-risk environment and not jeopardise the top-level service associated with your brand, so any expansion decision must be considered very cautiously and very seriously.”
While adaptability is a necessary element of entering new markets or territories, quality and authenticity cannot be compromised.
“You should never expand for the sake of expansion,” he adds. “There’s a danger that you can dilute the very things that make your brand so powerful if you do things for the sake of it.”
Brand dilution is not the only risk of expanding internationally. The resources required to run a centre in another jurisdiction are immense.
Looking in the mirror
Part of the effort of setting up in a new territory is a rigorous scoping exercise to assess the nature, strength and depth of the overseas interest and ensure that the level of demand is sufficient and sustainable. Then comes the task of making sure the UK ‘offer’ will translate to another healthcare system and the intricacies of how it operates. Chaudhury notes that demand differs depending on geography. The NHS brand is particularly popular in south and south-east Asia, for instance.
“There is a pull, but that depends where in the world you look,” he says.
The ethos of education, teaching and research which Probert refers to should not be underestimated in this regard. That ethos is responsible for much of the international interest in UK healthcare.
“A large part of the pull is usually linked to education and training,” says Chaudhury. “Royal Brompton and Royal Marsden do fantastic work abroad, and most of this is because the UK has clinical expertise based on having some of the best medical schools in the world.”
The UK must recognise this, in order to ‘sell’ it internationally. In an even broader sense, to export successfully and be a major player on the international scene, the UK must acknowledge its strengths and weaknesses – and act accordingly.
Education and training are strengths, while healthtech may be less of a point of difference. While Great Ormond Street Hospital, Sunderland Royal Hospital or Cambridge University Hospitals may be very digitally mature and lead the way in the UK, the majority of hospitals that are rated level 7 (outstanding) according to the Healthcare Information Management Systems Software (HIMSS) criteria for digital maturity are based in the US. In the same way the UK can guide best practice for teaching and education, internationally, it should not be afraid to import technological learnings from overseas. GOSH leadership figures acknowledged this when the HIMSS stage 7 recognition was awarded, which was itself the result of a concerted effort to improve digital capabilities.
“We knew what could be achieved by looking at our international peers in places like Melbourne, Toronto and Boston, we also knew what was missing,” Neil Sebire, Professor and Chief Research Information Officer at GOSH, told Digital Health News at the time.
Public and private collaboration is key to helping the UK incubate innovation and take the next step in its digital maturity journey. Chaudhury explains that the NHS Export Collaborative at Healthcare UK is focused on how consortia can be formed to achieve this.
“If there’s an opportunity, it shouldn’t be about one hospital bidding against other NHS hospitals,” says Chaudhury. “We’re shifting the focus onto questions like ‘how do we help UK plc win?’ This will help the right opportunities go to the right hospitals, rather than to the bidder with the best business development team. We can make more compelling offers with private sector involvement, too.”
All the world’s a stage
According to Chaudhury, the conversation about international and cross-border healthcare is centred on the word ‘platforms’.
“Everyone wants to move to a platform, and the buzzword is ‘PAAS’ (platform as a service). There are separate data and application layers, which must be independent but consistent and compatible. You need a platform in the cloud that has an application layer, structure and data, and then above it the UI and UX. The whole world is moving to that; it’s a platform world. We have to recognise that it’s the future – and not just in healthcare.”
Probert agrees. Moorfields has the largest collection of eye images in the world, and has been looking at better harnessing the cloud to store such data. But the benefits of investing in healthtech and PAAS are not confined to data storage, security and management. Technology will aid teaching, learning and research, too, amongst others.
“One of the reasons Moorfields formed the Department of Digital Medicine and got involved with Health Data Research UK was that we saw digital data and technology as the future when it comes to globalisation, commercial opportunities and focusing on better research to deliver better care,” says Probert, who adds that his former colleagues are putting vigour and energy behind such efforts and making sure governance issues are dealt with. “Medicine will change, probably forever, as a result of some of the things being done around data.”
Digital health group HealthHero is one such platform, providing a virtual primary care ecosystem for businesses and patients in the UK, France, Germany and Republic of Ireland. HealthHero offers a suite of healthcare services delivered 24/7, with digital triage and communications tools directing user to the right practitioner or course of treatment.
“This approach makes it easier for people to manage their health, with more convenient access to a holistic range of health services and better outcomes for patients,” says Aseem Sadana, HealthHero COO. “A digital front door improves patient experience while improving system inefficiencies.”
To achieve a more seamless and efficient future for healthtech, Sadana says you cannot simply digitise various steps of the patient journey while preserving the same inefficient structure. That’s where platforms come in.
“A platform approach allows for configurability for different user situations while reusing core components,” he says.
HealthHero has used M&A as part of its corporate growth strategy, with international expansion via acquisition of Qare in France and Fernarzt in Germany, while it has bolstered its UK operations by acquiring online consultation provider Doctorlink. Amidst this dealmaking activity, platform services remain a core component.
“Our acquisitions are with a clear purpose – a target state where the component parts enhance the whole. The combined technology platform as well as the holistic proposition is a sum of these parts,” says Sadana.
Of course, while users in France or the UK will have a similar experience, data governance and service provision – including any consultation or clinical content – is locally delivered in the relevant language. In this way, HealthHero can overcome the national versus international challenge. Like Moorfields, the organisation’s modus operandi and values cross geographical boundaries while service provision is catered to each jurisdiction in which it operates.
Fragmentation and interoperability
When it comes to technological investment, another consistent challenge comes in the form of fragmentation. Platforms have to enable different parts of the system to communicate. Chaudhury says the best model is to have a consistent platform into which other things can ‘dock’. He also notes that, for technological platforms to be a success, the ideal model is open by design and secure by design. Open source allows digital transformation to thrive.
Healthtech entrepreneur Mindy Daeschner talks about these interoperability challenges, which are so important when it comes to technology that applies to an ecosystem as sprawling and complex as healthcare, with many moving parts. Again, consumer brands are highlighted as examples to follow, with Daeschner pointing to Amazon and Salesforce as organisations that have thrived in adapting to a platform world.
“They have a really well-designed core system that is service based. They use open web standards and therefore are simple to integrate with and build upon, supporting multiple parties working at scale as part of a consistent approach,” says Daeschner.
For Daeschner, the comparison is particularly poignant for the NHS given its makeup, which she describes as “…not just one organisation. It is thousands. It was described to me early in my time at the NHS as ‘a shoal of fish rather than a whale’.”
The internationalisation of healthcare is well underway. If technology can be better harnessed and interoperability challenges can be overcome, cross-border healthcare will be transformed and the game-changing results Probert references can be realised.
