Britain's Secret Health Tourists Panorama

The NHS.

A national institution since 1948.

Promising free health care to the residents of Britain.

But now, we reveal how NHS managers can cash in on that promise.

So how much is that in total?

800? That's a bit much.

Every year, the NHS is being used by thousands

of so-called health tourists -

foreign nationals who are not entitled to its care

and who don't pay for the privilege.

Using journalists from all over the world, we go undercover

in a black market where access to GPs is being bought and sold.

We find out how easy it is for health tourists

to get X-rays, MRI scans and blood tests in hospital for free.

Did anybody ever ask you if you were ordinarily resident in the country?

Nobody did.

Critics say the whole system is flawed.

This is the poor old NHS being given the task

of implementing something which is unworkable.

We discover how the NHS is losing millions of pounds

to other European countries.

And how our NHS passport into Europe is wide open to fraud.

'Tonight on Panorama, as the NHS struggles to make savings, we show

'how secret health tourists cost us millions.'

-You've been abusing your position.

-I haven't done anything. Sorry.

Britain is one of the most multicultural societies on earth.

Every year, thousands of tourists and migrants come here

for pleasure, to do business or to make a better life for themselves.

So how much of our public services SHOULD they be allowed to use?

The short answer is, it's not clear.

Despite recent NHS guidance, we've discovered continuing uncertainty

about who has the right to register with a GP.

Hospitals are a different story.

Most foreigners should pay for hospital services,

either in person or through their governments.

Now, all of this has led to confusion

and left the system open to abuse.

SIRENS

We began our investigation in the spring, by finding out

whether we could buy our way into the GP system.

Through contacts in Lagos, we've been given

the details of a Nigerian in London called Femi,

who says he gets health tourists

registered with a doctor for a price.

'I'm going to meet a Nigerian journalist

'who now lives here, Francis.

'He'll be pretending he's come to Britain

'to get treatment he's not entitled to.'

Hi. I'm Declan. Nice to meet you, how are you doing?

He says he can get someone registered with a GP for a price.

Film what happens next, go along with it,

-and see if he can get you registered as he says he can.

-All right.

It's early June. Our man Francis

has arranged to meet the fixer in Woolwich, south-east London.

If the fixer, Femi, can get us registered with the GP,

it will be the first step to getting free treatment on the NHS.

Francis heads to the bookies' and waits.

And then the fixer, Femi, arrives.

We have given Francis a medical complaint -

a problem with his legs known as restless leg syndrome,

a nervous condition which causes discomfort, particularly at night.

It's enough to make Femi curious.

So can this fixer get us registered, no questions asked,

at a doctor's surgery?

'Femi is offering an open door'

'into the NHS. But it doesn't come cheap.

'He says we'll have to pay £300 for the privilege.'

'It looks like Francis is about to enter the system.

'The common term for what he's doing is health tourism.

'The NHS is a magnet for people of all backgrounds,

'some wealthy, some not.

'But it has its own police force to fight fraud.

'I went to meet its former head.'

I can think of examples of people who came from China

to actually obtain free treatment.

There are examples from Africa too.

But it would be wrong to imagine that there is one source of people

who come to this country to actually seek free health treatment,

wherever their own countries

don't provide the quality of health care that they would want,

or they're seeking to get something on the cheap.

'Gail Beer is the former head of a large London hospital.

'She believes when it comes to health tourism,

'the biggest problem isn't people flying in for treatment,

'but people already here who need to access the system.'

We define it as health tourism,

but in fact that's a small number of people who come over here

deliberately to have a particular treatment.

There is a much larger number

who are not eligible for treatment,

because they're not ordinarily resident.

It may be an illegal immigrant.

But on the other hand, it's ex-pats who've lived abroad

and then come back into this country. So there's quite a wide range.

For illegal immigrants living in a shadow economy,

becoming ill can be a costly and dangerous business.

It can lead to them being exploited by unscrupulous middlemen.

I wanted to meet one for myself, so I'm going undercover,

and I'll be helped by our second undercover operative, Raj.

'We had heard that in immigrant communities all over the country,

'these middlemen were taking cash to get people access to doctors.'

