Oral evidence: NHS Treatment for Overseas Patients, HC 771

Oral evidence, 21 November 2016.

Witnesses

Chris Wormald, David Williams and Bob Alexander.

Chair

Good afternoon, everybody, and welcome to the Public Accounts Committee on Monday 21 November 2016. Today we are looking at the funding of NHS treatment for overseas patients and how the NHS recovers the cost of that treatment for people who are not resident in the UK. Our witnesses this afternoon are David Williams—welcome back, Mr Williams—the director general of finance and group operations at the Department of Health. He is the man who managed to balance the budget this year; I am sure a knighthood is winging its way to you from the Government. This Committee, as you know, has concerns, so we are particularly watching this area of funding. Chris Wormald is the permanent secretary at the Department of Health. Welcome to you, Mr Wormald; we haven’t seen you for a few weeks. Bob Alexander is the executive director of resources and deputy chief executive of NHS Improvement. Welcome. I think this is your first Committee with us, Mr Alexander.

Bob Alexander

Yes.

Chair

Welcome. We are a friendly bunch—honestly. Aren’t we, Mr Wormald?

Chris Wormald

Oh yes.

Chair

Our hashtag today is #nhs. We are looking today at this Report by the National Audit Office on the use of the NHS by overseas visitors. To be clear, the NHS provides immediately necessary and urgent treatment for any patient who needs it. There is quite a complex category of who should pay and who shouldn’t. A number of overseas visitors will pay. The NHS has a duty to recover costs, to defray the costs to the British taxpayer. It is relatively small in the context of the NHS budget, but we watch the pounds very closely, as I know you do, Mr Williams and Mr Wormald. If overseas visitors do not pay, that is a dent in the budget accounts of about half a per cent of the NHS budget. Is that right, Mr Williams?

Chris Wormald

It is about that.

Chair

But you never know—it might be more. We will uncover that in the hearing. We want to know this afternoon why the Department has not met the target for cost recovery. We want to particularly touch on the difference between charging and what you actually collect, because I know there are quite big differentials there; that is certainly one of the issues for my own hospital at Homerton. We want to know what you are doing to tackle the barriers to those on the frontline who have to start the process of logging the correct money and making sure that people are billed. We then want to know how well prepared the Department is, post-Brexit, when we are going to see a number of changes to the already complex categories of who qualifies for free treatment and who does not. Caroline Flint is going to kick us off.

Caroline Flint

Welcome, everybody. Mr Wormald, for the Committee and people watching, could you explain what the statutory responsibility is for those working in the NHS to recover payments from overseas patients?

Chris Wormald

There is a statutory requirement on NHS trusts to identify and recover, in accordance with the relevant regulations. We issue guidance on how to do that, but the statutory responsibility is on trusts.

Caroline Flint

Could you say a little bit more about how the charges apply and how they should be recovered, for the benefit of all of us and those watching?

Chris Wormald

It is, as the Chair said, an extremely complicated picture. I think the National Audit Office did an excellent job of laying out how it works. I should say straight away that we thought this was a very fair Report that correctly identified where we have made progress and where we have further to go. There are basically three systems that we run in this area. The first and simplest is the visa surcharge, which we charge to anyone who applies for a visa lasting over six months. That is paid as part of the visa system, before people get anywhere close to the NHS. That is probably the simplest part of the system. The second part of the system is that which applies for people who come to the UK from the European economic area, where there are several schemes in operation, but the basics of all of them is that for people who are resident in other European countries, it should be the sending country that pays, with the exception of old-age pensioners, which we might come back to later. As I say, there are several schemes, as set out in the National Audit Office Report, that apply in that area. The most complicated category for trusts is where people who have not paid the visa surcharge, are not from the European economic area and are not otherwise exempt need to be identified and then charged individually by a trust. Certainly at trust level—I think it is fair to say, Bob—those are the most complicated category for our hospitals to deal with. Sorry, that is a very brief—

Chair

So you underline the complexities, Mr Wormald.

Chris Wormald

Yes. As I say, the National Audit Office has done a fine job of setting out the complexities in this area and, as I am sure we will address in this hearing, the complexity of the system, which was built up over quite some considerable time, is one of the big challenges here. We all know why these things become complicated, but when you are an individual trust trying to apply the system, it is a complicated picture.

Caroline Flint

For the record, there have been some improvements in collection in this area, and some of the incentives seem to be producing a result, but compared with what has been estimated as the cost to the NHS—earlier this year, on 1 February 2016, Lord Bates, I think, who was then a Minister in the Home Office, said that based on the 2013 figures, the NHS was losing something like £2 billion a year from non-payment for treatment that should be charged. The trajectory that you established was to recover £500 million and, while there have been some inroads into that, more recently you have had to adjust that to make it less than £5 million[1]. So what is your understanding about the cost to the NHS of not recovering what is owed to it from overseas visitors?

Chris Wormald

Just to be clear about that £2 billion number, which comes from research carried out by the Department: that is the total cost to the NHS of people who are not ordinarily resident. That is not the same as the chargeable amount, because we have, in one way or another, decided—this is all done through parliamentary regulation—to exempt a whole series of categories of charging. So we do not charge for any primary care for anyone, for very good public health reasons, and that is all included in the £2 billion. We do not currently charge for accident and emergency treatment, for ambulances, for a lot of community treatment or for a lot of mental health treatment—also included in that £2 billion. So there is a total cost, which was estimated—and it is a very rough estimate, and I am sure we will come back to some of these questions—at £2 billion. I don’t want to overplay the science of this, but out of that we came to the figure of £500 million as the chargeable amount—up to £500 million, which is what we therefore set as—

Caroline Flint

So how did you work out the £500 million?

Chris Wormald

As I said, I am not going to overplay the science of this—[Interruption.] I thought that might amuse Mr Bacon, but I thought I should say it straight up before you said it.

Caroline Flint

May I help you out? Because my colleague, Ms Smyth, has some useful information about how the NHS, since its inception, has applied formulas to this area.

Karin Smyth

Bevan, when he looked at this in 1948, asked the Department to do some estimates of what the cost of overseas visitors was, and he came up with £200,000, which was roughly 0.5% of the NHS total budget and which this figure currently seems to be lingering around—at roughly 0.5%.

Chris Wormald

The history of this is indeed interesting—

Caroline Flint

Would you agree with my colleague that you are still using the same formula as Bevan used in 1948?

Chris Wormald

What we did in 2013—as I said, no one had really looked at this question before we did those stats—was to do a top-down analysis. We had some consultants who did it for us. The analysis came up with these numbers, which are calculated top-down, based on a series of assumptions about the number of people here and the charging amount. One of the things that we have not had previously, and still do not have fantastically, is bottom-up data about what is really happening. So all the numbers we are quoting are done by top-down calculation. The history of this is indeed—

Caroline Flint

Is that because they are not collecting the information locally?

Chris Wormald

Well, the only information that we currently collect is about who is charged right now. Given that we know that there is a gap between who is charged right now and who should be, we have to find an estimate, which we did via that top-down process, of what the gap is. As I say, I do not want to put too much science behind it, but it is the first and best estimate we have had. As you say, the history is interesting, because the first charging regulations were introduced in the national health service in 1982. Essentially, there were then three decades when very little happened. We have made much more progress in the last three years than we had made in the previous 30, both to enrich our knowledge on this and to get more cash in, but we fully accept—this goes with your question and the National Audit Office Report—that although we have done a lot, there is an awful lot more to do before we can say, hand on heart, that we are doing our duty to the taxpayer in this area. We think we have achieved a lot, and a lot more than has been done previously, but we are not at all defensive about the fact that we have a lot further to go.

