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thomas davison

Sickening! No other country lets foreigners exploit its health system the way we do... and a top surgeon says it could even bankrupt the NHS

By J Meirion Thomas

PUBLISHED: 23:49, 14 June 2013 | UPDATED: 01:13, 15 June 2013

Recently, David Cameron estimated that the cost to the British taxpayer was �20million. Health Secretary Jeremy Hunt said it was �200million. The truth is far more shocking.

I believe abuse of the NHS by health tourists is costing taxpayers billions of pounds - and I will explain why. It happens because we encourage the belief that our NHS is 'free at the point of use', and because the Department of Health guidelines defining eligibility for free care are so porous, ineffective, contradictory and difficult to enforce that they can be easily breached by any patient motivated enough to try.

But first, let us define the offenders. We are not referring to illegal immigrants, nor to people who need Good Samaritan care of the kind you might expect the NHS to provide after someone has suffered from an accident or an unforeseen illness.
Prime Minister David Cameron
Secretary of State for Health, Jeremy Hunt

Change: Prime Minister David Cameron (left) and Health Secretary Jeremy Hunt (right) both promised reform but perhaps the Government could introduce emergency legislation to send the message that our valuable NHS is 'free at the point of use' only for eligible patients

No, health tourists are people who visit the country perfectly legally. They come into Britain, usually on a visitor visa, with a pre-existing illness and their arrival in hospital is premeditated: the very purpose of their visit is to access free NHS care.

Nor do they come with trivial problems. It is specialist, expensive and resource-intensive treatments that they are after. The most common examples include complex pregnancies, cancer, HIV and renal dialysis.

NHS hospitals have overseas visitor officers whose job it is to identify and charge patients who are not eligible for free care.

And Jeremy Hunt has based his figure of �200 million on the invoices which these officers have sent to patients who have been treated by the NHS.

But the fact is that most health tourists are either invisible to the overseas visitor officers or use loopholes in the regulations to get round them.

Which means that, in the vast majority of cases, no charge is made and no invoice is sent out. This means that the cost of their treatment does not appear in Hunt's �200 million figure.

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Dismayed by the increasing burden on the NHS caused by overseas visitors that I have encountered as a senior consultant in the NHS, I have researched this issue thoroughly and have spoken in depth to many overseas visitor officers.
Free: Health tourism in the UK is a particularly attractive option for patients from some Southern European countries where there is little elective (non-emergency) surgery because of the financial crisis

Free: Health tourism in the UK is a particularly attractive option for patients from some Southern European countries where there is little elective (non-emergency) surgery because of the financial crisis

They are acutely aware of the problems and are desperate for them to be aired. Their experience and knowledge is essential to resolving the crisis of health tourism. And they say two reforms are immediately necessary.

First, visitors to the UK should no longer be automatically given an NHS number. It is an astonishing fact that, unlike almost every other country in the world, visitors are entitled to free primary care in GPs surgeries.

On their first visit to a GP, they are given a unique and permanent NHS number which not only implies they have a legitimate right to use the NHS, but renders them relatively undetectable to the most vigilant overseas visitor officer should they ever be referred for hospital care.

Second, the overseas visitor officers say entitlement to free NHS hospital treatment should depend on patients being able to prove they are permanent residents of this country.

At the moment, NHS rules say that to receive free treatment in hospitals, they should be 'ordinarily resident'.

But the term is so lax, so difficult to define, that once the health tourists have their NHS number from a GP, many find ways of getting round the question of residency.

Health tourists fall into three main groups. The first - those from other EU countries - is probably the most expensive because it involves so many patients.

As a result of the EU Treaty, all EU citizens are guaranteed freedom of movement between countries - something that was primarily intended to facilitate workforce mobility.
Unfair: The NHS has a finite capacity, and the tragic consequence of all these ineligible patients is that British taxpayers are kept on waiting lists and drugs are denied them while the emergency treatment of overseas visitors takes precedence

Unfair: The NHS has a finite capacity, and the tragic consequence of all these ineligible patients is that British taxpayers are kept on waiting lists and drugs are denied them while the emergency treatment of overseas visitors takes precedence

The unintended consequence of this is that entire families, including extended family members, can come to Britain from an EU country for free healthcare.

Why would anyone not take advantage of this unique opportunity? It is a particularly attractive option for patients from some Southern European countries where there is little elective (non-emergency) surgery because of the financial crisis, and for patients from some Eastern European countries with an appalling healthcare record and where cancer survival rates are the worst in Europe.

Once here, these patients can easily obtain an NHS number by turning up at a GP's surgery. Having done that, they can pretend they are 'ordinarily resident' in the UK and, therefore, eligible for free hospital treatment.

The second group of health tourists come from outside the EU. Many are pregnant mothers; it is not unreasonable to describe the NHS as the world's maternity wing.

They come to the UK in late pregnancy, sometimes expecting twins or triplets, and the cost can be enormous if neo-natal intensive care is necessary.

