People's History of the NHS

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Learning to pay for the NHS: Students, Universities and the NHS Surcharge

by Roberta Bivins

Across the UK in the next few weeks, universities will welcome thousands of new and returning students, many of them coming from abroad. These students have been actively recruited by Britain’s higher and further education sectors, and almost universally pay higher fees than their UK and European Economic Area [EEA] counterparts. But they pay other fees as well: for instance, unlike tourists, business travellers, EEA students, and non-resident British expats, non-EEA students (like other non-EEA migrants entering the UK for more than six months) have since April 2015 paid what is call the ‘Health Surcharge’: a fee of £150 per year, paid up-front for the entire duration of their student visas. Indeed, according to the National Union of Students, the circa half a million non-EEA students make up 75% of those to whom the surcharge is applied.

When this new fee was introduced by the Conservative/Liberal Coalition government, British ambassadors around the world scurried to explain it to key student-sending nations. Charles Hay, Britain’s ambassador to South Korea, for example, acknowledged the ‘very valuable contribution’ made by Korean students to the UK economy. In recognition of this, he said, Britain had ‘deliberately kept this surcharge at a competitive level – lower than most private health insurance policies’ required by ‘our competitor nations’. Additional dependents accompanying the student would each pay the same charge, and there was no reduction in the charge for students coming from lower-income nations. Mike Harper, Minister for Immigration at the time that the Health Surcharge was added to the 2014 Immigration Bill, took a slightly different line, asserting, ‘We have been clear that the UK has a national health service not an international health service’ (not a novel claim – it has regularly surfaced in various forms since 1948 – though one for which the 1946 Act establishing the NHS offers no support): the charge, he added, merely represented a ‘fair contribution to the costs of the health service’.

Politicians justified the new surcharge on the basis that ‘international students’ cost the NHS £430 million per year, or around £700 per head. Notably, this is less than half of the cost estimated per head for British expats who return to the UK for free NHS treatment despite living abroad, to whom the charge does not apply (not least because it could not be collected alongside visa fees). In fact, it is an intriguing figure for many reasons: first, since the very earliest days of the NHS, auditing the cost of ‘health tourism’ has proven to be an almost impossible challenge – for more on this murky area, see reports from Full Fact and this government-commissioned research from 2013. Second, most overseas students, like their domestic and EEA peers, are young and healthy, and consequently make few demands on NHS services. In fact, even the weighted estimate of their cost per head – that £700 figure – incorporates assumed costs based on the higher birth rates common among women in their early twenties: yet very few overseas students actually give birth while at university. As the report on which the introduction of the surcharge was based admitted, the estimated costs to the NHS of each student reflected ‘a considerable margin of uncertainty’.  The NHS services that young people are more likely to use – emergency services, treatment for certain contagious diseases, family planning services and compulsory mental health treatment – remain free, either because they benefit the general public health and safety, or because access to such care is still deemed to reflect core UK values (and simple human decency). One might therefore wonder: are the students getting any additional services for their money?

Within six months of its implementation, the Health Surcharge brought over £100 million into the Treasury. According to the Home Office at the time, this income ‘contribute[d] to the NHS for the benefit of us all.’ Perhaps this why this charge on international students produced few ripples in public opinion or the media, particularly in today’s atmosphere of constant NHS crisis. The NUS and voices from the education industry certainly deprecated the charge for students, noting that it might harm the sector and make individual students feel unwelcome. Migrants’ rights organisations also criticized the charges, though their emphasis was almost entirely on the potentially negative impacts it could have for international workers and their families, and for the British communities whose own entitlement to NHS services might be questioned in the rush to ensure compliance with the new rules. Not only were most long-stay migrants already likely to be healthy young taxpayers, and thus net contributors to the NHS, but as one such body, the Migrants’ Rights Network noted:

“The Home Office advice does not explain how NHS service providers in the UK are going to be able to identify non-EU national patients whose eligibility for treatment will be dependent on payment of the surcharge…a lack of clarity on this issue will give rise to confusion as to who is entitled to treatment on the NHS and who will stand to be refused.”

