When asked what makes them proud to be British, more people cite the NHS than anything else, ahead of British history, sense of humour, and the monarchy.1 Its popularity transcends all ages and political allegiances.2
The NHS’s founding principles—to meet the needs of everyone, to be free at the point of delivery, and to be based on clinical need, not ability to pay3—were restated as recently as 2011, when a “wider social duty to promote equality” was added. The intention was not that everyone in the UK would be entitled to care; entitlement is based on lawful residence. However, even those not entitled to free care would be given it, with healthcare providers seeking to recoup the costs later. Health professionals could therefore concentrate on the tasks of diagnosis and treatment. This is no longer the case. From 23 October 2017, anyone, including children, attending healthcare facilities in England who is unable to establish their entitlement to free care will be charged upfront for the estimated cost of treatment.4 If they are unable to pay, treatment may be refused.
Healthcare teams face two challenges.4 Firstly, they must establish whether the patient is entitled to NHS care. This is not straightforward. Our searches of websites of hospitals participating in a pilot scheme5 suggest that they require proof of identity such as a passport and, where appropriate, visa and proof of residence, such as a utility bill.67 However, these do not in themselves establish entitlement, and there has already been confusion; one trust initially asked for these documents for HIV care, which is exempt from charging.8 Also, it is not clear whether all patients are asked for documents or only a selection, and, if so, how they are selected.
When a person has no documents—one in six UK residents does not hold a passport9—providers must consider several questions to determine entitlement, such as whether the person has “an identifiable purpose for their residency” in the UK that has a sufficient degree of continuity.4 Clearly, this requires considerable judgment, based on what will often be incomplete information.
Secondly, if the patient is not entitled to care, clinicians must decide whether the condition requires “immediately necessary” or “urgent” treatment (box 1). To make this decision they can examine the patient and do some initial tests but no more. Yet, if they get this…