..A man by the name of Ayub...

'He's made contact with a middleman in the Indian community

'who claims he can register you with a doctor at a practice

'that normally requires ID. To see if that's true,

'I'm pretending to be an illegal immigrant from Kosovo

'who has severe back pain.'

And you're going to go by the name of Dardan Luma.

Dardan Luma.

'It's risky, but it will allow me to meet the middleman up close.'

So we're on our way to meet Ayub.

He's given us a time and a place to meet him.

Now, he says he can get me a legitimate NHS card

and also get me on a doctor's list.

And that will be the first step

towards me getting treated for free on the NHS.

Ayub? Dardan.

'I tell him I've got a bad back and I need a doctor.'

'What will I actually get for my money?'

'I ask how many times I can see the doctor.'

'Ayub has bought my Dardan Luma character, the Kosovan alias.

'Dardan is going to get his own NHS number on the doctor's card

'and a place on a doctor's list.

'Remember, everything about Dardan is fake - his name, his address,

'his date of birth.

'Now it's a waiting game to see if Ayub delivers.'

Back in south London, and we've heard from Femi again.

He's the Nigerian fixer, promising our undercover man

posing as a health tourist free treatment on the NHS.

And he's offering a personal service.

He takes our secret health tourist, Francis,

to be registered at a GP's surgery.

Together, they fill in the registration form.

It looks like the fixer has delivered on his promise.

Francis is registered.

So is the fixer, Femi, telling the truth?

Does he have someone on the inside?

Or is this service available to anyone who walks into the surgery

with a friend from overseas?

To find out, we call the surgery to check.

To see how they'd handle a request from any other overseas visitor.

They told us they wouldn't register a health tourist.

So Femi is getting a service not available to the rest of us.

It looks like he's got an arrangement to register

whoever he wants, no questions asked.

And by taking cash for this service, he may be committing fraud.

So should the NHS be opened up

to anyone who has made it to this country?

Or should it draw a line in the sand

and deliver only emergency treatment

to people who are not entitled to care,

as happens in some other countries?

Nice to meet you...

'That has become a hot political issue.

'The pressure group, Migration Watch, campaigns on immigration.'

It's a National Health Service.

It's not an international health service.

Our founding fathers... Nye Bevan, I'm sure,

didn't think he was going to provide

a service that provided health care for the whole world.

That wasn't what it was all about.

And it shouldn't be.

But others believe that

the regulations governing the health service

should allow it to treat EVERYONE in the UK.

Visitors, residents, and illegal immigrants alike.

It is going to cause damage to individuals' health.

The other side of it is public health as well.

If you're dealing with contagious diseases of one sort or other,

then there could be other victims as a result of poor regulation.

Under the current system,

some vulnerable illegal immigrants are paying middlemen

so that they get treatment on the NHS

without questions about their immigration status.

But for a few, accessing the NHS below the radar

can come at a huge personal cost.

Meet Daljit.

He's an illegal immigrant who got

£15,000 worth of free treatment on the NHS.

In 1996, Daljit was smuggled into the UK from India

and worked illegally on building sites.

He began to feel debilitating pain in his hips.

It turned out that long hours operating a pneumatic drill

had destroyed his hip joints.

He needed help.

So this is a middleman?

'Daljit says he had no choice

'because, officially, he didn't exist.'

Did the GP know that you were an illegal immigrant?

He says the hospital did ask him

if he was living here legally.

He simply lied. And nobody checked.

So you got treated, then, on the NHS?

Yeah.

What did they do for you?

What was wrong with your right leg?

Right, so you've had a double hip replacement?

On the NHS?

Following his hip replacement,

Daljit should have seen his GP regularly.

But, remember, he was operating through a middleman.

Every GP visit would have cost him money.

That's why, four years after his operation,

he's in bad shape.

So this is where you live?

This place is horrible.

And...you must be freezing here at night? Are you?

Now he's desperate to go home to India.

He claims he asked the Home Office to deport him,

but he says they refused.