Caroline Flint

I fully accept that you are starting from a low base and, to be honest, the culture has not really existed in our NHS to apply the sort of machinery that is necessary to find, identify and treat people fairly. That is the other issue: we want everybody to be treated fairly and it is very important how information is collected. Perhaps we could go on to the target of £500 million. Determining how that was arrived at has been interesting, but now, even though more money has been recovered in the last few years, you are reassessing the trajectory and are going to make it lower than the £500 million—

Chris Wormald

No, we haven’t changed our target.

Caroline Flint

Your expectation of what you are going to get.

Chris Wormald

What we did—the National Audit Office correctly quoted this—is, from our internal monitoring, set a trajectory of what we would expect to charge if nothing changed. So, if we took no further action between now and the target date, what would we expect to happen? That is the trajectory that gets us to basically about £350 million of charged expenditure, which is obviously short of where we want to be. The question we then have to ask ourselves is, what further action on top of what we are doing already do we need to take to move us towards that up to £500 million? That is a piece of internal monitoring of how well we are doing right now, which shows exactly what you said it shows, which is that we have more to do. I can say a bit about what those things are, if you like.

Caroline Flint

We are going to explore how the system can be improved and what more could be done at a local level to identify and follow through, but could I ask you to look at figure 5 on page 23? We can see here the Department’s ambition for cost recovery and internal forecast for amounts charged. Looking at some of the forecasts on EEA, non-EEA and the surcharge, will you say something about how that is broken down and particularly about what you expect should be charged for treating patients from the EEA? Let us be clear that this is not about charging individuals directly, but about reclaiming from the EEA country of origin.

Chris Wormald

That is exactly right, and this chart clearly shows the nature of our challenge. Going from the top, the amount raised by the surcharge is simply a function of how many visas of over six months there are. It will go up and down with that and I am sure that people will debate whether a high number is a good thing or not.

Chair

That is easy for you to collect.

Chris Wormald

That was the centrepiece of our strategy. It is much easier for the NHS—

Chair

We know that; it is the other bits we are interested in.

Chris Wormald

The issue in the non-EEA part of the block there is both about identification and recovery. Those are our two issues in that area. In the bottom block, our issue, as you say, is purely one of identification, where what we need to do is identify more EEA people, get their EHIC number out of the system and then go about reclaiming. Once we have that information, the reclaiming bit is actually pretty easy. The question—right down in the nuts and bolts, and Bob might want to say a bit about this—is about how trusts identify the people. As you said a few moments ago, this is very difficult for the NHS. As the NAO points out, the system is not set up to check identity and charge people. It is much easier for systems that are set up to check identity and charge people to do that as a natural course of business. Were we in the United States, where everyone is charged, it would obviously be much easier to identify them. Our system is not set up like that.

Mr Bacon

How long has there been a statutory obligation to identify?

Chris Wormald

As I said, the first regulations that we found that introduced charging were in 1982.

Mr Bacon

So there has been an obligation for 34 years?

Chris Wormald

Yes. As I said, at an individual trust level, given that you don’t routinely check the identity of who walks into A&E or who you’re treating, it is something you have to do on top of what you would normally do.

Chair

There is possibly one exception to that: dentists, where people have to pay. Opticians are slightly different, because they are private.

Chris Wormald

Yes, exactly, but for the majority of free healthcare, hospitals do not routinely either check identity or charge, so we are trying to introduce this system.

Mr Bacon

With respect, I think that is complete nonsense. I’ve been treated in hospital myself in the past five years. Both of my children have. My wife has. Other members of my family have. I don’t recall a single occasion when we were not asked who we were. The idea that it is something extra—

Chris Wormald

Obviously, people are asked who they are, but they are very rarely asked—we have some examples now of where we’re doing this—for example, to produce two forms of ID, including one form of photo ID.

Mr Bacon

I accept that, but you are saying that it is just not routine for people to be asked to be identified.

Chris Wormald

I should have been more specific in my answer.

Mr Bacon

Is that not part of the problem? For 34 years, you’ve had this statutory obligation.

Chris Wormald

Sorry. I will be more specific with my answer: the NHS does not routinely ask people to prove their identity; it of course asks for their identity, you are correct.

Caroline Flint

On this issue around charging visitors from within the EEA, perhaps I could move us to figure 4 on page 19 of the Report, which shows the reported amount charged in 2012-13 and the potentially chargeable amount estimated by research that was done in 2013 as well. I presume that part of this research underpins the changes you are trying to make to recover more. It really stands out, doesn’t it, how much we are not getting back, even of the money we are due from the country of origin? Would you agree with that?

Chris Wormald

Yes, and since we introduced the incentive scheme that you mentioned earlier, and the various changes to the NHS IT that we’ve made over the past two years, we have seen the number of EEA treatments identified going up.

Caroline Flint

Where would figure 4 be if it was drafted today, based on what you’ve just said? What would it show, in terms of what is potentially chargeable and the reported amount for now?

Chris Wormald

That is the amount—

Laura Brackwell

Page 9, figure 1.

Chris Wormald

That number is going up. The number of EEA nationals being identified is going up, but it is not going up fast enough. We accept that, and that is one of the things we need to take further action on.

Caroline Flint

Have you taken a close look? Obviously, we have got a problem in our system because, I think you would agree, it is nowhere near where it should be. Have you had a look at other countries and how they are making claims against the UK for UK nationals receiving treatment in their countries? Have you had a close look at that and thought about what they are doing that we could do better?

Chris Wormald

In most cases, and the National Audit Office reported on this in its Report, they have a system that has charging built into it from the beginning. It is obviously much easier if you are charging everybody, either through insurance or through direct payment.

Chair

Is there an example anywhere in the country that is doing really well at this that you think is worth highlighting?

Chris Wormald

I do not think we have found a comparable system to ours, and I don’t think the NAO did either.

Chair

Mr Alexander, do you know of anywhere that is doing a particularly good job?

Chris Wormald

Within the UK? Yes, we do have examples. I misunderstood your question.

Bob Alexander

In the analysis that we’ve done to support the Department and the Home Office, and using Trust information, there are certainly particular trusts that are markedly recovering more than others. The thing that we don’t know yet, which is something we need to find out, is whether they are just doing better relatively because other trusts are quite poor, for want of a better word—that is a pejorative line—or, how much more can they do? That is a piece of work that we are actively engaging with an initial cohort of significant trusts about.

Chair

I partly raise it because my own finance director says a greater access to identified best practice in this area would be a great help, just to highlight that. That is the Homerton. In the past two years, they have billed £830,000 for non-residents in receipt of NHS treatment. Of that sum, payments of £127,000 have been received. That highlights a couple of things: they are wondering whether there is better practice they can learn from; and when they are billing, they are only getting a fraction of it back.

