Literature Essay

Medical Tourism: A Cost or Benefit to the NHS? Johanna Hanefeld1*, Daniel Horsfall2, Neil Lunt2, Richard Smith3

1 Department Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom,

2 Department of Social Work and Social Policy, University of York, York, United Kingdom, 3 Faculty of Public Health & Policy, London School of Hygiene & Tropical

Medicine, London, United Kingdom

Abstract

‘Medical Tourism’ – the phenomenon of people travelling abroad to access medical treatment - has received increasing attention in academic and popular media. This paper reports findings from a study examining effect of inbound and outbound medical tourism on the UK NHS, by estimating volume of medical tourism and associated costs and benefits. A mixed methods study it includes analysis of the UK International Passenger Survey (IPS); interviews with 77 returning UK medical tourists, 63 policymakers, NHS managers and medical tourism industry actors policymakers, and a review of published literature. These informed costing of three types of treatments for which patients commonly travel abroad: fertility treatment, cosmetic and bariatric surgery. Costing of inbound tourism relied on data obtained through 28 Freedom- of-Information requests to NHS Foundation Trusts. Findings demonstrate that contrary to some popular media reports, far from being a net importer of patients, the UK is now a clear net exporter of medical travellers. In 2010, an estimated 63,000 UK residents travelled for treatment, while around 52,000 patients sought treatment in the UK. Inbound medical tourists treated as private patients within NHS facilities may be especially profitable when compared to UK private patients, yielding close to a quarter of revenue from only 7% of volume in the data examined. Costs arise where patients travel abroad and return with complications. Analysis also indicates possible savings especially in future health care and social costs averted. These are likely to be specific to procedures and conditions treated. UK medical tourism is a growing phenomenon that presents risks and opportunities to the NHS. To fully understand its implications and guide policy on issues such as NHS global activities and patient safety will require investment in further research and monitoring. Results point to likely impact of medical tourism in other universal public health systems.

Citation: Hanefeld J, Horsfall D, Lunt N, Smith R (2013) Medical Tourism: A Cost or Benefit to the NHS? PLoS ONE 8(10): e70406. doi:10.1371/journal.pone.0070406

Editor: Pieter H. M. van Baal, Erasmus University Rotterdam, The Netherlands

Received January 31, 2013; Accepted June 19, 2013; Published October 24, 2013

Copyright: � 2013 Hanefeld et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Funding: This project was funded by the National Institute for Health Research Health Services and Delivery Research (HS&DR) Programme (project number HSR 09/2001/21). The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the HS&DR Programme, National Institute for Health Research, National Health Service or the Department of Health. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing Interests: The authors have declared that no competing interests exist.

* E-mail: [email protected]

Introduction

The phenomenon of people travelling abroad to access medical

treatment – commonly termed ‘Medical Tourism’ – has received

increasing attention in academic and popular media [1]. The

confluence of available and affordable air travel, internet-based

marketing by providers, and an increasing requirement for out-of-

pocket expenditure, even in universal public health care systems

such as the UK NHS, suggests that increasing numbers of patients

may consider travelling for treatment. The PIP scandal highlighted

challenges for UK patients in seeking redress from private

providers, especially where these may be based in other

jurisdictions [2,3].

As the new NHS reforms introduce yet greater market elements,

including the removal of the cap on income from private patients

[4], and the EU Directive on crossborder healthcare is

implemented which codifies rights around patient mobility [5], it

is imperative to consider the challenges and opportunities that

medical tourism – inward and outward – may present to the NHS

[6].

Yet, reliable information on even the basic number, character-

istics, motivations and experiences of such patients is scarce, as

patients arrange and pay for such care privately [7]. Indeed, a

recent review of medical tourism literature [8] found that

academic literature relies heavily on opaque data from private

consultancy firms or unverified media reports [9,10]. In the

absence of even the basic level of information in these areas, it is

understandable that rhetoric has filled the vacuum. In this paper

we present evidence from the largest study yet conducted

concerning medical tourism, undertaken from an NHS perspec-

tive, to provide a firmer footing for debate and discussion by

health professionals, NHS managers and those involved in the

wider policy-making context.