Back in Southall, our undercover reporter

has met up with the middleman

to check whether my alias,

the Kosovan builder, Dardan Luma,

has got his doctor's appointment.

To make sure it's done, the middleman is introducing us

to his accomplice, one step up the chain -

Chamanlal.

Chamanlal has promised our man will be an NHS patient soon.

So far, we've uncovered a world of middlemen

and fixers who have paved the way

into GP surgeries from the outside.

Then, we heard about an NHS insider

working within the system.

He's a practice manager here in Birmingham,

said to be arranging access for health tourists to doctors.

'Our undercover man, Raj, has already been to see him.'

-You've made a contact?

-Yes.

I've made a contact with a man called Asif Butt.

'And it appears he's willing to do business.'

I let it be known to him my cover,

which is that I'm a travel agent, tour operator, based here,

who is taking care of wealthy clients from India.

But our undercover man isn't working alone.

Meet our next undercover operative.

She's an English journalist,

but that's not what she'll be telling the NHS practice manager.

And your name is going to be Preeti Tagar.

Preeti Tagar. OK. Got it.

Raj's cover story is that Preeti is his niece.

He'll say she's just arrived from India

and is not entitled to NHS care.

A health tourist.

Asif Butt greets us outside

the large Sparkbrook Health Centre in Birmingham

where he's one of the practice managers.

He ushers our man, Raj, into a doctors' private room.

Asif had already offered to register Preeti at the centre

without the ID they normally request.

We wanted to know how he was progressing.

Our undercover reporter has already discussed that he may have

tourists from his travel agency who are interested.

Asif is keen.

Asif then hands us the registration forms for our potential

health tourists - 14 of them. It looks like open house on the NHS.

12, 13, 14.

It seems it couldn't be simpler.

Our fictitious health tourists don't even need to show up.

All we have to do is fill in the forms, and they are in.

Asif tells us that he's not processed a big group of health tourists like this before,

but he has done them one at a time.

Having sworn us to secrecy, Asif says he'll be in touch soon.

Until recently, there was huge confusion in the system

as to whether health tourists and illegal immigrants had the right to register on an NHS list.

Some GPs did, many didn't.

But in July of this year, an NHS body issued a clarification of the guidance.

Doctors are now told overseas visitors,

whether lawfully in the UK or not, ARE eligible to register with a GP.

The guidance adds that GPs should NOT turn down patients

because they fail to provide proof of ID or address.

In effect, GPs are advised they should now take all comers.

It follows a number of successful legal challenges to GPs

who have refused primary care to illegal immigrants.

Adam Hunt is one of the lawyers leading these challenges.

A particularly memorable case that I dealt with was

a young and vulnerable teenage mother.

She had a young baby, she'd been a victim of sex trafficking,

and the baby was a result of enforced prostitution.

And before she came to me for help, she'd spent nine, 12 months

looking for a GP and being turned away and turned away and turned away.

How many cases have you taken against GPs who've refused to register people?

Er, I suppose probably about 30 or 40 over the last two or three years.

-And have you ever lost?

-No. No, no-one's fought any of them.

I suspect because as soon as they take legal advice,

they know that they... That we are right.

But not everyone agrees.

Dr Chris Clayton-Payne has a practice in rural Saffron Walden.

He says his surgery still sees

eight to ten overseas visitors a week.

The guidance changed radically in July of this year

when we received an e-mail from the NHS Primary Care Commissioning organisation.

And quite clearly states who is and who is not entitled

to National Health Service care in the UK as an overseas visitor.

-That is, basically, everybody is now entitled to...

-Everybody?

-Everybody.

We are not allowed to make any discrimination.

What's your reaction to that?

It seems very strange, when we are shaving off the pennies here and there,

to actually open the door wide open to the citizens of the world

to walk in and have free medical care at primary care level in the UK.

I went to ask the health minister at her constituency office about the change in guidance.

If doctors are now obliged to register everyone, though,

isn't it the case that the system is therefore open to abuse?

We know there are abuses, but we know that some GP practices

put quite strict rules and regulations in place

before they will accept somebody on their books,

and we've got to tighten up the system. That's why we're having the review.

