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Yet again, we are talking about the costs to the NHS of ‘health tourists’. It’s pretty clear to me that this argument is distracting from the larger debate about central funding.
People who deliberately come to the UK to benefit from NHS care cost £100-300 million per year, 0.3 per cent of the annual health spend.
Compare this to the estimated funding gap of £30 billion by 2020/21, and you have to ask why we are being encouraged to focus our attention on overseas visitors. But this is the debate we are having, so let’s duke it out.
I believe – like the UN - that healthcare is a fundamental human right. I worry about the ethical and practical implications of frontline staff being involved in determining eligibility for care.
What effects will this have on the trust underlying the doctor-patient relationship? What will we ask our patients, or stop ourselves from asking? What won’t they tell us? What will we write in the notes? What is our duty of care?
But that’s not what I will focus on in this blog. I’m going to talk money.
I get it. We work in a service with finite resources, and we ought to put systems in place to recover funds where they are due. However, we must look at what effects placing restrictions on NHS care has.
Systems to charge patients deter many people from presenting in the first place, including documented and undocumented migrants. They may not present at all, but more often, it means that they present later, when their condition has advanced further.
As a result, opportunities to apply preventive care are missed. To put this another way, opportunities to save money are lost. When patients with infectious illness present later, this increases the risk not just for them, but also for the wider population.
And to top it off, the patients who are put off seeking care include people who are eligible for free NHS care, as Dr Rebecca Farrington explained to me: “I know of patients who have been put off accessing care they were entitled to because they were afraid they would be billed.
“I know another who was pursued relentlessly by a debt collection agency for an erroneous bill for something he was entitled to for free. He had two extra consultations with me in primary care to manage the anxiety it created - this would have cost the NHS more than the £60 for which they were hounding him.”
As Dr Farrington’s experience illustrates, systems to recover costs of healthcare rely on humans, and humans make mistakes. These errors have a negative impact on patients’ health, which increases costs to the healthcare system further down the line.
This is on top of the cost of creating, training and maintaining a bureaucracy to do eligibility checks and chase unpaid fees.
I have focused on the financial aspects of the debate to demonstrate this: the seemingly axiomatic point that restricting access to care saves money is actually false.
The argument for “cracking down on health tourism” fails on its own terms. The proposed restrictions would also have a negative impact on the health of vulnerable groups, which could impact on the wider population.
Whichever way you look at it, the government’s plans are indefensible.
Piyush Pushkar is a CT3 trainee in psychiatry
Follow him on Twitter
No wonder the NHS is in trouble if £100-300 million can be dismissed so easily!
Hi anonymous poster.
I'm not sure what has led you to believe that any funds are being dismissed at all, let alone easily.
The article started with a brief invitation to question why our attention has been focused on this particular fraction of the budget deficit.
And then the main body of the argument focused on why restrictions to NHS care have not been shown to actually save money.
I hope that helps.
Thank you for taking the time to respond. I'm only anonymous because I am outside the medical profession but looked up the BMA to get an insider view on this matter.
I don't believe front line staff should be at all responsible for collecting payment. That is not their role but I cannot fathom why we simply don't insist on medical insurance for overseas visitors that may need to use the NHS.
I'm not againt NHS treatment for overseas visitors; as you state it could be dangerous both to the persons themselves and the wider population if treatment were not given but I am against systematic abuse of the NHS and fraction as it may be, £100-300 million is surely too much to lose.
Thanks for engaging in this debate. Clearly, this is an emotive issue for lots of good reasons that matter to well-meaning people.
Planned overseas visitors do have to pay a healthcare surcharge already, as part of their visa. (See here - www.gov.uk/.../how-much-pay ) This is the kind of insurance system that you mention, and it works to deal with 'systematic abuse', i.e. people travelling to the UK specifically to benefit from free NHS care. It is an insurance system in the sense that you pay beforehand, and are then eligible for care for the time that your visa lasts. Essentially, I am saying that I agree with you that an insurance system would be useful. Thankfully, it exists.
The blog focuses on the unintended consequences of instituting systems that attempt to recover the costs of care for people after that care has already been delivered. Putting any ethical issues aside, such systems do not help to recover that £100-300m pounds, for the reasons explained in the article. If you click the links, they will take you through to studies where this has been investigated.
Thank you for this excellent article. I recently looked after a traveller visiting from overseas with a suspected new diagnosis of cancer. In order to organize an urgent staging CT scan I had to spend half an hour tactfully discussing with the patient and their upset relatives who had just been informed of the suspected cancer that we needed their bank details before our radiology department would even consider scheduling the scan. I found this whole attitude of the health service completely disgraceful when patients and their relatives are dealing with the worst experience of their lives. My personal view is that the NHS should not discriminate based on country of origin, much the same as it shouldn't discriminate based on the grounds of social class, race or gender and I appreciate that may not be the view that everyone holds, but it's nice to read an article that shares some of my views rather than the usual scaremongering about health tourists.
