Dr Charles Tannock

Member of the European Parliament for London

The world's sick are flocking to the NHS - and we're paying

The Daily Telegraph - 23 May 2003

Special Investigation by Harriet Sergeant

More foreigners than ever are exploiting the health service - but staff rarely dare to complain. I spent two months in London hospitals and clinics, talking to nurses, doctors, porters, managers, asylum seekers and illegal immigrants. To encourage them to speak freely, I agreed not to reveal their names or where they worked.

NHS tourism is Britain's new growth industry. It is now producing major problems in our cities - lengthening waiting lists and draining resources. But the Home Office and Department of Health have ducked the issue, and the system for weeding out those with no right to treatment is in chaos.

Under this Government, the number of foreigners who are entitled to free health care has also dramatically expanded. Anyone from asylum seekers, to people here on work and student visas of more than six months can claim it - and so can their dependents, from spouses and children to ailing grandparents.

What no one is charting is the vast numbers of people who are not entitled to NHS care - yet manage to receive it.

An NHS tourist typically runs up big bills - the consultants I met talked of sums anywhere from 50,000 upwards. Most are in search of expensive treatments that are not available in their own country. And Britain's surreal asylum policy means that anyone able to afford a people smuggler can claim asylum and enjoy free NHS treatment. So the NHS often inspires them to migrate in the first place.

In 1998, the Department of Health's website estimated that more than a quarter of a million refugees were living in London. Last year, 120,000 asylum seekers entered this country - another new record.

No one knows how many will come in this year - whatever Tony Blair may say - nor can anyone predict next year's intake. At the same time, the Government has increased the number of work permits - from 41,000 in 1996 to a target of 175,000 every year. Student visas have also increased to 339,000 a year. These numbers do not include dependents.

Britain is also granting the right to live and work in the UK - and to use the NHS - to all eight of the Central European countries about to join the EU next May. Yet France and Germany have put this off until 2011.

It is not just a question of numbers - but where the numbers come from. The Government has announced that it wants to increase the intake of students and workers from Eastern Europe and the Third World. At the moment, applicants from these areas received two thirds of all student visas and the majority of work permits. Unfortunately, TB, Hepatitis B and HIV - all contagious, life-threatening diseases - are endemic in these parts of the world and taking hold at an even faster rate in China and Russia.

In London alone, the rates of TB have doubled in 15 years, with 50 people a week now developing the disease. TB Alert estimates that the NHS needs to spend 10 million a year on containing it.

In each of the past four years, 95 per cent of all new cases of Hepatitis B have arrived from abroad. Each patient costs the NHS about 10,000 a year. The disease can result in liver cancer or the need for a liver transplant - and it is more infectious than HIV. We are now contemplating vaccinating the UK population in order to protect it from a danger that the Government has created.

Yet we seem oblivious to the cost of healthcare for these increasing numbers of people. The Government has made little attempt to draw up budgets, to make plans or even to collect data that might prove embarrassing. Sir Andrew Green, of the pressure group Migration Watch, pointed out recently: "Over the last 10 years, a third of a million asylum claimants have been refused, while there is no evidence that they have left the UK. Others are smuggled in, but there is nothing to stop them claiming health care. Nor is there any effective check on tourists, visitors or those who overstay their visas."

Other countries demand health checks: Belarus and Uzbekistan are among 46 that require an HIV test before approving immigration. A Filipina nurse, astounded by the laxity in the UK, explained the procedure before taking a job in Dubai. The authorities, she said, refused to admit anyone infected with HIV. Nurses diagnosed with Hepatitis B were asked to sign a document agreeing to pay for their own health care.

Nobody entering the UK is required to take a health check. A diagnosis of HIV infection - far from being a bar to entry - is grounds for a successful claim of asylum and treatment for life.

And who wouldn't want life-saving treatment for their family - and do everything possible to get it? A Filipina nurse who has cancer told me: "It's quite simple. In the Philippines, I would be dead. I cannot afford the treatment there that I receive here for free."

