Government’s ‘hostile environment’ policy left fearful NHS patients avoiding treatment

Hospital trust warns NHS charging policy needs ‘radical redesign’

The A&E department at University Hospital Lewisham

The government’s ‘hostile environment’ for charging overseas visitors for the cost of NHS services has been blamed for causing fear among vulnerable patients, with some avoiding treatment.

An independent review of the charging regime at one NHS trust found that while the trust was complying with government rules it did not act with compassion or empathy towards affected patients.

In some cases, patients at Lewisham and Greenwich NHS Trust faced bills of thousands of pounds while living on benefits or without any income. The trust referred 1,085 debts worth £5.4 million to debt collectors between 2016 and 2018 – more than any other trust in the country.

Bosses at the trust told The Independent it was sorry for the way it had treated some people and was working to improve its processes.

But campaigners say the situation in the south London trust is symptomatic of broader mistreatment of vulnerable migrants and overseas visitors who are at the mercy of legislation requiring the NHS to pursue them for the costs of non-emergency treatment.

In a report published by the trust in late June, independent panel chair Peter Gluckman said: “During the course of the past 18 months, the panel has received evidence of a number of occasions when the trust’s approach to individual patients that were not eligible for free NHS treatment, has not treated individuals with appropriate levels of compassion and respect and consequently has fallen short of the standards the trust Board would aspire to achieve.”

He added: “The panel’s work has also highlighted to management a number of instances where the Trust’s past approach to implementation of its legal duties to charge patients has not been delivered in the most empathetic or compassionate way.

“The panel has received details of a number of instances when the Trust’s approach to patient charging may have resulted in patients feeling uncomfortable, scared or unable to seek timely treatment and/or choosing to go to other hospitals for their care.”

Access to free NHS care is based on being ordinarily resident in the UK.

A person must be lawfully settled in the UK and have Indefinite Leave to Remain to class as ordinarily resident but some groups such as asylum seekers and illegal residents who have been trafficked also get free care. The definitions can lead to confusion among patients and trusts as to who is eligible, the panel said.

All NHS Trusts have a statutory obligation to identify patients who are not entitled to free NHS treatment and to charge them for the treatment they receive. Emergency treatment including maternity care is free, as is Covid testing and vaccination.

The NHS can write-off debts for some patients where they are classed as being destitute but this did not happen for some people treated by the trust.

In one case submitted to the inquiry, a patient told how they screamed and fell to their knees when they received their invoice for £15,480 for life-saving maternity care. At the time, this patient was living in supported accommodation and had no income.

Another patient told the inquiry how their blood pressure rose after hearing they were being charged for their stay in hospital. The news was delivered just hours after giving birth and they blamed news of the £6,000 charge for having to stay in hospital longer.

Another patient, interviewed by the Lewisham Refugee and Migrant Network, said: “I was charged about £7,000. I was staying in one room accommodation and I couldn't even afford a payment plan to pay back the debt. There were threats that they were going to report me to the Home Office and I received calls every day. This was at the same time that my child was diagnosed with autism.”

In 2019 the trust was exposed for sharing all patient data with the credit agency Experian who carried out soft credit checks to establish if patients had a credit footprint in the UK, meaning they were likely to be eligible.

This approach was later criticised by the NHS national data guardian and the trust suspended its relationship with Experian as a result.

Responding to the inquiry’s report, the trust said it “recognises the past implementation of its legal duty to charge patients not eligible for free NHS care may have led to some patients not feeling comfortable in seeking treatment, choosing to go to other hospitals for care, and in some cases may have delayed patients approaching the trust for treatment.”

It added it “sincerely regrets, and apologises for, any instances where patients were not treated with compassion, or in a manner consistent with the values of trust.”

Highlighting the challenge for all trusts, it said the “ethical, financial and clinical tensions identified during the panel’s work (for patients, trust staff and clinicians), which arise from the current legislative approach to charging, are unlikely to be fully resolved without radical redesign of the current patient-charging framework.”

Since the report, the trust said it had changed its processes, improved training for staff and would no longer send out bailiffs to collect debt without specific approval. It will also review its approach to writing off debt for patients who meet the definition of being destitute.

Lewisham Refugee and Migrant Network said: “We remain completely opposed to the legislation that is part of the continuing hostile environment and which we believe will continue to harm patients in the future. Organisations such as ourselves and many others will continue to campaign to end these charges once and for all.

“We recognise that NHS staff have to comply with this discriminatory and harmful legislation, targeted at undocumented and vulnerable people, and we welcome measures the trust has now taken to minimise the damage the policy causes.”

The Save Lewisham Hospital Campaign added: “The panel report reflects much of what we know about this harmful legislation which is putting patients' lives at risk up and down the country. The charging practices are a result of the hostile environment legislation which has had far reaching effects on universal access to NHS healthcare free at the point of need. Once considered a precious right, the right to healthcare is slowly being chipped away.”

A spokesperson for Lewisham and Greenwich NHS Trust said: “Over the last 18 months, we have worked closely with patient groups and partners to review our arrangements for charging patients who are not always eligible for free NHS treatment.

“We’ve made a number of changes to ensure that we act in an empathetic, compassionate and supportive way towards these patients, and apologise for any instances in the past where this was not the case.”

The Department of Health and Social Care has been approached for comment.