BMJ 2013;347:f6483 doi: 10.1136/bmj.f6483 (Published 29 October 2013)
Page 1 of 3
Feature
FEATURE DATA BRIEFING
Migrants’ healthcare: who pays? While there has been much heat generated by the charging suggestions in the government’s new Immigration Bill, there has been less light, finds John Appleby John Appleby chief economist King’s Fund, London, UK
Despite the National Health Service being designed expressly on the basis of free access, the complications of who, exactly, is entitled to free access and who should be charged for what type of care has a long history.
Since almost the day of its inception the NHS has had the power to charge people not “ordinarily resident.” In practice the charging regulations in the 1949 act were not implemented until the 1980s. And while NHS hospitals have always had a statutory duty to identify, bill, and collect charges from patients not ordinarily resident for the services specified in the 1949 act, in practice this has been somewhat ad hoc. This is partly because of the costs of collection relative to income, misaligned incentives (hospitals now get paid for their work by commissioners regardless of who they treat, for example), and possibly a degree of ambivalence about charging. There is also the confusion created by a complex set of exemptions and the largely undefined term ordinarily resident. Current charging rules for those not ordinarily resident cover only some NHS secondary care services. Accident and emergency services are excluded, for example, as are treatments for infectious diseases, and no primary or community based services can be charged for. Oddly, the same (chargeable) service provided by an NHS hospital is exempt if provided by the independent sector as part of a contract with the NHS. The charging system is such that some parts of a patient’s treatment could be chargeable and other, even related, parts could not be. Overall, the current regulations exempt seven NHS services and 33 categories of person.
Costs of treating non-residents
A review of charging policy in 2012 presented some tentative figures on the scale of use of the NHS by overseas visitors.1 It suggested that in 2010-11 the total cost of NHS services consumed by non-permanent residents and visitors to England could amount to around £1.4bn (€1.6bn; $2.3bn)—around 1.2% of the total NHS spend. But only about £125m of this was possibly recoverable under existing charging and recovery rules.2 3 Now, following new research to try to establish a more
accurate estimate of the scale of use of the NHS by migrants and visitors in 2012-13, the figures have been revised. The authors of the new research are at pains to point out that their estimates should be treated with caution as they are based on incomplete data and a large number of assumptions.
The new estimates have revised the amount spent to just under £2bn (around 1.8% of total English NHS spending) with £328m potentially recoverable.4 5 Of the £328m, around £261m (of which around £50m is currently actually recovered) is either chargeable or recoverable from European Economic Area (EEA) governments as part of the European health insurance card scheme (figure⇓).6 Non-EEA temporary visitors and British ex-patriots visiting the UK account for just £67m of chargeable costs. The new research also suggests that “deliberate health tourism” accounts for just £60m- £80m, and, what the research terms “taking advantage”—such as overseas relatives of British citizens using (mainly primary) care services while visiting—could amount to between £50m and £200m.
What will the changes save? The proposed Immigration Bill would extend the scope of charging to currently exempt groups—non-EEA temporary migrants and non-EEA students. This might increase revenue by around £94m.4 Other measures in the bill—such as imposing a charge of £200 as a precondition of entry to the UK for certain groups—coupled with the deterrent effects of such charging would, says the Department of Health, raise around £500m for the UK NHS.7
Well, it’s possible. But there are many uncertainties. Despite the new estimates on migrant and visitor use of the NHS, the authors of the figures stress the tentative nature of many of the numbers. And of course there is the small matter of implementing any changes. As the 2012 Department of Health review noted, “Although there may be good policy reasons, and potentially significant income opportunities in extending the scope of charging, the NHS is not currently set up structurally,
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BMJ 2013;347:f6483 doi: 10.1136/bmj.f6483 (Published 29 October 2013)
Page 2 of 3
FEATURE
operationally or culturally to identifying [sic] a small subset of patients and charging [sic] them for their NHS treatment. Only a fundamentally different system and supporting processes would enable significant new revenue to be realised.” 1 Competing interests: I have read and understood the BMJ policy on declaration of interests and have no relevant interests to declare.
