The regulations, updated on 23 October 2017, now place a legal obligation on secondary care NHS providers to establish whether a person is an overseas visitor or lawful resident before providing them with treatment.
If they are not lawful residents, NHS organisations – excluding primary medical, dental and ophthalmic services – are legally required to charge patients not eligible for free care upfront in advance of providing treatment.
The DH has released guidance on how these new regulations should be implemented. Parts relevant to general practice have been summarised below.
Will GPs be expected to charge overseas patients for care?
Patients can still receive free care at their GP practice regardless of their right to live in the UK, and practices should continue to provide free care to all, even if they should be charged for secondary care services.
The DH guidance says: ‘No registration application can be refused on the grounds of race, gender, class, age, religion, sexual orientation, appearance, diversity or medical condition.
‘In reality, this means that the practice’s discretion to refuse a patient is limited. There is no minimum period that a person needs to have been in the UK before a GP can register them, although practices may wish to consider the length of time the patient anticipates spending in the practice area when deciding whether to register the patient as a full or temporary patient.’
Will GPs have to decide whether patients are eligible for care?
The DH has confirmed that GPs will not be responsible for deciding whether patients are eligible for free secondary care, even if they are aware they are not a lawful UK resident.
Hospitals are expected to hire an overseas visitor manager (OVM), who will investigate whether patients should be charged for care – and organise charging their home country if they are from the European Economic Area (EEA) or the patient themselves if they do not have insurance.
GPs now provide all new patients with a revised GMS1 form, which includes a set of supplementary questions to determine whether they are eligible for free hospital care, which is added to their patient record.
Should GPs flag up non-resident patients when making referrals?
The official guidance does not say GPs are compelled to inform secondary care that a patient is not a lawful resident when making referrals.
It does, however, advise secondary care providers that GPs are ‘sometimes willing and able to indicate on a referral letter where they know a patient is only in the country for short time’.
But GPC chairman told GPonline that GPs are under no contractual obligation to flag this information up when making a referral.
He said: ‘Practices are not border guards and have an obligation to provide free at the point of access primary care to all patients who register with them, regardless of background or nationality.
‘It is for hospitals to deal with the charging arrangements for those patients not eligible for NHS services and they have teams of administrators to do this. There isn't a contractual obligation for practices to make any assessment of immigration status when referrals are made and they don't have the ability to do this.’
RCGP chair Professor Helen Stokes-Lampard said in February: ‘We must stop perpetuating this idea that general practice should, in whatever way, assist with border control.
‘Patients share information with their GP on the mutual understanding that it will remain confidential. We are very concerned that any process that undermines that crucial trust between doctors and patients will both deteriorate the doctor-patient relationship, and deter vulnerable people from seeking medical assistance when they need it.’
What happens when a GP refers a non-resident patient?
If a patient referred by a GP is found to be ineligible for free NHS care, they will be assessed by a doctor to see whether they require urgent or immediately necessary care.
If it is neither, they will be asked to pay upfront before they can receive care. If they live outside of the EEA and do not have insurance, they will be charged at 150% of the NHS national tariff.
Should they refuse to pay, they will be declined treatment. The GP who referred them will be sent an ‘Advice to Doctors and Dentists’ letter, which will inform them the patient is not eligible for free secondary care treatment.
This letter says: ‘Your patient can continue to receive NHS secondary care treatment, but they will be required to pay for any future treatment they wish to receive upfront as their treatment needs are currently not considered urgent or immediately necessary and are not anticipated to become so.
‘If their condition unexpectedly deteriorates, or they develop a new condition, so that their healthcare needs are considered by a clinician to be urgent or immediately necessary, it should never be delayed or denied.’
Who is exempt from charges?
Certain types of overseas visitors are exempt from charges, including those who are refugees, asylum seekers, children who are looked after by a local authority and victims of modern slavery.
Patients who would otherwise be ineligible for treatment in secondary care can also be given care if their circumstances are deemed immediately necessary or urgent.
‘Immediately necessary’ treatment is defined as that which is needed promptly to either save their life, prevent a condition from becoming immediately life-threatening, or prevent permanent serious damage from occurring.
‘Urgent treatment’ is that which may not be immediately necessary, but nevertheless cannot wait until the person can reasonably be expected to leave the UK.
Examples include acute chest pain, major trauma, pregnancy-related problems, allergic reactions and overdoses.