A not so free NHS

 The NHS has had powers to charge for healthcare since the 1980s. Scotland, Wales and Northern Ireland have their own rules, but it is in England that the government is pressing hardest on the issue and has toughened the system for collecting payments. Ministers who now want to extend charges for overseas visitors and migrants to primary care and emergency services are even testing the water on charging for further aspects of care, such as hospices.

Those who have not paid an annual immigration health surcharge, of £150-£200 per person, introduced in April 2015, or do not have a European Health Insurance Card (Ehic), which allows for medical costs to be recovered from EU member states and other countries within the European Economic Area, are liable to be charged. While those from Europe without an Ehic face paying only the actual cost of treatment, others from the rest of the world without reason for exemption will, under government new proposals, soon face a bill equal to one and a half times the cost of what is provided free to most NHS patients, to help cover costs of recouping the money. Asylum seekers and refugees will remain exempt from charges.

No charges are levied for visiting a GP, A&E treatment or family planning – although abortions and fertility services are chargeable. Life-threatening illnesses, some diseases and diagnosis and treatment of sexually transmitted infections and other specified communicable diseases are exempt too.

Lucy Jones, the UK programme manager for ‘Doctors of the World UK’, a charity that specialises in helping vulnerable people get healthcare, is concerned that the system is increasingly confusing for patients and NHS staff. “Most people who come to us are migrants in a vulnerable situation. The vast majority are below the poverty line, in unstable accommodation, a mixture of asylum seekers, refugees, undocumented, having been refused asylum or having come in in an irregular way through Calais, or they have overstayed their visa.” Health professionals and the managers responsible for following through on charges do not understand the system either, she says. “They administer charges wrongly and wrongly refuse treatment to those who should be entitled to free care … We had a chap recently, an asylum seeker in his 30s, and he had just been diagnosed with terminal cancer,” said Jones. “He needed immediate palliative chemotherapy and they refused it because they had gone to the Home Office and they had said he was undocumented. That information was incorrect. He was an asylum seeker. This guy from Sri Lanka had been tortured.” She said “Almost all the people we see are destitute and don’t have any money. If they have a debt for treatment of more than £1,000 they get referred to the Home Office as well and that stays on their record, which they worry about.” Such patients, said Jones, might be so frightened that they never actually go for treatment. “We sort of coach them through the process, although we can’t get rid of the bill. Some do arrange a repayment programme. Occasionally families help but usually the people we see are very isolated. They don’t have networks, they have fled their own country and are just sort of surviving. Quite a lot might be working in exploitative conditions, earning very little money. We work with debt advice charities to try to come up with some sort of repayment plan.” According to Lucy Jones points out if such people are to be charged, it needs to be done sensitively. “Asking somebody about their status and presenting them with a bill can be terrifying. We see people who are entitled to free treatment, who don’t know they are entitled to free treatment. There are people who are just turned away.

“That is a big concern. Just because you have a foreign accent you are targeted. It is a distraction from the real issues. It is complicated and confusing, making decisions on eligibility to get back very small amounts of money and it is causing lots of unintended consequences. We don’t want to bash NHS staff. They are being asked to do something impossible, basically.”