Persons who require medical examination
Any person who intends to remain in the UK for more than 6 months should normally be referred for a medical examination. If the person declines, he or she can be refused. Longstanding policy has been for the Immigration Officer to refer to the Port Medical Inspector on arrival anyone who mentions health or medical treatment as a reason for their visit, appears to be unwell or is seeking entry for more than 6 months and comes from a country with high incidence of TB. Additionally, an ECO has discretion to refer any other person for an examination if necessary.
A returning resident may not be refused entry on medical grounds, although an Immigration Officer can require the person to undergo a medical examination on arrival in the UK.
The following should normally be referred for a medical examination (subject to local practice decided by individual Posts - see below) before you decide whether to issue an entry clearance.
- Work Permit holders and dependants, including those entering under the Training and Work Experience Scheme or as seasonal workers, intending to stay longer than six months.
- All dependants of persons settled in the UK applying for settlement.
- Long term students, i.e. those who intend a stay over 6 months, and their dependants.
- Those who appear bodily dirty.
- Those whose condition might interfere with their ability to support themselves and their dependants.
UK Border Agency, Visa Services Directorate recognise that many Posts will not need to maintain strict adherence to these medical requirements e.g. where a Post is satisfied that the health care system in the host country provides adequate guarantees that applicants for entry clearance will be in good health.
Each Post must have a clear policy on medical referrals which, if different from those recommended below, should be defensible in the light of local and (where appropriate) regional factors.
Where Posts consider that there are difficulties in following guidance in this chapter on resource or other grounds, they should report the problem to UK Border Agency, Visa Services Directorate.
The role of the Entry Clearance Officer
Where a medical referral is required for an applicant, the ECO may not issue an entry clearance without medical clearance.
An ECO is not expected to make any professional medical judgements. These are matters for the Medical Officer and Medical Referee (see below).
The recommended medical referral procedure
The Medical Officer (or designated doctor) undertakes a medical examination of an applicant when referred by an ECO.
Form PQ must be completed. The applicant completes questions 1 - 3 and the Medical Officer signs at 4. The Medical Officer will then complete the remaining questions 5 - 7. The applicant must supply two photographs, one of which the Medical Officer endorses with the words "I certify that this is a true likeness of ........". The Medical Officer then passes the completed form PQ together with the photographs directly to the Medical Referee.
The Medical Referee should enter a recommendation at the end of the form PQ, complete form XY on which the decision should be noted in code, and sign the photograph already endorsed by the Medical Officer. Both forms together with the photographs should then be sent directly to the ECO by the Referee.
Form XY is specially textured and must be ordered from the FCO catalogue. Copies must not be used.
Medical Officers, Medical Referees and their responsibilities
While the recommended procedure for arranging medical clearance is for each Post to appoint a Medical Officer (who does the medical examination) and a Medical Referee (who assesses whether the applicant can be medically cleared and reports accordingly to the ECO), Posts may adopt their own variants on this procedure provided that a reputable doctor always recommends on the question of medical clearance to the ECO.
For example, in Posts where large numbers of medical referrals are made, separate Medical Officers and Medical Referees are normally appointed. Elsewhere, however, the role of Medical Officer and Medical Referee can be combined.
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.
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.
Who pays for the examination for a medical referral
The costs of any examination must be borne by the applicant. However, Medical Referees fees can be paid by Posts and charged to the UK Department of Health. Agreement to pay these fees, (or increase existing fees), must be approved by the UK Department of Health in advance. Cases should be made to:
Department of Health
Aspects of Public Health Unit
80 London Road
LONDON SE1 6LH
Tel: 020 7972 2000
Voluntary medical clearance
There may be applications where the ECO will not require an applicant to be medically cleared but is asked by the applicant whether medical clearance is advisable.
Voluntary medical clearance may be encouraged for any person intending to remain in the UK for longer than six months on the grounds that under the Rules an Immigration Officer may require such evidence before admission.
Travellers who arrange their own medical clearance should be advised to take evidence of this with them so that they can show it to the Immigration Officer if required.
