How NHS health tourism is costing us billions: a surgeon's story

Since blowing the whistle on systematic abuse of the NHS, I’ve heard from dozens of NHS colleagues. This is what they have to say.

6 April 2013

When David Cameron proposed toughening the rules that govern foreign nationals being treated for free by the National Health Service, he faced — as one might expect — a barrage of criticism. The Prime Minister was accused of tilting at windmills. The threat exists only in the minds of xenophobes, said his critics. The actual levels of abuse are minimal, so why is he scaremongering? A few weeks earlier, I had written a piece for The Spectator from a different perspective; that of an cancer specialist who has spent his career in the NHS. I wrote for one reason only: that I cherish the NHS, and wish to stop its abuse.

My piece focused on the actual nature of the abuse, how it is carried out and why so little of it is detected. If a foreign national is impersonating a British friend (easy to do when no identification is required by GPs) then of course it will not show up in any statistic. I did not give too many examples. But since the publication of the piece, I have been overwhelmed with messages of support describing similar experiences and encouraging further investigation. It all adds up to clear, widespread abuse of our NHS by ineligible patients.

One of the first letters I received was from a junior hospital doctor working close to Heathrow airport. ‘Every single week, I see people who have been flown in from all over the world with a variety of extremely serious health problems,’ he wrote. ‘Many of these people had to be wheelchaired on to the plane because they were too unwell to walk on board. I understand the temptation to come to Britain, but we often have our Intensive Therapy Unit full of patients without NHS numbers who are there for weeks or months with no means or intention to pay, which impacts on our resources.’

The most revealing and scandalous reports of serial NHS abuse come from Overseas Visitor Officers (OVOs) who are employed by hospitals and whose job it is to identify, interview, invoice and recover costs from individuals not entitled to free NHS care. I have now been contacted by more than a dozen OVOs, desperate to be heard, who have given me scores of cases of abuse covering every aspect of NHS activity. Some, fearing reprisal from senior managers, have spoken to me on condition of anonymity.

This abuse may be costing the NHS (and therefore the British taxpayer) not millions but billions of pounds every year. Curbing the abuse is not just right in itself, but may save astonishing amounts — and it can be done through a few simple procedures. The mystery for those of us working in the NHS is how the Department of Health and 40,000 or so hospital managers have allowed this to happen.

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Let’s start with maternity health tourism, a massive and escalating problem. Foreign women often arrive in the UK in late pregnancy, often after detecting a complication. They come on a visitor’s visa and present to A&E while in labour. Often the patient refuses to pay, claiming that a childbirth qualifies as emergency care and therefore cannot be refused to anyone. In this way, the NHS can be used as the world’s maternity wing. If neonatal intensive care is necessary, the bills can run to tens of thousands of pounds — with little chance of recouping costs. There is much evidence of identity fraud. In every maternity unit, identifying the blood group of the mother is obligatory. Over time, patients have given a registered name, address and NHS number — but are found to have different blood groups from the one on record. This is conclusive proof of an identity being shared.

There are similar abuses in oncology, HIV, infertility and in the treatment of renal failure. Renal dialysis is probably the most costly form of abuse because the treatment needs to take place three times a week and may result in a kidney transplant. I am told of one example where a patient arrived in renal failure on a visitor’s visa and was blue-lighted to a hospital for dialysis. At the last count, this person has had 849 dialysis sessions as well as numerous other treatments.

Doctors in consultation with an ineligible but deserving patient face a moral and ethical dilemma which needs to be openly discussed. For example, cancer treatment is rarely urgent — it should be started soon, but not necessarily during a visit to the UK. An OVO from a major cancer centre wrote the following. ‘Eight out of ten times, cancer treatment offered at this hospital will be deemed “immediately necessary” by the treating consultant.’ The NHS does not have the resources for such largesse. And what about the rights of resident taxpayers, whose treatment is delayed?

Jeremy Hunt, the newish Health Secretary, has said he will address the problem. The good news that there is much he can do, at one stroke of the ministerial pen. First, we should cease the practice of granting an NHS number to overseas visitors. Those who work and pay tax here, and have a National Insurance number to prove it, ought to be granted full access to the NHS whatever their residency status. But it makes no sense to accord this right to visitors, especially when an NHS number can translate seamlessly into expensive long-term hospital care.