Chris Wormald

Yes. The first task, of course, is to ensure that we are billing everyone. There is then, as I said, the second task: actually getting the cash in. That sounds like a particularly low number. We normally see higher numbers than that. They may have particular issues with the demography of their area. We have some trusts that are looking at more radical approaches, and some of those are mentioned in the NAO Report. We do have some trusts that are now, either for some services or more generally, asking for two forms of ID before treatment. That is obviously a controversial thing to do, but in terms of how you get those numbers up, those are the kinds of things you will look at. We do not have evaluated results of those things yet. What those trusts are reporting is that that does lead to an increase in identification, although you might still have the collection problem that you mentioned at Homerton.

Caroline Flint

I have some DWP data on EHIC reporting for 2015-16. I find that for my own trust—Doncaster and Bassetlaw Hospitals NHS Foundation Trust—there was nil reporting in 2015. There were 22 trusts—some acute and some specialist—that did not report any cases under the EHIC scheme. What do you think about that?

Chris Wormald

As Bob said, we have a long way to go on these issues. I do not know the demography of Doncaster, but it seems quite unlikely that the number should be zero. One of the things we have done is identified the cohort of trusts where we think there is the biggest gap between what the demography would suggest they should be reporting and the actual amount. I do not know whether Doncaster is on that list, but we will be focusing our good practice work on that cohort of trusts. Do you happen to know, Bob?

Bob Alexander

No[2].

Caroline Flint

Again, it is interesting to see the two-way process that happens across the EEA community. In answer to a written question on 29 February, the then Minister, Alistair Burt, provided a useful table, from which the NAO has drawn its figures. That shows that we reclaimed something like £49 million against other EEA countries plus Switzerland, but close to £675 million was reclaimed back the other way against us. Do you think that is unrealistic in terms of what we should be getting back?

Chris Wormald

That number is hugely driven by the number of UK state pensioners who live abroad. Because of the way the system works, if you are a UK state pensioner, we are responsible, regardless of where—

Caroline Flint

How many British pensioners are living in Poland?

Chris Wormald

I do not happen to know.

Caroline Flint

The figures for Poland show that the Polish Ministry of Health claimed £4.3 million against the UK and we claimed £1.5 million for people receiving treatment here. Does that not sound a bit odd? For young Poles here who are working fit, we have claimed £1.5 million, and they have apparently claimed £4.3 million from us for people from the UK in Poland.

Chair

It should be familiar to you, Mr Wormald, but for ease of reference, the Clerk is going to provide a copy of the written answer.

Caroline Flint

And the Irish Government have claimed £215 million against the UK, and we have claimed about £19 million back.

Chris Wormald

I am not sure that those numbers are correct. I will go away and check. I had those numbers the other way around.

Caroline Flint

It is a written answer to a parliamentary question.

Chair

It is a written answer from your Department.

Chris Wormald

Right. They are not the numbers I have here, but I will go away and check. That clearly needs to be resolved.

Caroline Flint

When I looked at this table, my eyes immediately went to Spain. I understand what you are saying; we have a lot of older people living in Spain. I get that, but I don’t quite understand some of the other numbers in here. Can we send you the table that was provided by your Department, for you to give us some ideas on it?

Chair

To be clear, if that is not correct, you obviously will need to lay a correction in Parliament, as that was a parliamentary document. On Spain, one of the issues that raises is habitual residents, which we will get on to.

Charlie Elphicke

I posed a freedom of information request of your Department, which I got back in October this year. That also included those figures, which say that Poland claimed £4.3 million from the UK in 2014-15 but that the UK only claimed £1.5 million from Poland. Do you not think that the taxpayer is being taken for a ride not by tourists but by political correctness and a non-charging culture in the NHS?

Chris Wormald

I will say two things. I will come back to that general point. On the pensioner point, which we did not quite cover, we have about 190,000 pensioners—

Caroline Flint

Could you just answer the question about Poland? I think we all accept that there is an issue around pensioners, and there is another issue about residency tests and things like that, but this is a particular point.

Chris Wormald

The general point that we are not collecting as much as we should from the EEA is one we agree with. That is why we set out this plan in the first place, to get those numbers up. Overall, if you exclude the pensioner question, we pay out about £130 million and get back about £40 million. We think those figures should be much more balanced, which is why we want to increase our charging in the way that our plan has set out. I can’t comment on the individuals of Poland, but on your general point about whether we charge enough through the EHIC scheme and the other scheme, no, we don’t.

Caroline Flint

If there was one thing you would ask those on the frontline of the NHS to do, what would it be?

Chris Wormald

Bob may say more about this, but I should say that we are not here to criticise NHS front-line staff. It is a very, very difficult job that they are doing.

Caroline Flint

I’m not saying that.

Chris Wormald

No, but I want to make that clear. What we want—it is not just about this scheme, although it goes for this scheme as well—is a culture in the NHS where everybody who works in it feels not only the responsibility we want them to have for patient care and so on but also a financial rigour responsibility. That is the thing we want most of all from trusts. We are doing quite a lot to try to make it easier for trusts to do that through our IT changes and good practice, but we do need that culture within the NHS, which is not particularly about this issue but is about being careful with the tax pound. Would that be your answer, Bob?

Bob Alexander

Yes, it would.

Caroline Flint

It is the case, though, that if the trusts are not following the procedures and the guidance provided—there may be questions about how complicated the guidance and the systems are, which I totally understand—they then are reimbursed by the clinical commissioning group, which has to pay out of its budget for whatever treatment the trust asks it to pay for. Fundamentally, if that money is not then recovered, it is a loss to the clinical commissioning group for not only potential hospital treatments but primary care and public health services.

Chris Wormald

Yes. That is exactly the reason why we set ourselves this objective in the first place. We didn’t think that the levels of recovery in 2012, of about £80 million, were anywhere near what we needed. That was the whole purpose of the programme we set out: to begin to address those questions, for exactly the reason you say.

Kwasi Kwarteng

Obviously you set yourself the £500 million target for charging. I understand you have altered that target.

Chris Wormald

No.

Kwasi Kwarteng

Do you feel you can attain that target?

Chris Wormald

As I explained earlier, we have a trajectory that currently does not get us to that number, so there are various things we need to do in response to that. Some of those are policy and regulatory changes, which are dependent on the House agreeing, and we have a consultation out, which we will be responding to shortly, about that. Some of it is around the good practice I was describing earlier, particularly focusing on that cohort of trusts which have the biggest gap, and some of it is in the IT changes we are making, to enable people. So our intention—and this is the way this policy works: the decision that was taken in 2013, which I think is the right one, was to say we don’t know as much as we really want to about this; we’ve got some evidence but we just need to get going and then—

Kwasi Kwarteng

Let me just get this right—

Chris Wormald

So we are not backing off the £500 million.

Kwasi Kwarteng

So the target is still the same. You haven’t shifted the target.

Chris Wormald

Well, it is set out in the governing party’s manifesto.

Kwasi Kwarteng

But you are hoping to reach it, even though you are slightly behind schedule.

Chris Wormald

Just to be clear, the target is—I was going to use the word “symbolic”, but that is not quite right: what we want, and this has come out of the questions that have been asked, is for the NHS every year to charge the right amount. We have set “up to £500 million” as our stretch target in this area, but if the right amount is £450 million they should charge that; and if the right amount is £550 million they should charge that. We are using the target to try and get to a culture where people charge the right amount.

Kwasi Kwarteng

I want to pin you down on that—forgive me; because you have set yourself a target, and it seems to me that you are sort of waving it away and it was symbolic, I think the word was.

