Charging at what cost?

Sally Ruane | September 2, 2013 | Blog

Last week the government consultation on whether and how to extend charges for access to health care among those not permanently resident in the UK came to a close. The government’s proposals entail the introduction of a revised and narrower definition of qualifying residency; introducing an annual levy of several hundred pounds on temporary residents from outside the European Economic  Area (EEA) which would entitle them to NHS services, or requiring some alternative such as health insurance; ending free access to primary care for all non-EEA visitors and tourists;  the more effective recovery of reimbursements from the home countries of patients visiting from within the EEA; and the introduction of a system for identifying whether an individual is eligible for free care. Among non-EEA migrants and visitors, only those given indefinite leave to remain would be entitled to free NHS care.

Those affected by the proposed changes include undocumented or irregular migrants (sometimes called ‘illegal immigrants’), those whose applications for asylum have failed, short-term visitors on business and holiday trips and those who are temporarily resident for longer periods, including overseas students. The government insists that the proposals are not intended to prevent universal access to a comprehensive service but are designed to ensure that all make a ‘fair contribution’, thereby securing the sustainability of a service which is under financial pressure.

The idea of charging for health care has made a number of recent appearances. The NHS Confederation published a discussion document earlier this year claiming that increasing the financial contribution of patients to their health care, including through charges, had to be considered as part of a ‘tough choices’ response to the rising ‘burden’ of cost. In the Nuffield Trust’s collection of short essays, The Wisdom of the Crowd, to mark the 65th anniversary of the NHS, Baroness Shirley Williams, hitherto an advocate of health care free at the point of delivery, suggested charging for GP visits in some circumstances could be justified while Stephen Dorrell, chair of the Health Select Committee, believed charges on acute health care could be avoided by extra private spending on social care instead. And in July, Pulse reported that 51% of 440 GPs polled favoured the introduction of charges of between £5 and £25 per GP consultation in order to raise extra finance, to reduce access for time-wasters and to keep workloads manageable. So charging is on the political as well as government agenda.

 But are charges the best way to inject finances into the health system and ensure its sustainability? The Department of Health admits that we have limited evidence relating to the scale of the ‘problem’ either in terms of the numbers of individuals concerned, or in terms of their patterns of service use and cost to the system, or in terms of the funds likely to be raised through a new charging policy. Issuing a health warning with its own figures, the Department’s review of policy estimates that annual total treatment costs for non EEA short-term overseas visitors, undocumented migrants and non-permanent residents who are ordinarily resident in England are less than £1bn. Chargeable care appears to be disproportionately provided by a small number of Trusts, largely in London, and concentrated in obstetrics and maternity. The possibility that a small number of cases generate a high proportion of the costs adds further to the sense that most providers may have relatively little to gain in terms of income through charges should they be required to invest much more in imposing charges and chasing those liable to pay them.

On top of this, the Department’s review shows that over 60% of the chargeable population are thought to be undocumented migrants and ‘failed’ asylum seekers, many of whom are destitute or living in highly impoverished and overcrowded circumstances, and would simply to be unable to pay. Charging in whatever form would simply prevent those unable to pay from accessing necessary health care. Equally worryingly, it would endanger the health care of children whose parents are deterred from registering with a GP and reverse years of public health and preventative work aimed at ensuring timely take-up of appropriate services among these various marginalised and vulnerable groups.

 By imposing financial barriers to access GP care where there is the possibility of diagnosing early, treating more cheaply and putting in place measures for secondary prevention, it becomes all the more likely that those unable to pay will turn up with more serious conditions at already overstretched  and more expensive A&E departments. All of these additional costs need to be debited against any money raised in charges.

The costs of treating the various categories of non-permanent migrants and visitors are relatively modest when compared with their net contribution to the economy through their labour, their demand for goods and services and the taxes they pay – put by the OECD at some £16 billion annually. Given that many would simply be unable to pay, the economic case for extending charges as suggested seems far from demonstrated. So, what is the government trying to achieve?

One possibility is that the government is elaborating an anti-immigrant narrative. This interpretation is fuelled by the parallel consultation being run by the Home Office entitled Controlling Immigration: Regulating migrant access to health services in the UK and falling under the policy heading of ‘Securing borders and reducing immigration’.

There is another interpretation. The proposals would have the effect of tying health care access to ability to pay for some groups and moving one step towards an acceptance of this principle under the notion of fair contribution. They would also have the effect of putting in place a machinery for establishing tests for eligibility, invoicing and pursuing for payment, handling multiple forms of charging and across all parts of the health system, a machinery which can be subsequently rolled out to encompass other population groups, including groups amongst the permanently resident. Costs are incurred through employing overseas visitor managers and administrators, staff time to undertake screening and hiring translators and debt recovery companies and it is not known whether these costs are currently outweighed by revenue from charges. It isn’t clear how extensive and widely spread charges would need to be for a new approach to charging to be economically worthwhile.

Do we really want to invest a lot of policy planning energy, staff focus and organisational resources in building up a sophisticated charging apparatus? Surely the last thing the health service requires is yet more management, administrative and professional time diverted towards market-related activity and away from patient care. More importantly, do we want to take any steps at all along the path to charging for health care? The proposals not only  appear self-defeating  but also threaten to undermine universal access, damage the wellbeing of groups which are already marginalised and vulnerable, impair efforts to improve public health and introduce a culture in which charging becomes acceptable and routine.



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About the author

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Sally Ruane

Sally Ruane is the Deputy Director of the Health Policy Research Unit at De Montfort University, Leicester and a former member of the CHPI's EMT. She has published in books, academic journals and magazines in the UK and Spain and has a particular interest in the private finance initiative, service configuration and political aspects of the policy process.See all posts by Sally Ruane