A short break under the knife
The team of surgeons in a hospital in stare intently at a monitor, watching a tiny knife tear into flesh.
Bruno Dillemans is one of the world's experts in keyhole surgery and it's fascinating to watch him manipulate long-handled instruments that allow him to carry out this delicate operation.
Although the tools he holds look a bit like pruning scissors, the procedure seems more like playing a video game as fingers on left and right hands flick in a confident blur.
The intestine on the screen that we are all looking at belongs to Sara Jane Snocken, a 35 year-old primary teacher.
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She is having to lose weight. She says she has tried all sorts of diets and exercise but nothing has worked.
She's paying around £5,000 for the operation and has come to Belgium for a number of reasons. " here are a lot lower; this guy has a very low morbidity rate so I have a good chance of not popping my clogs while I'm under. Plus his name is the one that comes up the most on Google."
And here she is waiting to go down to surgery, just four weeks after entering the words "gastric bypass" into the search engine. She compares that to the plight of her friend.
"She's been waiting five years and she's seriously obese. Even bigger than I am. Five years to get exactly the same operation because it's only done in very few places in the UK, and more people need it."
In the end, it was both waiting lists and her lack of satisfaction with that tipped the balance: "I decided to take it into my own hands and get it sorted out myself.
"For three years I went to the obesity clinic. Every time they said there's a two-year waiting list; it's not worth it; you could do it yourself in diet and exercise in the time. And, hello, it's still not worked, so here I am."
We both thought there was a couple hours before the operation, but a nurse comes in and tell Sara Jane to get ready. She's going down to theatre now, having handed over £5,000 in cash for the operation.
Cashback
But a planned new European law, which I mentioned last week, might give a future Sara Jane the right to claim the money back off the NHS.
I've seen the document and it goes rather further than I expected. It not only enshrines people's right to go abroad if there is "undue delay" but says people should have the right to seek any health care that would have been provided at home. 
They would get back whatever it cost in their home country. If the operation or treatment is more expensive than that, people could top it up with their own money.
This would be pretty radical, and mean that Britain would have to adapt to a much more continental insurance-based system. But there is a potential opt-out.
If a Government can provide evidence that the impact of the law would undermine planning in their health service then they can partially opt out of the scheme.
They would be allowed to insist that patients get the green light from the health service before they travel.
British opt-out
It's widely thought that this clause has been stuck in to satisfy the British Government.
But it will mean patients have much less freedom in countries that invoke this clause. Sara Jane doesn't intend to try to get any money back off the NHS, but if the new law was in place she could try.
Under the main proposal, she would pay for the operation, prove that it is provided on the NHS, and then claim back whatever it would cost in Britain.
But if the Government invokes the get-out clause, she would have to get prior approval from her local NHS trust, which would first have to say that she needed the operation, and then agree a cost.
I’m Mark Mardell, the 91Èȱ¬'s North America editor. These are my reflections on American politics, some thoughts on being a Brit living in the USA, and who knows what else? My 
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I agree that in the case of unduly delay, a patient should be refunded if seeking treatment in another EU state. On the other hand, I don't think obesity can be cut down with a knife. Although this woman is claiming to have gone through diets and exercise, we don't know how true that is. Most people who are obese are NOT sick. It is a result of their lifestyle and how they eat. It is therefore their fault and they should not get reimbursed for such treatment. Northern European people are especially known (at least in Southern Europe) to be "fat". Again, I repeat that those who are obese due to sickness should be granted full compensation. Those who put a burden on the tax payer (including smokers et al) through their lifestyle, however, should pay for their own treatment.
This may benefit the few middle class patients that travel to Eastern Europe to avoid paying for private care in this country, or waiting their turns on the NHS, but what happens to our system of free at point of treatment? How many other countries in the EU have this system? Do their systems rely solely on the tax payer? What happens to NHS hospital that cannot cope with an influx of health tourist from poorer EU countries? Are they now expected to both accommodate extra capacity and chase insurance companies across the EU?
Also I have little sympathy for your report "subject". Just because she was too lazy to go on a diet, and too greedy to wait for a non essential operation on the NHS, why must we as tax payers now fund her jaunt to skip the queue? I am overweight and would never dream of inflicting my problem unnecessarily on an over stretched system because I was too lazy to go for a jog in the park, I dread to think what a thin person whom eats a balanced diet and exercises regularly thinks about this. She is hardly doing the stereotype any good.
Would this also apply to dental treatment? Now that might make the government pull its finger out and actually improve the situation regarding NHS dental care?
After reading Mark's blog I am really surprised that the National Health Service, which many consider to be the best health service in the world, is concerned that it's patients will be flocking to continental Europe for treatment. Surely if it really is the best in the world we should be concerned that those Europeans will be travelling to the UK to fill the beds meant for taxpaying Brits.
