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BMA says charging regulations for overseas patients are threatening the quality of NHS care

The BMA is calling for urgent action to address the impact of charging rules for overseas patients, on both NHS staff and the patients themselves. 

The call comes as frontline doctors describe their first-hand experience of the detrimental effects of the regulations.

Under 2015 regulations, NHS bodies were given new powers to charge overseas visitors not eligible for free treatment. 

In 2017 the regulations were updated to introduce upfront charging for non-urgent care and the requirement for NHS providers to record patients’ eligibility for free treatment1.

When the regulations passed through Parliament, the BMA raised concern that they may deter vulnerable patients from seeking care, thus endangering their own and the public’s health, and increasing the workload of doctors and NHS staff.  Other healthcare organisations and pressure groups have been equally clear in their condemnation.

While the Department of Health and Social Care launched a review into the regulations in December 2017 – just two months after they came into effect – it continues to reject calls from the BMA and others to publish the full findings of this review. This is despite Government admissions that the review received evidence of 22 cases of patients being wrongly charged upfront for care that was deemed immediately necessary and its own acknowledgment that there is ‘work to do’ in the application and communication of the regulations.

Now a survey of BMA members’ experiences of the regulations2 in action has found that:

  • many doctors have faced pressure from administrative staff called OVMs (Overseas Visitors Managers) when making clinical judgements regarding a patient’s need for care3;
  • the regulations, and particularly upfront charging, are deterring patients from seeking care, including for treatments that are not chargeable4;
  • based on their experiences thus far, our members have reported that the regulations are negatively impacting public health5;
  • vulnerable groups are being, and will continue to be, negatively affected by the regulations6;
  • the regulations have increased the workload for doctors and wider teams, taking time away from patient care7.

First-hand testimony from doctors also revealed the kind of problems the regulations are causing for vulnerable patients and the staff treating them on the frontline8:

“Patient (English born, 60 years old, lived abroad outside EU for 20 years) told immediately before an operation it would cost her £6,000. No interaction with clinical staff regarding immediacy. Patient left distraught being wheeled down for operation.”

“I have had a few patients tell me, they delayed coming to A&E for an acute problem as they thought they would be charged.”

“In [my area] women have not accessed antenatal care, present to hospital in labour, then do not access postnatal care nor care for infants.”

“I had a patient who did not seek help for a rare eye cancer as she was ineligible for NHS treatment. She died in her 40's as a result of this.”

“People won't access health services until too late; example in HIV...where we're trying to reduce ‘late diagnoses’.... The two policies are not compatible together…”

“Chronic conditions may be under treated if care is only sought when deemed worth paying for by vulnerable groups - either because of financial situation or concerns about the impact on seeking treatment on other aspects of life including residential status.”

The BMA believes that urgent action is needed to address this, which should include:

  • A full and independent review into the impact of the regulations on individual and public health;
  • The full publication of the findings of the DHSC review of the regulations; 
  • Simplification of charging criteria and exemptions to improve clarity for patients and providers and reduce instances of their misapplication;
  • The introduction of safeguards to ensure that vulnerable populations are not deterred from seeking care, are able to access the care they are entitled to and that necessary treatment is not denied due to difficulty or delay in proving eligibility;
  • An investigation into OVM performance and action in cases of interference with clinical decision-making;
  • Rigorous testing of the cost-effectiveness of the regulations.

Dr John Chisholm, BMA medical ethics committee chair, said:

“The role of doctors – and all of their healthcare colleagues – must be to treat and care for patients, not to act as border guards, policing patients’ access to and payment for treatment.

“While it may be appropriate to charge overseas visitors for certain NHS services in some circumstances, it is vital that the system is cost-effective, practical and does not unduly burden NHS services or staff. Crucially, urgent treatment must be prioritised over administrative process and safeguards must be put in place to protect vulnerable groups and ensure that patients are not deterred from seeking care.

“This is particularly important to mitigate risk to the individual patient, to avoid their health worsening considerably, but also to protect the wider public’s health, as infectious conditions can spread quickly if not treated at the earliest possible stage.

“Treatment for conditions at an advanced stage is also far more extensive and expensive than preventive care or early intervention – meaning the regulations’ core premise of economic saving to the NHS is flawed at best.

“The BMA has long made its concerns over the overseas charging regulations clear, and these findings reinforce the negative effect they are having on both NHS staff and patients.

“The Government must take urgent action and come clean over the evidence they have on the impact these rules are having on the ground. The public has a right to know what the evidence shows.”


Notes to editors

The BMA is a trade union representing and negotiating on behalf of all doctors in the UK. A leading voice advocating for outstanding health care and a healthy population. An association providing members with excellent individual services and support throughout their lives.

  1. Full title: The National Health Service (Charges to Overseas Visitors) (Amendment) Regulations 2017
  2. This research was conducted through the BMA’s quarterly omnibus survey, which is circulated to a panel of 2,300 members representing most areas of medical practice. Members were asked questions on a range of topics relating to the application of the regulations. Full report can be viewed at
  3. Of the 93 members who had made a judgement about whether a chargeable patient’s needs were non-urgent, urgent or immediately necessary, over a third had experienced undue pressure from OVMs at some point, with 15% experiencing it either ‘sometimes’ or ‘frequently’.
  4. Survey participants were asked whether, based on their frontline experiences, patients who are ineligible or unsure of their eligibility for free NHS treatment are deterred from accessing health care services because of the introduction of upfront charges for some care. Of the 285 respondents to this question, 35% answered that ineligible patients or those unsure of their chargeable status are being deterred from accessing care because of upfront charging, while only 24% felt that they are not. 
  5. Survey participants were asked, based on their experience, what impact the introduction of the regulations was likely to have on public health. Around 45% of the 284 respondents to this question felt the regulations would have a negative impact on public health, while fewer than 8% felt that their impact would be positive. 
  6. We asked survey participants, based on their experience, what impact the introduction of the regulations will have on vulnerable groups. Around 70% of the 282 respondents to this question felt the regulations would have an overall negative impact on vulnerable groups, with over 25% of respondents answering that the impact would be significantly negative. Only around 2% felt that the impact would be positive.
  7. The 93 respondents who had made a judgement about the urgency of a chargeable patient’s care under the new regulations were also asked about their impact on the workload of clinical staff: whether there was an impact on the overall workload, of either the individual or team, associated with the patient’s treatment when there was an obligation to charge for non-urgent care. 35% felt that the regulations had negatively impacted on the overall workload of either the individual or team associated with the patient’s treatment when there was an obligation to charge for non-urgent care. Only around 24% reported that there had been no impact on workload.
  8. Responses have been anonymised.

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British Medical Association, BMA House, Tavistock Square, London, WC1H 9JP
Telephone: 020 7383 6448 
Email: [email protected]
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