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

A health tourist is defined as a patient who comes to UK with a pre-existing illness, and the purpose of their visit is to access free NHS care. Not only is this abuse costly, but it takes up scarce resources within the NHS so that the treatment of patients entitled to free care is delayed.

The true cost of health tourism is unknown, but on 1st February 2016, during a House of Lords debate, Lord Bates, then Secretary of State at the Home Office, estimated that according to 2013 figures, the total cost to the NHS of treating visitors and migrants in England alone was £2 billion per year.

The Government’s flagship Cost Recovery Programme, effective from April 2015, was meant to collect a modest £500 million annually from health tourists by 2017-2018, but the National Audit Office report to the Public Accounts Committee in October 2016 predicted that only £346 million would be recovered by this target date.

This deficit prompted the Department of Health to issue a revised policy. (Guidance on implementing the overseas visitor charging regulations, August 2017). As of 23rd October 2017, all NHS Trusts in England would have a statutory obligation to identify health tourists and to demand payment upfront before any investigation or treatment was started. Two groups of patients were to be screened to determine entitlement to free NHS care: those attending a hospital out-patient clinic for the first time and those to be admitted to hospital from Accident and Emergency. The policy does not apply to patients attending general practice nor to patients attending A&E, which remain entirely free for all. Correctly, the new policy will not apply to asylum seekers, refugees and other vulnerable groups.

During the screening process, and to avoid any form of discrimination, the Guidance states that “the same baseline question must be asked of every single patient, and using these exact words: Where have you lived in the last six months”. If the patient replies “the UK only”, then no further questions are asked regarding residency or immigration status. The assumption is made that all patients will answer truthfully and that knowledge of his new massive loophole will not circulate rapidly!

If the patient answers otherwise to this single baseline screening question, then they are referred for interview with a member of staff called the Overseas Visitor Manager (OVM) who would be responsible for checking entitlement to free NHS care, obtaining a rapid estimate of cost from the hospital’s finance department and making sure that upfront payment is made. Throughout the Guidance, the pivotal role and the additional training requirement for OVMs to implement upfront charging is explicitly described.

Having campaigned against health tourism for several years, I knew that some NHS Trusts employed no OVMs, and others an inadequate number. To investigate this concern, in September 2017 I sent Freedom of Information requests (FOIs) to 17 acute NHS Trusts in London, Birmingham and Manchester. These are our largest cities, and where health tourism is most prevalent. All but one of the Trusts replied.

I asked how many OVMs each Trust employed and how many patients would need to be screened every week according to the criteria described above. The results were of greater concern than I had expected. Five large central London Trusts, each managing several hospitals, would need to screen 36,473 patients per week and employed 30.6 whole-time equivalent OVMs some of whom also had the responsibility of managing private patients. The two largest Trusts in Birmingham would need to screen 9,503 patients per week and employed 3.7 OVMs. The nine Trusts in Manchester would need to screen 29,512 patients per week and employed 3.5 OVMs. Five of the nine Trusts in Manchester employed no OVM.

FOIs were also sent to seven mental health Trusts in the same three cities, and six replied. None employed an OVM.

This information from our most vulnerable cities explains why the upfront charging policy will make little impact on health tourism. How can so few OVMs cope with so much work? Vital infrastructure is not in place to support the new policy.

Despite these facts, the lack of intent by the Department of Health is best displayed in paragraph 13.80 of the Guidance: “If a patient does not have sufficient funds, can they pay by instalments?” The answer given is “yes”, despite confirmation from previous research commissioned by DH that of invoices raised to health tourists, only 16 per cent are paid.

The new 2017 policy, however, does have some good points. For the first time NHS staff, including doctors, will have the responsibility to report patients they think may not be entitled to free NHS care. Also of great importance, the guidance makes it clear that NHS staff facilitating health tourism may be committing fraud. Nevertheless, overall, the policy is flawed.

The British taxpayer continues to contribute to an International, not a National, Health Service and, despite powerful representations, three Conservative (or Conservative-led) governments since 2010 have failed to take effective steps to protect the NHS from health tourism abuse. Sadly, my suggestion made several years ago that all new patients attending hospital should produce a utility bill in their name to prove residency and a passport to exclude identity fraud, have been ignored.