Medical issues (MED)

This is internal guidance for use by entry clearance staff on the handling of medical issues for visa applications made outside the United Kingdom (UK). It is a live document under constant review and is for information only.

MED1 Who requires a medical examination?

Paragraph 36 of the Immigration Rules states that any person who intends to remain in the UK for more than 6 months, including applicants proceeding to parts of the Common Travel Area should normally be referred for a medical examination. Paragraph 36 of the Immigration rules also allows an Entry Clearance Officer (ECO) to use their discretion to refer any other person for an examination if necessary.

If the person declines a medical examination, he or she can be refused entry clearance under Paragraph 320 (17) of the Immigration rules.

A returning resident may not be refused entry on medical grounds, although an Immigration Officer can require a person to undergo a medical examination on arrival in the UK (paragraph 38).

Where a medical referral is required, an ECO may not issue an entry clearance without medical clearance. The requirement for pre-departure medical checks applies mainly to applicants coming to the UK from areas of a high incidence of infectious TB. More information is available on our Health (TB) screening page.

MED2 What is the tuberculosis (TB) testing programme?

It is the targeted health screening for tuberculosis (TB) in high-risk countries at the entry clearance stage. This formed part of the UK Government's Five Year Strategy for Asylum and Immigration published in February 2005.

Applicants from participant countries (see below) applying for entry clearance for more than six months are required to produce a certificate issued by the International Organisation for Migration (IOM) showing that they are free from infectious TB.

MED2.1 Countries where TB testing programme operates:

Centres have been established to carry out the screening process in Bangladesh, Cambodia, Ghana, Kenya, Pakistan, Sudan, Tanzania, and Thailand.

In addition to their own visa applicants, these centres also carry out tests on applicants from Burkina Faso, Côte d'Ivoire, Niger, Togo, Eritrea, Somalia, and Laos. Applicants from the first four of these countries are screened in Ghana, those from Eritrea and Somalia in Kenya, and those from Laos in Thailand.

MED2.2 How does the TB testing process work?

The International Organisation for Migration (IOM) runs the testing programme in participant countries. IOM is responsible for accrediting the clinics and hospitals that do the testing and for ensuring that they meet the required standards. IOM-issued certificates contain anti-fraud safeguards and are valid for six months.

Applicants must pay the cost of TB testing. For exceptions, see MED2.5 below.

Applicants with infectious TB will not be issued with a certificate. They will be advised by IOM to seek medical treatment.

A full course of treatment for TB usually takes around six months. After the treatment is completed, the applicant can pay to undergo a further test. If found to be free from infectious TB, the applicant will be issued with a certificate.

Applicants must obtain a certificate from IOM before they make their entry clearance application.

MED2.3 Who is exempt from needing a TB certificate?

The following are exempt from the requirement:

• holders of diplomatic passports travelling on official business or on a posting;
• children under 11 years old;
• returning residents;
• Certificate of Entitlement holders.

EEA family permit applicants are NOT exempt from the testing requirement.

MED2.4 When should scholarship / sponsored students be TB tested?

IOM-issued TB certificates are valid for six months. Posts may consider advising potential scholarship / sponsored candidates of the need to allow sufficient time to be screened and, if necessary, treated, before applying for an entry clearance. The decision of when to undergo the TB test lies with the applicant - early TB testing cannot be enforced by Post.

MED2.5 Who is TB tested free of charge?

At Post's discretion, FCO funded scholars (eg Chevening). The use of this discretion should be very limited. In some cases the organisation offering the scholarship may wish to pay for the applicant's TB test. This should be arranged between the applicant and the organisation offering the scholarship.

A limited number of applicants in other categories who are entitled to gratis visas for whom Posts want also to provide gratis TB screening. See ECB6.6 and ECB6.7 for guidance on gratis visas.

If Post decides to offer a gratis test to any applicant they are responsible for covering the costs and paying IOM. The UK Border Agency is not able to reimburse Post.

MED2.6 What to do with the TB certificate when issuing the entry clearance

• Update PROVISO that the certificate has been seen.
• Advise the applicant to carry the original TB certificate (and their chest X-ray) in their hand luggage for presentation to an immigration officer on arrival in the UK to prevent delays or referral to the Port Medical Inspector (PMI).

MED3 What is the role of the Entry Clearance Officer?

