Overseas visitors' eligibility to receive free primary care (WHC/2025/025)

Status:

Compliance / action / information.

Category:

Legislation / delivery / public health / policy.

Title:

Overseas visitors' eligibility to receive free primary care.

Date of expiry / review:

Not applicable.

Action by:

• Chief executives of NHS trusts and Local Health Boards (LHBs).
• Directors of primary and community care.
• NHS Wales Shared Services Partnership.

For information:

• Chairs of NHS trusts and LHBs.
• Directors of finance.
• Directors of workforce and organisational development.
• Medical directors.
• Directors of nursing.
• Directors of therapies and health sciences.
• Directors of planning.
• Directors of public health.
• Directors of pharmacy.
• Heads of primary care.
• Overseas visitors managers.

Required by:

Immediate.

Sender:

• Claire Cullen, Primary Care, Health Social Care and Early Years.
• Chris Wright, Central Legislation Support Unit, Health Social Care and Early Years.

Welsh Government contacts:

• Claire Cullen, Primary Care, Health Social Care and Early Years.
• Chris Wright, Central Legislation Support Unit, Health Social Care and Early Years.

Mailbox:

• HSS-PrimaryCareMailbox@gov.wales
• HSSG-CentralLegislationSupport@gov.wales

Enclosures:

One.

Summary

1. This circular clarifies the circumstances when overseas visitors are entitled to free primary care. In all other circumstances further advice must be sought from Local Health Board (LHB) Overseas Visitors Managers (OVMs) to determine free primary and secondary care. It replaces WHC/2021/026.

Action

2. LHB chief executives in conjunction with their directors of primary care are asked to ensure copies of this circular are sent to all General Medical Services (GMS) contractors, pharmacists, dentists, optometrists and ophthalmic medical practitioners as well as local representative committees.

Background

3. The National Health Service (NHS) is primarily for the benefit of people who live in this country. It is therefore considered that eligibility to receive free medical treatment should relate to whether a person is ordinarily resident in the United Kingdom (UK) and not to nationality, the payment of national insurance contributions or taxes. There are however, a number of NHS services provided by LHBs which are free to everyone regardless of the status of the patient. Please refer to Annex A.
4. A person is regarded as "ordinarily resident" in the UK if he or she is lawfully living in the UK voluntarily and for a settled purpose as part of the regular order of his or her life for the time being. A person must have an identifiable purpose for his or her residence here and that purpose must have a sufficient degree of continuity to be properly described as settled. If GPs are unclear on the status of an individual they should contact the OVM in their LHB for advice.
5. "Overseas visitor" describes a person who is not ordinarily resident in the UK. It is essentially a short-term position until the person either returns abroad or is given leave to remain in the UK and becomes ordinarily resident here.
6. The National Health Service (Charges to Overseas Visitors) Regulations 1989 (“the 1989 Regulations”) provide the legislative framework for the making and recovery of charges in respect of overseas visitors. An overseas visitor is defined as “a person not ordinarily resident in the United Kingdom”. This WHC was first issued in 1999 and subsequently revised in 2021 following the UK leaving the EU and the subsequent reciprocal healthcare arrangements with the EU under the Social Security Co-ordination Protocol provisions of the UK Trade and Cooperation Agreement (“TCA”). Since 2021 there have been a number of further changes including new reciprocal healthcare arrangements with Switzerland (the UK-Switzerland Convention on Social Security Coordination) and with the EEA/EFTA States of Norway, Iceland and Liechtenstein (the UK-EEA/EFTA Convention on Social Security Coordination). It is therefore considered timely to update and re-issue the circular to clarify overseas visitors' entitlement to primary care.

Part I: medical care

7. In relation to primary medical care, this circular applies both to GPs operating under a GMS contract, an Alternative Provider of Medical Services (APMS) or GPs working in a LHB managed practice.

