Passport checking and charging for NHS care: what are its impacts on vulnerable populations?


This blog is based on a dissertation completed by Laura Cook as part of a Masters in Global Health Policy


The lack of access to healthcare for undocumented migrants and failed asylum seekers has for many years been considered one the United Kingdom’s most pressing human rights issues.1 Now, the government’s aim of creating a ‘hostile environment’ for immigrants is making things worse.

Last year, a new law required hospitals in England to check patients’ entitlement to NHS care, and charge upfront (at 150% of the standard NHS tariff) when people fail to produce the right documents.2

Failed asylum seekers and other migrants without the right to work or claim benefits are already among the most excluded and vulnerable groups. These people are likely to be among the worst affected by the requirement to pay, and asking them to do so at the point of use is likely to further undermine their access to care.3

Therefore, we conducted a systematic review of all the empirical evidence on the impacts of charging for these groups.  We looked at studies published since 2004, when the first “cost recovery” regulations for refused asylum seekers were introduced in England, to June 2018. Our findings give considerable cause for concern about the impacts of the new legislation.

A number of studies show that awareness of eligibility criteria among healthcare providers is limited, with the effect that free care is often being wrongly denied. And the financial impact of charging on the individuals affected is stark.  Evidence shows that the majority of those refused free care have been unable to pay their bills, leaving them with large medical debts. 4,5,6

In this context, the requirement that payment is made upfront results in an effective denial of care for a large number of vulnerable people.

There are also questions about the financial impact of these regulations for the NHS itself.  Most of the evidence suggests that the income received from patients is more than offset the administrative cost of charging7,8 – a lesson that may also be relevant to those calling for wider use of charging for migrants and other patients.

Though data on specifics is lacking, it is also apparent that people who are deterred from seeking care are likely to experience a deterioration of their health status, resulting in more costly healthcare needs in the longer term.

Direct out-of-pocket payments are seen by many to be inconsistent with the values of the NHS. Supporters of those values should be concerned when immigration policy is used in such a way as to further aggravate health inequalities in the UK. More investigation into how immigration policy is affecting behaviour on the ground, and with what outcomes, would appear to be a priority.



  1. Yates, T., Crane, R. & Burnett, A. (2007) Rights and the reality of healthcare charging in the United Kingdom. Medicine, Conflict and Survival. 23(4): 297-304.
  1. Department of Health & Social Care (2018) Guidance on implementing the overseas visitor charging regulations. Available at: [Accessed 24th April, 2018].
  2. Hargreaves, S., Holmes, A. & Friedland, J.S. (2005) Charging failed asylum seekers for health care in the UK. Comment. The Lancet. 365: 732-733.
  3. Maternity Action & Women’s Health and Equality Consortium (WHEC) (2017) The Impact on Health Inequalities of Charging Migrant Women for NHS Maternity Care: A Scoping Study. London: Maternity Action. Available at: [Accessed 9th April, 2018].
  4. Doctors of the World (2017) Deterrence, delay and distress: the impact of charging in NHS hospitals on migrants in vulnerable circumstances. Research Briefing. London: Doctors of the World. Available at: [Accessed 9th April, 2018].
  5. Medact Manchester (2017) Healthcare professionals’ views and experiences of dealing with refugees and asylum seekers: a survey of North-West practitioners. Available at: [Accessed 20th April, 2018].
  6. Ipsos MORI (2017) Overseas Visitor and Migrant NHS Cost Recovery Programme: Formative Evaluation – Final Report. Available at: [Accessed 26th April, 2018].
  7. National Audit Office (2016) Recovering the cost of NHS treatment for overseas visitors. Report by the Comptroller and Auditor General. Available at: [Accessed 25th April, 2018].