NHS costs for visitors and new arrivals

GP services are free to everyone. Registration with a GP practice is not restricted by immigration status, and a practice cannot require proof of address, identity documents or immigration papers as a condition of registering. NHS England has said this repeatedly, and practices that refuse are getting it wrong. If you are refused, ask for the refusal in writing, quote the NHS position, and contact the local integrated care board or NHS England if it is not resolved.

Someone in the UK for a short period can register as a temporary resident with a GP practice, and anyone in need of immediately necessary or emergency treatment must be treated by a GP whether or not they are registered.

Accident and emergency treatment is free to everyone, up to the point of admission or transfer to an outpatient appointment. So are NHS 111 and the emergency ambulance service. If treatment continues after admission, charging may then apply, but the initial emergency care does not.

Certain services are free to everyone regardless of residence because of the public health interest: diagnosis and treatment of specified infectious diseases, sexual health services and treatment for sexually transmitted infections, and family planning services in most circumstances.

Treatment for people who have been subjected to torture, female genital mutilation, domestic violence or sexual violence is exempt from charge, and so is treatment for identified or suspected victims of modern slavery and human trafficking. This exemption exists precisely so that fear of a bill does not deter people from seeking help.

Compulsory treatment under mental health legislation, and treatment provided as part of certain court orders, are exempt. Palliative care provided by a registered charity or community interest company is also exempt.

Crucially, no urgent or immediately necessary treatment may be withheld because a patient cannot pay. Clinicians decide whether treatment is urgent; the charging process runs alongside it. A patient told that essential treatment will not be given until a bill is settled should escalate immediately, because that is contrary to the framework.

Free hospital treatment in England depends on being 'ordinarily resident' in the UK. The test is that you are living in the UK lawfully, voluntarily, and for a settled purpose as part of the regular order of your life for the time being. Someone subject to immigration control must additionally have indefinite leave to remain to be ordinarily resident.

What is not part of the test matters as much. Paying UK income tax and National Insurance does not make you ordinarily resident. Owning a UK property does not. Being registered with a GP does not. Having a National Insurance number does not. People are frequently charged despite all four, and are frequently astonished by it.

The immigration health surcharge is the mechanism that resolves this for most migrants. It is paid as part of a visa application where the stay is for more than six months, and once paid, the holder can use the NHS broadly on the same basis as someone ordinarily resident for the duration of their leave. It does not cover assisted conception in England, and it does not remove ordinary patient charges such as prescription, dental and optical charges in England.

Refunds of the surcharge are available in specific circumstances — for people working in health and care roles who meet the conditions, and for some students from the EU, Switzerland, Norway, Iceland and Liechtenstein. Both are claimed through GOV.UK and are commonly unclaimed.

Visitors staying under six months do not pay the surcharge and are chargeable for hospital treatment unless an exemption applies. Travel insurance is therefore genuinely important for visitors, and the absence of it is the most common reason a UK visit produces a five-figure bill.

Reciprocal arrangements cover some visitors. A valid European Health Insurance Card or Global Health Insurance Card issued by an EU country, Switzerland, Norway, Iceland or Liechtenstein covers needs-arising treatment during a temporary stay in the UK, and the UK has healthcare agreements with a number of other countries with varying scope. These cover treatment that becomes necessary during the visit, not treatment the person came to the UK to obtain.

Some people are exempt as a group rather than by residence: asylum seekers with a claim outstanding, refugees, people granted humanitarian protection, people receiving support under the asylum support provisions, and people resettled under specific schemes. Children in local authority care are also exempt.

Expect to be asked about residence. NHS trusts in England have a legal duty to establish whether a patient is an overseas visitor liable to be charged, so overseas visitor managers ask questions about where you live, your immigration status and how long you have been in the UK. Answer accurately — a wrong answer given to avoid a bill is far worse than the bill.

Bring documents if you have them. A biometric residence permit or share code, a visa decision letter showing the health surcharge was paid, proof of settled or pre-settled status, or evidence of indefinite leave to remain resolve most queries immediately. For EU visitors, the EHIC or GHIC and a passport are the relevant documents.

Understand the upfront charging rule for non-urgent care. Where treatment is not urgent or immediately necessary, English trusts must charge in advance and can defer the treatment until payment is made. Where treatment is urgent or immediately necessary, it must be provided and the charge raised afterwards. If a clinician says treatment is urgent, it should go ahead.

Ask for the decision in writing, with the reason. If you are told you are chargeable, ask which regulation and which category applies, and ask for a written estimate before treatment. Errors are common, particularly where someone has recently been granted status, has an outstanding application, or falls into one of the group exemptions.

Challenge a wrong bill promptly. Write to the trust's overseas visitor team setting out why you say an exemption applies and enclosing evidence. If that fails, use the trust's formal complaints procedure and then the Parliamentary and Health Service Ombudsman. Advice agencies and specialist migrant health charities deal with these cases routinely.

Take the debt reporting rule seriously. An unpaid NHS debt above a threshold, outstanding for a defined period, is reported to the Home Office and can lead to a future immigration application being refused. If a bill is genuinely owed and you cannot pay it, contact the trust and ask about an instalment arrangement — trusts do agree them, and an arrangement being maintained is treated differently from a debt being ignored.

