End up-front charging for NHS health care
People are being wrongly charged, or denied treatment based on their immigration status
Up-front charging endangers public health
It can mean the difference between life and death for vulnerable patients and erodes trust between healthcare professionals and communities
UNISON wants up front charges to be abolished
Upfront charging for NHS treatment was introduced by the Conservatives on 23 October 2017. Migrants, visitors and former residents of the UK must pay for their care when they’re in England. Hospital departments and community health services are required to check patient’s paperwork, including passports and proof of address, and charge patients the government says are not eligible for free healthcare.
Staff are also required to refuse to provide non-urgent care if a patient cannot pay.
Recent figures show that 2,279 patients were charged upfront between October 2017 and June 2018. In 341 of these cases, treatment did not go ahead after patients were told they had to pay.
One such case was Albert Thompson, who arrived in the UK as a teenager in 1973. Because he was unable to “evidence his settled status,” he was asked to pay £54,000 upfront for his cancer treatment even though he had tax and national insurance records going back decades, that provided proof of his residency and his contributions to the NHS.
There are many cases of people being wrongly charged – or even denied – treatment based on their immigration status.
- In February 2019, the government admitted 22 people were wrongly asked to pay upfront for urgent care.
- The charity Doctors of the World has highlighted many cases of refugees and asylum seekers being charged or refused cancer care or cardiac surgery – even though they are entitled to free treatment.
This is not only inhumane. Withholding treatment from any individual costs more in the long term and threatens the health of the whole population. We know that the evidence proves that early diagnosis and treatment of disease costs less, with better outcomes. Withholding treatment affects all of us.
Up-front charging FAQ
Advice for UNISON members and branches
As a healthcare worker you have a primary duty of care to all patients, including patients who are not directly under your responsibility. If you have concerns about any of these issues around withholding treatment from patients deemed to be ineligible, you should speak with your UNISON rep as a matter of urgency. You should also check if the patient meets any of the charging exemptions – see below.
The following patients are exempt:
- refugees, asylum seekers and their dependents, refused asylum seekers receiving section 95 support;
- section 4 support or support under the Care Act in England;
- refused asylum seekers in Scotland and Wales children looked after by a local authority;
- victims and suspected victims of modern slavery survivors of torture;
- FGM, domestic or sexual violence receiving treatment as a result of their experience of violence;
- those receiving treatment under the Mental Health Act prisoners;
- those held in immigration detention.
You have the support of your union so you should always raise important questions about how a treatment like chemotherapy or renal dialysis can ever be considered to not be immediately necessary. Or how a health provider can be sure that an individual’s condition will not deteriorate if you do not offer them treatment for cancer or a heart problem.
Ask who is liable if delaying or refusing treatment for a patient on the basis of their residency or immigration status, or because it has been decided that they should pay upfront for treatment, results in significant deterioration of the patient’s health.
When you think harm or discrimination might have occurred or there was potential for it to occur, formally record this. This could be as a result of being asked to pay upfront for treatment; being told that they will be billed or receiving a bill retrospectively; or fear of having information shared with the Home Office for immigration enforcement.
You should also note when patients have been deterred from accessing care and you can submit incident reports using your trust’s formal system (eg Datix) when you observe situations where patients are at risk of harm or discrimination. This can include “near miss” incidents, for example if care is delayed but no actual harm occurred, or if a patient discloses fear about the impact of the regulations on them, even when in reality they are exempt
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