Reducing health inequalities

Lack of a NHS charging exemption for people receiving local authority support

In England, the NHS is required to charge ‘overseas visitors’ for secondary healthcare provided in hospitals or delivered in the community. Patients who are classed as overseas visitors are required to pay the full cost of treatment up front, unless the care they require is deemed by clinicians to be urgent or immediately necessary. Overseas visitors are charged at 150% of the standard treatment rate. 

Some types of secondary healthcare, such as treatment at an A&E service, are exempt from charging. Many overseas visitors will be exempt from charging, including people who paid the NHS surcharge when they applied for their visa.

A person will usually be required to pay for secondary healthcare in England if they have:

• Overstayed their visa
• Become appeal rights exhausted following an unsuccessful asylum claim, and are not receiving support from the Home Office or accommodation from their council under the Care Act 2014
• Leave to enter as a visitor for six months or less

A person who is required to pay for secondary healthcare will still need to pay upfront for treatment or to re-pay a NHS debt when they are receiving accommodation and financial support from their local council. Therefore, many adults with care and support needs, families, and care leavers (age 18+) who are homeless or who do not have sufficient income to meet their housing and/or basic living needs, will be denied access to vital healthcare or will have a significant debt to repay when treatment is provided on an urgent basis. 

The charging exemption that relates to adults accommodated under the Care Act 2014 only applies to people who are appeal rights exhausted following an unsuccessful asylum claim. At the end of March 2023, this group made up only 27% of adults with care needs who were being accommodated by their council because they have no recourse to public funds.

When a person is unable to receive the treatment they need because they cannot afford it, this can exacerbate any care needs they have and may present a public health risk. When a NHS debt is accrued, this could lead to a refusal of leave to remain and people can experience financial pressures making repayments. Social care staff who are supporting people being denied or charged for treatment have reported that a consequence of this is that they have spent a significant amount of time meeting the person's exacerbated care needs and liaising with the NHS about repayments.

Guidance for NHS service providers on charging overseas visitors in England now includes more detail about what NHS staff should do when a person cannot afford to pay their debt. When a person is destitute or at imminent risk of destitution, the NHS can chose not to chase the debt, although the debt cannot be cancelled.

Health inequalities in communities could be significantly reduced if the government ends upfront charging for secondary and community NHS care in England.

However, while people remain subject to upfront charging, the following changes are required to mitigate the impact of this on individuals and councils:

• Amend the Overseas Visitors (NHS) Charging Regulations 2015 to exempt anyone who is receiving local authority support from charging for secondary and community NHS care in England - this should apply to anyone receiving support under section 17 or the leaving care provisions of the Children Act 1989, and the Care Act 2014
• NHS Trusts should not pursue debts when patients are receiving accommodation and/or financial support from their local authority to alleviate destitution, in line with the overseas charging guidance

The governments in Scotland, Wales and Northern Ireland should also consider introducing a similar exemption for all families, adults with care needs, and care leavers receiving accommodation and financial support from children's social care or adult social care. 

In order to promote health outcomes for children, the UK government also needs to:

• Open up access to the Healthy Start scheme to all low-income pregnant women and families with no recourse to public funds 

Since the implementation of the Overseas Visitors (National Health Service) Charging Regulations 2011, we have been working with the Local Government Association (LGA) and Association of Directors of Children’s Services (ADCS) to put forward the case for a charging exemption for people receiving local authority support and to raise concerns about the impact of NHS charging on communities.

In 2014, we produced a report on the impact of the NHS (Charges to Overseas Visitors) Regulations 2011 on local authority supported service users. In 2016, we responded to a consultation on extending charges for NHS services and in 2018, we submitted a joint response with ADCS to the review of the National Health Service (Charges to Overseas Visitors) (Amendment) Regulations 2017. 

However, following the 2018 government review into the effect of the charging regulations, the Minister of State for Health informed Parliament that no changes to the charging regime or exemptions were needed.

Most recently, we have raised the impact of a lack of charging exemption for people receiving local authority support in our evidence to the joint APPG on Poverty and APPG on Migration inquiry into the effects of UK immigration, asylum and refugee policy on poverty.