Methods

Authors interviewed 77 UK medical tourists and 63 other UK

stakeholders between March 2011 and August 2012. Interviewees

gave written consent to participate in the study. Interviews were

recorded, transcribed and thematically analysed. The study

received ethical clearance from the National NHS Ethics review

process submitted through the Sheffield Research Ethics Com-

mittee approval (11/H1308/3).

Analysis is three-fold: (i) the volume and characteristics of

outbound and inbound UK medical tourists is based upon the

International Passenger Survey (IPS); (ii) assessment of NHS

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income from foreign patients is based upon freedom-of-informa-

tion requests submitted to 28 NHS Foundation Trust hospitals;

and (iii) evaluation of the challenges encountered, costs incurred

and potential savings for the NHS is based on a review of

published and grey literature and interviews with UK nationals,

NHS managers and policy makers. Each of these is described

below.

Analysis of the International Passenger Survey (IPS) The IPS, conducted by the UK Office of National Statistics

(ONS), collects information from passengers as they enter or leave

the UK. Passengers are randomly selected as they travel through

passport control and a brief survey is administered. One of the

survey questions asks passengers to define their primary purpose

for travel; ‘medical treatment’ is one of the answers recorded, thus

providing insight into the number of passengers who self-declare

that they are travelling for medical treatment.

The IPS dataset from 2000–2010, from the Office of National

Statistics (ONS), was analysed by two authors independently,

triangulating results. Data from the IPS, interviews, literature and

NHS tariffs were used to calculate cost impacts. Authors used the

different data sources accessed to carefully triangulate and better

understand the reliability of the data from the IPS, which is

reflected on in the discussion.

FOI Requests Submitted to 28 Foundation Trust hospitals on volume and

income from international private patients. Trusts were purposely

selected to be those most likely to be visited by inbound tourists

i.e., large and well-known Trusts, such as Great Ormond Street

Hospital for Sick Children, many of which are based in London.

Data on foreign patients was analysed to understand the potential

of earnings from foreign patients.

Qualitative Analysis Authors interviewed 77 UK residents who travelled abroad for

treatment and 63 other UK stakeholders between March 2011

and August 2012. Interviews were recorded, transcribed and

thematically analysed. The study received ethical clearance from

the National NHS Ethics review process.

Results

While the level of inward travel of foreign patients to the UK

(although not necessarily the NHS) has been relatively stable over

the last decade, there has been a substantial increase in the

number of UK residents travelling abroad to access medical

treatment, as indicated in Figure 1.

Destination of UK Outbound Medical Travellers Figure 2 shows UK residents most commonly travel for medical

treatment to North, West, and Southern Europe with France

being the most visited country over the decade.

Examining this in greater detail (Fig 3) suggests that Central and

Eastern Europe are second most popular, and that Poland and

Hungary are increasingly popular.

South Asia, primarily India, also attracts large numbers of UK

patients, making it the most frequently visited non-European

country, with a relatively stable pattern of travel to India, Pakistan,

and in much lower numbers Sri Lanka and Bangladesh, possibly

reflecting a diaspora effect. In contrast, East Asia shows a different

pattern, with virtually no medical travellers recorded by the IPS

prior to 2003, yet by 2010 15% of all UK medical travellers went

to East Asia. This increase of 430% is unlikely to be solely related

to diaspora patients, but does correlate with many South East

Asian countries marketing strategies at this time [11].

Based on the IPS data, and patient interviews, treatment specific

destinations emerge. For example, UK dental patients increasingly

travel to Hungary and Poland, which corresponds to the varied

availability of NHS dental treatment over the last decade [12].

Fertility tourists often travel to countries in Eastern Europe,

Cyprus and Spain possibly owing to more easily accessible

gametes, and less stringent regulation which allows anonymous

donation as well as a greater number of embryos transferred [13].

Inward Medical Travel As evident in Figure 1, data from the IPS suggests that

international patient inflows to the UK (independent sector and

NHS private services) were in the region of 52,000 in 2010. Data

over the decade also confirms that while growing, the overall

numbers of patients travelling into the UK to access medical

services is rising at a much slower rate than UK residents travelling

out for care. So, contrary to some popular media reports, far from

being a net importer of patients, the UK is now a clear net

exporter of medical travellers.

Major source countries for patients coming into the UK include

Spain, Greece, Cyprus and the Middle East. The number of

Greeks and Cypriots travelling into the UK to access treatment

rose rapidly in 2009 and 2010. These figures may reflect a change

as a result of the economic crisis, which in turn has meant severe

public sector cuts in these countries, including in health [14].