An ECO is not expected to make any professional medical judgements. These are matters for the Medical Officer (that is, a designated doctor) and Medical Referee. Where a medical referral (for examle, TB certificate) is required for an applicant, the ECO may not issue an entry clearance without medical clearance.

• Medical Officers must not be asked to examine women to establish whether they have had sexual intercourse or given birth to children.
• A chest X-ray is not required for pregnant women nor for children aged under 11 years.

MED4 What are the responsibilities of the Medical Officer (designated doctor) and the Medical Referee?

The recommended procedure for arranging medical clearance is for each Post to appoint:

• a Medical Officer who carries out the medical examination and,
• a Medical Referee who makes a recommendation to an ECO on the suitability on medical grounds of an applicant for entry to the UK.

The role of Medical Officer and Medical Referee can be combined.

Following a medical examination by the Medical Officer, a Medical Referee may wish to examine the applicant if:

• there appears to be some irregularity on the Form PQ; or
• after considering Form PQ, the Medical Referee is not sure whether to recommend refusal of UK entry on medical grounds; or
• the Medical Referee wishes to make an occasional check on the adequacy of the medical examinations.

The Medical Referee may defer making a recommendation in certain circumstances, for example, to await the result of a course of treatment for acute infectious diseases, contagious skin diseases etc.

The Medical Referee may decide that the prospective applicant should have a further examination at a later date, in which case the Medical Referee will have to state whether or not this should preclude entry to the UK.

The Medical Referee may also recommend that the applicant undergo a course of medical treatment after arrival in the UK.

MED5 Who pays for a medical referral examination?

The costs of any medical referral examination must be borne by the applicant.

MED6 What are the objectives and criteria for the medical recommendation?

This section is under review.

MED7 What medical recommendations can the Medical Referee make?

For returning resident category:

• The Medical Referee may only bring to the attention of the ECO any condition which might require treatment when the applicant is admitted to the UK.
• A returning resident cannot be refused entry to the UK on medical grounds. However, an Immigration Officer (IO) can, upon a returning resident's arrival in the UK, give a notice to that person requiring them to report to a Medical Officer for Environmental Health with a view to further examination and any necessary treatment.

For all other categories of applicant the Medical Referee may either recommend:

• refusal;
• defer making a recommendation; or,
• draw the attention of the ECO to the circumstances of the case.

MED8 Voluntary medical clearance

Voluntary medical clearance may be encouraged for any person intending to remain in the UK for longer than six months. This is because an Immigration Officer (IO) may require such evidence before admission.

Applicants who arrange their own medical clearance should be advised to take evidence of this with them so that they can show it to the IO, if required.

MED9 Long-term sponsored students and medical clearance

Long-term sponsored students who are medically examined for their sponsor before their award is confirmed should provide evidence to the ECO that they have been declared medically fit. If the evidence is satisfactory the ECO need not ask for further medical clearance.

In these circumstances, when the entry clearance is issued, the ECO should advise the applicant to take the medical evidence with them to the UK so that it can be produced to an Immigration Officer if required.

MED10 When compassionate grounds for issuing entry clearance outweigh refusal on medical grounds

If the ECO considers that there are compassionate grounds that might outweigh the Medical Referee's recommendation to refuse admission to the UK, the ECO should refer the case for a decision to RCU (UK Border Agency) through the Home Office referral mailbox.

Forms PQ and XY and all related correspondence / supporting material should be scanned and sent by email. For further information see section on Referrals (see ECG Toolkit).

If there are urgent and compassionate reasons for an applicant to travel, then it is at Posts' discretion whether to allow the application to continue without a certificate being held. In the very rare instances where this occurs, applicants should be referred to the Port medical inspector (PMI) on arrival in the UK.

MED11 How do I assess a person's age?

A physical examination by a doctor can be helpful in establishing the age of persons from countries without reliable systems of birth registration. But such assessments are approximations which need to be considered along with other evidence of age.

The use of X-rays to assess age is not admissible. Medical Officers / Referees should not be asked to use radiological data when giving age assessments.

MED12 How do I process an application from a person with a serious (for example, terminal) illness?

If an applicant for entry clearance has a serious illness, for example HIV / AIDS, the ECO should decide on the application under the provisions of the Rules or, if in doubt, refer it to:

Entry Clearance referrals, RCU, UK Border Agency, through the Home Office referrals mailbox. Supporting material should be scanned and sent by email. For further information see section on Referrals.

