NHS charging: the unacceptably high cost of recovering debt from vulnerable users

Sarah Steele, University of Cambridge 

It was revealed recently that members of the Windrush generation of migrants to the UK and their children were having difficulty getting care on the National Health Service because of confusion over their healthcare entitlement. The fiasco highlighted critical issues with the newly expanded charging regime.

Under this, those who can’t prove they are entitled to free care have to pay upfront for a range of treatments. These include many hospital treatments and outpatient services, but also some mental health services and community care.

When instituting and expanding charging, the UK government guaranteed it would be fair and the vulnerable would be protected – and that immediately necessary and urgent care would never be withheld. However, cases of patients denied cancer treatment unless they can pay significant sums in advance, as well as reports from Doctors of the World of patients scared they might receive large bills if they go to the NHS for help, reveal a real problem.

A hardening environment around the issue of immigration doesn’t just leave Commonwealth citizens who arrived in the UK decades ago with issues, it also affects vulnerable people, such as survivors of modern slavery, domestic violence, female genital mutilation, forced marriage and other forms of violence, who are supposed to be exempt from the charging regime.

The issue for these patients is that they must first access the NHS in some form, be identified, and then, often, they must be referred to other agencies to be certified as exempt from charging. If they are not exempt, they must either pay upfront, where the law demands, or be billed for their care. If they are billed, they risk racking up NHS debts that are then reported back to the Home Office, which, if unpaid, act as a ground to deny future immigration status.

Take one vulnerable exemption

Half the people trafficked into slavery encounter at least one healthcare worker at some point during their captivity, but many aren’t spotted because healthcare workers don’t have enough training and knowledge to recognise them.

Even the new Independent Anti-Slavery Commissioner agrees that the NHS has a critical role in the national strategy. It acts as a lifeline for slaves, offering both essential care and, where trapped, access to other services. But the new regime adds many roadblocks to these vulnerable adults and children to receive the care they need. For example, these people may lack their legal documents, which may have been taken away from them. This will make it hard to prove they are exempt from upfront payment even when they are entitled, if they, for instance, hold a European Health Insurance Card.

Training could help healthcare workers flag potentially exempt patients but they, and the future generation of healthcare workers, aren’t being taught about these patients. Trafficked people also often fear authorities, so may not want to be referred when a healthcare worker does identify them. This is especially true where a trafficker has cultivated a fear of retaliation, directed not only on the slave but also their loved ones, if they cooperate with authorities in any way.

News that the NHS is charging and that they report debt to the Home Office only adds to the existing fear of the service. The prospects of spotting more slaves and exempting them from charging looks tragically poor. Other vulnerable groups likely face equally significant barriers.

Not worth the bother

What is most troubling is that the charging regime is not recovering the projected costs. In fact, Freedom of Information requests sent to NHS trusts across the country show many are spending more on charging than they are recouping. This was confirmed by the National Audit Office in 2016, before upfront payment requirements were expanded in 2017. The government’s response was to blame healthcare workers for refusing to implement the broken system, and to apply pressure to trusts across the country to recover more.

As a result, rather than scrapping the regime, NHS Improvement has been sent in to ensure more people are identified for charging, that these people are subsequently billed, and that 95% or more of costs are recovered. NHS Improvement proposes to use computer algorithms to identify a greater number of chargeable patients.

However, we should be worried about proposals to use such technology, and any rapid expansion of automated charging and debt recovery, as these further threaten to levy charges against some people who may be exempt but can’t prove it, causing them stress and anxiety. Experiences in Australia of electronic debt recovery systems show how wrong it can go for governments. Over 20,000 welfare recipients were wrongly sent debt recovery notices, leading to the programme being suspended. The answer to healthcare workers refusing to charge is not to deploy algorithms in their place.

With a review of the charging regime underway, it is time to scrap this failing project and focus the the NHS on what it does best: delivering care.

Sarah Steele, Senior Research Associate, Jesus College and Affiliated Researcher, Department of Politics and International Studies, University of Cambridge

This article was originally published on The Conversation.