Similarly, while medical tourists from Ireland may choose to travel

to access treatment not available there, including termination of

pregnancies, the rapid increase in patients from Ireland in recent

years may reflect the cuts in the health sector there and greater

numbers of UK citizens resident in Ireland returning to the UK

for treatments (see Figure 4). The ‘dip’ in both inbound and

outbound medical travel evident in Figure 1 in 2008 may be

attributable to the onset of the crisis. Examining the number of

travellers by quarter found a much lower number of inward and

outward medical travellers in Quarter 3 of 2008 during the onset

of the crisis, than the rest of the year, or Quarter 3 in 2009. In the

case of Irish, Spanish (and perhaps French) residents, it is highly

likely that a substantial number will be UK expats and it is unclear

whether these engage in out-of-pocket medical treatment (in the

private sector or NHS) or whether they accept NHS services free

at the point of use for which they may (or may not) be eligible.

A further significant number of patients travel from the Middle

East (specifically from the United Arab Emirates and Kuwait)

although visitor numbers from both countries dropped sharply in

2008 and 2009 respectively. Despite some variation between years,

a stable inward flow of medical travellers from Nigeria is also

evident over the past decade, perhaps reflecting the growing

wealth of some sections of that population.

International activity within hospital trusts. Our Free-

dom-of-Information requests suggest that Trusts could not always

clearly identify international patients within their pool of private

patients because nationality was not recorded when they

underwent treatment and nationality/place of residence may

differ. Looking at the 28 Trusts within our sample, their

international activity ranged from relatively marginal to being

one-third of their total private work.

Where Trust managers were interviewed (at seven sites) they

spoke of international patient flows and activities within the

context of pressure on NHS resources, and pre-existing interna-

tional activities and linkages. Commercial imperatives were

balanced with strong statements regarding the core NHS role,

centred on NHS services and prioritising NHS patient care.

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International patient activity was typically specialist where it was

not possible to treat locally because of relatively small volumes and

the complex nature of treatment required. Relationships, primarily

clinical ones, for example where a clinician from aboard had

trained or worked in a UK hospital were paramount in

maintaining flows of international patients. Established practices

of education, training, consultancy and linkages were reported to

help facilitate referrals. Rather than systematic links these personal

networks appeared paramount in linking UK hospitals to

international patients.

What is the Impact of Medical Tourism on the NHS ‘Bottom-line’?

Using the IPS data, analysis from interviews with medical

tourists, academic literature and published NHS data we

calculated possible costs and savings for the NHS for three types

of medical tourism identified (see annex S1 for calculations).

Fertility tourism. Based on data from the Office of National

Statistics on multiple births in the UK and evidence from a

hospital in London which found over a quarter of multiple births

were in women who had travelled abroad for fertility treatment

[15], we estimated the cost incurred through multiple births as a

result of individuals travelling abroad for fertility treatment.

Figure 1. The number of people who travelled into or out of the UK for medical treatment during the period 2000–2010. doi:10.1371/journal.pone.0070406.g001

Figure 2. Map depicting total numbers of medical travellers and their destinations from the UK over the period 2000–2010. doi:10.1371/journal.pone.0070406.g002

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Multiple pregnancies pose risks to mothers and children. We

concentrated on the actual costs of multiple births per se as the

exact needs throughout pregnancy and possible complications are

highly variable between women, and thus our estimates will be

highly conservative. We calculated the additional cost of a twin or

triplet over singleton birth resulting from fertility travel in 2010 to

be £15.5 million.

The long-term costs resulting from assisted reproductive

technologies, including multiple pregnancies will not differ

between medical tourists and fertility patients who received care

in the UK. However, our research indicates that patients will

travel in search of reproductive care to countries with regulations

that will allow fertility treatment likely to result in a higher number

of multiple births. Any effort to address the rise in multiple births

in the UK therefore needs to take account of medical travel and

involve specific targeted information to be effective.

