The recent Conservative Party conference has given much food for thought over the long term future of healthcare in the UK.
Having collaborated recently on a publication calling for across the board entitlement checking for maternity services, it is encouraging at least one NHS Foundation Trust is taking the initiative in recovering payment from those who have hitherto cheated the system.
The question facing Brexiteers, willing or otherwise, is how we interface a system that assumes entitlement to free care with the outside world. We are not an island in terms of health economics and haven't been for many decades. It's about time we grew up and accepted that. There are several ways in which the NHS can provide care free at the point of delivery, while assuring those required to pay, do so.
The decentralised nature of the NHS requires this interface to be at the highest level of government to ensure a robust means of securing payment. I believe it is time the UK government formalise this arrangement by creating a virtual Clinical Commissioning Group (CCG) - a travel adapter - that we can refer to for the sake of this article as "NHS Arrivals".
NHS Arrivals would automatically register everyone for a fixed fee arriving from outside the UK with a non-UK passport for three months given the nature of current European Health Insurance Card (EHIC) arrangements. This database would be accessible by NHS Trusts by a simple login website. NHS Arrivals would log passport details, EHIC card data and a copy of travel insurance if the person declared an intention to stay beyond 3 months. Self-check-in style facilities at arrivals lounges would make this simplicity itself and upfront fees for those failing to register would incentivise forward planning allowing a seamless replacement for EHIC for European arrivals which as I have written previously needs reform.
This new system would facilitate two crucial areas of healthcare. The first is a substitute for Temporary GP registration which creates a nuisance for GP practices and offers little income for the work delivered. NHS Arrivals could instead fund visits on a fee per service basis for those requiring a GP appointment, much like UK patients pay for private GPs today.
The second is in accessing urgent care. A GP address, recorded on a database, or a NHS Arrivals registration would both demonstrate entitlement to care and avoid needless and time wasting ID checks at point of care. GP registration itself would constitute entitlement to care.
A blank box on the front sheet where there is neither NHS Arrivals or GP practice data on an urgent care front sheet would trigger a challenge to provide evidence of entitlement to fee free care. This procedure happens now to ensure the correct CCG is billed and so does not create any additional workload for the hospital.
Instead the current system automatically assumes entitlement and so bills the local CCG whether this is appropriate or not. If instead entitlement is proven not to be present the care provider is left with the liability to collect payment. This is unfair to patients whose CCG loses out and unfair to hospitals who are punished for honesty.
After three months, NHS Arrivals would automatically remove the patient from the database for entitlement but would retain insurance details for use in extremis.
It is for government to decide at which point a traveller is deemed ordinarily resident. This needs codifying as the current system is vague to the point of being useless.
Travellers would have ample time to either secure health insurance privately or ensure they were covered by National Insurance through employment during the transition period between NHS Arrivals and Ordinary Residence. The same rules apply today for people who would otherwise overstay their visas and have to make arrangements for their extension.
The UK should continue to invoice primary care groups and health boards for every A&E visit as they do now and simply invoice NHS Arrivals for overseas travellers.
The UK government is not required to recover costs from travellers if it wishes not to but it is required to make sure local impacts on unpaid NHS tourism are addressed instead of relying on a don't ask don't tell system which fails everyone.
There is a case to be made that given the small sums involved for GP visits and ambulatory care the UK simply pays these out of goodwill and this would reduce charges to travellers arriving to the UK and make the UK more attractive to travellers on lower income.
There is likewise the case to be made that such a fee on arrival would be no different to the travel insurance UK tourists pay to ensure cover when travelling abroad. In any care big ticket items like maternity care including delivery simply have to have their costs recovered; failing to do so would be a dereliction of duty to mothers in this country through the deliberate under funding of maternity care.
It is no longer credible for NHS workers to dismiss unpaid NHS tourism as someone else's problem. It affects the salaries one can competently argue for and the quality of service that is delivered. Brexit simply provides a unique impetus to close loopholes that have existed for far too long. It is also not right to allow the suspicion that overseas patients are draining the NHS when other nations’ healthcare systems are setup now to prevent this.
We need a common sense travel adapter so visitors to the UK can plug into healthcare free at the point of need without compromising care for the rest of us.
We need it now.
Dr. Jon Stanley is Health Research Fellow at the Bow Group, a Junior Doctor and a Fellow of the Royal College of Surgeons