Chris Wormald

No, I said I wouldn’t use the word “symbolic”.

Kwasi Kwarteng

Forgive me: the word you avoided was “symbolic”. I just wanted to know: why did you set that target, and why do you think you are not on the right trajectory?

Chris Wormald

As I say, the decision taken in 2013 when the Government decided to highlight this issue—and it was a proactive decision by Government to do so—was it should make, even on what was undoubtedly limited evidence, its best estimate of what we should be able to get in; and to set a stretching target that would help us change the culture of the NHS in the way that a number of Members have pointed to. The evidence we had at the time suggested that £500 million was in the right ball park. It was phrased as “up to £500 million”; as I say, I am not going to say that there was a glorious formula that sat behind it, but it was to set the expectation of the sort of step change we wanted the system to make. As I say, the ultimate target is, as various people said, to pay what should be paid.

Charlie Elphicke

Let me take you to figure 5 on page 23, where it sets out this target of £500 million. Will you confirm that £200 million of that target is from EEA?

Chris Wormald

Yes.

Charlie Elphicke

Right, and that figure was set as a target in 2013. In that year we collected from other EEA countries £52.9 million. Is that correct?

Chris Wormald

I think that is right.

Charlie Elphicke

Okay. This is a target for 2017, so let us look at how you have been doing. In 2013-14 we collected £52.3 million. In 2014-15 we collected £49.7 million and then in 2015-16 we collected £56.2 million. We are light years away from achieving £200 million, aren’t we?

Chris Wormald

Yes, we are.

Charlie Elphicke

This is not going to be met, is it?

Chris Wormald

Well, as I say, if we do the changes that we want to make—and we have not been running this programme for very long—we do believe that we can get our current trajectory, which as has been said is about £350 million, up towards that £500 million.

Charlie Elphicke

Are we going to make the £200 million from EEA: yes or no?

Chris Wormald

I am not going to guarantee that we will make that £200 million, because it is dependent on a whole range of factors. What we are doing—

Chair

So you are not going to guarantee it—that is the answer to Mr Elphicke’s question.

Chris Wormald

Yes, just as a statement of fact.

Chair

That is fine—we appreciate the honesty.

Charlie Elphicke

The point I am making is it seems that no progress has been made and the whole thing is a complete shambles.

Chris Wormald

We are talking about a situation where we have gone overall from collecting about £80 million to collecting about £280 million a year.

Charlie Elphicke

But on the EEA we are not making any progress at all.

Chris Wormald

Well, with the bit we have targeted—because that number: some of it is numbers driven around the other schemes. The actual EHIC bit has gone up from us identifying about 5,000 treatments a year to us identifying about 18,000 treatments a year under EHIC over two years. Now, we haven’t seen that show through in the cash amounts yet, but we do expect that to go up. Are we going to get to £200 million? Well, as you have said, that is clearly a tough ask, given where we are right now; but we are going to keep at it.

Charlie Elphicke

Last year they collected from us £565 million didn’t they; so they seem to be really effective at this. We are not making any progress.

Chris Wormald

As I said earlier, the vast majority of that is paying for the 190,000 pensioners that we have living abroad, whereas the number of EEA pensioners in the UK is, I think, 5,500 and that is what drives the massive distinction.

Chair

You mentioned pensioners a couple of times—not as a “get out of jail free”, but as a cause of a chunk of the money. We have the habitual residency test here, so that as soon as someone arrives in the country, as we understand it, they can say, “Now I am going to be settled here.” Even a week in they can say, “Right, I am looking for work,” or, “I have got work,” or, “I am renting a place,” or, “I have bought a place”. They immediately qualify for NHS treatment, but if they are visiting with an EHIC card, they do not. What about pensioners in Spain? When do they qualify to be under the Spanish health system? Have we got a reciprocal arrangement?

Chris Wormald

Under the current European rules, if you are a state pensioner of a country, that country pays for your healthcare regardless of where you live in the EEA. So if you are in receipt of a UK state pension, and that is your only state pension—that is the 190,000 people who live mainly in Spain, France and Ireland—the UK pays for your healthcare regardless, because—

Chair

That is reciprocal—just to be absolutely clear. If I was a Spanish pensioner living in the UK, the same would apply. Do you have any comparative figures—

Chris Wormald

Yes, of whom there are 62. At our last count, there are 62 Spanish—

Mr Bacon

Not 62,000?

Chair

Sixty-two Spanish pensioners? You are kidding me.

Chris Wormald

Sixty-two Spanish pensioners live in the UK, and about 70,000 British pensioners live in Spain. That is where the vast—

Chair

Sixty-two?

Chris Wormald

We are not the retirement place of choice.

Chair

That is clearly an opportunity for the Tourism, or Tourism Retirement, Minister or whoever.

Chris Wormald

The unbalances are enormous; it is 190,000 against 5,000.

Chair

Can I just be clear? Just the comparative cost of treatment—Mr Williams, on this figure.

David Williams

In terms of what we pay for UK pensioners abroad, for 2015-16 as a share of that £565 million you mentioned, our costs were £429 million. The income that we received as part of the 56 was 13.

Chair

There is a comparative cost of treatment. Let us say you break your leg in Spain—do you know how much it costs to put it in plaster and treat it, compared to what costs in the UK? Is there any comparison done by your Department about the relative costs?

Chris Wormald

I don’t have that with me. There will be one, so we can go and—

Chair

We’ll get on. I’m not going to interrupt the flow, because we want to get on to the issues around the tariff.

Karin Smyth

There is a degree of sophistication to NHS costing, that the answer is not just—

Mrs Trevelyan

Mr Elphicke is asking about the gap in trying to get to that £500 million. That is presently being filled by the surcharge, which is a very useful way to get to a target, but if we could take the target out, and say you are way off getting anywhere, can you confirm that you are charging the NHS tariff rate to other countries, not the actual cost of what it might be?

Chris Wormald

We set the tariff for overseas visitors higher than we do for NHS patients.

Mrs Trevelyan

So are you charging the actual cost—if BUPA were to charge, there would be an actual cost of the operation—or are you charging a tariff figure that may or may not relate to the actual gross cost of whatever the treatment was?

Bob Alexander

My understanding is that it is NHS tariff for EEA.

Mrs Trevelyan

So not necessarily the cost. Can you confirm that those two are not always the same thing?

Bob Alexander

They are not the same thing, although they are built up by the costs of treatment in the service. However, it is not specific to the event in Trust X—

Mrs Trevelyan

So we are not fully charging the total cost to the NHS of whatever that treatment was for either an EEA or a non-EEA person. Although there is a surcharge, it is not necessarily the total cost.

Chair

For a non-EEA person it is a surcharge of 50% on top of the tariff, but that still may not be full cost.

Mr Bacon

Mr Alexander, is that a yes?

Bob Alexander

Yes, it is.

Caroline Flint

On page 24, in part 2 of the NAO Report, paragraph 2.2 says, “Of the 50 trusts that responded to our consultation,”—that is 50 trusts out of 154 acute trusts, so it is quite worrying that only 50 could be bothered to reply to the consultation—”only 11 expected income from overseas patients to increase significantly in future.” What do you think about that?

Chris Wormald

That number clearly needs to go up.

Caroline Flint

What do you think about that, as a ringing endorsement of the system by 11 trusts?

