NHS migrant charging system ‘unfit for purpose’ and ‘harmful to public health’, think-tank says

A new report suggests that granting free healthcare to all residents, regardless of immigration status, could be more cost-effective and improve medical outcomes, Andy Gregory reports

A paramedic walks past ambulances outside the Royal London Hospital (Daniel Leal/AFP via Getty Images)

England’s current system for charging migrants to access the NHS has been dubbed “unfit for purpose” and “harmful to public health”, after a report found it may be incentivising racial profiling and is deterring people from getting vital treatment.

In conjunction with the Home Office’s “hostile environment” policies, the rules for charging anyone not deemed “ordinarily resident” in the UK for healthcare have become more stringent in the past decade – with charges for their hospital and community care increasing to 150 per cent of the cost to the NHS.

But a new report from the leading Institute for Public Policy Research (IPPR) think-tank has found that recent changes to the “highly complex” system may not be cost-effective for the taxpayer, and may have hampered the country’s collective response to the coronavirus pandemic.

Furthermore, the report – which comprises interviews with NHS staff, patients and policy professionals – carries allegations that the rules can “distract” hard-pressed frontline staff from their care roles by forcing them to make decisions about which patients to refer for charging, sometimes in a potentially discriminatory manner.

“Discrimination and the profiling of patients were seen by many who we interviewed to be inherent to the design of the charging system,” the report stated, with ethnicity, name, country of origin and accent said at times to be used as markers to differentiate between and discriminate against patients.

One former Overseas Visitor Officer, tasked with identifying chargeable patients, told IPPR: “If you’ve got a, I don’t know, Mohammed Khan and a Fred Cooper, you’re obviously going to go for [investigating] the Mohammed Khan ... You’re just trying to save yourself time because there’s not enough hours in the day.”

The think-tank is calling for serious reforms to improve the system and ensure access to healthcare for all residents in England, irrespective of immigration status, thereby meeting the NHS’ first principle of “providing a comprehensive service, available to all”.

Marley Morris, IPPR associate director, said: “The current system for NHS charging in England is unfit for purpose. Under these rules, many long-term residents are left facing extortionate bills for receiving critical treatment.

“These rules are debilitating for patients, stressful to enforce for doctors and nurses, and harmful to public health.”

Close to a million people may currently be subject to the charges in England, the think-tank estimated – two thirds of them people without immigration status, who are often long-term residents.

While the report states that charging overseas visitors has been a feature of the NHS for decades, it points to a number of changes specifically targeting those without immigration status since 2013, when then home secretary Theresa May announced the government’s aim to “ensure that only legal migrants have access to the labour market, health services, housing, bank accounts and driving licences”.

With Ms May’s Immigration Act in 2014 excluding everyone without indefinite leave to remain from free healthcare, the government’s ensuing Cost Recovery Programme and charging regulations then increased charges to 150 per cent, and introduced powers for NHS Trusts to recover these sums. In 2017, the charges were expanded to community care, and trusts were forced to charge patients upfront for care deemed non-urgent.

As a result, the rules have become increasingly complex and difficult for staff to follow, with the official guidance for providers now extending to more than 130 pages, IPPR said.

Although there are some exemptions within the charging system, including for A&E and conditions resulting from domestic or sexual violence, experts warned that often those making critical decisions about who should qualify lack the necessary skills to do so.

“There is in theory an exemption for domestic violence,” one policy professional told IPPR. “It doesn’t work, we’re currently dealing with overseas visitors managers who are making their own assessment as to whether or not a woman has experienced domestic violence according to Home Office definitions.

“They do not have the skills to do that. They’re making bad decisions.”

According to IPPR’s report, the charges “are often imposed on those who cannot afford to pay, forcing people into prolonged indebtedness”, while the majority of the 24 participants interviewed “believed the charging system was not cost effective, and that any recovered costs did not justify the outlay of staff time and resources”.

Correspondingly, only a fraction of the costs invoiced for are recovered, with the report pointing to official data suggesting that only £39m in cash payments were received by NHS providers in the year 2019-20, despite them issuing invoices of £93m.

Previous research has suggested that the charges – and fears that information will be shared with the Home Office during the process – may have deterred a significant proportion of those affected from seeking timely treatment.

And despite charges relating to treatment, testing and vaccines for Covid-19 having been waived during the pandemic, recent studies have “highlighted how this ‘deterrent effect’ has seriously undermined” the government’s response, the report said.

“Even where people have known about the existence of the exemption for coronavirus and they have coronavirus symptoms or think they’ve been exposed, they’ve still been too scared to go to the NHS,” one policy professional told IPPR.

Among a range of proposals aimed at overhauling the system, the report argues that the “most effective alternative to the current system” would be to replace the current definition of “ordinary residence” with one which includes all residents, regardless of immigration status.

Under this strategy, people would be able to demonstrate proof of their residency in England with statements from community figures or organisations, such as charities, GPs, social workers, schools, landlords or neighbours.

“While there would no doubt be challenges in implementing such a system, our analysis suggests that this change would reduce delays in treatment, improve medical outcomes and ultimately help achieve the UK’s commitment to health coverage for all,” the report states.

The Independent has approached the Department for Health and Social Care for comment.