London School of Hygiene & Tropical Medicine

From 23 October 2017, any patients, including children, attending secondary healthcare facilities in England who are unable to establish their entitlement to free care, will be charged upfront for the estimated cost of treatment. If patients are unable to pay, treatment may be refused.

Writing in The BMJ, Martin McKee, Professor of European Public Health at the London School of Hygiene & Tropical Medicine, and Lucinda Hiam, GP and Health Adviser at the humanitarian aid charity Doctors of the World (Médecins du Monde), say the proposals threaten patient safety and should be withdrawn “until a thorough impact assessment on people in vulnerable situations has been carried out.”

The authors point to challenges faced by healthcare teams, such as establishing whether the patient is entitled to NHS care and deciding whether the condition requires “immediately necessary” or “urgent” treatment. “Clearly, this requires considerable judgment, based on what will often be incomplete information,” they explain. “Yet, if they get this wrong, they face considerable risks.”

They say the new guidance has obvious implications for people who are not entitled to care, but its implications extend to everyone using the NHS, with no clear evidence that it will save appreciable amounts of money.

Adding to the work of clinicians already struggling simply to diagnose disease and treat people entitled to care “seems dangerous, especially when the performance of the NHS has been implicated as a possible reason for rising death rates,” they write.

Furthermore, many people who are entitled to care are likely to struggle to prove it, including those who are homeless or have mental health problems, and although contagious disease is uncommon among migrants, late detection, undertreatment, and lack of routine immunisations of children “could pose a direct threat to UK population health.”

Finally, with primary care remaining free to all in England, they warn that the increased workload on already overextended general practices “is likely to be unmanageable.”

Despite funding failing to keep pace with demand, the NHS still outperforms many other healthcare systems, while upholding its founding principles, they write. Refusing treatment to those unable to pay, including children, would render it unrecognisable.

Healthcare should not be used as a means of immigration control, they conclude. These proposals should be withdrawn until a thorough impact assessment on people in vulnerable situations has been carried out, ensuring the “wider social duty to promote equality” is at the forefront of moving forward.

Publication

Lucinda Hiam and Martin McKee. Upfront charging of overseas visitors using the NHS. BMJ. DOI: 10.1136/bmj.j4713