Immigration health surcharge

Aneurin Bevan dealt with the political issue in his essay In Place of Fear (1952):[1]

One of the consequences of the universality of the British Health Service is the free treatment of foreign visitors. This has given rise to a great deal of criticism, most of it ill-informed and some of it deliberately mischievous. Why should people come to Britain and enjoy the benefits of the free Health Service when they do not subscribe to the national revenues? So the argument goes. The fact is, of course, that visitors to Britain subscribe to the national revenues as soon as they start consuming certain commodities, drink and tobacco for example, and entertainment. They make no direct contribution to the cost of the Health Service any more than does a British citizen.

He pointed out that the cost of treating visitors was negligible, but the costs of administering checks would be great:

For if the sheep are to be separated from the goats both must be classified. What began as an attempt to keep the Health Service for ourselves would end by being a nuisance to everybody.

The whole agitation has a nasty taste. Instead of rejoicing at the opportunity to practice a civilized principle, Conservatives have tried to exploit the most disreputable emotions in this among many other attempts to discredit socialized medicine.

It is alleged that health tourists in the UK often target the NHS for its free-at-the-point-of-care treatment, allegedly costing the NHS up to £200 million.[2] A study in 2013 concluded that the UK was a net exporter of medical tourists, with 63,000 UK residents travelling abroad for treatment and about 52,000 patients getting treatment in UK.[3]

In the summer of 2015 immigration officers from the Border Force were stationed in St George's University Hospitals NHS Foundation Trust to train staff to identify "potentially chargeable patients".[4] In October 2016 the trust announced that it planned to require photo identity papers or proof of their right to remain in the UK such as asylum status or a visa for pregnant women. Those not able to provide satisfactory documents would be sent to the trust's overseas patient team "for specialist document screening, in liaison with the UK Border Agency and the Home Office.” It was estimated that £4.6 million a year was spent on care for ineligible patients.[5] A pilot scheme to check whether patients were entitled to free NHS care in 18 NHS trusts, 11 in London, for two months in 2017 asked 8,894 people for two forms of ID prior to non-emergency care. Only 50 were not eligible for free NHS treatment. Campaigners claimed this was “part of the Government’s hostile environment policy”, and that in Newham hospital "you will see huge signs saying you may not be eligible for free NHS treatment".[6]

Eligibility for free care NHS treatment is based on a person being ordinarily resident in the UK. Amendments to the National Health Service (Charges to Overseas Visitors) Regulations 1989 have excluded a number of vulnerable groups from being eligible for free healthcare, including failed asylum seekers, undocumented migrants and those who had overstayed their visa. Very extensive guidance has been repeatedly issued to NHS organisations on the implementation of the rules, but with little effect because NHS organisations, unlike commercial health providers, are not organised to check eligibility.[7]

People moving to the UK from outside of the European Economic Area for longer than six months are required to pay the surcharge of £200 per year.[8] The Health Surcharge entitles them to 100% free health care on the NHS. Most travel insurance would cost more than this, and would mainly cover emergency care only. The surcharge was introduced in April 2015 and has raised £175m, with 450,000 surcharges issued in the first year. People from the Democratic People’s Republic of Korea have to pay for this surcharge in cash only.[9] It was raised from £200 to £400 a year in 2018 which is expected to raise an extra £220 million a year for the NHS although NHS trusts are already having to loan overseas recruits funds to pay these upfront costs.[10] A discounted rate of £300 is charged to students and people between 18 and 30. The NHS spends an average of £470 a year on treating the people who pay the surcharge.[11]

Charges for treatment for those not entitled to free treatment - ie those who have not paid the surcharge were set at 150% of the actual cost to the NHS in 2015.[12] when people accessing the NHS were identified and charged, only 16% of these people paid the invoices, so the surcharge was introduced. The money for the NHS should be collected by an Overseas Visitor Manager,[13] but many hospitals in England do not have one of these.

Lewisham and Greenwich NHS Trust has used Experian to identify overseas visitors who could be charged for NHS treatment. NHS England has encouraged other trusts to do likewise, having identified 51 NHS trusts with an “income opportunity” from overseas visitors.[14]

There is evidence that the existence of the charging regime deters people from seeking early treatment, and that will incur additional costs, and in the case of infectious conditions, risks to public health.[15] Women are thought to be particularly vulnerable as they are excluded from maternity care and have no access to free abortions.[16]

The surcharge applies to people who are admitted as children and granted limited leave to remain. It has been criticised as part of the Home Office hostile environment policy.[17]

The Royal College of Nursing says that migrants working in the NHS should be exempt from the surcharge because this would help tackle the health service’s staffing crisis. The surcharge applies to each member of the family, and the college quotes the case of a Kenyan nurse working in Luton, whose children had to return to Kenya because she could not afford to pay £3,600 to ensure that she, her partner and four children could receive NHS care during her three-year stint working in the NHS.[18]

Immigrants in the UK in most cases already pay taxes. Immigrants are in effect paying for the National Health Service twice.[19]

The Royal College of Physicians, the Royal College of Paediatrics and Child Health, the Royal College of Obstetricians and Gynaecologists and the Faculty of Public Health called for the suspension of all NHS overseas visitor charges in December 2018. They said that the regulations were a danger to health because they deterred people with infectious conditions from seeking early treatment, and undermined trust in doctors.[20]

• Healthcare in the United Kingdom

• Paying for the NHS as a non-EU migrant