NHS charging for overseas visitors – wrong on every level

Regulations that deny visitors NHS care – except for certain infectious diseases and to relieve death pains - are riven with contradictions. And will hit some unexpected victims as well as the intended scapegoats.

Martin McKee
5 September 2018

Image: Poster in Newham hospital. Rights: Newham Save Our NHS.

Given the choice, the British government’s guidelines on implementing their overseas visitor charging regulations would not have been top of my reading list. Especially because I had already read them once – but still had to revisit them to formulate an answer to a question on a list server. The question was, at least superficially, simple. The regulations contain a list of diseases which -  for any visitor to the United Kingdom unlucky enough to have one of them – the NHS will still provide free treatment. Is this list appropriate? Is there anything that is missing? As is often the case, an apparently simple question opens up many other less obvious issues. Here are just a few of them.

The guidelines were written for health professionals and managers who must decide whether a patient is entitled to free NHS care, in the light of recent regulations restricting access for visitors.

To make their decision, NHS staff are confronted with a set of guidelines that stretches to 117 pages, which they are expected to understand and apply, even in the midst of working frantically to save a patient’s life.

It gets worse. NHS organisations “are advised to seek their own legal advice on the extent of their obligations when necessary”. Why? Because the regulations are incredibly complex, and involve balancing requirements under a wide range of other legislation, including data protection, prohibition of discrimination, and much else. Also there are still unresolved ambiguities. As the guidelines note, “’Ordinarily resident’ is not defined in the 2006 Act”, even though it is a key concept in making decisions under the regulations.

NHS staff really don't need all of this. In a health service that has been starved of resources for almost a decade, health workers are already overstretched. Posts remain unfilled, and rotas have many gaps. In some parts of the country, many of those providing direct patient care are agency staff, who must spend precious time orientating themselves to different settings. The rapidly changing nature of healthcare means that they must constantly update their knowledge, both in relation to clinical matters and to an often bewildering array of statutory requirements. 

“providing timely and effective care to migrants saves money in the long run”

Leaving aside the morality of the government’s “hostile environment” to visitors, these regulations also completely fail to recognise that what is presented as a cost saving measure is anything but. For many hospitals, the cost of complying with the regulations far outweighs any income that they may generate. And research from Germany shows clearly that providing timely and effective care to migrants saves money in the long run. But then, as is apparent with the government’s pursuit of Brexit, deterring migrants is much more important than growing the economy.

The politics behind the regulations are obvious. The main exemption from charges is for infectious diseases deemed to pose a threat to the resident population. Visitors will be entitled to care in an emergency department, but only until the point where they require admission to hospital. Palliative care is also exempt, presumably because of the media attention that visitors dying in agony might attract.

The list gives an impression of having been drafted several decades ago

It is the list of infectious diseases that is most intriguing. Some are highly contagious but others are not. Leprosy, for example, is only transmitted when there is prolonged contact between people. Others are included even though they are transmitted by vectors not normally present in the United Kingdom. Yet other vector borne diseases (such as Chagas Disease, increasingly being diagnosed among migrants from South America) are excluded. Smallpox remains on the list, despite having been eradicated globally almost 40 years ago. The list gives an impression of having been drafted several decades ago, with individual diseases being added on an ad hoc basis.

There will, however, be an opportunity to update the list. The guidelines are full of references to the European Union and the European Economic Area. Visitors from the countries concerned are, of course, entitled to treatment paid for by their home health authorities. Should British ministers ever manage to agree on a feasible plan to leave the European Union, then this will have to change completely. However, given the many other challenges that they will face, including shortages of staff, medicines, equipment, and above all money, this may be well down the list of priorities.

British pensioners who have retired to the Mediterranean…will find, to their surprise, that they are not entitled to NHS treatment under the regulations

So it may take some time for them to address one of the more pressing issues. This is the potential return of large numbers of British pensioners who have retired to the Mediterranean. Many of them will find, to their surprise, that they are not entitled to NHS treatment under the regulations as they are not ordinarily resident. Given that many are elderly, with multiple chronic conditions, this will pose a considerable challenge. In some cases, they will have family members who are not British citizens, just to add to the complexity.

Postscript: As I was finalising this blog, the Home Office issued its guidance on applications for settled status for EU citizens post-Brexit. The good news – it is only 59 pages long. Remember that the then Home Secretary said this would be as simple as opening an account at a certain upmarket retailer. The bad news – the guide to the process for such applicants is almost as incomprehensible as the guidance for NHS staff outlined above. This time, the government claims the default position will favour the applicant but, given this would be a 180 degree turn by the Home Office, and totally at odds with the culture of xenophobia it has worked so hard to create, no-one believes it.

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