But the government review into how the NHS deals with overseas visitors

won't be out until next year.

For the time being, many GPs seem unaware of the new guidance.

Each of the surgeries where our undercover operatives are buying black-market access

officially still has a policy of not registering health tourists or demanding ID.

Meanwhile, the black market prospers.

In West London, Chamanlal meets us again to let us know

how the registration of the Kosovan immigrant, Dardan Luma, is going.

Chamanlal seems happy to do this for illegal immigrants like Dardan, but that's not all.

Chamanlal is confident that he's selling access not just to a GP,

but to the whole NHS.

Dardan Luma is registered with a doctor,

and by selling a place on a GP's list,

Chamanlal may be committing fraud.

And the doctor's appointment has come through.

So I'm handing over the Dardan Luma identity

to an Eastern European, Alex, who's really from the region.

-Hi.

-Hi.

'Alex will be better placed to answer any questions that might come up about Dardan Luma's background.'

We'll see how far we can get,

-and I'll meet you afterwards and see what happens.

-Definitely.

-All right, good luck with it.

-Thank you.

Back in Birmingham, our undercover operative is meeting Asif Butt, the NHS practice manager.

He wants to talk money.

Raj's fictitious niece is registered with a doctor,

and Asif has offered to help a group of Indian tourists get registered

so they can come here for medical treatment.

Asif's services don't come cheap.

Even registering Raj's fictitious niece, Preeti, will be expensive.

Asif says there are four mystery men further along the chain,

all of whom need to be paid off.

Raj is now apparently paying off Mr Butt and four other people.

The cost is rising fast.

We only have £500 on us, so we promise to come back with the rest.

Asif tells us we're getting a bargain.

Finally, Asif makes an appointment for Preeti with a doctor for the following week.

By selling access to the GP's list, he may be committing fraud.

There is no suggestion that anyone else at the clinic

was involved in this, or received any money from Asif Butt.

By now, each of our undercover patients, through the fixer, the middleman and practice manager,

has been registered with a GP, and has an NHS number to show for it.

The next step will be to introduce them to hospitals.

But the rules are different when it comes to secondary care,

to hospital care.

Then, only people who are ordinarily resident in the UK,

who have been here for more than a year, are entitled to free care.

Virtually everybody else should pay.

But we've been hearing problems

with how hospital checks work in practice.

We've been told that being registered with a GP means

many overseas visitors are accepted into the system,

no questions asked.

Pam Ward was responsible for ensuring overseas visitors

pay their bills in hospital.

So a GP's referral could be a gateway into the system?

Very easily.

GPs would send a referral,

there's no mandatory obligation for a GP

to identify an overseas patient

or a possible overseas patient to the hospital,

so it could easily not get picked up.

They have an English address, a registered GP, an NHS number,

so there is really no way that the hospital will pick up from that.

It's a common criticism from those making checks on overseas visitors.

Once the hospital receives

a referral from a general practitioner,

I think there's an assumption

that that patient is eligible for treatment.

Not an unreasonable assumption -

you would think that's something that had been checked with the GP,

so many staff won't check.

We've decided to put that to the test.

Remember, we have three undercover reporters

all now registered in the NHS on fraudulent grounds.

Could they obtain free hospital treatment

without anyone really checking who they are

or whether they're entitled to NHS care?

According to our NHS insider Asif Butt,

that's not going to be a problem.

Asif coaches us on how Preeti should behave to slip through the system.

Asif logs on to the surgery's computer system

to find out more about Preeti's medical condition.

£800 to get into the NHS.

A bargain, according to Asif.

It's the day of the scan.

Time to see if it's really as easy

for someone who isn't entitled to get treatment as Asif makes out.

Just outside the hospital here at Heartlands in Birmingham,

about to go in for my MRI scan.

Preeti goes for the scan, which, if she was a real health tourist

and paid privately, would have cost about £800.

But did the hospital detect her?

So how did that go? What happened in the hospital?

Basically, went in with my appointment card.

I was asked to confirm my name, which is obviously my fake name,

my date of birth, which I gave the fake date of birth,

and also the first line of the address, which was also fake.

