What do you do if a patient who is not entitled to free treatment comes to you for help? Melea McFarlane explores the practicalities

What can health service managers do when faced with a patient who needs secondary care treatment but is not entitled to it without charge? Irrespective of their status in the UK, everyone is entitled to accident and emergency treatment without charge. The Department of Health has also said treatment deemed immediately necessary to save life, including maternity services, should always be given without delay and recovery of charges pursued as far as reasonable afterwards.

Treatment outside those parameters is governed by trusts' non-discretionary obligation under the National Health Service (Charges to Overseas Visitors) Regulations 1989 to recover charges. But what does this mean in practical terms?

Moral dilemma

Trusts have to balance a number of issues when deciding whether to withhold treatment: the moral dilemma of the health implications for the patient if treatment is refused; criticisms that could be raised at a coroner's inquest if the person dies from the illness for which they were seeking treatment; the publicity implications if they fail to treat or continue to treat an individual without charge; and meeting the demands of the budget in which they operate.

Health service managers should always endeavour to establish a person's entitlement to treatment quickly. Any treatment provided while their entitlement is being investigated should always be on the basis that if no entitlement is established, there will be a charge, likely to be£X. If treatment is commenced on the basis that there will be no charge, a trust cannot then charge for the remainder of that course of treatment.

Ongoing treatment

If managers find themselves treating a patient with ongoing needs who is not paying for the treatment, they would be well advised to write to the patient, explaining the sum of money now owed and the cost of future treatment and providing a cut-off date when treatment will cease if no advance payments are received. They should also write to the local primary care trust and, if there is one, the patient's GP, advising them of the intended discharge and allowing a reasonable time for them to make any representations.

The input of the treating clinicians should always be sought, not least because they are likely to have useful information about treatment cycles and therefore the dates on which it would be most reasonable to discharge a patient. If the patient is thought to be in the UK unlawfully, then liaising with the Home Office could provide the trust with a deportation date around which treatment could cease.

The NHS has maintained its core principle of providing healthcare free at the point of delivery, but entitlement to its benefits is not universal. Therefore, trusts may have to, delicately and pragmatically, consider withdrawing treatment from those with no entitlement to receive it without charge.