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Charging overseas visitors for primary care

The government has proposed changing how overseas visitors access NHS care. Fiona Barr explains how the current system works, looks at the proposals and assesses their impact on practices.

The government plans to change how non-EU visitors access GP care (Picture: iStock)
The government plans to change how non-EU visitors access GP care (Picture: iStock)

Rules on charging overseas visitors for access to GP care could be changing. Earlier this summer the government launched proposals for new arrangements almost ten years after the last government’s attempt to change the system.

The 2004 consultation resulted in no action and no new guidance, which is probably an indication of how contentious this area is.

Current system

As things stand GPs must provide emergency and immediate treatment to anyone in their practice area for up to 14 days and have discretion for longer stays (see below) which leads to complicated decision making for practices.

Current rules on charging overseas visitors

Contractual obligations

  • Practices have a contractual obligation to provide emergency and immediately necessary treatment free for up to 14 days to anyone in their practice area.
  • Immediately necessary treatment includes treatment of pre-existing conditions that have been exacerbated during the person’s stay in the UK.

Practice discretion

  • Practices can accept overseas visitors as temporary residents if their list is open and they will be in the area for between 24 hours and three months.
  • Practices can accept applications for inclusion onto their list. Overseas visitors have no formal obligation to prove their identity or immigration status to register with a practice. Several areas are now advising practices to accept all patients without question.

European Health Insurance Card holders

  • EHIC holders from EEA countries (EU plus Norway, Iceland, Lichtenstein and Switzerland) should have care provided free and the costs then reimbursed to the NHS by their home country. However, there is no mechanism for capturing treatment costs outside hospitals.

Charging

  • Practices can charge any patients who does not require emergency or immediately necessary treatment and has not been accepted onto a patient list or accepted as a temporary resident.

Source: Overseas visitors accessing NHS primary medical services. Guidance for GPs from the GPC

Current difficulties

In 2013 the increasing financial strain facing the NHS means plans to toughen up the rules could find more supporters, but most practices will probably be hoping for a simpler system.

Dr Richard Brown, deputy chief executive of Surrey and Sussex LMCs, says the current rules are difficult for practices to administer as the need to avoid discrimination mean it is almost impossible for practices to establish whether someone is entitled to free primary care or not.

Indeed NHS London issued advice last year, which suggested that all patients should be accepted onto a practice list provided the list is open.

Dr Brown adds: ‘The current system is fraught with difficulty and our advice is for practices to be very cautious about registration processes to make sure they are not discriminatory. I think what practices would like from any new system is clarity.’

Dr Dan Bunstone, a GP in Warrington, can see why the government wants to look again at the provision of free care to those arriving from abroad.

‘I understand the principle that the NHS needs to save money,’ he says. ‘If we are looking at clinical priorities and asking people to make sacrifices it seems only fair to also look at those who haven’t contributed to the NHS.’

He says his own practice has had little difficulty charging visitors from such countries as India and Canada and says many patients expect to pay – and in the case of holidaymakers, often have travel insurance to cover the costs.

However, he believes the kind of proposals in the latest review would be ‘an impossible ask’ for surgeries in practical terms.

The proposals for a new system

The consultation document, Sustaining services, ensuring fairness, argues that the NHS cannot continue as an international rather than a national health service. As a result the government has commissioned an audit of use of the NHS in England by visitors and temporary migrants to establish the costs involved.

At the same time the Home Office is consulting on proposals to redefine qualifying residency, charge a ‘migrant health levy’ on entry to the country for non-EEA nationals who intend to stay for up to five years, and extend charging to primary care. This means that those who are not exempt or who have not paid the levy would be charged for GP services, possibly including emergency treatment.  

What concerns GPs like Dr Bunstone is firstly how practices would be expected to identify who has paid and the additional bureaucracy involved. 

The consultation document itself points out that even at the moment only a fraction of the charges due are collected and says better systems are needed to identify patients when they register and then track them through the system.

GPs also have concerns about the impact the proposals might have on overseas visitors in need to care. Dr Osman Bhatti, a GP in Tower Hamlets, London says: ‘I feel that it is passing the policing to primary care and would want to be very careful to ensure that we do not deny healthcare to patients who may be eligible and potentially refused under this policy.’

Discrimination fears

It is illegal for practices to turn down someone for reasons including their race and religion which means that simply identifying eligibility can be a minefield as NHS London’s advice would suggest.

In Bedfordshire a complaint about the way a practice was handling registrations from migrants led to the Practitioner Services Unit (PSU) changing its advice, according to Ampthill practice manager Caroline Cook.

She says the PSU used to advise practices to ask for proof of residency in the UK but is now advising practices to accept all patients without proof unless the practice is prepared to check residency for all patients on its list.

Again Ms Cook is sympathetic to the aims behind the current consultation but concerned about the practicalities. ‘I totally understand why they are trying to do it, but I don’t know how it could be policed.’

Dr Nigel Watson, chief executive of Wessex LMCs, says practices take a variety of stances but that many simply provide care because the bureaucracy of working out who is entitled to free care and then collecting any payments due from those who aren't is too complicated.

He adds that most of the cost from so-called ‘health tourists’ is borne by secondary care where charging rules are different.

The BMA’s guidance also emphasises that it is not the duty of GPs to establish patients’ entitlement for free NHS secondary care treatment and that GPs should simply refer where clinically appropriate.

For most GPs the current system is far from perfect but anything which replaces it will need to be clear, simple and fair to win support. Dr Watson adds: ‘My role is to treat patients’ health, not run the administration of the system.’

  • The consultation on the Sustaining services, ensuring fairness proposals closes on 28 August.

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