Wouldn't we do the same? And could we really turn away the sick who asked for help?

Governments, though, are not meant to act as individuals - they are supposed to make decisions on behalf of their citizens. We are finding it difficult enough to fund a National Health Service - can we really afford an International Health Service?

At present, little stops the one turning into the other. What should anger us is the lack of controls and lack of government will - not the sick people themselves. As sheer numbers, they cause disquiet. As individuals, their stories are unbearably moving. A nurse in communicable diseases summed it up: "It's not the people using it that are at fault. It's the system that allows itself to be screwed."

When I visited several genito-urinary clinics, the main providers of HIV diagnoses and treatment, they all told the same story. Previously, most HIV infection in this country was confined to the gay community and intravenous drug users. Immigration, said the staff, had transformed that.

Last year, African immigration overtook gay sex as the main cause of HIV in Britain. According to the NAT (National Aids Trust), Africans in 2001 accounted for 34.7 per cent of all HIV infections - although they make up less than 1 per cent of the population. Rates amongst women, the majority of them from sub-Saharan Africa, have trebled since 1990.

In just a few years, immigration has transformed HIV into a mainly heterosexual disease. As one doctor in a GU clinic remarked: "Ninety-five per cent of our patients are now heterosexual and from Africa."

Despite the surge in patients, the clinics have not received a penny more for staff or drugs. One doctor said that they were trying to subdivide the rooms to increase space. Another told me: "Rising numbers mean that we are constantly seeing new patients. The initial interview is very demanding and time-consuming. Often, they can't speak English." Another pointed out that HIV infection in a young, heterosexual community means that "we have to set up clinics for families and pregnant women and provide creches - and all with no more money."

Seventy-seven per cent of HIV positive women who gave birth in the UK in 2001 were born in sub-Saharan Africa. Zinab comes from Sudan, but her story is typical. She moved to the UK in 1999 with her husband and three children, and has since had another child.

In Sudan, she had been diagnosed HIV positive by Medecins Sans Frontieres, a French charity. They had offered her a handful of pills, explaining that it was too expensive to give her more. Zinab's family owned a number of shops and was considered wealthy, so she asked for a prescription for the necessary drugs. They were unavailable in Sudan, she was told. In desperation, she sent the prescription to an aunt living in Kilburn, north London. Her aunt took it to her GP, who told her he could not prescribe through the NHS and sent her off to a chemist. There, the aunt received a shock: a month's supply would set her back 580 - too much even for Zinab's family.

She left empty-handed, but continued to ask around. Finally, an Aids charity told her of the help available from the NHS, social services and local support groups. Overjoyed, the aunt telephoned Zinab, who had had no idea that treatment was free in the UK.

A people smuggler charged the family 4,700 to bring them to Britain, and, on arrival, the family claimed asylum, settled in north London and duly registered with a GP. Zinab's husband and two of her children also proved to be HIV positive, so four of them are now on anti-retroviral drugs, which they will take for life. They have received refugee status and about 370 a week from social services.

The cost of the drugs, together with treatment and benefits, add up to about 80,000 a year for this one family. For Zinab, there was no choice. As she said: "Since I got this medicine, I am healthy. In Sudan, I would be dead. My children would be dead or orphans. Now, we have a happy life."

She is one of an ever-increasing number of similar cases. A report to Parliament by doctors working in genito-urinary medicine describes how "the unprecedented demand" in 2002 affected all patients suffering from venereal disease. Waiting time for a first appointment has doubled from five to six days the year before, to 12 working days for men and 14 for women.

The number of new patients waiting "unacceptably long" is more than 40,000 - and growing. Yet early appointments are vital, not only for the patient but to contain the spread of disease. One GU clinic admitted that its waiting time was now a month, "and would be three months if we did not have constant walk-in clinics."