Acceptance of patients

8. GPs' attention is drawn to the following provisions of the National Health Service (General Medical Services Contracts) (Wales) Regulations 2023 (“the 2023 Regulations”).
9. The contractor must, if its list of patients is open, accept an application for inclusion in its list of patients made by or on behalf of any person whether or not resident in its practice area or included, at the time of that application, in the list of patients of another contractor or provider of primary medical services. (Paragraph 23(1) of Part 2 of Schedule 3 of the 2023 Regulations).
10. The contractor must, if its list of patients is open, accept a person as a temporary resident if, when that person arrives in that temporary place, he or she intends to stay there for more than 24 hours but not more than 12 weeks. (Paragraph 25(1) of Part 2 of Schedule 3 of the 2023 Regulations).
11. The exception to the two cases outlined above is if paragraph 26(1) of Part 2 of Schedule 3 of the 2023 Regulations applies where the contractor may only refuse an application made under paragraphs 23, 24 or 25 or terminate its responsibility for a person accepted by it as a temporary resident under paragraph 25(3) if it has reasonable grounds for doing so which do not relate to the applicant's race, social class, age, religion or belief, sexual orientation, appearance, gender or gender reassignment, marriage or civil partnership, pregnancy or maternity, disability or medical condition.
12. Therefore, when an overseas visitor from any country requests non-emergency treatment or treatment that is not immediately necessary, it is for the GP to decide whether to accept that person onto his or her list for NHS treatment. If the GP wishes to accept the overseas visitor onto his or her list, he or she may treat the visitor as either a fully registered patient or as a temporary resident. Either way, if the GP accepts the patient onto his or her list, the normal contractual terms will apply and therefore the GP has to provide that treatment free of charge to the patient (except for special cases where the 2023 Regulations or equivalent legislation for APMS and LHBMS (Local Health Board Medical Services) providers allow the GP to charge or accept a fee).
13. If the GP does not wish to accept the overseas visitor onto his or her list, the GP may treat the patient on a private, paying basis (with the exceptions in paragraph 26 below).
14. GPs are encouraged to do so on the grounds that eligibility to receive free medical treatment is intended to relate to whether a person is ordinarily resident in the UK.
15. Many overseas visitors will expect and wish to obtain private treatment. GPs and their staff are however advised to do all they can to ensure that patients fully understand whether they are being treated as private or as NHS patients. Misunderstandings on this point are a common cause of subsequent disputes. It would be particularly appropriate to offer private treatment if it appears that the patient has come to the UK specifically to obtain treatment.

Assignment of a patient to a GP by a local health board

16. An overseas visitor may be assigned to a contractor whose list of patients is open (Paragraph 43 of Part 4 of Schedule 3 of the 2023 Regulations). The contractor who is assigned the patient is obliged under the 2023 regulations to treat that patient under the NHS.
17. In certain circumstances, a LHB may also assign a patient to a contractor who has closed its patient list. The patient would receive the same clinical services from the contractor as if the patient had been assigned to a contractor whose list of patients was open. The procedure for this is outlined in Part 4 of Schedule 3 of the 2023 Regulations.

Treatment and services that patients must receive free of charge:

Immediately necessary treatment

18. Under the 2023 Regulations (or equivalent legislation for APMS and LHBMS Providers) a contractor must provide primary medical services required in core hours (Regulation 17(2)(b)) for the immediately necessary treatment of any person to whom the contractor has been requested to provide treatment owing to an accident or emergency at any place in its practice area (Regulation 17(7)). The 2023 regulations make no distinction on grounds of nationality or residence.
19. The 2023 regulations also require a contractor to provide primary medical services required in core hours for the immediately necessary treatment of the following:

• a person whose application for inclusion in the contractor's list of patients has been refused in accordance with paragraph 26 in part 2 of schedule 3 of the 2023 regulations and who is not registered with another provider of essential services (or their equivalent) in the area of the LHB(regulation 17(10(a))
• a person whose application for acceptance as a temporary resident has been rejected in accordance with paragraph 26 in part 2 of schedule 3 of the 2023 regulations (regulation 17(10(b))
• a person who is present in the contractor's practice area for less than 24 hours (Regulation 17(10(c))

20. The contractor shall give the person concerned, free of charge, any immediately necessary treatment for a period of up to 14 days or in the case of persons who are present in the contractor’s practice area for less than 24 hours, for 24 hours or such shorter period as the person is present in the contractor’s practice area (regulation 17(11)(a)–(c)).
21. It follows that any necessary drugs or dressings which are supplied or prescribed as part of immediately necessary treatment, should be provided free of charge in the same way as for a UK resident. Also, the quantities supplied should be no more than are essential for immediate purposes. GPs may be asked to justify unusual prescriptions.
22. It is, of course, a matter for the GP's professional judgement to determine whether treatment is immediately necessary in each individual case. However, immediately necessary treatment is considered to include treatment that is required as a result of a pre-existing condition that has become exacerbated during the period of the overseas visitor's stay in this country.

Oxygen therapy, renal dialysis and other benefits

23. Oxygen therapy is regarded as a benefit that is immediately necessary and visitors to the UK from the EU, Switzerland, Norway, Iceland and Liechtenstein who are eligible under the reciprocal healthcare arrangements, and who are coming on a non-medical visit (such as whilst on holiday or on a business trip) who need oxygen therapy are eligible to obtain supplies through the NHS during their visit on the same terms as UK residents, that is they should not be charged for any oxygen therapy service for which a UK NHS patient is not charged.
24. Similarly renal dialysis is regarded as a benefit that is immediately necessary. EU, Swiss and EEA/EFTA nationals requiring routine renal dialysis on a visit to the UK must make advance arrangements with the NHS renal units concerned. GPs are not usually involved in arranging such treatment. Special asthma treatment, echocardiography in case of chronic autoimmune diseases and chemotherapy are also regarded as benefits that are immediately necessary.
25. Visitors from outside of the EU, Switzerland, Norway, Iceland and Liechtenstein will need to make private arrangements in advance of their arrival for any treatment and will be responsible for any costs incurred.

