Immigration health surcharge

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The immigration health surcharge was introduced by the Cameron–Clegg coalition by the Immigration (Health Charge) Order 2015, made under the provisions of the Immigration Act 2014, to deal with the issue of medical tourism involving the NHS in England. Once the surcharge is paid people are entitled to use the NHS in a similar way to UK residents.

Extent of abuse[edit]

It is alleged that health tourists in the UK often target the NHS for its free-at-the-point-of-care treatment, allegedly costing the NHS up to £200 million.[1] A study in 2013 showed that the UK was a net importer of medical tourists in ten of the eleven years between 2000 and 2010.[2]

In the summer of 2015 immigration officers worked with staff in St George's University Hospitals NHS Foundation Trust to train staff "to make savings by better identifying overseas, chargeable patients".[3] In October 2016 the trust claimed "that individuals are currently offering paid assistance to women in Nigeria to have their babies for free on the NHS at St George's" and consequently announced plans to require proof of eligibility for the non-emergency maternity care of pregnant women. It was estimated that £4.6 million a year was spent on care for ineligible patients.[4] A pilot scheme to check whether patients were entitled to free NHS care in 18 NHS trusts, 11 in London, for two months in 2017 asked 8,894 people for two forms of ID prior to non-emergency care of which 50 were not eligible for free NHS treatment. Campaigners claimed this was “part of the Government’s hostile environment policy”, and that in Newham hospital, which billed patients found to be ineligible a total of £104,706 as part of this pilot, "you will see huge signs saying you may not be eligible for free NHS treatment".[5]


Aneurin Bevan dealt with the political issue in his essay, "A Free Health Service" (1952):[6]

One of the consequences of the universality of the British Health Service is the free treatment of foreign visitors. This has given rise to a great deal of criticism, most of it ill-informed and some of it deliberately mischievous. Why should people come to Britain and enjoy the benefits of the free Health Service when they do not subscribe to the national revenues? So the argument goes. The fact is, of course, that visitors to Britain subscribe to the national revenues as soon as they start consuming certain commodities, drink and tobacco for example, and entertainment. They make no direct contribution to the cost of the Health Service any more than does a British citizen.

— "A Free Health Service", In Place of Fear (1952)

He pointed out that the cost of treating visitors was negligible, but the costs of administering checks would be great:[6]: 81 

For if the sheep are to be separated from the goats both must be classified. What began as an attempt to keep the Health Service for ourselves would end by being a nuisance to everybody.

The whole agitation has a nasty taste. Instead of rejoicing at the opportunity to practice a civilized principle, Conservatives have tried to exploit the most disreputable emotions in this among many other attempts to discredit socialized medicine.

Ordinarily resident status[edit]

Eligibility for free care NHS treatment is based on a person being ordinarily resident in the UK. Amendments to the National Health Service (Charges to Overseas Visitors) Regulations 1989 have excluded a number of vulnerable groups from being eligible for free healthcare, including failed asylum seekers, undocumented migrants and those who had overstayed their visa. Very extensive guidance has been repeatedly issued to NHS organisations on the implementation of the rules, but with little effect because NHS organisations, unlike commercial health providers, are not organised to check eligibility.[7]

Entrance to the United Kingdom[edit]

People moving to the UK from outside of the Common Travel Area for longer than six months are required to pay a surcharge of £624 per year.[8] The surcharge was introduced in April 2015 and has raised £175m, with 450,000 surcharges issued in the first year. People from the Democratic People’s Republic of Korea have to pay for this surcharge in cash only.[9] It was raised from £200 to £400 a year in 2018 and later to £624. NHS trusts may have to loan overseas recruits funds to pay these upfront costs.[10] A discounted rate of £470 is charged to people under 18 as well as visitors on youth mobility visas. The NHS spends an average of £470/per individual a year (the majority of which is raised from general taxation[1] of visitors as well as residents[6]) on treating the people who pay the surcharge.[11] In 2018–2019, £251 million was collected.[12]

Payment to the NHS[edit]

Charges for treatment for those not entitled to free treatment – ie those who have not paid the surcharge – were set at 150% of the actual cost to the NHS in 2015.[13]

Lewisham and Greenwich NHS Trust has used Experian to identify overseas visitors who could be charged for NHS treatment. NHS England has encouraged other trusts to do likewise, having identified 51 NHS trusts with an "income opportunity" from overseas visitors.[14]


There is evidence that the existence of the charging regime deters people from seeking early treatment, and that will incur additional costs, and in the case of infectious conditions, risks to public health.[15] Women are thought to be particularly vulnerable as they are excluded from maternity care and have no access to free abortions.[16]

Schedule 1 of the National Health Service (Charges to Overseas Visitors) Regulations 2015 has a list of infectious conditions in respect of which there are no charges. Family planning services, palliative care and services provided for the diagnosis and treatment of sexually transmitted infections are also exempt from charges.[17]

The surcharge applies to people who are admitted as children and granted limited leave to remain. It has been criticised as part of the Home Office hostile environment policy.[18]

