Healthcare charging – unethical practice, unacceptable outcomes

Newly amended government legislation, which came into force on November 5th 2017, mandates that any individuals who cannot provide evidence of their entitlement to NHS “non-urgent” care (excluding primary care), must pay upfront for services at 150% of the usual billing. Failure to do so risks treatment refusal. It also introduced charges into other secondary services, such as community health services and charities that provide NHS funded care.

This legislation brings change to an NHS which already serves to dissuade some of the most vulnerable living in the UK from engaging with its services. Billing had already been in place for non-urgent hospital services for certain groups such as undocumented migrants and asylum seekers who have had claims refused.

As a junior hospital doctor currently working towards a career in paediatrics, I am dismayed by what this new legislation asks of healthcare professionals. It is inhumane, impractical and will likely incur serious harm.

Obstructing the Flow

The new legislation will impact upon each stage of a patient’s journey through the NHS. When any patient steps through the hospital threshold, their care is prioritised in the safest possible manner – a challenging and dynamic process. Given that patients deteriorate and priorities frequently shift, plans must be changed efficiently. Children in particular decompensate fast and with minimal warning signs. The Government’s new legislation appears to wilfully obstruct the flow of this already complicated process.

Patients who do not require “urgent” or “immediately necessary” treatment must now have their identity checked prior to care delivery. To comply with equalities legislation and avoid the charge of racial profiling, this would mean checking every single individual (though accounts from pilot projects suggest racial profiling has already occurred). 1 in 6 of the UK population have no passport, with the most vulnerable (especially those who are homeless) least likely to have documentation. In such circumstances the legislation burdens healthcare providers with the responsibility to determine ordinary residence – a time consuming process which will inevitably involve highly subjective judgements. Providers will also be asked to determine patients’ Indefinite Leave to Remain (ILR) status for non-EEA migrants, with a two-way highway of information sharing between the NHS and the Home Office.

Under the previous system in which services were billed but without upfront payment requirements, research conducted with Doctors of the World (DoTW) found that 34% of patients eligible for charging who attended their London clinic delayed seeking care directly as a result. It is hard to see that this new legislation will have anything other than a compounding effect on this shocking statistic.

Defining Urgency

The new legislation also asks healthcare providers to decide what constitutes “urgent” or “immediately necessary” treatment for individuals deemed ineligible for non-urgent services. Though many clinicians may not undertake ID checks, they will inevitably be involved in this aspect of decision making.

All hospital clinicians make decisions regarding whether someone needs to be admitted or to remain in hospital, and on a daily basis they will encounter situations in which there is a degree of uncertainty over the urgency of care required. If they neglect to provide urgent necessary care, they can reasonably expect an investigation into surrounding events. However, under new legislation if they are also too cautious and provide care deemed non-urgent to somebody ineligible for this service, they can expect consequences.

This additional dimension to the decision process is a fundamental and unexamined change to the way clinicians practice, and has been implemented without proper consultation. As encounters such as this mount up, it is a change many health workers will find unacceptable and antithetical to the values instilled throughout their clinical training.

Preventing Prevention

Perhaps the most malign effects will occur outside of an emergency setting, where much non-urgent services provided by the NHS and charities are specifically designed to prevent unexpected and catastrophic events. Antenatal care is instructive in this regard, as an essential resource to plan safe deliveries and counsel families appropriately. In the research noted above, as many as 62% of women eligible for charging who attended the DoTW clinic did not seek appropriate antenatal care. Again, those who are currently deterred from seeking healthcare will put themselves at even greater risk of tragic consequences under the new legislation. Moreover, the economic impact of barriers to accessing preventative medicine has been unacknowledged in any assessments of the expected recuperation through upfront charging.


Already, the charging bill has garnered significant concern amongst healthcare professionals for its potential for serious harm. An open letter garnering over 1,000 signatures, including a former NHS CEO, was sent to the Department of Health in October last year. A growing movement of health workers and patients are raising their voices on the issue.

Upon announcing this legislation, Health Secretary Jeremy Hunt stated that We have no problem with overseas visitors using our NHS – as long as they make a fair contribution”. Documents surrounding the amended legislation also utilise the term “overseas visitors”. Though this phrasing may have the correct legal implications, its use, along with the seemingly innocuous but loaded term “health tourism”, implies someone who decides to come across for a short period of time to holiday or to visit friends and family. It is misguided at best and wilfully misleading at worst to implicitly suggest that this legislation merely affects those who voluntarily choose to pay a visit to England.

Rather, this legislation looks like a particularly punitive means to develop this government’s “hostile environment”. In doing so the government jeopardises the health of a diverse range of vulnerable communities and fundamentally distorts the decisions facing frontline clinicians. They are using healthcare as a tool of immigration policy with the hospital functioning as a quasi-national border. At a time of unprecedented, multifarious healthcare crises, that this is a policy priority at all will strike many as an outrageous attempt at scapegoating. I did not train to become a doctor in order to implement such a programme.