Health Tourism in the NHS

Health Tourism in the NHS

Earlier this year the Department of Health issued a guideline that GPs should provide free healthcare to any overseas visitor requesting treatment. The guidance GPs have received was displayed on the NHS Choices Website.  It read as follows:

GP services

If you need to see a doctor during your stay in the UK then you can register with a GP (general practitioner) practice as an NHS patient. You can register as a temporary patient with a GP practice when you are in the area for more than 24 hours and less than three months. It is up to the GP practice to decide whether to accept new patients or not. Treatment will be free of charge.

When these guidelines were published it produced a firestorm of e-mail traffic from GP practice managers in Buckinghamshire, Berkshire and Oxfordshire. In response to the concerns of my practice manager colleagues, I contacted my local MP, Sir Tony Baldry,  to advise him of the concern the new guidelines had caused. I received a ministerial response informing me that the matter was being looked into but, other than that, not saying very much. I was, however, pleased to hear the Health Secretary, Jeremy Hunt, discuss the subject on Radio 4’s Today program on 3rd of July 2013… http://www.bbc.co.uk/programmes/p01c7pst . Later that day the following question was asked at Prime Minister’s Question Time .

Q14. [162816] Dr Phillip Lee (Bracknell) (Con): As a doctor who once had to listen incredulously to a patient explain, via a translator, that she only discovered she was nine months’ pregnant on arrival at terminal 3 at Heathrow, I was pleased to hear the statement from the Secretary of State for Health today on health tourism. Does the Prime Minister agree that although the savings are modest, the principle matters? The health service should be national, not international.

The Prime Minister: My hon. Friend makes a very important point. This is a national health service, not an international health service. British families pay about £5,000 a year in taxes for our NHS. It is right to ensure that those people who do not have a right to use our NHS are properly charged for it…..

Source – Hansard

Despite all the rhetoric and hyperbole in the debate surrounding the question of health tourism, very little has changed apart from the tone of the NHS Choices website.  The previous guidelines have been removed and had been replaced with the following text:

Non-UK residents will also be charged for hospital treatments. If you are an overseas visitor to the UK you may be charged for some treatments and, depending on how urgent it is, you will usually have to pay in advance….

The NHS is a residence-based healthcare system. If you are planning to live and work in England you’ll have to register with a general practitioner (GP). GPs are the first point of contact for nearly all NHS patients. They can direct you to other NHS services, and are experts in family medicine, preventative care, health education and treating people with multiple and long-term conditions.

You can also register as a temporary patient with a GP practice when you are in the area for more than 24 hours and less than three months. It is up to the GP practice to decide whether to accept new patients or not. Treatment will be free of charge.

I don’t have a problem with GPs providing a one-off GP consultation free of charge. The real problem, however, is that in order to register and treat overseas patients, GP practices will have to issue them with an NHS Number. Once the patient has an NHS Number they will, de facto, be eligible for NHS prescriptions, treatments and referrals. It becomes a lot easier for them to slip through the net to acquire free NHS hospital treatment.

The Solution

I offer the following suggestion as to how screening for entitlement to free NHS treatment can be achieved without turning GP surgery staff into NHS Border Guards.  The current NHS Number is in the format 999-999-9999.  I propose that this format should only be available to patients currently registered with a UK GP surgery.  When an overseas patient presents to register at a GP surgery, they will be asked where they are currently registered.  If they are not currently registered with the UK surgery, they will be issued with an NHS Number in the following format X99-999-9999. This would indicate that the patient is not necessarily entitled to free treatment under the NHS.

Patients who are issued such an NHS Number would still be eligible for free GP consultations.  However, any prescriptions, treatments or referrals recommended by the GP would have to be paid at the market rate, in advance, to pharmacies, treatment centres and hospitals.  The onus would be on the patient to prove their entitlement.  The GP surgery would have no role in either checking or policing the entitlement.

I fully accept that what, on the face of it, sounds like a simple idea would have significant logistical problems in implementation.  One of the problems would be that current clinical systems are designed to recognise the NHS number in its existing format.  This is not an insuperable problem and should not be used as an excuse not to take this forward. In this time of austerity, I am in full agreement with the Prime Minister when he says

‘This is a national health service, not an international health service. … It is right to ensure that those people who do not have a right to use our NHS are properly charged for it.’

