Department of Health and Social Care guidance sets out the circumstances in which chargeable secondary care patients should be provided with treatment that is not exempt from charge, regardless of whether they can pay for it in advance.
The seriousness or pressing nature of the need for treatment is divided into three categories: immediately necessary, urgent and non-urgent. It is the responsibility of the doctor alone to decide the urgency of a patient’s needs through initial assessments of a patient’s symptoms and other factors, and further investigations required to make a diagnosis. The assessments and investigations will be included by administrative staff in any charges made.
Doctors should use the Clinician Patient Assessment form when documenting these decisions. More details can be found in DHSC's upfront charging operational framework. The framework also provides clinical case studies relating to emergency department admissions, dialysis and elective treatment, which doctors may find helpful.
Immediately necessary treatment
Immediately necessary treatment is that which a patient needs promptly:
- to save their life; or
- to prevent a condition from becoming immediately life-threatening; or
- to prevent permanent serious damage from occurring either to themselves or, in the BMA’s view, to the wider community.
All maternity services are classed as immediately necessary. Maternity services include antenatal, intrapartum, and postnatal services provided to a pregnant person, a person who has recently given birth or a baby.
Urgent treatment is that which clinicians do not consider to be immediately necessary, but which cannot wait until the person can be reasonably expected to leave the UK.
In deciding on whether a treatment is required urgently, the Department of Health and Social Care lists the following range of factors on which doctors may base their decision:
- the pain or disability a particular condition is causing
- the risk that delay might mean a more involved or expensive medical intervention being required
- the likelihood of a substantial and potentially life-threatening deterioration if treatment is delayed until they return to their own country.
Non-urgent treatment is routine, elective treatment that can wait until the patient leaves the UK.
When should immediately necessary, urgent and non-urgent treatment be provided?
Immediately necessary treatment
Immediately necessary treatment should never be withheld or delayed. It remains chargeable, but must be provided even if a patient cannot afford to pay or is unwilling to do so. Patients will be informed of the charges and will be billed for the cost after receiving treatment.
Similarly, urgent treatment remains chargeable but cannot be withheld from a patient. The Department of Health advises non-clinical staff to try and secure payment before treatment is scheduled, but they must take account of what is appropriate given the patient’s circumstances. Doctors are not, and should not be, expected to charge patients or administer payments.
Where applicable, relevant bodies must recover costs up-front for non-urgent treatment. If patients do not proceed with payment, treatment will not be provided but they must be advised to present again for reassessment if their condition changes. NHS bodies are also required to record the chargeable status of patients on the NHS record.
The requirements to charge up-front and to record a patient’s eligibility status do not apply to services that are exempt from charge that are provided by a relevant body.
Using the patient’s estimated return date
In making these decisions, doctors are expected to use the estimate of when it is likely the patient will be able to return home provided by the OVM. This is decided on a case-by-case basis. It may not always be clear when a patient can be expected to return to their country of origin.
For some undocumented migrants, including refused asylum-seekers, it may not be possible to return because of circumstances that are out of their control. In such cases, the estimate from the OVM can therefore be up to six months or longer. The decision about what treatment a patient needs within this timeframe and with what urgency is a clinical decision and the responsibility of the doctor alone.