Treating overseas visitors in primary care

MDU medico-legal adviser Dr Kathryn Leask answers key questions about treating people who have arrived from overseas, including new arrivals from Ukraine, and changes to the rules post-Brexit.

Arrivals sign at UK airport
(Photo: alice-photo/Getty Images)

Overseas visitors are exempt from charges for accessing primary care services and GPs are not expected to establish entitlement for free NHS hospital treatment. However, practices are encouraged to work with overseas visitor managers in NHS bodies to ensure relevant patients are informed about entitlement to NHS hospital treatment, as explained below.

Following an update of the National Health Service (Charges to Overseas Visitors) Regulations 2015 in August 2017, charges apply mainly to patients from outside the European Economic Area (EEA), treated in hospitals in England. WalesScotland and Northern Ireland have their own legislation and guidance.

The DHSC has also updated its guidance which is primarily aimed at staff within NHS trusts. It recommends that all NHS bodies appoint an overseas visitor manager whose responsibilities include ensuring that local GPs are aware of the main provisions of the regulations.

Who is entitled to NHS care?

The regulations surrounding entitlement are complex. NHS care is provided free on the basis of an individual being 'ordinarily resident' in the UK. Issues such as nationality, payment of taxes or national insurance contributions, or having an NHS number are irrelevant. In fact, because the NHS is a residency-based system, a UK national living overseas might not be eligible for free NHS care.

Other individuals entitled to free NHS care include EEA nationals insured for healthcare by a member state, those from countries with reciprocal healthcare arrangements with the UK, refugees, asylum seekers, prisoners, and immigration detainees. However, from 1 January 2021 the immigration health surcharge needs to be paid by EEA and Swiss nationals coming to the UK for stays of more than six months (unless they are exempt).

The regulations require NHS trusts, private providers of secondary or community care, and local authorities to establish whether a person is an overseas visitor to whom charges apply, or exempt, and then to recover the charges.

Non-exempt overseas visitors must pay up front for any care not deemed by a clinician to be immediately necessary or urgent.

The charges apply to most non-emergency hospital care and treatment. Primary care, emergency department treatment, family planning and palliative care services provided by a registered charity or community interest company are all exempt from the regulations.

Treatment under the Mental Health Act is also exempt, as are diagnosis and treatment of sexually transmitted diseases, and certain other infectious diseases such as TB.

What should I do when an overseas visitor applies to register with my practice?

GPs have discretion to accept any overseas visitor as a registered NHS patient, or as a temporary resident if they are to be in an area for between 24 hours and three months.

No registration application can be refused on the grounds of medical condition or any protected characteristics including age, disability, gender assignment, marriage or civil partnership, pregnancy or maternity, race, religion or belief, sex or sexual orientation.

In reality this means that the practice’s discretion to refuse a patient is limited. Furthermore, GPs have a contractual and ethical duty to provide immediately necessary treatment, regardless of whether that person is an overseas visitor or registered with that practice.

Where a patient applies to register with a practice and this is declined, the GP must still provide immediately necessary treatment, free of charge, for up to 14 days, although this can vary depending on the circumstances.

What administrative checks should I make?

There is no obligation on GPs to ascertain the entitlement status of overseas visitors, and it would be unlawful to perform any checks that would not be routine for any other person applying to join the list.

Where individuals have newly arrived from a country where conflict is taking place, they may be unable to provide proof of ID or immigration status. The NHS standard operating principles state that ‘registration and appointments should not be withheld because a patient does not have the necessary proof of residence or personal identification’.

What clinical checks are recommended for those arriving from Ukraine?

The government has produced guidance to help health professionals assess and address the health needs of people coming from Ukraine. The UK Health Security Agency has also produced guidance specifically for primary care.

The guidance provides a list of clinical checks to consider when treating individuals from Ukraine. These include screening all new entrants, including children, for TB, screening for Hepatitis B and C if risk factors indicate this is necessary and considering nutritional and metabolic concerns including anaemia and vitamin A and D deficiencies.

It is also important to note that there is a risk of typhoid infection in newly arrived migrants. As well as physical health, the impact of culture, religion and gender on health should be considered in addition to mental health and the effects of trauma. Immunisation status should be reviewed to make sure they are up-to-date with the UK immunisation schedule, including the COVID-19 vaccination. Pregnant women should be referred for antenatal care.

It is important to engage the services of a professional interpreter where a language barrier exists and try to see patients face-to-face where possible.

What changes have taken place as a result of Brexit?

Following the transition period, short-term visitors from the EU can continue to access necessary healthcare through the EHIC scheme, or planned healthcare through the S2 funding route.

Short-term visitors from the EU who are not covered by the new UK-EU agreement on reciprocal healthcare, including former UK residents, may be charged for NHS treatment. There are, however, no changes to healthcare entitlements of short-term visitors who are covered by bilateral healthcare agreements between the UK and countries outside the EU.

Can I refer an overseas patient to hospital?

The guidance emphasises that GPs should not be discouraged from referring their patients to the relevant NHS body, nor, as mentioned above, is it the GP's duty to establish entitlement for free NHS hospital treatment. However, it encourages trusts’ overseas visitor managers to establish formal contacts with local GP surgeries and suggests that, while there is no obligation, practices can help by:

  • Displaying posters regarding entitlement to NHS hospital treatment.
  • Indicating in referral letters when they understand a patient may be an overseas visitor or may only be in the country for a short time or is an EHIC holder so the relevant NHS body can check whether the patient is entitled to free NHS hospital care.
  • Informing patients that they may be chargeable for some hospital services.

Are there special measures in place for migrant children who are arriving unaccompanied?

The Royal College of Paediatrics and Child Health has developed resources to support access to healthcare for undocumented and migrant children. These aim to assist health professionals support vulnerable migrant children and their families.

I believe a patient has accessed free NHS care fraudulently. What should I do?

When there is a suspicion that an overseas visitor is attempting to access, or has accessed, free NHS treatment by fraud or deception, you should consider reporting this to the relevant body’s Local Counter Fraud Specialist. You should consider your duty of confidentiality, whether the patient had consented to disclosure, and whether disclosure without consent could be justified in the public interest, in accordance with GMC guidance.

How do we identify overseas patients registering with a GP?

Changes to the GP contract were agreed in 2017/18 which help to identify overseas patients’ status with respect to the charging regulations. The GMS1 form (used to register patients permanently with a GP practice now includes supplementary questions to determine a patient’s eligibility to free hospital healthcare. Patients are not, however, required to complete the questions to register at the practice.

For those patients who self-declare that they hold either a non-UK issued EHIC or a S1 form, the practice will be required to take a scan of the registration forms, including the supplementary questions, and send an email to NHS Digital to be processed. The original copies of the forms should be retained by the practice.

Am I obliged to share personal information with government agencies?

Healthcare professionals should not usually share personal information without the consent of the patient, even where this is requested by a government agency. As with all patients, you should balance your duty of confidentiality to the patient with the public interest in disclosing information.

The Memorandum of Understanding between NHS Digital and the Home Office was amended in May 2018 so that NHS Digital’s sharing of information with the Home Office is limited to information needed for the tracing of individuals who are being considered for deportation, have been investigated for or convicted of a serious crime, or where they are a risk to the public.

If you are unsure whether disclosure of information is appropriate, seek advice from your data protection officer and medical defence organisation.

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