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Charging migrants - crackdown on health tourism or just health?

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I don’t know about you, but I’m swatting up on public health and maternity care - it might seem an odd combination, but it looks like we’re going to need it. The Department of Health - renowned for its undying faith in the virtues of general practice - has decreed that only primary care will remain free at the point of delivery for non-EU migrants, while A&E and secondary care will be withdrawn behind a solid paywall. This is seen by some as a U-turn, bowing to concerns that charging for all medical care could lead to serious threats to public health, such as outbreaks of TB - as has already happened in Spain.

The Department of Health has reassured the public by stating that, in keeping GP consultations free, everyone will have ‘initial access to prevent risks to public health such as HIV, TB and sexually transmitted infection.’ That’s all right then. There’s no statement, of course, about what is meant to happen after this initial access. When I’ve made my initial assessment that the impoverished patient sitting before me could well have TB, can I order a chest x-ray before I obtain their credit card details? And when the report of a cavitating apical lesion arrives on the fax machine, should I brush up on treatment regimes for mycobacterial disease when my patient informs me that he can’t afford hospital care? Perhaps I should learn bronchoscopy and start offering it as a minor op? Oh, but they plan to charge for that too, don’t they? Oh well, it’s not like TB is making a bit of a come-back or anything.

Then there’s maternity. Apparently no-one will be turned away, but they will be charged. How does that work then for a pregnant woman with no money? Cross your legs until you’ve saved enough? Visit Wonga and ask for a labour day loan? Or try a home birth with a cost-free GP and hope you find one that’s been around long enough to remember how to do it? Even if the moral argument doesn’t grab you, it makes poor economic sense - obstetric catastrophes are very expensive as well as tragic.

The thinking behind this, of course, is that the NHS is broken (it isn’t), and so called ‘health tourists’ are the cause (they aren’t). The real reason, however, is more ideological. Read the DH document in detail and you find a recurring argument that goes something like this:

We’ve considered Situation X; we recognise there are moral and ethical difficulties, but we are going to charge anyway because the Hard-Working-British-Tax-Payer can’t put up with the idea that someone, somewhere might be getting a free ride.

The document makes a clear distinction between medical tourists (those who choose to travel for better health care, but are willing and able to pay for it) and health tourists (those who have health needs but cannot afford to pay for it). They want to encourage the former (the rich), while denying healthcare to the latter (the poor) – how very like this Government.

Now I’m not that keen on people being able to take cynical advantage of the NHS, but neither do I wish to see the most vulnerable in our society shut out of receiving healthcare; the new rules will apply to asylum-seekers – many of whom have genuinely fled from horror to the safety of our more tolerant society – and even people who have become victims of human trafficking may have to pay; the Government is still consulting about this, and is clearly stuck with how to identify the ‘worthy’ immigrant from the ‘unworthy’ one.

It will not be long before doctors will have to decide which is the higher calling on their professional duty. When faced with a sick patient – not quite an emergency, but not something to ignore - will it be Government policy that will prevail? Or the urgings of a hospital manager desperate to balance the books? Or should we insist that, whatever the political will we are up against, our duties are laid out by the foundations of our profession as laid down in the World Medical Profession declaration of Geneva:

I WILL NOT PERMIT considerations of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, social standing or any other factor to intervene between my duty and my patient.

Or our own GMC:

MAKE THE CARE OF YOUR PATIENT YOUR FIRST CONCERN; Protect and promote the health of patients and the public; Respect patients’ right to confidentiality; Never discriminate unfairly against patients or colleagues.

Or the United Nations Human Rights Treaty:

States are under the obligation to respect the right to health by, inter alia, refraining from denying or limiting equal access for all persons, including prisoners or detainees, minorities, asylum seekers and illegal immigrants, to preventive, curative and palliative health services; abstaining from enforcing discriminatory practices as a State policy.

When these charges start to bite doctors will be faced with dilemmas on a daily basis. Do we do as we are told, and turn away patients whom we know we can help on the basis of their nationality, or do we consider something more radical? When Iona Heath reflected on the above statements recently on Twitter she had no doubt which was the right way for the profession to act, and recommended civil disobedience. Are we brave enough to follow her lead?

Dr Martin Brunet is a GP in Guildford and programme director of the Guildford GPVTS. You can tweet him @DocMartin68


Readers' comments (9)

  • Masterclass in ethics. Loved it.

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  • Yes we are and speaking up at every opportunity! Bravo for your ethical and courageous piece. I am currently working for doctors of the world London clinic where we see those turned away by GPs and hospitals or too frightened to access health care. Things will get much worse now, I fear...I have protested about the immigration bill at every opportunity including interviews with BBC, written for BMJ, Pulse, given lectures etc. We need to join forces and show our professionalism by refusing to comply with this shocking and dangerous policy/practice and by acting as a community of influence. Join us at @HVHForum Paquita

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  • Vinci Ho

    There was well known stories a few years ago in mainland China - if you had a serious accident and bled a lot, the first question you will be asked before being treated with IV fluids and blood on arriving a hospital is ,'have you got any money? Pay now or will have no IVs'
    An ignorant person asked, ' I thought China was a communist and socialist country ?'
    Sorry, it is currently the most capitalist country with no human rights on earth.
    Now you understand why Osbourne and Cameron both had to go visiting China last year. Money and GDPs are everything .......