Doctors also believe that a high number of Africans with HIV go undiagnosed, either because they are illegal immigrants or afraid of the stigma involved. One said: "It is a major public health concern. The virus must spread into the resident population. We are not seeing it yet because it takes five to 10 years to appear. But, if something is not done, we will have the heterosexual Aids epidemic we have so far avoided in the UK."

Another doctor was equally pessimistic: "The Department of Health gives us no guidance. We don't know what the government policy is. Is there one?"

Government policy is, indeed, unclear. The Department of Health states that people can be tested for HIV and receive counselling for free, but not treatment. However, as Zinab and her family discovered, infection with HIV is grounds for a successful asylum claim. The Human Rights Act makes it impossible to return people to a country where the appropriate medical care is not available. Consequently, patients are constantly asking their GU doctors for letters affirming HIV infection in order to pass them on to immigration lawyers.

The report by GU doctors points out the price of this policy. The present caseload of 23,000 patients with HIV or Aids costs the NHS "in excess of 345 million" a year, rising to 5 billion over the lifetime of those being treated. But the numbers are open-ended - and so are the costs.

UNAIDS, the United Nations agency, estimates that 42 million people are infected with the virus - 70 per cent in sub-Saharan Africa. The NHS is their only hope, and a powerful incentive to migrate. And there is nothing to stop the relatively well-off, such as Zinab, from paying traffickers and claiming asylum in the UK. But what about those without an aunt in Kilburn, or too poor to afford a smuggler?

It costs an average of 15,000 to look after one HIV patient for a year. Yet an Indian generic drug-maker, such as Cipla, charges less than $1 day to provide one patient in Africa with an appropriate cocktail of medication. For every one person we help in the UK, we could save 50 left behind in Africa - and this does not take into account the cost of social security.

Rafaela Ravinetto, pharmaceutical co-ordinator at Medecins Sans Frontieres, explained: "There are six million people in urgent need of receiving anti-retroviral therapy in the world, and the vast majority are not getting it." As Anthony Browne has pointed out in The Spectator: "Spending these vast sums in Africa itself would save millions of lives, not just thousands."

Zinab and her family are entitled to NHS care - but many who are not still manage to receive it. Margaret Arnett, a former overseas manager at St Helier Trust and founder of the Overseas Visitors Support/Action Group, wrote in 1998: "The NHS is being drained of millions of pounds a year by overseas visitors receiving `free' medical treatment to which they are not entitled." In 1992, the A&E department of St Mary's Hospital in London calculated that non-eligible patients cost them a "substantial" 4.7 per cent of the total budget - if anything, an "underestimate." The percentage is now a lot higher.

One nurse in communicable disease told me that she had been thwarted by her NHS trust when she asked to audit the figures. "The NHS is deliberately trying to hide the data, she said. "I am so sick and tired of the whole business - I just want to run away." A senior consultant estimated that a staggering 20 per cent of patients on his inner-city ward round were asylum-seekers, refugees and foreign nationals not entitled to NHS treatment.

Some psychiatric doctors claimed that a quarter to a half of acute psychiatric beds in London are occupied by people who have no right to be there. One consultant in a teaching hospital described how the problem had "crept up slowly over the last few years." It had now reached the level "where I and my colleagues think it is scandalous."

But no one is saying much in public. As one put it: "You'll have management down on you like a ton of bricks." Data is hard to come by, partly because the managers are reluctant to provide figures. One explained: "This Government is really vicious once the gloves are off. It's more than a senior manager's job is worth to collaborate with the opposition." Those who did talk - and many were from the Third World themselves - insisted on anonymity.

HIV is by no means the chief reason for NHS tourism. Hakim's story is typical: a farmer from Somalia, he had five daughters and one much-loved son, aged 10, who suffered from congenital heart disease. The best doctors in Somalia told him: "Take him to Europe - it's your only hope."

Recalling that he had a cousin in London, Hakim wrote a letter, enclosing his son's medical notes. The cousin visited a private hospital that priced the operation, air fare and accommodation at 20,000. But, as Hakim said: "For a Somali, this is an undreamt amount of money. Never in my entire life could I hope to see such money."

