Reducing health inequalities

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. A person who is required to pay for secondary healthcare will need to pay upfront for treatment or to re-pay a NHS debt after receiving urgent treatment, including maternity care. Overseas visitors are charged at 150% of the standard treatment rate. 

Many overseas visitors will be exempt from charging, including people who paid the NHS surcharge when they applied for their visa and people with a pending asylum claim. 

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

• Overstayed their visa
• Become appeal rights exhausted (ARE) 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

There is no charging exemption for people in these groups who are supported by their council, unless they are an ARE asylum seeker accommodated under the Care Act. Therefore, charges for NHS treatment will still be made where a family, adult with care needs, or care leaver (aged 18+) is being provided with accommodation and financial support by their council because they have insufficient income to meet their basic living needs. 

When a person is unable to receive the treatment they need because they cannot afford it, this can exacerbate any care needs they already have, creating an increased need for social care intervention, 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. Guidance for NHS providers on charging overseas visitors in England states that 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.

Similar charging rules apply in Scotland, Wales and Northern Ireland, although people may not be charged up front for treatment and different exemptions apply. 

Parents or carers will also have to pay for secondary care for children who are not exempt from charges. Some migrant families are also unable to access the healthy start scheme in England, Wales and Northern Ireland, to help with the costs of formula milk, vitamins, and healthy food for pregnant women and young children. Currently, parents with no recourse to public funds can only access the healthy start scheme if their child is British. The government has consulted on extended the scheme to all children but has not yet changed the qualifying criteria or published a response.

Content updated: 29 October 2025

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 better 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 

Content updated: 23 October 2025

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 charging regulations on people supported by councils. In 2016, we responded to a government consultation on extending charges for NHS services and in 2018, we submitted a joint response with ADCS to the government review of the 2017 NHS charging regulations. 

However, following the 2018 government review into the effect of the 2017 charging regulations, the Minister of State for Health informed Parliament that no changes to the charging regime or exemptions were needed.

In 2022, we 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.

In October 2024, we submitted evidence to the Department of Health and Social Care consultation on expanding the healthy start scheme to all low-income families.

Read our recent evidence submissions. 

Content updated: 29 October 2025