Up-front charging

The Conservative government introduced ‘up-front’ charges for those patients they say are not eligible for free healthcare from the NHS – including community healthcare services.

In addition, all hospital departments and community health services are required to check every patient’s paperwork, including passports and proof of address, and charge up-front for healthcare.

They are also required to refuse to provide non-urgent care if a patient cannot pay. The final decision is supposed to rest with clinical staff, but it is clear to UNISON that other staff may be expected to make initial assessments.

Our concerns

The government’s introduction of ‘up-front’ charging can mean the difference between life and death for vulnerable patients. It also erodes trust between healthcare professionals and the communities they serve and endangers public health.

UNISON wants up front charges in the NHS to be abolished because there are many cases of people being wrongly charged – or even denied – treatment based on their immigration status.

One such case was Albert Thompson who arrived in the UK as a teenager in 1973 but because he was unable to “evidence his settled status”  in the UK, he was asked to pay £54,000 upfront for his cancer treatment even though he had tax and national insurance records going back decades, which not only proved his residency but also proved his contributions to the NHS.

Recent figures show that 2,279 patients were charged upfront between October 2017 and June 2018. And for 341 of these patients, their treatment did not go ahead after they were told to pay.

In February 2019 the government admitted that at least 22 people were wrongly asked to pay upfront for urgent care – this this is the tip of the iceberg. The charity Doctors of the World has highlighted many cases of refugees and asylum seekers being charged for, or refused, cancer care or cardiac surgery even though they are entitled to free NHS treatment.

This is not only inhumane, it means that healthcare staff and NHS trusts are breaking their own rules. It also makes no financial sense. Withholding treatment from any individual costs more in the long term and threatens the health of the whole population. We know that the evidence proves that early diagnosis and treatment of disease costs less, with better outcomes. Withholding treatment affects all of us.

What you can do

UNISON branches/reps

The Windrush scandal has shown that not having documentation doesn’t mean a patient is not eligible for treatment. The  paperwork can be complicated, so much so that even the Home Office has failed to correctly identify legitimate documentation.

UNISON branches should speak to their employer to ensure there are safeguards to prevent the denial of necessary and urgent care to all those who are entitled to it. This will support our members who are dealing with these patients.

Reps and branches should also be speaking to employers about raising awareness around who is exempt from charges. The following are exempt:

  • refugees, asylum seekers and their dependents, refused asylum seekers receiving section 95 support, section 4 support or support under the Care Act in England, refused asylum seekers in Scotland and Wales
  • children looked after by a local authority
  • victims and suspected victims of modern slavery
  • survivors of torture, FGM, domestic or sexual violence receiving treatment as a result of their experience of violence
  • those receiving treatment under the Mental Health Act
  • prisoners and those held in immigration detention.

Trusts should be encouraged to do more to ensure that all staff know this.

UNISON members

As a healthcare worker you have a primary duty of care to all patients, including patients who are not directly under your responsibility. If you have concerns about any of these issues around withholding treatment from patients deemed to be ineligible, you should speak with your UNISON rep as a matter of urgency.

You should check if the patient meets any of the charging exemptions – details here (see above).

Express your concerns

You have the support of your union so you should always raise important questions about how a treatment like chemotherapy or renal dialysis can ever be considered to not be immediately necessary. Or how a health provider can be sure that an individual’s condition will not deteriorate if you do not offer them treatment for cancer or a heart problem.  Ask who is liable if delaying or refusing treatment for a patient on the basis of their residency or immigration status, or because it has been decided that they should pay upfront for treatment, results in significant deterioration of the patient’s health.

Make formal complaints and record harm

When you think harm or discrimination might have occurred or there was potential for it to occur, formally record this. This could be as a result of being asked to pay upfront for treatment; being told that they will be billed or receiving a bill retrospectively; or fear of having information shared with the Home Office for immigration enforcement.

You should also note when patients have been deterred from accessing care and you can submit incident reports using your trust’s formal system (eg Datix) when you observe situations where patients are at risk of harm or discrimination. This can include “near miss” incidents, for example if care is delayed but no actual harm occurred, or if a patient discloses fear about the impact of the regulations on them, even when in reality they are exempt. 


You will find useful resources on these websites:

Help us

UNISON is working with several other groups including Doctors of the World, the TUC, Asylum Matters, the National Aids Trust to campaign against these charges.

Your stories will help us make a real difference.

Email us at health@unison.co.uk to tell us your experiences.

Have you or other members been asked to check if a patient is liable for upfront charges? What training or support were you given? What impact has it had on you or your colleagues? We won’t use your name if you ask us not to, but we need your voice to be heard.

We are also putting pressure on the Nursing and Midwifery Council (NMC) to issue advice to registrants on the matter of upfront charging. We have a template letter you can use if you want to write to the NMC to express your concerns about the lack of professional guidance available to tell them that upfront charging raises significant ethical concerns for members, potentially compromising their duty of care.

Please email the Health team (health@unison.co.uk) if you would like a copy of this letter.