His cousin then suggested Hakim use a people trafficker. For 5,000, a trafficker offered to bring over not just his son, but the entire family. They would all be eligible for free treatment, not to mention a peaceful and secure existence. As Hakim remarked: "There's no question which was the better deal." The cousin put up 2,000 and Hakim raised the rest by selling his animals, house and land. Once the family had claimed refugee status, Hakim took his son to a GP. The boy's lips were turning blue, and he was referred to a specialist and operated upon within the month. He is now cured.

Meanwhile, Hakim and his family have become British citizens. He does not work. He has never been to school and has no qualifications. When asked for his views of the NHS, he says simply: "We came to heaven from hell. My son is alive. In Somalia, he would be dead."

Access to the NHS is wide open to abuse, as a look at every stage of the process reveals. There are two routes to specialist treatment in an NHS hospital: through an accident and emergency department or by referral from a GP.

Many consultants saw GPs as a problem: "They are less than honest," remarked one. Another claimed: "They connive with the patient." Margaret Arnett, the former overseas visitors manager, pointed out that GPs can charge overseas patients at their own discretion - "So, non-UK residents are often able to use GP services for free and can be given an NHS number, with no questions asked by the health authority." Consultants complained of being sent tests and X-rays that had been arranged by the GP for an obviously private patient from abroad. Other GPs, they said, take on patients temporarily, then refer them to an NHS consultant without mentioning their status.

Ali, a 28-year-old Iranian who is married with three children, was registering with his local GP when they discovered that they were both Shia Muslims. The GP offered to coach Ali in the symptoms of epilepsy so that he could claim a disability allowance when assessed by an independent doctor. "My doctor said: `Don't claim kidney pains or TB, because they can test your urine or X-ray your lungs. But they can't test epilepsy because it's too expensive to send everyone for a CT scan."'

The independent doctor duly declared that Ali was epileptic, although he has never had a fit in his life. He now receives a disability allowance, and his wife gets an attendance allowance for looking after him. He also receives income support and child benefit, not to mention a flat from the council, free schooling for the children and health care. He claims he is getting nearly 400 a week - and says he has no intention of ever working.

I asked social services to check these figures. They had no idea, they said, of the maximum amount a claimant could receive. Patients new to a GP have to fill in the "family doctor services registration". This asks for your town and country of birth and the date you first came to live in the UK. Here, I thought initially, was the NHS safeguarding the interests of the taxpayer.

A woman at a primary health care trust, whose job it is to check these forms, soon put me right. The question is asked only for "administration purposes" and allows her "to avoid unnecessary paperwork." Otherwise, she would have to go through the national database to ensure the patient was not registered with another GP. She certainly did not check if the patient was entitled to NHS care. That was up to the GP. But GPs are instructed not to ask questions.

One London borough sent a letter in January to its directors of primary care. It said that it was "very concerned" to find GPs asking refugees and asylum seekers for documentation. "This procedure," the letter stated in capital letters, in case anyone should miss the point, "is contrary to Department of Health and BMA advice."

The department advice states that "there is no obligation for any patient to produce documentary evidence of identity - the GMS1 form requires only a name, address, and some medical details." Any investigation into entitlement, another London borough warned, might lead to a charge of racism.

GPs anxious to know how to differentiate between the unentitled and an asylum seeker will find reassurance on the Department of Health's website. Everyone is entitled to emergency treatment, it says - so there is no point in checking. This fails to address the crucial issue: how can a GP act as a gatekeeper to NHS consultants and hospital care if he has been ordered not to check?

One Chinese GP described his dilemma. An Iraqi patient, eager to claim disability benefit, produced a weak ankle. "The injury was so old, I could not even see a scar," said the GP. Unimpressed, he told the patient to get a seated job in packing or security, adding, "The longer you take sick leave, the more difficult it will be to get a job."

