A fundamental and enduring principle of the NHS is that it is ‘free at the point of use’. All major political parties subscribe to this mantra and none dare challenge it. Herein lies the problem. The consequence of such altruism — all at the UK taxpayer’s expense — is health tourism and abuse of the NHS by ineligible patients. The general public seem unaware of this deception despite being rightly exercised about other examples of similar abuse, such as benefit fraud. How is this any different?
The rules and regulations laid down by the Department of Health governing eligibility for free NHS care are so porous, ineffective and difficult to enforce that they can be easily breached by would-be patients motivated enough to try. Those patients don’t come for the trivial stuff; the usual reason is a serious illness recently diagnosed in a country with poor or unreliable medical services — or where the best care is expensive and has to be paid for. The illness will probably require lengthy and resource-intensive treatment. Any health tourist planning to breach the rules of entitlement will find that the Department of Health’s online guide — ‘Eligibility for free hospital treatment under the NHS’ — provides the essential information and identifies the loopholes.
It must be explained why the NHS is more vulnerable to exploitation than comparable health systems which are as good as ours, such as those in Scandinavia, Germany, Holland and France. These countries have an insurance or employer-based service: patients have personal identification to prove entitlement, which acts as a barrier to abuse. Proof of entitlement is deemed unnecessary in the UK because NHS services are ‘free at the point of use’. This deficiency is compounded by the fact that many, if not most, transgressors are invisible to our feeble screening systems. Even when a potentially ineligible patient is identified, hospital managers are likely to give them the benefit of the doubt because the situation is usually clinically urgent and the fear of a potential complaint or, worse, a legal challenge, is often overwhelming. (Clinical urgency must be distinguished from emergency in terms of eligibility. The former need treatment soon — but not necessarily here — while the latter should be offered immediate treatment on a ‘good Samaritan’ basis.)
I have worked for the NHS for 43 years, 31 as a consultant surgeon. Several years ago I went with my father, a retired coal miner, to see the monument on the hillside overlooking Ebbw Vale which commemorates the life of Aneurin Bevan, his hero. I believe that the NHS is precious and should not be misused. Perhaps the most important statement in the recent report by Robert Francis QC into the Mid Staffordshire scandal was that we have a ‘statutory duty of candour’ — i.e., health professionals should feel supported and protected should they ever need to speak out. It is in that spirit that I write this article.
I am frustrated at seeing the NHS targeted by patients who are ineligible for free care, but who usually get through the net. Specialist units may be especially vulnerable. Reluctantly, I have decided to share my concerns. The final trigger to write this article was a potentially ineligible patient who accused me of unethical behaviour because I would not promote his application with my Trust for immediate and free NHS care. In any event, it is not the doctor’s job to decide on eligibility, but often it is only at the time of the initial or even subsequent consultations that the breach is first recognised.
At this point, where does the doctor stand with regard to ‘Good Medical Practice’ as defined and enforced by the General Medical Council? Their document states that every patient has the right to privacy and to confidentiality. So if a potentially ineligible patient has been overlooked by the screening system and is first identified by a doctor, should the doctor report their suspicion, bearing in mind that the patient will know how they had been exposed? If the patient is deemed to be eligible on appeal, which is usually the case, then the doctor may have to defend a charge of professional misconduct and risk the opprobrium of their Trust.
The Department of Health has abrogated its duties by delegating responsibility to individual hospitals. But the ‘Eligibility Officers’ at each hospital have a near impossible task, because the guidelines they have to follow are vague and open to interpretation. Moreover, ineligible patients are often familiar with the guidelines and can exploit their ambiguities.
The Department of Health states that NHS treatment is free to those who are ‘ordinarily resident’ in the UK, meaning that they live here ‘on a lawful, properly settled basis’. But on this score, there is a long list of exemptions. For example, any student on a minimum six-month course in the UK is eligible for free NHS care. Once treatment is started, it cannot be stopped because that would amount to an infringement of the patient’s human rights.
