Guidance

NHS debtors (accessible)

Published 1 August 2023

About this guidance

This guidance tells Border Force officers how to process passengers who owe a debt to the National Health Service (NHS), which meets or exceeds the relevant NHS debt threshold.

Contacts

If you have any questions or you believe there are factual errors about the guidance, you should refer to your line manager or senior caseworker. If they are not able to provide an answer, you should contact your Regional Command and Control Unit and if necessary, they will contact Border Force National Command Centre. For questions relating to the NHS debtor rule email the Compliant Environment and Enforcement Unit, Health Policy team or AWBS Correspondence for assistance.

If you notice any formatting errors in this guidance (broken links, spelling mistakes and so on) or have any comments about the layout or navigability of the guidance then you can email the Guidance Rules and Forms team.

Publication

Below is information on when this version of the guidance was published:

• version 7.0
• published for Home Office staff on 24 July 2023

Changes from last version of this guidance

Guidance updated to outline the difference in how Border Force officers should deal with NHS debtor cases, for passengers who hold extant permission to stay in the UK and those who are seeking permission to enter.

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• the guidance has been updated to reflect that NHS charges may apply to EEA nationals as of 1 July 2021 and as such NHS debt may be attributed to an EEA national
• clarification provided on the instances when officers are required to contact the NHS body to verify a debt - confirmation provided that NHS bodies should only be contacted in specific circumstances
• the instruction requiring Border Force officers to take contact details for the passenger or provide contact details for the NHS body has been removed

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Qualifying debt

This page tells Border Force officers who is an NHS debtor.

A person is considered to have a debt to the NHS if a relevant NHS body has informed the Home Office that the applicant has failed to pay a charge to the NHS which meets or exceeds the required threshold, following the invoice being unpaid for a period exceeding two months. Debt can include invoices from multiple NHS bodies or multiple invoices from a single NHS body.

The term ‘relevant NHS body’ is defined in paragraph 6 of the Immigration Rules.

The NHS debtors rule may apply where either:

• the applicant has an outstanding NHS debt, or cumulative debts, of £1000 or more incurred on or after 1 November 2011
• the applicant has an outstanding NHS debt, or cumulative debt of £500 or more incurred on or after 6 April 2016
• the applicant is an EU, EEA or Swiss national and has an outstanding NHS debt, or cumulative debt of £500 or more incurred on or after 1 July 2021

A person who has incurred charges of under £1000 before 6 April 2016 cannot be refused entry clearance, permission to enter or permission to stay on this basis unless either of the following apply:

• they incur further charges of at least £500 on or after 6 April 2016
• they incur further charges on or after 6 April 2016 bringing the total outstanding NHS debt incurred since 1 November 2011 to over £1000

NHS treatment which occurred prior to 1 November 2011 does not count towards the threshold for eligible NHS debt. The NHS debt rule is not retrospective and does not include debts for treatment incurred prior to 1 November 2011.

Appendix FM, Appendix Armed Forces and Appendix Private life

Appendix FM applies to those seeking to enter or stay in the UK based on their family life with an individual who is:

• a British Citizen
• settled in the UK
• in the UK with limited permission to stay as a refugee or person granted humanitarian protection
• in the UK with limited permission under Appendix EU, in accordance with paragraph GEN 1.3 or in the UK with limited permission as a worker or business person under Appendix ECAA Extension of Stay, in accordance with paragraph GEN.1.3.(e)

The Appendix Armed Forces routes are for members of the armed forces, civilian employees, and their families.

Appendix Private Life is for those seeking to stay in the UK on the basis of their private life, including private life claims under Article 8 ECHR.

On 24 November 2016, the threshold for considering refusal on the basis of NHS debt was reduced from £1000 to £500 for applications considered under Appendix FM, Appendix Armed Forces and Appendix Private Life of the Immigration Rules. This aligns with the rules change which came into effect in April 2016 for all other categories. The lower threshold for applications received under these categories would only apply to debts incurred on or after 24 November 2016.

NHS charging

This section tells Border Force officers about who is chargeable for treatment, what types of treatment are chargeable and what debt can be reported to the Home Office.

Individual NHS bodies decide who is eligible for NHS treatment and who is charged. To be eligible for free secondary NHS care, an individual must either be:

• a British or Irish national who is ordinarily resident within the UK
• an individual who has been granted indefinite leave to remain or settlement who is ordinarily resident within the UK (including grants of settled status under the EU Settlement scheme)
• subject to one of the exemptions from charge such as payment of the Immigration Health Surcharge (IHS) or being granted in a protection category (for example, asylum seekers and individuals granted refugee status)

NHS charges are applied for treatment provided to migrants who do not hold lawful status within the UK and those who have entered the UK on the basis of short-term temporary permission (e.g., Visit/ Seasonal Worker). If a visa holder has paid the IHS or is exempt from payment as part of their successful visa application, they are entitled to access NHS treatment on broadly the same basis as a British national.

