J.Meirion Thomas: The cost of health tourism - is it millions...or billions?

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

Abuse 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.

Recently, 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?

Let’s 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.

It 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 necessary.

Firstly, 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”.

Health 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.

For 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.

The 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.

To 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?

As 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.

So 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 spent?