An NHS number is a valuable commodity which confers legitimacy and has market value. But there is no black market for NHS numbers: they are given away free. Primary Care regulations encourage overseas visitors to take an NHS number. ‘A patient does not need to be ordinarily resident in the UK to be eligible for NHS primary care,’ say the rules. ‘Overseas visitors, whether lawfully in the UK or not, are eligible to register with a GP practice.’ And woe betide any clinic that wants to take its own precautions. The Department of Health is even advising GPs that it could be a violation of a patient’s human rights to ask them for identification at the time of registration.

Mr Hunt could bring in a range of simple measures to reduce abuse. The most powerful would be to ask that, when GPs refer a patient to hospital treatment, they make sure the patient is eligible for such care. There is no such requirement at present, nor any opportunity for doctors to raise questions about a patient’s eligibility, which is why the extent of the abuse has gone unnoticed. An NHS number makes an ineligible patient almost invisible to the most vigilant OVO. The system is an open invitation to the world to abuse the NHS.

Next, GPs should be asked to ensure that the patients on their books are still living in Britain. This would end a niche form of exploitation, by those who once lived in the UK. From abroad, they phone their GP’s clinic, where they are still registered, to request repeat prescriptions. These can be collected by a relative or friend, and the medicine posted abroad. Also, student eligibility could be tightened. Why should those on 15 hours per week courses be entitled to free NHS care? And why should this also apply to their dependent family members? Home Office research shows that as many as one in four foreign students allowed into Britain may not be genuine.

In just a few weeks, I have been able to gather remarkable evidence about the extent of the problem — supplied by NHS workers who love the health service and hate to see it abused. An official audit of this problem could be undertaken, focusing on information provided by OVOs who see it all, but who would need full immunity from reprisals to report. Such disclosure, and protection, would be very much in the spirit of the recent reforms Mr Hunt proposed in response to the Stafford Hospital scandal. An audit should be manager-free, because it is the mandarins and officials who have presided over the genesis and evolution of the current problem.

It could well be that the NHS is too addled with too many loopholes and has reached the point of no return. I say that with the sadness of a committed NHS surgeon who is acutely aware of its financial constraints. But it can be saved. Mr Hunt has indicated his willingness for a paradigm shift in understanding and response to overcome the rot which has set in so deeply to the NHS. A proper audit would confirm the problem, and a few simple procedural changes would implement the solution. All that is required is ministerial resolve.

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Show comments
  • Latimer Alder

    Seems to me that the NHS – like all ‘public services’ – is riddled with rules and processes and guidelines and directives.

    But applying common sense is not one of them.

  • http://www.facebook.com/kalkikalki.kalki Kalkikalki Kalki

    Having worked in the failed UK education sector (examination board), it may unfortunately be best to let the NHS collapse completely and then start again rather than trying to fix a failed system.

    If there is no controls over migration and any sense of sovereignty then you’re completely open to abuse not just in Health, but across the board in all sectors.

    A beginning solution could be to produce a passport and/or identity card for treatment. But we can’t have that!
    Overseas patients need to be charged up front. But we can’t have that!
    Visiting Student’s need compulsory medical insurance. Not allowed!

    Or just scrap the NHS and force EVERYONE to pay for any medical treatment and allow anyone from any country to come and go as they desire. Like it is now.

    • Glen Wallis

      “A beginning solution could be to produce a passport and/or identity card for treatment. But we can’t have that!” – why ever not? NZ does it. I am sure they are not alone.

      • How_delightful

        NZ is not run by mental cases; is it?
        And what irritates ms is that the people who wrecked the UK all seem to retire there.

        • Glen Wallis

          First point – NZ is run by the National Party headed by John Key – so , yes, mental cases it is. Second point. – You exaggerate. If they are here they are well hidden.

          • How_delightful

            I suspect they don`t tell you that they are now in NZ and are ruining there also. Its a habit of public officials.

