Access to the NHS - Who Should Be Entitled?

27 November, 2012


1. The question of access to the NHS has long given difficulty. Some believe that free treatment at the point of need should apply to anyone in the UK. Others believe that it should be strictly confined to those who, through their taxes, pay for it. There are also practical difficulties in distinguishing those who might or might not be entitled. There are those who believe that doctors, still less medical receptionists, should not be asked to perform a function more suited to immigration officers.

Previous discussion

2. The previous government went out to consultation in May 2004 on proposals to exclude overseas visitors from eligibility for free NHS primary care. In his foreword, the then Minister of State for Health (John Hutton) said:

“We must remember that the NHS is a national institution and not an international one. It is there to provide free treatment for those who live here and not for those who do not. Our aim must be to maintain the principle of providing services free at the point of delivery – but to ensure, in the process, that these services are provided only to those who are properly eligible to receive them. We wish to see close links established between free use of the NHS and UK citizenship or residency.”

The Labour government reached no conclusion and took no further action on the matter. The Coalition government eventually issued guidance in July 2012 which appears to have gone in exactly the opposite direction. It grants access to GP’s services for all foreign visitors and also to illegal immigrants.

Levels of care

3. It is important to distinguish the three principal levels of care;

  1. Accident and Emergency
    Emergency treatment is available free of charge, to anyone in the UK. In this context pregnancy is considered a medical emergency
  2. Primary Care
    This is mainly provided by general practitioners. Treatment is available to anyone registered on a GP’s list. This process of registration has been at the centre of the debate.
  3. Secondary Care
    This is primarily hospital care. Hospitals are expected to check a patient’s eligibility before undertaking medical treatment. However, they must do so without any form of discrimination. The regulations are complex and the staff available for the purpose are few.

The latest guidance

4. The latest guidance was dated 17 July, the day that Parliament rose for the summer recess. There was no press release. The guidance, in summary, stated that:

  1. Overseas visitors
    1. An overseas visitor could register with a GP provided that he or she was in the area for more than 24 hours. This applies whether or not the visitor is lawfully in the UK. A GP is paid £64 per head for each patient on his register; there is no means of knowing whether a visitor has subsequently left the UK.
    2. Registration and appointment should not be withheld because the patient does not have proof of residence or personal identification.
    3. Past or present payment of taxes or National Insurance is not to be taken into account.
    4. A GP practice is required to offer free treatment to anyone who requests it (if they have not been accepted on the list) if, in the opinion of a health care professional, it is immediately necessary.
  2. Illegal immigrants
    All of the above applies to illegal immigrants (refugees and asylum seekers whose cases are undecided are not illegal immigrants; they already have the right to free NHS care both by GPs and hospitals).
  3. Hospital treatment
    It is the duty of the hospital, not the GPs, to establish entitlement to free hospital treatment.

Implications of this policy

5. The implications of these changes are wide ranging. They are an unequivocal invitation to “health tourism” at a time when the NHS is obliged to make substantial savings. Nearly 8 million non EEA visitors arrive in Britain every year. It will not be long before substantial numbers seek free treatment while they are here, especially if they come from countries such as the United States where most medical treatment is both private and very expensive. There could also be an inflow of visitors from EU countries where health standards are not as high as in the UK. (If they come here to settle they are entitled in any case but they could now come as visitors). The recent rapid rise in births to mothers born in Poland could be a pointer to the future.

6. Illegal immigrants will be a significant additional burden on the NHS. The total number is not known but is thought to be somewhere between half a million and one million. Furthermore, the availability of free medical treatment is bound to encourage further illegal migration into Britain.

7. There will be no measure of the extent of health tourism as no questions are to be asked about the identity of patients. The average cost per head of primary care in the NHS in 2011/12 was £394. By contrast, applicants for a visitor’s visa to the Shengen area (most of the other countries of the EU) are required first to obtain health insurance worth about £20,000.

Admission to hospital

8. In theory, admission to hospital is a different matter. The new regulations make it clear that the responsibility is one for the hospitals themselves. However, a Freedom of Information Act request submitted on behalf of Henry Smith MP found that most NHS Trusts only cursorily audit the treatment of foreign nationals who are not entitled to automatic free healthcare. Many hospitals do not even ask whether patients are foreign nationals. In addition, a Panorama programme broadcast in October found extensive evidence that no proper checks were made.