The Royal College of Nursing says that migrants working in the NHS should be exempt from the surcharge because this would help tackle the health service’s staffing crisis. The surcharge applies to each member of the family, and the college quotes the case of a Kenyan nurse working in Luton, whose children had to return to Kenya because she could not afford to pay £3,600 to ensure that she, her partner and four children could receive NHS care during her three-year stint working in the NHS.[19]

Immigrants in the UK in most cases already pay taxes. Immigrants are in effect paying for the National Health Service twice.[20]

The Royal College of Physicians, the Royal College of Paediatrics and Child Health, the Royal College of Obstetricians and Gynaecologists and the Faculty of Public Health called for the suspension of all NHS overseas visitor charges in December 2018. They said that the regulations were a danger to health because they deterred people with infectious conditions from seeking early treatment, and undermined trust in doctors.[21]

During the COVID-19 pandemic the Doctors' Association UK called for frontline healthcare workers and their families to be exempted from the Immigration Health Surcharge in recognition of their service to the UK.[22] The Labour Party subsequently took up the cause and tabled an amendment to the Immigration Bill at Prime Minister's Questions.[23] The Government confirmed that healthcare workers would be exempt from the surcharge in the coming days and later extending this to the dependents of NHS workers.[24][25]

See also[edit]


  1. ^ a b "Health tourists: How much do they cost and who pays? - Full Fact". 6 September 2015.
  2. ^ Hannefeld, Johanna; Horsfall, Daniel; Lunt, Neil; Smith, Richard (24 October 2013). "Medical Tourism: A Cost or Benefit to the NHS?". PLOS ONE. 8 (10): e70406. Bibcode:2013PLoSO...870406H. doi:10.1371/journal.pone.0070406. PMC 3812100. PMID 24204556.
  3. ^ "Immigration officers at London trust for patient charging pilot". Local Government Chronicle. 20 July 2015. Retrieved 24 September 2015.
  4. ^ "Pregnant women could need photo ID to get maternity care as St George's Hospital in Tooting cracks down on NHS tourism". Richmond and Twickenham Times. 11 October 2016. Retrieved 29 October 2016.
  5. ^ "8,900 checks on NHS 'health tourists' find just 50 liable to pay". Evening Standard. 29 May 2018. Retrieved 30 May 2018.
  6. ^ a b c Bevan, Aneurin (1952). "A Free Health Service". In Place of Fear. pp. 73–91. Retrieved 30 May 2018.
  7. ^ "Implementing the Overseas Visitors charging regulations" (PDF). National Archives. 2004. Archived from the original (PDF) on 5 January 2013. Retrieved 30 May 2018.
  8. ^ Health Surcharge
  9. ^ Cash surcharge
  10. ^ "Why hiking the immigration health surcharge is bad for the NHS". New Statesman. 6 February 2018. Retrieved 30 May 2018.
  11. ^ "Charge for migrants to use NHS to double to £400, government announces". Independent. 11 October 2018. Retrieved 11 October 2018.
  12. ^ "Trusts missing out on tens of millions from overseas patients". Health Service Journal. 19 November 2019. Retrieved 9 January 2020.
  13. ^ "Improving Systems for Cost Recovery for Overseas Visitors" (PDF). NHS England. May 2015. Retrieved 30 May 2018.
  14. ^ "Revealed: Mass use of credit check firm to find NHS patients to charge". Health Service Journal. 30 September 2019. Retrieved 19 November 2019.
  15. ^ "Pregnant and ill migrants going without medical care as Government intensifies NHS immigration policy". Independent. 22 October 2017. Retrieved 30 May 2018.
  16. ^ Potter, Jessica (6 February 2018). "Who has to pay for the NHS and when?". The Conversation. Retrieved 30 May 2018.
  17. ^ "The National Health Service (Charges to Overseas Visitors) Regulations 2015". 2022. Retrieved 5 July 2022.
  18. ^ "Anger after Theresa May denies plight of 120,000 young migrants who must pay £10,000 to avoid 'hostile environment'". Independent. 27 May 2018. Retrieved 30 May 2018.
  19. ^ "Scrap healthcare fees for non-EU staff in NHS, say nurses' leaders". Guardian. 12 May 2018. Retrieved 30 May 2018.
  20. ^ "UK Visa Tier 2 visa costs plunge foreign academics into debt". 29 May 2018. Retrieved 30 May 2018.
  21. ^ "Royal colleges call for suspension of NHS overseas visitor charges pending review". Royal College of Physicians. 19 December 2018. Retrieved 20 December 2018.
  22. ^ Correspondent, Richard Ford, Home. "Fee on foreign medics for using NHS is branded a gross insult". The Times. ISSN 0140-0460. Retrieved 19 August 2020.
  23. ^ Chappell, Elliot. "Labour celebrates U-turn on NHS immigration surcharge exemption". LabourList. Retrieved 19 August 2020.
  24. ^ Marsh, Sarah (21 May 2020). "'It's great for morale': doctors welcome NHS surcharge U-turn". The Guardian. ISSN 0261-3077. Retrieved 19 August 2020.
  25. ^ "Boris Johnson drops NHS fee for migrant healthcare workers in humiliating U-turn". The Independent. 21 May 2020. Retrieved 19 August 2020.

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