Chair

What are you going to do about it? Now you know you want it to go up—

Caroline Flint

There is a serious point here. You talked before about not blaming the front line—of course not. The crucial part in this process is the capture of information as and when people enter the NHS for the parts of which we are expected to recover a payment. If we are talking about only 11 out of the 50 trusts that replied, when 154 could have replied, that is worrying, isn’t it?

Chris Wormald

Oh yes, it is.

Caroline Flint

It is not exactly a ringing sound of confidence in the system.

Chris Wormald

No.

Caroline Flint

Or even a sign that they are taking it seriously.

Chris Wormald

As I have said all the way through this hearing, we agree with the National Audit Office that we have a long way to go on these things, both to ensure that all trusts deal with it with the seriousness it deserves, and so that we are doing enough to make it easy for trusts to do so. We have an extensive work programme around good practice and particularly IT changes to do so, but the bottom line is that we do need trusts to get better at doing this and we need to help them do so.

Caroline Flint

Let’s talk about changes. You have mentioned IT changes several times. Can you outline for us what will change?

Chris Wormald

The things we have done—there are two big things. The first is that we are much more linked up with Home Office systems around the visa charges, so that people who are on the visa scheme are now flagged on the NHS IT system. Secondly, and probably more importantly from this point of view, we are making it much more explicit on the NHS record where someone has been identified as being chargeable, and we are allowing the overseas visitor managers within trusts to directly amend that record so that when they have identified somebody who has been identified for charging in one part of the health service, forever more they will be charged wherever they then present. Those charges are quite significant, but what they don’t get to, obviously, is how you identify people in the first place. That is the bit where we need to make a lot of progress.

Kwasi Kwarteng

I am looking at the table of the amounts you are getting in and your targets—and I’m giving you the immigration surcharge, so let’s not talk about that; let’s strip out the £200 million, so you have £300 million. And let us strip out the visitors from outside the EEA; let uws look just at visitors from within the EEA. There is obviously a huge gap between the £56 million stated for 2015-16 and the £200 million target, so I am going to re-ask the question, but just looking specifically at that portion of people within the EEA. How do you think you can essentially quadruple the amount of money that you are getting in from EEA visitors in two years?

Chris Wormald

I’ll ask Bob to comment as well, because unfortunately this is all in the practicalities of how individual trusts identify people when they present. There is no getting round this. When somebody appears in hospital, does that trust identify them as somebody who should be charged, regardless of whether they are in the EEA or outside the EEA, and then take the appropriate action in the case of the EEA people to alert us so that we can charge the country concerned? I would love it if there was an easy answer to that question, but it is in the practicalities of what a trust actually does when somebody arrives there. Bob, do you want to say a bit about the trust operations part?

Meg Hillier

Mr Alexander, in answer to Mr Kwarteng’s question—

Kwasi Kwarteng

Let’s hear from Bob.

Bob Alexander

It is extremely difficult, in busy clinical areas, always to identify. As you rightly said in an earlier point, there is something about the extent to which we have been able as yet to appropriately embed full cost awareness throughout the workforce.

Chair

Can we just be clear about this? The questions you are asked when you arrive anywhere are your name and address.

Bob Alexander

Absolutely.

Chair

So it would be quite simple for the script online or on the piece of paper—the form—also to have the question: do you expect to pay, or are you an NHS patient?

Karin Smyth

You would just say, “What country are you from?” The practicality is that you would have to ask somebody what country they were from and perhaps have identification via passport.

Caroline Flint

Why can’t you ask for a passport?

Bob Alexander

There are obviously organisations that do that. What we need to do is to work with organisations that are obviously identifying and collecting appropriate charges from foreign visitors and migrants. We need to identify what that best practice is and then, first, make that best practice available to all and, secondly, through a process of reporting and intervention, ensure that appropriate processes are, first, in place throughout the acute sector, for the moment, and secondly, report on that on a regular basis and appropriately intervene through oversight arrangements and performance management to ensure that that happens.

Sir Amyas Morse

This is probably completely off field but, when I buy a train ticket, I have to identify myself by putting my credit card or debit card into the machine. The most convenient way to tell who somebody is is that virtually everybody uses electronic payment. I am not saying that they should necessarily pay but, as an easy identifier, it is about the most effective thing available. Would that just be completely off limits, to ask people to stick their card in a machine to verify who they are?

Chris Wormald

As I said earlier, we are looking at whether trusts should do more on the upfront identification. What a credit card does not do is tell you whether you are ordinarily resident—

Sir Amyas Morse

I think you would probably find it could do that quite easily, if you really wanted it to.

Chris Wormald

I am not aware. We can discuss that offline. The general question is, are we are looking at whether trusts should proactively ask people to prove identity? Yes, we are looking at that. As I said, there are individual trusts such as Peterborough that are doing that and reporting that it makes a big difference. There they do say, “Please come with two forms of identity: your passport and your address.” They use that to check whether people are eligible. That is obviously quite a controversial thing to do; to say to the entire population, “You now have to prove identity.”

Karin Smyth

But if we listen to Mr Bevan, what he said was that you would have to separate the sheep from the goats. That would be in order to determine whether I am a foreigner or you are a foreigner. Essentially, you would need to go down the ID card route in order to separate out people who are entitled or not. Is that what you’re thinking?

Chris Wormald

Right, yes. I don’t think I will debate ID cards with the Committee at this time.

Chair

I am going to bring in Mr Kwarteng, Mr Elphicke, Ms Trevelyan and Mr Bacon on quick points and then we will go back to Caroline Flint.

Kwasi Kwarteng

I have a very quick point on figure 1. I want to understand it. This is not a trick question. The bit I am slightly confused about is, for whatever reason, with the visitors from outside the EEA you are 69% there in terms of the target. Whereas, with the visitors from within the EEA, you are falling very short. That begs the question: was the target too ambitious for visitors from the EEA? There is a big discrepancy, you will understand, if you follow me, between where you are with the targets you have set yourselves and your attainment, with respect to visitors from outside the EEA, and visitors from the EEA.

Chris Wormald

I think—I’ll ask Bob to comment—that that probably arises because, as it stands at the moment, the incentive structure on trusts is much greater to identify people from beyond the EEA than within the EEA. That is one of the things we need to look at for good practice. Is that correct, Bob?

Chair

I think one of the factors is that the charging is relatively easier because you are not chasing an individual; you are chasing a Government. So it should be easier.

Chris Wormald

The key difference is when it is an out-of-EEA patient, it is the trust itself that receives the income. When it is the EEA, it is the Government.

Chair

So what you are saying is, it is the incentive that is driving the performance not the ease at which it might be to track down an individual versus a Government.

Chris Wormald

It will be a mixture of both but I think it is true that the incentives are about that.

David Williams

Both categories require identification of the treatment by the provider.

Chair

And that is the sticking point.

David Williams

The financial incentives for the provider are stronger for the out of EEA, particularly with 150% surcharge.

Chair

Mr Alexander, briefly on that, and then I am going to Mr Elphicke.

Bob Alexander

I absolutely accept that answer, Chair.

