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LOCAL GUIDANCE ON OVERSEAS VISITORS ENTITLEMENT TOFREE NHS PRIMARY CARE

This Document is intended for guidance only and to assist Practice staff in making informed decisions aboutan applicant’s entitlement to free NHS Primary Care and GP registration. Please do not consider this to be adefinitive or authorative document as decisions need to be made on the available facts and the merits ofeach case. For detailed guidance it is suggested that the DH Overseas Visitors Desk is contacted on: 0113254 5258.

Author:

Mark Bishop (with kind permission of Navin Morjaria, ACFS)

Local Counter Fraud SpecialistNHS Doncaster and NHS RotherhamTel: 01302 796049Fax: 01302 796716Email: mark.bishop@rdash.nhs.uk

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GENERAL GUIDANCE ON ELIGIBILITY TO FREE NHS PRIMARY CARE

ELIGIBILITY

1. Who is eligible?

Free NHS care is generally for those ‘Living Lawfully’ within the UK and considered to be ‘Ordinarily Resident’ in this country i.e.here for ‘Permanent’ settlement or ‘Habitually’ residing here. It is not related to one’s Nationality, how much Tax or NationalInsurance he/she has paid in the past. Most important: One must establish what commitment the new arrival has made thatconfirms his/her permanent settlement in the UK. Another point to confirm is what the individual is intending to do here for the next 6to 12 months i.e. employment, studies, renting accommodation etc. The answer would confirm as to whether he/she can beconsidered as ‘Ordinarily Resident’ in the UK.

Note: The onus is always on the patient to prove their eligibility to free NHS care.

2. How do you decide?

Living Lawfully – To confirm ‘Legal Status’ – Request Passport, check visa and its validity dates, European Nationalsmay only produce an ID card. This is acceptable and will confirm whether one is legally in the UK. Recent arrivals from EEUonly travel with an ID card and no passport. Ensure ID photo matches the person in front of you. (EEU Rules: see lastpage)

Ordinarily Resident - Confirming or determining a persons ‘settled status’ is key. For the purposes of the NHS if a newarrival provides documentary evidence that confirms he/she has been or intends to be in the UK for a particular purpose for6 months or more i.e. Work Permit for a fixed period and tied to a particular post, being a full time student, Spouse joiningthe other half for settlement as a dependant, Asylum Seekers, Dependents of an NHS Patient etc. In such cases you mustprovide full registration as they are eligible to free NHS care from the moment they arrive in the UK. Please note that anewly arrived individual does not have to first live here for 6 months before NHS care can be provided – practicesare in error when refusing to register using this reasoning.

3. Beware - Possessing a British Passport does not automatically qualify someone to free NHS care i.e. NHS eligibility is not relatedto one’s Nationality as mentioned above. A person can be in the UK with any passport and in many cases with a valid visa toprove ‘Legal Status’. Proof of their ‘settlement’ or ‘habitual residency’ is the essential ingredient to confirm a patient’seligibility.

4. Beware – If you see ‘No recourse to Public Funds’ endorsed within a visa – Do not refuse NHS care because this is notrelevant to the NHS. The NHS is not included within the Home Office Public Funds List so you cannot refuse NHS care to those

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with this endorsement within their visa. It merely relates to the person not being allowed to access Income Support, Child TaxCredit, Housing Benefit, Disability Living Allowance, Working Family Credit, Council Tax Benefit, Carer’s Allowance & StatePension Credit etc.

5. Remember that your decision is on the provision of NHS Primary Care – Patients can be referred to Secondary Care but ifthey don’t meet the latter’s criteria, they would be charged by the hospital in question. It is a matter for Secondary Careto identify patients who must pay and the Department of Health has issued very clear guidance to Secondary Caretherefore they have full powers to charge a patient found not to be eligible to free NHS care. However, giving access toPrimary Care will affect Secondary Care providers sooner or later and it is for this reason one needs to be cautious intaking the right decision at local level.

