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At the heart of general practice since 1960

Should GPs charge overseas patients for care?

Dr Russell Brown argues that GPs need funding for treating overseas visitors, but Dr Jackie Applebee argues this will rock the foundations of the NHS for little benefit

Dr Russell Brown

YES

These overseas visitors are patients like any other, and so we should be paid for treating them. This is not about making a political point, this is not about GP surgeries policing eligibility for NHS care, this is not about denying care, it is about proper resourcing of work which is currently unfunded.

In Eastbourne we have many young foreign students, visiting for a few weeks, some of whom need to see a GP. Many of them are from countries with no reciprocal arrangements for healthcare. Even if there are arrangements in place, that funding doesn’t reach us. But if they apply to join our lists, we are obliged to see them, for no extra funding. This is not in the global sum: there have been no adjustments to the global sum made for temporary residents since 2004.

Why? If visiting the UK, is it unreasonable to expect them to have adequate travel insurance, as we would when going abroad? It’s not hard to arrange and it would simplify matters considerably. Then there would be no burden on the UK taxpayer to support people from outside the UK who seek access to a GP. The Government recognised this cost to the public purse in the recent Queen’s speech. A bill is to be enacted to allow charging, but the Government consultation on this only concerns charging in A&E. If it is going to happen, it needs to happen in general practice too or we will potentially be inundated.

This doesn’t need to have an impact on public health issues. If there is a person seeking care for tuberculosis for example there are already services in place to deal with it.

So if we assume that these patients will need to fund or resource their care, who should take the money? Well, given this is work happening in our practices, why should we not use that money to provide the service? And that being the case, why should we not collect the money ourselves? This would move any need for a complex claiming process, with annual uplifts and clawbacks, reconciliations, audits etc. We already take money for things like HGV medicals. It isn’t difficult or ethically dubious.

Some argue that this would be too much administration for our practices. However, EU citizens would expect to show a European Health Insurance Card. Visitors from elsewhere will be used to providing insurance details. This would not be a problem.

Importantly, collecting fees in this way is not removing resource from our NHS patients. Don’t forget opportunity costs: if a GP is seeing a foreign visitor, that is time they cannot devote to their NHS patients or to tasks necessary to the running of a busy general practice.

And if this is unpalatable to the Government or others there is already a multitude of services which could care for these patients including walk-in centres and A&E departments. So if there is no wish to fund activity in general practice, it should be directed elsewhere. We are busy enough already.

Dr Russell Brown is Chair of East Sussex LMC, co-founder of Resilient GP and a GP in East Sussex. He proposed the motion in favour of charging overseas patients at the LMCs conference in May. 

NO

Charging overseas visitors for care will endanger the fundamental principles of the NHS, that care is free at the point of delivery, for almost no financial benefit to us as GPs.

How much money would charging overseas visitors actually bring in? Would it even cover the costs of the extra administrative burden that this policy would place on our already overstretched reception staff? Reception staff who would have to police all patients coming to the practice to check whether they would be eligible for free care.

Previous LMCs conferences have voted overwhelmingly to reject GP practices becoming outposts of the UK Border Agency. It is disappointing that this year, a motion was passed in favour of charging overseas visitors for GP care. However it must be said that the hall was half empty because many delegates had gone for a break after a long and emotional debate on the response to the crisis in general practice.

During this debate, speaker after speaker described desperate situations, some were moved to tears. The message was unambiguous. General practice is dying, and has received a decreasing proportion of an increasingly squeezed NHS budget for far too long. The GP Forward View promises too little too late for most of us. I have no doubt that those in favour of charging overseas visitors feel overwhelmed and wish to do all they can to cut their workload. However, we are in crisis because the Government underinvests in the NHS, not because foreign visitors get free primary care.

Research tells us that migrants are a net benefit to the economy. Overall, even if they do get free general practice care, they contribute more in taxes than they receive from benefits and public services.

A lot of overseas visitors are poor and charges will stop many consulting about their health problems. Even those who object to foreigners getting free GP care must agree that it is in none of our interests for people to be in the community with untreated infectious diseases.

The Commonwealth Fund repeatedly reports that the NHS is the most cost effective health care system in the developed world yet the Government constantly complains that the NHS is unsustainable. Moves to charge overseas patients plays into their hands. Once the mechanisms are in place to charge overseas visitors it is a smaller step to charging everybody.