NHS debt can only be attributed to a Home Office record where a migrant is aged 18 or over. NHS debt is only applicable to the individual who received the treatment, unless treatment was provided to a child, in this case the NHS debt may be attributed to the parent or legal guardian of the child.

The NHS debtor rule applies only to those who are subject to immigration control.

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The debt can be owed to one or more NHS body, but the accumulated debt must meet or exceed the relevant threshold, dependent on when the debt was incurred.

Health provision is devolved and there are different NHS charging regulations in different parts of the UK. However, the Immigration Rules apply to the whole of the UK. The Home Office has arrangements with NHS bodies to ensure that NHS debts are referred to the Home Office regardless of where they are raised in the UK.

Primary Health Care, General Practice (GPs) and Secondary Health Care

Primary Health Care provides the first point of contact into the Health Care system. Within the NHS, the main source of Primary Care is General Practitioners (GPs).

Secondary Health Care is provided within a hospital, following a referral from a GP or as a result of the requirement for further treatment following an admission to Accident and Emergency (A&E) which is deemed as primary care.

Treatment within an A&E department and at a GP surgery is free to all, regardless of immigration status.

An overseas visitor or migrant may, therefore, register as an NHS patient and see a GP without charge, but any subsequent secondary NHS treatment may be subject to charge under the relevant NHS Charging Regulations, unless an exemption from charging applies to the type of treatment. Exemptions to charge based on the type of treatment include:

• diagnosis and treatment of certain communicable diseases, including TB, HIV and COVID-19
• certain family planning services (such as contraception)
• services provided for the diagnosis and treatment of sexually transmitted infections
• treatment of a condition caused by female genital mutilation (FGM), torture, sexual violence or domestic violence (unless they have entered the UK to seek this care)

In addition, certain groups are exempt from NHS charges. For the list of exempt treatments and groups see: NHS entitlements: migrant-health-guide.

Evidence of unpaid charges

NHS bodies pursue their own internal processes to recover monies owed, and only notify the Home Office after the debt has been outstanding for a period exceeding two months from the date of invoice.

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No new records or updates of NHS debt are added to CID, as it is in the process of being decommissioned. You must, therefore, check Atlas (not CID) for up-to-date information on NHS debt.

The NHS debt entry on Atlas includes the individual’s biographical details, the amount owed and the NHS body (or bodies) who are owed the debt. An individual’s clinical details will not be shared with the Home Office.

NHS bodies regularly liaise with the Home Office and should inform the Home Office as soon as the debt has been repaid or the patient has entered into a debt repayment plan.

Where the debt owed to the NHS has been paid in full or a repayment plan entered into, the NHS confirms this to the Home Office to ensure immigration records are updated and the NHS debtor record is closed. Further information on debts paid in full and repayment plans can be found in Payment of debt and contacting the NHS.

Refusal of permission to enter

This page tells Border Force officers how to refuse permission to enter to a passenger who is an NHS debtor. If the passenger arrives with an entry clearance or continuing permission, you must follow the guidance relating to those with Entry Clearance or Permission to Stay.

Paragraph 2 of Schedule 2 to the Immigration Act 1971 confers on Border Force officers the power to examine arriving passengers and conduct any further examination, for the purpose of determining whether a passenger requires permission to enter the UK, and, if so, whether that permission should be granted or refused.

Where such a passenger seeks permission to enter and has an entry against their name on the Home Office systems due to an unpaid debt to the NHS that meets or exceeds the threshold, you may refuse permission to enter. Paragraph 9.11.1 of part 9 of the Immigration Rules allow an application to be refused if an applicant has a qualifying NHS debt.

Refusal of permission to enter on the basis that the individual has a qualifying NHS debt is discretionary not mandatory. You must be satisfied that there are no compelling or compassionate circumstances (including human rights considerations) that would make refusal disproportionate. More information on this ground for refusal, is set out in Suitability: Debt to the NHS and should be read alongside this document.

The refusal wording must reflect the provisions of the rules, stating both the:

• amount of debt owed to the NHS
• NHS body who reported the debt

The principle that an individual’s personal medical history is confidential is not affected by this rule. Details of the condition and treatment which the passenger received to incur the debt are not required information for the purposes of this decision, and you must not ask for them or record them, even if the passenger offers this information.