Most GPs, he explained, just sign or make the referrals - "but I want to do it properly. This is taxpayers' money." The Iraqi did not take kindly to this advice. He made a formal complaint to the primary care trust, who then reprimanded the GP. "The authorities gave me no support. I have lost all trust in them. If they don't support us, who will?" the doctor told me.

The other path to a consultant and hospital treatment is through an accident and emergency department. The manager of one A&E department of a London hospital put it bluntly: "If the English taxpayer knew how many overseas visitors we treat, they would be horrified. In my casualty department, one in 20 people should not be there - and that does not include asylum seekers and refugees. I get no funding for them. We are very frightened to stand up and say that this is a fact."

This attitude affects everyone else using the service. In Wales, 84 per cent of patients see a doctor within one hour of arrival. In London, only 30 per cent do. One London hospital spends 178,000 a year on translators. In one rural hospital in the West Country, they have never needed one. A senior house officer in a London A&E explained: "A large proportion of the population in my area is not registered with a local GP and has no idea of how to access appropriate healthcare." In other words, accident and emergency departments are where the hidden world of the economic migrant reveals itself. And not just the economic migrant.

The American with a sore throat is also a problem. The 1989 Act of the NHS (Charges for Overseas Visitors) Regulations states that no charges will be recovered from any overseas visitor for treatment at an accident and emergency department.

Otherwise, access to the NHS is based on residence. Anyone who has lived in the UK for 12 months is entitled to free care. So are students and workers with visas for not less than six months. Leaving the EU aside, we also have a reciprocal arrangement with 22 countries to provide urgent treatment for a condition arising during a visit to the UK.

Once admitted on to a ward, however, the foreign patient is liable for costs. But there are many ways around this - as I saw for myself when I visited some A&E departments in London.

An A&E receptionist is supposed to ask a new patient if he or she has lived in the UK for less than 12 months. But whether this is done appears to depend entirely on the receptionist and how she is feeling that day. One told me that she only questioned those who did not speak English or spoke with an accent. Another asked hardly anyone.

I watched as a Chinese girl, unable to provide either a GP or an address, offered a mobile phone number. It was accepted without question. The receptionist shrugged: "I don't want to be accused of racism," she said. One overseas manager admitted: "Half of my receptionists don't like asking. They feel uncomfortable. I tell them: `Would you stand at Gatwick airport and hand out 1,000 to every visitor? No, you would not!' "

The majority of patients from other countries claimed to have lived here for more than 12 months. But the receptionists I met made no attempt to check their name and address against, for example, the voters' register. As one receptionist explained: "We don't check anyone. How could we? You can call yourself Mickey Mouse and give an address in Disneyland, for all anyone cares."

An A&E manager pointed out the consequences of lax security. "Relatives of families already living here fly over and use their uncle or cousin's address. Some with chronic conditions come backwards and forwards on six-month visas for treatment. We see many women and children from outside Europe. Women are coming over all the time from the Third World to give birth on the NHS. The abuse is blatant."

Another A&E manager said bitterly: "At the same time as so much money is being spent on treating foreigners, I can't afford to take on more nurses or even an extra porter because there is not enough in the kitty. It's a can of worms that no one wants to deal with."

A&E is only meant to offer treatment for an ailment arising in the UK. However, consultants complained that many NHS tourists had serious diseases of long standing. As one said: "They arrive at Heathrow, take a taxi to my A&E, and are referred to us with illnesses like chronic leukaemia, HIV infection or renal failure. They are coming here deliberately."

An emergency from A&E gets priority when it comes to beds, so the operation on a patient who has waited for months will have to be cancelled. One consultant complained: "The NHS tourist blocks beds, bounces elective admissions and uses up scarce resources. And these are well-off people who can afford an airline ticket. At this moment in my hospital, we have a judge and the brother of a minister taking up NHS beds."

