I got a call from Jeremy Hunt about health tourism — but he still doesn't get it

The government's solutions will fail because it can't grasp the scale of the problem, says our NHS whistleblower

2 November 2013

9:00 AM

2 November 2013

9:00 AM

On Monday morning, Jeremy Hunt’s diary secretary rang me to arrange a time for me to speak to the Secretary of State over the telephone. I had already received an email from his special adviser the previous week, saying, ‘The two points which the independent research make clear are central to what you’ve been saying for a long time; namely that health tourism is a huge problem with a substantial cost to the NHS and the current system is an unfair burden on frontline staff.’

When Jeremy rang, he was charming, full of praise, and eager to tackle the issue of health tourism — the exploitation of the NHS by ineligible, non-tax contributing patients. Yet for all the Health Secretary’s good intentions, I fear his department is failing to grasp the nettle. The government has not recognised the extent of the problem, so its solutions are inadequate.

When I first raised this issue in The Spectator, I quoted from the Department of Health’s website section on ‘Eligibility for free hospital treatment under the NHS’, to show how open to abuse the rules and regulations governing free access to NHS care are. (Strangely enough, the page was removed and archived soon after my article was published.)

On the back of my article, the government employed a company called Creative Research to investigate the health tourism problem. It too found that the eligibility criteria for free NHS care were porous, ineffective and difficult to enforce, and that any determined non-resident can breach them. Nevertheless, Creative Research has grossly underestimated the extent of the problem.

Let’s first remind ourselves of the strict definition of a health tourist. It’s someone who arrives in the UK with a pre-existing illness whose purpose is to access free NHS care. (The term does not apply to visitors who suffer accidental or incidental illnesses during their stay, nor to asylum seekers or disadvantaged migrants who are entitled to ‘Good Samaritan’ NHS care.) The claim by Creative Research that this activity costs between £70 million and £300 million cannot possibly be correct. Where is the data to confirm that estimate? I still maintain that the cost of this component of the problem, as defined, is in billions, not millions. For example, the cost of treating expatriates who have lived abroad for decades and returned for treatment has not been included.

Creative Research is a market research company. It has little financial or commercial expertise. Its website states that it depends on freelance researchers to deal with commissions. It lists 32 examples of previous projects, only three of which are connected with health matters. The rest are client-based satisfaction surveys based on interviews and relating to museum attendance, water companies and the RSPB.

The Department of Health response to the Morecambe Bay scandal was to commission a report from Grant Thornton, a multi-national management consultancy with almost inexhaustible investigative potential. Is it too harsh to conclude from this enormous discrepancy in investigative skill that the Department of Health does not wish to investigate the true cost of health tourism?

In the next few weeks, in an attempt to reduce the cost of health tourism, the government will announce new rules about who can access NHS care. There is a proposal for an annual health levy or surcharge set at £150 for foreign students and at £200 for other temporary migrants. The levy will apparently generate £1.9 billion over a ten-year period, based on approximately 490,000 applicants who would be required to pay.

This amounts to the cheapest travel/health insurance on the planet! All that students and temporary migrants have to do is cough up £150 or £200 and they will be fully entitled to unlimited free health care. Besides, don’t the geniuses who thought up this plan realise that, apart from a few students who exploit the system, most health tourists come on a visitor’s visa, so would be exempt even from this minimal charge? Why shouldn’t students and temporary migrants be required to have health insurance, as is necessary for any British citizen studying or working abroad?

And how is the levy going to work? If the student is on a three-year course, would the outlay charge be £450 plus the cost of the visa? If the same student is bringing his/her spouse and three children, then would the outlay charge for three years be £2,250 plus the cost of five visas? Does this fit with the government’s idea of encouraging students to come to UK because they bring us so much revenue?

In any event, access to the NHS is based on residency, not contribution. The immigration minister Mark Harper has said that ‘Payment of the surcharge will ensure that most NHS services would then be free for migrant use.’ In a BBC interview, Jeremy Hunt said, ‘The levy could be set higher and might exclude certain treatments like IVF, cosmetic surgery, renal dialysis, transplantation and pre-existing pregnancies.’ That should definitely be the case — and let’s hope this idea will not become another coalition casualty.

Hunt’s other measure is to appoint a director of cost recovery. It has been assessed that £500 million per year could be saved through the health levy, by deterring health tourists, and finally by recovering costs from chargeable patients — meaning those who have received treatment but are deemed to have been ineligible for free NHS care. Invoices for this category of patient are already raised; but currently only 20 per cent are paid.

If proper entitlement controls were in place, though, surely this debt collector role would be unnecessary? Health tourists need to be identified and excluded from the NHS. But there is no method for enforcing payment. It’s fraud without penalty. Any charge made is at the NHS tariff, which is about 25 per cent of the equivalent cost in a private UK hospital. The only permanent solution is a method of personal identification to prove entitlement to free NHS care, as you can find in all other countries with health systems equivalent to our own. Health tourists come to the UK because we let them.