And apart from that I was taken in, had the MRI scan, came out.

So all of the information you gave in the hospital was fake?

Correct, yeah. Everything.

So did anyone ever ask you

if you were ordinarily resident in the country, or...?

Nobody did.

If our undercover reporter was a real health tourist,

the MRI scan could be just the beginning

of a lifetime of free health care.

We asked Heartlands Hospital about their failure

to check Preeti's residency.

They said that on this occasion,

as the patient was referred via a known local GP practice,

they assumed that they would have had to give details

of their home address and national insurance number

when registering at the doctor's.

And what about Francis, who paid rather less - £300 -

to the Nigerian fixer Femi, to join a South London practice?

I caught up with him

close to St Thomas' Hospital in central London.

So, how's it going? Where are we at, at the moment?

So I've been in to see the GP. I described my condition to her,

and she said it must be restless legs syndrome.

Restless legs syndrome?

Yeah, and she gave me a referral to come to St Thomas' for some tests.

-Oh, so you're going for some blood tests?

-Blood tests.

-So you're in the system now?

-Yeah. That's what it looks like.

I'm in the system, yeah.

This is the form our undercover health tourist got from the doctor.

It's a routine referral for blood tests to a hospital,

but really, it's his ticket from the primary care system,

which is the GP system,

into the secondary care system, which is hospitals.

Francis is going into the hospital for his blood tests.

St Thomas' did not check whether he was eligible for free treatment

before doing the tests, and he wasn't asked for any payment.

A procedure that would have cost about £100 privately.

We asked Guy's and St Thomas' Hospital why they didn't check

our undercover man's story.

They said they believed that in the vast majority of cases,

patient eligibility would be established before treatment.

They added that they've implemented more rigorous checks in A&E,

which they anticipate extending to other outpatient services.

'That's two of our undercover operatives

'who've had free treatment,

'but could the third get a free X-ray?

'I caught up with Alex, who had taken on my role as Dardan Luma,

'the Kosovan builder, to find out.'

The last time I saw you, you were on your way to the doctor.

-You done that now?

-Yes, I did. I went to visit my GP.

I asked for a referral to go to hospital and have an X-ray.

He gave me one.

This particular hospital, actually, is said to be

at the forefront of policing this kind of thing,

so we would expect them...

-To check and ask? OK. Let's try. Let's see.

-OK. Let's do it.

'West Middlesex University Hospital.

'It's been held up in Parliament as an example of best practice

'for identifying and charging overseas visitors.

'So if Dardan Luma is going to be exposed anywhere,

'it should be here.'

'Within 20 minutes, the X-ray for his bad back is all done.'

-That was really quick, wasn't it?

-Very quick indeed.

-So I was with you at reception - they didn't ask much there.

-No.

They only asked, when I gave them the referral paper, my name,

date of birth, and address.

Now this hospital is quite close to Heathrow,

and it's said to be at the forefront of policing

whether people are really entitled to care, but today,

for Dardan Luma, it was plain sailing.

When we approached West Middlesex, they told us that in this case,

because the patient was referred by a GP,

staff assumed he was entitled to free NHS treatment.

The hospital said it was retraining staff always to double-check

that GP-referred patients are entitled to free testing.

Generally, it said it's confident that its systems are very robust.

Now, one of the reasons staff may not be checking is because

the rules on who should and shouldn't pay

are just so complicated. Have a look at this.

This is the Government guidance on the issue.

It's nearly 100 pages long - not exactly light reading.

And this concerns who should pay

and the kind of questions they should be asked.

The guidance all hinges on one key term.

"Ordinarily resident" is a phrase which sounds good common sense,

but when it comes down to actually implementing it,

the policy is often unworkable. This is the poor old NHS

being given the task of implementing something which is unworkable.

How does it work on the ground?

People do their best to try and recover the money

after patients have often dispersed back around the world.

That's an even harder task.

Hospitals are meant to check if a patient is entitled to care,

whether they're referred by a GP

or arrive through Accident and Emergency.

A&E itself is free,

but overseas visitors should pay for any further treatment.

