Guidance

Suitability: debt to the NHS caseworker guidance (accessible)

Updated 19 March 2026

Version 4.0

About this guidance

This guidance tells caseworkers and Entry Clearance Officers when an application for entry clearance, permission to enter or permission to stay (including settlement) may be refused because the applicant has an NHS debt, in that they have failed to pay charges under relevant NHS charging regulations.

Contacts

If you have any questions about the guidance and your line manager or senior caseworker / Entry Clearance Manager cannot help, email the Access, Compliance, Removals and Enforcement Unit (ACRE) or AWBS Correspondence for the attention of the IHS policy team for assistance.  

If you notice any formatting errors in this guidance (broken links, spelling mistakes and so on) or have any comments about the layout or navigability of the guidance then you can email the Guidance Rules and Forms team.

Publication

Below is information on when this version of the guidance was published:

• version 4.0
• published for Home Office staff on 18 March 2026

Changes from last version of this guidance

• Changes to reflect Part Suitability replacing Part 9: grounds for refusal of the Immigration Rules
• Addition of a section advising when an NHS debt record should be removed from Home Office systems

What is an NHS debt?

This section explains what is meant by an NHS debt.

An NHS debt is where a person has failed to pay charges under relevant NHS regulations. A person may have accrued an NHS debt if they have received secondary healthcare (which is healthcare provided to the person by a hospital) when they are not eligible for free treatment.

An applicant should be considered for refusal on the basis of NHS debt if a relevant NHS body has informed the Home Office that such a debt exists. For further information see guidance on checking the casework systems for an NHS debt

The terms ‘relevant NHS body’ and ‘relevant NHS regulations’ are defined in paragraph 6 of the Immigration Rules.

This ground for refusal is set out in paragraph SUI 16.1. of Part Suitability of the Immigration Rules (the rules).

The burden of proof is on the Home Office to prove the existence of an NHS debt. The standard of proof is the balance of probabilities (which means it is more likely than not). You must be able to provide evidence of the NHS debt’s existence if it is contested. If a debt is contested by the applicant, you must contact the NHS body using the contact details listed to confirm if the debt remains outstanding. Evidence of an NHS debt may include confirmation received from the NHS body via email that the NHS debt remains outstanding.

This ground for refusal does not apply to the following applications:

• protection claims (this means decisions on asylum and humanitarian protection claims as well as protection-based claims under article 3 of the European Convention on Human Rights (ECHR)), except applications under paragraphs 352ZH to 352ZS (Section 67 of the Immigration Act 2016 leave), 352I to 352X (Calais leave), and 352A to 352FJ (Family Reunion) of the rules
• Appendix S2 Healthcare Visitor
• Appendix Service Providers from Switzerland
• Appendix EU
• Appendix EU (Family Permit)
• Nationality applications
• Appendix Ukraine Scheme (including applications under the Ukraine Family Scheme, Homes for Ukraine Scheme or Ukraine Extension Scheme)

If you are a Border Forcer Officer and require additional guidance, see NHS debtors.

Immigration Health Charge (Surcharge)

The Immigration Health Charge (also publicly known as the Immigration Health Surcharge (IHS) must normally be paid by migrants seeking to enter or stay in the UK for more than 6 months. It is not payable on all routes and there are exemptions.

The IHS is intended to ensure migrants with a temporary immigration status contribute to the cost of NHS services available to them during their stay. Where an individual has paid the IHS and is granted immigration permission, they will be able to access the NHS on broadly the same basis as UK residents for the duration of their immigration permission. They may be charged for certain services such as prescription charges in England which UK nationals would also pay. Temporary migrants who do not pay the IHS, such as visitors, may be subject to NHS treatment charges.

Those applying for settlement (also known as indefinite leave to enter or remain) do not need to pay the IHS and are entitled to receive free healthcare if they are granted settlement and are ordinarily resident in the UK.

Qualifying NHS debt

This section explains which NHS debts qualify when considering refusal based on NHS debt.

When was the debt incurred and how much is the debt?