6. Practices must provide NHS care to those listed below irrespective of their eligibility:

a. Emergency Care – life threatening situation or the same as patient accessing A & E service at a hospital or and NHSWalk-in Centre

b. Immediate & Necessary Treatment (I&NT) – It’s a clinical decision which no one would interfere withc. Certain diseases – To protect wider public e.g. TB, Meningitis, Viral hepatitis, Smallpox, HIV/AIDS (where it is only the

first diagnosis and connected counseling sessions that are charge free etc)d. Sexually Transmitted Diseases (STD)e. Mental Health Act 1983 – i.e. those detained under the Act and where there is a need for Compulsory psychiatric

treatmentf. Patient’s already registered with a GP and provide a medical card as evidence i.e. those within the NHS systemg. Spouse and Dependents of and NHS patient: are automatically eligible if living with the NHS patient

7. How do you identify a Health Tourist?

Generally there are two types of Health Tourist. (1) Those who are former resident UK Nationals (Ex Pats) who have chosen topermanently live overseas and come back to the UK looking to obtain GP & secondary care services. They can often be spotted asthey will utilise a relative’s address as a contact point. Look out for long delays in answering practice correspondence, repeateddifficulty in contacting them or faxed requests for repeat meds from an overseas number? (2) The other type are generally ShortTerm Visitors from non EEA states who are not eligible to any NHS care except for those circumstances listed in paragraph 6. Shortterm visitors will possess a Category ‘C’ visit visa and will seek to access free NHS Primary & Secondary Care during their shortvisits to the UK.

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There are two types of Cat ‘C’ visitors visa as explained below: -

Short Term Visitors to the UK are normally issued with a 6 month Category ‘C’ visit – Visit visa. Their stay in the UKis limited to 180 days and will be marked accordingly on the visa and one is expected to leave the UK within that timeframe

However, immigration authorities also issue a ‘Mult’ visa for 2, 3 and 5 years to frequent travellers to the UKbut each time the individual arrives in UK, the stay is limited once again to 180 days.

Important Don’t be misguided by the 2, 3 & 5 year periods – the individual is still a short term visitor oneach visit and not entitled to any NHS care except emergency care – Practices have been duped intobelieving the individual is here to settle for 2, 3 or 5 period which is not true. An example of one is shownbelow:-

You will notice it’s a 2 year visa expiring August 2002, a ‘Mult’ (allows 4 entries into the UK of 180 days each, clearly specifiesit’s a Cat ‘C’ Visit visa therefore a short term visitor).

A valid UK entry visa is required by nationals from the following countries – (Alphabetical)

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Afghanistan Gambia PeruAlbania Georgia PhilippinesAlgeria Ghana QatarAngola GuineaArmenia Guinea Bissau RussiaAustralia *** Guyana RwandaAzerbaijan Haiti Sao Tome e PrincipeBahrain Hong Kong (other than British Saudi ArabiaBangladesh Overseas Nationals) SenegalBelarus India Sierra LeoneBenin Indonesia Singapore ***Bhutan Iran SomaliaBosnia Herzegovina Iraq South Africa ***Bulgaria Ivory Coast South Korea ***Burkina Faso Jamaica Sri LankaBurma Japan *** SudanBurundi Jordan SurinamCambodia Kazakhstan SyriaCameroon Kenya TaiwanCanada *** Kuwait TajikistanCape Verde Kyrgyzstan TanzaniaCentral African Republic Laos ThailandChad Lebanon TogoPeople’s Republic of China * Liberia TunisiaColombia Libya TurkeyComoros Macedonia TurkmenistanCongo Madagascar UgandaRepublic of Croatia Malaysia *** UkraineCuba Mali United Arab EmiratesDemocratic Republic of Congo Mauritania United States of America ***Djibouti Moldova UzbekistanDominion Republic Mongolia VietnamEcuador Morocco YemenEgypt Mozambique ZambiaEquatorial Guinea Nepal ZimbabweEritrea New Zealand *** Yugoslavia (former states)Ethiopia NigerFiji Nigeria * Except Chinese nationals holding passports issued byGabon North Korea Hong Kong or Macao Administrative region

OmanPakistan *** Where it’s national is seeking 6 months or more stay in UK

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DOCUMENTS NORMALLY AVAILABLE TO PROVE ‘SETTLEMENT’

Important Always request permission from patient before photocopying their documents. If refused refer the patient to your LCFS.

