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NHS Audit Requirements (Foreign Nationals)

Volume 550: debated on Tuesday 11 September 2012

Motion for leave to bring in a Bill (Standing Order No. 23)

I beg to move,

That leave be given to bring in a Bill to require the Secretary of State to instruct the National Health Service to record and audit the cost of treatment of individuals not entitled to free health care and of foreign nationals under the European Health Insurance Card Scheme and other reciprocal healthcare agreements; and for connected purposes.

Last year’s figures show that under the European health insurance card scheme alone the UK paid out £1.7 billion for the treatment of British nationals abroad, but claimed back only £125 million from qualifying countries. Freedom of Information Act requests have shown that most NHS trusts at best only cursorily audit the treatment of foreign nationals not entitled to automatic free health care and GP practices do not record this information at all, despite the fact that in many other countries access to primary care has a nominal charge for all patients, including British visitors. That is the case in France and Germany, where an entry fee for primary care is required, and in Spain, where proof of insurance is needed. The purpose of the Bill is not to deny health care to foreign nationals; rather, it is to ensure that the reciprocal arrangements that we have with European economic area nations and other countries are properly used so the British health budget is not unfairly burdened.

Many hospitals do not even ask whether patients are foreign nationals, with one poll of NHS managers showing that a third of them did not routinely ask patients about their eligibility for free care. The issue of fairness is key—fairness to the taxpayers who fund the system, and fairness to those who use it. Emergency medical treatment should, of course, always be provided to those who require it at the point of need, without exception. Beyond that, entitlement to free health care is considerably more generous to visitors to the UK and short-term residents than is reciprocated for UK citizens abroad, and our system is more liberal, and lax, than anywhere else in the world.

GPs may choose to register any person as an NHS patient, and, indeed, are actively encouraged and incentivised to register all who approach them, even where an individual has no right to free NHS care. Thus, many foreign nationals receive free primary care, including free prescriptions, and, once registered with a GP, essentially have unlimited access via referral throughout the NHS without charge.

Secondary care providers have a duty to enforce the regulations and screen all patients for eligibility, applying charges where appropriate, but most do not—they either struggle to do so or do not bother at all. Earlier this year I sent Freedom of Information Act requests to 445 health organisations including primary care trusts, foundation trusts and acute trusts, inquiring whether they screen foreign patients for auditing purposes and, if so, requesting the breakdown figures over a number of previous years. However, there is an added layer of complexity, because a number of small health organisations referred the request to larger regional facilities as they did not hold the information themselves. In addition, several trusts are dealt with in terms of a cluster of PCTs, with one response covering numerous PCTs.

A total of 212 responses were received. What was extremely concerning was that only 105 trusts were able to respond with data at all. Information, therefore, was supplied by fewer than a quarter of NHS organisations, and the data that did exist were patchy. It is worth noting that of the minority who responded with data, four trusts took over 100 days to reply. One trust, which was unable to provide any information, even asked, “What do you mean by a patient?” Some 340 said they were unable to supply any data because the information was not held or was too complex. Clearly, the semblance of a system that does exist is at best varied, confused and obscure, and at worst is chaotic, inadequate and non-existent.

Problems with the data that were supplied included recording members of the armed forces who are based abroad as being foreign patients; many British citizens were also considered foreign just because they had moved abroad. In addition, some trusts cited information relating to EU/non-EU patients instead of EEA/non-EEA patients, and, thus, their information is not in line with the European health insurance card scheme. The most common reasons for not supplying data included the fact that the information is not held, with information relating only to ethnic origin and not nationality being recorded. Some trusts claimed that they were not required to collect the information and, thus, do not hold it, whereas others that had some data said that they had held none before 2011. Where there was a refusal to supply information, we encountered statements that to do so would entail the investment of an unreasonable and significant amount of time and resource; suggestions were also made that no audit code existed for such costs.

Confusion was evident, with some NHS organisations refusing to disclose information and citing section 40 of the Freedom of Information Act. They claimed that disclosure could enable individuals to be identified, despite the fact that figures for those foreign nationals treated by the trusts that did respond often ran into the tens of thousands each year.

EU citizens coming to live in the UK do not need to register or take out health insurance, whereas many other EU countries require Britons to have insurance and/or charge an entrance fee for care. There are similar reciprocal agreements with other nations, including New Zealand, Australia and Russia, but the problems are similar to the European example. Any foreign national who has legitimately lived in the UK for more than a year is entitled to free NHS care—this is one of the most generous schemes anywhere in the world.

Refugees and asylum seekers are given free NHS treatment, but if their application to remain in the UK is turned down by the Home Office they lose that entitlement. However—my hon. Friend the Member for Kingswood (Chris Skidmore) publicised this fact in May—a local Bristol-based human rights law firm had warned GPs that they face legal action if they refuse to admit illegal immigrants as patients. In addition, one surgery in Essex was ordered to reinstate two failed asylum seekers from Nigeria, despite current Government guidance making it clear that if an application to remain in the UK is turned down people lose the entitlement to free NHS treatment. I must pay tribute to my hon. Friend for the extensive and effective investigations he has made in this area. He is certainly an asset to the Select Committee on Health, and I am honoured that he is one of the co-sponsors of this Bill.

In my constituency, UK Border Agency officials see, on average, 150 cases a year at Gatwick airport of heavily pregnant passengers arriving with visitor visas. The other week there was an infamous case of a “health tourist” who travelled more than 3,000 miles from Nigeria to Wythenshawe hospital for an emergency caesarean. It is understood that the woman, who is apparently Harvard-educated, flew to Manchester airport and went directly to the hospital, where she told doctors that she required the procedure and that she had had a scan in Nigeria. Even when overseas patients try to pay, they are often unable to do so because the cost of their care is not recorded. A US citizen who asked for a receipt after receiving medical care in order to claim the cost back on their health insurance was told that an invoice was unavailable.

I very much welcome the implementation of the overseas visitors hospital charging regulations published in May, but clearly they need to be confirmed by the force of primary legislation. My hon. Friend the Member for Guildford (Anne Milton), when she was a Health Minister, and my hon. Friend the Member for Ashford (Damian Green), when he was Immigration Minister, said in a March written statement that the Home Office plans to introduce immigration sanctions on overseas visitors who refuse to pay appropriate charges for treatment of more than £1,000 and to share such data between the Department of Health and Home Office. That is a very welcome start, but the law needs to be changed to provide certainty.

In conclusion, this Bill would qualify residency criteria for free NHS care; extend current charging principles to primary care; create more effective and efficient processes to screen for eligibility; and establish more robust methods of securing the recovery of treatment costs, including options for requiring health insurance. Those measures would save the NHS hundreds of millions of pounds a year, and I commend this Bill to the House.

Question put and agreed to.

Ordered, That Henry Smith, supported by Chris Skidmore, John Pugh, Nicholas Soames, Mr Frank Field, Dr Julian Lewis, Gareth Johnson, Priti Patel, Andrea Leadsom, John Glen, Mr David Davis and Andrew Rosindell, present the Bill.

Henry Smith accordingly presented the Bill.

Bill read the First time; to be read a Second time on Friday 1 March 2013, and to be printed (Bill 67).