Policy Exchange: Unpaid overseas patient bills leave NHS £252m out of pocket in three years

A Policy Exchange analysis of NHS trust data finds unpaid charges for overseas patients totalled £252,401,866 across three financial years, a shortfall the think tank says would be enough to fund thousands of GP salaries or dozens of new surgeries.

The report, based on Freedom of Information requests to 202 NHS trusts in England, says trusts invoiced £384,245,201 to overseas patients between 2021/22 and 2023/24. Of that amount, £131,843,335 was collected, £167,911,874 remained outstanding and £84,489,992 had been formally written off. The study received 82 full responses and five partial replies, and the authors say the true figure is likely to be significantly higher because many trusts did not respond.

Policy Exchange reported an average collection rate of 39% nationwide. Some trusts recovered as little as £40 for every £1,000 invoiced, and 19 trusts recovered under 20% of what they billed. Ten trusts accounted for £143.4 million — 56% of the national unrecovered total, the report said.

The report quotes figures comparing the lost revenue with front-line services, saying the unrecovered sum would be enough to pay for 3,200 additional GPs or to build 68 new GP surgeries. It also highlights longstanding guidance that overseas visitors can access some NHS services for free — including GP appointments and accident-and-emergency care — while people who are not "ordinary residents" can be charged for other services, with payment suggested up front unless doing so would delay urgent or immediately necessary treatment.

Sir Sajid Javid, who wrote the foreword to the report and served as health secretary between June 2021 and July 2022, said the NHS "is not a charity or an international aid organisation" and warned that failing to recover overseas charges "while British residents face long waits is corroding confidence in the system." He said asking British taxpayers to shoulder costs owed by others was "fundamentally unfair."

Migration campaigners and critics of current enforcement said the service is open to abuse. Alp Mehmet, chairman of the Migration Watch think tank, said the NHS was now regarded as an "International Health Service" and suggested the report may understate what is owed. Officials and trusts cited practical difficulties in pursuing debts, particularly when patients have left the country.

Daniel Elkeles, chief executive of NHS Providers — the membership body for NHS trusts — described the report as "unfair" and said hospitals do check eligibility for planned procedures and try to secure payment in advance. He said trusts use debt collection agencies but enforcement is hard when patients are no longer in the UK.

An NHS spokesperson said providers must identify chargeable overseas visitors and take all reasonable steps to recover costs, adding that payment for non-urgent care must be secured in advance while urgent or immediately necessary treatment is provided without delay. The spokesperson said the NHS had recovered more money so far in the current year than in previous years and that officials were working on a variety of measures to improve recovery.

Policy Exchange said its data showed widespread variation in how trusts identify and pursue overseas charges. The report also noted that some clinicians have admitted to not carrying out eligibility checks because they believe doing so fosters a "hostile environment" on wards, a dynamic that can complicate enforcement.

The issue of so-called "health tourism" has been politically resonant. The Conservative Party's 2019 manifesto pledged to "clamp down on health tourism, ensuring that those from overseas who use NHS services pay their fair share." The subject did not feature in Labour's 2024 general election manifesto, although Labour said it would create extra appointments funded by measures targeting tax avoidance and non-dom tax rules.

The Policy Exchange analysis includes high-profile individual cases used to illustrate enforcement challenges. One widely reported example involved a Nigerian woman identified only as Priscilla who received emergency maternity care at St Mary's Hospital in London after her flight stopped at Heathrow. Her treatment for unborn quadruplets led to a bill reported to have reached about £330,000.

The authors of the report called for stronger and more consistent enforcement of existing charging regulations, better data collection across trusts and clearer guidance for staff on administering rules without compromising patient care. Trust leaders and NHS officials said they faced legal and operational constraints when attempting to recoup costs, and that patient care and clinical judgment would continue to take precedence in urgent situations.

Given the incomplete response rate to the FOI requests, Policy Exchange said the scale of unrecovered charges is likely understated in its figures, and recommended further central action to standardise identification and collection practices across NHS providers. NHS leaders have acknowledged recovery challenges and said they are pursuing reforms and improved data as part of wider efforts to protect NHS finances and prioritise patient services.