The NHS was set up to be free at the point of delivery, publicly funded and publicly provided. It is the envy of the world and the most popular institution in Britain. General practice is the jewel in its crown. I believe that bringing in charges for foreign visitors will rock these vital foundations for very little, if any, financial benefit.

Dr Jackie Applebee is chair of Tower Hamlets LMC and a GP in east London

 

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Readers' comments (22)

  • Jackie, one of the main reasons that 'General Practice is dying' as you put it, is because we are trying to squeeze the last drops of blood from a dried out husk. Your altruism is very laudable I'm sure but is misguided. By failing to charge we encourage health tourism and deny resources to our own registered patients. Foreign students on exchange visits are not poor and should (do) have travel insurance. If I travel to Australia or Canada I am not expecting the residents of those countries to pick up the bill if I fall sick while I'm there.

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  • Jackie Applebee’s argument is seriously flawed.

    1. Until not long ago practices did charge overseas visitors under the basic rule that we treated UK residents. Residency is a complex legal issue but it simplified down to – is the person here for a settled purpose of 6 months or more? If not, do they need “emergency” treatment which we would give for free. Otherwise we charged £30 per 10 minutes and not a single visitor complained, almost all expected to pay before we even told them, and many were surprised it was so cheap.

    2. A handful of years ago the Government changed the rule to a more complex flow chart depending on country of origin, but we still charged plenty, such as American visitors, and they expected to pay.

    3. It was only recently that this hopeless Government allegedly wanting to stop health tourism changed the rule yet again to make general practice give treatment for free! REALLY FREE. Not just paid for by the taxpayer and free at the point of abuse, but since the practice gets no income the GPs and nurses and reception staff are working for nothing.

    4. Her argument centres on the NHS founding principle of free for all. When Bevan started the NHS he never envisaged tourism on the scale that it is now, or the possibility of tourism purely to get free healthcare. Bevan will be turning in his grave at the thought of the poor working class tax payers paying their precious little money to buy healthcare for foreigners.

    5. Since Dr Applebee approves of free for all, at what level would she say it cannot go on? When 1/3 of a practice’s work is tourists, unfunded by the NHS? ½ of a practice’s work? Her premise is bonkers, the UK taxpayer cannot fun a healthcare system that is free for anyone in the world to come and use.

    6. She says it is difficult and costly to police. Certainly not true in our experience when we used to charge, most people from overseas are expecting to pay and declare themselves right at the start, if they try to deceive us then they don’t match to the spine, we need to know more details from them, sure some will slip through and get treated free but others will be discovered, the majority of visitors get charged for little extra effort.

    7. How does Dr Applebee explain every other country in the world managing to charge yet somehow we would find it too cumbersome, too costly?

    8. How does she explain that only in the UK would practices be the “border police” yet no other country on the entire planet thinks that?

    Frankly Dr Applebee, I find your attitude to the poor UK taxpayer, and the overstretched NHS to be deeply troubling and fundamentally wrong.

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  • "A lot of overseas visitors are poor and charges will stop many consulting about their health problems"

    Really Dr Applebee? Really? Then explain how they got here? Explain how they get treated back home?

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  • " It is the envy of the world"

    In your dreams Dr Applebee. Please explain why no other country, even socialists' paradises like Sweden, have attempted to copy this system that you claim they envy so much?

    If they envy it, then why did the French Foreign Minister describe the NHS as "medieval" a few years ago? Why did France issue official guidance to French tourists coming to Britain that if they fell ill they should go private immediately and avoid the NHS?

    Envy? laughing stock more like.

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  • " I believe that bringing in charges for foreign visitors will rock these vital foundations"

    Until not long ago we were allowed to, and did, charge foreign visitors. I didn't notice it rocking the NHS for all the decades that we did charge them.

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  • We should, but we can't

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  • Patients need to know the full cost of a GP visit, as in Canada, and charge the full costs. Then it will be up to the patients to claim back a portion from Department of health.

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  • Jackie there will be no more finance for GPs. Like I or not we will end up charging

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  • Jackie, I think you have lost the debate

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  • No she hasn't. Why implement something that will cost just as much as it saves? Let alone the negative effect on patient care. A ridiculous idea.

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