Published: 2026-04-06 02:20
NHS Charging Guidance: Example Letters for Visitor and Migrant Patients
The Department of Health and Social Care (DHSC) has published updated guidance, including a suite of example letters, designed to assist NHS trusts in consistently applying charging rules for overseas visitors and migrant patients. This resource aims to standardise communication and ensure clarity for both healthcare providers and individuals accessing NHS services.
The provision of healthcare to non-UK residents has long been a complex area for the NHS, requiring careful navigation of legal frameworks and individual circumstances. These new example letters are intended to support trusts in fulfilling their obligations under the NHS (Charges to Overseas Visitors) Regulations 2015, as amended, which mandate charging for certain services for individuals not ordinarily resident in the UK.
Understanding the NHS Charging Framework
The fundamental principle of the NHS is that it is a residency-based healthcare system, not a nationality-based one. This means that individuals who are “ordinarily resident” in the UK are entitled to free NHS hospital treatment. Those who are not ordinarily resident may be charged for the care they receive.
Determining ordinary residence can be complex, involving an assessment of an individual’s habitual and normal residence, considering factors such as their purpose for being in the UK, the length of their stay, and their ties to the country. NHS trusts are legally required to identify and charge overseas visitors for secondary care services unless an exemption applies.
Who is Subject to Charges?
Generally, anyone who is not ordinarily resident in the UK and does not fall under an exemption category is liable for charges for NHS services. This includes visitors, some students, and individuals who have moved to the UK but have not yet established ordinary residence or paid the Immigration Health Surcharge (IHS) where applicable.
It is crucial to note that while charges apply, immediately necessary or urgent treatment must never be withheld. Emergency departments (A&E) services are free to all up to the point of admission as an inpatient or referral to a specialist. However, any subsequent inpatient or outpatient care, even if deemed urgent, is chargeable if the patient is not ordinarily resident and not exempt. Non-urgent elective treatment can be deferred or charged for upfront.
Key Exemptions from NHS Charges
A wide range of exemptions exist, reflecting various international agreements, humanitarian considerations, and UK immigration policies. Understanding these exemptions is vital for NHS staff to ensure correct application of the rules and avoid inappropriate charging.
Common exemptions include:
- Ordinarily Resident Individuals: Those who are settled in the UK and habitually reside here.
- Reciprocal Healthcare Agreements: Citizens of countries with reciprocal healthcare agreements with the UK (e.g., EU countries, Australia, New Zealand) may be covered for medically necessary treatment, often requiring an EHIC, GHIC, or S2 form.
- Immigration Health Surcharge (IHS) Payers: Individuals granted leave to remain in the UK for more than six months, who have paid the IHS as part of their visa application, are generally entitled to free NHS care.
- Refugees and Asylum Seekers: Individuals who have applied for asylum or have been granted refugee status, or who are seeking humanitarian protection.
- Victims of Modern Slavery or Human Trafficking: Those identified as victims of modern slavery or human trafficking.
- Certain Communicable Diseases: Treatment for specific infectious diseases, such as tuberculosis, HIV, and sexually transmitted infections, is exempt from charge.
- Compulsory Psychiatric Treatment: Treatment provided under the Mental Health Act.
- Prisoners and Detainees: Individuals held in prison or immigration detention.
- Armed Forces Personnel: Members of the UK armed forces and their families.
This list is not exhaustive, and specific criteria apply to each exemption. NHS administrative staff are responsible for verifying eligibility.
The Purpose of DHSC’s Example Letters
The newly published example letters serve as a practical tool for NHS trusts to communicate effectively and lawfully with overseas visitors and migrant patients regarding their potential liability for charges. They cover a range of scenarios, from initial assessment to debt recovery, aiming to bring consistency across the NHS.
The letters are designed to:
- Inform Patients: Clearly explain the charging rules and why a patient may be liable for charges.
- Request Information: Guide trusts on how to request necessary documentation from patients to assess their ordinary residence status or eligibility for exemptions.
- Notify of Charges: Provide templates for formally notifying patients of the charges incurred for their treatment.
- Explain Payment Processes: Detail how payments can be made and the consequences of non-payment.
- Outline Appeals: Inform patients of their right to appeal a charging decision and the process for doing so.
- Promote Compliance: Help trusts adhere to their legal obligations under the NHS (Charges to Overseas Visitors) Regulations.
By providing standardised, legally sound templates, the DHSC aims to reduce ambiguity and ensure that patients receive clear, consistent information, regardless of where they access care in England.
Navigating Complex Scenarios
The application of charging rules can be particularly challenging in complex cases, such as those involving individuals with unclear immigration status, victims of domestic abuse, or those requiring long-term care. The guidance accompanying these letters is intended to help trusts navigate these situations with sensitivity while upholding the regulations.
Frontline NHS staff, including clinicians and administrative teams, play a critical role in the initial identification of potential overseas visitors and in signposting them to the relevant overseas visitor teams. While clinicians’ primary focus remains patient care, an understanding of the charging framework helps in efficient patient flow and appropriate referral to administrative colleagues.
Implications for NHS Trusts and Patients
For NHS trusts, these example letters represent a valuable resource for streamlining administrative processes, improving compliance, and potentially enhancing debt recovery efforts. They underscore the importance of robust training for staff involved in overseas visitor charging to ensure accurate and empathetic application of the rules.
For patients, the clarity provided by these standardised letters can help them understand their position regarding NHS charges, their rights, and their responsibilities. This transparency is crucial for maintaining trust and ensuring that individuals can access necessary care without undue distress or confusion about financial implications. The guidance reinforces that while the NHS is free at the point of use for those ordinarily resident, it is not free for everyone, and these rules are in place to protect the sustainability of the service for those entitled to it.
Source: DHSC Updates
Contains public sector information licensed under the Open Government Licence v3.0. Clinical summary provided for healthcare professionals; not for patient self-diagnosis.