But there were no backbench rebellions, no street marches, and few if any attention grabbing public protests, even on university campuses.

This muted response is strikingly different from what happened the last time a Conservative government tried to impose costs on university students and other overseas ‘visitors’ (then defined as anyone neither in work nor resident in the UK for at least 3 years) accessing the NHS. When on 12 March 1981, Margaret Thatcher’s Secretary of State announced plans to introduce NHS charges for overseas patients, including students, it provoked uproar. As in 2015, the Joint Council for the Welfare of Immigrants and other similar bodies were highly critical, as were organizations dedicated to improving what were then called ‘race relations’.  But in 1981, many other voices were also raised in protest. The Trade Unions Council [TUC] rejected on behalf of the combined NHS unions the very idea that NHS staff should operate identity checks before providing necessary care. The Lecturers’ Union (roughly equivalent to UCU) ‘condemned’ the policy outright as it applied to students and ‘deplored’ its probable effects on ‘race relations’. The Government’s proposals, they proclaimed, ‘would be seriously detrimental’ and it was ‘iniquitous’ for any government to push students into the unscrupulous hands of private insurers who already discriminated against the disabled and, by excluding pregnancy from cover, women. The National Union of Students vigorously protested a policy which would generate NHS ‘apartheid’ and many organizations pointed out the bitter irony that the NHS depended heavily on the labour of overseas student nurses and trainee doctors – but might be forced to charge them for the very care that they provided for free to others, at least until they met certain residency requirements. In fact, protest was so widespread and so vigorous – and so much attention was drawn to the uncertainty both of figures about the costs and benefits of the policy, and to the possibility and effects of enforcement – that the Government was forced to back down.

Like today, the years leading up to Thatcher’s 1981 proposals were marked by economic recession and corresponding austerity, civic and labour unrest (including in the NHS), major concerns about a rising tide of xenophobia and racism, and a widespread sense that the NHS was in crisis, and perhaps at the verge of disaster. Public and political concern about ‘medical tourism’ and the unfair exploitation of the NHS was also widespread and sometimes outspoken. So why did the 1981 proposals fail, while 2015’s ‘surcharge’ passed into law without a hitch? In part, the Coalition Government avoided some of the most deadly pitfalls of the earlier policy: in particular, they outsourced the ugly task of extracting payment by building the ‘health charge’ into the already expensive process of gaining legal permission to enter the country as a student. They also exempted students already in the country, reducing the number of campus voices who would be directly affected by the new policy. Finally, unlike Thatcher’s government, they also offered no model for how the policy might be enforced within the UK. Rather than charging individuals as they incurred NHS costs, the ‘Health Surcharge’ relies on the collection of an (admittedly regressive) fixed universal charge abroad. It does not (yet) require UK health staff to perform identity checks or to assume associated administrative and ethical burdens, and thus did not raise hackles in the NHS itself.

But perhaps too the Coalition relied on us, the anxious and austerity-conscious electorate, to passively accept a charge that would affect none of ‘us’. Are we more ready than in the past to  be convinced by even the sketchiest anecdotal evidence of ‘foreigners’ abusing the NHS? Maybe years of erosion in support for free education — years in which we have heard much about the ‘graduate premuim’ and little about its sharp variations across universities, ethnic groups and fields of study — have made us disinclined in any case to trouble ourselves about students. After all, what is an additional £150 pounds per visa year for young people already willing to assume costs of tens of thousands of pounds a year in tuition alone? And maybe too ‘Thatcher’s children’ (and ‘grandchildren’, the students of today) see access to the NHS with different eyes, as a privilege of citizenship, or a taxpayer’s perquisite, not an outward sign of a national commitment to equity or the human right to health. Nye Bevan, challenged in 1949 to justify visitors’ free access to the new NHS, responded that access to medical care should be seen as part of the ‘normal hospitality’ of a civilized nation. Can we still be proud and confident in our own norms of hospitality, or indeed, in our commitment to that egalitarian post-war vision?

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