The hospitals we tested with our undercover reporters

let them through without a problem.

But what's the national picture?

To find out, we asked all 171 trusts in England and Wales

about their checks to identify overseas visitors.

133 of them responded,

and those responses were checked by two experts.

They found that 45 trusts, a third of them,

were not following Government guidance.

'I put those results to the Health Minister.'

-And a third of them are not doing the checks?

-Yes.

Actually, I think, if I was being honest about it,

I'm surprised it's not

-more than that.

-Really?

-Yes!

Because we know that there is... We KNOW there is a real problem

and that is why we are having the review.

The hospital trust which appears to be one of the weakest

at detecting unentitled overseas visitors

was the Worcestershire Acute NHS Trust.

They said they'd identified just one health tourist

in the last four years, charging them a grand total of £889,

despite serving a multicultural community.

It turns out that the Worcestershire Trust

doesn't have anyone responsible for identifying overseas visitors.

Chris Skidmore is a Conservative MP who campaigns on this issue.

The fact that we don't have somebody

specifically co-ordinating and recording

does suggest that's one of the reasons why so few people

have actually ended up being logged on their books

as being not eligible for care.

-Save the NHS!

-Save the NHS!

Worcestershire is a trust under pressure.

It has to make savings of £50 million by 2015.

A&E and maternity services at Redditch Alexandra Hospital are at risk.

Locals are up in arms at the proposed cuts,

so could Worcestershire be wasting valuable resources

by not charging overseas visitors?

Worcestershire said it was committed to managing its finances effectively

and that losses have to be judged against the costs of recovery.

It said whilst it doesn't have a specific role,

it does have systems to monitor and recover money

owed by overseas patients.

It said it was currently in the process of recovering money

from three such patients.

It's government policy that hospitals should make these checks

so what does the new minister say?

You might be surprised.

There are many people who are watching this programme,

probably myself amongst them,

who would be offended, frankly, if every time I went to hospital,

I was effectively being asked to prove

I was entitled to free NHS treatment.

I don't think anybody wants that system.

What we don't want are the abuses.

Despite the obvious confusion in the system,

some overseas visitors are identified and charged,

but how many?

Well, we asked all of the 190 hospital trusts in the UK.

121 trusts told us that in the last four years,

just under 40,000 overseas visitors had been detected.

But is that anything like the full story?

I think the scale of the problem is really difficult to find.

We just don't know how many people there are on the system

because the processes we have in place are not robust enough.

So we don't know because the system just doesn't pick people up?

We don't know because the system isn't picking people up.

So how much is overseas visitors' failure to pay

actually costing the NHS?

Well, Panorama asked all 190 hospital trusts in the country

how much money they've had to write off

or how much is still outstanding

from the treatment of foreign visitors since 2008.

147 of them gave us a response

and they told us that just under £40 million is outstanding

or has had to be written off

in the last four years.

But that's just when hospitals actually do detect

the overseas visitors.

How many thousands don't get picked up and billed?

I do think it's the tip of the iceberg.

40 million, some people will say,

"That's not much compared to the £110 billion budget of the NHS."

But when you look at some of the trusts who've come back and said,

"We have no bills whatsoever that are owed to us,"

that's clearly not the case.

They've clearly not been collecting the data.

So the NHS seems to be haemorrhaging cash

and we simply don't know how much. But beyond our shores,

there's another way in which the NHS

is paying out money it doesn't need to.

And it's all to do with this...

-ADVERTISEMENT:

-This is the magic key.

A European Health Insurance Card or EHIC.

Like these holidaymakers,

every year, millions of European citizens travel throughout Europe

and during their holiday, thousands of people need urgent medical care.

If you fall ill in Europe,

you can use this card and the country you're in

will bill the NHS for the cost of your treatment,

so you might think there'd be close scrutiny of who gets an EHIC card.

Think again.

In fact, in Southall,

our middleman Chamanlal is getting them for anyone

who's willing to pay him for the privilege.

We asked Chamanlal if he can get us a card

in a randomly chosen fictitious name.

To get the card, we'll have to supply a National Insurance number.