The fact that an applicant has a serious illness is not sufficient grounds in itself for ECOs to exercise discretion in issuing an entry clearance. Where in any case it appears that public health may be at risk, advice should be sought from the Department of Health.

Department of Health
Aspects of Public Health Unit
Room 601A
Skipton House
80 London Road
LONDON
SE1 6LH

Tel: 020 7972-2000
Fax: 020 7972-5138

The ECO must refer all such persons to the Medical Officer for a medical examination. The Medical Referee's recommendation should contain a recommendation as to whether the applicant is able to maintain himself / herself and, if relevant, any dependants, during his / her stay in the UK. For instance, although a person who is HIV positive may be well enough to work, study or undertake a visit, a person with full blown AIDS may not be capable.

If an applicant appears to be so ill that it is likely that he / she would require medical treatment while in the UK and the person could not meet the cost of the treatment privately, the ECO should consider refusal under the general provisions of the Rules. Paragraph 37 of the Rules covers those who suffer from a disease or condition which would prevent them from supporting themselves or their dependants.

If the ECO believes that the applicant intends to travel to the UK as a visitor in order to obtain free medical treatment, the ECO may refuse entry because he/she is not satisfied that the applicant is genuinely seeking entry as a visitor (paragraph 41(i)). Visitors to the UK are not entitled to receive free (non- emergency) National Health Service hospital treatment on a visit to the UK unless they are considered exempt from charge under the NHS (Charges to Overseas Visitors) Regulations 1989, as amended (see guidance in the Visits section).

More information is available on the Department of Health - Information for overseas visitors

MED13 How do I process an application from a person with a serious illness who wants to go to the UK for private medical treatment?

A person with a serious illness who wishes to go to the UK for private medical treatment will have to meet the usual requirements of the Immigration Rules paragraph 51 (see guidance in the Visits section).

The ECO need normally only refer such applications to the Home Office for a decision when the circumstances are particularly difficult or sensitive.

MED14 Pregnancy

Referring a woman to a medical inspector for confirmation of a suspected pregnancy should be made only where there is a strong evidence that the purpose of the passenger's visit is to take advantage of National Health Service facilities. Medical Officers must not be asked to examine women to establish whether they had sexual intercourse or have given birth to children. A chest x-ray is not required for pregnant women nor for children aged under 11 years.

If the applicant is over 28 weeks pregnant, most airlines will ask for a letter from a doctor or midwife stating that the applicant is fit and well, that it is safe for the applicant to fly.

MED15 Applications from women coming to the UK to act as surrogate mothers

There are no provisions in the Immigration Rules for a woman to be admitted for the purpose of being a surrogate mother. The UK Government does not encourage the practice of surrogacy. Consequently the UK Border Agency does not operate a concession outside the Rules to enable women to come to the UK for this purpose.

Admission as a visitor under the Immigration rules to act as a surrogate mother is inappropriate given the six month limit, as is admission for private medical treatment since the applicant would not be suffering from any medical condition.

An application from a woman to enter in the UK to act as a surrogate should normally be refused on the grounds that there is no provision in the Immigration Rules.

For information about children who are the subject of inter-country surrogacy arrangements, see SET7.24 - Inter-country surrogacy.

MED16 Organ donation (NHS)

There is no provision under the rules for applicants to come to the UK as an organ donor when the surgery is being completed under the NHS. Applicants who wish to apply to come to the UK in order to be assessed further as a suitable donor must submit a visa application as a general visitor.

These visa applications will act as a pre-assessed (potential) suitable organ donor where the UK sponsor is resident in the UK and is undergoing NHS treatment, and should immediately be referred to RCU (Referred Casework Unit) using the Home Office Proforma, for consideration outside the Immigration Rules. They must include in their supporting documentation a letter endorsing their application from the NHS along with evidence of how they meet the general visitor rules.

Example of the letter can be seen in the Referrals/deferrals section under section RDF3.7

Each letter will have the hospital's own letterhead.

See the Referrals / Deferrals (RDF) section, (found in ECG Toolkit) for guidance on making a referral.

Organ donors are usually advised that check ups after donation should be conducted in their country of residence and they are provided with a medical letter to this effect (which should be dated post operation). We are aware that the NHS has seen overseas donors for follow up action but this tends to be coincidental for instance the donor is here as a visitor and while here they make an appointment to undergo a check up.