My initial response to this was a mild sense of panic and a vision of the NHS haemorraging money out to "cheap" countries where even private hospital treatment undercuts NHS treatment, with little or no reverse traffic due to the premium above local costs which people would have to pay. If I was a hospital administrator in Poland or Greece, I could imagine it being like a lifetime of Christmases all rolled up into one. I would have no hesitation not to fast-track people embarking on this gravy train.
We are short on detail at the moment, but it would be interesting to get an idea of relative costs of common operations across the EU - most NHS costs are hidden from the UK public (which is one of the reasons it is undervalued - I have a friend who works in Audiology, and the number of no-shows to his clinics staggers belief - people seem to think that because it's "free", not coming doesn't waste any money)
Also, some idea of how a UK citizen's decision making process (where, effectively, you get as much treatment as you want for as long as you want, based on availability) would compare to that of someone in another country which has an insurance-based system.
Also, if I move to France or Spain or Holland, when would I switch over to being under their jurisdiction? Would this effectively wipe out UK health tourism from the EU?
And what about post-operative care? If I had a heart op, I would expect to be going to see my doctors for months if not years after. Will my Belgian surgeon's responsibilities end when I'm wheeled out of his theatre? Will we end up with scenes akin to what you see on US cosmetic surgery shows where people who would be on ward for days if not weeks in the UK are wheeled out of hospital bloodied and bandaged the same day to be cared for elsewhere to cut costs?
Of course, all of this would require large amounts of confidential medical (and financial) records to be moving back and forth across the EU. Although, the main problem might be that even in the less well off countries they would expect electronic files which the UK can't currently provide...
And what would be the chances of this being extended beyond healthcare - might Poland be asked to stump up social housing costs/child benefits at Polish rates for Poles in the UK?
But, these operations are free on the NHS, so surely she'd be claiming back a total of £0 if she were to pay for treatment abroad? What if a Belgian were to come to the UK for this treatment (Rather hypothetical, I know), would the Belgian then be able to claim £5,000 off the Belgian Health Service, while paying nothing for the treatment in the UK?
I think this is going to lead to either an EU-wide insurance-based health system, an EU-wide tax-paid NHS system, or, as is more likely, a hodge-podge system, with a basic framework, various national opt-outs, opt-ins, opt-overs and different interpretations throughout Europe. Just like most EU-wide legislation, it'll serve more as evidence of countries' unwillingness to change, rather than act in any unifying way.
Dear Mark
Many thanks for informing us so well about those Europeans. Is there then no end to their cunning, now they want to operate on us, just because we have the odd waiting list. I can just imagine a true Brit travelling to Brussels or some such place on the continent to have his ingrown toenails removed. They probably "put him under" so that he may not realise what they do to him. When he wakes up his toenails are gone and with it a few other bits and pieces that have been his pride all along, such as his xenophobia.
Thanks for warning us Mark.
Joe
Surely this is a perfectly logical comnsequence of a "Common Market" -not even a "dreaded state called Europe"...... If there really was a "free market" then presumably anybody could get any service anywhere provided by anybody else......
So any "shock, horror" would appear to confirm suspicions that the "free market" is a myth.
As George Mikes wrote in "How to be an Alien", the British love to queue and have incorporated that love in their NHS system. The bloody continentals haven't and so they get their medical care when they need it. How unfair of them ! And how shamefull of Brits to try and jump the queue by taking the Eurostar to get treatment in a country that can't even get a government together in six months....
"They would get back whatever it cost in their home country".
Presumably only if it cost the same amount or more in the country they go to?
Otherwise people would be making a profit by doing it on the cheap and claiming full costs.
Obviously, you would find that additional costs added by the foreign hospital to cater for foreigners (multi-lingual staff, special facilities, admin, etc), would ensure that such an eventuality never happened.
But what about if you have complications and have to stay in intensive care for 2 months, or be shipped home. Who pays for that? Or would the operation cost also factor in the chance of that happening (with no rebate if it doesn't)?
Prior agreement from the local Primary Care Trust would just put the European supplier on all fours with the local UK hospital trusts, and is a straightforward and practical response. There is no reason why a UK Trust could not commission work from European Trusts if demand exists.
Two caveats - the contract would have to include any follow-up or rework - at present we have patients who opt to go abroad but then expect their local NHS to sort out any problems after the event, which means that EuroHospital A has been paid for work than NHS Trust B ends up doing; and the patient would have to realise that the public liability insurance position may be very different abroad. All UK Trusts (except one, I believe) are members of the Clinical Negligence Scheme for Trusts, so any payout due is effectively guaranteed. That may not be true everywhere.