      • QuixoticRocket

        People in UK are very resistant to anything like an identity card that could track them or impede their privacy.
        Personally I don’t care about ID cards. If someone in government really wants to follow my exceptionally boring life let them. If it means better NHS treatment then I’m all for it.
        But then I grew up in South Africa where it’s pretty mandatory to get your ID at the age of 16 and everything is based around that.

        • Donafugata

          There is a roaring trade in fake passports and the same would happen with ID cards or any other documentation.

    • Kadiyali Srivatsa

      I like and agree 100% your comment “let the NHS collapse completely and then start again rather than trying to fix a failed system”. This is like buying a second hand car and trying to make it work.

      • How_delightful

        Better the devil you know?

      • petermorris

        Or driving your used car into the ground and then buying a new car. Better car but at what cost?

  • thesickmanofeurope_com

    Good article…..but it could be better….
    How do other countries in Europe deal with this?
    Are they just as incompetent as we are?

    • Edward1

      I believe in France you have to have a health card. You also can only claim back 70% of your treatment from the French state and the rest is paid by you or by an insurance company if you are covered.

      • How_delightful

        That is with the European National Health card…

        • Edward1

          I don’t believe so.

        • Christopher Kenway

          As with French nationals and perminant residents

    • How_delightful

      Reality outside the UK for non-nationals?
      In Japan I could not get my 6 y/o daughter treated for an open bleeding head wound until my wife arrived with her medical insurance card after she had to cycle 10Km to the hospital to bring it (she doesn`t drive). I had already cycled the 10K with her on a child seat. No car then. No taxi service in the mountains.

  • Terry Eyres

    The powers to be be do not care about the NHS because they have the means to go private,if they had there way it would go the same way as the dental service where you now pay twice,it would be easy to stop the abuse but like most things in this country the politicians have there heads so far up ther own backsides that nothing ever gets sorted.

  • http://twitter.com/outofafrica46 lindaoutofafrica46

    It’s about time that something is done. We need to have clear guidelines so that everybody knows where they are. Junior doctors know exactly what is going on as they really are at the front line. There will always be left-wing apologists who advocate treating every Tom, Dick or Harry who turns up on the doorstep of our precious NHS for which the British taxpayer pays dearly. We must be ruthless now, as other countries are. We are not a universal health service. We need to make it clear that our free for all NHS is at last closing the door on people from other shores who have made absolutely no contribution. The British taxpayer is behind this. Sitting in A & E at St Thomas’ Hospital is an eye opener .

    • Latimer Alder

      ‘We need to have clear guidelines so that everybody knows where they are.’

      Everybody does know where they are. They are over here and in the hospitals!

    • Donafugata

      The French system is far better controlled.

      • Noa

        Any useful references or links to demonstrates this?

        • Ytongs

          I can offer first hand experience if you like.
          A visit to a French A&E recently was necessary following a DIY accident.
          A 45 min wait in A&E, nurse appears and escorts me to the treatment area. Injury cleaned up and X-ray deemed necessary.
          Nurse appears with form. Usual details filled in. How did it happen she asked?
          This innocuous question is to ascertain if the bill should go to someone else. ie: car accident, then car insurance pays. DIY accident invokes the question “were you being paid by someone else to do this?” A positive reply sends the bill (and the Gendrames for tax evasion) round to the someone else.
          Can you read this notice please? The Notice states:If you are English then how are you going to pay for the treatment? Health insurance, Carte Vitale (French health care entitlement card), EHIC card or cash? If you wish to be invoiced then can you provide your English address and proof of identity please?
          All done in about 2 mins. and on my way to the X-ray.
          After returning with the x-ray all was bandaged up and I was given a prescription for bandages and antiseptics and a form to present to the district nurse when she visited my home twice a week for three weeks to change bandages.
          All in all I spent some one and a half hours in the hospital. No fuss or drama, it was just organised and worked.

          • TR

            This is for European people only. Because they pay part of the treatment and their country pays the bulk, while illegal immigrants pay nothing at all thanks to the AME (State medical help), which costs around one billion a year, just to treat illegal immigrants for their six first months; because, if they need a medical treatment for more than six months, they will be entitled to a renewable one year visa for health motives, treatment still all costs paid unlike French taxpayers but on behalf of the CMU (so getting out of the statistics of the AME) and receiving housing (wholly paid thanks to the Allocation Logement), and the Allocation Adulte Handicapé of 790€ per month (reduced to 237€ if they live at the hospital) plus 105€ of autonomy complement, plus miscelleanous.

