Eligibility for NHS primary care

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Current situation

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It’s Your Practice A patient guide to GP services RCGP The situation is slightly different according to which part of the country you are seeking care and what type of care you are seeking. All UK residents are entitled to the services of an NHS GP. UK citizens not permanently resident in the UK may not be entitled to some other NHS care free and GPs may be part of the process of determining such eligibility. You are treated as a temporary patient if you will be resident in a GP practice area for less than 3 months. There is a tension as GPs may not have capacity to accept more NHS patients or welcome their need to do eligibility checks.

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As an NHS patient and you are planning to live and work in England, you need to register with a local GP. It is up to the GP practice to decide whether to accept new patients or not, but they can only refuse for non-discriminatory reasons. However, being registered with a GP practice does not in itself mean you will be entitled to free NHS hospital treatment.

For overseas visitors there is a guide at "Migrant health guide"

GP and nurse consultations in primary care and treatment provided by a GP are free of charge to all, whether registering as an NHS patient, or as a temporary patient, when the patient is in the area for more than 24 hours and less than 3 months.

There is guidance for primary care at migrant.health.

Payment may definitely be expected for some overseas visitor access to some NHS services. This is detailed in the The National Health Service (Charges to Overseas Visitors) Regulations. Be aware that a health care charge may have been made with a visa application and that certain groups such as refugees will be exempt.

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The services so provided shall be free of charge, except in so far as the making and recovery of charges is expressly provided for by or under any enactment, whenever passed.

There is a guide at "Overseas Visitors to Scotland"

The overseas visitors charging regulations do not permit charging for NHS general medical services other than certain dental and optical services. It is for GP practices to decide whether or not to register an overseas visitor or to treat them privately, taking into account the terms of the National Health Service (General Medical Services Contracts) (Scotland) Regulations as amended

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Primary care providers i.e. General Practitioners, dentists, opticians and pharmacists need to establish if a patient seeking treatment meets the definition of ordinarily resident as defined in Welsh Health Circular WHC (1999) 32, if not, the patient is deemed an overseas visitor.

There is a guide at "Overseas Visitors to Wales"

When an overseas visitor requests non-emergency medical treatment or treatment that is not immediately necessary, it is for the primary care provider to decide whether to accept that person as a NHS patient or as a private patient.


Of course, there is constant tension between on the one hand pressure to cut costs, and antagonism towards the idea that money contributed by UK citizens is being spent on "immigrants" and "health tourists" mean that cutting support for people who can be portrayed as not deserving it is very attractive to politicians; while on the other hand evidence as to why it might be a good thing to e.g. treat visitors with infectious diseases rather than allowing these diseases to spread to UK citizens. Entitlements are likely to be discussed, and may well change.

Introduction

See Eligibility for NHS secondary care for information on eligibility for e.g. hospital treatment.

Since this document was first drafted the new GP contract has been introduced, the original key reference (HSC 1999/018) has gone "out of time", and the systems by which GPs are paid for providing "immediately necessary" and "emergency" treatment have been changed. Revised guidance has been published, and the basic facts about eligibility for NHS treatment have not changed (as the underlying legislation has not been amended). Links to current guidance are included below. Devolution is likely to have made some of the detail below inaccurate, as has the introduction of an health insurance component to some types of visas.

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Contents

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How to decide if somebody is eligible for NHS treatment

LogoKeyPointsBox.png If somebody expects to be resident in the UK for at least six months, they are likely to be eligible for NHS primary care, including to register with a GP. They do NOT have to have already been resident in the UK for six months to be eligible.
LogoKeyPointsBox.png NHS Numbers are now assigned at birth. A birth does not need to have been registered for a baby to be registered with a GP.
People are eligible for NHS treatment, like any UK citizen, if they are "ordinarily resident" in the UK (see Residence in the UK below).

European economic area (EEA) nationals carrying Form E128 are also fully eligible for NHS treatment. (see Visitors from EEA members... below).

People who are visiting the UK, but who are not "ordinarily resident" in the UK are entitled to "immediately necessary treatment" from a GP.

Visitors to the UK may carry a Form E112, which entitles them to seek treatment for a specific condition – see DH guidance (in References and external links, below) for details.

People entering the UK from certain countries, who expect to stay here for at least 6 months, may be referred to the PCO or HPU where they expect to reside for new entrant screening. If a patient presents to a GP practice carrying a letter asking them to register for a GP, and/or a chest x-ray report or request form from the PCO or HPU, it is almost certain that this is because the immigration officials at the port of entry have confirmed that they are eligible for NHS primary care.

Residence in the UK

Health services circular HSC 1999/018 refers mainly to people who are not classified as resident. It states (in paragraphs 2 and 3):

The National Health Service is primarily for the benefit of people who live in this country. It is therefore considered that eligibility to receive free medical treatment should relate to whether a person is ordinarily resident in the United Kingdom (UK) and not to nationality, the payment of National Insurance contributions or taxes.

