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Independents' Day

Dilemma: Should you treat an overseas visitor?

Two GPs and a medicolegal expert advise on assessing eligibility for NHS care

A patient brings her father to your clinic for a same-day appointment. He tells you he’s visiting the UK from South Africa ‘to get his health sorted out’. He has multiple medical problems including COPD, diabetes, ‘kidney problems’ and ischaemic heart disease – but he has no medical notes or record of what medication he is on. What should you do?

This patient is not eligible for NHS treatment for pre-existing conditions

Dr Richard Van Mellaerts - LMCs conference 2013 - online

In a global society, issues of this kind present with increasing regularity. Health inequalities around the world remain wide, and ‘health tourism’ is a favourite hobby horse of the national press, although the scale of the problem is probably far smaller than feared by some.

This gentleman has a number of pre-existing conditions that have all developed prior to coming to the UK. If he were to need emergency care while here he would be able to access it, but he is not ordinarily resident in the UK and so is not entitled to register with a GP as an NHS patient. Equally, South Africa does not have a reciprocal care arrangement with the UK and so he does not qualify for treatment in this way either.

He is not entitled to be seen as an NHS patient for these pre-existing conditions, so you are left with the option of offering a private consultation or signposting him to alternative non-NHS services.

Without access to his medical records or even his medication notes, there are considerable difficulties in advancing his care, and the limits of your position would need to be made clear.

The medicolegal risk of consulting without adequate medical history may be exacerbated by medical defence bodies being unable to provide cover for proceedings taking place outside the UK.

Eligibility for NHS care is complex. You need to explain this to him and his daughter, and offer potential solutions to allow him to ‘get sorted out’ in a way that complies with NHS regulations.

Dr Richard van Mellaerts is a GP in Kingston, Surrey, and a GPC member

GPs do have discretion to accept overseas visitors as NHS patients

Dr Rachel Birch - online

GPs have a duty to provide immediate and necessary treatment to any patient, regardless of whether that patient is entitled to NHS healthcare.1 You have discretion to accept overseas visitors as fully registered NHS patients or you can accept them as temporary residents if their stay is between 24 hours and three months.2

It is impossible to address all of the issues in a short appointment – therefore take time to establish and treat the most pressing symptoms. Make a plan to address the other concerns and book follow-up appointments. Ask the practice nurse to obtain some baseline bloods, blood pressure and spirometry readings.

The patient doesn’t appear to know what medication he is on. Ask him to bring in all his medications, so that you can identify them and arrange for ongoing prescriptions and any necessary monitoring. Seek his consent to contact his doctor in South Africa so that you can obtain relevant information.

You should also be impartial about his care in South Africa. Listen to his concerns but do not express any negative views. He is likely to return to South Africa, and you don’t want to undermine his trust in its healthcare system.

Refer him to secondary care if this
is clinically indicated. Avoid making judgments about the likelihood that he will be charged as it is the responsibility of the trust to decide this.  

Dr Rachel Birch is a medicolegal consultant at the Medical Protection Society

Make the likely costs clear and clarify the daughter’s role

Dr John Canning online

This is not an unusual situation for a GP. There are at least three dilemmas to resolve here: first, whether he is entitled to NHS care; second, how you should treat him (using NHS resources or his own money); and third, what his daughter’s role is in his attendance.

This patient is here for less than six months, has no settled purpose in the UK and is therefore not entitled to NHS care unless he has an immediate need or an infectious disease (which does not appear to be the case).

While you can treat him as an NHS patient there is no obligation to do so and you may wish to consult with him privately. 

If you do this you should make the costs clear to him and that these will include your consultation fees, the cost of all investigations and drugs.

He should also be made aware that any hospital treatment beyond A&E is likely to be chargeable or require private referral. I would advise you to put this in writing, with details of your fees.

Ensure he understands the financial consequences and has sufficient resources to pay.

Finally there is the position of the daughter. Does he want her involved? If she is a patient of yours already, is there going to be a difficulty in that relationship?

You must make it clear to her that her role – unless her father is in agreement or she has power of attorney – is that of a concerned relative, and no more.

Dr John Canning is secretary of Cleveland LMC and a GP in Middlesbrough

Readers' comments (6)

  • At the risk of being controversial, if the GP sees this patient in routine appointment time then if they charge the patient privately aren’t they in affect being paid twice for the same time? Would that appointment not otherwise have been taken up by an NHS patient? The same really applies to any subsequent appointments unless they GP provides additional designated time to see private patients!