            As a French living in Britain, it was quite difficult to register and I still don’t have my NHS number though I applied for it about two months ago, and I had to show the GP secretary, with a print of the NHS site, that I was entitled to have one. Yet I had my French registration cancelled right when we came here… I need care now and though a whole British taxpayer since two years, with “good” contributions, I am not entitled to, yet.

            It seems that both the French and the Britons have a better care for foreigners than for Europeans, and a better care for Europeans than for nationals.

    • RobertC

      I don’t think it is Tom, Dick or Harry that we should worry about!

    • 1965doc

      I agree, but how is the staff member to know whether the presenting patient is entitled to treatment or not? It would require the re-introduction of ID cards, which I hope we are all opposed to.

      • Ytongs

        No it wouldn’t. Just issue NI numbers to those who are indigenous to the UK and ask for this if you visit a hospital. Proof of identity? This already gets asked for in pubs and suchlike. All you need is something of yours with a photo on it, like a driving licence. Not difficult at all and not a national ID card either.

        • petermorris

          NI numbers do not necessarily demonstrate an entitlement to the NHS treatment. Some people from say, Commonwealth countries, may work and pay tax and NI in the UK but their visa may say they are not allowed access to things financed by public monies, i.e. the NHS. So they have a NI number but no NHS access. Also there are tens of millions of NI numbers that are not allocated to people currently living in the UK.

      • NB

        Actually the most sensible point made on here. the practicalities of this are the problem, and one not easily solved. the other considerable problem I have with this piece, and others like it, is the routine overestimation of the scale of the issue. millions if not billions? really? i’d like to see the actual numbers on this one. please (PS. I know you don’t have them). and let’s not forget the number of ‘foreigners’ who are entitled to free NHS care by dint of living here, working here, and paying tax here, who choose to leave to have their babies at home.

  • http://www.facebook.com/geoff.smith.904 Geoff Smith

    Sir David Nicholson, who earns £270,000 and takes numerous first class rail journeys, should have a look at this, as he said he is absolutely the right person to lead the NHS.

    • 1965doc

      He is a Labour apparatchik, appointed to carry out New Labour’s desires, and he is just a bully boy, with no knowledge whatever of medicine. He is incapable of running a whelk stall, but is supported by Camoron. He is also paid three times as much as a senior medical consultant——–appalling!!!!!

      • petermorris

        And he is paid just a third of that of some GPs.

  • How_delightful

    Telling the truth can get you labelled a Nazi; but I say `Live long and prosper` Dr dude.

  • http://www.facebook.com/Danzig.Jon Jon Danzig

    This article claims that billions, not millions, may be lost to the NHS because of health tourism, but only offers anecdotal evidence. That doesn’t make the points in the article untrue, but neither does it adequately verify them. We surely need reliable, properly collated empirical evidence to accurately measure the extent of the problem. Currently in the UK ‘anecdotal evidence’ is being used to promote feelings of animosity against foreigners, and we need to be careful when relying too heavily on what unnamed doctors or health workers are claiming about abuses of the system.

    Under existing regulations, the NHS is entitled to charge foreign visitors not ordinarily resident in the UK for the cost of healthcare, with the exception of accidents and emergencies. We already have an NHS Counter Fraud Service responsible for investigating, detecting and preventing fraud. There is no reason that the cost of providing care to foreign visitors should be a threat to the NHS if existing regulations are efficiently administered.

    When an answer was given to the House of Commons by Health Minister, Anne Milton, it was revealed that the audited costs to the NHS for these losses came to just less than £7 million in 2009-10. That’s a tiny fraction of 1% of the NHS annual budget. If Parliament was given inaccurate information, this needs to be promptly corrected.

