Behind the headlines: NHS care and overseas patients

While our care is always provided on the basis of clinical need, for some patients, the delivery of that care will be followed by the delivery of an invoice, as you see in episode four of Hospital on BBC Two. Sensational headlines about overseas patients can make it difficult to understand the reality of how the NHS responds to those who are not entitled to free care. Here, Richard Alexander, chief financial officer at Imperial College Healthcare NHS Trust, provides more details and general context.

Less than one in 1,000 patients who come to our Trust are not eligible for free NHS care. That’s because they are not ordinarily resident in the UK – and do not live in countries with whom we have reciprocal healthcare arrangements, primarily those in the European Economic Area. Generally, NHS care is free to those who have paid in to the NHS ‘pot’ through their taxes. In that sense, it is not really free to anyone – it is simply free at the point of delivery.

As the episode shows very clearly this is an area that requires great sensitivity and we know that different people feel very differently about what is the right way for us to handle it so it is helpful that there is clear national guidance and assistance available. This guidance covers how NHS trusts should identify patients who are not eligible for free care and seek to recoup the costs of any care that is provided. All of the patients whose stories are followed in Hospital arrived as emergencies. Everyone, regardless of residency, is entitled to emergency NHS care – we will not turn patients away when lives are at stake. But we do have a duty to do our best to recoup the costs for the care we provide to those who are ineligible.

For most patients, we are able to bill local NHS clinical commissioning groups or, in the case of very specialist treatment, NHS England. They foot the bill for residents locally or nationally. If a clinician determines that a patient who is not eligible for free care needs emergency treatment, we start to log charges at the point he or she is admitted. The bill may be paid through the patient’s health insurance or by their embassy but otherwise the patient is liable themselves.

It is worth noting that GP care is free for all. If a GP refers a patient to our Trust for specialist care, it is our responsibility to carry out residency checks to ensure the patient is entitled to free NHS care. When it comes to planned, non-emergency care, patients who are not entitled to free NHS care must pay for their treatment as private patients before they receive treatment. In total, the Trust received £8.5 million from overseas patients last year for healthcare provided privately, with all profit reinvested back into the NHS.

To put the issue in context for our Trust, in the last financial year we invoiced some 600 overseas patients just over £4 million. Around £1.6 million was received from overseas patients in the same year. We see just over a million patients a year and have a turnover of around £1 billion. Updated national guidance in 2015 helped us to improve our approach and in the first nine months of this financial year, we have both billed more – £3.8 million – and collected more – £1.7 million – than in the same period last year. As the programme showed, we are expanding our overseas patient team currently and expect to see further improvement in costs recouped. It is also an area where we work with national experts and other trusts to compare best practice and ensure consistency across the service.

The national rate of debt recovery from overseas patients across the NHS is estimated to be about 50 per cent – we estimate our recovery rate is slightly lower than that, probably as a result of the major trauma and highly specialised services we provide. Although the examples in the programme highlighted patients whose bills have not yet been settled, many patients do appreciate that the care is not free, have the means to pay and settle in full, even the largest bills.

If a patient does not pay for their treatment in full, despite continued follow up, there are further steps we take to recoup the money. This can include using debt recovery agencies and we also log any unpaid bills of over £500 with the Home Office. The Home Office will in turn mark the debt against that individual’s passport, which may prevent them from entering the UK again until the debt has been paid.

We are often asked what happens if a patient passes away. In this case the Trust, like any other creditor, will make a claim on the patient’s estate to settle the bill. If the patient dies with few or no assets, the debt has to be written off.

Behind the headlines about health tourists, as you see in Hospital, there are complex and sensitive human stories. We have to focus on making sure we treat all of our patients with dignity and respect and on the basis of clinical need, as well as ensuring we manage our finances as effectively as possible for the benefit of all. We would not normally disclose any details of individual patient care, including the cost or whether the bill was paid, however for the programme the patients consented and we are grateful to them for that.

Visit NHS Choices to learn more about healthcare when travelling and watch Hospital on BBC Two.