Issuing entry clearance after medical recommendation
You may issue an entry clearance once medical clearance has been received. The certified photo should be attached to the XY form and authenticated so that the stamp covers a portion of both the photo and the form.
Form XY may then be handed to the person concerned with an instruction that it be produced to the Immigration Officer at the port of arrival.
Additionally, and when issuing entry clearance to work permit holders, the work permit/card should be endorsed "med/X-ray" (or "med", if no X-ray was undertaken) and authenticated with the official stamp. The uncertified photo should be attached to the permit/card and similarly authenticated.
Long term students
Many sponsored students are medically examined for the sponsor before their award is confirmed. In such cases, you should ask to see evidence that the student has been declared medically fit to accept the award. If the evidence is satisfactory, you need not ask for further medical clearance. In these circumstances, when the entry clearance is issued you should advise the applicant to take the medical evidence when travelling to the UK so that it can be produced to the Immigration Officer if required.
When there are compassionate grounds
When a Medical Referee recommends refusal of admission to the UK but you consider there are compassionate aspects which might outweigh any medical considerations, you should refer the case for a decision to the Home Office, with copies of form PQ and XY together with all related correspondence.
Referrals should be sent to Entry Clearance referrals, NCC2, UK Border Agency, through the Home Office referrals mailbox. Supporting material should be scanned and sent by email.
Refusal resulting from medical recommendation
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.
Whether the refusal attracts a full right of appeal or a limited right of appeal depends on the reason for entry to the UK. For example, a visitor cannot appeal: a student can. 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 work permit holder or a seasonal agricultural workers scheme card holder after a medical referral, you should return the relevant permit/work card together with an explanatory covering note to UK Border Agency, PO Box 3468, Sheffield, S3 8WA.
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 .."
Assessment of 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.
Persons with a serious (e.g. terminal) illness
If an applicant for entry clearance has a serious illness e.g. HIV/AIDS you should decide on the application under the provisions of the Rules or, if in doubt, refer it to NCC2, Home Office.
The fact that an applicant has a serious illness is not sufficient grounds in itself for you 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.
You must refer all such persons to the Medical Officer/Referee (see above) for a medical examination which should contain a recommendation as to whether the person is able to maintain himself/herself and, if relevant, any dependants, during his or her stay in the UK (see the requirement above). 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.
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 Rules (see guidance in the Visits chapter).
You need normally only refer such applications to the Home Office for a decision when the circumstances are particularly difficult or sensitive.
If an applicant appears to be so ill that it is likely that he or she would require medical treatment while in the UK and the person could not meet the cost of the treatment privately, you 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. Where you believe that a person intends to travel to the UK as a visitor in order to obtain free medical treatment, you may refuse entry because you are not satisfied that the applicant is genuinely seeking entry as a visitor. Visitors to the UK are not entitled to receive free National Health Service hospital treatment on a visit to the UK unless they are considered exempt from charge under NHS (Charges to Overseas Visitors) Regulations 1989, as amended. See Visits chapter for further details.
Applications from women to enter or remain in the UK to act as surrogate mothers for friends or relatives should be rare.
There are no provisions in the Immigration Rules for a woman to be admitted for the purpose of being a surrogate mother. 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 on this basis should be considered according to the applicant’s individual circumstances which are likely by the nature of the application to involve particularly difficult compassionate factors. However, because of the complex legal and difficult ethical and practical problems which may arise the Government does not encourage the practice of surrogacy and consequently the UK Border Agency does not operate a concession outside the Rules to enable women to come to the UK for this purpose. An application from a woman to enter or extend her stay in the UK to act as a surrogate should normally be refused on the grounds that there is no provision in the Rules.
Tuberculosis (TB) testing programme
As part of the Five-year Strategy for Asylum and Immigration published in February 2005, the Government stated that there would be targeted health screening for tuberculosis (TB) in high-risk countries at the entry clearance stage. The initial phase of the programme has been in place since late 2005 in Bangladesh, Sudan, Tanzania and Thailand (Bangkok is also the designated entry clearance post for nationals of Cambodia and Laos). These countries were chosen as the first to be included in the programme as they have a high incidence of TB and represent a variety of entry clearance operations. The initial phase has allowed us to test the systems before further roll out.
