Migrants pay 30% of what the NHS costs per resident

England's day-to-day NHS budget works out at about £3,500 for every resident this year. An adult on most work and family visas pays £1,035 toward it, with students, Youth Mobility applicants and children on £776. Even the full rate is thirty pence in every pound of average NHS spending and the name carries the rest. Call it an "immigration health surcharge" and people hear migrants covering their own care, when the standard charge is under a third of what the NHS spends per resident.

Paying it gives access to NHS treatment broadly on the same basis as a resident for the length of the visa, apart from limited exclusions such as assisted conception. You hand it over upfront for the whole grant. Five years means £5,175 before the visa is issued.

None of this happened by accident. The method is on the record. To set the rate the Department of Health estimated the average NHS cost of the people who pay it, a younger group, and landed on £1,036 a head. That came to about 38% of the government's own estimate of an average resident's cost at the time, the difference being the cohort's lower expected use. Rounded off, that £1,036 became today's £1,035 charge.

In other words, the benchmark is the cohort rather than the system. That 38% sets the government's 2023 estimate of a payer's cost against its resident-average estimate at the time. Since then the charge has not moved and against today's £3,500 it works out at about 30%. Defending the rate, the minister conceded its shape, calling the charge "considerably lower" than the average cost of treating a resident. The government then put that average at about £2,700. Whitehall is not really pricing access to the NHS so much as pricing a younger pool at that pool's lower average.

Nobody else pays for the NHS by what they are likely to use. A 25-year-old on £30,000 hands over full income tax and National Insurance while barely seeing a hospital all year. Her bill is not trimmed because she is young, healthy and unlikely to need one. That is the design. The NHS is a pool. You pay in by what you earn and draw out by what you need; those two things are kept deliberately apart. An insurer does the reverse, charging the young and healthy less because they are expected to claim less. Only the surcharge benchmarks an NHS access charge to the expected use of one distinct cohort.

None of this means a young migrant runs up £3,500 of treatment, any more than the young worker does. That £3,500 is average spending per resident, not the cost of adding one more person. The people who pay the surcharge come in cheaper than average to treat anyway. That is the point. Access to a pooled system is not priced at one user's expected claims. Price it that way for migrants alone and £1,035 is the figure you get.

On the government's current treatment of the surcharge as a cost-recovery fee, Whitehall could not simply raise it to the £3,500 average without redesigning the charge. A fee cannot exceed the cost of the service to the people who pay it, which is exactly why the rate sits at the cohort's modelled cost and no higher. Lifting it to the per-resident average, roughly three times what the cohort is assumed to use, would mean turning the fee into an access levy. That probably needs primary legislation, not a line added to a statutory instrument.

Set the standard rate at £3,000, a round figure that sits below the current £3,500 average, then index it each year to NHS spending per head. At about 86% of the per-resident figure, it leaves a margin below the average and rises automatically as the budget grows. On a static basis, holding the payer mix and the number of applications steady, that lifts receipts from about £2.4bn a year toward £7bn, money passed to the health departments rather than kept as general tax.

Put that next to what the Treasury is hunting for elsewhere. The £4.5bn is an upper bound, mind. It assumes the same people keep applying, when a higher charge would put some off and lower the take. Even so, the contrast holds. Raising the headline rate of Capital Gains Tax does not bring in money like this: on HMRC's own ready reckoner a ten-point rise in the higher rate runs at a net loss, about £540m in the first year and £3.6bn by the third, as people stop realising gains. A fee that already collects £2.4bn can nearly triple its rate and still raise billions. For scale, £4.5bn is roughly three-quarters of the £6bn a year it costs to lift defence to 2.5% of GDP, though that money goes to the health budget rather than the Treasury's general pot.

For a single adult on a five-year visa the charge would go from £5,175 to £15,000, paid in one sum before the visa fee. It multiplies across a household, because everyone pays separately and upfront.

The mainstream salary floor for a skilled worker is £41,700. A £15,000 charge is more than a third of a single year's gross pay, due in full at the point of application. Graduate-route applicants have no salary floor at all; partner-route applicants face a separate £29,000 household income requirement rather than the £41,700 sponsored-work threshold.

Rates used: £1,035 per adult and £776 per child now, £3,000 and £2,250 at the proposed level. Health and Care Worker visa holders are exempt from the surcharge and are not affected.

Two arguments against a higher charge are serious and worth meeting head on. Start with the claim that migrants are young and use less, so £1,035 already matches their cost. It does, on the cost-recovery basis the law currently requires. That basis is the wrong one, though. It measures expected short-term use. Nobody else who funds the NHS has their access priced that way. The calculation is accurate; the benchmark is the cohort when it should be the system.

A higher charge can also look like charging twice, since surcharge payers who work already pay income tax and National Insurance, under the same rules as anyone else. They do pay both. That matters, because £3,000 is not a claim that migrants are a net drain. The point is narrower. Once Britain places a separate charge on temporary NHS access at all, that charge should be set against what the system costs, not the lower use of a cohort selected precisely because it is cheap to treat.

Collecting the charge upfront at the visa desk has a reason too. A 2016 investigation by the National Audit Office found the NHS recovered less than a fifth of what it could from chargeable visitors once they were in the country. Taking the surcharge at the visa stage sidesteps that. Public opinion has backed the general principle. In a 2020 YouGov poll, 62% said immigrants should pay to use the NHS.