Another consultant revealed: "Today, I am operating on a rich person from the Third World who has come to me through A&E as an emergency. This means I had to cancel the operation I was meant to perform on the poor, elderly Caribbean who has waited six months for his operation, is a citizen of this country and has paid taxes all his life. Tell me the morality in that."

One consultant recalled the case of the brother of a minister from Africa, whose sight had begun to fade. He flew to London and turned up at A&E, where he was diagnosed with HIV. "He knew he had HIV, because his wife had it and he had been secretly dipping into her pills. We now had a man resistant to medication. So we had to treat that. Then he went blind and needed social services when he was discharged. He lives here now, and the whole thing has cost hundreds of thousands of pounds."

A nurse claimed that some staff are themselves abusing the system. In her hospital, a doctor had brought over his father from India for treatment, having arranged registration with a local GP beforehand. The old man saw a consultant within five days, "when the current waiting list is 15 months." Another elderly man, whose son also worked as a doctor, had arrived with a shopping list - hernia, cataract and gall bladder - of problems, she said. His son arranged for him to see a fellow consultant in the hospital the following day. Soon afterwards, the man flew home, where he planned to wait until his operation.

Overseas managers in hospitals are supposed to pick up on the NHS tourist. But, with no system of registration, they rely on doctors, nurses and A&E receptionists reporting a suspicious patient. Many are too busy, or unwilling to do so. When they do, even an energetic and motivated manager is not optimistic about rooting out the unentitled. "There are two of us and 1,400 beds," said one. If she does catch up with a patient, they may simply announce they have no money. "What can I do? They're lying in bed in front of you. You can't get blood out of a stone."

Or they may claim that they have been in the country for 12 months - "And how am I meant to prove different? We are not allowed to ask to see their passports. They can announce they are Saddam Hussein or George Bush, for all we can do. Our debt-collecting agency said if only we could take down their passport number, it would help. But we are not allowed to do that." She added: "When UK citizens travel abroad, we take out health insurance. Why don't people coming here do the same?"

Of the money owed by overseas patients, she got back about half every year - "and that's a vast improvement." Another London hospital admitted that they managed to claw back less than a third.

Managers felt that they rarely had the backing of their trusts. As one said: "In my trust, once the sum goes over 20,000, I am told not to issue any more invoices. The figures look so terrible on the books."

It is not just medical care that attracts the NHS tourist. The consultant psychiatrists and managers to whom I spoke claimed that a "significant" proportion - as high as 40 per cent of acute psychiatric beds in London - is taken up by foreigners, including refugees and asylum seekers. This should not be confused with the higher proportion of mental illness amongst Caribbean men, who are not included in these figures.

The situation has, if anything, worsened. Psychiatric clinics, like those for sexually transmitted diseases, operate a walk-in service where there is no need for a referral from a GP. There, a patient can make an appointment directly with a psychiatric consultant.

As one consultant explained, no one is going to question entitlement. "Clinics are used to dealing with frightened, angry and anguished individuals whose answers are vague at best. The priority is to stabilise them - not to ask where they have come from."

A manager of a psychiatric hospital confirmed that once the patient is stabilised, "there is no checking procedure whatsoever. We won't compare a name against the voters' register. We won't ask for a passport or a birth certificate."

Why is psychiatric tourism to the UK so popular? Like HIV infection, insanity is grounds for a successful claim of asylum. Facilities in southern, eastern Europe and developing countries are - if they exist at all - harsh and primitive. And families tend to be ashamed of insanity, which harms marriage prospects because it is often considered hereditary. Far better to dispatch relatives to a place where treatment is free, humane and, above all, anonymous.

It costs about 1,500 a week to keep a patient on an acute psychiatric ward and patients can stay for months. Once they are out of hospital, patients move into "care in the community". This means registration as an outpatient with a consultant, plus visits by a psychiatric nurse and social services. All this costs money.

Charles Tannock, now an MEP for the Conservative Party, recalled his attempt as a consultant psychiatrist at University College Hospital to retrieve funds. Embassies proved "singularly unhelpful." They told him: "We know from previous experience that the NHS will pick up the bill." And they were right. The NHS even paid for patients to fly home, each accompanied by two nurses.