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  • 11.23am GPs do not have an arbitrary limit on numbers of patients and time to see them, if it did I'd be refusing to see many patients every week. Seeing an overseas patient is unlikely to stop another patient being seen as it is in our core contract to see everyone who is or believes themselves to be unwell.

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  • The clue is in the first sentence - that he is visiting the UK "to get his health sorted out". I cannot believe Dr Rachel Birch's comments - does she have no idea what actually goes on in both primary care and secondary care? Does she visit surgeries, walk-in centres and hospitals, or sit at a desk in the office of the MPS? Overseas visitors such as this gentleman are DELIBERATELY targetting the NHS for care which they know they are likely to get for free simply because our identification of such visitors is woefully inadequate; the costs are enormous. Dr Birch would do well to visit the Overseas Visitors Officer at any major hospital (particularly in London) and then analyse the result; maybe then she wouldn't so glibly suggest the South African gentleman be referred for secondary care for his many (and no doubt costly) problems.
    GPs do have a duty to provide INT, but they ALSO have a duty to protect NHS resources. Access to the NHS is based on residency, yet registration with a GP is at the latter's discretion. The "guidelines" for GP registration need to be much firmer so that overseas visitors, if they wish to see a GP, should be obliged to pay privately. Furthermore the guidelines for secondary care require overseas visitors who do not benefit from an exemption to be charged; why then are the guidelines for primary care not the same as for secondary care? The NHS is haemorrhaging money to overseas visitors who will not, cannot, or do not pay their bills. We can no longer treat the world - those who are not resident must pay - simple.

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  • As far as I am aware primary care is to be given in all cases irrespective of whether the patient is "ordinarily resident" or not. However should the patient require referral to secondary care then they become liable to pay for the treatment they receive at that stage. The law is in disarray. The term "ordinarily resident" and its definition springs from an Education Act rather than either immigration or health legislation. I think we as a country need to actually determine our objectives first before legislation as the cart always seems to come before the horse and we end up in quandaries open to loose and varied interpretation. (See above)

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  • This is area is a complex one and as a NHS Local Counter Fraud Specialist in the London area I find that every GP can interpret requirements anyway they choose to suit the circumstances they are often faced with.
    It is my understanding that with regards to primary care, the current position is that anyone can access services and care free of charge. Practices may accept onto their list of patients anyone who applies. They may also refuse to accept people as patients but only if there are reasonable and non-discriminatory grounds for doing so that do not relate to the applicant’s race, gender, social class, age, religion, sexual orientation, appearance, disability or medical condition.
    Being registered with a GP, or having an NHS number, does not give a person automatic entitlement to access free NHS hospital treatment even if they are referred by their GP. It is the relevant NHS body’s duty, not the GP’s, to establish entitlement for free hospital treatment.

    So in practice, GPs’ discretion to refuse a patient is limited.

    Overseas visitors, whether lawfully in the UK or not, are eligible to register with a GP practice even if those visitors are not eligible for secondary care services. Treatment can be provided to overseas visitors as follows:

    Registration with a practice

    A person may register with a practice as a permanent patient or be accepted as a temporary resident. A person is a temporary resident if they live in an area for more than 24 hours but not more than three months.
    A person who is accepted onto a practice’s list of patients is entitled to free NHS primary medical services.

    Alternatives to registration
    A person who has not been accepted onto a GP practice list, or accepted as a temporary resident, can still be treated by a GP practice.

    A practice is required to offer free NHS treatment to anyone who requests it if, in the opinion of a healthcare professional, it is immediately necessary.

    Immediately necessary treatment includes treatment, in the clinical judgement of a healthcare professional, of a pre-existing condition that has become exacerbated during a person’s stay in the UK.

    A practice is also required to offer free-of-charge emergency or immediately-necessary treatment to a person who:

    Has been refused acceptance for inclusion on the practice’s list of patients for up to 14 days from the date of refusal or until registered elsewhere – whichever is sooner

    The practice has refused to accept as a temporary resident for up to 14 days from the date of refusal or until accepted elsewhere – whichever is sooner

    Is in an area for less than 24 hours up to 24 hours.

    Also, individuals can still be seen on a private basis, for which they would also be charged.

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  • Well this is now as clear mud then!
    Basically you can take the humanitarian approach, or send them on their way i.e. to another practice. A proper legal framework here would be really useful.

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