If a passenger is seeking entry as a Visitor, you still need to ask appropriate questions to ensure the purpose of entry is not to seek further medical treatment.

There is no facility for, or obligation on you, to ask for or accept payment of the outstanding NHS debt at any point in the proceedings. Arrangements for payment of the debt are between the passenger and the NHS. Although, you should provide the contact details of the relevant NHS body if requested by the passenger.

If a debt is settled in full or a repayment plan has been agreed and you can confirm this, there are no longer grounds to refuse entry on this basis. You then need to be satisfied that the passenger meets the other requirements for the category in which they are seeking permission to enter.

Example of refusal wording where a non-visa national passenger is to be refused permission to enter as a Visitor:

You have sought permission to enter as a [category] for [period] however I am satisfied that you owe [amount, if known or a debt of at least £1000 or £500] to [the relevant NHS body(s)] in accordance with the relevant regulations on charges to overseas visitors and I therefore refuse you permission to enter.

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The NHS debtor rule creates no additional rights of appeal.

If an applicant is a visa national who does not hold prior entry clearance, you must refuse on the basis of paragraph 9.14.1 (no entry clearance grounds), this is the primary reason for refusal. NHS debt may be referred to as a contributing factor.

Earlier debts and ongoing treatment

The NHS debtor rule is not retrospective and does not cover any debt incurred before 1 November 2011. The date that relevant NHS services were provided is the key factor, rather than the date the individual was invoiced for treatment. For example, if the date of treatment was 1 October 2011 but the patient was not invoiced until 1 January 2012, any debt incurred for this treatment must not be considered, as it precedes the introduction of the NHS debtor rule.

There are also specific rules to cover the change in threshold from £1000 to £500, see: Suitability: Debt to the NHS.

Where you become aware of an earlier outstanding NHS debt relating to an ongoing medical condition and have reason to believe that a passenger is seeking entry as a visitor to obtain further treatment, you must make sure the passenger does not intend to access medical treatment, other than private medical treatment, or to donate an organ, and that they meet the eligibility requirements of paragraphs V7.1 - V 7.3 or V8.1 – V8.4

If you have any doubts about the passenger’s intentions and think the passenger is entering the UK to access further medical treatment you must refuse under Paragraph V4.4 (c) of Appendix V: visitor to the immigration rules.

Entry clearance or permission to stay

This section tells Border Force officers what they should do when encountering an NHS debtor who holds valid entry clearance or permission to stay.

Paragraph 2 of Schedule 2 to the Immigration Act 1971 confers on Border Force officers the power to examine arriving passengers and conduct any further examination, for the purpose of determining whether a passenger requires permission to enter the UK. Where a passenger arrives with permission in force (either permission conferred by an entry clearance or continuing leave), they may be examined under Paragraph 2A of Schedule 2 for the purpose of determining whether there are any reasons why that permission should be cancelled.

A person who holds valid entry clearance or who has continuing leave (such as permission to stay in the UK) cannot have their immigration permission cancelled solely on the basis that they have incurred an NHS debt.

Once it is established that a passenger is only on Home Office systems due to NHS debt, they must not be subject to further examination unless the Border Force Officer has reason to believe there are grounds for the permission held to be cancelled, including but not limited to a change of circumstances (paragraphs 9.20.1 and 9.20.2 of the Immigration Rules) or false representations (paragraph 9.7.3 of the Immigration Rules). Any questioning undertaken to determine whether permission should be cancelled should focus on the reason the passenger is subject to further examination and details of the further examination should be recorded on Home Office systems.

Passengers with continuing permission should not be refused entry for an outstanding NHS debt as this is not (in and of itself) a ground for cancellation of permission.

Consequently, once it has been established that a passenger holds valid entry clearance or permission to stay and the passenger is only on Home Office systems as an NHS debtor, and there are no reasons to justify further examination to determine whether permission should be cancelled, they should be permitted to proceed.

If NHS debt is considered alongside further indicators which fundamentally change the circumstances of the applicant’s entry to the UK, it may be a contributing factor for a decision to cancel permission.

You can remind the passenger that the outstanding debt may prevent any further permission being granted but must not indicate that the passenger being permitted to proceed beyond the Primary Control Point (PCP) is dependent on the passenger paying the debt.

You must not request contact details from the passenger, to be passed to the NHS body. If the passenger requests contact information for the relevant NHS body, you should provide the contact information provided on the NHS Debt case on Atlas.

Multi entry Visit Visas

Holders of multiple-entry Visit visas may have incurred NHS charges on a previous visit to the UK on their Visit visa. If a migrant holds a multi-entry Visit visa, you must check when the debt was incurred and reported to the Home Office, to determine whether the NHS treatment was incurred on a previous entry.

