Who exactly is entitled to access the U.K. NHS?

Free NHS treatment is based on your residency in the UK.

People of any nationality coming to the UK are entitled to the same National Health Services as any other citizen; this is as long as they are coming to the UK to make this their permanent home and this is dependent upon certain criteria being satisfied – cover is not always automatically granted.

The Department of Health has stated that those who come to this country to make it permanent should show evidence of this, for example, registering with a local GP. NHS Hospital Trusts have a duty to check evidence of entitlement to free healthcare and so  documentary evidence of exemption and entitlement must be shown, if required.

If you are a UK citizen who has moved abroad for more than three months, or six months for pensioners living in another EEA member state, you may lose your entitlement to free NHS treatment until you can show evidence that you intend to re-settle in the UK. However, if you have lived in the UK for ten continuous years at some point, but are now living in an EEA member state or another country with which the UK has a bilateral healthcare agreement, then you may still be entitled to free NHS treatment and care.

Also, if you are a UK pensioner and live part time in an EEA country you are entitled to free hospital treatment during the period that you live in the UK if you stay here for at least six months each year and you are not registered as resident in the other member state.

If you are residing in a country within the EEA, but you are visiting the UK, you should present your European Health Insurance Card (EHIC) issued from that country. If your EHIC is lost or stolen you can apply to your overseas domestic healthcare insurance provider for a Provisional Replacement Certificate (PRC) which you should then present to the hospital.

If you have returned to the UK from a non-EEA country with which the UK has no bilateral agreement, you will be expected to pay for medical treatment unless another exemption applies to you.

Treatment which is always free of charge

Some hospital treatment is free of charge for everyone who needs it, regardless of how long they have been or intend to stay in the UK. This is:

• treatment for accidents and emergencies as an outpatient in a hospital’s accident and emergency department. Emergency treatment in a walk-in centre is also free of charge (England and Wales only). However, if you are referred to an outpatient clinic or admitted to hospital from an accident and emergency department, you will be charged

• compulsory psychiatric treatment

• treatment for certain communicable diseases, such as tuberculosis, cholera, food poisoning, malaria, meningitis and pandemic influenza. Testing for the HIV virus and counselling following a test are both free of charge, but any necessary subsequent treatment and medicines may have to be paid for

• family planning services.

Who can receive all NHS treatment free of charge

Some people from abroad can receive all NHS hospital treatment free of charge. If you are entitled to free NHS hospital treatment, your spouse, civil partner and dependent child(ren) will also be able to receive free treatment, but only if they live with you permanently in the UK.

You can receive free NHS hospital treatment if you:-

• have been living legally in the UK for at least 12 months when you seek treatment, and did not come to the UK for private medical treatment. Temporary absences from the UK of up to three months are ignored

• have come to the UK to take up permanent residence, for example, if you are a former UK resident who has returned from abroad, or if you have been granted leave to enter or remain as a spouse

• have come to the UK to work, either as an employee or self-employed person. This does not include people on short business trips

• normally work in the UK, but are temporarily working abroad, have at least ten years continuous residence in the UK, and have been abroad for less than five. However, if you are studying abroad you are not entitled to free NHS treatment

• are receiving a UK war disablement pension or war widows’ pension

• are an asylum seeker or have been granted exceptional leave to remain or refugee status. Proof of your immigration status from the Home Office may be required. In England and Scotland, if you're refused asylum, you do not have the right to free treatment if you have temporary admission. However, if you're a failed asylum seeker who was receiving a course of treatment, that course of treatment should continue until it is finished without you being asked to pay for it have been identified as having been trafficked from abroad or are believed to have been trafficked from abroad

• are imprisoned in the UK or detained by UK immigration authorities

• are a UK state pensioner who spends up to six months a year living in another European Economic Area (EEA) state, but are not a resident of that state

• are working in another EEA country, or in Switzerland, but are paying compulsory UK national insurance contributions

• are a student following a course of study which lasts at least six months, or is substantially funded by the UK government.

Visitors who might be able to receive NHS hospital treatment free of charge

You and your dependants are entitled to free NHS hospital treatment if your need for it arose during your visit to the UK. A medical opinion may be needed in order to decide if treatment should be provided free of charge.
You have the right to free NHS hospital treatment if:-

• you are a national of an European Economic Area (EEA) country, living in an EEA state or Switzerland, or a refugee or stateless person living in an EEA state or Switzerland, or you are a non-EEA national who lives in an EU state and pays national insurance contributions there

• you normally live abroad, and are receiving a UK state pension, and have lived in the UK in the past for at least ten years

• you have lived in the UK for at least ten years in the past, but now live in an EEA state, or in a non-EEA state with which the UK has a reciprocal agreement

• you are a national, or a resident of certain non-EEA countries, with which the UK has a reciprocal agreement.

