Challenging decisions and dealing with bills

Published: 26 September 2012
  • NHS staff may sometimes misinterpret the regulations.
  • Hospitals can often be persuaded to write debts off when a person is unable to pay a bill.
  • Outstanding debts may adversely affect future immigration decisions.

Overseas payments officers may misinterpret the rules and judge a person to be liable for charges that they do not need to pay.

An individual who believes he or she is not liable to charges is advised to get the advice of THT Direct, an HIV support organisation, or a refugee organisation that has experience in this area. In addition, many HIV clinicians can be powerful advocates for their patients.

It can be helpful for a well-informed advocate to calmly discuss the case with the overseas payments officer. It may be helpful to make reference to the legislation itself1 (rather than the Department of Health guidance), in order to show that it has not been correctly applied. Overseas payments officers are not always familiar with the original legislation.

If this approach is not successful, contacting more senior officials in the organisation, insisting that the case is considered by the NHS trust’s lawyers, using complaints procedures or bringing a judicial review are all possibilities.

Bills and debt advice

In some cases, an individual may receive medical treatment from the NHS (for example, treatment that is considered immediately necessary) and subsequently receive large bills for the treatment.

Department of Health guidance states that patients should not be discouraged from receiving immediately necessary or urgent treatment, even if they have indicated that they will be unable to pay for it. However they should be fully informed of the charges they might face.2

Bills and charges can cause considerable anxiety and are associated with patients not attending subsequent appointments. Moreover, many people are discouraged from seeking treatment by the prospect of receiving a bill, with consequences for both the individual’s health and for public health.

While the guidance clearly states that NHS bodies cannot waive charges, they can decide to write off debts. It is noted that some people, such as destitute refused asylum seekers, will be unable to pay. When, given the patient’s circumstances “it would not be cost-effective” to pursue the debt, the NHS body may decide to write the debt off.3

More generally, the law treats people with debts quite differently, depending on whether they can’t pay or won’t pay. In other words, the treatment of people without resources is much more humane than that of people who are simply unwilling to pay a bill.

Moreover, implementation of the charging regulations varies from trust to trust, with some being relatively lenient while others employ debt collection agencies who pursue debts quite aggressively (including attempting to recover the money overseas). It’s advisable for individuals to tell the hospital as soon as possible if they will find it difficult to pay the bill. NHS trusts are more likely to call in debt collectors if bills are ignored and they have heard nothing from the patient.

Any individual who receives a bill that he or she is unable to pay is advised to get the advice of THT Direct, a local HIV support organisation, or a refugee organisation. It is usually possible to negotiate with the NHS trust, in order to convince them of the impossibility of recovering the debt or to agree a repayment plan in which a token amount is paid on a regular basis.

Refused asylum seekers receiving ‘section 4’ support have been judged to be destitute by the UKBA, and this fact should persuade an NHS trust to write off a debt.

Debts and the UKBA

In October 2011, the government introduced legislation that allows the UK Border Agency (UKBA) to take past debts into account when making immigration decisions. People who have an outstanding debt to the NHS of £1000 or more will normally be refused permission to enter or remain in the UK.4

For example, this would affect people who have received medical treatment during a previous visit to the UK and who apply for a new visa. It would also affect individuals who apply for leave to remain while they are in the country but have already incurred NHS debts.

The rules affect a wide range of individuals who are subject to immigration control, including people applying for work permits, student visas, visitor visas and as family members. The UKBA has said that the rules will be applied on a case-by-case basis, taking into account the UK’s obligations under the European Convention on Human Rights. This should mean that previous NHS debts will not affect applications for asylum or humanitarian protection.

Only debts incurred from November 2011 onwards are affected. NHS organisations are expected to pass on details of debts to the UK Border Agency: they should state the person’s name, nationality, address, date of birth, name of NHS trust and amount of debt. Medical information should not be supplied. However, the Department of Health is yet to issue guidance to NHS trusts on how such information should be shared.

Moreover, data sharing between the NHS and the UKBA risks undermining the trust that patients have in their clinicians and the NHS. The policy does not make a distinction between people who are unwilling to pay and people who are unable to pay.

Confidentiality and the UKBA

As noted in the previous section, above, NHS bodies may soon be permitted to share information about NHS debts with the UK Border Agency.

The Department of Health guidance raises the issue of confidentiality in relation to NHS staff who are aware that a patient is in the UK without legal authorisation or documentation. The guidance notes the obligations of clinicians and the NHS with respect to confidentiality and also states that immigration offences are not usually serious enough crimes to justify passing on information to another organisation (e.g. the UK Border Agency). Nonetheless the guidance does not say that such breaches can never be justified.5

Moreover, if NHS staff wish to request information from the UK Border Agency about a person’s immigration status, the patient must agree to this first. Information about the person’s health status should not be shared.6


  1. National Health Service Charges to Overseas Visitors Regulations 2011. NHS, 2011
  2. Department of Health Implementing the Overseas Visitors Hospital Charging Regulations. See paragraphs 4.23 and 4.40, 2011
  3. Department of Health Implementing the Overseas Visitors Hospital Charging Regulations. See paragraphs 4.39 to 4.41, 2011
  4. UKBA Immigration Rules. Part 9, paragraph 320(22), see, January 2012
  5. Department of Health Implementing the Overseas Visitors Hospital Charging Regulations. See paragraphs 5.51 to 5.55, 2011


Written by: Roger Pebody

With thanks to: Chris Morley (George House Trust), Joe Murray (NAT), Yusef Azad (NAT), Sarah Radcliffe (NAT), Fizza Qureshi (Doctors of the World UK), Gary Christie (Scottish Refugee Council), Hannah Abbs (Southend Borough Council)

This content was checked for accuracy at the time it was written. It may have been superseded by more recent developments. NAM recommends checking whether this is the most current information when making decisions that may affect your health.
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This content was checked for accuracy at the time it was written. It may have been superseded by more recent developments. NAM recommends checking whether this is the most current information when making decisions that may affect your health.

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