Do not let this stop you seeking care. Emergency treatment is always given, GP care is always free, and the exempt services listed above are always free. The charging regime applies to hospital treatment for people who are not ordinarily resident, which is a narrower category than the anxiety around it suggests.

Students on a course of more than six months pay the immigration health surcharge with their visa and then use the NHS on the same basis as a resident for the duration of their leave. Students from the EU, Switzerland, Norway, Iceland and Liechtenstein should check the specific refund route, which exists for some cohorts.

Workers on skilled worker and similar routes pay the surcharge in the same way. Those employed in health and care roles should check the health and care worker refund, which is claimed after arrival and is frequently missed.

Returning UK nationals are the group most often caught out. A British citizen who has lived abroad for years is not automatically ordinarily resident on landing — the test is about settled purpose and the regular order of life, so someone returning permanently generally becomes ordinarily resident on return, while someone visiting family for a few weeks does not. British citizens visiting from abroad can be, and are, charged for hospital treatment.

People with pre-settled or settled status under the EU Settlement Scheme are treated as ordinarily resident where the conditions are met, and holders of a valid EHIC or GHIC issued by an EU state may be covered for needs-arising treatment during a visit.

Anyone coming to the UK specifically to obtain treatment is chargeable regardless of nationality, and the exemptions for needs-arising treatment do not apply. This includes British citizens living abroad who return for planned surgery.

Short-term visitors should have travel insurance that covers medical treatment and repatriation. The absence of insurance does not prevent emergency treatment, but it does leave the visitor personally liable for the cost of everything that follows admission — and those costs are charged at a rate above the standard NHS tariff.

Check the position before travelling for anyone with a known condition. Trusts charge for maternity care to non-exempt patients, which surprises many families, though maternity care is treated as immediately necessary and must never be withheld or delayed because of an unpaid or unpayable charge.

There is no single NHS. England, Scotland, Wales and Northern Ireland each run their own health service with their own overseas visitor charging regulations, made by their own governments. The broad architecture is similar — free primary care, chargeable secondary care for people who are not ordinarily resident, a list of exempt services and exempt groups — but the detail, the administration and the guidance are separate.

The most visible difference is patient charges for residents rather than visitors. Prescriptions are free in Scotland, Wales and Northern Ireland and charged in England, and the arrangements for dental and optical charges also differ. Someone who pays the immigration health surcharge and then moves between nations will find their day-to-day costs change accordingly.

Scotland's charging rules are administered by NHS boards under Scottish regulations, and NHS inform publishes guidance for overseas visitors. Scotland's approach to who is exempt and how the ordinarily resident test is applied is set out in Scottish guidance rather than in the English framework documents, so use NHS inform rather than nhs.uk for a Scottish hospital.

Wales operates its own charging regulations through NHS Wales, with guidance published for visitors alongside the NHS 111 Wales service. As in Scotland, GP registration is free and open, and prescriptions are free to residents.

Northern Ireland's health and social care system is integrated and administered by trusts. nidirect publishes specific guidance for visitors on entitlement to health services, and the Northern Ireland rules — including the treatment of visitors from the Republic of Ireland and the operation of the Common Travel Area — reflect its land border in ways the Great Britain rules do not.

The practical rule: identify which health service will be treating you, and read that nation's guidance. A person living in England but treated in Wales, or a visitor moving around the UK, is dealt with under the rules of the service providing the treatment, not the rules of where they happen to have registered a GP.

Start with the trust's overseas visitor manager. They are the people who make the chargeable determination and they are also the people who correct it. Ask for the specific ground on which you have been assessed as chargeable, in writing.

Gather the evidence that answers the ordinarily resident question directly: a tenancy agreement or mortgage, employment records, school registrations for children, utility accounts, immigration documents, and a clear account of when you arrived and what your intentions are. The test is about the pattern of your life, so evidence of that pattern is what shifts it.

Use the exemptions properly. If you are an asylum seeker, a refugee, a person receiving asylum support, a victim of trafficking or modern slavery, or a survivor of torture, domestic or sexual violence, say so and provide what evidence you have. These exemptions are not discretionary and are frequently missed by administrative staff.

Escalate through the NHS complaints process if the trust will not correct a decision, and then to the ombudsman for the relevant nation. Where the issue is a GP practice refusing to register you, the route is the integrated care board or the equivalent commissioner rather than the ombudsman, and it is usually resolved quickly once challenged.

Get specialist help. Migrant health and refugee organisations, law centres and Citizens Advice all deal with NHS charging disputes, and the specialist organisations know the exemption categories in detail. Legal aid is available for some immigration and community care matters that overlap with this.

Finally, separate the two questions in your own mind, because the system does not do it for you. 'Am I entitled to care?' and 'will I be charged for it?' have different answers. Everyone is entitled to a GP, to emergency treatment and to the exempt services. Only the hospital bill turns on residence — and even then, treatment that is urgent is given first and charged afterwards.