1. Passporta. British & EEA passports - Will not have an immigration stamp or visa within it therefore need to show commitment to settle

i.e. Tenancy Agreement, Contract of Employment, Worker Registration Scheme Certificate for Rumanian & Bulgariannationals etc

b. Non EEA passports – Will have an immigration clearance stamp or a visa with conditions attached to the issue of it

2. Tenancy Agreement – Normally for 6 months or more. (If for 12 months it would confirm the patient has made commitment tosettle therefore eligible to free NHS Primary Care)

3. School/College letter – will confirm the student / child is committed to studying Full Time course for more than 6 months

4. Benefits book/receiving pension in UK – Confirm settlement or continuous stay in the UK

5. Bank Statements – Patients may not have any other evidence but are willing to show a bank statement as proof of address –There maybe evidence of their name and address within the bank statement, which can be confirmed (Do Not photocopy any foryour files)

6. Work Permit - A4 size document issued by the Immigration Authorities will state the name of the company the individual and theperiod of employment. These can be anything from 1 year to 3 year so if the patient has a letter to confirm he/she has commencedwork, I would say provide full registration to the patient and any dependants

7. Sale of goods and properties overseas/Receipts to show shipping of goods – These will confirm the individual has made uptheir mind to settle permanently in the UK in which case full registration would need to be provided

8. Asylum Seekers -a. A4 size Home Office entry document confirming the individual has applied for asylum.b. IND Card – Credit card size with photograph of individual, name, DoB and Home Office reference No. (Example on Page 6)

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European Economic Agreement (EEA) Countries

AustriaBelgiumBulgaria (New member from 01/01/07 – Accession Country)Cyprus (Southern only)Czech RepublicDenmarkEstoniaFinlandFranceGermanyGreeceHungaryIcelandIreland

ItalyLatviaLiechtensteinLithuaniaLuxembourgMaltaNetherlandsNorwayPolandPortugalRomania (New member from 01/01/07 – Accession Country)SlovakiaSloveniaSpainSwedenSwitzerland

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EEA NATIONALS

Two aspects with regards to EEA Nationals: Firstly, the individual is either in UK for a Short Term Visit or alternatively here for LongTerm Permanent Settlement:

Short Term Visit (i.e. holiday)In general, EEA short term visitors would be those who frankly admit to or have no evidence of making any commitments to staypermanently in the UK.

As a result of Bilateral Agreement within the EEA, the guidance says that the NHS should provide temporary care (during their short termstay) for any new condition that occurs following their arrival in the UK the treatment of which cannot wait until they return home.This can be interpreted more like an Immediate and Necessary Treatment (I&NT) and is a clinical decision which no one would interferewith. Important Running short of medication during a short visit from EEU is not something the NHS considers an emergency.In this instance the individual would need to seek a private prescription.

Another point to make is that EEA nationals will not have an immigration stamp of arrival in the UK neither would they have a visa withintheir passport so the onus is on the new arrival to prove their eligibility to NHS care. Holding an EEA passport (if genuine of course) givesone a legal status in the UK but to be fully eligible to NHS care the second half of the equation is vital i.e. what documentary evidencehas been shown to confirm their ‘Settlement status’ i.e. what commitments have been made to stay permanently? - Temporaryregistrations would be recommended in cases where there is no such evidence and it is quite important that practices remainin control of their registration process.

Long Term Stay (Permanent Settlement)As mentioned above, EEA nationals will not have any visa or immigration stamp so it is quite important that the patients provide proof Ofarrival into the UK together with documentary evidence of any commitments they have made to stay permanently in the UK i.e.employment contract, Tenancy Agreement, Children being given places at local schools etc will confirm the family is not going anywherefor the foreseeable future. - I would say you are obliged to provide a full registration if there is sufficient evidence to confirmsettlement

As you can see from the above, EEA nationals have to fall into one of the two above categories? Should matters become complicated, Iwould recommend you seek my advice on: 01302 796049 or fax the details to me at: 01302 796716. Alternatively, contact your PALSoffice for guidance.

