In September 2005 I was recruited to West Middlesex University Hospital to increase income from overseas visitors by ensuring all money due was paid and that any losses were minimised.
We are sited close to Heathrow airport and can only roughly estimate what the loss in income from treating visitors has historically been. When I arrived, the 2004 overseas visitors charging regulations had not been applied. The result was that most overseas visitors had not even been identified and the ones that had were only required to give scant details to access the hospital.
All treatment was given regardless of ability or willingness to pay. Patients were only sent bills after treatment. They could, and many did, give false details, move after being discharged to other temporary accommodation, or just ignore letters from our debtors’ department.
Feel the pull
The main problem with identifying visitors after they had been treated is that we had lost the pull factor: a patient who has had their treatment needs nothing else from us and is free to disappear, especially if the details they gave on admission were false.
My first task was to identify overseas visitors, recover payments from them and ensure we had a system to identify new ones and ensure our income recovery.
The policy I wrote initially followed the charging regulations almost to the letter. The emphasis was on recovering fees before discharge. Invoices would be sent afterwards to act as receipts for payment.
I invested in a wireless credit card machine and conducted my interviews at the patient’s bedside.
That piece of equipment was the best prop that I had. It gave the patients the impression that the trust was taking income seriously and would go to any lengths to recover it.
By December 2005 we had recovered over£100,000, but we were still finding problem patients who refused or were unable to pay. The charging regulations rightly make no adjustments for ability to pay, but this did leave the trust with a problem, as we were billing failed asylum-seekers large sums knowing that we would never be paid. Something had to change.
The answer came about in a ‘road to Damascus’ moment after I interviewed a particularly clued-up patient, who said: ‘Well I’m not paying, what are you going to do?’
I went away that day to plan a new approach, bearing in mind three questions:
What is the minimum level of service we have to provide?
How much does it cost?
What does it entail?
Around Heathrow it is prudent to identify and recover income from overseas visitors. Not to do so would be financial suicide. And in a trust with a historic deficit it would be extremely irresponsible.
All patients, regardless of their nationality or immigration status, are treated for free in accident and emergency. However, at this stage overseas visitors are identified and advised that they may have to pay. If patients require treatment that goes beyond the A&E department, they are stabilised as quickly as possible and then told how much it will cost to continue treatment.
If the patient is willing to pay for the rest of their treatment, then the normal patient pathway resumes and the patient stays until well. However, if the patient refuses to pay then they are discharged, but only after three consultants have ruled that they are stable and not in immediate life-threatening danger.
Cash in full
At our trust we call this strategy ‘stabilise and discharge’ and have made it a clause written into our overseas visitors policy.
This approach takes into account the Human Rights Act and other international obligations the UK has. It ensures all patients get life-saving treatment if they need it, it does not withhold treatment and it protects NHS resources for those that are eligible.
Patients identified as overseas visitors and discharged under the stabilise and discharge policy are not readmitted to the hospital unless their condition has changed or deteriorated. This prevents the failed discharge scenario when the patient just walks back into A&E and presents themselves again.
Overseas visitors are charged using the payment by results national tariff rates. In most cases now where overseas visitors are unable or unwilling to pay and are discharged as soon as they are stable, this is before the short-stay threshold is passed. This allows the trust to write off only a very small sum, usually 20 per cent of the tariff price. Early identification is vital to this; doctors write where a visitor is from in the social history, nursing staff make observations in the nursing notes or tell me. I sometimes get information about the same patient several times, which shows how aware staff are of the issue.
Without senior support the system would not work, as the potential for bad publicity fights the potential for good publicity. Headlines screaming ‘local hospital throws patients out into the cold’ could be damaging.
A standard press release to the local media on how the trust best uses its scarce resources, how those who are not entitled are asked to pay and what happens if they do not – including the implications for the local health economy and ultimately the public – worked quite well.
We also launched a public poster, plasma screen message and press campaign called ‘Did You Know?’. It told overseas visitors clearly that they would have to pay; it warned UK residents that we would ask them if they were entitled; and it told them why we were asking them. It worked.
Andy Finlay is income generation manager at West Middlesex University Hospital trust, firstname.lastname@example.org.