    See also the investigation by FullFact.org “Is ‘health tourism’ costing the taxpayer £200 million?” http://goo.gl/oSyQU And my own blog, ‘End of the National Health Service?’ http://goo.gl/34D2k

    • Fraser Nelson

      Dr Thomas’s point is that the official accounts of ‘health tourism’ only glimpse a fraction of the abuse, because so many are being wrongly accounted for as UK citizens. The data simply does not exist, and he’s calling for an audit.

      • http://www.facebook.com/Danzig.Jon Jon Danzig

        Yes, but it seems the doctor has made his diagnosis without conclusive test results. The article’s headline is also presumptive and alarmist, ‘How NHS health tourism is costing us billions..’ Shouldn’t the practice of medicine be ‘evidence based’? From the information available, it cannot be calculated or concluded that ‘billions’ are lost to ‘health tourism’.

        Further, the article claims, ‘The Department of Health is even advising GPs that it could be a violation of a patient’s human rights to ask them for identification at the time of registration.’ Is this correct? How is asking someone for proof of identity a violation of their human rights? Banks ask for identification all the time.

        I fear this article will simply fuel more xenophobia, and based just on anecdotes. See my article, ‘Human rights: What are they?’ http://goo.gl/pijER

        • http://www.facebook.com/Danzig.Jon Jon Danzig

          Update: The Spectator article claimed, ‘The Department of Health is even advising GPs that it could be a violation of a patient’s human rights to ask them for identification at the time of registration.’

          I checked this with the Department of Health, who replied, ‘As far as we are aware, the Department of Health hasn’t issued guidance that says it is against the patient’s human rights to ask for identification at the time of registration.’

          FullFact.org, which ‘promotes accuracy in public debate’, has also just published a ‘Fact Check’ into the cost of ‘health tourism’ to the NHS, in response to the Spectator’s headline that put the bill in the ‘billions’. See:


  • Kadiyali Srivatsa

    It looks as if this hospital near NHS seem to open the door for tourist. I have worked in Ashford Hospital and know how this door was closed in 1990s for tourists. I worked in paediatrics and was involved in accepting or ejecting children who were shipped from Middle-eastern countries to get admitted for cardiac surgery. Not one child was turned back because the Embassy paid the cost.

    To tell you frankly, UK welcomed patients and keen to admit because they were earning a lot of money. Ashford Hospital was one of the richest because they always had surplus income until they sold the land to Local Superstore.

    I am surprised to hear this doctor or the whistleblower highlighting a problem that did not exist.

    • Donafugata

      Everyone has their own anecdote.

      In 1975 I was doing my training in casualty at, what was then, St. Stephen’s hospital in Fulham Road.

      At least once a day, an emergency ambulance would bring someone of middle-eastern origin who complained of abdominal pain. This, invariably, was found to be of minor importance but, on examination, other, serious conditions would be revealed. The patient would need referral to a specialist, most often for congenital cardiac and orthopaedic conditions.

      Once a condition comes to light, the doctor is obliged to treat it.

  • MK

    This is appalling! From my personal experience, I know a friend’s pregnant sister is coming over to UK as a student, and the sole purpose is to give birth with NHS, not the higher education. Other instances I know includes non-resident/citizen parents of friends who has registered with NHS using only utility bills. I like the whole idea of free health care for everybody, even if the person is a visitor and requires emergency medical treatment. But when generosity is abused, it needs to be stopped.

    • Donafugata

      A neighbour came from Slovakia specifically to have a baby as a single mother, decided to stay and is now installed in a two-bedroom flat. She boasts that she won’t have to pay for her cigarettes ever again.

  • faustiesblog

    As always, cui bono?

    It seems to me that pharmaceutical companies and the like, stand to gain the most from this: unlimited business, paid for by the taxpayer, who is not in a position to say no.

    So who facilitates this practice, if not the civil service? Isn’t it time an audit was done on civil service vested interests? How many are in the pay – directly or indirectly – by those who stand to gain the most?

    But I’m sure you know that already. It is a brave man who takes on the pharmaceutical companies.

  • Sheumais

    There is a lot of emotive nonsense spoken about the NHS and declaring love for it is most certainly emotive nonsense. Affection for the ideal that the country should arrange to take care of its people is one thing, declaring love for a behemoth that has been placed on a pedestal to avoid any criticism by far too many who should know better is quite another.