Dear Piyush Pushkar
Thanks you for making this comment with which I whole-heartedly agree. I am a member of Defend our NHS Wirral, and a long time carer of someone with a mental health diagnosis. I am appalled especially at the cuts to all aspects of mental health and other disabled care; these are fast taking us to a de-civilised situation reminiscent of Tudor times. As Judge James Mumby (?sp) commented yesterday when no facilities could be found to care for a suicidal adolescent girl, the situation is disgraceful, totally unacceptable in this wealthy country.
I am beginning to think that lack of mental health provision both inside and outside the hospital alongside deprivation of financial support for disabled people in the community amounts to genocide UK style in the 21st century. People have their benefits terminated after a WCA assessment has found them supposedly 'capable of work' and though they appeal immediately, months later there still isn't a date when their appeal will be heard - let alone whether it will be successful of course. So how are they supposed to feed themselves and survive? Isn't this policy a deliberate act amounting to terrorism?
I see you are moving into psychiatry. Did you know that the International Conference of ISPS will be held in Liverpool 30 Aug - 3 Sept? It's a fabulous programme of the most innovative approaches to helping people recover from mental health problems - regain a foothold back in main stream life. It's the first time the International meeting has ever been held in the UK so a great opportunity if you are able to come. Do come if you can.
When I was in the deepest despair as a carer, and when no-one seemed to understand what I was talking about, the ISPS psychiatrists gave me enormous support. It is such an important organisation.
best wishes with your endeavours.
Facts: on 1st February 2016, in a House of Lords debate, Lord Bates, then Secretary of State at the Home Office, estimated that according to 2013 figures, the total cost of treating visitors and migrants in England alone was £2billion per year. (Hansard: Column 1612). This figure was calculated on the "NHS tariff" which is the subsidised amount hospitals receive from CCGs.
Health tourism is a major problem and maternity tourism is close to the top of the list.
Those that think the cost is irrelevant should consider the adverse impact on capacity.
I started writing about health tourism when I was forced by my managers to cancel an eligible NHS patient to allow a breaching health tourist to take priority.
J Meirion Thomas
This moral grandstanding by my fellow doctors has to stop. The taxpayer pays doctors salaries. The reality is entitlement checks are not carried out by medics. As with any other health system this is an administrative process.
The BBC Panorama investigation in 2012 showed that a large proportion of hospitals never ask for the necessary documents to show entitlement to free NHS care. So any calculations of costs of health tourism that rely on data collected by the NHS were vast underestimates. We pay nearly £1 billion for UK citizens resident in Europe but only claim one twentieth of this for European citizens who need treatment here. The financial accounting system that has been used by the NHS to make financial recompense was flawed and unfit for purpose.
NHS Trusts did not collect the data because it was not in their interest to do so- if they uncovered someone who was not eligible they risked not being paid, so the vast majority did not.
Anything to do with health will always be an emotive subject, but that does not mean that the very vexed but real issue of health tourism should be ignored. The Dept of Health has issued 'Guidance on implementing the overseas visitor hospital charging regulations, 2015', which states inter alia........ "The Department of Health strongly recommends that relevant NHS bodies have a designated person/s – hereafter referred to as an Overseas Visitor Manager (OVM) – to oversee the implementation of the Charging Regulations. All staff, including clinicians and managers, have a responsibility to ensure that the charging rules work effectively. The success of the charging rules also depends on NHS staff being aware and supportive of the role of the OVM. The OVM should be given the authority to ensure that the charging rules can be properly implemented in all departments." One major problem lies with the fact that not all trusts employ such a person; furthermore there is often little support for such a role which will inevitably show up debts, since many overseas VISITORS do not, will not, or can not pay their bills. There will always be vulnerable people who are exempt from charges, but any visitor to the UK should be obliged to contribute to their costs, just as we would have to in their country (I am not talking about the EU or reciprocal agreements); it should also be mentioned that visitors are generally only charged the NHS tariff price, not the cost of the private treatment that they should in fact be seeking. The NHS is paid for out of general taxation - there is no such thing as a free lunch.
