Make the NHS universal again

by John Chisholm

Access to healthcare in the UK is fast becoming limited to those who the state chooses can use it

Location: UK
Published: Sunday 12 December 2021

The NHS is known worldwide as one of the first and best universal healthcare systems.  

At its founding in 1948, it was guided by three core principles: 

  • That it covers the whole population (universality) 
  • That it be free at the point of delivery 
  • And that it be based on clinical need, not ability to pay (equity) (1). 

Unfortunately, today, these values no longer apply to everyone living in the UK. The universality of the NHS has been broken.  

Who struggles to access NHS care?

The sad reality is that, even during the unprecedented crisis of the COVID-19 pandemic, NHS care is often inaccessible to some of the most vulnerable members of the population: people living in the UK with insecure immigration status.  

People without an official immigration status include those who entered the UK without immigration permission or stayed on after their permission expired. Others may have lost their official status, for example, through falling ill and being unable to work and thus to afford an expensive visa application fee.  

People with a less common official status and documents, such as refugees and asylum seekers, also frequently struggle to access care. This affects people, such as members of the Windrush generation, who have an official status but may lack documents to prove it.  

Far from being an accident, this is one of the intended results of the ‘hostile environment’. 

What is the hostile environment?

Over the last decade, the UK Government has brought in a range of policies aimed at making it as hard as possible for people without an official immigration status to access employment, rent property, open bank accounts, or to access benefits and essential services – including free health and social care.  

Doctors, teachers and other public sector workers are often tasked with enforcing these policies, effectively forcing them to act as border guards (2).

This undermines trust in what should be supportive and confidential relationships (3), and takes time away from performing professional duties, such as providing treatment and education. 

How does the hostile environment affect the NHS?

Since 2015, these policies have increasingly become part of the NHS in England. Hospital trusts and community services are required to identify and charge ‘overseas visitors’ for care – a complete misnomer given that many of these people are not visitors, but residents who may have been living in the UK for years.  

Most people classed as ‘overseas visitors’ are not eligible for free NHS care. Instead, they are charged 150% of the normal rate for care (except for GP primary care and treatment in emergency departments, which remain free of charge for all). They are also required to pay upfront for care that is considered non-urgent.  

To make matters worse, the NHS continues to report patient with outstanding debt to the Home Office, despite the suspension of systematic data-sharing agreements in 2018. This can affect future immigration applications, and puts vulnerable people at risk of detention and deportation, or other punitive immigration controls. The fear of being saddled with an unpayable debt also deters people from seeking the care they need.  

Determining eligibility for free care is complex, and many patients are incorrectly charged or even refused treatment if they cannot pay. This confusion also means that people who do not have an official immigration status, or who lack documents, frequently face administrative barriers that prevent them from registering with a GP surgery, despite being fully entitled to this care.  

Doctors play a key role in advocating for patients who find themselves caught up in the net of these rules, but this takes vital time away from patient care. Many are sadly forced to bear witness while their patients’ health deteriorates and are only able to intervene when the situation becomes much more severe and potentially life-threatening.  

How can we make the NHS universal again?

It has never been clearer that any policy preventing people from accessing safe, clinically appropriate care harms the health of the individual and puts public health at risk. This approach also harms the NHS, since treating conditions at an advanced stage requires much more time and resource than early intervention or indeed prevention.  

That is why the BMA has long been a leading voice calling for the fundamental overhaul of the NHS charging system, including simplification of eligibility criteria. We have repeatedly called on the Government to suspend charging, at least for the duration of the pandemic, and to launch a concerted public information campaign to make this clear to vulnerable groups.  

Making COVID-19 treatment exempt from charging is simply not good enough – patients seek care for symptoms, usually without knowing their diagnosis. If there is also confusion and lack of trust, it will come as no surprise that people do not seek treatment to which they are entitled and come to harm as a result.   

Although we advocate for the abolition of the NHS charging system – to once again make the NHS truly universal, equitable and free for all at the point of delivery – we recognise that there are intermediate steps on the road to this goal.

We therefore welcome the proposals set out in the recent IPPR (Institute of Public Policy Research) report, Towards True Universal Care: Reforming the NHS Charging System, to simplify and expand eligibility for free NHS care by broadening the definition of ‘resident’ to include everyone living in the UK, regardless of immigration status.  

This approach would dramatically improve access to NHS services for those most unfairly disadvantaged by the current system.

It would also represent a major step towards universal health coverage for all, to which the UK has committed as a signatory to the UN Sustainable Development Goals (4) and other UN declarations (5)It would mean a return to the founding principles of the NHS: universality and equity. 

John Chisholm is chair of the BMA medical ethics committee



Delamothe, T. BMJ (31 May 2008) Founding Principles

Institute for Public Policy Research (2020) Access denied: The human impact of the hostile environment

See for example our recent lobbying on information sharing and medical confidentiality in the Police, Crime, Sentencing and Courts Bill

United Nations (2015) Goal 3: Ensure healthy lives and promote well-being for all at all ages

E.g. the Political Declaration on Universal Health Coverage: moving together to build a healthier world (2019); Also see WHO fact sheet on Universal Health Coverage (2021)