2Responsibilities across the health system
16.Only 11 of 50 trusts responding to a National Audit Office consultation said that they expected income from overseas patients to increase significantly in future. The Department for Health (the Department) said that number needed to go up.40 It acknowledged that there was a long way to go, both to ensure that all trusts dealt with overseas charging with the seriousness it deserved, and that the Department did enough to help trusts get better at tackling the issue.41 In particular, the Department told us that it wanted to foster a culture where everybody who works in the NHS feels responsible not only for patient care, but also for financial rigour.42
Variable performance across trusts
17.There is significant variation in the amounts that individual trusts charge. Just 10 of the 154 acute and specialist hospital trusts accounted for half of the charges to visitors from outside the EEA&S in 2015–16. Eight trusts did not charge any visitors from outside the EEA&S and 22 trusts did not report any cases under the European Health Insurance Card (EHIC) scheme. Larger trusts and those in regions with more visitors are likely to charge more. However, trust size, type and location can explain only around half the variation in the amounts trusts are charging overseas visitors.43
18.Once they have charged patients, trusts have varying success in collecting payments. Nationally, trusts collect only around half of the amounts they invoice to overseas visitors directly. However, performance varies significantly from trust to trust, with some collecting just 15% and others collecting 100% of the amounts they charge (even after excluding the top and bottom 10% of trusts).44 The Department suggested that one technique was for trusts to be clear to patients about charging and the likely cost of treatment, and ideally secure payment for non-urgent treatments up front. It described this as an element of best practice that it wanted to see adopted more widely.45 The Department suggested that debt collection was a service that might well be included were groups of trusts to join up their back-office functions. It also highlighted that trusts could link through to the Home Office system and a record of bad debt could be taken into account the next time a person applied for a visa.46 The Department told us that it hoped to see the amounts of bad debt written off go down, but it did not have any projections for what it expected, or wanted, the level of written-off debts to be.47
19.The Department and NHS Improvement recognised that some trusts were charging and recovering much more than others, but could not explain why this was the case. They told us they were unsure whether trusts that charged and recovered more were actually doing well, or whether they just appeared to be doing well relative to the poorer performance of other trusts. NHS Improvement had, however, identified the cohort of trusts where there appeared to be the biggest gap between what the demography suggested the trust should be charging and the actual amount charged.48 It said that it needed to benchmark trusts, identify best practice and share this information across the system. It also indicated that it would use the information it gathered to develop helpful improvement tools for trusts to use.49
20.The Department told us that it had added benchmarking information on cost recovery for overseas visitors to the ‘model hospital’ data it made available to trust governing boards. In future it therefore ought to be much more explicit to the boards of trusts when trusts were out of line with where they should be. It would also give those charged with oversight and intervention the opportunity to inquire and ask questions and allow more targeted follow-up.50
The wider health system
21.The Department has introduced financial incentives to encourage trusts to improve their processes and increase charging. There are two incentives: one for the EHIC scheme, and one for visitors from outside the EEA&S. The Department argued that the EHIC incentive, introduced in October 2014, has had a positive effect, with trusts reporting more treatments. The rise in reporting had not led to an increase in charging, but the Department told us that it expected charging would go up.51 The non-EEA&S incentive, introduced in April 2015, allows trusts to charge patients 150% of the normal NHS tariff price. The amount charged has increased much in line with the change in prices, but there is no evidence that trusts are identifying more chargeable patients from outside the EEA&S.52
22.Healthcare commissioners (NHS England and local clinical commissioning groups) bear the cost when trusts do not identify chargeable overseas patients, and have powers to audit trusts to ensure they have appropriate policies and procedures in place. The NHS standard contract makes clear that clinical commissioning groups should not have to pay for treatment provided to chargeable overseas visitors if a trust does not make reasonable efforts to recover the costs.53 It is the responsibility of commissioners to challenge hospital trusts to show they are identifying and charging all the overseas patients they should.54
23.It has been reported that the more stringent tests of eligibility for maternity care put in place by St George’s Hospital in London were prompted by the local clinical commissioning group’s refusal to pay for overseas patients that it thought should have been charged directly. The Department described this as commissioners doing exactly what they were supposed to do.55 NHS Clinical Commissioners told us that clinical commissioning groups recognised their role, and suggested that targeted data and training for commissioners would go a long way in helping the health system to achieve the aims of the cost recovery programme.56
24.NHS Improvement, as the regulator of trusts, has the potential to influence trusts’ behaviour. It told us that it needed to ensure that appropriate processes were in place throughout the acute sector. Building on its work to collect data and benchmark trusts, it planned to intervene where it thought organisations were not fulfilling their obligations and needed support to do so. It agreed that there also ought to be clear, consistently applied, sanctions when trusts that needed to improve did not do so.57
The role of GPs
25.The Department explained that GPs were not contractually obliged to do anything to identify overseas visitors.58 Its charging guidance does recommend that GPs should note in the referral letters they send to hospitals if they know that a patient is an overseas visitor, holds an EHIC or might be directly chargeable.59 We note that, in practice, some GPs do provide hospitals with information to indicate that patients might be chargeable, but the capability for systematic data sharing is not built into NHS IT systems.60
26.At our evidence session, the Department was unsure about the arrangements for reclaiming the costs of primary care, such as GP appointments, from other EEA&S states. It subsequently confirmed the legal basis for charging for primary care under the EHIC scheme. The cost of all ‘needs arising’ treatment carried out, subject to valid documentation being presented, can be reclaimed. This includes services currently exempt from charges under domestic legislation, such as GP care and also accident and emergency services. Were GPs to identify EEA&S visitors, the UK would be able to recover the costs of treatment from other EEA&S member states, increasing income for the health system. The Department told us that it did not collect information on whether GPs were identifying EEA&S patients and that, while it was keen to support any GP surgeries that wished to pass on relevant information, it was not able to mandate any systematic reporting.61
40 Q 60; C&AG’s Report, para 2.2
43 C&AG’s Report, paras 2.16–2.20
44 C&AG’s Report, para 3.33
52 C&AG’s Report, para 3.32 and Figure 6
60 C&AG’s Report, paras 3.10 and 3.21
61 Qq 148–150; Department of Health (TOP0010), para 5, para 6
30 January 2017