A national wealth service

Monday, October 3, 2016
Dr. Myles Harris


The NHS should be expensive at the point of delivery, says Dr. Myles Harris

When an Argentinian visitor , we will call him Pedro, fractured his ankle in Oxford St, an ambulance was at his side in five minutes. The latest in splints was applied and he was soon in a well-equipped Accident and Emergency Department of a major teaching hospital. Not only was his fracture attended to, but when he told the doctor he had previously had heart trouble, an ECG and blood tests were speedily organised to see that all was well. Two hours later, on crutches, a follow up card in his hand to see two specialists, medical and orthopaedic, he approached the front desk to pay.

The lady behind the desk nearly fell off her chair. “But my dear it is free, this is the NHS”, she said. “But I would like to pay”. “You can’t I am afraid, them‘s the rules. It’s an emergency see, emergencies are free”. “Anyhow,” she added frostily, “the office where people have to pay is closed.”

Pedro, sensing he was causing offence, the English were a strange people, felt it wise to retreat. He was however a man who believed in honouring his debts, and three months later a large cheque appeared on the desk of the CEO of the hospital. It has yet to be cashed in case it breaches payment rules. There have been four meetings already about it.

Although Pedro’s story is not real, it reflects the truth. The lady behind the desk was absolutely right, the NHS is practically free, the list of exemptions for foreigners so extensive one would have to be a Martian demanding a face lift to have to pay, and the reason why Pedro’s cheque is still lying in the CEO’s in tray is that overseas visitors, as one source said, “create debt” . Debt is a dirty word in the NHS, an embarrassment to administrators who run the service and a threat to their bonuses.

This is because treatment is paid out of general taxation, it is not an insurance scheme where treatment is related to the size of the premiums you pay. This latter mechanism is what most countries offer , with a safety net offering free treatment for the poor. Instead the NHS is like a gigantic soup tureen with doctors, not actuaries, ladling out portions strictly in terms of clinical need. Rich or poor you get the same. The arrival of foreigners bearing VISA cards upsets this. They can’t be refused treatment, but if it is to be fair, they can’t pay for it either. If they want to do that sort of thing they can go to a private hospital.

The Department of Health claims it is about to change this. By the start of the next financial year 2015 visitors to the UK from countries who do not have reciprocal agreements with the NHS, the government is trying to wind such deals up to save costs. Visitors who are not on the big list categories exempt from paying for NHS treatment, but who are planning to stay in Britain for more than six months, will have to pay a £200 insurance premium to obtain a visa. In addition the process of chasing debt within hospitals is to be tightened up with alerts sent automatically to the Office of Visitor Management when a patient is admitted. If you leave the country without paying you risk not being readmitted. One has the sneaking impression that such changes are cosmetic with Whitehall determined on absolute lack of business as usual.

Nor will such checks cover A&E where anything from a stubbed toe to a stroke is treated free. It gets around the difficulty of enforcing payment in a shifting crowd of people, as well as the problem of identification, more so now with millions of visitors from abroad. The British are not expected to carry ID cards, even NHS cards, so how would anybody check?

The general practitioner would be a good place to start, but GPs recently invited to take part in a scheme to do some low level vetting of patients’ eligibility taking at most about three minutes of a receptionist’s time, refused. They cited past delays by the Home Office in answering queries about a patient‘s eligibility, the risk of being sued if they refused treatment and the failure of successive governments to say who and who was not eligible. They were egged on by the left-leaning Royal College of General Practitioners. Its representatives declared that any checks would result in undetected asylum seekers being deterred from seeking medical attention. As a result TB would sweep the nation. Why it has not swept through France, Spain, Germany Italy or Greece, who have checks, was not explained. There was no chance of it working anyway. Following a lawsuit brought by Nigerian asylum seekers, family doctors received specific instructions from the government that, under no circumstances, even if they suspected blatant fraud, were they to check on the eligibility of new patients for NHS treatment. Besides, the NHS numbers of patients registered with a GP are not cross checked to see if they are eligible for treatment. It is merely an administrative convenience to make access to patients’ notes easier, and despite the fact that printed on NHS Medical cards is the statement that the card ‘is proof that you are entitled to NHS treatment’ .

Hospitals are supposed to do their own checking, many until now relying on a GP‘s letter, an NHS number and general appearance as proof. An old Cockney is unlikely to be dodging payment. Often however eligibility depends on a tricky definition of what is meant by ordinary residence. For example a wealthy American with severe heart trouble who has just come to live with his family in Britain, as long as he can prove he intends to go on doing so, can get his coronary arteries reamed out at your expense. But if you visit the US uninsured, suffer the same thing, and can’t pay, you may find the US hospital seeking a warrant from a British court to seize your house to pay off the debt.

Asylum seekers in general are off the hook as you are only an illegal until you ask for asylum. All you have to do then is to play the system until you have been here too long to deport.

Why do we keep such a system? The same arguments could be applied to having a free Waitrose or Sainsburys. Food is even more essential than health. Just as our city A&Es are crammed with patients, many of whom are too lazy to register with their GPs or fear (incorrectly) detection if they do, so our supermarkets would degenerate into giant scrums with all the best foods swept from the shelves by the fittest and those who shout loudest.

Administrators argue the cost of chasing NHS debt, even providing the means to pay, is not worth the money we would collect. They miss the point. Payment, like justice, has to be not only made, but seen to be made. Ideally everybody should have an NHS card with their photograph and a finger print linked to a database. This we know is impossible, not because it can’t be done, we have passports after all, but because Whitehall has proved itself too lazy and too incompetent to do so. Billions have been wasted on failed NHS computerisation.

Yet it need not be expensive. It would cost hospitals no more than the price of a 200-metre ethernet cable and a computer to link the Overseas Visitors Management office to a desk in the A&E above which is written, ‘Foreign Visitor? Please Pay Here’. Most foreign visitors are decent people only too willing to pay. Moreover with a simple collection service the rules could be changed from the present giant list of exemptions – designed so administrators can avoid work - to a list of those who to have to pay.

The new desk could also be used for the rest of us to pay a universal charge of £5 a visit to A&E, which would clear Britain’s casualties of trivial illness (in Ireland the charge is €100 per visit, which, while people there grouse about it, they understand the need, many realising it is a deterrent to illegal migrants thinking of coming to the country). GPs should charge the same. Apart from lives saved, the saving of lost time from work, inconvenience and the anxiety of waiting would be huge. Soon we would wonder why it was not started years back

Dr Myles Harris, a GP, is editor of the Salisbury Review

This article was originally published in Crossbow, the Bow Group Magazine - Conference 2014 on 27/09/2014. Published online 03/10/2016