Treatment and services which GPs have discretion to offer the patient either free (that is on the NHS) or on a private, paying basis

26. Patients from the EU, Switzerland, Norway, Iceland and Liechtenstein who have come to the UK specifically for treatment should have the approval of their sickness insurance institution to obtain that treatment here and should be able to produce form S1 or S2. Both form holders would be able to access free primary treatment on the basis set out below:

• if an S1 holder is UK-insured but residing in an EU Member State, Switzerland, Norway, Iceland or Liechtenstein and visiting Wales, then the National Health Service (Charges to Overseas Visitors) Regulations 1989 (“the 1989 regulations”) would apply, that is, primary care is free and they would be able to access primary care as a temporary visitor without paying anything, subject to finding a GP who is willing to accept them onto their list
• if an S1 holder is EU member state, Norway, Iceland, Liechtenstein or Swiss insured and has moved their residency to Wales, they would be able to access primary care in Wales without incurring any costs once they have been accepted onto a GP’s list; the UK can claim the costs back from the relevant state, provided that these costs have been reported to NHSBSA (National Health Service Business Services Authority), GPs should contact their LHB OVM to submit these details to the NHSBSA; however, an EU Member State, Norway, Iceland, Liechtenstein or Swiss insured S1 holder who resides elsewhere in the UK other than Wales would not be entitled to access primary care free of charge in Wales to the extent that primary care charges apply in Wales for non-ordinary residents
• if an S2 holder is EU Member State, Norway, Iceland, Liechtenstein or Swiss insured and has travelled to Wales to receive planned treatment with an S2, their S2 allows the person to access the treatment that is specified on the S2 certificate (this is usually elective secondary care); if this includes primary care then any primary care consultations would be covered by the S2 and reclaimed from the relevant state through NHSBSA; if primary care is not included in the S2 they would be able to access primary care using their EHIC (European Health Insurance Card), as necessary care.

Overseas visitors staying for over six months in the UK

27. An immigration health surcharge is payable by persons subject to immigration control who apply for a visa to enter the UK for more than six months or who apply to remain in a temporary capacity. People with indefinite leave to remain in the UK as well as those not subject to immigration control (such as diplomats posted to the UK) are not liable to pay the immigration health surcharge, but may be ordinarily resident and entitled to receive relevant services free of charge on that basis.
28. Payment of the immigration health surcharge entitles the payer to relevant services on a similar basis as someone who is ordinarily resident. Payment of the immigration health surcharge is mandatory when making an immigration application, subject to exemptions for certain categories of people and the discretion of the Home Secretary to reduce, waive or refund all or part of the immigration health surcharge payment. The LHB OVM can provide further information on this if required.

Refugees / asylum seekers / failed asylum seekers

29. A refugee / asylum seeker who has made an application to the Home Office for refugee status residing in Wales should be regarded as ordinarily resident for the purposes of primary and secondary NHS care. This includes refugees / asylum seekers who are in Wales and have been granted leave to remain, those awaiting the result of their application to remain in the UK and refugees / asylum seekers whose applications for leave to remain in the UK have been refused – these individuals should also be regarded as ordinarily resident and exempt from charging until the point they leave the UK.

Persons leaving the UK for more than 3 months

30. The LHB shall remove a patient from the contractor's list of patients where it receives notification that that patient intends to be away from the United Kingdom for a period of at least three months or more.

Referrals to hospital

31. GPs who refer overseas visitors to hospital should warn them that they are liable to be charged unless they or the treatment is covered by the withdrawal agreement, the new reciprocal healthcare arrangements with the EU, Norway, Iceland, Liechtenstein or Switzerland, or other exemptions that apply under the 1989 regulations. This applies irrespective of whether the patient has been given treatment under the NHS or on a private basis by the GP. The GP’s practice can seek further information on the patient’s charging status from the LHB OVM or can choose to direct the patient to the LHB OVM for further information and advice.

Part II: pharmaceutical services

32. A pharmacist or doctor providing pharmaceutical services may dispense any NHS prescription presented regardless of whether the patient is ordinarily resident or not. In Wales prescriptions are exempt from NHS charges. However NHS charges may be payable where an English prescription form is presented at a pharmacy in Wales. In these situations unless the patient has a qualifying exemption, NHS charges will be payable in the normal way. A pharmacist may refuse to dispense an NHS prescription if a patient who is required to pay a charge does not do so. If a patient's chargeable status is not clear, the charge should be paid and the patient given an NHS receipt (form WP57). Their entitlement to exemption or remission may then be established retrospectively and refund made if appropriate.