Because these patients often arrive in A&E with pregnancy problems and other emergencies - sometimes in ambulances driven straight from the airport with blue lights flashing - they will not have an NHS number from a GP, which means they are more likely to be identified and charged by overseas visitor officers.
Because the Department of Health guidelines defining eligibility for free care are so porous, ineffective, contradictory and difficult to enforce, they can be easily breached by any patient motivated enough to try

Because the Department of Health guidelines defining eligibility for free care are so porous, ineffective, contradictory and difficult to enforce, they can be easily breached by any patient motivated enough to try

The trouble is that they then claim their illness or condition is an emergency and refuse to pay. Only about 30 per cent of the costs they incur to the NHS are recovered.

The third, and most difficult to identify, are British nationals or patients with dual citizenship who have lived abroad for many years or even decades, and who return for treatment because they have recently been diagnosed with a serious illness.

They already have an NHS number from an earlier life in Britain, so they register with a GP who will happily refer them to a hospital.

In the unlikely event that they are identified by an overseas visitor officer, they will be asked if they are 'ordinarily resident' in the UK.

They can either lie about where they live or claim that they plan to resume life over here. Their stories are hardly ever checked: they are not asked for proof of residence and no one investigates whether they really are returning to Britain.

After treatment, patients from this group are free to return abroad, and they can shuttle back and forth for NHS treatments ranging from major operations to repeat prescriptions.

All of this will be at the taxpayers' expense - and, once again, none of these patients are included in Jeremy Hunt's �200 million estimate.

So there is already clear evidence that it is woefully short of the true figure. But there is another very important reason why the Health Secretary should be talking about billions rather than millions.

To understand it, we have to look at the different prices charged by an NHS subsidised by the taxpayer, and private hospitals.
Jeremy Hunt estimates that the cost of health tourism is �200million but the true figure could run into billions of taxpayer's money

Jeremy Hunt estimates that the cost of health tourism is �200million but the true figure could run into billions of taxpayer's money

Typically, it can be assumed that prices charged by the heavily subsidised NHS are about a third of those charged by private medicine, although it will vary between treatments.

For example, an NHS hospital will charge around �180 for a renal dialysis treatment, compared to �500 in the private sector.

I believe that patients who are identified as ineligible for NHS care ought to be charged for any treatment at the same price they would have to pay in the private sector. Why on earth should health tourists, even in the event of payment being made, be charged the highly discounted, 'bare bones' NHS tariff?

After all, they have no automatic right to be treated on the NHS. For this reason alone, Jeremy Hunt should immediately triple his estimates of the cost to Britain of health tourism. But it is not just the financial penalties that are so damaging.

The NHS has a finite capacity, and the tragic consequence of all these ineligible patients is that British taxpayers are kept on waiting lists and drugs are denied them while the emergency treatment of overseas visitors takes precedence.

Then there's the erosion of motivation and goodwill among NHS staff as junior doctors, trainee midwives, nurses and others are regularly exposed to this exploitation of the health service.
Aneurin Bevan
William Henry Beveridge

Reform: The NHS pioneers William Beveridge (right) and Aneurin Bevan (left) would be outraged by the abuse of their flagship social reform by health tourists

Does this abuse not impact on the problems of care and compassion in the NHS, problems so regularly reported in the media and which need to be urgently addressed?

As far back as December 2003, John Hutton, then Minister of State for Health, recognised the problem of health tourism and promised reform. But the truth is that he and a series of successors at the Department of Health have presided over a rapidly deteriorating situation and have failed to address the crisis. Britain's specialist healthcare is internationally recognised as exemplary.

The combination of cheap flights and free access to doctors has made this abuse grow exponentially. The problem of health tourism is now so acute as to threaten the principles upon which the NHS was designed to function when it was created in 1948.

Back then, the UK population was 49 million (not 63 million as now) and almost exclusively indigenous.

The NHS pioneers William Beveridge and Aneurin Bevan would be outraged by the abuse of their flagship social reform and on such a scale.

In March, David Cameron and Jeremy Hunt promised reform. But the process will take time. The Department of Health has commissioned a review to be followed by a consultation period.

This initiative is to be applauded. But given the gravity of the situation, could not the Government in the meantime introduce emergency legislation, possibly with cross-party agreement, if only to send out a loud message that, yes, our valuable NHS is 'free at the point of use' although only for eligible patients?
Cost: An NHS hospital will charge around �180 for a renal dialysis treatment, compared to �500 in the private sector

Cost: An NHS hospital will charge around �180 for a renal dialysis treatment, compared to �500 in the private sector

Removing automatic entitlement to an NHS number for all visitors to the UK would be a good start.

Ultimately, however, the only solution is an 'NHS passport' which defines entitlement on the basis of permanent residency.

Every other country in the world with a health service comparable to ours has rigid systems of personal identification in place to prevent exploitation and abuse.

Examples include Scandinavia, Holland, France, Germany, Canada and Australia - all of them civilised democracies. Why do we allow the NHS to be managed so differently?

It has taken several years of austerity to focus attention on benefit fraud, which is a criminal offence. Why should defrauding our health system to the tune of billions be any better tolerated?

It has to be one of the great wonders of our age doesn't it? The NHS employs 37,314 managers, but they're still absolutely hopeless at procurement and have no ability to manage even basic invoicing. But their tick box system is designed to show many more patients than they actually have. One patient should be one patient no matter how many pillars and posts they get passed between. Mr Bevan said in a speech that an out of control admin was his greatest fear, he must be spinning in his grave