If a passenger seeks entry on a multiple-entry Visit visa and an NHS debt has been incurred after the visa was issued, the passenger should be issued an IS81 and be subject to further examination. In this instance, the stop permits officers to determine whether the circumstances of the passenger have changed significantly since the permission was initially granted or whether the passenger made false representations regarding their intention for seeking entry to the UK on the previous Visit such that the visa should be cancelled. In these instances, refer to the guidance on false representations and change of circumstances.

If the Border Force officer is satisfied that the circumstances of the passenger have changed significantly since the grant of the Visit visa or the primary purpose of entry is to access healthcare, the visa should be cancelled on the basis of paragraph

9.20.1 or 9.20.2. If, however, the Border Force Officer considers that the change of circumstances is insufficient to merit cancellation of the visa, passengers should be advised that the existence of NHS debt may impact on future applications.

If NHS debts are paid or have been paid recently by a Visit visa holder but you have reason to believe that the passenger’s main or primary intention is to seek further NHS treatment during the current visit, you can refuse permission to enter under:

• paragraph 9.20.2 of part 9 of the Immigration Rules, on the grounds of change of purpose

Payment of debt and contacting the NHS

This page tells Border Force officers how to check if an NHS debt has been paid or whether a repayment plan is in place and provides information about when the NHS body should be contacted.

Evidence of payment

If the passenger provides satisfactory evidence that they have paid the debt and there are no other reasons to refuse permission to enter, you should grant them entry and allow them to proceed.

Satisfactory evidence may take different forms and you must decide based on the evidence presented if the debt has been paid. All evidence provided to confirm payment of an NHS debt, or the existence of a repayment plan must have originated from the NHS body which levied the debt, evidence provided from any other source is not acceptable (for example, if a passenger shows their bank statements highlighting full payment or a repayment plan without evidence from the NHS body, this cannot be accepted in isolation).

If there are any doubts regarding whether the passenger has paid the debt or entered into a repayment plan, the NHS body who charged for treatment can be contacted to confirm whether a debt has been repaid. If the NHS body confirms that the passenger has not paid the debt or entered into a repayment plan as claimed, this can form grounds for permission to enter to be refused.

However, where a debt has recently been paid in full, you must also be satisfied that all the requirements of the relevant rules are met before granting permission to enter. You will need to consider whether payment of the NHS debt may impact on the ability of the passenger to financially maintain themselves for the duration of their stay.

Contacting the NHS

You should not contact the NHS body in order to determine whether a debt is valid unless

• the passenger is seeking permission to enter, and the validity of the debt is required to determine whether refusing permission is suitable
• the passenger states that they are unaware of the debt or are challenging the validity of the debt
• the passenger has stated they have paid the debt in full which is unable to be verified without contacting the NHS body
• the passenger has stated they have entered into a repayment plan which is unable to be verified without contacting the NHS body

Payment of debt before refusal

You must not defer refusal of entry simply to allow a passenger to settle their debts, you must progress cases as normal. However, it may be the case that a passenger has paid their debt after being stopped at the Primary Control Point (PCP) and before being served with a refusal notice. You must treat such cases like any other where new information comes to light during the examination and consider whether refusal is still appropriate.

Payment of debt after refusal

It may be that a passenger pays their outstanding debt after they have been refused permission to enter but before removal. You must consider these cases like any other where new information emerges that may cause a refusal decision to be reviewed.

You may cancel any decision to refuse under paragraph 6(3) of schedule 2 to the Immigration Act 1971.

Repayment plans

Some debts incurred will be for substantial amounts and some NHS bodies will accept payment in instalments. If a repayment plan has been agreed between the debtor and the relevant NHS body since the Home Office was initially notified, the NHS body will notify the Home Office of the repayment plan, in order for the debt to be removed from Home Office systems.

However, a passenger may make such an arrangement once they have been identified as an NHS debtor on arrival. If satisfactory evidence of an agreed payment plan is not produced, a short period of immigration bail should be granted, if necessary, to allow contact to be made with the NHS body to verify that a payment plan is in place.

If an NHS debtor has been reported to the Home Office and a repayment plan has been agreed or the debt has been paid in full, the NHS body should provide details of the individual to the Home Office, in order for the NHS debt to be removed from the migrant’s records. If a payment plan has been agreed, resulting in the debt being removed from the migrant’s records, the NHS may notify the Home Office if the migrant defaults on the payment plan, leading to the NHS debt being re-added to the individual’s immigration records.

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