Part III: dental treatment

33. As with GPs, General Dental Practitioners (GDPs) have discretion over whether or not to accept a patient for NHS treatment. GDPs will find the guidance at paragraphs 6 and 7 of this circular helpful in judging whether a person who applies to them for NHS dental treatment is ordinarily resident. A GDP’s discretion is limited to accepting patients on either a NHS or private fee paying basis. Where a patient is accepted for NHS treatment, the charges payable, exemptions and remissions available under the general dental services / personal dental services regulations apply to the patient. If a patient's chargeable status is not clear, the charge should be paid and the patient given a NHS receipt. They can then submit a claim to see if they are eligible for a refund by completing form HC5W(D). The patient's entitlement to exemption or remission may then be established retrospectively.
34. Holders of EU, Swiss, Norway, Iceland or Liechtenstein issued EHICs and refugees / asylum seekers are entitled to immediately necessary NHS hospital dental treatment without charge, although GDPs still have discretion over whether or not to admit them to their list.
35. People resident in the EU, Switzerland, Norway, Iceland or Liechtenstein, and not resident in the UK, may visit this country for the purpose of receiving specific dental health treatment under the NHS, but will need to bring with them form S2 (formerly form E112) which they should obtain from their own relevant state office dealing with health services. The S2 entitles them to receive NHS treatment as specified in the S2 form in this country in the same way as a UK resident.

Part IV: optical services

36. Subject to the eligibility criteria detailed in the National Health Service (Ophthalmic Services) (Wales) Regulations 2023 (WGOS (Welsh General Ophthalmic Services) Regulations 2023), Ophthalmic opticians (optometrists) have discretion over whether they accept a patient for an NHS sight test (WGOS 1) or an eye health examination (WGOS 2).
37. Where the 1989 regulations do not apply, the WGOS Regulations 2023 and the WGOS service manuals pursuant to the National Health Service (Wales Eye Care Services) (Wales) (No. 2) Directions (“the 2024 directions”) set out the eligibility criteria. Where a patient is accepted for NHS treatment, he/she may receive a free sight test or eye health examination and, where necessary, be issued with an optical voucher if eligible under the National Health Service (Optical Charges and Payments) Regulations 1997. If a patient's chargeable status is not clear, private charges should be paid and the patient can claim a refund by completing form HC5W(O). Their eligibility for NHS sight tests or eye health examination and help towards the cost of glasses may be established retrospectively and a refund claimed. WGOS service manuals pursuant to the 2024 directions, prescribe the eligibility criteria for higher-level clinical services in which the arrangements are not set out in the WGOS 2023 regulations.

Some NHS services provided by LHBs are free to everyone regardless of the status of the patient. The current list of services includes:

1. treatment given in an accident and emergency department or casualty department; this exemption from charges ceases once the patient is admitted to a ward or given an out-patient appointment; for example, where emergency treatment is given elsewhere in the hospital such as intensive care or coronary care, it is chargeable – it is the location that is exempt, not the type of treatment
2. treatment given elsewhere than at a hospital, or treatment given by someone who is not either employed by or under the direction of the LHB; this means that some services provided in the community will be chargeable only where the staff are employed by a LHB (for example District Nurses employed by the LHB) but not where they are employed by a general practitioner (for example practice nurses)
3. family planning services
4. certain diseases where treatment is necessary to protect the wider public health; this exemption from charge will apply to the diagnosis even if the outcome is a negative result; it does not apply to any secondary illness that may be present even if treatment is necessary in order to successfully treat the exempted disease.
   The exempt diseases are:
   • acute encephalitis
   • acute poliomyelitis
   • amoebic dysentery
   • anthrax
   • bacillary dysentery
   • coronavirus (COVID-19)
   • cholera
   • diphtheria
   • food poisoning
   • leprosy
   • leptospirosis
   • malaria
   • measles
   • meningitis
   • meningococcal septicaemia (without meningitis)
   • monkeypox
   • mumps
   • ophthalmia neonatorum
   • pandemic influenza
   • paratyphoid fever
   • plague
   • rabies
   • relapsing fever
   • rubella
   • salmonella infection
   • Severe Acute Respiratory Syndrome (SARS)
   • scarlet fever
   • smallpox
   • staphylococcal infections likely to cause food poisoning
   • tetanus
   • tuberculosis
   • typhoid fever
   • typhus
   • viral haemorrhagic fever
   • viral hepatitis
   • whooping cough
   • yellow fever
5. treatment given in, or as the result of a referral from, a sexually transmitted diseases clinic
6. treatment given to people detained under the provisions of the Mental Health Act 1983
7. treatment given for mental health problems as part of a court probation order