Repatriating psychiatric patients

In a psychiatric intensive care unit in central London 17% of consecutive admissions between 1 October 1997 and 1 October 1998 were foreign nationals from European Union (EU) countries. It was our experience that the process of repatriation varied considerably depending on the country involved. There have been several reports of the experience of hospitalisation of foreign nationals for the treatment of psychiatric disorders (Ktiouet, 1982; Postrach, 1989; Bar-El et al, 1991). In the UK, Jauhar & Weller (1982) and Cooper (1997) described admissions to hospital from Heathrow airport, of which a proportion were foreign nationals. The only references to the process of repatriation, however, are descriptions of French nationals repatriated from various countries via medical insurance companies (Sauteraud & Hajjar, 1992; Zittoun et al, 1994; Sauteraud, 1997) and of the experience of two nurses who escorted a patient from England to Sierra Leone (Birch, 1983).

We discuss our experience of arranging repatriation and some of the relevant legal, ethical and clinical issues involved. We also report the results of contacting all the EU embassies regarding the process of repatriating psychiatric patients to their respective countries.

Legal aspects

Section 86 of the Mental Health Act 1983 allows the Home Secretary to authorise “the removal of alien patients” to another country. This applies to patients who are neither British citizens nor Commonwealth citizens having the right of abode in the UK and who are receiving in-patient treatment for mental illness (not other categories of mental disorder as defined under the Act). These patients must be detained for treatment under certain sections of the Mental Health Act (excluding sections 35, 36 and 38). Section 86 does not apply to informal patients or to those granted extended leave of absence under section 17.

In order for the Home Secretary to authorise repatriation certain conditions must be met. Proper arrangements must have been made for the removal of patients, including travel arrangements and nurse escorts, and for treatment in the receiving country.

Repatriation should be in the patient's best interests and the approval of a Mental Health Review Tribunal, which will have considered these facts, must have been obtained. Section 86 also enables the Home Secretary to give directions for patients to be kept under escort on their journey home until arrival at any specified place in the receiving country. In practice, the Home Office is involved in only one or two cases each year in which repatriation is arranged under Section 86.

For patients who are willing to travel and for whom suitable arrangements have been made, application to the Home Office is not necessary. If patients are subject to a Section 41 restriction order, they may be conditionally discharged from section 37, with the conditions being that they return to their country of residence and accept appropriate treatment there. The restriction order may remain in place and will apply if the patient returns to the UK.

The current arrangements would seem to satisfy the obligations in respect of “persons of unsound mind” arising under article 5 of the European Convention of Human Rights (the right to liberty and security of the person). The impact of the Human Rights Act 1998 should therefore be minimal with regard to the process of repatriation.

Financial aspects

There is provision within the National Health Service Act for patients detained under the Mental Health Act (but not for voluntary patients) who are receiving treatment from the NHS to have the cost of repatriation paid for by the NHS. Prior to 1 April 1999 the Department of Health set aside a budget, held by Leeds Health Authority, for overseas visitors entitled to free treatment from the NHS. This applied to all EU citizens. They made decisions regarding funding for repatriation that largely depended on the relative cost of repatriation compared with financing ongoing treatment in the UK. Providers paid and were refunded. However, from 1 April 1999, this budget ceased to exist. Instead, money was allocated directly to health authorities and decisions regarding repatriation were made locally. We are unclear as to how these local arrangements are working in practice.

Clinical, practical and ethical issues

In our experience the following steps are required in order to arrange repatriation.

Contact the relevant embassy

This should be done soon after admission as planning repatriation and obtaining information can take longer than expected.

Arrange for an interpreter in order to interview the patient (and his or her relatives), if necessary

The complex issues involved in conducting interviews with interpreters have been described by Westermeyer (1990). Obtaining suitable interpreters can be difficult. The Mental Health Act 1983 Code of Practice (Department of Health and Welsh Office, 1999) states that local and health authorities and trusts have a responsibility for arranging an easily accessible pool of trained interpreters and for ensuring that staff receive sufficient guidance in the use of interpreters. It also recommends that friends and relatives should not be used as interpreters. The Royal College of Psychiatrists has a list of psychiastrists who speak a variety of foreign languages, which can be a useful resource.

Obtain information regarding previous contact with psychiatric services in the patient's country of origin and establish which hospital in that country should be responsible for their care

Patients, or relatives, may know the name of the patient's local hospital and even a specific psychiatrist. Embassies are usually willing to find details of the appropriate hospital.

Obtain specific information regarding patient's past psychiatric history, including previous diagnosis, treatment, response to treatment and any history of dangerousness

Some embassies liaise directly with the psychiatrist and relatives to obtain this information (eg. French embassy). Others provide a telephone number to contact a specific doctor (eg. German embassy). The latter can lead to problems if, for example, little English is spoken by hospital staff. We found that certain countries (eg. Ireland and Italy) were more reluctant to release information without patients' consent, despite patients being unable to give informed consent. Sometimes consultants provide considerable information by telephone, even when unable to release written documentation.

Translation of correspondence

Some embassies (eg. French embassy) will automatically translate correspondence. Others cannot provide any translation service.