You can only consider refusing an application on grounds of NHS debt if any of the following apply:

• the applicant has an outstanding NHS debt, or cumulative debts, of £1000 or more incurred on or after 1 November 2011
• the applicant has an outstanding NHS debt, or cumulative debt of £500 or more incurred on or after 6 April 2016
• the applicant is an EU, EEA or Swiss national and has an outstanding NHS debt, or cumulative debt of £500 or more incurred since 1 July 2021

A person who has incurred charges of under £1000 before 6 April 2016 cannot be refused on this basis unless either of the following apply:

• they incur further charges of at least £500 on or after 6 April 2016
• they incur further charges on or after 6 April 2016 bringing the total outstanding NHS debt since 1 November 2011 to over £1000

Appendix FM, Appendix Armed Forces and Appendix Private Life

Appendix FM applies to those seeking to enter or stay in the UK based on their family life with a person who is:

• a British Citizen
• settled in the UK
• in the UK with limited permission as a refugee or person granted humanitarian protection
• in the UK with limited permission under Appendix EU, in accordance with paragraph GEN 1.3 or in the UK with limited permission as a worker or business person under Appendix ECAA Extension of Stay, in accordance with paragraph GEN.1.3.(e)

The Appendix Armed Forces routes are for members of the armed forces, civilian employees and their families.

Appendix Private Life is for those seeking to stay in the UK on the basis of their private life, including private life claims under Article 8 ECHR.

You should consider refusing the application under Appendix FM, Appendix Private Life or Appendix Armed Forces if either of the following apply:

• the person has an outstanding NHS debt or cumulative NHS debt of £1000 or more incurred on or after 1 November 2011
• the person has NHS debt or cumulative debt of £500 or more incurred on or after 24 November 2016

A person who has incurred charges of under £1000 before 24 November 2016 cannot be refused on this basis after 24 November 2016 unless either of the following apply:

• they incur further charges of at least £500 on or after 24 November 2016
• they incur further charges on or after 24 November 2016, bringing the total outstanding NHS debt since 1 November 2011 to over £1000

When considering whether to refuse an application under Appendix FM or Appendix Armed Forces you must consider any human rights factors in accordance with:

• Appendix FM guidance
• Private Life guidance
• Armed Forces guidance

Consideration of NHS debt

You must check the relevant case work system to determine if the applicant has an outstanding NHS debt that meets or exceeds the thresholds set out in Qualifying NHS debt. Further details of how to check casework systems for an NHS debt can be found in checking the casework system for an NHS debt.

A person may have accrued an NHS debt if they have received secondary healthcare (which is healthcare provided to the person by a hospital) when they are not eligible for free treatment.

NHS bodies use their own internal processes to recover NHS debt and will only notify the Home Office once the debt has been outstanding for 2 months or more from the date of invoice and there is no agreement in place to pay by instalments.

You must only consider refusing an application for entry clearance, permission to enter or permission to stay on the basis of NHS debt if the NHS debt information has been supplied or confirmed by an NHS body. For an NHS debt to appear on an applicant’s immigration record, the NHS body must have reported the debt to the Home Office through the monthly return. Upon receipt, NHS debtor information is quality checked prior to being attributed to an individual’s case records to ensure debts are applicable.

Official sensitive: start of section

The information on this page has been removed as it is restricted for internal Home Office use.

Official sensitive: end of section

If checks do not confirm the application has an outstanding NHS debt, you must not refuse the applicant on this basis. Applicants may declare they have previously received NHS treatment. However, this does not mean they have incurred an NHS debt. Applicants who paid, or are exempt from paying, the Immigration Health Charge (Surcharge) (IHS) at the point they accessed treatment are entitled to access NHS treatment on the same basis as individuals who are ordinarily resident within the UK. It may also be possible that an individual has been treated previously by the NHS but has paid for the treatment or settled the debt.

Where there is an NHS debt, the individual’s biographical details, amount owed, and the NHS body or bodies to whom the debt is owed will be shown on the Home Office System.

Official sensitive: start of section

The information on this page has been removed as it is restricted for internal Home Office use.

Official sensitive: end of section

NHS debt incurred in relation to a child

Where the NHS treatment was received by a child (anyone under the age of 18), their parents or legal guardians may be liable for any healthcare charges. These cases will be identified and recorded by the healthcare provider. Further information regarding the actions that caseworkers should take are listed in NHS debt which relates to a linked dependant.

Checking the casework systems for an NHS debt

Cases in Atlas

When an NHS body has notified the Home Office that an individual is the subject of an NHS Debt, this will be recorded on Atlas by Interventions, Sanctions and Compliance by creating an NHS Debtor case card. The NHS Debtor case card is visible on the Atlas Person Summary View and will contain information relating to the NHS debt, including the amount owed and the NHS body where the debt was incurred. The following are all outcomes available to determine whether the NHS debt is still outstanding or the NHS debt has been repaid or cancelled:

• debt outstanding
• debt defaulted – debt still outstanding
• debt repaid
• debt cancelled by NHS
• repayment arrangement

Official sensitive: start of section

The information on this page has been removed as it is restricted for internal Home Office use.