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EUROPEAN UNION IDENTITY CARDS

Difficulties can be experienced by practices when an EU national applies to register with just his/her EU ID card and nopassport. I would like to clarify the present situation in such circumstances. There are no longer any frontier controls atthe borders between 13 EU countries. This is due to the Schengen Agreement which is part of EU law. The Schengenrules remove all internal border controls but put in place effective controls at the external borders of the EU andintroduce a common visa policy. The full Schengen members are Austria, Belgium, Denmark, Finland, France,Germany, Greece, Italy, Luxembourg, the Netherlands, Portugal, Spain, Sweden (but not Ireland and the United

Kingdom) plus Iceland and Norway (which are not EU members). The 12 countries that have joined the EU since 2004 do not yet fullyparticipate in Schengen. One would therefore be required to have a valid passport or ID card to travel to those countries and to Irelandand the United Kingdom.

Agreements with Iceland, Liechtenstein, Norway, and Switzerland enable their nationals to be treated in the same way as EU citizensand to travel with just an ID card or passport in the EU.

When entering the UK one needs a valid passport or an ID card. To enter the UK from an EU country one is only required topresent an Identity Card with machine readable zone, a recent model of ID or a Passport with validity of at least another 3months … if the identity card or passport is valid, that is all one needs. Any children travelling with parents should have theirown passport or ID card or are registered within parent’s/Guardian’s passports. Therefore EU countries Photo ID cards shouldbe accepted as evidence of their legal status within the UK. This is how people within the EU will be travelling from now on.

Ireland and the United Kingdom never signed up to the Schengen Convention and thus they have not ended border controls with otherEU Member States, although they will participate, in the future, in those aspects of Schengen that entail cooperation between policeforces and the judiciary. For this reason EU citizens still have to show their passports or an ID card when travelling between the UK andthe rest of the EU.

Every person holding the nationality of a Member State is a citizen of the Union. This status confers a primary and individual right tomove and reside freely within the territory of the Member States, subject to certain limitations and conditions laid down in Communitylegislation. Community legislation provides that every Union citizen has the right to enter any EU Member State with a valididentity card or passport. The right to move freely is granted to one on grounds of his/her Union citizenship and these documentsconfirm that he/she is indeed a Union citizen. It is irrelevant whether one is traveling for professional or private reasons, whether one isgoing to work in an employed or self-employed capacity or whether one is simply a tourist.

Beside the requirement to hold a valid identity card or passport, there are no other conditions or formalities for the purpose of entry to theUnited Kingdom. However, immigration officers are entitled to check the validity of one’s identity card or passport but they should respectan individual’s fundamental rights and his/her dignity.

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SOME EXAMPLE DOCUMENTS(Please note this is to be taken as a definitive guide as National types & styles change frequently)

Romanian ID card specimens

German ID Card Specimen Spanish ID Card Specimen

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Portuguese ID Card Specimen Polish ID Card specimen

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SUMMARY GRID

NHS Practices must provide NHSPrimary Care in the followingcircumstances:

a. Emergency Care – life threatening situation or the same as patient accessing A & Eservice at a hospital or a NHS Walk-in Centre

b. Immediate & Necessary Treatment (I&NT) – A clinical decision that can only be made bya doctor.

c. Certain diseases – To protect wider public e.g. TB, Meningitis, Viral hepatitis, Smallpox,HIV/AIDS (where it is only the first diagnosis and connected counseling sessions that arecharge free etc)

d. Sexually Transmitted Diseases (STD)e. Mental Health Act 1983 – i.e. those detained under the Act and where there is a need for

ccompulsory psychiatric treatmentf. Patient’s already registered with a GP – Can provide a medical card as evidence i.e.

those within the NHS systemg. Spouse and Dependents of an NHS patient - Automatically eligible if living with the NHS

patient

The Rest fall into two categories

Those already within NHS system(Documents/Information that will help confirm eligibility)

Medical Card is produced: - (Hold back the old Medical Card as a new one will be issued following acceptance of registration)

No Medical Card but knows their previous GP details: – patient needs to complete the GMS1 form and sign declaration

