Charges for pregnancy tests
14. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that something has gone wrong.
15. Guidance-on-implementing-the-overseas-visitor-charging-regulations.pdf paragraph 8.4 and 8.5, says that ‘immediately necessary’ or urgent medical treatment should not be denied to anyone on the grounds of inability to pay.
16. Upfront charging operational framework to support identification and charging of overseas visitors - GOV.UK (archive.org) section 5.3 defines immediately necessary treatment to be treatment or tests needed to save the patient's life or to prevent serious damage occurring. Urgent treatment is where the treatment cannot wait until the person leaves the UK because of the risk to the patient.
17. The Trust’s Overseas Visitors policy says where immediate treatment is needed, then it should not be delayed by establishing a patient's chargeable status.
18. In practice, these guidelines all mean that urgent or life-saving treatment should not be delayed to check if a patient needs to pay, or to inform them about charges. Non-urgent treatment should not be provided until charges have been explained and payment is received.
19. Ms W says she was not advised before undergoing pregnancy tests at the Trust that she would have to make payment for these. As such, she says she was denied the chance to make an informed decision as to whether to have the tests carried out.
20. The Trust says the charges are correct as the treatment was chargeable and, as it was needed immediately, no advance warning of charges was necessary.
21. Following the scan at the private organisation on 26 October 2021, Ms W was referred to the Trust.
22. Using the guidance referenced above, overseas visitors should generally be charged before treatment is given. However, there are instances when this does not apply and payment for treatment can be pursued after treatment has been provided. These include situations where there may be a threat to the patient’s life or where there is potentially a long-term impact if immediate treatment is not provided.
23. To help decide whether the pregnancy tests carried out when Ms W attended needed to be carried out at once, we consulted our adviser.
24. Our adviser explained the private organisation’s scan was not clear enough to be able to decide whether Ms W had been pregnant in the first instance, whether she had miscarried or whether there was a possibility of an ectopic pregnancy. Ectopic pregnancy and miscarriage: diagnosis and initial management (nice.org.uk), 1.2 says patients who are suspected to have an ectopic pregnancy or miscarriage should be seen at once with relevant testing carried out without delay.
25. As such, as Ms W suspected she was pregnant, our adviser said it was necessary to rule out the potential of an ectopic pregnancy as, on rare occasions, this can be fatal or may cause damage leading to infertility if not treated as soon as aware.
26. Our adviser confirmed the first action needed was a urine test for pregnancy as this would show positive for several weeks after a miscarriage or if there was an ectopic pregnancy. As this came back negative, it was necessary to undertake a pregnancy blood test to be certain this was the case. This too was negative, and our adviser explained it the negative blood test indicated it was unlikely Ms W had been pregnant in the first instance.
27. Thus, the pregnancy tests carried out following Ms W being referred to the Trust by the organisation were needed at once to prevent potential loss of life and were immediately necessary. This means the Trust had no requirement to obtain payment before carrying out the treatment following NHS policies and UK law and could not delay treatment.
28. The Upfront charging operational framework to support identification and charging of overseas visitors - GOV.UK (archive.org) also says the patient should be made aware of the estimated cost of the treatment provided as soon as possible, but that treatment should not be withheld if not paid for upfront when urgent or immediately necessary. The Trust’s policy also states that it will always provide immediately necessary treatment whether or not the patient has been informed of, or agrees to pay, charges.
29. Having checked the medical records and notes of Ms W’s attendance at the Trust on 26 October 2021, there is nothing to show she was advised of the charges whilst at the hospital. The first instance of her being made aware of these appears to be the invoice issued on 4 November 2021, ten days after the visit.
30. We consider there may have been opportunity for the Trust to have made Ms W aware of the charges before she left hospital or on the call to her later the next day, but that this did not happen.
31. We do not consider this falls so far short of the above guidance as to indicate a failing overall in the way the Trust managed the charges. As above, it followed guidance in that her treatment was immediately necessary and there was no clear requirement to request payment before providing it.
32. It also appears likely that Ms W would already have been aware that charges would apply for treatment. This is shown in the email of 22 June 2022 where the Trust refer to payment being received for an earlier invoice for NHS treatment Ms W received. In addition, her letters of complaint refer to the use of a private organisation in the first instance to avoid NHS charges. This shows us she would have reasonably know her treatment would be chargeable.
33. Ms W not being advised in advance of the charges for treatment does not mean charges do not apply. The Trust has a duty to impose these charges. Had she been advised in advance, this would not have changed the outcome, as she still would have needed to receive the treatment.
34. From the information provided and the guidance and requirements in respect of charging for NHS treatment, we cannot see that the Trust failed to meet the relevant standards and guidance. As such, we have decided to take no further action on the complaint.
35. We are sorry to hear of the impact these charges have had on Ms W and hope our decision provides some reassurance about the Trust’s actions.