Charlie Elphicke

We have talked a lot about trusts, but that is secondary. Let us talk about primary care. I read a report in the Daily Mail—that excellent family newspaper—on 16 April that asked, “Does a visitor to the UK from any other EEA country who does not have an EHIC have to register as a patient?” It says “Mr Burt”—the then Health Minister—“replied that holding an EHIC card is ‘not required’ to register with a GP and that practices ‘cannot legally refuse’ to register any applicant even if they don’t have any identification. He also warned GPs against only asking migrants for ID, saying it could be ‘discriminatory’ and that they should ask all patients.” Is there not a massive hole here? If we go to EEA areas, we get charged by primary care and have to show our EHIC cards, yet they do not here. Isn’t that something that should change and needs to change? What are your plans to change it?

Chris Wormald

We are here to implement the system as is currently set out in law, which does not charge for primary care, as I said right at the beginning. The arguments made—it is a question of the law rather than of our implementation—are that the public health risks of putting up barriers to people seeking primary care are greater than the benefits. Now, people can debate that, but, as I say, it is a question of the law. What we focus on is applying the law and getting people who are currently required by the law to pay. That is currently limited basically to being in hospital. So your point is correct, but it is a question of where we choose to draw the line—

Chair

I think we should leave this issue for a minute, because it is a policy matter, which Mr Wormald cannot stray beyond—

Charlie Elphicke

On an operational level, my GPs raised this with me and complained to me about it. They said they felt this was due not to a policy matter but simply a culture of political correctness. They were cross because the British taxpayer is being taken for a ride. Do you not think it is something that ought to be looked at and investigated?

Chris Wormald

In the consultation we have live at the moment we are looking at the range of things that should be charged for and whether we should charge for A&E, ambulances and those sorts of things. As a matter of policy, we do not currently have primary care on that list. I am sure people will debate it, but, for the reasons you say, it is not really a question I can comment on, I am afraid.

Chair

If I can interject, I have GPs with different views on this, but when you hear the stories about what some people get from the GP it is not all about public health. I throw that in just as a thought.

Mrs Trevelyan

I think all of us here and those watching will be bemused. Will you clarify that it is your view that it is difficult to identify people at the point of entry within our acute system? Let’s park the primary care area. I took a French cousin of mine to my local hospital last Christmas. They were not on the NHS system because they are not resident here, so my hospital asked them for identification, which was provided, and the broken bone was fixed. I assume that my hospital was then able to bill France for that treatment. Are you telling me it is not standard procedure across every hospital in the land that if you turn up and you are not on that system—because you are not a local person on the NHS register—this is a difficult thing to follow through on? I am not saying anyone is going to be charged, but are you telling me that you do not find it possible to identify that individual?

Chris Wormald

Clearly not. The numbers, as various people around the Committee have—

Mrs Trevelyan

So we are treating patients who we have not identified.

Chris Wormald

Yes. Not in—

Mrs Trevelyan

In large numbers.

Chris Wormald

It is quite clear from the numbers, the expectations we have set and the research we did in 2013 that there are patients who should be charged who are not currently being identified—

Mrs Trevelyan

They are not identified at the point of arrival at the hospital, in order for us to follow that through.

Chris Wormald

Yes, not identified as being a patient who should be charged.

Mrs Trevelyan

But if a patient is not on the NHS system with a British NHS number, by definition he probably will be in that category.

Chris Wormald

No. Those individuals are the most likely to be identified, but an NHS number does not prove eligibility; anyone can get an NHS number. So once you—

Mrs Trevelyan

No, but if you follow that through, you have an identifiable marker attached to that treatment cost.

Chris Wormald

This is the IT change we were describing earlier. We can now track that through the system, so it should become easier, but has that been standard practice? No, it hasn’t—that is the straight answer to your question.

Mr Bacon

Mr Wormald, you started an answer to Caroline Flint’s first question by saying there was a statutory obligation to identify patients. More recently in your evidence, about five to 10 minutes ago, you said, “We are looking at whether trusts should do more in terms of up-front identification.” Given that there is a statutory obligation—it is not a choice; they have to do it—why is it a case of whether trusts should do more in terms of up-front identification?

Chris Wormald

What I was describing was the method by which you do up-front identification and whether you require—

Mr Bacon

Actually that’s not what you said. You said, “We are looking at whether trusts should do more in terms of up-front identification.” That suggests two possibilities. First, that they do do more, and secondly, that they don’t do more.

Chris Wormald

We certainly want them to do more. I may not have worded my answer to you absolutely correctly. The question I was getting at was whether, as some trusts are looking at, you require people to prove identity by bringing a passport and some other form of ID with them—which, as you said, is not the culture of the health service up to now and would mean a change.

Mr Bacon

I don’t think I said that, but someone did. It might have been you.

Chris Wormald

That is what I was referring to—whether more trusts should be going down the route that some trusts within London and elsewhere have gone down, of causing people to prove identity, and where that is proportionate. As we have said, this does locate in some quite specific places in the country, so it is about whether you want to apply that rule to the whole country. Those are the questions we are looking at.

Mr Bacon

But it is clear that the obligation to identify exists and is a statutory obligation; you said that right at the beginning. That is correct, isn’t it?

Chris Wormald

Yes.

Mr Bacon

Can you tell us under what legislation that obligation exists?

Chris Wormald

The original legislation was in, I think—

Mr Bacon

I think you said 1982.

Chris Wormald

It was in 1977, to allow charging. That was implemented by regulations in 1982.

Mr Bacon

There is a difference between allowing and requiring. By all means send us more than this. I notice that in the Report, there is a reference to the immigration rules that give the power to the Secretary of State to charge, but I am asking a different question about the obligation to identify, which sounds to me not like a choice but something you are obliged to do.

Chris Wormald

I will write you out the full legal history, but as I say, the first regulations coming into force requiring charges were in 1982. There have been a whole series of Acts.

Mr Bacon

And prior to that there were some opportunities or possibilities, but then it became a legal obligation.

Chris Wormald

I am not aware that there was anything legal before 1982, but if I may, I will get one of my lawyers to write to you.

Mr Bacon

Send us a legal narrative. I am looking at the National Health Service (Charges to Overseas Visitors) Regulations 2015, which I imagine are an update or later iteration of something before. A thorough summary of that would be helpful. What strikes me, listening to all this, is how extraordinary it is that if there has been a legal obligation to identify for several decades, most NHS trusts, most of the time, are still struggling with the basic question of identifying, when they have had 30 years to get used to the idea. That is what I can’t understand.

Chris Wormald

As I said before, if you look at those three decades, it is clear from the amount of money collected that there was not a huge amount happening. We have had a much greater focus since 2013, and we believe we are beginning to see the results. Why wasn’t there that focus in the previous 30 years? I don’t think I can answer that question. I could speculate, but I don’t know why people didn’t choose to focus on it in previous decades.

Mr Bacon

There are two parliamentary questions. One is from 29 February 2016, and it sets out the amount claimed by states against the UK and the amount claimed by the UK against other states for the EEA and Switzerland. It is very helpful and sets out it out very clearly. There is another PQ that was also tabled by Mr John Mann, the Member for Bassetlaw, about 10 other countries that are not EEA or Switzerland—they are listed there: Russia, China, Nigeria, America, India, Australia, Pakistan, Brazil, New Zealand and Canada—for which no information was given about the cost. It was from around a similar date; in fact, it was 4 March, only five days later. Is that because you don’t have the information? I understand from the earlier answers that actually things are going better for non-EEA than they are for EEA. I think that was in figure 5. Why was there not more detail in your answers when they were given only a few days later?

