We know of no good evidence that “health tourism” – individuals travelling to England solely to access NHS services – is a significant burden on the NHS (Hospitals to check patients’ right to care, 6 February). Such patients are seen very rarely, if at all, in clinical practice.
Assurances that individuals with infectious diseases and those requiring “emergency treatment” will not be turned away fundamentally misunderstand how healthcare is delivered. People present with symptoms, not diagnoses. Unless people can access routine investigations, communicable diseases and life-threatening conditions will go undiagnosed. Case studies show that, even under the existing charging regulations, individuals are coming to harm.
The NHS in England sees around a 650,000 patients every 24 hours. The administrative costs involved in accurately assessing whether each patient is “lawfully resident” would be substantial. Everyone would be inconvenienced by the requirement to carry means of identification. As Nye Bevan wrote, “if the sheep are to be separated from the goats both must be classified. What began as an attempt to keep the Health Service for ourselves would end by being a nuisance to everybody.”
It is not naive to suggest that the NHS should offer treatment to everyone regardless of immigration status and that the task of policing our borders be left to the immigration authorities. This is the approach taken in Scotland, in Wales, and in a number of other European countries. The media noise about health tourism is a distraction. The primary reason the NHS is struggling is that we choose to spend a much lower proportion of gross domestic product on healthcare than other high-income countries.
Dr Tom Yates CT1 doctor in acute medicine, London, Ibrahim Abubakar Professor of infectious disease epidemiology, University College London, Dr Rob Aldridge ST5 doctor in public health, University College London, Dr Alex Armitage Paediatric registrar, Lewisham Hospital, London, Dr Peter Baker Public health speciality registrar (ST4), Imperial College London, Dr David Barr Specialist registrar in infectious diseases, Glasgow, Dr Sunil Bhopal Wellcome Trust research training fellow, London School of Hygiene & Tropical Medicine, Dr David Biles GP Trainee, London, Dr David Blane Academic GP, Maryhill Health Centre, Glasgow, Dr Mike Brown Consultant, Hospital for Tropical Diseases, University College Hospital, London, Dr James Chan ST2 doctor in emergency medicine, West Yorkshire, Dr Jim Cole General practitioner, Tower Hamlets, London, Dr Rosie Crane Paediatric registrar, Oxford, Dr Jonny Currie GP and public health specialty registrar, Liverpool, Dr Angharad Davis Neurology registrar, National Hospital for Neurology and Neurosurgery, London, Dr Delan Devakumar ST5 doctor in public health, University College London, Dr Chris Dugan Specialist registrar in infectious diseases, London, Dr Chi Eziefula Consultant in Infection, Brighton and Sussex University Hospitals, Dr Catherine Isitt CT1 Doctor in Haematology, London, Dr Søren Kudsk-Iversen LAS senior house officer in anaesthetics, Reading, Dr Michael Marks Infectious diseases registrar, Guy’s Hospital and St Thomas’ Hospital, London, Dr Lizzie Moore ST2 doctor in public health, Oxford, Dr Miriam Orcutt Research associate, Institute for Global Health, University College London, Dr Tom Parks ST3 registrar in general medicine and infectious diseases, University College Hospital, London, Dr Erica Pool Academic clinical fellow (CT3) in HIV/genitourinary medicine, Brighton, Dr Helen Preston ST4 doctor in obstetrics and gynaecology, North West Deanery, Dr Carl Reynolds Specialist registrar in respiratory medicine, Imperial College Healthcare NHS Trust, London, Dr Jenny Riches ST2 doctor in obstetrics and gynaecology, North West Deanery, Dr Rafi Rogans-Watson Specialist registrar in geriatrics, London, Dr Partho Roy ST3 doctor in public health, Croydon, Dr Adam Sandell General practitioner, Cumbria, Dr Deepa Shah General Practitioner, London, Dr Catherine Sikorski ST3 doctor in paediatrics, London, Dr Vasundhara Verma GP trainee (ST2), Brighton, Dr Stephanie Wilmore Specialist registrar in microbiology, London, Dr Christopher Wood Consultant HIV physician, North Middlesex University hospital, London, John S Yudkin Emeritus professor of medicine, University College London
• The proposal detailed in your report adds “action to recoup treatment costs from overseas visitors” to an already expanding list of government “responses” to the current healthcare crisis. This now includes: sundry restructurings; experiments with private/public partnerships; periodic “efficiency” drives; reallocating existing limited funds between cash-strapped services; increasing calls upon the voluntary sector; and blaming health workers and managers for their ineffectiveness, patients for their lifestyles and obesity, and relatives for failing to observe their in-family care responsibilities. Indeed, it includes anything but the establishment of a properly weighted, fully progressive system of taxation that can alone provide the fundamental human and material resources needed to solve the problem, and expand much-needed services, jobs, incomes and purchasing power among the poor and needy in deprived areas.