3
4
5
Provenance and peer review: Commissioned; not externally peer reviewed. 1 2
Department of Health. 2012 review of overseas visitors charging policy: summary report. www.gov.uk/government/uploads/system/uploads/attachment_data/file/210439/Overseas_ Visitors_Charging_Review_2012_-_Summary_document.pdf. Department of Health. Sustaining services, ensuring fairness: a consultation on migrant access and their financial contribution to NHS provision in England. 2013. www.gov.uk/ government/uploads/system/uploads/attachment_data/file/210438/Sustaining_services_ _ensuring_fairness_consultation_document.pdf
6 7
Department of Health. Sustaining services, ensuring fairness: a consultation on migrant access and financial contribution to NHS provision in England: evidence to support review 2012 policy recommendations and a strategy for the development of an impact assessment. 2013. www.gov.uk/government/uploads/system/uploads/attachment_data/file/210440/ Sustaining_services__ensuring_fairness_-_evidence_and_equality_analysis.pdf Department of Health. Quantitative assessment of visitor and migrant use of the NHS in England: exploring the data. 2013. www.gov.uk/government/uploads/system/uploads/ attachment_data/file/251909/Quantitative_Assessment_of_Visitor_and_Migrant_Use_of_ the_NHS_in_England_-_Exploring_the_Data_-_FULL_REPORT.pdf. Creative Research. Qualitative assessment of visitor and migrant use of the NHS in England: observations from the front line. 2013. www.gov.uk/government/uploads/system/ uploads/attachment_data/file/251908/Qualitative_Assessment_of_Visitor___Migrant_ use_of_the_NHS_in_England_-_Observations_from_the_front-line_-_FULL_REPORT. pdf. NHS Choices. EHIC—European health insurance card. www.nhs.uk/NHSEngland/ Healthcareabroad/EHIC/Pages/about-the-ehic.aspx. Department of Health. New report shows the NHS could raise up to £500 million from better charging of overseas visitors. 2013. www.gov.uk/government/news/new-reportshows-the-nhs-could-raise-up-to-500-million-from-better-charging-of-overseas-visitors
Cite this as: BMJ 2013;347:f6483 © BMJ Publishing Group Ltd 2013
For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
BMJ 2013;347:f6483 doi: 10.1136/bmj.f6483 (Published 29 October 2013)
Page 3 of 3
FEATURE
Figure
Estimates of total UK NHS spend on non-permanent residents and visitors, total possible income under current charging/recovery arrangements and additional potential income from widening the scope of chargeable non-European Economic Area (EEA) visitors4
For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
Page 1 of 3
Feature
FEATURE DATA BRIEFING
Migrants’ healthcare: who pays? While there has been much heat generated by the charging suggestions in the government’s new Immigration Bill, there has been less light, finds John Appleby John Appleby chief economist King’s Fund, London, UK
Despite the National Health Service being designed expressly on the basis of free access, the complications of who, exactly, is entitled to free access and who should be charged for what type of care has a long history.
Since almost the day of its inception the NHS has had the power to charge people not “ordinarily resident.” In practice the charging regulations in the 1949 act were not implemented until the 1980s. And while NHS hospitals have always had a statutory duty to identify, bill, and collect charges from patients not ordinarily resident for the services specified in the 1949 act, in practice this has been somewhat ad hoc. This is partly because of the costs of collection relative to income, misaligned incentives (hospitals now get paid for their work by commissioners regardless of who they treat, for example), and possibly a degree of ambivalence about charging. There is also the confusion created by a complex set of exemptions and the largely undefined term ordinarily resident. Current charging rules for those not ordinarily resident cover only some NHS secondary care services. Accident and emergency services are excluded, for example, as are treatments for infectious diseases, and no primary or community based services can be charged for. Oddly, the same (chargeable) service provided by an NHS hospital is exempt if provided by the independent sector as part of a contract with the NHS. The charging system is such that some parts of a patient’s treatment could be chargeable and other, even related, parts could not be. Overall, the current regulations exempt seven NHS services and 33 categories of person.
Costs of treating non-residents
A review of charging policy in 2012 presented some tentative figures on the scale of use of the NHS by overseas visitors.1 It suggested that in 2010-11 the total cost of NHS services consumed by non-permanent residents and visitors to England could amount to around £1.4bn (€1.6bn; $2.3bn)—around 1.2% of the total NHS spend. But only about £125m of this was possibly recoverable under existing charging and recovery rules.2 3 Now, following new research to try to establish a more
accurate estimate of the scale of use of the NHS by migrants and visitors in 2012-13, the figures have been revised. The authors of the new research are at pains to point out that their estimates should be treated with caution as they are based on incomplete data and a large number of assumptions.