Cosmetic tourism. We also calculated the likely cost of

complications resulting from cosmetic tourism based on a recent

study by Miyagi et al. [16], who described a cohort of patients in a

tertiary facility which reported problems arising from cosmetic

surgery undertaken abroad over a period of three years. The

authors calculated the cost of treatment provided within the NHS

for complications and highlighted the reimbursement received by

the hospital from the PCT (which was less than the expenditure of

the hospital). Based on our calculations complications of medical

tourists are at a cost of £8.2 million per annum within the NHS.

Bariatric surgery. Compared to other types of tourism

discussed, bariatric tourism may represent savings rather than

costs for the NHS, as well as wider social savings. With 25% of the

UK population classified as clinically obese, the financial impact of

obesity on the NHS is calculated as £4.3billion by the DoH [17].

Obesity also has wider costs for social services. For example, a

study by the National Office of Accounting estimated that 18

million working days were lost due to obesity with surgery offering

potential savings. Hawkins et al. [18] demonstrated that there was

a 32% increase in bariatric patients in paid work after surgery.

Based on these estimates, the 13 bariatric tourists interviewed

for this research would represent a saving of £112,506 (in cost of

procedure and in future health care and social services savings).

Even as a high estimate, the key point remains that patients

travelling abroad to receive bariatric surgery are likely to represent

a saving to the NHS and social services. Further research on the

longitudinal effects of bariatric surgery is needed and now

underway in the University of Glasgow at the Surgical Obesity

Treatment Study (ScOTS).

Income Generated by Inbound Medical Travellers Income generated by inbound medical travellers can be divided

into additional tourism revenue, capturing the general expenditure

related to patients visit to the UK, and medical expenditure

(revenue to hospital).

Tourism revenue from all inbound medical

travelers. Tourism revenue by medical travellers to the UK

per annum is based on the most recent IPS data for inbound

medical travellers (2010). As respondents in the IPS survey

specifically state they are visiting for health care, it is assumed they

would not have otherwise have visited the UK, and thus are an

addition to visitor/tourist numbers to the UK. Hence, any

spending would be seen to be a net benefit not otherwise coming

to the UK.

Based on hospital data for patients treated within NHS

hospitals, it can be assumed that 20% of inbound medical

travellers receive treatment as inpatients, the remainder as day-

case procedures. Expenditure was calculated for patients staying in

the UK for a number of different scenarios, ranging from those

who stay for four days to receive outpatient treatment to patients

who receive in-patient treatment for 10 days and stay a further two

weeks for follow-up (see Table 1). Assumptions were based on

Figure 3. Pie Chart showing total outward medical travel by UK residents by destination region over the time-period 2000–2010. doi:10.1371/journal.pone.0070406.g003

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interview data collected and on an average hospital stay of

inpatients (not just medical tourists) in 2010 to 2011 from the NHS

Hospital Episode Statistics. These assumptions were that: patients

likely arrive some days before treatment and remain additional

days to fully recuperate or even take the opportunity for additional

tourism activities; people travel with one companion, and

travellers from the Middle East travel with two, and that these

are not captured by the IPS (based on interview data and

corroborated by a 2008 national survey conducted by Which?).

This seems reasonable given the higher foreign patient number

captured from the FOI letters and interview data from patients

who often reported reluctance to be identified as medical tourists

possibly due to the negative public image of medical tourism,

making it unlikely that accompanying persons will identify as

medical tourists. Cost of accommodation was calculated at £80

per night and £100 per day as spending for patients when they

were not in hospital and for their travel companions.

Figure 4. Nine most common countries of origin for those who travelled to the UK for medical (2000–2010). doi:10.1371/journal.pone.0070406.g004

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Calculations are summarized in Table 1 and further explained

in Annex S1 suggest that, even without taking the cost of the actual

medical treatment into account, medical tourists to the UK

contribute around £219 million in additional ‘tourism spending’

to the UK economy per year. Healthcare revenue from all inbound medical

tourists. To estimate the spend on medical procedure by

inbound medical tourists in NHS facilities as accurately as

possible, we submitted Freedom-of-Information requests for data

on income from private patients in NHS hospitals, including UK

and non-UK patients, to 28 NHS Foundation hospitals. Of 28

hospitals 19 were able to provide data on the percentage of income

that resulted from non-UK resident patients and number of non

UK residents treated as private patients. Authors excluded

Moorfields Eye Hospital, as a review of the data across different

hospitals indicated this as an outlier. Given the focus on eye

medicine, it has a very large number of patients visiting for

outpatient procedures at a lower per cost treatments compared to

other elective procedures. The remaining 18 reported a combined

income from private patients of £195 million over a period of 12

months between 2010–2011.

