Access to NHS healthcare in England does not depend simply on whether a person is described as a migrant, or on whether they have paid tax or registered with a GP. The rules differ according to the service being provided and the legal basis on which the person is exempt from hospital charges. Some primary care and emergency services are available without charge to everyone, while hospital treatment may depend on ordinary residence, immigration status, payment or exemption from the Immigration Health Surcharge (IHS), or another statutory exemption.

This guide explains the principal rules for people who have moved to England to work, study or join family. Separate rules apply in Scotland, Wales and Northern Ireland, and visitors should also consider our guide to accessing the NHS in England as an overseas visitor.

1. How Do NHS Charging Rules Work in England?

The NHS began operating in 1948. Many NHS services are free at the point of use, but the overseas visitor charging rules require relevant healthcare providers in England to identify and charge certain people who are not ordinarily resident and who do not fall within an exemption.

The most important distinction is between services that fall outside the hospital charging regime, services that are specifically exempt from charge, and hospital or other relevant services for which charges can apply. The label attached to a visa route is not, by itself, a complete answer.

2. Who Is Ordinarily Resident for NHS Hospital Charging?

Ordinary residence is assessed on the facts. Broadly, a person must be living in the UK lawfully, voluntarily and for settled purposes. It is not determined by nationality, payment of tax or National Insurance, registration with a GP, possession of an NHS number, ownership of property or a minimum period of residence.

For the statutory hospital charging provisions, a person who requires immigration permission and has only limited permission is generally not treated as ordinarily resident. This does not mean that every limited-permission migrant must pay for hospital care. Many are exempt from charges because they have paid, or are exempt from paying, the IHS, or because another exemption applies.

Ordinary residence and the IHS are different legal bases for NHS charging purposes. Paying the IHS does not make a person ordinarily resident. Instead, a qualifying grant of immigration permission normally gives a separate exemption from relevant NHS hospital charges for the period covered by that permission, subject to the limits explained below.

3. Which NHS Services Are Free to Everyone?

A number of services are outside the overseas visitor charging regime or are specifically exempt. These include:

• GP and other primary medical services, subject to any separate charges that apply to items such as prescriptions, dental treatment or eye care;
• NHS 111 telephone advice;
• accident and emergency services, emergency ambulance services and care in an A&E department before admission as an inpatient;
• diagnosis and treatment of specified infectious diseases and sexually transmitted infections;
• family planning services, although the exemption does not extend to termination of pregnancy;
• treatment for a condition caused by torture, female genital mutilation, domestic abuse or sexual violence, where the statutory conditions are met; and
• certain palliative care, mental health aftercare and community services.

Everyone in England may register with a GP surgery without providing proof of identity, proof of address, proof of immigration status or an NHS number. Registration with a GP does not, however, establish an entitlement to receive hospital treatment without charge.

4. When Can NHS Hospital Treatment Be Charged?

Hospital, outpatient and other secondary care may be chargeable where a patient is not ordinarily resident and no exemption applies. NHS bodies will usually seek payment in advance for non-urgent treatment and, in most cases, the charge is 150% of the NHS Payment Scheme.

Urgent or immediately necessary treatment must never be withheld or delayed because a patient cannot pay. This includes all maternity services. The treatment may nevertheless remain chargeable unless the patient is exempt, so free access to the treatment should not be assumed merely because it cannot be delayed.

A&E care is exempt only up to the point at which the patient is admitted as an inpatient or receives chargeable follow-up care. Treatment after admission may be charged if no exemption applies.

5. How Does the Immigration Health Surcharge Affect NHS Access?

Most people applying from outside the UK for permission lasting more than six months, and most people applying inside the UK for limited permission of any length, must pay the immigration health surcharge unless an exemption or waiver applies. Private medical insurance does not remove the requirement to pay the IHS.

The current IHS rates are £1,035 per year for most adult applicants and £776 per year for students, their dependants, Youth Mobility Scheme applicants and applicants who are under 18. The amount is calculated by reference to the length of immigration permission applied for, and each dependant normally pays separately.

IHS cover does not begin when the surcharge is paid. It begins only when the immigration application has been granted and the person has entered, or is present in, the UK under the relevant permission. The exemption generally ends when that permission expires, is curtailed or is rescinded, unless another basis for exemption applies.

An IHS payer can normally receive relevant NHS services without charge during the validity of the permission, including treatment for pre-existing conditions. Ordinary NHS charges may still apply to prescriptions, dental services and eye care. Assisted conception services, including IVF, are generally excluded from the IHS exemption.

6. Can a Person on a Fiance Visa Use the NHS?

A fiance visa or proposed civil partner visa is normally granted for six months and does not attract the IHS. The holder can use GP and other services that are free to everyone, but hospital treatment may be charged unless another exemption applies.

When switching from a fiance visa to a spouse visa or civil partner visa in the UK, the applicant will normally pay the IHS as part of the application. Paying the surcharge does not itself create NHS entitlement. The relevant exemption normally applies after the new immigration permission has been granted and the applicant is present in the UK under that permission.