Patient is able to provide their NHS number: - in which case patient needs to complete GMS1 form and sign declaration

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New Arrivals – First time NHS Registrations

(Documents that will confirm their legal status)

Category Documentary Evidence Special Comments

Asylum Seekers (Example of IND Card) 1. Home Office letter/document confirmingclaim of asylum, address, date of arrival,details of any dependants, personaldetails etc

2. Immigration & Nationality Directorate(IND) card (example on left) withphotograph, DoB, Home Officereference etc

Asylum seekers are eligible to NHSfrom the day they land in the UK –Reason – They are not going anywhereuntil their case is determined by theHome Office – For Primary Care we arelooking at a 6 month period and their stayis bound to be longer than that

Refugees They are normally a follow-on to being

asylum seekers Now grant leave to stay as refugees They are eligible to full NHS care and in

most cases they would have registeredwith an NHS GP practice

1. Brown or Blue Travel document withphotograph

2. They are eligible to work so employmentdetails

3. They are to maintain their stay on theirown accord so there will be utility bills,benefits documents etc

Refugees are those who have beengiven Asylum in the UKIt would be very unusual to find a refugeewho has never registered with an NHSGP

Spouse/ Dependant joining other half orFamily Reunion Normally the other partner’s name would

be mentioned within visa – if not oneneeds to confirm they are spouse of aregistered NHS patient in which case aMarriage Certificate needs to berequested

1. Non British Passport2. Visa would clearly state ‘Spouse joining

…………. In most cases the partnersname may be mentioned

3. Visa is normally given for a initial periodof 2 year & normally extended if thecouple show their marriage is genuineand ongoing

Examples : -Asylum Seekers – whose family areallowed join him/herMarried Overseas - spouse is allowedto join partner following marriageoverseas – it will be a 2 year visa – veryoccasionally 6 month only

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Dependants of an NHS patient As a general rule all dependants of an

exempt NHS patient are eligible

1. Non British Passport2. Visa will confirm if ‘Dependant’ and

length of visa issued3. May be marked ‘Dependant of …….’

Eligible to NHS care only on provisiondependant lives with the NHS

Students Course must be full-time and for more

than 6 months Full-time I would expect to be at least 30

hours a week

1. Passport – Visa would confirm ‘StudentStatus’

2. A letter from college/universityconfirming student is attending

3. Proof of payment of fees will confirmcommitment by individual to study

There have been cases of studentsclaiming to be on English courses for 15hours a week-The college may considerthis to be a full-time course but that istheir personal opinion – I do not agreethey are on full-time courses thereforefeel they do not satisfy the NHS criteria of‘Full-time’ studies

Student Dependanta. Provide registration only if student partner

is already an NHS patientb. Both would have same validity dates and

must be at the same address

1. Passport – Visa will confirm ‘Studentdependant of ………….. ‘

2. Students may have dependant children– they are eligible if confirmed as such

The Home Office allows dependants ofstudents to join them during stay in UK.

Work Permit Holders Are normally issued to anyone overseas

who has secured employment with a UKcompany for a specific length of period

Work Permit Holders are eligible to freeNHS care from the time they arrive

1. Non British Passport2. Visa would confirm – Work Permit3. A4 size Work Permit document issued

by the Immigration authorities – it wouldmention a specific company name and aperiod of contract of employment –Letter from company confirming theindividual has commenced employment

Work Permit Holders are eligible from theday they land in the UK as they have aspecific purpose during their stay

Highly Skilled Migrant Programme (HSMP) A non British Passport holder on reaching

a certain number of qualifying points dueto their professional skills are issued witha HSMP visa

They are normally qualified in theirspecialised fields

The visa does not require the individual tofind employment in the UK prior to their

1. Non British Passport2. Visa would confirm ‘HSMP’ legal status

– initially for 2 year period3. All dependants of an HSMP would have

similar legal status and for the sameperiod as the principal holder

Question is whether the individual is inemployment in his field. If children havejoined local schools while parent is looking

This is a difficult one as HSMP visaholder has been allowed to come to theUK without employment being in placeprior to arrival.