Those who were able to provide differentiated data indicated

that £42 million of their total income was from non-UK resident

patients; looking across these 18 hospitals, this meant close to 25%

of their private income was from incoming medical tourists. While

our sample of hospitals was weighted towards large London-based

facilities which do experience a higher number of international

patients, income ranged vastly between hospitals surveyed: from

over £20million to just £2,466 with a mean of £2.5million.

Those hospitals that were able to report numbers of patients

reported a total of 6,722 patients from abroad out of a total of

88,775 private patients counted, i.e. seven percent of private

patients were inbound medical tourists. It might therefore appear

that medical tourists may be especially profitable, yielding close to

a quarter of revenue from only 7% of volume. For a detailed listing

of patients and income per hospital, see Annex S2.

Discussion

Results confirm that a small but increasing number of UK

patients are travelling abroad to receive medical treatment.

Medical travel is complex and not a uniform phenomenon. The

majority of UK patients travel within Europe, but an increasing

number are seeking treatment further afield. Patients are traveling

specifically to Poland and Hungary, and increasingly to India and

East Asia. Diaspora, country-specific marketing campaigns, and

specific specialism’s seem to determine patterns of flows of UK

patients seeking care abroad. Patients returning from treatment

abroad experience complications.

The analysis demonstrates both the possibility of costs and

savings to the NHS as a result of patients travelling abroad, which

need to be considered. Unsurprisingly, the largest numbers of

inbound medical tourists were in the large hospitals which are

internationally known for their specialism; foremost amongst these

Great Ormond Street Hospital for Sick Children which reported

income of over £20million from 656 patients. Data received and

summarised in Appendix 2 also highlights the variation in the

percentage of income that international revenue represents for

hospitals; to some, especially the large hospitals in London, it

marks a significant proportion of private patient income while for

others it contributes a very small percentage of funding.

Table 1. Calculation of additional spend by incoming medical tourists and their travel companions.

Inbound medical travellers No Nights in hotel Cost hotel Expenditure Total expenditure

52000

Inpatients* 10400

Hospital for ten days 75% (75% from ME) 7800 14 8,736,000 10,920,000 19,656,000

Hospital for five days 25% (5% from ME) 2600 7 1,456,000 1,820,000 3,276,000

Subtotal inpatients 10,192,000 12,740,000 22,932,000

Accompanying persons inpatients

Hospital for ten days 75% (75% from ME) 13650 24 26,208,000 32,760,000 58,968,000

Hospital for five days 25% (5% from ME) 2730 12 2,620,800 3,276,000 5,896,800

Subtotal accompanying persons 28,828,800 36,036,000 64,864,800

Total inpatient and accompanying 39,020,800 48,776,000 87,796,800

Outpatients 41600

4 day stay (25%) 10400 4 3,328,000 4,160,000 7,488,000

7 day stay (40) (2.75% ME) 16640 7 9,318,400 11,648,000 20,966,400

14 day stay (35%) (2%ME) 14560 14 16,307,200 20,384,000 36,691,200

Subtotal outpatients 28,953,600 36,192,000 65,145,600

Accompanying persons outpatients 41600

4 day stay (25%) 10400 4 3,328,000 4,160,000 7,488,000

7 day stay (40) (2.75% ME) 17098 7 9,574,880 11,968,600 21,543,480

14 day stay (35%) (2%ME) 14809 14 16,586,080 20,732,600 37,318,680

Subtotal accompanying persons OP 42307 29,488,960 36,861,200 66,350,160

Total outpatient and accompanying 131,495,760

Total 219,292,560

doi:10.1371/journal.pone.0070406.t001

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Our analysis of data suggests that the UK is now a net exporter

of medical tourists. While incoming medical tourists may be less

likely to declare treatment as primary purpose for their visit to the

UK than outbound tourists, data over time clearly shows a greater

acceleration in outbound over inbound medical tourists. Despite

the variations in numbers of patients visiting different hospitals and

in the income per patient, the number of medical tourists was

comparatively smaller than the percentage of income generated by

them (7% of patients generating close to 25% of private income).

