The NHS (Charges to Overseas Visitors) Regulations 2015 came into force on 6 April 2015 and have implications for access to free secondary NHS healthcare for mission partners (UK nationals) for their stays in England.
- The Regulations are available online and can be found at The NHS (Charges to Overseas Visitors) Regulations 2015.
- The Guidance that goes with the Regulations can be found at Guidance on implementing the overseas visitor hospital charging regulations 2015. Global Connections was involved in ensuring that missionaries and volunteers overseas are specifically mentioned in this Guidance (on page 29).
- Another consultation took place in 2015/16 and examined the principle of extending charging, for example, into primary care. The full Government response to the consultation on the extension of charging overseas visitors and migrants using the NHS in England, February 2017 can be found here. A shorter Summary of changes made to the way the NHS charges overseas visitors for NHS hospital care was updated in October 2017.
1. Wales, Scotland and Northern Ireland
Healthcare is devolved in Wales, Scotland and Northern Ireland and different rules apply. At the moment there are no changes in the other three nations approach to overseas visitors’ access to the NHS and as far as we know none are planned in the near future. Currently missionaries still have an exemption from charges in Wales and Northern Ireland, and although missionaries have never had an exemption in Scotland, in practice they have not been charged as far as we are aware (in addition, exemption 4 (k) might well apply to some mission partners visiting Scotland).
2. England – the implications
- Currently, access to A&E and ambulance services is unchanged and remains free (and will include tests and treatment while someone is still under the overall care of A&E.) Once care is handed over to another team such as transfer to inpatient (admission to hospital) or follow-up outpatient care, it becomes chargeable.
- Registering with a GP and initial access to a GP is free for all overseas visitors.
- All patients using the NHS will be asked questions about their chargeable status - and this includes when registering with a GP. Those who are not ‘ordinarily resident’ in the UK will be asked to provide information about their non-UK EHIC/S1 form (if they have them) and if they understand themselves to be chargeable for NHS secondary care or exempt from charge for it. Note that this will be on a self-declaration basis (i.e. voluntary) and not providing the information will not prevent them from being registered with that practice. If the person is ‘ordinarily resident’ then they won’t be asked to provide the extra information.
- It is the intention, in time, for all other NHS funded care to be chargeable to those not ‘ordinarily resident’ (‘OR’).
- Do note that the diagnosis and treatment of specific infectious diseases will remain free to all, as will some other services e.g. family planning services, NHS111 services and services needed for certain types of violence.
- When the documents refer to ‘UK residents’ this includes people who are ‘ordinarily resident’ in the UK. The Charging Regulations currently do not apply to people who are ‘OR’ in the UK.
- No person should be denied timely treatment necessary to prevent risks to their life or permanent health, or put the public’s health at risk1.
- NHS organisations will be required to identify whether someone is chargeable before non-urgent treatment is given and a patient’s eligibility for free NHS care will be checked more regularly than is currently the case2.
What is absolutely clear is that the decision has now been made to continue the basis of the NHS as a residence based healthcare service. So, the key (and only) criteria as to whether or not mission partners working overseas will be entitled to free access to NHS care (for their stays in England) without charge, is whether they can be deemed ‘ordinarily resident’ (OR) during their times in the UK (for further information about OR see Understanding 'Ordinary Residence'). If they are considered OR they will be eligible for free secondary NHS healthcare from day one of their arrival. And please note, this is not linked in any way to your status as understood by other government departments (e.g. for tax or education purposes).
However, whilst we have genuine reasons to believe that some of our mission partners will meet the criteria for OR, it is clearly evident that others will not. And even for those who we think have a good case, there can be no absolute guarantee. If they are deemed OR, then they will have access to free NHS care, if not, they will need to pay 150% of the normal cost of any secondary health treatment, or pay through a private health insurance.
- The Ordinary Residence tool: A ‘tool’ has been created which will be used by Overseas Visitor Managers in hospitals to help determine ordinary residence, and will be part of an online ‘toolbox’. It can be found here. The Guidance on meeting the Ordinary Residence Test is based on the questions that are included in this tool.
- Private Medical Insurance: If in any doubt about your mission partners’ entitlement (especially for those who have been out of the country for a number of years), you should seriously consider reviewing their existing medical insurance to ensure it provides cover in the country that they are serving in, and when they stay in the UK. As mentioned above, people who are not deemed ‘ordinarily resident’ will be charged 150% of the NHS tariff. With the help of a representative group of agencies Global Connections has set up a group Private Medical Insurance scheme for our members. The Global Connections Group Scheme offers annual worldwide (excluding USA) medical cover with Talent Trust Consultants. For further information, download Do your mission partners need Private Medical Insurance cover when they visit England?
