When David Cameron proposed toughening the rules that govern foreign nationals being treated for free by the National Health Service, he faced — as one might expect — a barrage of criticism. The Prime Minister was accused of tilting at windmills. The threat exists only in the minds of xenophobes, said his critics. The actual levels of abuse are minimal, so why is he scaremongering? A few weeks earlier, I had written a piece for The Spectator from a different perspective; that of an cancer specialist who has spent his career in the NHS. I wrote for one reason only: that I cherish the NHS, and wish to stop its abuse.
My piece focused on the actual nature of the abuse, how it is carried out and why so little of it is detected. If a foreign national is impersonating a British friend (easy to do when no identification is required by GPs) then of course it will not show up in any statistic. I did not give too many examples. But since the publication of the piece, I have been overwhelmed with messages of support describing similar experiences and encouraging further investigation. It all adds up to clear, widespread abuse of our NHS by ineligible patients.
One of the first letters I received was from a junior hospital doctor working close to Heathrow airport. ‘Every single week, I see people who have been flown in from all over the world with a variety of extremely serious health problems,’ he wrote. ‘Many of these people had to be wheelchaired on to the plane because they were too unwell to walk on board. I understand the temptation to come to Britain, but we often have our Intensive Therapy Unit full of patients without NHS numbers who are there for weeks or months with no means or intention to pay, which impacts on our resources.’
The most revealing and scandalous reports of serial NHS abuse come from Overseas Visitor Officers (OVOs) who are employed by hospitals and whose job it is to identify, interview, invoice and recover costs from individuals not entitled to free NHS care. I have now been contacted by more than a dozen OVOs, desperate to be heard, who have given me scores of cases of abuse covering every aspect of NHS activity. Some, fearing reprisal from senior managers, have spoken to me on condition of anonymity.
This abuse may be costing the NHS (and therefore the British taxpayer) not millions but billions of pounds every year. Curbing the abuse is not just right in itself, but may save astonishing amounts — and it can be done through a few simple procedures. The mystery for those of us working in the NHS is how the Department of Health and 40,000 or so hospital managers have allowed this to happen.
Let’s start with maternity health tourism, a massive and escalating problem. Foreign women often arrive in the UK in late pregnancy, often after detecting a complication. They come on a visitor’s visa and present to A&E while in labour. Often the patient refuses to pay, claiming that a childbirth qualifies as emergency care and therefore cannot be refused to anyone. In this way, the NHS can be used as the world’s maternity wing. If neonatal intensive care is necessary, the bills can run to tens of thousands of pounds — with little chance of recouping costs. There is much evidence of identity fraud. In every maternity unit, identifying the blood group of the mother is obligatory. Over time, patients have given a registered name, address and NHS number — but are found to have different blood groups from the one on record. This is conclusive proof of an identity being shared.
There are similar abuses in oncology, HIV, infertility and in the treatment of renal failure. Renal dialysis is probably the most costly form of abuse because the treatment needs to take place three times a week and may result in a kidney transplant. I am told of one example where a patient arrived in renal failure on a visitor’s visa and was blue-lighted to a hospital for dialysis. At the last count, this person has had 849 dialysis sessions as well as numerous other treatments.
Doctors in consultation with an ineligible but deserving patient face a moral and ethical dilemma which needs to be openly discussed. For example, cancer treatment is rarely urgent — it should be started soon, but not necessarily during a visit to the UK. An OVO from a major cancer centre wrote the following. ‘Eight out of ten times, cancer treatment offered at this hospital will be deemed “immediately necessary” by the treating consultant.’ The NHS does not have the resources for such largesse. And what about the rights of resident taxpayers, whose treatment is delayed?
Jeremy Hunt, the newish Health Secretary, has said he will address the problem. The good news that there is much he can do, at one stroke of the ministerial pen. First, we should cease the practice of granting an NHS number to overseas visitors. Those who work and pay tax here, and have a National Insurance number to prove it, ought to be granted full access to the NHS whatever their residency status. But it makes no sense to accord this right to visitors, especially when an NHS number can translate seamlessly into expensive long-term hospital care.
An NHS number is a valuable commodity which confers legitimacy and has market value. But there is no black market for NHS numbers: they are given away free. Primary Care regulations encourage overseas visitors to take an NHS number. ‘A patient does not need to be ordinarily resident in the UK to be eligible for NHS primary care,’ say the rules. ‘Overseas visitors, whether lawfully in the UK or not, are eligible to register with a GP practice.’ And woe betide any clinic that wants to take its own precautions. The Department of Health is even advising GPs that it could be a violation of a patient’s human rights to ask them for identification at the time of registration.
Mr Hunt could bring in a range of simple measures to reduce abuse. The most powerful would be to ask that, when GPs refer a patient to hospital treatment, they make sure the patient is eligible for such care. There is no such requirement at present, nor any opportunity for doctors to raise questions about a patient’s eligibility, which is why the extent of the abuse has gone unnoticed. An NHS number makes an ineligible patient almost invisible to the most vigilant OVO. The system is an open invitation to the world to abuse the NHS.
Next, GPs should be asked to ensure that the patients on their books are still living in Britain. This would end a niche form of exploitation, by those who once lived in the UK. From abroad, they phone their GP’s clinic, where they are still registered, to request repeat prescriptions. These can be collected by a relative or friend, and the medicine posted abroad. Also, student eligibility could be tightened. Why should those on 15 hours per week courses be entitled to free NHS care? And why should this also apply to their dependent family members? Home Office research shows that as many as one in four foreign students allowed into Britain may not be genuine.
In just a few weeks, I have been able to gather remarkable evidence about the extent of the problem — supplied by NHS workers who love the health service and hate to see it abused. An official audit of this problem could be undertaken, focusing on information provided by OVOs who see it all, but who would need full immunity from reprisals to report. Such disclosure, and protection, would be very much in the spirit of the recent reforms Mr Hunt proposed in response to the Stafford Hospital scandal. An audit should be manager-free, because it is the mandarins and officials who have presided over the genesis and evolution of the current problem.
It could well be that the NHS is too addled with too many loopholes and has reached the point of no return. I say that with the sadness of a committed NHS surgeon who is acutely aware of its financial constraints. But it can be saved. Mr Hunt has indicated his willingness for a paradigm shift in understanding and response to overcome the rot which has set in so deeply to the NHS. A proper audit would confirm the problem, and a few simple procedural changes would implement the solution. All that is required is ministerial resolve.
This article first appeared in the print edition of The Spectator magazine, dated 6 April 2013