The courts have decided that a person is regarded as “ordinarily resident” in the UK if he or she is lawfully living in the UK voluntarily and for a settled purpose as part of the regular order of his or her life for the time being. A person must have an identifiable purpose for his or her residence here and that purpose must have a sufficient degree of continuity to be properly described as settled. It is unlikely that anyone coming to live in the UK, intending to stay for less than 6 months, will fulfil these criteria.

Advice received on calling the Department of Health’s advice line (020 7210 4850). is consistent with HSC 1999/018 (and confirmed in more recent publications). The rule of thumb they gave was that somebody is ‘ordinarily resident’ if both of the following apply:

  • They will be in the UK for at least 6 months.
  • Their passport is open-ended – allowing them to stay for at least 1 year, without any restrictions.

Please note that some people – including, for example, some au pairs from non EU countries – might have passports or visas stamped with a statement that they are not entitled to state benefits. This does NOT apply to NHS treatment if they meet the eligibility criteria above.

Asylum seekers and refugees (including asylum-seekers – see Refugees below) are regarded as “ordinarily resident”. (Recent guidance from DH that asylum seekers should no longer be considered "ordinarily resident" and entitled to free primary care has been rescinded following a recent judgement - there is a letter from DH detailing the current position.[1])

Immigration officials report some new entrants to the local PCT or Health Protection Unit (HPU), so that they can be offered screening for e.g. tuberculosis. Only people who will be staying in the UK for over six months are so notified, so if a patient attends a practice with a letter from the PCT or HPU asking them to register with the practice, it can be assumed that they are bona fide examples of people who are eligible for NHS treatment.

Visitors from EEA members states carrying Form E128

In paragraphs 18 & 19, regarding visitors from EEA member states carrying Form E128, HSC 1999/018 states (and confirmed in more recent publications) states:

This form … applies to two groups of EEA nationals only: *workers posted temporarily to another member state and any members of their family who accompany them; and *students temporarily in another member state to study and any accompanying members of their family.

For people in these two groups who come to the UK, form E128 will give entitlement under the NHS to necessary treatment for any condition, that is their entitlement is not restricted to treatment that is immediately required. Routine treatment for on-going conditions existing before arrival in the UK cannot be excluded, and such patients should, in effect, receive full health care under the NHS on the same terms as UK residents. They may either be accepted by the GP of their choice, or be assigned to a GP by the Health Authority. As an NHS patient, the overseas visitor carrying form E128 should not be treated on a private, paying basis.

Refugees

(See also Asylum seekers and refugees.)

In paragraph 27, HSC 1999/018 (and confirmed in more recent publications) states:

A refugee given leave to remain in the UK should be regarded as ordinarily resident. A refugee who is in the UK awaiting the result of his application to remain in this country should also be regarded as ordinarily resident because he or she is residing lawfully for a settled purpose.

The BMA produced guidance relating to asylum-seekers .[2]

Other

The HSC includes detailed information on the entitlements of overseas visitors who are not technically “resident” in the UK (not repeated here).

Emergency or immediately necessary treatment

Treatment within an accident and emergency department, or emergency/immediately necessary treatment from a GP is free to overseas visitors.

"Under the new GMS contract or PMS agreement, a practice is required to offer free NHS treatment to anyone who requests it, if, in the opinion of a clinician, it is immediately necessary. This is essential treatment, which in the clinical judgement of a health care professional cannot be delayed or avoided." (DH/HSCD-ACCESS-PC. Annex A, para 16, p16)

Sexually transmitted diseases

No charge is made for the treatment of sexually transmitted diseases, except for HIV. Diagnosis and counselling are provided free for HIV, but not treatment. (DH/HSCD-ACCESS-PC. Annex B. Full list of exemptions from charges for hospital treatment.)

Public health Schedule I diseases

No charge is made for the treatment of notifiable diseases public health (control of disease) act 1984, section 10 (1984 c. 22) and Public health (infectious diseases) regulations 1985 (S.I. 1985/434): Cholera, Food poisoning, Plague, Relapsing fever, Smallpox, and Typhus. (DH/HSCD-ACCESS-PC. Annex D. Exempt diseases for which no charges can be made.)


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From time to time other conditions - such as swine flu - can be added to this list. Statutory Instrument 1166 states:

No charge shall be made and recovered under this regulation in respect of a supply which is made —

(i) while a disease is, or
(ii) in anticipation of a disease being imminently,

pandemic and a serious risk, or potentially a serious risk, to human health[3][4]

This guidance has been updated - see e.g. pp17-19 here and includes "accident and emergency services... family planning services... certain diseases where treatment is necessary to protect the wider public health" (list follows); "treatment for all sexually transmitted diseases, including HIV treatment..." (and a few others).[5][6]

Detainees

Anybody detained by the criminal courts (including on probation), or under the mental health act, is eligible for free NHS treatment.