I think a different format of NHS Number for patients with an unclear entitlement to free treatment under the NHS would help, significantly, to stop health tourism.

What do you think?

The Existential Threat to the National Health Service.

I am not given to hyperbole but I honestly believe the NHS is facing an NHS Existential Threat. By this I mean that it is possible that, within four years, the NHS as we know it will have ceased to exist. When I say as we know it, I mean largely in public ownership, available to eligible patients on the basis of need, not the ability to pay and, accepting current exceptions, free at the point of delivery.

What is the nature of the existential threat?

Everyone involved in running or delivering the National Health Economy has heard of The Nicholson Challenge. In his Annual Report 2008-9, the Chief Executive of the NHS, Sir David Nicholson, announced a £15-20 Billion hole in future NHS funding. This can be found on page 47 of NHS Chief Executive’s annual report 2008/09. This states:

Looking ahead to the next Spending Review, we need to be planning for a much tighter financial environment than we have had in recent years. We need to start that work in earnest now.
We know that NHS investment will grow by 11 per cent over the next two
years. That growth will be locked in on a recurring basis, so we have a real opportunity to prepare for harder times. After those two years, we must be prepared for a range of scenarios, including the possibility that investment will be frozen for a time. We should also plan on  the assumption that we will need to release unprecedented levels of efficiency savings between 2011 and 2014 – between £15 billion and £20 billion across the service over the three years. This is so that we can deal with changing demographics, the implementation of the regional visions and cost pressures in the system. That level of productivity gain can only be realised through the kind of quality improvements and advances in innovation described earlier in this report.

So What?

This £15-20 billion of efficiency savings is from where the threat to the NHS comes. This blog will not favour one political party over another. It does, however, need to be realised that the Nicholson Challenge predates the last General Election and Andrew Lansley’s bottom-up Clinical Commissioning Health Reforms.

Not many people are aware that the new Clinical Commissioning Groups that replaced the old Primary Care Trusts have one statutory objective – to deliver a 1% surplus within an operating year. A large Clinical Commissioning Group, purchasing services for a population of around 720,000 could receive in the order of £700 million a year to purchase hip replacements, prescriptions, X Rays, Out of Hours Service, Cancer treatments etc. It’s only statutory obligation is, at the end of the year, to be left with £7 million in the bank.
That newly formed Clinical Commissioning Group, led by eager and dedicated GPs, is, however, likely to find that when it speaks to its Hospitals, Community Trusts, Ambulance Services, Mental Health Trusts etc that it will have calls upon its £700 million funding in excess of £730 million. The plan to meet the shortfall, very simplistically, is to strip activity out of the hospitals and to get GPs to do it for a fraction of the cost. This is called the Quality, Innovation, Prevention and Productivity programme or QIPP for short.
The frightening thing for me is that nothing is changing. We have the QIPP agenda and we attend regular meetings to monitor progress. All the right noises are being made but, when you put GPs on the spot and ask ‘Being aware, as you are,  of the problems that face the NHS, what are you doing differently when the consulting room door closes?’ The answer is overwhelmingly ‘Nothing different at all.’ This speaks volumes for the dedication of GPs in putting their patients first but the failure to act is posing an existential threat to the very NHS that they all love and support.
What will  happen when the new CCGs fail to deliver their commissioning plans within budget has not been made clear. The Department of Health has made clear that CCGs will deliver ‘or else’ (my words – hyperbole I know) . Failure to deliver is not an option according to the Department of Health.
What follows is my personal assessment of what will probably happen in the event of failure to deliver within budget:
Year 1. Chief Executive of CCG sacked.
Year 2. special Measures – Department of Health put Special Task Force into CCG
Year 3: CCG commissioning role put out to tender.

The Nuclear Option

This is the ‘nuclear option’. If the role of the CCG is put out to tender there are likely to be a number of private health companies and partnerships who would bid for that role. This has already happened in the running of Hospital Provider Trusts.  If and when this happens, the commissioning of high quality health services that are cost-effective, sustainable and reduce inequalities will become subordinate to a profit motive and the interests of shareholders and/or partners. At the this point, the NHS as I know it, and as the population at large know and love it, will have ceased to exist.

So what should we do? More anon……