These figures suggest that non-UK residents travelling to the UK

for medical treatment seek high-end specialist expensive proce-

dures, and may generate substantial revenue. Additional numbers

of patients for specialist procedures may also help NHS doctors

with surgical learning curves.

The changing destinations of UK travellers and the differing

origins of those travelling to the UK show that medical travel is a

dynamic phenomenon, which can rapidly increase and change.

This highlights the importance of continuous routine monitoring

to understand medical tourism and to enable researchers,

professionals and policymakers to better consider the costs and

benefits of medical tourism to the UK.

UK residents who had travelled abroad reported experiencing

complications following their return, which echoed case reports in

the literature. While we calculated potential costs of these to the

NHS, complications experienced also pose an ethical question.

There is currently no guidance or regulation on risk or safety for

UK residents who consider travelling abroad for treatment.

Potential savings as a result of medical travel, especially evident

from bariatric patients here, are noteworthy especially at a time of

constrained public resources.

Our findings from NHS Trusts indicates that for those wishing

to increase their private income as a result of the income cap being

raised foreign private patients may be more attractive than

domestic private patients.

While this particular research focused on the impact of medical

tourism on the UK NHS, the findings give an indication of

possible impact of medical tourism in other countries. They are

likely to have particular resonance for other universal public health

systems.

Strengths and Weaknesses of the Study While the study used the most robust data set available to

measure volume of medical tourism to the UK, the International

Passenger Survey, it has several weaknesses. The IPS only surveys

0.2% of travellers entering and leaving the UK. In addition,

inbound figures on medical tourists do not provide information on

whether these are accessing treatment in the public or the private

sector. Interviews with medical tourists also suggested that not all

may identify themselves as travelling for medical purposes.

Moreover, costs calculated are based on published literature often

drawing on small samples.

Thus, although data and analysis presented here represent the

most comprehensive analysis of inbound and outbound medical

tourism to date, they clearly identify the significant gap in

understanding of this increasingly important phenomenon. The

particular strength of the findings here lies in the mixed–methods

approach. Authors undertook the first comprehensive analysis of

the IPS from a medical tourism perspective. Findings were

triangulated by drawing on published literature, and by analysis of

interviews with 77 UK medical tourists. Similarly, the cost

estimates were developed based on results from interviews, costs

reported in the published literature, the IPS data set and freedom

of information requests to 28 hospital foundation trusts. Hence,

each finding has carefully been considered and based on more

than one data source.

Directions for Future Research The impact of medical tourism warrants better monitoring.

Findings demonstrate impact in terms of possible costs and

benefits and the highly dynamic nature of the phenomenon means

that the absolute numbers presented here could grow rapidly.

Only continuous monitoring will allow better understanding and

informed policy-making to ensure patient safety.

Estimates of cost presented here mark a first step based on the

limited data available. To better understand costs and potential

savings of medical tourism requires not only better data on volume

of travel but also on the differences in long-term health outcomes

between patients who travelled and those having received

treatment at home. Further research of comparative outcomes is

needed.

This research does not explore the ethical dimensions that are

involved in many of the considerations relating to medical tourism,

including why patients opt to receive care outside of the UK.

While data here represents the economic costs of complications

experienced by patients these obviously will have to be considered

alongside considerations of patient safety.

Conclusions UK medical tourism is a growing phenomenon. To fully

understand its implications and guide policy on issues such as NHS

global activities and patient safety will require investment in

further research and monitoring. Despite existing data limitations

it is evident that UK medical tourism is dynamic and changing.

Findings indicate costs arise where patients travel abroad and

return with complications. Analysis also indicates possible savings

in the case of specific procedures especially in future health care

and social costs averted. Inbound medical tourists offer potentially

high income to NHS hospitals. Results of this research may also be

indicative of the impact of medical tourism in other public health

systems.

Disclaimer The views and opinions expressed therein are those of the

authors and do not necessarily reflect those of the HS&DR

Programme, NIHR, NHS or the Department of Health.

Supporting Information

Annex S1 Cost calculations.

(DOCX)

Annex S2 Responses to FOI requests to 28 Foundation Trust Hospitals.

(DOCX)

Author Contributions

Conceived and designed the experiments: JH DH NL RS. Analyzed the

data: JH DH RS. Wrote the paper: JH DH NL RS. PI on overall research

project: NL. Investigator: RS.

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