I had this op on the NHS in February. I have lost 40kg and I am free of diabetes.
I first went to my doctor seeking the op in September last year so only five months between asking and getting. That included waiting for my PCT to agree to pay the neighbouring trust to do the op.
Why is there such a disparity between different trusts in the NHS?
Presumably the EU Health Directive will aim to ensure health care equality between member states. However, it will still permit discrimination within national borders i.e. the British Government will still get away with the current system of "health apartheid" at the expense of England. No different to the permissable "Education apartheid" already in place to detriment of English, Welsh and Northern Irish students, but not our EU cousins.
No doubt the 91Èȱ¬ will fail to explore this angle when questioning European Commissioners and of course the British minister who is effectively only responsible for the NHS in England.
Garry Young,
what on earth are you talking about? Westminster sets the budgets.
Brits need to wake up and realise you get what you pay for - the NHS is still the cheapest system in Western Europe, Brits pay less for health care than Belgians, so of course there are longer queues.
Despite the myths, the NHS still has less admin costs than insurance systems - if we paid the same as Belgians we'd have an even better system than them and they'd be coming to us...
I certainly don't see why people shouldn't avail of this. Irish people already have taken this initiative.
Whether or not obesity affects you, I do know of Irish people who clearly needed joint replacement or cardiac surgery & who suffered needlessly from delays in the so-called public healthcare system while enduring much pain. During this time, they have to limit their activities, cannot work a full week, have to avail of taxis or ambulances - to be treated simply for pain relief. Even retired people are affected - they aren't up to babysitting, driving neighbours about, delivering Meals on Wheels; all the very necessary services they contribute are lost to society.
Difficult though it is for the last generation to admit to having needs, surely they deserve to have them met adequately by their own nation? One way or another. You can't pretend this isn't an issue worth addressing. People are voting with their feet on this one.
Irish people are reimbursed for having their operation performed in a timely manner - by private surgeons in the UK, for example. They don't actually want to travel far whilst in pain; but nor would they wish wait for years instead, and why on earth should they, while being useless? Who can work properly while on strong painkillers? There's a further difficulty in getting off morphine later on - that's not good.
By contrast, I know one retired fellow in the UK who badly needs a hip-replacement operation. When he was interviewed by the NHS, they asked him how many painkillers he takes. He played that down, saying he only takes one when he absolutely has to. He's prepared to admit that he might have a problem, but not to own up to the constant wearing pain he now endures - that would be too personal an admission. So the NHS in their wisdom decide that he can wait three years from the day he admits that he does need treatment?!
Stoicism is fine while it lasts; when it wears off, you do need surgery urgently. He's off to have it done in Turkey, and I salute him for getting on with it at last. Would that the NHS were up to the job, for people like him. But it costs them nothing to do nothing about people who have paid taxes all their lives, investing in their training and experience, hoping that it would be there for those who need it, when they need it. This scheme might make them pull their socks up. If even people who still respect their doctors are prepared to be treated by foreign surgeons in their lifetime, good for them for doing what they have to, I say.
This is my friend, she great, good luck sara for losing the weight, i am havin the same op done in 2 weeks, hopefully get rid of this 30 stone fat body hehe
Bishop Artemije and the nuns of Gracanica are modern-day confessors, persecuted for their Orthodox Christian faith and for their love of their native land not only by Albanian nationalists, but also (and more importantly) by Godless and hypocritical Western politicians.
I have been to Gracanica myself and I have seen how Serbs their live in prison-like conditions. If any of them risked going beyound the barbed wire, he (or she, for that matter) would be killed by Albanian thugs.
My heart bleeds for Christians of Kosovo. But for their patience and fidelity to Jesus Christ they will inherit the Kingdom of Heaven.
And their tormentors - Messrs Clinton, Blair, Solana, the charming Madame Albright and all the rest of that international gang will have to answer for their crimes at the Last Judgment. May God take pity on these unfortunate sinners. I do not wish them harm, though I am amazed at their madness.
sara is a friend of mine, she has been on diets as she says she has in the report and she found they didn't work,diets don't work for everyone.
if she has paid for this treatment herself why the hell are some of you complaining? she's not on our waiting list in england no more to have this operation which is giving someone else who might not beable to afford it on the nhs to have it for free(as some people are entitled to it free) sara is not and does not have any intentions of claiming the money back and is very happy at the moment with the rate of her weight loss. sara also teaches abroad so she she hasn't really gone out of her way to have it done, she doesn't sponge of our country like some people do who want this treatment, i say good luck to sara and anyone else who is thinking of having it done!! and to all the lazy spongers of our society who want to get this for free, try getting off your bum and get a job and then instead of waiting for free treatment on our nhs you can pay for it with your hard earned money.