The NHS operates on a clear statutory principle with regards to treatment: treatment is available to those ordinarily resident in the UK, with certain exemptions, but charges must be recovered from overseas visitors who do not meet those criteria.

This paper explores what happens when that principle is put to the test, not in theory, but in the day-to-day practice of NHS trusts, integrated care systems, and clinical leadership teams. It documents how some NHS Trusts have entered into partnerships with charities and pressure groups such as the ‘Cities of Sanctuary’ movement.  It examines how policies concerning cost recovery from overseas visitors and the identification of chargeable patients are implemented across the health system. It asks how national legislation translates into institutional behaviour, and what role organisational culture, professional norms and third-sector influence play in that process. Following papers will address immigration law compliance and right to work checks.

Policy Exchange conducted an extensive FOI exercise that found that between 2021 and 2024, NHS trusts in England invoiced £384,245,201 to overseas patients. The total value of unrecovered charges over the three years is over £250 million. That’s enough to pay the annual salaries of around 3,200 GPs or to fund the building of approximately 68 new GP surgeries. The national average recovery rate over the period was 39 percent.

Recommendations include:

• Require trust publish annual figures regarding overseas health costs
• Publishing league tables with automatic audits for low performers
• A trust CEO’s bonuses are tied to a 50% collection performance target
• Require all trusts disclose all formal external partnerships
• Embed immigration status checks in the professional guidance for healthcare workers
• Deny new visas to those with outstanding NHS bills

The launch of this report was covered by:

• The Telegraph
• The Daily Mail
• The Sun
• The Express
• LBC
• GB News
• POLITICO’s London Playbook