A passport to care?

By Sarah Chalmers-Page

This article is written from a personal perspective and does not in any way reflect the opinions of any organisation that I work for, in any capacity.

The UK Government’s Department of Health (DoH) has proposed that, to combat the risk of people claiming care given by the National Health Service (NHS) they are not entitled to, we should introduce the need for two forms of proof of identity for non-emergency hospital care (in the UK, emergency care and treatment of infectious diseases are free for everyone, including undocumented immigrants and visitors).

A lot of people have reacted with revulsion to this proposal. But on the face of it, we are one of very few nations that do not ask for some form of photo identification (ID) when people come to hospital. Surely this is a practical approach, given that we appear to be spending millions of pounds on care for people who are not entitled to it?

Let’s leave aside moral arguments for a moment. There are many practical reasons why I, personally, don’t think this is a good idea.

Firstly, the UK does not have a national ID document – we already turned that down. Around one in five people ordinarily resident in England and Wales don’t hold a passport. Proof of address is also potentially tricky. The last time I was offered a job within the NHS I needed proof of address. I moved in with my husband so all the utilities were under his name, apart from my online bills for my mobile phone and credit card, which were unacceptable because they were not physically mailed to me. Many people have pay as you go phones, and the poorest and most vulnerable people in our communities have electricity metres rather than monthly bills.

Since there is no legal requirement to hold ID, some people don’t. This includes many vulnerable people including migrants, sex workers, people with no fixed address, those fleeing domestic violence, homeless people, people who are elderly and confused, or people who are mentally ill. These people often need more care than average; requiring proof of identity will stop them from going to hospital. And the only way this system will work is if we are prepared to turn them away at the door.

What about children? They won’t hold ID, let alone bills in their name. Of course children could be exempt from providing proof of identity. That would be very easy for a cute 5-year old. But 16 year olds can often look like adults, especially, if they’ve experienced a hard life. Do we x-ray their teeth on the way through the door too?

Secondly, there will be increased costs associated with queues and did-not-attend rates. Based on NHS Reference Costs, on average it costs the NHS £60 for an outpatient appointment. When Mrs Smith arrives at the hospital with a family carer, but without a recent utility bill and a valid passport, she and her carer are going to plead with reception – a 10-minute interaction rather than a 3 or 4-minute interaction, with queues mounting. Then we turn them away, because that’s how the system will work. We will need to reschedule her for a day when she can come, hopefully with her ID – mounting queues for appointments in an already overloaded system. Additional appointment slots, left empty, have costs in money and delayed care. And in the meantime, Mrs Smith is not getting her care. If that is a cancer biopsy, for example, and there is a delay getting her back into the system, then it may seriously damage her chances of getting well again.

In some cases, frustrated, frightened patients and carers may even become aggressive. It’s unfortunate, but it’s true. So we will need to redesign waiting areas to ensure the safety of our staff, placing a currently human interaction behind safety glass. That’s not free either.

Thirdly, we have one of the lowest management overheads for health of any health system in the developed world, partly because we have a single payer system and no need to pursue bad debt. Under the new system, we would have to verify identity and where necessary collect debts far more often and aggressively. For this, hospitals will need additional financial management staff. Inevitably, in the short term, recruiting finance staff will mean leaving other vacancies open, for example band 5 nurses, until the day that we collect enough money in bills to pay for the costs of administration. Assuming that a percentage of people will not just pay immediately, we also have to allow a budget for lawyers, court cases, and all the apparatus of collecting unpaid debts.

So, we will need to introduce:

  • Cheap compulsory national identity cards
  • Universal, paper-based proof of address
  • Safer waiting areas
  • Additional finance assistants and possibly additional outpatient staff
  • Safeguards for people fleeing violence or who otherwise cannot provide paperwork

And we need to tolerate:

  • Rising queues and costs for appointments, both in the hospital and in terms of waiting lists
  • Turning people away at the door for the wrong ID, even where this will delay care or lead to aggression

All this, just to avoid sharing 0.3% of our budget with sick, vulnerable people.

This is not about turning away people who have nothing wrong – we are talking about consultations and treatment that have been offered by a GP for someone who needs them. These people are sick, they’re in pain, and they need help. We are one of the wealthiest nations in the world. But we are being asked to believe that it’s better to turn away a proportion of sick Britons for having the wrong paperwork, to avoid treating a few sick foreigners.

Disclaimer: The opinions expressed in this article are the author’s own and do not reflect the official policy or view of Manchester Global Foundation.