Official sensitive: end of section

Checking whether an NHS debt has been repaid

This section explains how to check whether an NHS debt has been repaid.

You may contact the applicant where checks have identified there is an outstanding NHS debt and request evidence of whether the outstanding debt has been repaid or whether a repayment plan has been agreed with the NHS body.

An example of the wording to use in your information request is:

Home Office records show that you have an outstanding NHS debt of £[amount] owed to [insert details of healthcare provider debt is owed to] from [insert date debt was raised].

If you have paid the outstanding NHS debt of £ [amount] or have agreed a schedule of repayment, you must provide written confirmation from [insert details of healthcare provider] to show that this debt has been paid or is subject to an agreed schedule of payment by instalment which is being maintained. We will only accept formal documentation and receipts from the healthcare provider as evidence of payment or an agreed plan for repayment.

Please provide this information within 14 days from the date of this letter by [insert how to provide the information, such as email / post]. If you fail to respond within this timescale your application will be assessed against the evidence available regarding the outstanding NHS debt.

If the NHS debt has not been repaid or a payment plan is not being maintained (for example, agreed payments have not been made), your application may be refused. If you believe there are reasons why your application should not be refused despite the NHS debt you must include them in your response to this request and include any relevant evidence.

You should only accept evidence of payment from the healthcare provider that charged for the treatment, not from any other person. A valid receipt may also show the debt has been paid. You must verify with the healthcare provider that a receipt has been genuinely issued.

If the applicant fails to respond to your request, you must assess the application based on the available evidence. Any requests for an extension to submit evidence must be considered on a case-by-case basis.

Details of the nature of medical treatment received by the applicant should not be passed to the Home Office by the healthcare provider. If such details have been received from the NHS body, that data should not be retained on the applicant’s record and no mention must be made of the nature of the treatment in the decision letter. Information on what actions to take can be found in Consideration of NHS debt.

Consideration of an application where there is an NHS debt

This section provides guidance on considering an application where there is an NHS debt.

If there is an NHS debt and it has not been repaid, and there is no agreed repayment plan in place, you will need to determine whether to refuse the application on the basis of NHS debt. It is for the NHS body (or the debt collection body representing the NHS body) to determine schedules of repayment. Any repayment plan will be agreed between the NHS body (or the debt collection body representing the NHS body) and the individual.

NHS debt is a discretionary ground for refusal, so you must not automatically refuse an application for this reason. Although it will often be appropriate to refuse an application where there is an NHS debt you must consider whether to do so based on the circumstances of the individual case.

Where an applicant has an outstanding NHS debt and they say there are compassionate or other circumstances which mean discretion should be exercised in their favour, you must consider that representation to decide whether to refuse on this basis or whether it is appropriate to exercise discretion in the applicant’s favour.

Relevant factors may include:

• the applicant’s circumstances, for example are they in the UK or seeking to return to the UK, and for what purpose
• family circumstances (like the need to stay in the UK to care for a family member, such as the parent to a British child)
• illness of applicant (which may affect ability to work to repay debt)
• financial circumstances (such as whether the applicant could repay the debt or agree a repayment plan)
• other compelling or compassionate circumstances

Example 1

An applicant has applied to come to the UK as a tourist for 2 weeks and has an outstanding NHS debt, no mitigating circumstances have been raised. It is unlikely to be appropriate to grant the application.

Example 2

An applicant has applied to come to the UK as a visitor to see their mother who is terminally ill. They have an outstanding NHS debt. It is unlikely to be appropriate to grant the application.

Example 3

An applicant has applied to enter the UK as a Skilled Worker. They incurred the NHS debt 6 years ago when they entered as a visitor. They have made no efforts to repay the debt despite being employed overseas. They have stated they will repay the debt when they start work if the application is granted. Stipulating that a debt will be repaid in future does not add weight to the merits of an application, the caseworker must only consider the facts of the case and must not give credence to promises to pay in future. It is likely to be appropriate to refuse the application.

Example 4

An applicant has applied to remain in the UK on the Family route. They incurred the debt after overstaying their previous Visit visa. The applicant has a British child and is applying to remain in the UK as the sole carer for the child. It is likely to be appropriate to grant the application.

NHS debt which relates to a linked dependant

A linked dependant is a person who is applying for entry clearance or permission to stay (including settlement) at the same time as the main applicant. If you refuse the main applicant because they owe an NHS debt, you must also reject as invalid any linked dependants applying at the same time. This is on the basis that they do not meet requirements of being a dependant of a person who has, or is being granted, entry clearance or permission to stay, see: Validity, variation and void applications.