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Show comments
  • Mynydd

    “The only permanent solution is a method of personal identification to prove entitlement” It’s called an ‘ID card’, come on just say it, an ‘ID card’ is the answer.

    • Jackthesmilingblack

      Bit rich a Brit national resident abroad can`t get NHS treatment after five years away.

      • Tom M

        Quite so Jack.
        The Brit returning would have an NI number. To me that means that you are entitled to health care anytime. Why wouldn’t the country of your birth’s health system look after you? Where else would you go?

        As far as entitlement goes compare someone who has been abroad working with someone living on benefits all their lives.

        • Jackthesmilingblack

          A couple of rhetorical questions:
          Why wouldn’t the country of your birth’s health system look after you? Why indeed? But when you fly the coop, don`t leave one foot in UK.
          Where else would you go? I was treated under the Japanese health service from Day 1.

          Jack`s comment: How can you betray a country that`s already betrayed you!
          Jack, Japan Alps

        • Toby Esterházy

          A bit of a faux anger. An expat would be eligible, provided that he lives in this said Country, and not fully tanned-up, speaking with a strange accent and only coming here just for the holidays.

          • Tom M

            Well if he lives in this country whether an expat or not he would be eligible. I agree about the holidays makers but how about a British citizen, born and grew up in the UK and worked for say 20 years abroad. Returned to the UK in their 40s. Are we saying that they should be treated exactly the same someone who fell of a lorry at Dover?

  • zanzamander

    If we’re talking about non EU legal immigrants only than the solution is simple, I’m surprised no one’s thought about it and that is compulsory insurance.

    Everyone who enters the UK must have a valid insurance certificate purchased via our overseas embassies which must be attached to the passport and shown to the immigration officer.

    No insurance, no entry.

    Why is it that muggins here has to fork out hundreds of pounds in insurance when going abroad but these foreigners can just waltz in here without one?

    • zanzamander

      Another idea!

      Charge at least £3,000 in visa to “visitors” from flea infested hell holes of this world, out of which £2,950 could go into a fund dedicated to treat these scroungers when they fall ill.

      And once they do fall ill here, just patch them enough to load them on to a plane back to the cesspit whence they came.

    • Jackthesmilingblack

      This would do more to shoot Britain`s international trade in the foot than any number of my “UK Trash Culture” presentations. Keep up the good work, Zan.

    • Tom M

      I wouldn’t check it at entry to the country. Just ask for it if they turn up at hospital like France (post above). “How would you like to pay? We take credit cards” Emergency treatment only if you don’t have the means.

    • Patricia

      “Everyone who enters the UK must have a valid insurance certificate purchased via our overseas embassies which must be attached to the passport and shown to the immigration officer.

      No insurance, no entry.”

      So simple – why can’t we do it ?

      • nonsequiturcouk

        Small point but “purchased via our overseas embassies” is a bit OTT. Travel insurance can be bought quickly and easily off the net, all that’s required is proof of insurance.

  • ohforheavensake

    They still don’t get it, because it’s not that big a problem.


    You’ll forgive me if I believe something from an impartial fact-checking site, rather than something posted in The Spectator.

    • Ricky Strong

      Well I can’t verify the credibility of full fact.org but I can tell you that I have a dear friend working very high up within the NHS who deals with very important figures and they will you that while health tourism won’t bring the NHS down it is a massive growing problem that needs stamping out.

  • Tom M

    “…the cost of treating expatriates who have lived abroad for decades and returned for treatment…”
    I think you need to redefine this category Meirion.

    I live in France and have done so for a decade. If I choose to come back to the UK for NHS treatment (in the very unlikely event that is) why shouldn’t I be entitled? As a retired person any health care costs I incur here in the French system go back to the UK in any case. That is an EU wide agreement.
    Broadening the point out, why shouldn’t British subjects be entitled to NHS health care at any time in their lives? Think about this. What you are saying is someone comes from Rumania next January gets a job on a building site and on day one has more right to health care than a British subject who has worked abroad for 20 years and comes back.

    How would this hypothetical returnee be any different to someone who born in and has always lived in Britian and never worked a day in their life?
    You are correct about health tourism but your definitions of entitlement are way off.
    The simple answer is just do as others do. No need to re-invent the wheel.
    In France you are either entitled, and have a “carte vitale” or you aren’t. If you aren’t you pay. How is your choice, insurance or cash. You only have a carte vitale if you are a French citizen or subject to some EU rule that allows the bills to be recovered from where you were born. Just do it right. No stupid sticking plaster fudges such as those proposed.

    • manonthebus

      Your comment strikes a chord and is an accurate example of what is now wrong with the NHS. It does not work because too few people are paying for it. This is a symptom of Britain’s declining economic rectitude caused by the extension of progressive taxation. Far too many people in Britain pay nothing throughout their lives for the services they consume and many now see this as an inalienable right.