British citizens who have lived abroad for more than six months, even if they have paid tax in the UK during that time, are ineligible. This rule would apply to British citizens who have worked abroad for years and to those tens, if not hundreds, of thousands who took early retirement to live in the sun. Rest assured, though, there is no need to panic when you need a hip replacement or stents for your coronary arteries or when you find that nasty cancer. Return to the UK and stay with a relative or rent a property if you don’t already own a home. You may find you are still registered at your old General Practice. If not, a temporary or permanent registration with a GP is easily obtained. Better still, present yourself to an NHS hospital as if you had never been abroad. Almost certainly you won’t be identified or challenged. (It’s a good idea, though, not to show the mammogram from Cyprus, the colonoscopy report from Spain or the CT scan from Thailand.) Answer ‘Yes’ to the question: ‘Are you taking up or resuming permanent residence in the UK?’ Nobody will check.
What if you are not British, but resident in the European Union? Again, no problem. Say that you plan to relocate and, at worst, you may be asked to prove that you have rented a property or asked to produce a utility bill in your name. It is unlikely that you will be asked to show evidence from an estate agent that your foreign home is for sale, but anyway that is easy to obtain and would support your case. No one will know that you have no intention of accepting even the most generous offer on the sale of your house abroad or, indeed, that you have multiple properties. The process is much easier if you stay with a relative or friend who is already resident in the UK, because you can explain that they alone can support you through your illness and treatment. Again don’t volunteer the MRI scan from Greece or the PET scan from Portugal which will prove that your condition was diagnosed only days or weeks before you decided to relocate to the UK. After treatment in the UK you can return home, because no one will ever check that you kept your relocation pledge. If they do, you can say that you failed to settle and decided to return abroad. It’s that easy.
What if you are not a citizen of the EU? A bit more difficult, but not insurmountable. A valid visitor’s visa will allow you to obtain GP services and an NHS number legally. From there, with some initiative and persistence, it is not too difficult a step to access expensive and long-term medical care.
There is also anecdotal evidence that is even more frightening but undoubtedly true. There are stories of heavily pregnant women arriving in the UK because childbirth qualifies for emergency care and the child would be British, thereby providing the mother with residency rights. There are tales of families relocating because a child has severe congenital or acquired illness and of large numbers of patients with HIV coming to the UK because that is their only hope of getting effective treatment. There are even stories of patients landing at Heathrow in kidney failure and being blue-lighted to hospital for dialysis.
Anyone who is shocked by all this can at least be consoled by the fact that we have bilateral healthcare agreements with countries such as Armenia, Azerbaijan, Belarus, Russia, Serbia, Tajikistan, Turkmenistan, Ukraine and Uzbekistan to name but a few — though not Canada or USA, which are two of the countries outside the EU most commonly visited by Brits.
What is the solution? We must have an ‘NHS passport’ to prove eligibility for free and unlimited care. This could be either physical or virtual but must include a photograph or a biometric scan to protect against fraud. In the meantime, the Department of Health regulations must be made rigid, unambiguous and less amenable to misinterpretation. Trusts must be supported to allow more vigorous investigation, unhindered by intimidation or the threat of legal challenge. British people moving abroad before retirement age should be required to continue National Insurance contributions or some other form of payment to retain NHS entitlement. The message must be that our NHS provides care free at the point of use, but only for eligible patients.
In 1948, when the NHS was created, the UK population was 49 million and almost exclusively indigenous. The exploitation described above could not have been foreseen. But now the UK population is 63 million, with freedom of mobility within the EU and with the world beyond. Heathrow, Manchester, Birmingham and other British airports are large global hubs. We have one of the most advanced health services in the world with the latest technology and therapies freely available.
William Beveridge and Aneurin Bevan would be outraged by the abuse of their flagship social reform and on such a scale. The time has come to protect our NHS. British taxpayers should not be funding an International Health Service.
Professor J. Meirion Thomas is a consultant surgeon with the NHS.