Bryony Hopkinshaw, Jonathan Broad, Lisa Murphy, and Sarah Boutros
Aisha is a 3-month-old baby who presented three days ago with severe breathing difficulty, and was found to be in heart failure secondary to a large ventricular-septal defect (VSD). She is now improving with diuretics. You have been in liaison with the tertiary cardiology centre, but on your next call with them, they tell you that Aisha’s immigration status means that her family will need to pay the cost of corrective surgery upfront, before it is scheduled.
The NHS was founded on the principle of universality. This has changed in recent years, with increasing legislation to restrict access to patients with uncertain or irregular immigration status. This means some children experience delays to or denials of healthcare, and many families are fearful of accessing the NHS.
This 3-part guide explains the laws around NHS charging for healthcare in the UK, and how you can support your affected patients. This is Part 1, which gives an overview of the legislation, with a specific focus on general inpatient care. Part 2 focuses on access to primary care, the impacts of destitution, and what to do if patients suffer harm due to the regulations. Part 3 looks at how the regulations relate to maternal & neonatal care, and recognising survivors of human trafficking. Although this guide is specific to the UK, restrictions on healthcare for migrants are widespread in Europe & elsewhere. This guide is written for paediatric trainees, but the information on the regulations is also applicable to adult patients!
When can children be charged for care?
- NHS charging applies in secondary care. This means hospital services, including outpatient clinics, and inpatient services, but not A&E. It also applies to many community services, but GP services are free to all.
- Patients of any age can be charged for NHS treatment if they are not “ordinarily resident” in the UK. In practice this includes: families who came to the UK as asylum seekers but whose applications have been rejected, people whose visas have expired, children born to parents who are undocumented (even if the child was themselves born in the UK) and short term visitors/tourists.
- In England & Wales, charges can be made “upfront” before treatment is received, unless treatment is felt to be “immediately necessary or urgent”. (In Scotland & Northern Ireland billing will usually be retrospective.)
- If a patient has >£500 worth of debt to the NHS, this can be reported to the Home Office which can affect visa applications and in some cases result in deportation.
What if treatment is immediately necessary or urgent?
Patients deemed “chargeable” will be billed for all treatment, however urgent. If care is deemed to be “immediately necessary” or “urgent” this allows the hospital to treat first, and then bill later, instead of charging up-front. Immediately necessary” treatment is anything needed promptly to:
- Save life
- Prevent a condition from becoming immediately life-threatening
- Prevent permanent serious damage
It is the lead consultant’s decision whether treatment is “urgent” or “immediately necessary”.
“Urgent” treatment has a broader definition and means any treatment which cannot wait until the patient can be reasonably expected to leave the UK. This may be because of pain, disability or risk of deterioration. The longer a child is expected to remain in the UK, the more treatments might potentially be seen as urgent
If Aisha were on a 2 week holiday to the UK, her VSD repair could likely reasonably wait until the end of her trip without significant deterioration. On the other hand, if she has lived in the UK her whole life, it may be reasonable to assume she will never move out of the UK, so any risk of future deterioration could arguably fall under the above definition of urgent.
It is the lead consultant’s decision whether treatment is “urgent” or “immediately necessary”. If it is unclear how long the family will be in the UK, then Home Office guidelines are to assume a minimum of 6 months.
Are there any exemptions?
Certain patient groups are exempt from charging, as is treatment for some specific conditions or in specific settings. Unfortunately these exemptions are often poorly understood among both healthcare staff and patients. Identifying patients as being within certain exempt groups will require a rapport to be built to allow sharing of relevant information.
|Exempt services||Exempt patient groups||Exempt conditions|
Primary Care services
(but not abortion services)
Health visiting & school nursing
Treatment under Mental Health Act
Children under care of local authority
(including Unaccompanied Asylum Seeking Children)
Survivors of human of trafficking & their dependents
(only if referred and given reasonable grounds decision by National Referral Mechanism)
|Certain infectious diseases, including:|
All notifiable diseases
In England only – care given for conditions arising from:
A nurse who has good rapport with Aisha’s family talks to them about their story to check whether any potential exemptions are being missed. Aisha’s parents came to the UK to study, but felt unable to return to their country of origin after their student visas expired, due to political unrest. Their application for asylum has been refused.
You discuss the case as a team. Aisha does not meet any exemptions to charging, however the consultant in charge feels that surgery should be deemed “urgent” due to the risk that her condition will deteriorate if not treated for 6 months or more. She discusses Aisha’s case with the cardiology consultant who – after liaison with the Overseas Visitors Manager at the tertiary centre – agrees to schedule Aisha’s surgery before any payment.
You may need to advocate on behalf of the family with the overseas visitors managers team as they may feel unable or too scared to do so themselves.
You know that, even though they are not being charged upfront, Aisha’s family will still receive a large bill for her treatment. You let them know that they have the right to request an affordable payment plan, or – if the family is destitute – for the debt to be written off at the trust’s discretion. You encourage them to seek immigration advice and you look into other organisations that can offer them support locally.
Key Learning points
- Everyone has the right to access care at a GP and in A&E, regardless of immigration status.
- Charging for hospital based services can lead families to fear coming to hospital, as well as delays in treatment once they arrive.
- Deciding that treatment is “immediately necessary or urgent” is a clinical decision which means families will be billed retrospectively rather than up-front.
- Click here for a summary flowchart
- Doctors of the World
- Local Migrant centres (often include immigration advice services)
- Organisations that can help with debt management (e.g. Mary Ward centre)
- RCPCH guideline on charging (upcoming)
- Winters, M., Rechel, B., de Jong, L. et al. A systematic review on the use of healthcare services by undocumented migrants in Europe. BMC Health Serv Res 18, 30 (2018). https://doi.org/10.1186/s12913-018-2838-y
- Murphy L, Broad J, Hopkinshaw B, et al. Healthcare access for children and families on the move and migrants. BMJ Paediatrics Open 2020;4:e000588. doi: 10.1136/bmjpo-2019-000588