Dr Pushkar's arguments sound superficially reasonable, but are actually wrong. If you don't offer any deterrent to stop health tourism, the word soon gets around that we are a "soft touch". Then, as with immigration, we will end up being overwhelmed, and Dr Pushkar's maths will be totally superceded and irrelevant. When word got round that Tony Blair and Jack Straw had effectively removed all restriction on immigration, we got EIGHT MILLION extra people who don't speak English moving permanently to this country in just a few years (plus many more who do speak English), whilst Blair and Straw claimed that it would be about five per cent of that total. I'm sorry Dr Pushkar, and I know you are probably speaking with a good heart, but your argument is sadly naive. I wish that were not the case, but we have a moral responsibility to stop this country being abused any more than it already has been.
Dr John Eggleton, GP.
If you swindled the benefit system of £20,000 you would likely be convicted of theft and rightly face imprisonment. You can swindle the NHS out £20,000 with impunity. Which is presumably the reason why so many do it.
It may have escaped your notice, as it has clearly has some of the other commentators, that we are running a £50 billion budget deficit. The sums of which you speak are not trivial.
Can I suggest that you direct your razor-sharp intellect, of which you are clearly so very proud, to the question of how much 'health care' you can purchase with £300,000,000 and then reflect upon the consequences of this dishonesty for your poorer fellow citizens, most of whom have spent many years contributing financially to the development of the NHS.
I have read all the comments below and I disagree with many of them. I know we live in a world where economics is supposed to be the main driver (and indeed Dr Pushkar's article deliberately focuses on the economics of heath care for overseas visitors), but may I point out that when I first came to Britain twenty-seven years ago, healthcare was free for all, no matter whether you lived in this country or elsewhere in the world. Today foreigners have to pay. In either case, the numbers have not changed dramatically. There was no deluge of foreigners trying to access UK healthcare when it was free. The question for me really is this - we are one of the richest nations on this earth. Is it not our moral obligation to look after people, no matter where they come from, without having to charge for everything? If we genuinely re-nationalised the NHS, we would save the money we spend on foreigners by simply taking away wastage and profits from the private sector. The question genuinely is: what kind of society do we want - one that cares or one winges? After all, the people who need to access our NHS are not well; why burden them some more with worry and debt? And I thoroughly abhor the use of debt collectors. Shame on us!
If a commentator is anonymous, their comments should be disregarded.
That having be said, a recent commentator stated 'we have a moral obligation...'.
No we don't. That's a matter of opinion, as are all morals.
And it not just the poor who come.
But I have treated a number of apparently (relatively) wealthy patients who have come to the UK with pre-existing conditions.
So, fine feelings are fine. But what practical steps do correspondents recommend to ration healthcare?
Or does the NHS pay for the world?
Wow, thanks so much to everyone for commenting. Obviously my blog has stimulated a lot of debate. I just wish we were talking this much about the largest ever sustained reduction in overall NHS funding as a share of GDP ( www.kingsfund.org.uk/.../nhs-spending-squeezed-never ), or the projected ongoing reductions in spending ( www.nuffieldtrust.org.uk/.../how-much-the-parties-would-spend-on-health-care-as-a-proportion-of-gdp ).
To all of the blog’s supporters, thank you.
To all of the critics, I will try to respond to each of you individually.
J Meirion Thomas, I am working with the government’s own figures, as published most recently ( www.gov.uk/.../nhs-visitor-and-migrant-cost-recovery-programme ). There is also a link in the blog to a FullFact investigation. At no point did I say that any costs were irrelevant. Please see my response to the first anonymous poster.
Anonymous 07.08.17, thanks for throwing a few more figures into the mix. I have not seen the 5 year old BBC documentary that you mention. I am not sure if the figures you quote are from that documentary. As mentioned above, I am working with the government’s own figures, which they have used to defend and support the proposed changes. Regardless, I mentioned the £300m figure to contextualise the argument that follows it, which is not to do with how much is spent on non-UK citizens, but with the unintended consequences and costs of creating a system to recover those costs. It is difficult to imagine how such a system would not involve frontline staff since it is us that collect information on patients when we see them, documenting it in the notes that administrative staff would then have access to. Finally, with regard to moral grandstanding, I am grateful to you for your kind advice.
Dr Eggleton, I am touched by your concern for my naivety. I promise to join you in shaking my fist at those “EIGHT MILLION” migrants who don't speak English who have come here to abuse our poor country.
Anonymous 07.08.17, thanks for noticing my razor-sharp intellect. Regarding your point on the £300m, you seem to be making the same mistake as J Meirion Thomas and the very first anonymous poster. Please see my response to him/her.
Quite a few foreign visitors, who are not health tourists, become acutely ill while staying in the UK & receive care free of charge because their conditions are deemed to be emergencies. Most of these visitors have health insurance. Thus, the NHS is subsidising their insurance companies. This is madness which would be tolerated in few other countries.