Chris Wormald

For the European ones—for those that are claimed—we have all the information because we are reclaiming from those countries, so it all goes through the Department. For non-EEAs, we have traditionally collected very little data indeed.

Mr Bacon

Why? Because it is simply held at the trust level?

Chris Wormald

Yes. Those will be held at the trust level.

Mr Bacon

Are you planning to ask the trusts to tell you what they’re doing on this?

Chris Wormald

We have already increased the data we receive on cost. We have not gone into individuals and nationality in the same way, and that is one of the things that we’re looking at.

Mr Bacon

The question is, “To ask the Secretary of State for Health, how much was recharged to—”, and then there is a list of countries. To Mr Mann’s question, there is no answer. There are a couple of big paragraphs of stuff but there is no answer.

Chris Wormald

The data are not held at national level.

Mr Bacon

Are you planning to get into a position where you can answer that question?

Chris Wormald

We are looking at what data we collect. We are not collecting that information at the moment. It is, of course, a question of whether we should.

Mr Bacon

You are looking at it. Are you planning to be in a position to answer that question?

Chris Wormald

As I say, we have not taken the decision to change the data that we are collecting from trusts at the moment. We try to change what we collect from trusts very rarely, for reasons you will understand, but it is something we keep under review.

Chair

Can I just be clear: to break the data down to answer a question of that nature, you would actually have to have every trust asking the nationality, whereas some of those patients would presumably just be dealing with their insurance company and the nationality would not be a primary question. Is that one of the issues here?

Bob Alexander

That is correct.

Caroline Flint

I am going to ask a few questions about the immigration health surcharge. Looking at the various figures in the Report, if it wasn’t for the immigration health surcharge, the trajectory would look a lot worse than it does. Is that correct?

Chris Wormald

That’s correct. It’s a central part of our policy.

Caroline Flint

Every non-EU student, or migrant with a UK visa for more than 6 months on or after 6 April 2015, has to pay this surcharge. I understand it is £150 for each student and £200 for migrants. That gives those people full and free access to our NHS. Is that correct?

Chris Wormald

Yes, that’s correct.

Caroline Flint

I understand that, in 2013, the Department of Health commissioned work to estimate the baseline cost, and the consultants that you were using came to the view that a realistic cost per year was actually going to be £736 per person, but it was fixed at £150 to £200. Why?

Chris Wormald

In these cases we are striking a balance between what we think is fair to individuals and fair to the UK taxpayer. Of course, a number of people who are here working for over six months would also be taxpayers and contributing to the economy, but we also do not recognise that £736 figure. I recognise that that is what they estimated, but this is quite a vexed area and it does look like that is high.

Caroline Flint

According to some figures I have got, between 6 April 2015 and 14 March 2016, the cash raised was around £175.6 million, but 423,278 student migrant visas were issued in that time. The expectation is that that sort of level of applications is likely to continue. That is a lot of application, and £175.6 million sounds a lot of money, but am I also correct that, in applying the surcharge, no questions are asked of the individuals of any pre-existing conditions?

Chris Wormald

I think it is just a flat-rate charge.

Caroline Flint

What I am trying to get at is, if you applied for health insurance for a holiday or something—or for any sort of insurance policy in the UK—you would be asked about any pre-existing conditions such as kidney problems. They might even ask if you were pregnant, for example, or any other matter. That is not asked at all of any of these people who, for £150 or £200 a year depending on what status they are coming in on, can get full and free access to our NHS.

Chris Wormald

As I understand it, the decisions—

Caroline Flint

Also, if students bring members of their family with them, I understand that they pay the same rate as well.

Chris Wormald

Yes, I think we charge it to every person there. The idea, as I understand it—this slightly pre-dated me—was to have a very simple system that was easy to administer. Of course, as you say, the entire cost—

Caroline Flint

Do you think there should be a question about pre-existing conditions to ensure that we are not being possibly taken for granted by someone applying for a course because they have a pre-existing condition and can get care better or cheaper here?

Chris Wormald

If I am honest, that is not a question I have asked, so I will not give you a view.

Caroline Flint

Are you considering it as part of your review? You are looking at a review at the moment, aren’t you?

Chris Wormald

I do not think it is being considered at the moment.

Chair

Is it something that you would be able to identify in the data? For someone having kidney treatment, the condition could have just come on.

Chris Wormald

As will be clear from my answers, this is not a question that I have thought about or particularly briefed myself on. May I go away and think about it?

Chair

Thank you. We appreciate that.

Caroline Flint

I have a last point on the data. If I get the terminology wrong, forgive me. From what I understand, once a student or a migrant with a six month-plus visa pays a surcharge, they get what is called a green banner on their NHS records. But that means that we cannot track how much people are treated. Some people might come in, pay £150 and not use the NHS at all, which is fair enough. But we do not have any sense of being able to track what treatment—or not—they have had from the NHS, and trusts are not obliged to keep any costs about what that treatment involved for that surcharge. Is that correct?

Chris Wormald

They certainly will not be required to keep costs because, of course, we are not charging. We ought to be able—I will go away and check this answer—to see who is flagged and how much treatment they actually take, even if we cannot get a cost. I think we get some information, but I will go away and check.

Chair

Will you write to use with that?

Chris Wormald

Yes.

Caroline Flint

Thank you. The figures state that 423,278 visas were issued to students and migrants between April 2015 and March 2016. That is a lot of applications. Potentially within that, every year, there is a lot of use of our NHS, whether at primary care or at trust level. Isn’t that the case?

Chris Wormald

Yes, but just to be clear, this is an addition to the system that we have introduced previously. Those people would have been in the systems that are not collecting cash that we have just been describing. This is net addition to what HMG gets to fund the health service.

Caroline Flint

I appreciate that. It is obviously quite worrying, from the earlier questions, whether the changes to the systems and the recovery of money is relying quite a lot on this particular surcharge to make things look better than they actually are.

Chris Wormald

I do not accept that. We had a strategy.

Caroline Flint

It is new money. It is not recovery of what we should have got anyway.

Chris Wormald

No. When we set out the policies to address this question, the surcharge was a fundamental part of this, and it was a reflection that we have not been great at recovering costs. Having this very simple mechanism that gets in really quite a lot of cash, and has done very quickly, is an important plank of the policy.

Caroline Flint

Are there any examples of other countries that have a similar surcharge for students or people on a six month-plus visa? Do they ask about pre-existing conditions?

Chris Wormald

No, most countries are insurance-based, so that would be the equivalent process. I am not aware of any other country that does a surcharge quite like this but, as I say—

Chair

From my time on the Immigration Bill, I think you are right.

Chris Wormald

Yes, you probably know more about this than I do.

Caroline Flint

My last question is about the ordinarily resident status because that sets us out pretty much from every other country in that most countries operate on a contributory principle, not because someone happens to be resident in that particular country. Will you be looking at the ordinarily resident status and whether that needs to be tightened up as part of your review?

Chris Wormald

We have already tightened it significantly in one regard: non-EEA residents are only counted as ordinarily resident if they have indefinite leave to remain. That is quite a big tightening of the system. I don’t think that is one of the things we are consulting on, is it?

David Williams

I don’t think so.

Chris Wormald

I don’t think that’s one of the things we are consulting on at the moment.

Caroline Flint

Because it does mean that somebody can come in and basically, through their resident status—without having any other identification or anything—get access to our GP services and everything else.

