- Providers received just £35m in cash payments from patients from outside EEA in 2018-19 while issuing bills of £91m
- Comes despite high-profile efforts to collect more money from overseas visitors
- Last year, London providers wrote off more debt than they received in cash payments
Providers are failing to recover tens of millions of pounds from overseas visitors despite a major clampdown on so-called health tourists.
Figures from NHS Improvement’s consolidated provider accounts reveal bills of £91m were issued to patients from outside the European Economic Area in 2018-19, but only £35m of cash payments were received.
Trusts also wrote off £30m in unpaid fees in 2018-19. Write-offs and payments often relate to bills issued in previous financial years as well as the current financial year, so do not account for the total sum billed in the year.
The amount billed in 2018-19 is up £4m on 2017-18, while the amount received has increased by just £5m and the amount written off by £3m.
There have recently been a string of high-profile initiatives to beef up NHS charging regimes for overseas patients. An immigration surcharge was introduced in 2015 and, in 2017, rules were tightened to legally oblige providers to obtain upfront payment before carrying out non-urgent treatment.
However, such measures have drawn criticism over their impact on vulnerable groups and difficulties facing frontline NHS staff in identifying patients and chasing invoices.
Calls for review
The British Medical Association has been calling for an independent review of the charging system.
Its medical ethics committee chair, John Chisholm, said: “The system as it stands is not working and, given the difficulties in recouping charges and assessing a patient’s ability to pay, it is not cost effective or beneficial to the NHS.”
NHS Providers deputy chief executive Saffron Cordery said trusts understood costs should be recovered and improvements were being made.
But she added: “Recovering costs can be challenging and efforts to do so must not compromise patient care.
“We need to bear in mind the workforce and demand pressures that make this a difficult task for frontline staff.
“Trusts will continue to work to guidance from the centre, but we need to make sure there is the support when it comes to the means and resources to recover these costs.”
NHSI’s overseas visitor improvement programme, set up last year, focused on 50 trusts to better identify people ineligible for free care and improve debt recovery amid concerns many had no dedicated staff in place. It aims to “achieve 95 per cent of the potential opportunity from overseas visitors by the end of March 2020”.
In a statement, it said the NHS had recovered an additional £20m last year from all overseas patients compared to two years ago.
It added: “As we are still only part way through the 2019-20 financial year, any claims about the position that will be reached by March 2020 are purely speculative.”
HSJ analysis revealed providers in London wrote off more debt than they received in cash last year. These providers charged £51m, 56 per cent of the total in England, but received payments of £16m and wrote off £19m.
In particular, Barts Health issued £10.2m in fees — the most of any provider — but received just £1.1m in payments.
Lewisham and Greenwich, which was at the centre of controversy earlier this year when HSJ revealed it was handing patient details to credit check firm Experian to identify overseas visitors, charged £4.1m, slightly down on the previous year, but collected only £528,000.
Outside the capital, Sandwell and West Birmingham Hospitals Trust charged the largest amount, totalling £2.5m, but received cash payments of £255,000.
In a statement, Barts Health said: “We make every effort to recover payment from patients who are liable for the cost of their treatment.
“However, these patients are not usually resident in the UK and recovering payment is therefore often difficult.
“In addition, some patients are able to demonstrate their eligibility for treatment after invoices have been issued.”
Kam Dhami, director of governance at the Sandwell and West Birmingham trust, said every patient was asked about residency to determine if they should be charged for NHS treatment.
She added: “We invoice the identified visitors and continue to pursue recovery of the funds and are working with new recovery agents overseas to improve our success rates.”
The charges are not the only way the government and NHS seek to secure income from overseas visitors. Home Office figures show the immigration health surcharge imposed since 2015 on visitors from outside the EEA spending more than six months in the UK is by far the biggest source of NHS revenue from foreign visitors, totalling £251m in 2018-19 for distribution to all four home nations. The prime minister has in recent days proposed increasing the value of the surcharge.