Organ donation (Private medical treatment)

Applicants may apply to enter the UK as suitable donors to a person (sponsor) receiving private medical treatment in the UK. They must be assessed under visitors rules for private medical treatment. Particular care must be taken when considering the applicant's ability to maintain and accommodate themselves without recourse to public funds. (The availability of possible free NHS treatment or chargeable urgent or immediately necessary NHS treatment, which can not be delayed for reason of payment should not be considered when considering the applicant's ability to maintain and accommodate themselves without recourse to public funds.)

The whole process for transplant including expenses for recuperation of the donor applicant must be undertaken as private medical treatment.

Organ donation (If sponsor is resident in the channel Islands or the Isle of Man)

All entry clearance applications, including those applicants who wish to donate an organ, must be refererred to the appropriate Island for authority to issue or refuse, by email and include the Channel Islands and Isle of Man Referral form.

MED17 NHS and GP practices: payment for treatment

The National Health Service (Charges to Overseas Visitors) Regulations (as amended) states that the NHS will charge and recover payment for treatment provided to visitors, or non-residents (someone who is not considered as settled in the UK). Hospitals can also use their discretion whether or not to withhold treatment if payment is not made in advance. (Note: GPs are not currently subject to the same rules as secondary health provision*).

*primary health provision = GP and dentist treatment and secondary care = hospital treatment

Regulation 3. Schedule 1 of the NHS regulations 1989 sets out those that are exempt from the charges. Importantly, certain conditions which arise during a visitor's leave will often warrant exemption from charges.

Whilst not exhaustive, examples of such exemptions are as follows:

• Treatment at A&E, casualty or 'walk-in' centres
• Treatment for incapacitating illnesses, such as food poisoning, diarrhoea, salmonella infections, whooping cough etc (see Schedule 1 of the Regulations for a full list)
• Treatment for a sexually transmitted disease (see HIV below)
• Family planning services
• Services provided for those under the Mental Health Act 1983
• Psychiatric treatment required by a court.

Those exempt from NHS charges:

• Permanent residents
• Those based in the UK for employment, including self-employment
• Those that can obtain services due to reciprocal agreements with certain countries
• Those who are part of HM Forces and NATO armed forces
• Long term students (over 6 months leave) or students whose course is substantially funded by the UK government.
• Refugees, including applicants for refugee status; but not refugees who have been refused asylum - more information is available on the Department of Health website: asylum seekers and refugees
• Those who have previously had 10 years continuous lawful residence in the UK and who have worked overseas for less than 5 years
• Those who work in another EEA state
• EEA nationals, including refugees of EEA states and their dependants

GPs

Under the current regulations, while GPs must offer treatment to anyone who asks for it, if a doctor deems further treatment as necessary they can use their discretion to refuse to register people as permanent or temporary patients. If someone is not entitled to free hospital treatment, then a referral from a GP for treatment does not allow exemption from charges, unless the treatment falls under an exempt category (see above).

MED18 Assisting NHS recovery of debts

With effect from 1 November 2011 changes to the Immigration Rules will mean any unpaid debt to one or more relevant NHS Bodies, with a total value of at least £1,000 in agreement with the relevant NHS regulations on charges to overseas visitors, will be grounds to refuse an application for entry clearance, taking into consideration any compelling compassionate circumstances and/or human rights considerations.

MED18.1 What to do if the NHS debt has been paid

Once the debt has been cleared, there will no longer be a reason to refuse entry on these grounds. The applicant will still have to satisfy the visa officer or immigration officer that they can meet the rest of the requirements of the Immigration Rules for the category in which they are seeking entry. Where the applicant has only recently discharged their debt to the NHS, the visa officer must be satisfied that the applicant is able to maintain him/herself and any dependents whilst in the UK and if there is not any intention to seek further NHS treatment before entry clearance.

MED18.2 What to do if the NHS debt has not been paid

Entry clearance should normally be refused if the applicant has unpaid NHS charges of £1,000 or more taking into consideration any compelling compassionate circumstances and/or human rights considerations.

Where a refusal application is also linked to a dependant application, any dependent will also fall to be refused. If the dependent is responsible for refusal, due to unpaid NHS debts. There is no requirement that the main applicant is also refused. Where the debt relates to a dependent minor the parents/guardian will be responsible for the debt. The new changes only apply to debts acquired on or after 1 November 2011.

Refusal will be under the Immigration Rules paragraph 320(22) stating the charges owed and the NHS Bodies concerned if more than one NHS body is involved. No mention must be made of the nature of the treatment. There are no additional appeal rights.