EEA countries are the European Union countries and Liechtenstein, Iceland and Norway.
In addition, people from some countries can get free hospital treatment if they have been referred to the UK for that treatment, under the terms of the reciprocal agreement, most commonly known as either an E112 or Article 42. There are also special arrangements with certain countries which enable people from outside the UK to get free treatment. The Department of Health can give details of countries with which the UK has a reciprocal agreement and for which there are special arrangements.

So who is entitled to access the National Health Service?

The answer is, basically, anyone who is deemed to be ordinarily resident** in the UK is entitled to free NHS hospital treatment in England. “Ordinarily resident” is a common law concept interpreted by the House of Lords in 1982 as someone who is living lawfully in the United Kingdom voluntarily and for settled purposes as part of the regular order of their life for the time being, with an identifiable purpose for their residence here which has a sufficient degree of continuity to be properly described as settled.

Anyone who is not ordinarily resident is subject to the National Health Service (Charges to Overseas Visitors) Regulations 1989, as amended.  These regulations place a responsibility on NHS hospitals to establish whether a person is ordinarily resident; or exempt from charges under one of a number of exemption categories; or liable for charges.

The UK Border Agency quite clearly states that “Visitors are not allowed to enter or stay in the United Kingdom to receive free medical treatment from the NHS. Except for treatment given in a hospital's accident and emergency department, you will be charged for any treatment you receive. You should ensure that you have enough medical insurance to cover your stay.”

What about British Nationals? I have paid taxes in the past.

Nationality or past or present payments of UK taxes and National Insurance contributions are not taken into consideration when establishing residence.  The only relevant fact is whether you ordinarily live in the UK.

How do I know if I have to pay?

The Regulations state that the hospital providing treatment is responsible for establishing who is entitled to free NHS hospital treatment. They will make their decision in accordance with the Regulations. The hospital can ask you to provide evidence to support any claim to free treatment and it is your responsibility to do so if asked. If the hospital decides you are eligible for free NHS treatment you will still have to pay statutory NHS charges such as prescription charges unless you are otherwise exempt. If the hospital decides you are not entitled to free NHS treatment charges will apply and cannot be waived.

What if I do not meet one of these exemptions from charges?

If you are not ‘ordinarily resident’ or exempt under the Regulations, charges will apply for any hospital treatment you receive and cannot be waived. If this is the case you are strongly advised to take out private healthcare insurance that would cover you for the length of time you are in the UK.  There is no facility to purchase healthcare insurance from the NHS therefore any necessary insurance must be organised privately.
However, to reiterate, some health services are free of charge to everyone. These are:
• treatment given in an accident and emergency (A&E) department or in an NHS walk-in centre that provides services similar to those of an A&E department;
• treatment for certain infectious diseases (but for HIV/AIDS only the first diagnosis and counselling that follows it are free);
• compulsory psychiatric treatment; and
• family planning services.

** ‘Ordinary residence’
• Entitlement to full NHS treatment hinges on the concept of 'ordinary residence’ i.e. “Living lawfully in the United Kingdom voluntarily and for settled purposes as part of the regular order of their life for the time being. Whether they have an identifiable purpose for their residence here and whether that purpose has a sufficient degree of continuity to be properly described as 'settled'.”

• This definition, accepted by House of Lords, does not include reference to employment status or duration of stay. 
• Entitlement does not depend on past or present payments of UK taxes or National Insurance contributions.

This definition is different from HMRC definitions.

Broad definition:

Whilst the term ‘ordinarily resident’ has not been precisely defined by Parliament, it has in case law been applied to ‘someone who has moved into an area with the intention to settle for the time being, whether of short or long duration’.

Department of Health Guidelines:
http://www.dh.gov.uk/en/Healthcare/Entitlementsandcharges/OverseasVisitors/Browsable/DH_074374
The National Health Service (Charges to Overseas Visitors) Regulations 1989
http://www.opsi.gov.uk/SI/si1989/Uksi_19890306_en_1.htm
The National Health Service (Charges to Overseas Visitors) (Amendment) Regulations 2006
http://www.opsi.gov.uk/si/si2006/20063306.htm
The National Health Service leaflet:

'Did you know that you may have to pay for hospital treatment whilst here?'

http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4088998.pdf

Basically, what the above amounts to is, that in many cases any visitor, either wishing to reside temporarily or permanently in the United Kingdom, will often be required to provide evidence of comprehensive sickness insurance and that must include emergency cover.

If you are required to have ‘comprehensive sickness insurance’ surely, you can take a private medical policy when you arrive?

If you are required to take out private medical insurance as a condition of residing in the United Kingdom, unless you have been “Ordinarily resident” in the United Kingdom and registered with a U.K. General Practitioner you will be unable to take out domestic United Kingdom private medical insurance.

In many cases, particularly if you are coming to the United Kingdom from outside the EEA/EU, you will be required, as a condition of obtaining a Visa, to provide documentary proof that you hold current and sufficient comprehensive sickness insurance before you receive the visa.

Depending upon your circumstances we have a range of comprehensive sickness insurance plans that can be tailor made for your circumstances.

The above is offered as guidance only and no liability is accepted under any circumstances for any errors or omissions contained therein.