Making a fair contribution - a consultation on the extension of charging overseas visitors & migrants using the NHS in England
Her Majesty's Government is aiming to reclaim £500m a year from overseas visitors and migrants by 2017-18 and wants to put this towards the £22b savings required by 2020 to deliver the Five Year Forward View. The previous consultation in 2013 concentrated on secondary care in hospitals but "set the direction of travel" for extending charging into all secondary care settings as well as primary care. It is this latter that, naturally, concerns us. At present no patient can be charged for NHS primary medical care (nor for ambulance services or A&E, unless admitted). This is in stark contrast to what UK subjects (and tax payers!) can expect when travelling abroad.
The government makes two vital statements early on in this document: the first and most important is that GP consultations must remain free to all: that immediately necessary and urgent treatment must always be provided so that no-one in genuine need should be turned away or discouraged from seeking help. This is a matter of public health and might also save costs later on "downstream" in the system. "Without restricting access to NHS treatment, we need to ensure everyone makes a fair contribution to the costs of care they receive" (1.24). It also states that any new system should be workable and efficient and not compromise the efficient delivery of good quality healthcare by placing "undue burdens" on the staff. "The role of NHS staff should not extend to immigration control, and clinicians should not be diverted from treating patients" (2.1).
The second vital statement, is that government wants to "share the risk" between commissioners and providers which implies that the latter will be incentivised to reclaim payments. This is considered at the end of this commentary.
The specifics for primary care are considered in sections four (primary medical care) and five (NHS prescriptions). Interestingly it is stated that, currently, all overseas visitors can only be charged for treatment if they are offered the choice of being an NHS patient or a private patient and opt for the latter. Overseas visitors can register with a practice if they want to but those staying for less than three months should be registered as temporary residents. Patients ordinarily resident in the European Economic Area (EEA) and possessing an European Economic Insurance card (EEIC) are not currently asked for their details in primary care although the technology already exists for the DWP's overseas healthcare team to reclaim costs from home governments. A pilot involving nine practices between April and June 2015 asked all new registrants about an EEIC. Of the 2,116 new patients 272 were from the EEA (although many were ordinarily resident in the UK), others did not know about the EEIC but 49 (2.3%) presented one. This is said to added one or two minutes per registration and 30 minutes a month processing and uploading the data, presumably in each practice. The assumption is that this is a trivial amount of extra work but straws and camels' backs do come to mind.
The government would like to extend this process to all practices but because of the overarching principles regarding patient and public health given in the second paragraph above they are seeking agreement to this approach and also to a wide range of given exceptions ranging from asylum seekers (including those seeking appeal from a deportation order), unaccompanied children, victims of human trafficking, anyone requiring treatment for a condition caused by torture, FGM, domestic and sexual violence all the way to UK pensioners resident in another EEA state. Tests for serious infectious diseases would also never be charged for in order to protect the public health.
In summary there are two proposals: the first is that practices should ask EEA residents for a EHIC card. If he or she has one then a claim for £41 will be made by the DWP for a GP or practice nurse consultation as well as any other costs for other treatments. If there is no EHIC there will be no claim for primary care consultations as now.
The second concerns Non-EEA residents who have paid (or had waived) the £200 health surcharge. If this is the case there are no charges for any NHS service. If it has not been paid there would still be no charge for primary care services but patients would be charged for any other treatment.
The DH is "exploring making changes to the GMS1 & GMS3 registration forms to improve data collection and sharing between primary and secondary care." This sharing would, of course, be limited to accredited NHS staff only and only include demographics and chargeable status. Representative bodies are being consulted including the BMA and RCGP.
There are four consultation questions in this section asking about: recovering costs from EEA residents without an EHIC (more work for practices?); recovering costs from non-EEA residents to who health surcharge arrangements do not apply (ditto?); that primary care consultations should remain free on public health grounds and, finally, comments on the implementation of the primary care proposals.
Section five is about NHS prescriptions. At the present anyone within the existing exemptions from prescription charges does not pay whether EEA or non-EEA residents. People with an EHIC not exempt pay the £8.20 charge but the first proposal here is that the balance of costs should be reclaimed from the home government. The second is that non-EEA residents who have not paid the health surcharge (and are not excluded as above in the fourth paragraph) should pay prescription charges unless they are in one of the exemption categories.
The three consultation questions are about reclaiming costs from home governments over and above prescription charges paid by EEA residents with an EHIC, making non-EEA residents to whom surcharge arrangements do not apply pay prescription charges (unless in an exemption category) and the traditional process comment question.
It seems that these are modest proposals in terms of the money they seek to raise. Whether any extra, unpaid work caused in practices would be proportionate must be open to question especially given that the target £500m a year is intended to be raised not just from general practice and prescription charges but also from dental, opthalmic, A&E, and ambulance services as well as assisted reproduction, non-NHS providers, NHS continuing healthcare and even overseas visitors working on UK-registered merchant ships. These are all outside the scope of this summary. If there is simply a change to the GMS1 & 3 registration forms then one could hope that this would mean that practice staff would not be caused too much extra work. Such hope, of course, has often been misplaced in the past! The question of remuneration for this extra work is not discussed. The assumption is that it is all for the greater good of sustaining the NHS and there might well be sympathy in practices for this view. Furthermore, the data collected in practices would be shared to allow hospitals to claim larger sums in remuneration.
The question of including everyone from abroad in the NHS prescription exemption categories for all drugs - so for example a diabetic will also get an antibiotic prescription for free as well as his or her insulin - is only raised to state that to alter this would be discriminatory under EU law.
Finally, given the concept of sharing the risks between commissioners and providers, practices should be concerned about possible clawbacks of monies that the DH thinks should have been claimed for but were not. This, however, would require a higher level of sophistication than contained in this consultation for primary care at any rate.
I hope that this is helpful. The closing date for responses is 7th March 2016. I wonder if the committee would be interested in expressing any views before Somerset LMC makes its views known?
Dr Barry Moyse
Deputy Medical Director