Others

The "rules" are not entirely clear for interventions such as immunisation against infectious diseases, and screening for tuberculosis, where the purpose is at least partly to protect the health of the population.

If people have problems registering with a GP

LogoKeyPointsBox.png The new GMS contract states (clause 181) "The contractor shall only refuse an application [to join the practice list] if it has reasonable grounds for doing so which do not relate to the applicant's race, gender, social class, age, religion, sexual orientation, appearance, disability or medical condition".

Clause 182 defines not living in the practice area as reasonable grounds. Most PCTs would not accept being a new entrant per se as reasonable grounds.

PMS practices are different, with more discretion; but it would be unreasonable of them to decline to register a patient just because they are a new entrant.
Anybody who is entitled to free NHS treatment is entitled to register with a GP. If they expect to move out of the practice area within three months they should be registered as a temporary resident.

GPs do not have to accept anybody onto their list, or to give any reason for refusing to admit anybody to their list. That said, if they are refusing to accept anybody onto their list because they have misunderstood the eligibility criteria, then they may be happy to change their minds once they have been reassured that they may provide NHS treatment.

See also

References and external links

  1. It’s Your Practice A patient guide to GP services RCGP
  2. "England Migrant health guide"
  3. "Overseas Visitors to Scotland"
  4. "Overseas Visitors to Wales"
  5. Good "reading list" of resources (mostly with web links) relating to refugee health care, from The Kings Fund.[7]
  6. BMJ article "Restricting access to the NHS for undocumented migrants is bad policy at high cost"[8]
  7. Are you taking up or resuming permanent residence in the UK? Rules, procedures and documentation on access to hospital and primary health care, NHS charges and exemptions. Not dated. Last viewed (31 July).
  8. Department of Health. HSC1999/018. Overseas visitors' eligibility to receive free primary care: a clarification of existing policy together with a description of the changes brought in by the new EC health care form E128. London, 1999.
  9. Entitlements to NHS care page in the Migrants and the NHS area of the HPA web site. (Undated and possibly out of date, but otherwise very useful.)
  10. DH/HSCD-ACCESS-PC. Proposals to exclude overseas visitors from eligibility to free NHS primary medical services: a consultation. London: Department of Health. Within this document there are various particularly relevant annexes, including:
  • Annex A. NHS primary medical services - an explanation of the current rules.
  • Annex B. Full list of exemptions from charges for hospital treatment.
  • Annex D. Exempt diseases for which no charges can be made.
  1. DH page with resources for asylum seekers and refugees (some of the ASCT newsletters you can download from that page contain some very useful links).
  2. DH leaflet for refugees and others ("This fact sheet has been written to explain the role of UK health services, the National Health Service (NHS), to newly-arrived individuals seeking asylum. It covers issues such as the role of GPs, their function as gatekeepers to the health services, how to register and how to access emergency services.")
  3. NHS charges for people from abroad - guidance from the Citizens Advice Bureau.
  4. Asylum Support
  5. Refugee Council
  6. "Overseas visitors accessing NHS primary medical services." From the General Practitioners' Committee of BMA (GPC).[9]
  7. Lords Hansard, 14 Jan : Column WA141. GP Registration: Non-British Subjects (states: "If a non-British subject presents for registration at a general practitioner the following occurs. If they state they are to be in the country for less than three months, the GP completes a temporary services (GMS3) form. If they state they are to be resident in the country for over three months, the patient is registered with the GP using the GMS1 form. These forms are submitted by the GP to the local health authority.")
  8. International Organization for Migration (and a document from them about pre-entry TB screening.
  9. NHS Counter Fraud Service. Guidance to GP practices on GP patient registration fraud: NHS, Undated (Status uncertain; document on Pulse web site.)

References

  1. ↑ Failed asylum seekers and ordinary residence. Department of Health Dear colleague letter to Chief Executives. 1 May. Gateway Reference 9854.
  2. ↑ British Medical Association. Access to health care for asylum seekers and refused asylum seekers – guidance for doctors. London: BMA.
  3. ↑ Department of Health. Overseas visitors: pandemic flu. Last modified 17 June. Last viewed 23 June.
  4. ↑ Statutory Instrument 1166. National Health Service (Charges) (Amendments Relating to Pandemic Influenza) Regulations
  5. ↑ Department of Health International Health and Public Health Policy Division. Guidance on implementing the overseas visitors hospital charging regulations: Department of Health, International Health and Public Health Policy Division, (31 October).
  6. ↑ The National Health Service (Charges to Overseas Visitors) Regulations (Statutory Instrument). No. 238. London: The National Archives
  7. ↑ [Kings Fund. Reading list: Refugee health care. London: The Kings Fund, (April); 1-22
  8. ↑ Keith L, van Ginneken E. Restricting access to the NHS for undocumented migrants is bad policy at high cost. BMJ 350:h3056.
  9. ↑ General Practitioners Committee. Overseas visitors accessing NHS primary medical services. London: British Medical Association, (February)
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