news focus

Published: 15/01/2004, Volume II4, No. 5888 Page 10 11

A betrayal of Labour's roots or a necessary process to recover the costs of care? Plans for PCTs to charge overseas patients for treatment were always going to cause a stir, reports Mark Gould

As if they do not have enough to do already, primary care trusts face the prospect of becoming debt collectors chasing defaulters around the world for unpaid primary care treatment bills.That is the prospect following controversial plans, revealed exclusively by HSJ last week (news, page 3), to charge overseas nationals for primary care services as well as hospital care.

The proposals are at an embryonic stage, but expect them to be trailed in strategically 'leaked' stories in the run-up to a general election as part of a major Cabinet Office review of eligibility criteria for all public services.

The proposals, in a restricted policy paper written by Department of Health director of access Margaret Edwards and director of finance Richard Douglas, assume stiff resistance from the medical establishment.

As a way of taking some of the pressure off, they suggest the charging system should be on hold until 2007 when UK citizens may all be carrying identity cards, which would ease identification of those who should be paying.

They also want the payment system developed outside general medical services and personal medical services contracts. In this way, interested GPs can provide a charged service as an add-on. And it would not confuse NHS lists or interfere with target-related pay streams.GPs would be paid for the extra work but recovered charges 'would then be PCT income'.

The 'preferred way forward', according to Ms Edwards and Mr Douglas, is for no restrictions on access to services or on the PCT to purchase or provide services for overseas nationals. They would like to see patients charged in the same way as will happen for hospital services and place the responsibility for collecting the charge on the PCT: NHS accounting systems would not allow the GPs to collect the cash themselves.

However, those likely to have to carry out the new arrangements are going to take some persuading.

NHS Confederation chief executive Gill Morgan says: 'Any new proposals to charge overseas patients must not compromise the provision of primary care services to those in genuine need, or place undue burdens on PCTs.

Full consultation with the service will be vital to ensure new arrangements are both ethical and workable. They will also need to reflect the different circumstances faced by PCTs in different parts of the country.'

Head of advisory services for doctors' indemnity organisation the Medical Defence Union, Dr Peter Sch³tte, says the scheme must not compromise doctors' ethical duty: 'There is a requirement for all medical practitioners registered with the General Medical Council to give what help they can in an emergency - even if that means stabilising an injury or simply getting someone with chest pain into hospital.'

The DoH document predicts opposition from the BMA. North London GP Dr Ron Singer, president of the Medical Practitioners Union, and a member of the BMA's general practice committee, will urge colleagues to oppose the move.

He says the plans present intractable ethical and practical problems. 'How are GPs going to decide if they are providing emergency treatment or not unless they take a thorough examination? Do they do that and then say they are charging afterwards or do they say they are charging before and then realise it was an emergency which should not be charged?' he asks.'

Another serious flaw in the proposals is the lack of any accurate data on the scale of the problem.

An internal note from October by another DoH official, Tim Baxter, estimates that£15m a year could be clawed back thorough charging for primary care. Ms Edwards and Mr Douglas warn that this may underestimate bad debts and recovery costs.

And the DoH admits that 'we have no firm figures on the number of overseas visitors accessing free care or the cost of treatment'.

But it says that once such a system is running there will be 'up-front implementation costs in advance of income and a proportion of the charges will not be recovered'.

Health minister John Hutton, who commissioned the proposals, has also asked the Directorate of Counter Fraud Services for advice on 'inappropriate' use of the NHS.

The DCFS has not measured the level of fraud on the NHS resulting from 'health tourism'.

Although in a statement it says it will look at how it can pursue individuals who falsely claim entitlement to free treatment.

But GP leaders say they will need hard figures to convince them there is a problem. BMA GPs committee chair Dr John Chisholm says: 'We do not believe that there is accurate data about the scale of a perceived abuse of the health service and feel that evidence is needed to show the scale of the problem before definitive remedies are proposed.'

So is this simply another cynical stunt based on flimsy evidence just to retain the Daily Mail vote? Dr Singer thinks so.

'This is a betrayal of Labour's honourable liberal past, which says we have a commitment to look after those more vulnerable than ourselves. I do not want anything to do with it.' l