For weeks now, we have been reading about a crisis in A&E — a symptom, we’re told, of a funding crisis in the National Health Service more generally. Since I started working for the NHS almost 45 years ago, this has been a familiar theme: the system is creaking, but a bit more tax money should suffice. To many of us who have seen the system close at hand, another question presents itself: what if the NHS were to cut down on waste? And perhaps recover costs from the health tourists who turn up for treatment to which they are not entitled?
I first made the case for doing so four years ago, in the pages of this magazine, when I was the senior surgeon of a rare cancers unit at the Royal Marsden Hospital in London. Because of my specialist interest, I had become increasingly aware that I was being personally targeted by people who came to the UK with a pre-existing illness whose sole purpose was to claim free NHS care. When I encountered such cases, I would bring them to the attention of senior managers at my hospital. They’d ring a Department of Health helpline, and every patient was waved through.
The laxity of NHS checks had evidently become famous throughout the world. There was the lady from the Middle East with a large tumour who was deemed eligible for free NHS care on the basis of a photocopy of a British passport and whose ‘proof’ of residence was a handwritten tenancy agreement (in Farsi). A woman from the Caribbean with another large malignancy conceded to me that she had never lived in UK, but claimed that her husband was now resident here. No checks were made in either case.
For NHS doctors who believe in the service, this misuse is troubling — but the inability of politicians to do anything about it is more so. It does raise questions as to how safe the NHS is in their hands. To treat health tourists, sometimes at the expense of postponing eligible patients, in the knowledge that every ineligible case encroaches on the depleted resources of the NHS, is extremely frustrating for doctors.
In the four years since I blew the whistle, the massive gaps in our system have persisted. We heard in 2015 about a Nigerian woman who flew to Britain to give birth to twins: both babies were born underweight and needed intensive neonatal care for weeks. The bill came in at £350,000, which has not yet been paid back.
Often the overseas mothers deliberately present very late for antenatal care, because airlines are unwilling to allow pregnant women to travel within a month of their due date, and so there is no possibility that they will be able to return to their home country to give birth. It is likely that much of this maternity tourism is organised with facilitators and accomplices to the fraud.
Jeremy Hunt, the Health Secretary, has promised to crack down on all this and collect £500 million a year by three methods: getting better at recovering costs from EU governments and two surcharges — an extra 50 per cent on the NHS tariff for all visitors, plus a flat-rate charge for non-EU ones. This is to incentivise hospitals to identify, charge and collect from patients who are ineligible for free NHS care. As things stand, only £1 in every £6 invoiced is retrieved.
Hunt’s plan, alas, is failing. The National Audit Office recently found that barely half of the £500 million target was raised last year, and only £350 million will be found next year. There are three reasons for this failure.
The Immigration Health Surcharge, for non-EU citizens, is set at £150 for students and £200 for migrants (per family member and per year) — far below the government’s estimate of true cost. The failure to retrieve the cost of healthcare means this NHS surcharge remains the cheapest health insurance on the planet, and is costing the British taxpayer a fortune. Or, more accurately, denying the NHS a fortune.
The second problem is the European Health Insurance Card (Ehic) system. Despite being a migration magnet, the UK pays five times as much to other EU countries as it receives. This is because most European migrants have no ‘home’ Ehic card, being unemployed and not contributing to their domestic health system. On arrival in UK, they are ‘ordinarily resident’ and entitled to any healthcare they need.
Finally, the 50 per cent surcharge imagines that the NHS has the same instincts about cost control as the rest of the country. This is not so. The system is still a bureaucracy, which does not respond to price signals: hence the mass inefficiency, and the funding crisis. This is why pouring more money into an unreformed system will not achieve the desired results.
Last October, it emerged that half of the 1,783 overseas women who gave birth at St George’s Hospital in London last year were later found not to have been entitled to free NHS care. The hospital admitted it had probably been targeted because it didn’t carry out robust eligibility checks.
Jeremy Hunt’s failing plan to recover the expense of health tourism needs urgent revision, preferably with abolition of the costly Immigration Health Surcharge. Establishing and testing for every person’s entitlement to free health care is the only solution — and this is hardly inhumane; it happens in all comparable health systems. Is it so hard to ask patients turning up for non-urgent care to bring proof of identity in the form of a passport along with a recent utility bill? Patients unable to produce such documents could be rapidly and compassionately assessed. The change could be introduced quickly and cheaply. It would not entirely stop health tourism but would act as a major deterrent, and stop identity fraud.
We are told that radical thinking is required to overcome the NHS funding gap. So why is there not a greater emphasis on cutting costs? The biggest handicap confronting the NHS is not the parsimony of ministers but the expensive bureaucrats and managers who run the service and cannot — or will not — find solutions to this problem.
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