Doctors with borders
Imposing charges on migrants to use the NHS
This is a phrase you might be hearing more often in 2015. From spring 2015, overseas patients will be charged 150% of the cost of treatment they receive on the NHS, and the passing of the Immigration Act in May 2014 will mean that temporary migrant workers and students will be charged a fee to access healthcare during their stay in the United Kingdom. The Department of Health says that “visitors and migrants are currently able to access free NHS care immediately or soon after arrival in the UK, leaving the NHS open to abuse.” They estimate that £338m (€430m; $555m) is spent each year on patients from and outside Europe, who are eligible to pay for their treatment but are either not identified or not charged for the services they use. The department reports that this figure does not include the costs of so-called “health tourism,” which is accessed by illegal migrants who have no means to pay for chargeable care, with the cost estimated at between £70m and £300m. It is hoped that adding an extra 50% charge for treatment will further incentivise hospitals to chase the millions owed in unpaid bills. The Immigration Act will also seek to enforce new charges on migrants on temporary work permits, students, and overseas visitors on application to stay in England. The charge will cover primary and secondary care and include yearly payments of £200 to gain access to the NHS as well as a pay as you go system for some groups of patients and some types of treatments. Students from outside the European Union will have to pay £150 per year to access the NHS. Access to emergency treatment will remain available for all irrespective of their means or status, but the Department of Health says that “everyone should make a fair contribution. The NHS exists because, at its heart, is an agreement that taxpayers will pay for a comprehensive health service that is free at the point of delivery to all those who live here and are committed to our society.”
The primary motivation for these initiatives seems to be financial. The recent age of austerity and the Nicholson challenge—to find £20bn in efficiency savings within the NHS by 2015—have intensified efforts to find ways that the NHS can be more efficient, and charging migrants is seen as one solution. The UK is not a special case and we are seeing a broader crackdown across Europe on non-nationals accessing healthcare. France and Spain already have systems to charge migrants or non-nationals for healthcare. France is introducing new legislation that removes the right for foreign workers residing in France but working in neighbouring countries to opt out of paying the French national health insurance. In Spain, non-EU students have to pay the equivalent of £50 a month towards health services. Spain also restricts illegal immigrants’ access to healthcare. They are eligible to receive only emergency, maternal, and paediatric care. Elsewhere, in the United States and Australia, working migrants and foreign students are required to pay for private medical insurance.
Although there is a politically popular idea that migrants are draining the NHS of its resources, the true cost is unclear. Research published in PLOS One  reported that there is a growing number of UK patients who travel abroad to seek treatment. One of the authors of the study, Johanna Hanefeld, a lecturer in health systems economics at the London School of Hygiene and Tropical Medicine, said that their study “showed the number of patients travelling out of the UK with the explicit purpose of seeking medical treatment is greater than the number of those travelling in. We also found that those travelling for treatment did so with the intention to pay, and that incoming foreign patients using the NHS privately were a particularly lucrative source of income.”
Furthermore, some are concerned that these most recent measures focus too much on non-EU patients and do not deal with the major costs incurred by patients from within the EU. While £338m is spent each year on patients who can pay for their care, £305m is incurred by patients from the European Economic Area.
The costs of implementing charging systems could be very high. A Home Office impact assessment calculates that the scheme will cost £3m over 10 years, compared with a predicted £2bn in revenue over the same period. However, academics believe that the administrative cost of the incoming policy might have been grossly underestimated by the government.
Some doctors and professional bodies have raised concerns about surcharges for migrants and overseas visitors wanting to access NHS services. The revised charging policy might encourage migrants to seek care at emergency departments rather than from a general practitioner (GP), or the policy might discourage them from seeking care altogether until their health deteriorates into a condition requiring emergency treatment. Migrants with infectious diseases, such as tuberculosis, could damage their own health and endanger that of other people, if they don’t present for treatment. Writing in a blog for The BMJ, Johanna Hanefeld said that the prohibitive cost of treatment “will surely also act as a disincentive for patients needing care, and in doubt over their entitlement, to seek the treatment. Rather than raising additional resources through charging migrants and visitors who access treatment, it is likely to result in fewer seeking treatment where they need it. This is not good for individual or public health.” As well as the financial costs, Médecins du Monde (Doctors of the World) warn that some migrants might also be deterred because they fear being reported to immigration authorities. These scenarios could spell substantial cost to the NHS and put pressure on emergency services. In this case the new charging system may cost the NHS more than it recoups, with the average GP appointment costing £25, while a trip to the emergency department can cost the NHS between £59 and £117.
