The Barts Health group of hospitals serves one of the most diverse communities in the country with a catchment of around 2.5 million people living in east London. We take pride in providing quality care for all our patients, and do not wish to deter anyone from seeking treatment.
National regulations by the Department of Health stipulate that patients must be “ordinarily resident” in the United Kingdom to qualify for free NHS-funded hospital care. This means living here lawfully, with a settled purpose, for the time being. Nationals of countries outside the European Economic Area who have indefinite leave to remain in the UK are eligible for free care, but many British nationals who now live overseas may not be.
The Trust has a legal duty to recover costs from patients who are not entitled to free NHS hospital treatment. Any patient not entitled to free hospital care must be charged for treatment they receive unless a medical or service exemption applies. The regulations were tightened in 2017 to require full payment in advance of non-urgent treatment.
However, those who need care that is clinically deemed urgent or immediately necessary – such as maternity care - will always be treated promptly even if a patient indicates that they cannot afford to pay. We do not turn any patients away.
Nevertheless, the treatment is not free just because it is provided on this basis. Any patient booking into an emergency department or maternity unit is asked where they have lived in the last 12 months. If there is any question about residency status, the case is referred to the Overseas Visitors Team.
These staff do their best to help and support patients to understand our mutual obligations around payment. In some cases, they may check an individual’s immigration status with the Home Office in order to assess their entitlement to free NHS care. This gives prompt reassurance and clarity to the patient. Many team members have second language skills, and others can call on our Advocacy Service to support patients whose first language is not English.
We currently treat an average of 200 overseas patients every month and the income from this source is worth about £10m a year, less than 1% of our annual turnover. In recent years the Trust has taken a number of steps to ensure that our hospitals are consistent, clear and equitable in applying the eligibility rules.
How we have implemented the national guidance
The overseas visitor charging regulations are complex and often misunderstood by the public. For example, they apply to hospitals but not GP surgeries. During 2019, we worked extensively with community and patient groups to understand their concerns and share information about our how we apply the regulations.
We used their feedback to inform our approach, and made improvements to better support patients and their communities. An overseas visitor steering group chaired by the chief medical officer meets regularly to review progress.
- We refreshed the trust policy in line with the latest guidance from the Department of Health and Social Care (DHSC) and undertook our own equality impact assessment.
- We put more information on our website and staff intranet, including contact details for the overseas visitors team
- We reviewed communications materials for patients, and commissioned a short film to show how the Trust implements the national regulations
- We revised a patient facing leaflet [doc] 1MB for distribution in each hospital, giving details of external agencies that provide independent patient support and guidance
- With the input of local campaigners we redesigned the standard attendance form [docx] 376KB issued on arrival to all patients. This will include contact details for the overseas visitors team and the option for a patient to name an advocate for communication purposes.
- We enhanced the standard DHSC clinical assessment form to ensure clinicians alerted the overseas visitors team when patients were being treated for exempt medical conditions
- We developed a comprehensive training package to increase knowledge and awareness among reception and administrative staff, and ensure all new patients are asked about their residency status. This is being piloted and will be rolled out over the coming months, to form part of our statutory and mandatory training requirement for all frontline staff.
We recognise that charging is a sensitive issue for many people and are committed to being transparent, fair and equitable to patients and staff in fulfilling our statutory obligations.
Public statements from local Save our NHS groups
We have worked closely with local Save our NHS groups in particular to address their concerns about the implementation of the national charging rules. We would like to take this opportunity to clarify the trust’s position.
We have consistently made clear that anyone requiring treatment that is deemed immediately necessary or urgent – such as all maternity care – is treated.
We invoiced 739 patients for maternity care in 2018-19. That treatment was not delayed whilst entitlement to free care was established. No care was ever refused. All maternity care is classified as immediately necessary.
We billed these patients either if we established they were not entitled to free NHS treatment, or if it was not possible to confirm their residency status. We make every effort to obtain information from people that would prove their eligibility, through telephone calls and offering face-to-face meetings as well as writing to them.
Subsequently, it transpired that a large number of these invoiced patients were able to prove their eligibility for free NHS treatment after all. Of the revised cohort of 449 maternity patients, we received payments from 162 individuals, leaving 287 outstanding.
We are continually reviewing our processes and in the light of this latest learning, we will amend our standard billing procedure. In future, we will send out an advisory “notice to charge” rather than an invoice in the first instance.
We do not report patients to the Home Office. We do ask the Home Office for information about the immigration status of some patients, to help establish their eligibility for free treatment. For example, the Home Office can confirm a patient is a documented asylum seeker and therefore eligible for free NHS hospital treatment.
Our new information leaflet (accompanying the attendance form that is given to all new arrivals) sets out what we share with the Home Office: name, gender, date of birth, nationality, address and treatment dates. No medical information is disclosed.
The 2019 MBRRACE study on maternal deaths notes (but does not endorse) that three women who died may have been reluctant to access care because of concerns over the costs of care and the impact of their immigration status. These unidentified women were not Barts Health patients. The study observes that while no woman can be refused maternity treatment, this may not be commonly known.
