Another argument has broken out between the government and doctors over a proposal to charge immigrants to use the NHS. The government claims a levy will make the NHS more fair and sustainable and stop it being seen, as David Cameron put it, as “an international health service”.
On the other side are the doctors who say a charge to combat health tourism would force doctors to carry out immigration checks and leave migrants “wandering around” with diseases.
The government launched two public consultations on the issue last week - one from the Home Office and the other from the Department of Health - but the situation is apparently so bad it has already announced measures to tackle the problem. Further changes could see access changed for visitors and expatriates, as well as migrants who apply for a UK visa over six months.
We’ve seen a lot of figures bandied around (the government itself has stated £12m - 0.01% of the NHS’s budget) but how much does health tourism cost the NHS and who exactly are these health tourists?
Despite the stories and the calculations, this is likely to remain unclear until a detailed audit is completed later this year.
Who are health tourists?
Health tourists are seen as those who receive NHS treatments but don’t make an appropriate contribution to its funding. These include short-term visitors with visas of less than six months as well as illegal migrants.
Failed asylum seekers and illegal immigrants with infectious diseases including tuberculosis, measles or smallpox will be given free treatment but there is no policy yet in place for people with HIV and AIDS - something that greatly worries campaigners.
European Union and European Economic Area (EEA) citizens who hold EHIC cards and travel on holiday, for work, study or indeed for particular treatments aren’t seen as health tourists as treatment costs for these groups are supposedly reimbursed through established and well understood agreements and procedures. Or at least they should be.
But this has also come under criticism after reports that the UK pays out hundreds of millions more under this system than it gets back.
It’s clear that hospital trusts have little incentive to record the details of patients using EHIC cards. However, these EEA patients are not defrauding the system; it’s the administration of the system that’s the problem.
Everyone makes a contribution
One of the government’s new consultations emphasises the principle that “everyone makes a contribution” and has “full ties and permanent relationships that justify inclusion in our social welfare model”. Only permanent residents have full eligibility for the NHS. But people who are “ordinarily resident” may access services even when only in the country for a short time (but who nonetheless are paying UK tax and National Insurance). This category excludes expats.
Under new proposals those living abroad who have a history of National Insurance contributions could gain some eligibility. People who enter the country on migrant visas and who also have leave to remain will face a levy of about £200 per year collected at the time of their visa application, regardless of whether they go on to use NHS services during their stay
Their levy payment will appear on their residence permit and give access to most NHS treatments (excluding for example, organ transplants).
Health secretary Jeremy Hunt said contributions to the NHS costs taxpayers around £5,000 per family. Given that we know that average health costs are about £1,700 per person (for those aged 15-44, it’s £700) a £200 levy would appear to be a good deal.
International students, migrant taxpayers and those returning home for treatments may feel doubly charged because of different visa applications. But the proposed system could be adjusted over time and raise significant income. From entry visas in 2012-13, the proposal would have earned income of more than £150m; extension visas would have added another £30m, giving a grand total of more than £180m.
A single fixed fee also avoids complex risk ratings and billing arrangements.
Leaky income
The flow of international patients and the economics around it are complex. Some inward patients are clearly an advantage to the NHS and wider UK health economy - for many years London in particular has treated a lucrative inward flow of patients from abroad. These planned and booked admissions provide income for NHS coffers and promote the reputations of world-class clinicians and facilities such as the Great Ormond Street Hospital, the Royal Marsden and Moorfields Eye Hospital.
But potential income leaks in many ways. A policy, such as charging for GP services, may not exist. In this case a person could receive treatment without being charged, or administration and implementation of the policy may be colander-like.
While consultation documents are replete with individual terms such as “abuse” and “cheating”, there are also parts of the health sector that are resistant to policing charges, and problems in the system that don’t provide incentives to identify and recoup charges.
Looking at just supply and demand will not address these particular issues or prevent abuse.