Intended for healthcare professionals


Making “health tourists” pay for care

BMJ 2017; 356 doi: (Published 15 February 2017) Cite this as: BMJ 2017;356:j771
  1. Johanna Hanefeld, associate professor of health policy and systems1,
  2. Kate Mandeville, consultant in public health2,
  3. Richard Smith, professor of health systems economics and dean faculty of public health and policy1
  1. 1London School of Hygiene and Tropical Medicine, London, UK
  2. 2Ealing Council, London, UK
  1. Correspondence to: J Hanefeld johanna.hanefeld{at}

A pointless and damaging distraction from bigger problems in NHS

Concern that patients normally resident in one country use a tax based national health system in another without financial contribution is not unique to the NHS. Similar discussions are occurring elsewhere, including in South Africa1 and Thailand.2 The recent announcement by the secretary of state for health that all hospitals will need to charge patients not eligible for free NHS treatment before they receive non-urgent care seeks to address this in England.3 The question is, will it work?

The first barrier to success is the lack of a unique identifier of eligibility to NHS care. Passports or utility bills are not reliable indicators. Research funded by the Department of Health showed that British expatriates, holding British passports but no longer eligible for NHS care, incur the highest average cost of all visitor types.4 Given the chequered history of information technology in the NHS, implementing a reliable system of identification that will cost less to run than the amount to be recovered is likely to prove challenging.

Moreover, the Public Accounts Committee found that the NHS charged only 16% of the total possible amount for visitors from the European Economic Area (EEA), compared with 65% for those from other countries. EEA visitors thus seem to be the prime target for any identification system.5 Yet, with just two years to go until Brexit, any system designed to improve cost recovery under European Union rules would not seem the best use of stretched resources.

Secondly, upfront charges will have an unknown (but likely adverse) effect on front line clinical care and public health. At what point, and by whom, will patients be identified and told that they cannot have a clinically necessary procedure until they pay for it? Will it be the consultant running the outpatient clinic, the nurse, the receptionist? Whenever clinicians discuss eligibility based on criteria other than clinical need, this changes the doctor-patient relationship from advocacy to adversary.6 Misinformation about eligibility could easily dissuade hard-to-reach populations from accessing healthcare when they need it, hampering the control of communicable diseases and increasing the burden on emergency care as treatable conditions are ignored for fear of payment.7

But even if these difficulties are dealt with, how much does the NHS actually stand to gain? The Department of Health’s target of £500m (€590m; $630m) to be recouped annually is based on modelling that made a large number of assumptions: the number of irregular migrants comes from out-of-date population estimates, while estimates for health tourism “are a structured judgment.”4 The health department has acknowledged to the Public Accounts Committee that this figure should not be regarded as “overly scientific” and should be viewed as a “stretch target,” admitting that only £346m would be charged.5 This more realistic amount is around 0.3% of the total NHS England budget of around £116bn.

Reliable figures on health tourists are hard to come by. Analysis of the International Passenger Survey showed around 52 000 foreign patients coming into the UK for treatment annually.8 However, this figure includes people visiting the UK with the intention to pay for their care. These people are particularly lucrative when compared with domestic private patients.8 For example,18 hospitals in London receive 25% of their private income from foreign patients, who account for just 7% of their private patients.8 This income provides important extra revenue to the NHS at a time of stretched public resources.

But there are also 63 000 UK patients, eligible for NHS care, who go overseas for treatment, thus providing a saving for the NHS. Generating a picture of the net effect of patient mobility is thus notoriously difficult and unlikely to be robust enough to base a major policy initiative on.

Given that unrecovered charges from people not eligible for NHS care represent a tiny proportion of the NHS budget, are likely to be dwarfed by the administrative costs, and could have detrimental public health outcomes, it seems an odd policy priority. Rather, their pursuit seems more of a response to the xenophobic overtones of the Brexit movement and a smokescreen to divert attention from the more fundamental issues within the NHS, such as chronic funding crises and staff burnout.

That foreign patients’ access to health services is a political hot potato not just in England but in countries around the world, underlines how slow health systems have been to respond to the new reality of global patient mobility. For countries with mainly tax based systems, this can lead to tensions that are often exploited in the political discourse.

The current debate about overseas visitors and their access to the English NHS highlights not just funding problems within UK politics. More fundamentally, it is about our urgent need to manage international patient mobility at a global level rather than one country going it alone.1


  • Competing interests: We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

  • Provenance and peer review: Commissioned; not externally peer reviewed.


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