Intended for healthcare professionals


Upfront charging of overseas visitors using the NHS

BMJ 2017; 359 doi: (Published 18 October 2017) Cite this as: BMJ 2017;359:j4713
  1. Lucinda Hiam, health adviser1,
  2. Martin McKee, professor of European public health2
  1. 1Doctors of the World, London, UK
  2. 2London School of Hygiene and Tropical Medicine London WC1H 9SH
  1. Correspondence to: M McKee martin.mckee{at}

Changes are a threat to everyone

When asked what makes them proud to be British, more people cite the NHS than anything else, ahead of British history, sense of humour, and the monarchy.1 Its popularity transcends all ages and political allegiances.2

The NHS’s founding principles—to meet the needs of everyone, to be free at the point of delivery, and to be based on clinical need, not ability to pay3—were restated as recently as 2011, when a “wider social duty to promote equality” was added. The intention was not that everyone in the UK would be entitled to care; entitlement is based on lawful residence. However, even those not entitled to free care would be given it, with healthcare providers seeking to recoup the costs later. Health professionals could therefore concentrate on the tasks of diagnosis and treatment. This is no longer the case. From 23 October 2017, anyone, including children, attending healthcare facilities in England who is unable to establish their entitlement to free care will be charged upfront for the estimated cost of treatment.4 If they are unable to pay, treatment may be refused.

Healthcare teams face two challenges.4 Firstly, they must establish whether the patient is entitled to NHS care. This is not straightforward. Our searches of websites of hospitals participating in a pilot scheme5 suggest that they require proof of identity such as a passport and, where appropriate, visa and proof of residence, such as a utility bill.67 However, these do not in themselves establish entitlement, and there has already been confusion; one trust initially asked for these documents for HIV care, which is exempt from charging.8 Also, it is not clear whether all patients are asked for documents or only a selection, and, if so, how they are selected.

When a person has no documents—one in six UK residents does not hold a passport9—providers must consider several questions to determine entitlement, such as whether the person has “an identifiable purpose for their residency” in the UK that has a sufficient degree of continuity.4 Clearly, this requires considerable judgment, based on what will often be incomplete information.

Secondly, if the patient is not entitled to care, clinicians must decide whether the condition requires “immediately necessary” or “urgent” treatment (box 1). To make this decision they can examine the patient and do some initial tests but no more. Yet, if they get this wrong, they face considerable risks. If they breach the guidance by providing treatment to people lacking entitlement, they may reasonably fear potential disciplinary action, even if this threat is not explicitly stated. If they deny necessary treatment, they may be acting unlawfully under the Human Rights Act. Refusing care is unfamiliar to NHS clinicians and for many is an offensive prospect.

Box 1: Definitions for exemption from charges

  • Immediately necessary treatment is that which a patient needs to save their life, to prevent a condition from becoming immediately life threatening, or to prevent permanent serious damage from occurring

  • Urgent treatment is that which clinicians do not consider immediately necessary but which cannot wait until the person can be reasonably expected to return home. Clinicians may base their decision on a range of factors, including the pain or disability a condition is causing, the risk that delay might mean a more involved or expensive medical intervention being required, or the likelihood of a substantial and potentially life threatening deterioration in the patient’s condition if treatment is delayed until the person returns to their own country

  • Source: Department of Health

Everyone will be affected

The new guidance has obvious implications for those who are not entitled to care, but its implications extend to everyone using the NHS. The system is under unprecedented pressure, with many emergency departments failing to meet performance targets. Adding to the work of clinicians already struggling simply to diagnose and treat people entitled to care seems dangerous, especially when the performance of the NHS has been implicated as a possible reason for rising death rates.10 There are already concerns that the expected influenza epidemic this year will leave emergency department doctors “dangerously overstretched.”11 Furthermore, many people who are entitled to care are likely to struggle to prove it, including those who are homeless or have mental health problems.

Although contagious disease is low among migrants, late detection, undertreatment, and lack of routine immunisations of children could pose a direct threat to UK population health. Treatment of certain infectious diseases is exempt from charging, but given that many people already find the system difficult to navigate, this concession will often be of little practical importance. Doctors protesting against the measures have also voiced concerns about the risk of discrimination against those from ethnic minorities and of mistakes by the notoriously unreliable Home Office and Border Agency in enforcing immigration policies.12 Finally, with primary care remaining free to all in England, the increased workload on already overextended general practices is likely to be unmanageable.

Importantly, the changes do not only affect hospitals. Community services, including charities, will also be forced to check immigration status before providing any care and charge upfront those without documents.13 This will inevitably disproportionately affect people in vulnerable situations, thereby widening inequalities. An assessment of this new policy highlighted the complexity of assessing its effect on vulnerable groups.14 Furthermore, it is not even clear that these measures will save appreciable amounts of money, with evidence consistently challenging the myth of widespread health tourism.15

Despite funding failing to keep pace with demand, the NHS still outperforms many other healthcare systems16 while upholding its founding principles. Refusing treatment to those unable to pay, including children, would render it unrecognisable. Healthcare should not be used as a means of immigration control, and adding to the burden on NHS staff threatens patient safety. These proposals should be withdrawn until a thorough impact assessment on people in vulnerable situations has been carried out, ensuring the “wider social duty to promote equality” is at the forefront of moving forward.


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

  • Provenance and peer review: Not commissioned; not externally peer reviewed.


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