April showers: NHS hopes for rainy days

Date published



From April this year, NHS hospitals in England will be obliged to obtain payment from overseas patients in advance for non-urgent treatment, where the patient is not otherwise eligible for free treatment.

The clear intention is to cut down on ‘health tourism’ — the means by which patients who are not entitled to, or not able to pay, for treatment in their countries of origin seek out treatment from the NHS.

There is a very significant problem to be addressed.

Cost-benefit analysis

In October 2016, the National Audit Office (NAO) published a report titled: Recovering the cost of NHS treatment for overseas visitors. The NAO identified the fact that it was difficult to know how much money the NHS should charge and recover, given gaps in the data “but the best available estimates suggest that the NHS is recovering significantly less than it could”.

Recent well-publicised cases have further highlighted the fact that some patients have received hugely expensive treatment when they are simply in no position to reimburse the hospital. There is clearly a very significant problem to be addressed. The challenge is to deal both with treatment of citizens from within the European Economic Area (EEA), where the machinery is already in place for reciprocal arrangements to be enforced, and the treatment of those patients from outside the EEA.

The NAO report also highlighted that in 2014-2015 over £674 million was claimed from the UK government by other European countries to reimburse them for treatment received by Britons but only £49 million was claimed back from European countries for treatment of their citizens in this country. The NAO makes clear that “the figures are not directly comparable”. Nevertheless, there is clearly a very significant mismatch.

There are also significant differences between amounts charged and amounts recovered. A further complexity is that in many cases hospitals have charged less than they are entitled to charge in the first place.

Hot potato

Payment by patients for treatment is, politically, a ‘hot potato’ and we only have to look back at the uproar in the press in late in 2016 when it was announced that the government was considering requiring patients to show two forms of identification in order to receive treatment to see that feelings run high.

This sensitivity comes from at least two sources. Firstly, the general public is always keen to defend the notion that treatment is free at the point of delivery. It may also be fair to say that the ‘point of delivery’ element is often over-looked.

Secondly, there is understandable reluctance on the part of some doctors and other clinicians to become drawn into any investigation as to a patient’s eligibility to receive treatment at no cost. Clinicians, not unreasonably, view themselves as healers and not accountants.

Whilst a clinician doing ward rounds may regard a stethoscope as an indispensable part of their equipment, they may take a somewhat different view of card readers. Similar points can be made across the system, from medical secretaries to GPs making referrals from primary care.

Current law

The current law is set out in the National Health Service (Charges to Overseas Visitors) Regulations 2015 (as amended). It is interesting to note that the guidance to these Regulations — issued by the Department of Health — examined this very point (the role of clinicians in determining eligibility) at some length. However, as noted the key difference with the new Regulations is that from April payment must be made upfront. There have been several trials across the country that appear to have been successful.

It is also important not to overlook the fact that many so-called ‘health tourists’ may have had no intention of takRead related items in Healthcare Brief - March 2017ing any sort of advantage of the NHS and have simply discovered that treatment, albeit not urgent treatment, is required whilst travelling. There may be a further ethical complexity if patients are deterred from seeking treatment given their concerns about charges. Delayed treatments can of course lead to more severe conditions and so increased costs.

Financial pressures

The new law is consistent with financial and resourcing pressures being seen right across the NHS and it also fits with what we are seeing domestically (with the treatment of local patients who are entitled to free treatment), as well as internationally.

Contracts entered into by NHS Trusts (for all services and not just clinical provision) should always be robust and contain clauses to enforce, for example, extra charges in the case of late payment of commercial debts. However, in some cases and for a range of different reasons, Trusts have been reluctant to enforce such clauses. This is changing and is a key part of robust contract management.

Challenges ahead

Nevertheless, it will be a challenge to implement a robust and consistent system across the NHS in a matter of just a couple of months. The implementation of any sort of charging scheme will of course require extra administrative input and not just from NHS bodies. Help may be required from immigration officials at the Home Office and border controls, reviewing visas and perhaps alerting hospital Trusts to new arrivals.

A simple requirement for two forms of identification may mean that any lack of trust, on the part of patients, and resentment on the part of clinicians, who do not want to act as financial gatekeepers, can both be avoided. Any new system will also need to be agile in order to take account, in due course, of the UK’s departure from the European Union.
Read related items in Healthcare Brief - March 2017