The UK’s current policy of charging migrants for maternal and paediatric care has already had an impact on care seeking behaviour, giving midwives and medical charities cause for concern. Some migrant women are avoiding antenatal care for fear of being charged. A proportion of these women then present later when they are experiencing labour complications, a situation dangerous to the health of mother and child. Sally Hargreaves, senior research fellow at Imperial College London, suggested that the UK’s reputation among the international health community could be affected by the act. She told the Student BMJ, “The credibility of the government’s commitment to global health risks is being seriously undermined by domestic policies that exclude vulnerable migrants from care and treatment.”
For any of these plans to work it would require cooperation from healthcare professionals on the ground. However it is not clear how these new laws will be enforced and whether patients will be required to show proof of their migration status before receiving treatment. In the UK, there is currently little consequence if a doctor fails to report a patient if they are liable to be charged, but in Germany doctors, social workers, and civil servants can face legal action if they fail to report illegal migrants. The UK Equality Act 2010 makes it unlawful for GPs to discriminate against any particular group by refusing to register patients and modern versions of the Hippocratic Oath commit doctors to treating patients without racial discrimination and uninfluenced by political agendas.  Charging patients in this way could compromise confidentiality between doctor and patient as we know it. In 2008 the UK High Court ruled that it is unreasonable to require health workers to make a judgment of patients’ entitlement to free care based on their immigration status, and that they should provide care according to clinical need. Yet, in the Department of Health’s Visitor and Migrant NHS Cost Recovery Programme Implementation Plan 2014-16, it states that “providers should expect to be held to account through increased scrutiny of invoicing, transparency of identification, reporting and recovery rates and the introduction of financial sanctions. This is to ensure that providers support long-term NHS sustainability in abiding by their statutory charging obligations.”
Many medical organisations have raised objections to their members being effectively border agency staff. Maureen Baker, chair of the Royal College of GPs said, “GPs and practice staff enter the profession to care for patients and keep them safe. It is imperative that we are allowed to do this without being expected to police access to our care and turn people away when they are at their most vulnerable.”
A Department of Health spokesperson told the Student BMJ, “Our new plans will help recoup up to £500m a year, making sure the NHS is better resourced and more sustainable at a time when doctors and nurses on the frontline are working very hard. We will help and support our frontline medical staff to apply these new rules through effective information sharing and training.”
But Baker remains unconvinced that the plan to charge migrants will relieve the pressure on general practice. She added that, “GPs are facing increasing workloads but decreasing resources and the last thing we need is more administrative burdens. We are under pressure, but charging our patients for appointments is absolutely not the solution.”
What these new measures highlight is the balance between the duty to the patient versus stewardship of NHS resources. Keith Pearson, independent adviser to the Department of Health on charging overseas visitors and migrants for the NHS, announced on his appointment last year: “The first duty of health professionals is to treat the individual patient in front of them but they also have a responsibility to protect the NHS for the future and ensure best use of its resources.” But these awkward ethical scenarios are likely to become more frequent. Hargreaves says doctors are “facing ethical dilemmas in their day to day practice in terms of treatment options for migrants who were potentially not eligible for free NHS care and treatment . . . The changes proposed will mean that medical professionals are likely to confront these issues at some point during their careers.”
A first year medical student at Imperial College London, who did not want to be named, said, “I personally think that primary care, such as A&E [accident and emergency], should be free for whoever needs it, although if secondary care is required then non-residents should have to pay for it. However, my main concern is that this will make my life when I qualify much more difficult, as my primary aim is to help the man who is having a heart attack, not ask him for a down payment on his angioplasty.”
At a time where the NHS is under pressure in dealing with the needs of an ageing population, more efficient ways of delivering healthcare need to be found. It is clear we are seeing an effort to crack down on who can use the NHS for free. Although the 150% charge and the Immigration Act may purport to be a fairer system for taxpayers, there are still many questions on how the measures would be implemented, and on whether they are fair. Putting this new law into action will doubtless cause headaches for medical students and doctors, and put further strain on the NHS administration. Ultimately, it could be vulnerable migrants who pay the highest price.Emma Rietbergen, Master of Science in Public Health student at Johns Hopkins University, Baltimore, Maryland, USA
Correspondence to: firstname.lastname@example.org
Competing interests: None declared.
Provenance and peer review: Not commissioned; externally peer reviewed.
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Cite this as: Student BMJ 2014;22:g5686