IPPR - NHS migrant charging system ‘unfit for purpose’ as report reveals discrimination and risks to public health
An investigation by the IPPR think tank, into the operation and impacts of the NHS England system of charging people for healthcare who are not ‘ordinarily resident’ in the UK, has revealed that the system is ‘unfit for purpose’. Interviews with NHS staff have exposed a highly complex, costly system which incentivises racial profiling.
The report also warns that the system of NHS charging, which has become increasingly stringent as part of the government’s ‘hostile environment’, was a threat to individual and public health. The system was found to have delayed people receiving treatment and had a deterrent effect, dissuading both people liable for charging and those who mistakenly fear they might be charged from seeking urgent medical attention.
Even though charges were paused during the pandemic, the enduring suspicion of the system made many afraid to seek treatment for Covid-19, hampering our collective response to the pandemic, according to the report.
Under the current rules, anyone not ‘ordinarily resident’ in the UK is charged 150 per cent of the NHS national tariff for any secondary healthcare they receive, with some exemptions. ‘Ordinary residence’ is generally understood as residing in the UK legally and voluntarily for a settled purpose. To qualify, migrants typically need indefinite leave to remain or status under the EU settlement scheme.
These rules target short-term visitors, as well as undocumented migrants who may have lived in England for long periods. Some services such as A&E and treatments for conditions resulting from domestic or sexual violence are exempt from charging.
One person interviewed for the report who had previously worked as an Overseas Visitor Officer tasked with managing the complex system and identifying chargeable patients for the NHS said that they had felt forced to discriminate between patients based on their name:
“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… Even for someone who’s, you know, well I’d like to think hopefully open minded, like myself, you’re just trying to save yourself time because there’s not enough hours in the day.”
The interviews conducted with other officers, patients, policy professionals and doctors revealed that processes varied across the country, with a lack of consistent training.
Moreover, the current charging system was found to be significantly costly to administer in itself, and only a fraction of the amounts invoiced are recovered. This was especially true when chasing up patients who were destitute or in low-paid work, and so who were unlikely to be able to pay the charges.
The most recent NHS consolidated provider accounts suggest that only £39 million in cash payments were received by NHS providers in the year 2019-20, despite them issuing invoices of £93 million.
IPPR also criticised the fact that hard-pressed frontline staff, such as nurses and doctors, are facing the burden of having to consider whether to refer a patient for charging, distracting them from assessing them for illnesses. A lack of clarity was thought by many to stem from the length of the guidance on the charging system, which runs to more than 130 pages. The research also demonstrated that often people taking critical charging decisions lacked the necessary skills. One policy professional said:
“There is in theory an exemption for domestic violence. 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.”
IPPR proposes simplifying the system and expanding access to free healthcare by replacing the current definition of ‘ordinary residence’ with one which includes all residents, regardless of their immigration status. This reformed system would allow people to easily provide proof of UK residency through statements from community figures such as GPs, social workers, teachers, landlords or neighbours. This change would help to ensure that no resident is refused care in England because of their immigration status.
IPPR also calls for:
- Improved guidance for NHS professionals to navigate the new system, emphasising simpler and clearer processes which can be delivered consistently across different providers.
- High-quality training for NHS professionals who administer the charging system to tackle discrimination and ensure fairness.
- An independent body to receive complaints about the charging system and review decisions by NHS trusts.
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.
“Our proposals would ensure that all residents, regardless of their immigration status, would be able to access free secondary healthcare at the point of use, provided they were not a short-term visitor. This would allow for a fair system which protects the founding principles of the NHS – to treat people on the basis of clinical need, not the ability to pay.”
Marley Morris is available for interview
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NOTES TO EDITORS
The IPPR paper, Towards true universal care by Marley Morris and Shreya Nanda, is available for download at: http://www.ippr.org/research/publications/towards-true-universal-care
Healthcare has been a devolved policy area since 1999. The current rules for healthcare charging in Scotland, Wales and Northern Ireland are similar to the English rules, but differ in important respects. In particular the 150 per cent charge does not apply in Scotland, Wales and Northern Ireland and all those who have made a formal asylum application are exempt from charging.
Simplified summary of the secondary healthcare entitlements of migrants and overseas visitors
IPPR is the UK’s pre-eminent progressive think tank. With more than 40 staff in offices in London, Manchester, Newcastle and Edinburgh, IPPR is Britain’s only national think tank with a truly national presence. www.ippr.org
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