In January 2019, this surcharge was doubled from £200 to £400. The Department of Health and Social Care said in its annual report the move “better reflect[ed] the cost to the NHS of treating patients”.
A further £63m was recovered under reciprocal arrangements on visitors from the EEA.
Ten highest charging trusts in London
|Trust||Charges||Cash received||Amounts written off|
|Barts Health Trust||£10.2m||£1.1m||£1.5m|
|Imperial College Healthcare Trust||£6.7m||£2.4m||£1.9m|
|King’s College Hospital Foundation Trust||£4.9m||£1.3m||£4.3m|
|Guy’s and St Thomas’ Foundation Trust||£4.2m||£1.5m||£3.0m|
|Lewisham and Greenwich Trust||£4.1m||£0.5m||£1.0m|
|St George’s University Hospitals Foundation Trust||£3.6m||£0.5m||£0.0m|
|Chelsea and Westminster Hospital Foundation Trust||£3.3m||£1.8m||£0.1m|
|London North West University Healthcare Trust||£2.8m||£0.8m||£0.2m|
|University College London Hospitals Foundation Trust||£2.4m||£1.7m||£0.3m|
|Barking, Havering and Redbridge University Hospitals Trust||£2.3m||£0.6m||£4.7m|
Ten highest charging trusts outside London
|Trust||Charges||Cash received||Amounts written off|
|Sandwell and West Birmingham Hospitals Trust||£2.5m||£0.3m||£0.0m|
|University Hospitals Birmingham Foundation Trust||£2.3m||£0.5m||£1.4m|
|Manchester University Foundation Trust||£2.1m||£0.3m||£0.3m|
|Oxford University Hospitals Foundation Trust||£1.5m||£0.8m||£0.1m|
|Pennine Acute Hospitals Trust||£1.4m||£0.1m||£0.0m|
|North Bristol Trust||£1.2m||£0.2m||£0.0m|
|University Hospital Southampton Foundation Trust||£1.0m||£1.3m||£0.4m|
|University Hospitals of Leicester Trust||£1.0m||£0.4m||£2.8m|
|Frimley Health Foundation Trust||£0.9m||£0.6m||£0.1m|
|Royal Berkshire Foundation Trust||£0.8m||£0.5m||£0.1m|
|Newcastle Upon Tyne Hospitals Foundation Trust||£0.8m||£0.5m||£0.1m|
HSJ analysis of NHSI consolidated provider accounts
- BARKING, HAVERING AND REDBRIDGE UNIVERSITY HOSPITALS NHS TRUST
- BARTS HEALTH TRUST
- British Medical Association (BMA)
- CHELSEA AND WESTMINSTER HOSPITAL NHS FOUNDATION TRUST
- Department of Health and Social Care (DHSC)
- Finance and efficiency
- Foundation Trust Network (NHS Providers)
- FRIMLEY HEALTH NHS FOUNDATION TRUST
- GUY'S AND ST THOMAS' NHS FOUNDATION TRUST
- Home Office
- IMPERIAL COLLEGE HEALTHCARE NHS TRUST
- KING'S COLLEGE HOSPITAL NHS FT
- LEWISHAM AND GREENWICH NHS TRUST
- London North West University Healthcare NHS Trust
- Manchester University Foundation Trust
- NHS Improvement
- NORTH BRISTOL NHS TRUST
- Oxford University Hospitals NHS Foundation Trust
- PENNINE ACUTE HOSPITALS NHS TRUST
- ROYAL BERKSHIRE NHS FOUNDATION TRUST
- SANDWELL AND WEST BIRMINGHAM HOSPITALS NHS TRUST
- St George’s University Hospitals NHS Foundation Trust
- THE NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST
- UNIVERSITY COLLEGE LONDON HOSPITALS NHS FOUNDATION TRUST
- UNIVERSITY HOSPITAL SOUTHAMPTON NHS FOUNDATION TRUST
- UNIVERSITY HOSPITALS BIRMINGHAM NHS FOUNDATION TRUST
- UNIVERSITY HOSPITALS OF LEICESTER NHS TRUST