- Possible exemptions: A few mission partners or volunteers overseas who are in employment funded by the UK Government (and are not ordinarily resident in the UK) may be covered by the following exemption 6.3 Regulation 20 – armed forces, Crown servants and UK Government funded employment: Former residents may be working abroad as part of an armed service or as a Crown servant. They may also be in UK Government funded employment abroad or be employed by the British Council or Commonwealth War Graves Commission. Such individuals may be exempt from charges. See Regulation 20 2c, and also read the Guidance (pages 51-52) for further details concerning this exemption and examples of evidence needed.
Make sure your mission partners and your organisation are fully informed:
- Read Understanding ‘Ordinary Residence’ to ensure you have grasped this fully for each mission partner each time they stay in England.
- Download the Guidance on meeting the Ordinary Residence Test. Encourage your mission partners to insist that the OR tool is used to determine this.
- Download Registering with a GP for further advice on this issue.
- Ensure your mission partners have adequate medical insurance cover if they are not likely to be deemed ‘Ordinarily Resident’ - read Do your mission partners need private medical insurance?
- Download Post-Brexit - mission partners living and working in European Union countries for information for those to whom this now applies.
Monitoring the situation
It is really important that we build up a picture of how the new Regulations work out in practice with relation to missionary access to NHS healthcare – both those who are deemed Ordinarily Resident as well as those who are not. Please let us know your experiences by completing our simple survey which should take just a few minutes to complete (please note that we will not be requesting any names or medical information in this survey).
3. Upfront charging
We have heard recently of a case where a mission partner needed to access NHS secondary healthcare when staying in England and, although they had insurance cover, was asked to pay the costs upfront. We were concerned to subsequently find out that in the Upfront charging guidance it says “In cases where the patient has medical health insurance and does not require immediately necessary or urgent treatment, direct payment should be taken either from the patient or the insurance company prior to any treatment”. However, on p108 of the Guidance on implementing the overseas visitor charging regulations it says that if patients are deemed chargeable they should be asked if they have private health/travel insurance. Only if they do not possess this, or if the Trust deems the insurance to be insufficient to cover the costs of healthcare, should they charge the patient directly.
We have pointed out this contradiction to our contacts in the Dept of Health, and had it confirmed from them that in a non-urgent NHS treatment situation, the latter is what should happen. Please point your mission partners to p108 of the guidance so that they can show this to the Trust if they run into difficulties, and please do make sure they have adequate medical insurance cover for their stays in England if they are not likely to be deemed Ordinarily Resident.
4. Hospital pre-attendance forms - residency status questions
The Department of Health advises hospitals to ask patients to complete 'pre-attendance forms', particularly those who are seeking pre-planned elective treatment. Some of these forms may well ask questions about residency or 'the purpose of your stay in the UK'. The advice we have been given is that patients should provide the information asked for, and in ‘other’ explain that they are between missionary/charity work assignments and that is why they have been absent from the UK etc. That should prompt a discussion with the Overseas Visitor Manager to establish if the mission partner is in fact OR here, despite their absence from the UK. As already mentioned, please encourage your mission partners to then insist that the OR tool is used to determine this.
Please note that Covid-19 was added to the list of infectious diseases within the NHS (Charges to Overseas Visitors) Regulations in January 2020, which means there will be no charge made to any overseas visitor for any diagnostic testing for the coronavirus, and no charge for any treatment if the result is positive.
5. Post-Brext - mission partners living and working in European countries
Now that the UK has left the European Union there are changes that mission partners, agencies and churches need to be aware of regarding access to the NHS for those living and working in EU countries.
The Withdrawal Agreement set out the terms of the UK’s withdrawal from the EU in March 2020, and includes provisions on citizens’ rights. It protects the rights of EU citizens and their family members who live in the UK, and UK nationals and their family members who live in EU countries. The EEA EFTA Separation Agreement and the Swiss Citizens’ Rights Agreement extend the citizens’ rights provisions of the Withdrawal Agreement to nationals of these states and UK nationals who have moved between the UK and these states before the end of the transition period3.
For information specifically geared for those currently living and working in EU countries, read Post-Brexit: mission partners living and working in European Union countries - access to free NHS healthcare when visiting England.
6. Returning to the UK to settle permanently
As clearly stated on this gov.uk webpage: "Citizens who return to the UK on a settled basis will be classed as ordinarily resident, and will be eligible for free NHS care immediately."
Sandy Morgan, Global Connections
1 and 2 From: Government response to the consultation on the extension of charging overseas visitors and migrants using the NHS in England, February 2017, page 7 and 8.
3 More information on the citizens’ rights provisions can be found in Withdrawal Agreement explainer for part 2: citizens’ rights published by the Foreign, Commonwealth and Development Office (FCDO).