Continue treatment until patient is fit to travel

Patients are treated in hospital in the UK until either they are well enough to be discharged and make their own travel arrangements, or repatriation is arranged. Airlines and Eurostar have the right to refuse patients who they consider to be too ill to travel.

Consider repatriation and discuss this with patient

Often patients agree to repatriation shortly after admission and arrangements can be made for travel to take place as soon as patients are well enough. If patients refuse to be repatriated there are three options. First, treatment can continue until patients gain some insight, at which time they often agree to continue their treatment at a hospital in their country of origin. Second, treatment may result in sufficient improvement for patients to be safely discharged and to make their own travel arrangements. Problems can arise if patients are well enough to be discharged but do not want to return home, as they may fail the test of habitual residence, a condition of eligibility for benefits such as housing benefit and income support introduced by regulation 4 of the Income-Related Benefits Schemes (Miscellaneous Amendments) (No. 3) Regulations 1994. Third, repatriation under Section 86 can be arranged, as described above. This is a last resort and, in our experience, rarely necessary.

Decisions regarding whether repatriation is in patients' best interests depend on a number of factors. These include whether patients are known to psychiatric services in their own country and patients' support network available there. Their proposed plans for remaining in the UK, including entitlement to housing and benefits, are also important. Language is a consideration, as it is plainly difficult for anyone to be treated in a hospital where they cannot communicate with staff. Relatives may not always, for practical and financial reasons, be able to travel to the UK. It can be distressing and frustrating if they cannot have contact with patients or have difficulty communicating with staff by telephone. However, for practical reasons, it is extremely difficult to force patients to be repatriated if they adamantly refuse.

Arrange date and process of transfer

The receiving hospital should agree to make a bed available. UK hospital staff are responsible for travel arrangements, including nurse escorts. Escorts may accompany patients as far as the station or airport in the receiving country, or all the way to the hospital. French nationals usually go to a central hospital in Paris for assessment prior to transfer to their local hospital, even if they are known to their local hospital that has agreed to admission. The French embassy arrange a document that allows for patients to remain detained from the time they leave England to the time they arrive at the hospital in Paris. In countries where this arrangement is not possible, patients can abscond on arrival at the airport in their country.

Embassies

To prepare this paper we contacted all EU embassies and conducted telephone interviews with the member of staff usually involved in the repatriation of patients. A list of questions, which can be helpful when contacting an embassy following the admission of a foreign national, was used for the interviews. The questions are listed in Table 1. The results of the enquiry are listed in Table 2.

Table 1. Useful questions to ask embassy staff

1. Have you been involved in repatriating psychiatric patients?

2. Will you find information about which hospital the patient should return to?

3. Will you liaise directly with the hospital concerned to obtain information regarding the patient's past psychiatric history and to arrange plans for transfer?

4. Will you be able to translate discharge summaries and other correspondence, and will there be a charge for this?

5. If the patient is detained in this country under the Mental Health Act, is there any process ensuring the patient remains detained from the time they leave England until the time they arrive in the appropriate hospital?

6. Does the patient return directly to his/her local hospital or is he assessed at a central hospital initially?

7. Who is responsible for the cost of repatriation?

Table 2. Information obtained from contacting European Union Embassies

Country	Previous experience of repatriation?	Does embassy find appropriate hospital?	Direct liaison with hospital?	Translation service? Is there a charge?	Any means to ensure detention after leaving UK?
Austria	Yes	Yes	Yes	No	No
Belgium	Yes	Yes	Yes	No	Patients may be met at border by doctor or police. Mayor of town has to sign section papers, so arranging continued detention is not straightforward
Denmark	No	Yes	Prefers doctors to liaise directly, but will help if specific problems arise	No	No, Denmark is a very lenient country
Finland	Yes	Yes	Yes	No	No
France	Yes	Yes	Yes	Yes, no charge	Embassy issues permit, “Hospitaliation a la Demandé d'un Tiers”, ensuring continued detention until arrival at central assessment hospital in Paris, Hôpital Sainte Anne
Germany	Yes	Yes	Prefers doctors to speak directly as hospitals not always willing to release information to embassy	No, German doctors may translate documents prior to sending them	No
Greece	Yes	Yes	Yes	Yes, sometimes charge	No
Ireland	Yes, but embassy usually not contacted	Embassy contacts Irish Healthboard, which locates hospital	No	N/A	No
Italy	Yes	Yes	Yes	No	No
Luxembourg	No	Yes, but prefers relatives to do this	Yes, but prefers not to get involved	No	No
Netherlands	Yes	Embassy contacts Ministry of Foreign Affairs, which locates hospital	Embassy asks doctors in Netherlands to contact UK doctors	Correspondence translated in the Netherlands	No
Portugal	Yes	Yes	Yes	Not officially; Medical Attaché will give rough translation	Not sure
Spain	Yes	Yes	Yes	No	Spanish hospital can arrange a court order ensuring detention from time of arrival in Spain
Sweden	Yes	Yes	Yes, but prefer doctors to liaise directly	Not officially, but may give rough translation	No