The new estimates have revised the amount spent to just under £2bn (around 1.8% of total English NHS spending) with £328m potentially recoverable.4 5 Of the £328m, around £261m (of which around £50m is currently actually recovered) is either chargeable or recoverable from European Economic Area (EEA) governments as part of the European health insurance card scheme (figure⇓).6 Non-EEA temporary visitors and British ex-patriots visiting the UK account for just £67m of chargeable costs. The new research also suggests that “deliberate health tourism” accounts for just £60m- £80m, and, what the research terms “taking advantage”—such as overseas relatives of British citizens using (mainly primary) care services while visiting—could amount to between £50m and £200m.
What will the changes save? The proposed Immigration Bill would extend the scope of charging to currently exempt groups—non-EEA temporary migrants and non-EEA students. This might increase revenue by around £94m.4 Other measures in the bill—such as imposing a charge of £200 as a precondition of entry to the UK for certain groups—coupled with the deterrent effects of such charging would, says the Department of Health, raise around £500m for the UK NHS.7
Well, it’s possible. But there are many uncertainties. Despite the new estimates on migrant and visitor use of the NHS, the authors of the figures stress the tentative nature of many of the numbers. And of course there is the small matter of implementing any changes. As the 2012 Department of Health review noted, “Although there may be good policy reasons, and potentially significant income opportunities in extending the scope of charging, the NHS is not currently set up structurally,
[email protected] For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
BMJ 2013;347:f6483 doi: 10.1136/bmj.f6483 (Published 29 October 2013)
Page 2 of 3
FEATURE
operationally or culturally to identifying [sic] a small subset of patients and charging [sic] them for their NHS treatment. Only a fundamentally different system and supporting processes would enable significant new revenue to be realised.” 1 Competing interests: I have read and understood the BMJ policy on declaration of interests and have no relevant interests to declare.
3
4
5
Provenance and peer review: Commissioned; not externally peer reviewed. 1 2
Department of Health. 2012 review of overseas visitors charging policy: summary report. www.gov.uk/government/uploads/system/uploads/attachment_data/file/210439/Overseas_ Visitors_Charging_Review_2012_-_Summary_document.pdf. Department of Health. Sustaining services, ensuring fairness: a consultation on migrant access and their financial contribution to NHS provision in England. 2013. www.gov.uk/ government/uploads/system/uploads/attachment_data/file/210438/Sustaining_services_ _ensuring_fairness_consultation_document.pdf
6 7
Department of Health. Sustaining services, ensuring fairness: a consultation on migrant access and financial contribution to NHS provision in England: evidence to support review 2012 policy recommendations and a strategy for the development of an impact assessment. 2013. www.gov.uk/government/uploads/system/uploads/attachment_data/file/210440/ Sustaining_services__ensuring_fairness_-_evidence_and_equality_analysis.pdf Department of Health. Quantitative assessment of visitor and migrant use of the NHS in England: exploring the data. 2013. www.gov.uk/government/uploads/system/uploads/ attachment_data/file/251909/Quantitative_Assessment_of_Visitor_and_Migrant_Use_of_ the_NHS_in_England_-_Exploring_the_Data_-_FULL_REPORT.pdf. Creative Research. Qualitative assessment of visitor and migrant use of the NHS in England: observations from the front line. 2013. www.gov.uk/government/uploads/system/ uploads/attachment_data/file/251908/Qualitative_Assessment_of_Visitor___Migrant_ use_of_the_NHS_in_England_-_Observations_from_the_front-line_-_FULL_REPORT. pdf. NHS Choices. EHIC—European health insurance card. www.nhs.uk/NHSEngland/ Healthcareabroad/EHIC/Pages/about-the-ehic.aspx. Department of Health. New report shows the NHS could raise up to £500 million from better charging of overseas visitors. 2013. www.gov.uk/government/news/new-reportshows-the-nhs-could-raise-up-to-500-million-from-better-charging-of-overseas-visitors
Cite this as: BMJ 2013;347:f6483 © BMJ Publishing Group Ltd 2013
For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
BMJ 2013;347:f6483 doi: 10.1136/bmj.f6483 (Published 29 October 2013)
Page 3 of 3
FEATURE
Figure
Estimates of total UK NHS spend on non-permanent residents and visitors, total possible income under current charging/recovery arrangements and additional potential income from widening the scope of chargeable non-European Economic Area (EEA) visitors4
For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