We would welcome the opportunity to discuss these issues in more detail with Save our NHS groups and others. Our door is always open and the chief executives of our hospitals are keen to establish a regular dialogue with local campaigners.
On the most recent questions submitted in writing by Newham Save our NHS and asked verbally at the March 2020 board meeting:
1. No-one was denied maternity care. All 739 women referred to were treated in our hospitals. The issue at stake is whether they were eligible for free NHS treatment.
We do not routinely report on the numbers of overseas visitors patients who are not eligible for free NHS treatment, in either our public or private board papers.
We provided a short paper to the 27 January 2020 INEL JHOSC meeting about our policy on overseas visitors, as requested. We were not asked to attend to speak to the paper, and agreed in advance with the clerk to the committee that Dr Alistair Chesser, our chief medical officer, would give a fuller update in person at the forthcoming meeting on 24 June 2020.
We reject the charge of secrecy. We have answered all the questions asked by Save our NHS groups in writing and at board meetings. We would be happy to supply figures about overseas visitor numbers and eligibility for free NHS treatment in 2019-20 at the next public board meeting, as a step towards publishing some annual statistics on this topic.
2. The so-called MESH tool is an efficient method of accessing any information held centrally on the NHS spine about the immigration status of patients. It would allow us to check multiple records at the same time instead of keying in individual names one at a time. However, the trust did not use this tool at all during 2018-19. In practice, we find telephone calls with individuals are the most effective way of establishing eligibility to free NHS treatment, as it is more supportive to the patients and allows them to ask questions of us.
Overseas visitors who may or may not quality for free healthcare
Overseas visitors who may qualify for free healthcare
- A student studying full time in the UK or an individual who has come to work in the UK on a relevant visa. If you were required to pay the Immigration Health Surcharge as part of your visa application please note free treatment does not include assisted conception.
- A refugee or an asylum seeker whose formal application to the UK Border Agency is being considered. You will need to provide documentary evidence such as your Application Registration Card (ARC). Please note that you will need to pay for any medication prescribed to you.
- A citizen who normally lives in a country that is a member of the European Economic Area (EEA) and has a valid European Health Insurance Card (EHIC) in their name. This card covers emergency treatment only. You must bring this card with you to hospital.
- A citizen who normally lives in a country that has a reciprocal healthcare agreement with the UK. This covers emergency treatment only and does not cover planned treatment. Please note that if the agreement is withdrawn during your treatment you will become immediately responsible for the cost of the remainder of your course of treatment.
- You fall within a group of individuals who are entitled to receive healthcare on the same or similar basis as an ordinarily resident person. For further information in this regard please see pages 12- 15 of The Department for Health's Guidance on Overseas Visitor Charging Regulations or contact our Paying Patients Team for guidance and support.
Who may not qualify for free healthcare
- An individual without legal status at point of treatment including failed asylum seekers and illegal immigrants.
- Ex-pats who now ordinarily reside overseas.
- An individual with a Biometric Residency Permit (BRP) whose card is marked to confirm their “visitor” status. This may include academic visitors and private medical visitors.
Provision of treatment to overseas visitors in A&E
Treatment received in our Emergency Departments (A&E) is free. If you are admitted to hospital as an inpatient or receive any outpatient appointments charges will apply.
- For those overseas citizens in possession of a valid European Health Insurance Card (EHIC) please present your card to our A&E reception staff.
- If your country of residence has a reciprocal agreement covering your emergency treatment in the UK please advise our A&E reception staff.
In these instances we will re-coup the cost of your care from your country of residence.
Payment in advance for treatment
National guidance states that for treatment assessed by a clinician as non-urgent the full estimated cost of treatment must be paid before treatment is provided. This will include the cost of initial assessment and investigations to make a diagnosis. Find out the different ways that you can make payments for your treatment [pdf] 160KB
We will always provide treatment that a clinician has assessed as immediately necessary or urgent. All maternity treatment is regarded as immediately necessary. Treatment is not free however by virtue of it being immediately necessary or urgent and you will still be charged.
There are some NHS services which are free to everyone. Please see pages 30 and 31 of the Overseas Visitor Charging Regulations. EEA citizens with an EHIC card should present their card to reception staff.
Overseas visitors with private health insurance
If you have private health insurance you will be required to cover the costs to the Trust for all treatment it provides and then subsequently seek reimbursement from your insurer.
Who can help me if I have any further questions?
Please contact the Overseas Visitors Team for further guidance and support or to book an appointment to provide your documentation.
Our offices are open Monday to Friday 9am-5pm except bank holidays.
The Royal London and Mile End hospitals
Overseas Visitors Team
The Royal London Hospital
1st Floor, John Harrison House
Tel: 020 3594 6527, 020 3594 6526, 020 3594 6302
Overseas Visitors Team
Tel: 020 7055 5717, 020 7055 5626, 020 7363 9328
Whipps Cross Hospital
Overseas Visitors Team
Whipps Cross Hospital
Tel: 020 8535 6976, 020 8535 6712
St Bartholomew's Hospital
Overseas Visitors Team
St Bartholomew’s Hospital
3rd Floor, SMLG
West Smithfield, London
Tel: 020 3765 8565, 020 3765 8566