Health tourists: How much do they cost and who pays?

• 'Deliberate' use of the NHS—use by those who come here specifically to receive free treatment or who come for other reasons but take advantage of the system when they're here—is hard to quantify. It's thought to be very roughly between £110 million and £280 million a year.
• 'Normal' use of the NHS—by foreign visitors who've ended up being treated while in England—is estimated to cost about £1.8 billion a year.
• The majority of these costs aren't currently charged for. Only about £500 million is thought to be recoverable or chargeable at the moment.

Who do you think of when you hear the term 'health tourist'? A Spaniard who breaks a leg while on holiday in the UK? An American travelling here deliberately to use the NHS for free? What about a British expat who comes home every now and then to see their old, trusted GP?

All of them can be seen as 'health tourists' in that they've come from somewhere else and may have received healthcare in the UK for free. But for some the cost of their treatment is recoverable and for others it isn't. Keeping track of these cases is exceptionally difficult and so is working out the cost to the country.

The costs

We can split the estimated costs into two categories:

Normal use: The estimated cost of normal use of the NHS—by foreign visitors who've ended up being treated while in England—is £1.8 billion a year (including a small number of European visitors treated in the rest of the UK). This includes the cost of treating them in A&E, though visitors aren't currently charged for this, and the cost of treating some foreigners resident in England who currently don't incur charges.

Only around £500 million per year is estimated to be recoverable or chargeable according to the Department for Health. In reality only £100 million was recovered in 2013/14.

Deliberate use: This is the estimated cost of treating those travelling to England deliberately for free treatment, or those who take advantage of the health system while here (which means using it more intensively than they might have done otherwise). This group is particularly difficult to quantify as we don't really know who most of them are. It's thought they could cost the NHS somewhere between £110 million and £280 million a year, on top of the £1.8 billion a year.

Only hospitals are required to charge overseas visitors

The NHS was founded on the principle that it's a service "free at the point of use" for those ordinarily resident in the UK. But foreign or migrant patients usually need to pay a fee for their treatment.

Only services provided in or linked to a hospital in England are required to charge for overseas visitors. This excludes services like A&E and walk-in centres.

GPs in England have the discretion to register overseas patients in theory, and once registered they can be treated just like any other resident. But in reality they can only refuse a patient from their list if, say, it was closed to new patients, rather than because they don't have leave to remain. The situation is similar in the rest of the UK.

Who pays?

Currently, foreigners who are 'ordinarily resident' in the UK—those who are seen as settled in the UK—are exempt from charges. Full time students and some others are too. The definition of 'ordinarily resident' was tightened in last year's Immigration Act to include only those who have Indefinite Leave to Remain (ILR), but this hasn't come into force yet.

Most Europeans don't have to pay for treatment themselves. Charges for patients from countries in the European Economic Area are claimed back by the NHS from their country of residence. The NHS also has reciprocal agreements with some other countries such as Australia, where visitors can receive free urgent treatment if they find they need it when visiting the UK. These agreements are currently being reviewed.

Deliberate health tourism—a very rough estimate

Research commissioned by the Department for Health has estimated the gross cost of 'deliberate' health tourism for urgent treatment in England to anywhere between £110 million and £280 million. Which barely compares to the £1.8 billion gross cost for 'normal' use of the NHS. But these figures are rough, as the report makes clear: "[it's] impossible to estimate with confidence".

The research splits the 'deliberate' health tourists into two sub-groups:

• Deliberate intent: Those travelling to the UK for urgent, acute expensive surgery where they'll go straight to A&E: £60-80 million

• Taking advantage: Those accessing more routine treatments, having been able to register with a GP and visiting on a regular basis. This includes British expats who may be chargeable but who have an active GP registration: £50-200 million

To get a number for those coming with 'deliberate intent' to receive treatment the researchers calculated the risk of people coming from different countries. This 'abuse rate' is based on how close their country of origin is to the UK and the quality of publicly-funded healthcare there. It guessed an abuse rate of about 1 in 100 visitors from high risk countries being health tourists, and about 1 in 1,000 visitors from medium risk countries.

To work out the cost, the research assumes all health tourists will be receiving more expensive treatment—they're unlikely to travel to the UK for a flu jab—settling on about £7,000 per case using (incomplete) data on previous unpaid bills owed to the NHS.

So combining the abuse rate and the cost data, the report estimates the cost of providing care for this first group of deliberate health tourists could be anywhere between £20 million and £100 million.

For the second group of health tourists 'taking advantage' of the NHS, the researchers say:

"... we feel it would be potentially misleading to come up with an estimate".

Nevertheless it has a rough stab at it, suggesting a range of between £50 million and £200 million a year for these routine NHS users.

'Normal' use of the NHS by visitors

Gross costs to the NHS for the wider group (excluding the 'deliberate' health tourists) have been estimated by the same report as:

• £260 million per year for visitors and non-permanent residents from the European Economic Area (EEA) to England
• £1,400 million per year for visitors and temporary migrants from outside the EEA to England, and irregular migrants
• £95 million per year for English expats living abroad

A further £100 million a year could be added to this if you include UK-wide figures for use of the NHS by Europeans, according to the Department of Health.

The vast majority of the costs for non-EEA visitors and migrants are not recoverable, because they're related to GP, A&E or other services that don't charge or are exempt for some other reason. About £300 million also relates to irregular migrants who the report says are likely to have no means to pay.

About £500 million 'recoverable' currently

About £150 million can be invoiced to individuals living outside the EEA. Of this, it's thought that health Trusts get back about 15%. That's based on about 40% of people being identified, 85% of those being invoiced, and 40% of those invoiced actually paying.

About £340 million is recoverable from European (EEA) visitors (including those using the NHS in the rest of the UK), mostly under the European Health Insurance Card scheme.

The report is again at pains to point out that these are 'uncertain estimates' because of the full complexity of the eligibility rules.

Is it even worth the trouble to recover the money?

The Department of Health has previously estimated that the costs of recovering what's owed could be more than £18 million. That was compared to the costs being recovered at the time of about £15-25 million per year.

The money has to be recovered by the NHS bodies that provided the treatment and NHS Trusts don't have any incentive to identify overseas visitors. That's because, by flagging concerns about a patient's entitlement to free treatment, it'd be rejecting money that it would otherwise receive from the government. Once an overseas visitor is identified, the Trust instead has to recover its own debt, which will also run up administration costs.

To tackle this recovery problem the Government announced in July 2014 that it was introducing measures which would recoup an estimated £500 million a year by 2017/18. This is based on:

• £200 million from better identification of EEA patients and recharging to their home countries
• £200 million via a 'health surcharge' for non-EEA migrants with a visa to stay for over six months
• £100 million from better identification and recovery directly from non-EEA migrants

NHS Trusts will be paid 75% of the cost of non-EEA patients by health service commissioners, and will then be able to charge double that to the patient in fees.

So if treating a patient has cost £100, the provider will get £75 from the commissioning group and then will try to recoup £150 from the patient or their insurer. If successful, they'll pay the £75 back to the commissioning group. We've got more information on this here.

Medical tourism 

None of these measures consider the money the NHS actually brings in from medical tourists, that is overseas visitors coming here to pay for treatment. According to an independent review on overseas use of the NHS for the Department for Health, it's a "growing market".