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  • it appears uk current policy of making secondary care charge immigrants whatever their status in a non emergency situation, regular or irregular is breaking international un human rights law, which is interesting as health expenditure has increased and the charging from secondary care has been in place last few years only. ( overseas visitors centre)
    The principal being that it makes human being fearful of accessing health care when they could benefit from it.

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  • Certain diseases are exempt from any charges for public health reasons - see e.g. .

    While we must take care to ensure that these exemptions are not inadvertently removed, I think it extremely unlikely that any government would deliberately remove them.

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  • The good Doctor is mistaken on several levels. Treatment for infectious and contagious diseases such as TB is free, as is treatment for HIV (free since 2012). Much of the difficulties arising with the issue of chargeability stems from the fact that the guidelines for primary care and secondary care are at variance. In secondary care, the Overseas Visitors Officer has a DUTY to protect the NHS by identifying, charging, and recovering costs from those who do not benefit from an exemption. In primary care, even visitors to the UK can (and do) register with a GP, and access the NHS. Care for those visitors is NOT free in secondary care, yet the possession of a GP referral letter or an NHS number makes it hard for the Overseas Visitors Officer in hospital to identify the patient as potentially chargeable (access is based on residency, not contributions). Furthermore, if a patient has an NHS number it is easier for the hospital to let the CCG pay, rather than chase a potential debt.
    There is also much confusion about "medical tourists" and "health tourists". The former are UK nationals who go abroad to seek private care; the latter are VISITORS to the UK who deliberately target the NHS for free care, often with serious pre-existing conditions. A non EU national should obtain a "medical treatment" visa if they wish to use the NHS, and prove that they can pay privately not, as often happens, arriving as a visitor, using the NHS and, even if they are identified as chargeable, making every effort NOT to pay. This is fact, and the NHS IS haemorrhaging money from these visitors. Dr Brunet - please contact the Overseas Visitors Manager at the Royal Surrey in Guildford, then you would understand the issue a lot more.
    As for maternity - again the UK is being targeted by visitors who arrive heavily pregnant with the sole intention of having their baby on the NHS. Check with the Overseas Visitors Officer of any hospital with a maternity unit (especially those near Heathrow), for a true picture. This has been going on for years, with successive governments and the Dept of Health continually burying their heads in the sand about it. Unfortunately the NHS is not a bottomless pit, and can no longer afford to treat the world.

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  • Simple question ..
    If the NHS is free to anyone whop wants to use it, why do I have NI deducted from my salary without a choice re having to do so? If I have all my health care paid fro privately, this deduction still applies!

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  • In reply to Elizabeth Edmunds:
    You are right that visitors to this country are not usually entitled to NHS care, but that some still travel to the UK to try to get free healthcare. I don't condone this, but the new government guidelines are not about this. They are about people who are actually resident here being denied healthcare. Some will be allowed to pay a health levy on an annual basis (in addition to any tax/NI that they may be paying), others will not even be permitted to do this - such as people who have been denied asylum, trafficked people and illegal immigrants including pregnant women and children. These are people on the edge of society who do not have the easy option of returning home after their holiday. Whatever the rights or wrongs of them being here, a doctor, faced with an ill patient that they could help, has a duty of care that they should not ignore.

    The DOH document defines medical tourists as people coming to this country and are willing and able to pay for their healthcare, not just UK nationals going abroad.

    Treating TB or HIV may be free, but this makes the naive assumption that a doctor always knows what they are treating. TB can present in a number of ways and only become clear after numerous tests. These tests may never happen if the doctor is not certain of the cause and the patient has no means to pay for them. Meanwhile the patient gets more ill, and others are exposed to TB.

    In reply to anonymous:
    We need to see National Insurance as insuring the nation, not just ourselves. If it helps others in society more needy than ourselves then that is what it is designed for (and we will benefit indirectly from having a more functioning society). If we are the one in need, it should be there for us also.

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  • The word "resident" causes misunderstanding. According to immigration status a person is not "resident" if they are here as a temporary migrant, yet the present DoH definition of "ordinary residence" means a person can access free healthcare after one year of living lawfully in the UK - this has been much abused, and is one of the reasons the DoH is clamping down.
    Unfortunately the number of people "willing and able to pay for their healthcare" is overshadowed by those not so willing, because the current identification process for chargeable patients (plus the ease at which anyone can register with a GP) does not work, in spite of the best intentions of many NHS employees themselves. Some of the costs involved are in the many thousands, often for pre-existing and on-going conditions, and including any and every treatment you can think of.
    The DH are still in the process of considering the results of the summer consultation and remain engaged with several bodies, including the NHS, over the final details.

    Dr Brunet - I do urge you again to visit your local hospital (the Royal Surrey) and speak to the OVM there.

    In reply to anonymous - access to the NHS in the UK is based on residency, not on NI contributions, even though the NHS is paid for by general taxation. This is seen as unfair by many, especially as it is unlike most other countries where access to healthcare is based on contributions - ie those who have paid in are entitled to take out.

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