It should be an important check in the system to stop fraud.

But it's no problem, according to Chamanlal.

He'll provide one.

It costs us £340 for the EHIC card

and for that, we also get a National Insurance card

in the name of a fictitious tourist.

It seems that if you've got the cash and contacts, it's easy.

And just over a fortnight later, it arrived -

a genuine EHIC card in a fake name.

It's time to pick up the National Insurance card from the middleman.

Then we pay him the remainder of his cash for the EHIC card

and the fake National Insurance card.

Now, with this EHIC,

if the fictitious health tourist fell ill anywhere in Europe,

he would get treatment

and the NHS would pay the bill.

In fact, it seems so easy, I decide to try it for myself.

I'm going to use the online registration form

to apply for an EHIC, but every detail I put on there will be fake

or using details which don't match.

I'll start with my invented illegal immigrant from Kosovo.

Now, what I'm doing here is applying for an EHIC card for Dardan Luma

but I'm not going to use the NHS number associated with him.

In fact, I'm going to use a completely different one.

Now, you'd think that's the kind of basic inconsistency

that the system should pick up on.

We've rebooted this exercise six times

and each time, we got a real EHIC card.

Here it is - the card for the illegal immigrant Dardan Luma.

Each card is for a completely fictitious person.

The system is wide open to fraud -

fraud that's paid for by the NHS.

We informed the Department of Health about this vulnerability.

As it stands, there are very simple and obvious flaws

in the system for getting a European Health Insurance Card, aren't there?

-I mean, huge flaws.

-You tell me that they're simple.

-Well...

I don't know if they are simple.

I have no doubt that there is a problem with it

and it's one that we are going to address.

Bad as they are, the losses to the NHS from these card scams

are being dwarfed by a much bigger problem

in the way we deal with other European countries.

Panorama has discovered

that the NHS is losing significant amounts of money

because of the health care agreements we have with Europe.

Every year, nearly 11 million European visitors come here.

We have reciprocal health care agreements with the rest of Europe

so that each country claims back the cost of EHIC treatments

from other member states.

In 2010, the Government paid out £123 million

for UK citizens who received medical treatment in Europe

using their European Health Insurance Cards

but we got just £38 million from other European countries.

So why such a big difference

between what we paid out and what we received?

One major reason is that we don't add up

how much British GPs spend treating Europeans across the country.

Valerie Hughes was the NHS Counter Fraud Officer for Brighton and Hove.

There were lots of tourists on her patch.

The biggest problem is,

we don't collect the information about those patients,

the specific information relating to the individual,

to be able to claim that money back from the community.

We did a project in the Brighton city area and we...

came up with the information that our GP practices

that were working with us,

that we were losing in the region of £200,000 in one financial year.

So if we then times that throughout the whole of the country

in primary care, just purely primary care we're talking here,

we're talking millions.

Some doctors are also concerned we don't charge Europeans for GP care.

As an ordinary citizen,

not so much as a GP, is that I'm not afforded this right

in any other country I've ever been to.

I meet many patients that come back from other countries

and nearly always, there is some kind of payment arrangement.

For example in the United States, it would be laughable

to think of going to a family practitioner's clinic

and expecting free treatment.

We asked the minister

why many European countries charge US for primary care

but we don't charge them?

We've found that many doctors do not collect the data

so that we can charge the cost

of treatment of European visitors back to Europe.

Why aren't we doing that? That's a simple thing, isn't it?

Well, it sounds simple but, of course as we know, it's very complex.

We also know that the system is not working.

That's why we're having a review.

Every year, the NHS also pays European countries

for treating our pensioners who are living abroad.

In return, they pay us for treating their pensioners who live here.

Last year, we paid out £734 million to other European countries

but we got just £50 million back.

Now, part of that money

went towards payments on European Health Insurance cards

but the vast bulk of it went to pay other countries

for the health care costs of British pensioners who are living abroad.

So why is it that we paid out so much and got so little back?

Last year, one third of that money - £250 million -

was sent to pay for the health care of people living here, in Ireland.

These are people who have worked all of their lives in the UK,

are now eligible for a British state pension

and have come back here to retire.

