Upfront charging for NHS healthcare now in force

26 October 2017

We consider impact on social services' support for people with NRPF

In August we reported on new regulations which make significant changes to NHS charging for certain migrants living in England. All the changes have now been implemented. 

Prior to the changes that were implemented by the regulations in August and on 23 October 2017, only hospital treatment or community services provided by hospital staff could be charged for and payment was usually required after treatment had been administered. 

Since 23 October, certain migrants, and some British citizens who normally live abroad, will be required to pay for most types of secondary and community NHS healthcare, including NHS funded services provided by charities and local authority public health services, unless the treatment required is exempt from charging. 

The Department of Health has published new guidance for healthcare providers: Upfront charging operational framework and has updated its  , which provides some clarity about what community services may be charged for at pages 24 and 32-33:

  • Maternity care provided in the community
  • District nursing services 
  • Drug and alcohol treatment 
  • Mental health services 
Full payment for a course of non-urgent treatment must be made up front before any services can be provided. However, if the service required is exempt from charges, for example, mental health or maternity services to treat conditions caused by sexual violence, then a person will not have to pay for this. 

The charging guidance also confirms that services provided by school nurses and health visitors remain free of charge to all. 

Full details of what healthcare remains free, what must be paid for, and who is required to pay, are set out in our updated factsheet

Impact on local authority support for people with NRPF
About two-thirds of NRPF households supported by social services include a parent or adult with no current immigration permission who would be liable to be charged for secondary and community healthcare. There is no exemption from charging for people or families who are provided with housing or financial support under section 17 of the Children Act 1989, the leaving care provisions of the Children Act or the Care Act 2014. We have previously reported that the lack of an exemption has led to increasing demands on staff time and delays establishing pathways off social services' support.

The recent changes are of great concern as it is more likely that many people who are required to pay for healthcare will be left with untreated health issues and mental health conditions, which will exacerbate any current care needs and increase the level of support people require from social services, as well putting public health at risk. An inevitable consequence is that local authority safeguarding duties may extend to covering the cost of NHS healthcare where financial support is already provided to alleviate destitution for adults, families and care leavers with no recourse to public funds. It is currently unclear how the changes to healthcare charging interact with local government's duty to safeguard and promote the welfare of children. 

We have therefore assisted the Local Government Association (LGA) and Association of Directors of Children's Services (ADCS) to raise these concerns with central government.

It remains unclear how quickly the new measures will be implemented. Although hospitals already have processes in place to implement charging, and some have been piloting upfront charging over the last few months, other NHS services and non-NHS organisaitons will not have had to charge previously. 

It is essential that practitioners are fully aware of what kind of treatment still remains free to everyone regardless of immigration status, including GP services and A&E assistance, so that people receiving social services' support who are liable for charging obtain any free services they are entitled to. To help practitioners we have updated our factsheet which can be shared with people requiring healthcare:
We are collecting information to help assess the full impact of these changes on social​ services and the people they are supporting. Local authority practitioners are requested to provide anonymised case studies. For more information about the details we require​, please contact: nrpf@islington.gov.uk.