Unrecovered bills for overseas patients leave NHS £252 million out of pocket over three years, report finds

Overseas patients who did not pay for care have left the NHS £252.4 million out of pocket between 2021/22 and 2023/24, according to a Policy Exchange report that says many trusts are recovering only a fraction of what they invoice.

The think tank’s analysis of Freedom of Information responses from NHS trusts found that hospitals and mental health and community services invoiced a total of £384,245,201 to overseas patients over the three financial years. Of that amount, £131,843,335 was collected; £167,911,874 was outstanding and a further £84,489,992 was formally written off, producing a combined unrecovered total of £252,401,866. The report cautioned the true figure is likely higher because many trusts did not respond to the information requests.

Policy Exchange said the average collection rate across responding trusts was 39 percent and that 19 trusts recovered less than 20 percent of the charges they issued. The ten worst-performing trusts accounted for £143.4 million, or about 56 percent, of the national total unrecovered. The FOI requests were sent to 202 NHS trusts in England and elicited 82 full responses and five partial responses.

The report’s foreword was written by Sir Sajid Javid, the former health secretary and chancellor, who said asking paying patients to cover costs left by those who have not contributed is “fundamentally unfair.” He warned that writing off large sums while residents face long waits is “corroding confidence” in the service and said the NHS “is not a charity. It is not an international aid organisation.”

Migration campaigners argued the system has long been open to abuse. Alp Mehmet, chairman of the Migration Watch think tank, said the NHS is now seen as an “International Health Service” and that the £252 million figure may be a significant underestimate. “In reality, the NHS makes little effort to recover it,” he said.

NHS Providers, which represents hospital trusts, disputed the tone of the report. Daniel Elkeles, its chief executive, said hospitals do check eligibility for planned procedures and try to secure payment in advance where appropriate. He noted trusts use debt-collection agencies but that enforcement is difficult if patients have left the country.

An NHS spokesperson said providers must identify chargeable overseas visitors and take all reasonable steps to recover costs in line with regulations. The spokesperson reiterated that non-urgent care should be paid for in advance while urgent or immediately necessary treatment is provided without delay, and added that “the NHS has recovered more money so far this year compared to previous years” and is working on further measures.

Guidance allows some NHS services to be accessed free of charge by overseas visitors: general practice consultations and emergency department care are typically available without charge. However, people who are not considered “ordinary residents” in the UK can be charged for other hospital services, and guidance suggests payment should be secured upfront unless doing so would delay urgent or immediately necessary care.

The Policy Exchange figures include high-profile individual cases that have highlighted the issue in public debate. One reported instance involved a Nigerian woman, identified in news reports as Priscilla, who was treated as an emergency at St Mary’s Hospital in London after her flight stopped at Heathrow while she was pregnant with quadruplets; her bill was reported to have reached about £330,000 by the time of her discharge.

The question of charging overseas patients featured in political debate during the last two general elections. The Conservative Party’s 2019 manifesto pledged to clamp down on health tourism and ensure overseas users pay their “fair share.” The issue did not appear in Labour’s 2024 manifesto, which instead pledged to expand appointments by cracking down on tax avoidance and other measures to raise revenue.

Policy Exchange said the scale of unrecovered charges and variation in recovery rates across trusts point to inconsistent implementation of charging rules and to practical obstacles in collecting fees. NHS Providers and the health service have pointed to legal and enforcement limits, particularly when patients are no longer in the country. The report’s authors and supporters of tougher recovery measures say stronger systems are needed to protect taxpayer-funded services and to ensure resources are not diverted from UK residents.

The report, compiled from partial returns by a subset of trusts, leaves open questions about the full national scale. Policy Exchange noted that because many trusts did not provide the requested information, the overall shortfall could be substantially larger than the figures it published.