7. Who May Be Exempt From the IHS or Hospital Charges?

Not every person who is exempt from paying the IHS relies on the same legal basis for NHS access. Important examples include:

• eligible Health and Care Worker visa applicants and their eligible dependants, who are exempt from the IHS and can access relevant NHS services under the applicable charging exemption;
• people with EU Settlement Scheme settled or pre-settled status who meet the applicable residence conditions, and certain people with a valid pending EUSS application;
• people granted indefinite leave to remain who live in the UK lawfully, voluntarily and for settled purposes;
• asylum seekers, refugees and people granted humanitarian protection, together with qualifying dependants;
• identified or suspected victims of modern slavery, certain people covered by the domestic violence concession, and children looked after by a local authority;
• some failed asylum seekers who continue to receive specified Home Office or local authority support, or whose existing course of treatment is protected; and
• people ordinarily resident in Ukraine who are lawfully present in the UK, who are exempt from relevant charges other than assisted conception services.

An application for indefinite leave to remain is not subject to the IHS, but the application itself does not automatically determine NHS entitlement while it is pending. Entitlement depends on the applicant’s existing immigration permission, any continuation of that permission, and any other charging exemption. Similarly, applying to naturalise as a British citizen does not create a new NHS entitlement: the applicant continues to rely on their existing residence and immigration position.

8. How Can a Migrant Prove NHS Entitlement?

An NHS body may make reasonable enquiries and ask for evidence of ordinary residence or an exemption. Depending on the case, useful evidence may include an eVisa and share code, evidence of indefinite leave to remain or EU Settlement Scheme status, a Home Office decision, an Application Registration Card, evidence of IHS-linked permission, or confirmation from the Home Office.

Having an NHS number or being registered with a GP is not proof that hospital treatment is free. Where hospital charging status is unclear, the patient should ask to speak to the provider’s Overseas Visitor Manager and provide evidence of the relevant immigration permission or exemption. The current overseas visitor charging guidance contains the detailed framework used by providers.

9. Can NHS Debt Affect an Immigration Application?

An unpaid qualifying NHS debt can be considered under Part Suitability of the Immigration Rules. The usual threshold is a cumulative debt of £500 or more incurred on or after 6 April 2016. NHS bodies generally report a qualifying debt to the Home Office only after it has remained outstanding for at least two months and there is no agreed instalment arrangement.

A qualifying debt does not make refusal automatic in every route. The relevant Immigration Rules, exclusions, human rights considerations and any dispute about the existence or amount of the debt must be considered. A person who believes a debt is wrong should address it promptly with the NHS body and retain evidence of payment, an instalment arrangement or correction.

10. Contact Our Immigration Barristers

In this post we have highlighted the main factors that determine access to NHS services in England for migrants, including ordinary residence, the Immigration Health Surcharge, statutory exemptions and the possible immigration consequences of NHS debt. For expert advice in relation to a UK visa application, immigration status or immigration appeal, contact our immigration barristers on 0203 617 9173 or complete our enquiry form below.

11. Frequently Asked Questions

Does paying the IHS make me ordinarily resident in the UK?

No. Paying the IHS does not make a limited-permission migrant ordinarily resident for NHS charging purposes. A qualifying grant of immigration permission normally provides a separate exemption from relevant hospital charges.

Can a migrant register with a GP without proof of immigration status?

Yes. A person in England can register with a GP without proof of identity, address, immigration status or an NHS number. GP registration does not prove entitlement to free hospital treatment.

Is A&E treatment free for migrants and visitors?

A&E services are generally free until the patient is admitted as an inpatient. Hospital care after admission and later outpatient treatment may be chargeable unless an exemption applies.

Are NHS maternity services free for everyone?

No. All maternity services are treated as immediately necessary and must not be withheld or delayed, but they can still be charged unless the patient is ordinarily resident or exempt.

When does NHS cover begin after I pay the IHS?

IHS cover normally begins only after the immigration application has been granted and the person has entered, or is present in, the UK under the relevant permission. It does not begin on the payment date.

Does the IHS cover prescriptions, dental care, eye tests and IVF?

The IHS does not remove ordinary charges for prescriptions, dental services or eye care. Assisted conception services, including IVF, are generally excluded from the IHS exemption.

Can a fiance visa holder use the NHS?

Yes, but the fiance visa does not normally attract the IHS. GP care and other universally free services are available, while hospital treatment may be charged unless another exemption applies.

Are asylum seekers and refugees charged for NHS hospital care?

Asylum seekers whose claims are pending, refugees and people granted humanitarian protection are generally exempt under the charging regulations. The position for failed asylum seekers depends on support, treatment and other statutory criteria.

Can unpaid NHS charges affect a UK visa application?

Yes. A qualifying reported NHS debt may be considered under Part Suitability, although the effect depends on the application route, the amount and date of the debt, exclusions and any relevant human rights factors.