The founding principle of the NHS was that it should be provided based on need, free at the point of use to all. Over the last few years, charging regulations have increasingly meant that this is not the case for people who have (or are suspected of having) an irregular immigration status.
Recent charging regulations
- In 2014, the definition of ‘ordinarily resident’ is changed in the Immigration Act, meaning more people in the UK lose their entitlement to free NHS care.
- A person was previously regarded as ‘ordinarily resident’ if she or he was lawfully living in the UK voluntarily and for a settled purpose. However, the definition of ‘ordinarily resident’ changed under the Immigration Act 2014 and for non-EEA nationals is now limited to people who have ‘settled status’ in the UK (i.e. they have indefinite leave to remain)
- In 2015, regulations came into force as part of the Immigration Act 2014 (introduction of ‘hostile environment’ policies):
- Introducing a 150% charge – billed retrospectively – on secondary care for those deemed to be ‘not ordinarily resident’ in the UK.
- Those with a continuing debt of £1,000+ to the NHS after a year could have details shared from the Trust to the Home Office, and this may affect their immigration status and ability to re-enter the country with outstanding debt. The threshold has since been changed to £500
- introducing an ‘immigration health surcharge’ on visas for ‘overseas visitors’, such as students, tourists and workers requiring visas from countries without reciprocal health agreements.
- This also applies to children, started at £200, doubled in 2018 to £400 per year
- In 2017, these regulations were expanded, introducing:
- New legal requirement to charge for treatment upfront before the treatment is provided, unless the care is ‘urgent or immediately necessary’ (there is no definition for what this care is). Inability to pay upfront means care will be denied. Urgent or immediately necessary care still chargeable at 150%.
- Affecting the following services
- Secondary care
- NHS commisioned charities
- Community mental health
- Community midwifery
- Termination of Pregnancy
- So far, these most recent changes of 2017 apply to NHS England.
Charging regulations have been extended in recent years and have also been applied to children and pregnant women. In particular, the most recent regulations of October 2017 enforce a legal requirement for trusts (in England so far) to charge patients upfront before treatment at 150% of the actual NHS tariff for a range of services, to anybody unable to prove their immigration status (‘ordinary residence’), again including children. Upfront charging is applied to secondary care, and various community services including those provided by charities but commissioned by the NHS, as well as community mental health and community midwifery.
Pregnant women are also charged at 150%, meaning that a woman (of non-EEA status) is now charged approximately £6700 for antenatal care and delivery if there are no other complications, and she can be pursued in court if unable to pay. In addition, any debts to the NHS of greater than £500 may affect a person’s immigration application and their right to remain in the UK, potentially leading to detention and deportation.
The government has also stated it’s intention to extend charging into Primary care and even Accident and Emergency care, although the details of this are not known yet.
Asylum seekers in the process of making an application, and those that have been successful in their application (refugee status) are not included in the charging regulations, but many have been wrongly charged or denied treatment if they can’t prove their status. Many asylum seekers whose claims have been refused are now chargeable under the regulations. Some other exemptions exist, but specialist organisations have raised concerns that they are of limited practical value. For example, some infectious diseases are exempt, such as TB, however a patient may need to be referred to a secondary service before TB is diagnosed and 150% charging for this service will deter patients from accessing timely TB diagnosis, or being diagnosed at all. Patients with TB are already known to have died due to fear of seeking care. Patients, while unwell, will generally not be in a position to know in advance of a diagnosis if they have TB, and if it is chargeable or not. Other exemptions also apply, such as people who have been trafficked or people in situations of modern day slavery, however people are unlikely to feel able to inform their healthcare worker of these situations, and would be even less likely to be able to prove their situation or to know that they are exempt. So in practice these groups of people are often charged, denied and deterred from care as well. Therefore the exemption criteria are in reality more of theoretical reassurance to policy makers than being of significant practical value to patients.