Chris Wormald

That is the line that the law draws at the moment. It applies the ordinary residence test. As I said, we have tightened it once around the non-EEAs, but that is how the law works at the moment; it is based on that residency test.

Caroline Flint

St George’s hospital in Tooting has received quite a lot of coverage recently because of some changes in how they were looking at recovery for the use of their maternity services. It was reported that half the 1,783 overseas women who gave birth in St George’s in 2015-16 were entitled to free care, but action was only taken when the commissioners refused to reimburse the hospital for treating ineligible patients. What is your sense of what is going on at St George’s, in terms of how it is applying its rules, and is it not a bit worrying? If they had been actively engaging beforehand, maybe the recent changes they have made would not have been such a media story.

Chris Wormald

What you describe the commissioners doing is exactly what commissioners are supposed to do. Indeed, the National Audit Office made a recommendation in this area on commissioners being more vigilant, and NHS England has accepted it. St George’s is one of the hospitals that is looking, in maternity, at the two forms of identification before treatment. Should they have done that earlier? That is a question you can always ask in these circumstances.

Caroline Flint

But part of this again comes back to early identification.

Chris Wormald

Yes, it does.

Caroline Flint

We are not talking about an emergency service, but about people coming in for their antenatal classes and all the build-up to having a baby. I presume there will be quite a lot of record-taking during that period as well.

Chris Wormald

As I understand it—Bob may know more—that is exactly what St George’s do. On first contact now, they write out, saying, “You will need to bring two forms of identification to your first—”

Caroline Flint

But why do you think it takes the commissioners to start refusing to reimburse the hospital for that sort of action to be taken? I think that is what people find really difficult about this. We are always filling in forms for this, that and the other, whatever we do. We have all shared experiences of having to provide information when we have been in hospital ourselves. What is the big barrier to this, given that this is money for our health service?

Chris Wormald

I am not sure I can add much to what I have said. Clearly, there has not been the focus on these issues that there is now and there are quite a lot of things like that that could have been done earlier. One thing that ought to make a difference is that we have added to what we call “the model hospital”— which is basically all the benchmarking information that we make available to boards—benchmarking information on recovery rates for overseas visitors, so in future, it ought to be much more explicit to the boards of trusts when they are out of line with where they should be. I do not really think this is a satisfactory answer to your question, but I think it is probable that in a very busy hospital, these issues simply have not been surfaced before—until the focus that we have had in the last few years—in a way that has caused people to deal with them. I do not think that is really satisfactory answer to your question but I suspect that is what has been happening. Bob, you have had several cracks at this.

Bob Alexander

What I hear you describe is poor business process and management of regulation. Chris is absolutely right about the things that the Department is trying to do, and as the Report said, NHS Improvement have to get alongside and operationalise some of this stuff, and we are committed to doing that. We were talking about the initial cohort of organisations to engage with. They have opportunity and may or may not have good process—St George’s, Tooting is in that cohort because of opportunity—and inevitably, in the way you describe, there is opportunity to improve process. The model hospital reporting does more than Chris described, and it will certainly make things transparent to hospital boards so that they can compare and benchmark themselves. It will also give those charged with oversight and intervention an opportunity to inquire and ask questions, and it will give us an opportunity, via the best practice process we are going through now, to develop helpful improvement tools for organisations to use: “Here are processes that you should put in place. Have you done that?” That will allow us to follow up in a more targeted way than we have in the past. I say that as somebody who was a finance director in hospitals back in the ’90s, when frankly we did not do this at all well.

Caroline Flint

You can appreciate how in these times when there is so much coverage about pressures on the NHS, including the cost of treatment and the expectations on the NHS—in all good faith and in a very human way, a number of exemptions apply within our system for different vulnerable groups—it really undermines people’s confidence when, basically, we are not seen to get back what is due in a fair way.

Chris Wormald

Yes, and that is exactly why, as well as getting the cash in, the Government chose proactively to put a huge focus on this issue in 2013. They commissioned the research that has given us a better understanding of what is going on and made all the changes to the regulations and the surcharge. Those are exactly the reasons why we wanted to focus on this. As I hope we have been clear throughout the hearings, we do think they are making a substantial difference both to the cash amounts and to the culture but, as we have discussed a number of times in this hearing, we have a lot further to go before we have the system that we want.

Chair

We had some evidence, including from Doctors of the World—this particularly relates to the St George’s, Tooting example—expressing concern that the time required by staff to carry out the eligibility assessments would be an issue. They talked about the direct costs involved in implementing the programme, which have yet to be quantified. There is certainly a lot of anxiety about that from people on the frontline. Mr Alexander, you talk about trying to improve the system. Can you give any reassurance to people on the frontline that what you are trying to introduce will be workable and neither degrading for the patient nor unworkable for the front-line clinician or administrator?

Bob Alexander

That is exactly why we want to do this with cohorts of organisations to determine good process that is proportionate, that minimises burden and that appropriately discharges organisational responsibility to identify and recover appropriate costs.

Chair

The St George’s one is to provide photo ID and a utility bill, and I have to say that I would be hard-pressed to find a utility bill.

Caroline Flint

They can always bring it later.

Chair

No, I would be hard-pressed just to find a utility bill with my name on it.

Chris Wormald

You are often putting people in a dilemma. Yes, we want systems that correctly identify who needs to be charged, but we do not want to put an excessive burden either on individual trusts or on individuals who have every right to the NHS. That is the balance we are trying to strike, which is why we are trying to focus on those hospitals that appear to have the biggest opportunity.

Caroline Flint

Can you report back to the Committee? Good practice was mentioned earlier, and there have been a number of submissions about excessive burdens on individuals and trusts to provide information, but it is not quantifiable in any real way. That includes the allegation that the cost of setting up systems to recover outweighs what you will get back. Why can’t you do some more work on pinning down some evidence-based answers to those accusations, which are often made by people who do not seem to want us to charge anybody?

Chris Wormald

Yes, and the NAO raised that point, too. We need to do more about that but, as far as we have seen, the costs of setting up a system at trust level are very small indeed. It is normally one person, the overseas visitor manager, who runs the system for that hospital. As I said, if we get the IT right nationally, there is no burden. There certainly should not be a burden on clinicians actually treating people. We only ask clinicians in this system to do one thing, which is to distinguish between those patients who need urgent and emergency care and those who do not, and therefore whether they are charged up front or in retrospect. Obviously, that has to be a clinical decision that only a clinician can take. We do not ask clinicians to do anything else in the system; it should be the hospital administration that identifies who needs to be charged and pursued, not the front-line people treating patients in the system. Your questions sum up some of the balances that we are trying to strike in these policies about being fair to the taxpayer and to the individuals, and not burdensome to either individuals or individual trusts, while ensuring that we get the contribution that we should for the NHS. That is not an easy set of balances, which is why we do the policy in the way that we do. As you will have gathered from our answers, we decided to get some stuff going and then iterate it with what is happening.

Chair

I think we are hopefully helping you along. I will call Mr Mills now. I should just say that we could be having a vote in the next five minutes, but we have not had any notification yet, so we may be able to carry on.

Nigel Mills

Is the message you are sending out to CCGs, Mr Wormald, that they should be checking whether the hospitals they are funding are doing this job properly, and that if they are not, they should withhold payment?