The UK Government picks up the tab for their health care.

People like Maureen and her partner, Andy.

What difference does it make to you that the UK Government

-will pay for your health care here?

-Oh, a great deal.

We wouldn't be able to live here five minutes.

We couldn't be here.

And a lot of the return-to-Ireland people

and people that have just moved over to Ireland for a quiet life,

they wouldn't be able to stay.

'Many in Ireland have to pay for their health care

'but not Andy and Maureen.'

Because we were in England for 52 years,

you paid your contributions and you were entitled to that

as if you were still in England.

And the bill is taken up by...

the British Government pays all this.

-So for you, this is like having an NHS in Ireland?

-Yes, it is.

It is really the same thing.

I mean, people used to talk about the National Health Service in the UK

but, you believe me, it is the finest system in the world.

Andy and Maureen are far from alone.

In fact, the NHS pays for the health care

of more than 40,000 British pensioners living here.

But, for some reason, Ireland charges the NHS

nearly £6,000 a year per pensioner,

which is almost 50% more than the UK charges other countries

to look after their pensioners.

So why are we paying Ireland so much more?

-So it just is more expensive?

-It is more expensive.

But taking that altogether, it doesn't seem to me that

it would explain the full amount of that difference by some margin.

Because we're talking about 50% more here, aren't we?

I think if you were trying to do the calculations as carefully

as possible, the chances are that the result would be perhaps 25,

or even perhaps 30% more expensive than the equivalent care

for this population would be in the UK.

Do you believe it's likely then

that the UK is paying over the odds?

Maybe significantly over the odds for this?

I think it probably is paying quite a lot more

than the cost would justify, yes.

Panorama has calculated that if Professor Norman's right,

then the NHS has overpaid Ireland by £125 million

in the last three years.

The Irish Government dispute that figure.

They say that average health care costs...

..but, in any case, UK payments in recent years

are based on estimates yet to be finalised.

Therefore they said...

..whether the UK has overpaid.

In opposition, the Conservatives promised

an inquiry into the UK's overpayments to Ireland.

But that was three years ago.

Are we paying the Republic of Ireland too much

to look after UK pensioners living there?

There's a HUGE problem with what's happening over in Ireland

and that's why we're working with the Irish Government

because we recognise that's an awful lot of money

that we are paying back to the Irish Government,

quite properly under the existing rules

but they're very, very old rules.

Both Governments accept that we need to sort it out

so that it's not at the levels that it currently is.

Back in Birmingham, the NHS practice manager, Asif,

has been busy.

He seems very keen to meet our undercover man again.

It turns out he's already registered

five fictitious Indian health tourists

into the NHS even though we haven't paid him yet.

The numbers are on this sheet of paper.

It's an expensive piece of paper. Asif is expecting £5,000 for it.

With a fond farewell, Asif reminds us

he's eager to register another five health tourists on the NHS.

But there won't be any more health tourists

registered on the NHS through Asif Butt.

And he isn't going to see his big payday.

Instead, on the morning he comes to collect his money,

he's going to meet me and my camera crew.

Today he's a man of few words.

He wasn't quite as reticent with our undercover reporter.

And though he denies it, there's no doubt these people...

are in the NHS because of him and they don't exist.

We told Mr Butt's employers, Sparkbrook Health Centre,

about his activities and they said, "We have launched...

.."in conjunction with our local counter-fraud team

"and will take appropriate action when all the facts are known."

We asked the Southall middlemen, Ayub and Chamanlal,

about their activities. They didn't respond.

Femi has declined to comment

other than saying the allegations are false.

The NHS was never designed to charge people so, as we've found out,

the systems it has in place for working out

who's eligible for free treatment

and who should pay are just not effective.

Over the last six months,

we've registered eight health tourists with GPs

and we've had free treatment we should have paid for

at hospitals across the country.

No-one has been caught.

We will be reimbursing the NHS for all of these costs.

But in a world where people can travel ever more easily to Britain,

we have to decide -

who has the right to use the NHS for free?

And who doesn't?

Subtitles by Red Bee Media Ltd