    The people of this country may have affection for the idea that founded the NHS, but that should not be confused with what is today’s service, where far too many leave it in a worse state than when they arrived. Certainly squandering resources on people with no entitlement to them should be stopped immediately, but so must this airy fairy “I love the NHS” which has allowed the most appalling inefficiency and intimidation of whistle blowers and critics.

    I can only wonder just how different a national health service would be from today’s NHS if it was designed from scratch to efficiently and effectively service the health of the people of this country, but I suspect the differences would be huge. Taxpayers’ money is an increasingly scarce resource in itself and it should never, ever be taken for granted.

  • Donafugata

    It appears to be of little consequence which of the main parties are in power, all of them show exceptional magnanimity to the global population.

    The above abuses of the NHS are not news to most of us, is it any wonder that the system is over-stretched? It should be called the GHS, global health.

    While every government department is having its budget cut, overseas “aid” is being increased by almost 32% and much of it is going to countries that have nuclear weapons.

    The government needs to realise it is not their money but ours that they are squandering. Charity should be voluntary and precious health resources reserved for those who have already paid for them.

    In France a sysyem of socialised medicine exists whereby everyone has to pay but contributors are reimbursed, this eliminates the opportunity of abuse.

    Our governments are too free and easy with money that doesn’t belong to them.

    • 1965doc

      Indeed- and the foreign aid is £13 BILLION this year—-all of it borrowed!!! You couldn’t make it up, could you?

  • AdamDixon

    Wasn’t the true figure found to cost the Taxpayer only 7 million? Wheres this billions from?

  • Pat

    This seems strange to me, as all the foreigners I personally know (and count as friends) go home for treatment if they can. Perhaps there are healthcare systems worse than ours? Or perhaps there are naive people abroad?

  • http://www.facebook.com/stuartdj Stuart Britton

    If the Government had kept National Identity Cards, then we might have been able to better identify those who are entitled to public services such as this. But oh no, it was portrayed as so Big Brother it was undesirable and therefore completely pointless. And now we can’t tell who should be using hospitals and who shouldn’t.

  • Austin Barry

    So you’ve landed in England and want to have a procedure on the NHS.

    First you have to hope that your GP isn’t a Dr Shipman manque. You arrive at hospital, but it’s Saturday night and drunks are brawling at reception. You are finally admitted and, after a sojourn on a trolley in the corridor, are wheeled to a bed by a porter who is gazing at your body with a Jimmy Savile-style interest. You then hope that your nurse is not a Beverley Allitt copycat murderer.

    And now you are ensconsed as an in-patient at an NHS hospital, an institution responsible for killing thousands through neglect.

    And you think, “Perhaps I should have stayed in the Congo”.

  • jamesnorton

    All public services in Britain are being overwhelmed by immigrants, quite deliberately, as the Marxist and crony capitalist globalists speed up their neo-feudalism agenda to destroy the British nation.

    Either enough of the population wake up and put a stop to this, or Britons will quickly be marginalised in their own country.

  • 1965doc

    Trying to prevent this abuse is not possible without all citizens carrying an ID card.
    Otherwise, how are staff members in A & E to know whether or not the patient is entitled?

  • OGT

    Do the BBC know about this?

  • zaphod_es

    Three years ago my Brazilian wife and I (British) were visiting the UK. She had a pain in the chest, was rushed to hospital by ambulance and, over a period of hours was given several tests and examinations. Eventually she was diagnosed as having a non-urgent gall bladder problem that could we dealt with in Brazil and was discharged.

    When I asked where the bill could be collected I was told by the doctor ¨no problem, there is no charge¨ ¨but we have insurance and are happy to pay¨ I said. The doctor was just not interested and wandered off.

    So I found and administrator and told her the story and asked where I could start the insurance process. ¨Oh no. please don´t do that, it will generate mounds of paper, give me loads of work and all the cash will go to the Ministry in London. Just give me a break and leave well alone¨

    So I gave up and am still annoyed about it.

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  • Will Donald

    so did you ever publis a retraction of these lies? after you admitted it was pure speculation based on guess work as opposed to fact?

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