J Meirion Thomas is a Professor of Surgery and Consultant Surgeon in the NHS

Screen shot 2013-05-30 at 19.47.30Abuse
of the NHS by ineligible patients is rife. 
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 patients motivated
enough to try.

David Cameron estimated the cost to the British tax-payer as £20million while
Jeremy Hunt estimated £200million. In two recent articles on this subject in
The Spectator, I have estimated £billions. Who is right, how is the discrepancy
explained and why are there no reliable figures?

define the offenders. We not referring to illegal immigrants and not to “Good
Samaritan” care following an accident or unforeseen illness. Health tourists are
visiting the country legally, they arrive usually on a visitor visa with a
pre-existing illness and the purpose of their visit is to access free NHS care.
They don’t come with trivial problems but for specialist, expensive, and
resource-intensive treatments. The commonest examples would include complex
maternity, cancer, HIV and renal dialysis.

is the job of Overseas Visitor Officers (OVOs) to identify and charge patients
not eligible for free NHS care. The Cameron/Hunt £20/200 million estimates of
the cost of health tourism described above are calculated from invoices raised
by OVOs. Unfortunately, most ineligible patients are either invisible to the
OVOs or employ one of the many loopholes in the regulations. In either case, no
charge is made, no invoice is raised and the cost does not appear in the
estimates. I have now spoken in depth to about thirty OVOs, and their
experience and knowledge is essential to the profiling, auditing and resolution
of this problem. The message from OVOs is clear. Two reforms are immediately

visitors to UK should not be automatically given an NHS number. It is an astonishing
fact that unlike almost any other country in the world, visitors to UK are
entitled to free primary care. At their first GP attendance, they are given a
unique and permanent NHS number which not only implies legitimacy but renders
the patient relatively undetectable to the most vigilant OVO should they ever
be referred for secondary (hospital) care. Secondly, entitlement to free NHS
care should depend on contribution and not only residency. Many health tourists
pass through the capacious loopholes in the DoH regulations because of laxity
inherent in the definition of the pivotal term  “ordinarily resident”.

tourists fall into three main groups. The most difficult to identify are
British nationals who have lived or worked abroad for many years, often
decades, and who return with a recently diagnosed serious illness. Similarly,
patients with dual citizenship. They have an NHS number and if necessary can
easily register with a GP. In the unlikely event of being identified by an OVO,
they can either lie about their place of residence or claim that they plan to
resume residence in UK. In practice, nobody will check, no proof is required
and the patient is free to return abroad after treatment. They can shuttle back
and fore for other episodes of care, repeat prescriptions etc. Such patients
are never charged and therefore the cost is not included in the £20/200million
estimates. An NHS number guarantees payment from the Primary Care
Trust/Clinical Care Group  (PCT/CCG). In
other words, the cost falls to the tax-payer.

exactly the same reason, health tourists from the EU are infrequently charged.
Treaty rights guarantee freedom of movement which was primarily intended to facilitate
workforce mobility. The unintended consequence is health tourism for family and
extended family members. Why would anyone not take advantage of this freely
available and unique opportunity? It is an attractive option for patients from
some southern European countries where there is little elective surgery because
of the financial crisis and for patients from some Eastern European countries
with an appalling health care record, where cancer survival rates are the worst
in Europe and where bribery is necessary to achieve any level of medical care.
Such patients are entitled to relocate to UK and despite any transitional
arrangements, can easily obtain an NHS number. This abuse is probably the most
costly component of health tourism, but because the charges can go to the PCT/CCGs,
this cost, again, is not included in the £20/200million estimates made by our
political masters.

third group of health tourists come from outside the EU. Most are maternity
tourists and I have described the NHS as the “world’s maternity wing”. Patients
come to the UK in late pregnancy often with twins or triplets and the cost can
be enormous if paediatric intensive care is necessary. Because patients arrive in
Accident & Emergency with these and other emergencies, sometime
blue-lighted from the airport, they are more likely to be identified and
charged. Patient often claim that their illness is an emergency and refuse to
pay. Only about 30% of these charges are recovered.

understand the loss of revenue to the NHS by this abuse, it is necessary to
know the difference between the NHS tariff and the private tariff, meaning the
commercial price charged to private patients. Although prices vary by procedure
in both sectors, it can be assumed that the NHS tariff is about a third of the
private tariff. Herein lies a depressing tale and confirmation of financial
incompetence. Patients who are identified as being ineligible for NHS care should
be charged the private tariff and the losses incurred by non-payment should be
calculated in a similar way.

That is not what happens. The charge levied and
the accounting of lost revenues are based on the heavily subsidised NHS tariff
charged to PCTs/CCGs. Why should health tourists, in the unlikely event of
payment being made, be charged the highly discounted NHS tariff? Therefore any
estimate of cost of health tourism should be tripled to equate to the cost of
treatment in the private sector, which is where these patients should be
treated. They have no right to be treated in the NHS.

The NHS has a finite capacity. Apart from
cost, the tragic consequence of health tourism is that honest tax-payers are
held on waiting lists while unentitled emergencies take precedence – while there is an
the erosion of motivation and good will as junior doctors, trainee midwives and
nurses and other staff are regularly exposed to this exploitation of the NHS.
Does this abuse not impact on the care
and compassion agenda which urgently needs to be restored to the NHS?

far back as 2003, John Hutton, the then Minister of State for Health (now
Baron Hutton of Furness) recognised the problem of health tourism and promised
reform. He and a series of successors at the Department of Health, mostly Labour, have presided
over a rapidly deteriorating situation and have failed to address the problem. Our
specialist health care is internationally recognised as exemplary. The
combination of cheap flights and free access have made this abuse grow
exponentially. It is now so acute as to threaten the very existence of the NHS
as it was intended to function.

In March, David Cameron
and Jeremy Hunt promised reform. While awaiting the results of yet another
review, to be conducted by an organisation with little experience of the
problem, why could they not have attempted some emergency legislation with
cross-party agreement if only to send out a loud message that tour valuable
NHS is “free at the point of use” – but only for eligible patients? Removing automatic
entitlement to an NHS number for all
visitors to the UK would have been a good place to start.

who is right? Which estimate is closer? Is it millions or billions? Mr
Osborne, are you listening? Couldn’t the cost of health tourism be better