As the vast majority of us have made clear our willingness to contribute appropriately to this, it is difficult to see how the government can avoid the obvious conclusion; except for the fact that it would (at last) involve people like themselves and their wealthy friends making a full and proper contribution to society’s needs. As things get increasingly desperate, either we increase public pressure to an extent necessary to force them to take effective action and give a true moral lead, or we replace them with people more morally and humanly inclined.
Bernard Cummings
London
• We can all see that the government’s proposal to make foreign nationals show proof of ability to pay before receiving NHS treatment is monstrous; but have they realised it is also misplaced? If the problem is that too many travellers to Britain fail to acquire adequate health insurance before departing, surely the fault is not with our hospitals but the airlines? If the carriers were to be made liable for the NHS costs for any uninsured passenger that boarded one of their planes, they would take steps to ensure no one flew to Britain without insurance; which would mean no proof of payment at the hospital entrance would be necessary and also that the problem would be addressed before rather than after the passenger fell ill. Problem solved.
Ian Mackillop
Ilminster, Somerset
• The harrowing case of Iris Sibley and her family, reported on your front page (Six-month hospital ordeal exposes crisis in social care, 6 February), highlights the complexities and confusion that exist in relation to the long-term care of vulnerable elderly people, which no doubt adds to any stress and strain experienced by those caught up in the system.
In this case it was the lack of appropriate healthcare sector resources, not of those in social care, that created the so-called bed-blocking scenario, given that Mrs Sibley was assessed initially as needing continuous professional healthcare in a nursing home rather than in a residential care home. Most nursing home care of this type, ie continous healthcare provision, is not subject to financial assessment, while residential – ie social – care is subject to means testing and financial contributions from residents. There are also a variety of in-between “hybrid” options, as reported in your story, that can create further uncertainty and distress at very difficult times in people’s lives.
The mantra from ministers for greater integration of health and social care continues to ring hollow when, in addition to the problem of massive under-funding, the two systems are funded and resourced, commissioned, provided and managed so differently. Until these issues are addressed in their totality, the cracks in the creaking systems will just get bigger, adding to the current lamentable situation. I see no evidence of any coherent strategy, let alone the political will from this government to tackle these fundamental structural problems – time now for a royal commission, maybe?
Colin Biggins
Dedham, Essex
• Few people deny that the NHS and social care are underfunded. As a Conservative MP has pointed out, recent increases in funding have been less generous than ministers claimed. In the recent autumn statement, the chancellor declined to allocate more money for the adequate provision of social care for frail or lonely people leaving hospital.
It is not well enough realised that a major loss of funds from the health service arose in 1991 when the then government resolved to manage it as though it were a market, with “providers”, eg hospitals, “selling” their services to “purchasers”, eg health authorities.
For the market to work, tenders, contracts, invoices and payments from one part of the service to another were necessary, causing huge increases in administrative costs. Before the market, these costs were about 5% of the NHS budget. By 1997 they had risen to 12% of the budget, and by 2010 to 14%.
With the market comes competition, which many politicians thought would improve performance. Complex medical care needs cooperation, not competition. With a commercialised market hospital, managers have to consider the hospital’s income from a treatment, as well as what treatment the patient needs.
Parliament is soon to debate the NHS reinstatement bill, one of whose aims is to get rid of the expensive competitive market. All voters should write to their MP urging support for this bill. This is not a political matter because all political parties in government have supported this market, though individual MPs have not. MPs may change their minds, and their votes, when they consider the evidence and the views of their constituents.
Dr Richard Gunstone
Rugby, Warwickshire
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Health tourism claims are a distraction from NHS’s real problems | Letters
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