    • Toby Esterházy

      If you had a Carte Vitale and not already a British State pensioner, you are a full member of the French system, and the French have no claim on the NHS. You are never entitled in France simply because you were a Frenchman. The French unemployed for more than 2 years and the expatriates are out of the system. If we don’t count the Italians, only the Americans would grant access of the Medicare scheme to the expatriates, but only for those already receiving an American Social Security pension and also agree to a withholding deduction of the amount normally payable.

      You have to draw a line somewhere. British citizenship is transmittable for at least one or two generations born abroad, both from the male and the female line, and there would be literally millions eligible. Entitlement by citizenship (jus patriae) or by birth (jus soli) or even by both is unworkable, because Spain and Portugal would then demand 100% reimbursement from the NHS for all the British expats, regardless of the length of residence.

      • Jackthesmilingblack

        This must be the “sane” guest.

      • Tom M

        If I am a pensioner and live in France I have access to the French health care system but the bills go back to the UK. The same right extends to the French (or any other EU country) in the UK.
        If I am an EU citizen, not a pensioner and work in France I have automatic rights to health care.
        If I neither work or am a pensioner then I must provide myself with full health insurance (this requirement at the moment is under review in the EU).
        You are wrong about the French unemployed. They always have the right to health care. You are confusing two sets of “rights”. What they won’t have is state pension rights unless they have contributed (ie worked). And the difference, unlike the UK, between Social Security and State Pension is considerable.
        To my original point. Health care costs money. I agree with you it has to be limited by something. Understandably few countries are going to write a blank cheque for masses of immigrants who have contributed nothing anywhere.
        But surely a country has an obligation to look after it’s citizens wherever they are as a “health carer of last resort”. If not who will? The problems you describe are pivoting upon the far too broad definition of a British Citizen.

        Personally I would have been only too glad, as a net contributor to the system for 45 years, to have had a portable entitlement that I could have any care provided where I happen to be and the bills sent to the UK. Just like any other insurance (except the government spend the money as it comes in).

      • nonsequiturcouk

        Small point, but Americans pay tax to the US even as Expats.

  • Kiran Cheedella

    Dr Thomas you state ‘I still maintain that the cost of this component of the problem, as defined, is in billions, not millions.’ Where is your statistical evidence for this and what methods did you use to find this out?

  • Peter Baker

    I appreciate Mr Thomas’ concern for the NHS finances but he really has nothing to worry about. Health tourism does happen, but it is very rare. A group of 20 or so of my medical colleagues recently discussed the issue, and we agreed that none of us had ever seen a case. The reality is that when people are sick, they want to be seen near their home, by familiar people who speak their own language. Even within the UK people prefer their local hospital rather than a “better” one a few miles away. International travel for health care is rare.

    Equally importantly, all the steps suggested (charging, restricting access etc) have side effects that are much worse than the minor problem they are designed to treat. Firstly the cost of administering these systems nation -wide will be more than the revenue gained. ID cards were likely to cost £560m per year. Secondly, the international literature on restricting access to routine care is very clear, people with minor problems that could be treated just get sicker and sicker until they now need expensive emergency care that costs us even more. No one is suggesting we stop providing emergency care. Thirdly, many of these diseases will be infectious. By not allowing people access to the NHS whilst they are here, we are risking them spreading infectious diseases and harming the populations health.

    So in words that Mr Thomas might appreciate: Think of it like a invasive operation which is expensive and has well known harmful side effects, for a disease that may or may not even be there, and certainly isn’t causing any major symptoms.

    It is just bad medicine.

    • manonthebus

      Think of it another way. Your comment is unbelievably patronising and you and your 20 colleagues have not the foggiest idea of what is going on.

    • nonsequiturcouk

      ID already exists in the form of passports. If only we have some form of passport control like every other country in the world.

  • Rilman

    When we have to queue behind foreign people. who have not contributed in the slightest, to access our own NHS, something is not right. I was at an eye clinic at my local hospital just last week queuing for hours, the waiting room looked like an immigration centre.

    • nonsequiturcouk

      This is what the Political Elite want.


    Thomas doesn’t provide a shred of evidence to support his claims. For grown-up journalism, visit The Independent and The Guardian : http://tinyurl.com/p8abdu3 and http://www.theguardian.com/society/2013/oct/24/medical-tourism-generates-millions-nhs-health

    • nonsequiturcouk

      The Guardian – Grown up Jingoism… Owen Jones, Polly Toynbee, sure, that’s real grown up.

      My sister, A midwife in central London, would agree with everything in this post.

  • Grah101

    This article is just more self-important, weary cynicism from a perpetually dissatisfied and willful misrepresenter. If a non-entitled person incurs costs on the NHS they should be billed, and the costs recovered. A upfront deposit was never a ticket giving total free care. Does he really not get this?