However, if you refuse an application from a linked dependant because the dependant owes an NHS debt, you must not refuse the main applicant on the basis of the dependant’s debt.

Where the NHS treatment was received by a child (anyone under the age of 18), their parents or legal guardians may be liable for any healthcare charges. These cases will be identified and recorded by the healthcare provider. You must consider whether the main applicant’s claimed reason for entering the UK at the time of their previous application was genuine, or whether their intention was to access healthcare for their child. For guidance on false representations in a current application, see the Suitability: False representations and for previous applications, Suitability: previous breach of Immigration Rules.

If the checks show an outstanding NHS debt which relates to treatment for a child, the application should be referred to a senior caseworker before a decision is taken. The senior caseworker must ensure consideration is given to the best interests of any child affected by the decision as a primary consideration and any human rights implications of refusal of the application.

Recently discharged NHS debt

An NHS debt is regarded as recently discharged if it was repaid in the 6-month period before the application was made.

If the applicant has discharged their NHS debt since demonstrating that they have met the financial requirement of the route they are applying for, this may impact on their ability to maintain themselves. Caseworkers should consider whether paying the NHS debt in full means that the applicant no longer holds the required level of funds to demonstrate that they can maintain and accommodate themselves in the UK if there is a requirement for them to do so.

A refusal on the grounds of insufficient funds should be made under the relevant immigration route specific rules and not on the basis of the, now paid, NHS debt. Once the NHS debt has been paid there is no longer grounds to refuse on the basis of NHS debt under Part Suitability of the rules.

If a person is seeking permission to enter as a Visitor on arrival at the UK border, having previously repaid an NHS debt, you need to be satisfied the applicant is not intending to enter the UK to access further NHS treatment.

Settlement

Considering settlement applications made under Appendix Settlement Family Life and Appendix Private Life

In settlement applications made on the basis of family or private life, certain refusal grounds will result in a refusal of settlement and a variation to consider the application as permission to stay.

If you are considering a settlement application under Appendix Settlement Family Life or Appendix Private Life and the applicant has an outstanding NHS debt over £500 incurred on or after 6 April 2016 or over £1000 incurred since 1 November 2011, you should refuse settlement and consider whether it is appropriate to grant permission to stay: see guidance on when to grant permission to stay when a person does not qualify for settlement.

As soon as the applicant pays the debt in full, they will become eligible to apply for settlement immediately and will not have to accrue a period of further permission to stay.

Decision notice example wording

If you decide to grant the application even though there is NHS debt you should record the reason for exercising discretion on the case work system.

If you decide to refuse the application you must explain in the refusal decision, why you have decided to refuse on the grounds of NHS debt. You should be clear about whether they have failed to pay outstanding debt and whether you asked for evidence that the debt was paid but none has been received. To note, the Home Office cannot request or provide a copy of the invoice or any document pertaining to repayment plans from the NHS body, the onus is on the applicant to request copies of any documentation from the NHS body.

You should use plain and concise language and avoid jargon and acronyms.

If you have details of the medical treatment received by the applicant, no mention

should be made of that in the decision or on the casework system.

You may use the following refusal paragraphs (adapted to the facts of the case):

I am satisfied that you have an outstanding NHS debt with a total cumulative value of [amount at least £1,000 / £500] in respect of National Health Service (NHS) treatment you received, from [insert name(s) of relevant NHS body(ies)] [add approximate date].

[Option if evidence was requested]

You were contacted on DATE and given XX days to provide evidence that you had paid the NHS debt or set up a repayment plan, but you have failed to do so.

[End of option]

In deciding whether to refuse your application on the grounds of your NHS debt I have carefully considered the circumstances of your case. I am satisfied that refusal is appropriate because [reasons including what evidence has been considered and why discretion has not been exercised].

Any further application is also likely to be refused unless you pay your NHS debt. To pay the debt you must contact the NHS healthcare provider.

Removing a debt record where the NHS Debtor rule no longer applies

Information about an NHS debt should only be held on Home Office systems where it may be relevant to consideration of future applications. The NHS debtor rule does not apply to some forms of leave and does not apply once a migrant becomes permanently settled in the UK.

An NHS debt record should be removed from Atlas (even where the debt remains unpaid) where an individual has:

• Settlement or indefinite leave to remain
• Settled or pre-settled status under the EU Settlement Scheme
• Refugee status
• British citizenship

Caseworkers granting the above types of leave or citizenship must refer the case to Interventions, Sanctions and Compliance (ISC) who will remove the debt from the individual’s immigration record and the Home Office systems. The referral should be made after a case working decision is made, and cases should not be put on hold while a debt record is removed.