Dependants may also be allowed to jointhe breadwinner but what evidence isthere of permanent settlement?

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arrival for employment, my advice would be toprovide full registration to all. Otherwise onlyI&NT until time employment is found

Working Holiday Visa (WH) Usually issued to young 17 to 29 years

old Commonwealth citizens for a periodof 2 years

They are supposed to maintainthemselves by working for 12 months outof the 24 months and at the same timeenjoy the UK for the other 12 months

1. Non British Passport2. Visa would confirm Working Holiday

status3. Provide NHS care when required and

when in employment only. When not inemployment the individual is on holidayand may not be entitled to NHS care

Provide NHS care as a Temporary Patientonly - on condition evidence ofemployment is provided when requestingNHS care – Rest of the time they are onholiday and not eligible

This category of visa allows only oneperiod of stay in a lifetime i.e. 2 yearperiod of which 1 year is to be a holiday.The main basis of it is that it is anextended holiday with a benefit of beingallowed to work for 12 months

Diplomats (inc their family/dependants)Will have a visa within their passport toconfirm their legal status to be part ofdiplomatic services i.e. working with UKEmbassy or High Commission

1. A visa within their passport will confirmdiplomatic status

2. some proof of employment needs to beseen to confirm diplomatic status

Diplomat/Diplomatic staff/their families are alleligible to free NHS Primary and SecondaryCare

This category of visa is issued to foreignEmbassy or High Commission staff onlywithin UK

Domestic Workers(Includes chauffeurs, gardeners, cooks & nannies)

They are entitled for NHS care as herefor a purpose for a 6 to 12 month period

He/She must reside at the family addressso a letter from the family would suffice

1. Non British Passport2. Domestic Worker visa for 6 or 12

months

This visa can also be extended by theHome Office

EEA Nationals Their passports are not stamped by

immigration They need to show commitment to settle

i.e. Contract of employment, TenancyAgreement etc

1. EEA passport will not have visa orimmigration stamp

2. Tenancy Agreement for more than 6months would confirm commitment tosettle in UK

3. Contract of Employment for 6 monthsSee Page 12, 13 & 14

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EEA Accession countries – Romania andBulgaria Both countries joined the EEU on 1st

January 2007 but with restricted rights forits nationals

To be employees: they need to seekHome Office permission before startingwork

Self employed: do not require HomeOffice permission to work as selfemployed

Students: Need to obtain RegistrationCertificate to confirm student status -following that they are allowed to work 20hrs a week during vacations / term time

1. Romanian or Bulgarian Passports2. Worker Registration Scheme

Certificate from the Home Office3. Accession Worker Card from Home

Office is required for Au Pairs, DomesticWorkers, Ministers of Religion,Teachers, professionals withqualifications etc

Romania and Bulgaria are accessioncountries so do not have full rights as theother EEU countries.

New arrivals from these countries since01/01/2007 need to be registered on theWorker Registration Scheme with theHome Office or apply for an AccessionWorker Card before they can work in theUK

Entertainers (Not eligible to full registration)

They do not fulfil NHS criteria of ‘settlementas maximum stay allowed is 6 months so onlyEmergency care i.e. I & NT

They must have a ‘Work Permit’Maximum period of Work Permit is 6 months Only Emergency care or I & NT (can be

treated a s a private patient)

Au Pairs - Au Pairs only allowed to comefrom Andorra, Bosnia-Herzegovina*,Croatia*, Faroe Islands, Greenland,Macedonia*, Monaco, San Marino andTurkey*Individuals from any other country would notbe classified as Au Pair but would need tohave contract of employment with family

* Must have entry clearance before coming to UK

1. Passport of countries listed on left2. Visa will specify ‘Au Pair’ status3. Letter from family the ‘Au Pair’ is staying

with them and for how long They are notin paid employment

4.Romanian & Bulgarian – From 01/01/07 theyare required to apply for an AccessionWorker Card from the Home Office. Only thencan they call themselves Au Pair or be inemployment

Need to be: Unmarried Between 17-27 years of age Without dependants Come to learn English Live with an English speaking family Only receives pocket money &

lodgings