Application forms will also be revised to show these changes. If in the application form the applicant states they have received chargeable NHS treatment and there is no evidence that payment has been made, after taking into consideration any compassionate and human rights considerations, and if the applicant's statement indicates that the NHS debt is for £1,000 or more which is confirmed by the appropriate checks then the application should be considered for refusal under the Immigration Rules para 320(22). If the debt is for less than £1,000, the application must not be refused under paragraph 320(22). Before granting the application, the visa officer will still need to be satisfied that all relevant requirements of the rules are met. This will include the ability to maintain him/herself while in the UK and no intention to seek further NHS treatment.

When the applicant has stated they have received chargeable NHS treatment in their application form, the visa officer should email:

ukbaignhssupport@homeoffice.gsi.gov.uk

with all relevant details if no details appear on their system.

The NHS support team will then contact the hospital/trust and will feedback any information to post. Paragraph 320(22) should only be used to refuse cases where debt information has been supplied or confirmed by the NHS body.

MED19 Refusals

How do I refuse an applicant who does not have a (valid) TB certificate?

The requirement to produce a valid TB certificate is in addition to the normal procedures for medical referrals. If an applicant insists on making an application without a TB certificate, the ECO should accept it. The application should, however, be refused unless there are compelling compassionate circumstances (see MED10 above), the applicant is otherwise exempt from supplying a certificate or the applicant is pregnant (where special provisions may apply). Any other applicable reasons for refusals should also be included in the refusal notice.

Any applicant who does not supply a valid TB certificate at the time of their application and is refused should have their application refused under paragraph 320(8A) of the Immigration Rules, which states that:

'...where the person seeking leave is outside the United Kingdom, failure by him/her to supply any information, documents, copy documents or medical report requested by an Immigration Officer;'

Suggested refusal wording (assuming there are no other reasons for refusal):

'You have applied for entry clearance for the UK as a [reason for period over six months].

You intend to stay in the UK for more than six months and under paragraph 320(8A) of the Immigration Rules you were requested to produce a certificate issued by an approved clinic showing that you are free from infectious tuberculosis. You have not produced such certificate.

I therefore refuse your application.'

Failure to provide a valid TB certificate is distinct to someone who refuses to undergo a medical examination. If an applicant refuses to undergo a medical examination they can be refused under paragraph 320 (17) of the Immigration Rules which states:

'save in relation to a person settled in the United Kingdom, refusal to undergo a medical examination when required to do so by the Immigration Officer,'

Ensure that you are clear about whether you have a case of:

failure to supply the correct information, use paragraph 320 (8A)

or

a refusal to undergo a medical examination, use paragraph 320 (17).

These are not interchangeable or mandatory grounds for refusal.

Refusal of entry on medical grounds / confidential nature of medical certificates

Where the medical inspector has issued a certificate advising that it is undesirable for medical reasons that a person should be admitted, the immigration officer should normally refuse leave to enter on that ground alone. Refusal would be under paragraph 320 of HC 395.

As applicants refused entry are entitled to be informed of the grounds for refusal, the immigration officer must advise an applicant refused entry on medical grounds of the contents of the medical certificate. However, the medical inspector should be consulted before this is done.

Disclosure of the content of the certificate to any other person must not be made without the consent of the medical inspector and the applicant.

When appropriate, the Medical Referee may recommend that a person should not be issued with an entry clearance until he / she has undergone a course of treatment, or until after a stipulated length of time. The Referee may also recommend that the person undergo a course of medical treatment after arrival in the UK.

When an ECO decides to refuse entry clearance as a result of a recommendation by the Medical Referee, the applicant's passport should be endorsed 'EC Applied For / Med' and Forms PQ and XY retained.

When an appeal is made, the medical report must be annexed to the explanatory statement. If the results of an X-ray examination have formed part of the evidence in a refusal, the original X-ray(s) must be included with the report.

If you refuse a PBS applicant after a medical referral, the Certificate of Sponsorship (CoS) will lapse after 6 months.

Refusal wording

The refusal wording should read:
'I have received confirmation from the Medical Referee that it is undesirable to admit you to the United Kingdom for medical reasons and I am not satisfied that there are strong compassionate reasons justifying your admission...'

MED20 Is there a right of appeal against refusals?

Yes, but whether the refusal attracts a full right of appeal or a limited right of appeal depends on the reason for entry to the UK. (See Appeals (APL))