Visitor & Migrant NHS Cost Recovery Programme
Original document: Visitor & Migrant NHS Cost Recovery Programme Implentation Plan 2014-16
LMC Commentary, July 2014
Implementation Plan 2014-16
The Secretary of State for Health decided last year that the NHS could not treat the whole world, something that most would agree with, and decided that present systems for charging overseas visitors and migrants needed to be improved. He also wanted to increase the scope of services for which charges can be made. This two year programme is the formulation of this policy taking into account a consultation at the end of last year. The intention is that this work will be undertaken in future by NHS bodies rather than the DH. The simplest part involves recovery of money from the governments in the European Economic Area through the European Health Insurance Card scheme. The second and harder part is the statutory requirement of provider trusts to charge patients from non EEA countries directly. There is also to be a migrant surcharge chargeable on those living here without normal residency which was part of the Immigration Act 2014. There will be four phases: improving the
present system; aiding better identification of chargeable patients which will include primary care; implementing the migrant surcharge and then extending charging to more secondary care services and also to some primary care ones too but excluding GP consultations.
The income from the new surcharge and better EEA collection will be invested in front line services via allocation to commissioners. Trusts recovering non EEA costs will be kept by themselves. One wonders if the government will instruct commissioners to deduct baseline funding according to what the trust "should" have recovered or whether this really will be "extra money" thus incentivising trusts?
We can expect a campaign to “raise awareness” of the existing responsibilities concerning charging and a "toolbox of standardised documentation." There will be pilots on recovering costs in A&E for "national rollout" presumably if they are found to be cost effective (as the plan is sure they will be).
One area for concern when Mr Hunt was speaking to the news media last year was that of foreign visitors coming here to have babies. It is therefore interesting to read that clinicians have obligations under the Human Rights Act 1998 to provide immediately necessary and urgent treatment including all maternity care regardless of whether payment has been received in advance. In the case of urgent care providers are "strongly advised to obtain a deposit ahead of treatment" but nevertheless the treatment should not delayed or withheld. This is underscored it is so important. Changes found to be applied cannot be waived but providers should take "a pragmatic approach" about when to break the bad news.
The ambition is to recover some £500m to be made up of £200m from the surcharge, £200m from European governments and £100m from non EEA patients. The NHS budget in England this year is £96 800m and the £500m figure is UK wide, but every little helps.
NHS trusts will be made to collect the following "key metrics" by the DH: invoiced income; actual cash recovered; bad debt provision and written off debt. Monitor will enforce this. Staff and stakeholder attitudes, behaviours and knowledge of the programme will also be regularly monitored to see how these affect delivery. The reviewer could not easily find any information about how much all this will cost.
Happily there is to be a phased approach. Phase 2b includes updating primary care registration processes to better record the chargeable status of patients later on in the system. Phase 4 extends charging outside NHS hospitals and will "require considerable discussion and development over the coming year." Primary legislation will be required and given the fixed term Parliament this will be after the next general election. Consideration will also be given to the needs of vulnerable indigenous groups such as the homeless and travellers who might struggle to be able to "prove" eligibility for free care to the detriment of health inequalities. Another group to be thought about is the expatriates who have made substantial contributions to the UK in the past which can already lead to some of these people being shamefully handled.
Ominously another priory decision is whether EHIC collection and recording could be done in general practice. We are advised to expect more letters from secondary care providers to indicate patients' chargeable status and to inform visitors of potential costs ahead when referring them on. By the end of 2016 GPs will have a responsibility to indicate chargeable status in referral letters. Whether any subsequently realised mistakes or deception by patients will have consequences for practices is not discussed. Patients who have paid the new migrant surcharge will be eligible to register with a practice and will be exempt from secondary card charges.
This is an important policy document. Its aims are eminently defensible and have been supported by large majorities of electors in opinion polls. However the amount of money aimed at is relatively small given the total NHS budget and the amount the programme will cost is not taken into account. Not only trust staff, as now, are expected to supervise the new system but primary care is also expected to collect more data in future without any additional funding or incentive. The requirement to indicate chargeable status in referral letters will be much resented in the opinion of this reviewer. The threat of action under the Human Rights Act 1998 if immediately necessary treatment is withheld and the effective exclusion of all maternity care which is said to be a major drain on NHS resources in London and the South East seems bound to limit the sums likely to be recovered. Although DH civil servants have steadily driven NHS policy through successive changes of government the fact that the general election will fall in the midst of this two year programme and before the necessary primary legislation can be brought before Parliament does raise the question of whether any of this will actually happen. One could speculate that The Labour Party's heavy preponderance of support from immigrant communities will need to be weighed against its need to re-establish a connection with its disillusioned traditional white working class voters before we see a new modified policy after May 2015.
Dr Barry Moyse
Deputy Medical Director