It is not surprising that patients arrive regularly for treatment. One South African suffers an episode every two or three years. When he feels one coming on, he takes a plane to the UK. Once he is better, the NHS flies him home with two nurses - three long-haul air fares.

The Department of Health refuses to admit that these people exist. Little data is collected on them, and they are unlikely to appear on any census form - so, as Charles Tannock pointed out, "no specific provision is made for their funding."

All these invisible people take up beds - and, in London, there is an acute shortage of psychiatric beds. Bona fide patients are often forced to take the first available - sometimes in a different part of the country, meaning they will spend months away from their family.

Abuse of the system means that consultants cannot admit every patient who is seriously ill. This puts extra strain on outpatient lists, visiting nurses and social services. One psychiatric nurse is meant to care for 18-20 patients in the community - but, in some parts of London, there are more likely to be 40-50 to each nurse.

Inevitably, nurses find themselves unable to make essential visits or to chase up patients who fail to take their medication. Does this pose a danger to the public? One manager I spoke to picked his words carefully: "I am not saying that there are more dangerous people on the streets. I am saying it increases the risk."

So these are the consequence of the Government's failure to control immigration. The NHS is attracting sick migrants, and it is being exploited. Individuals cannot even be blamed for abusing the system. A system does not exist to abuse.

Once migrants are in this country, it is too late to withhold health care. Far better to have an immigration policy that restricts numbers but treats them properly.

The Government does the opposite. It allows in unlimited numbers, but then fails to provide the extra services or money required. As one frustrated nurse in communicable diseases put it: "We have hundreds of asylum seekers arriving every quarter into our borough, but the number of GPs stays the same. The number of hours they work stays the same. So what is meant to give?"

The Department of Health is thus unfair on NHS staff, asylum seekers and the ordinary citizen. It is most unfair on those who live in the inner cities - many of whom are former immigrants. It is time that the Government collected data on how much asylum seekers are costing the NHS and made suitable provision.

We also need to address other issues. Is it the best use of resources to treat the relatively well-off from the Third World in the UK? Should we be introducing health checks, as other countries do?

The NHS tourist puts hospitals in an invidious position. But the Department of Health's attitude is clear: they do not want to know about - let alone address - the problem: "It is for individual hospitals to determine whether, in accordance with the regulations, a patient is liable to be charged for treatment or not."

So the onus is on the doctor to tackle the patient, but most are unhappy with this role. They complain: "We are doctors, not policemen." As one explained: "By training and by inclination, our job is to treat the sick person in front of us. We are not trained or inclined to start questioning them and apply bureaucratic rules."

Another had discussed the issue at the clinical ethics committee of his hospital. "Once a doctor is in contact with a patient, it is too late. You have listened to a story of distress. You have a contract of care towards that patient - you must treat them to the best of your ability. You cannot consign a gate-keeping role to those who are carrying out care," he said. In his view, sorting out "who is entitled to care must be decided before a nurse, doctor or porter steps forward and says, `How can I help you?' "

As individuals, our impulse is to help. Who would not respond to Hakim's blue-lipped son? It is not just impulse, but our duty as one individual to another. A government's duty is different - its first duty is to the citizens who have elected it.

Citizenship is a set of rights and obligations given equally to all members of the community. But it is also a means of separating members from non-members in a world of limited resources.

Rights are costly - they cannot be for everybody. And states are necessarily inclusionary and democratic to their members, exclusionary and undemocratic to the outsider. Yet many in the Government are clearly uncomfortable with this fact, believing that all individuals are invested with inalienable human rights that must be protected. The NHS is where ideology crashes into reality.

Meanwhile, the Government is reluctant to appoint gatekeepers and give them powers. It seems unaware that in a society without gatekeepers, it is the weak, the inarticulate and the elderly - many of Labour's natural constituents - who are the first to suffer.