The main phase of the programme has already been rolled out in Ghana, Kenya and Pakistan and may be extended to a further group of high risk countries.
Applicants from countries that are part of the programme applying for entry clearance valid for a stay longer than six months are required to produce a certificate showing that they are free from infectious TB. The testing procedure is outlined below.
If an applicant is not issued with a certificate because they have been found to have infectious TB, or refuses to produce one, but insists on making an application, you should accept it. But the application should be refused unless there are compelling compassionate circumstances. If you refuse the application, any other applicable reasons for refusal should be included in your refusal notice.
This requirement is in addition to the normal procedures for medical referrals, but any refusal will be under Paragraph 320(8) of the Rules, not 320(17). The applicant is refused for not producing a certificate, not for refusing to undergo a medical examination - see below under Refusals.
Compelling Compassionate circumstances
We think it is unlikely that there will be many applicants intending to come for more than six months who will fall into this category. But if there are urgent and compassionate reasons for them to travel, then it is at Posts' discretion whether to allow the application to continue without a certificate being held. If Posts do allow anyone to make their application without a certificate, they will be referred to the PMI on arrival at the port.
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.
Any applicant who does not supply a 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.
The International Organisation for Migration (IOM) run the testing programme in the initial phase countries. Applicants must obtain a certificate from IOM before they make their entry clearance application. IOM will be responsible for accrediting the clinics and hospitals that do the testing and for ensuring that they meet the required standards.
Only IOM will issue certificates and these will have safeguards to avoid fraud. There will also be systems in place to stop applicants from submitting forged certificates.
Applicants will be required to pay for the cost of testing themselves. For exceptions please see below.
Any applicants found to have infectious TB will not be issued with a certificate, and will be advised by IOM to seek medical treatment. A full course of treatment would usually take around six months. After the treatment is complete, the applicant can pay to undergo a further test and, if found to be free from infectious TB, will be issued with a certificate.
Applicants issued with a visa are advised to carry the original certificate in their hand luggage to present to an immigratiion officer on arrival in the UK. Those not able to do so may be delayed, or referred to the Port Medical Inspector (PMI).
Exceptions and gratis testing
EEA family permit applicants are NOT exempt from the testing requirement.
Family Reunion applicants are required to undergo testing but they do not have to pay for their own tests. The Home Office pays the costs of their tests. Posts are responsible for ensuring that IOM staff are aware of what constitutes a family reunion applicant.
Scholarship Students and others who may be entitled to gratis testing
This guidance should be read in conjunction with the general guidance on TB screening.
Some students applying to study in the UK under government sponsored scholarship schemes (Chevening, Commonwealth Scholarship and Fellowship Plan - CSFP, Dorothy Hodgkins postgraduate, Scottish International and Overseas Research Student Award - ORSAS, are issued with gratis visas (sometimes at Posts' discretion), or have the cost of their visas refunded by, for example, the British Council or the awarding body. There may also be a limited number of applicants in other categories who are entitled to gratis visas, for whom Posts want also to provide gratis TB screening.
The introduction of TB screening will add an additional cost to some students' visa applications. Please follow this guidance when dealing with applicants under the various schemes.
Timing of TB testing
Scholarship students will not normally need to be tested until just before they apply for their visa, leading to a risk that any found to have TB may lose their scholarship because they are not able to travel until they have finished a course of treatment (usually six months). Posts may wish to consider advising potential scholarship applicants of this requirement at the very beginning of the process, so that they have sufficient time to be screened and treated, should they test positive.
We cannot, of course, enforce early testing and decision to do so lies with the applicant. If they choose to test early and use IOM, timing needs to be planned carefully, as a certificate is valid for only six months. Test too early and those testing negative would need to take, and payfor, another test before applying for their visa. Any testing positive would in any case need to be tested again, so timing is not so critical. We shall advise the scholarship awarding bodies along the same lines.
Who should pay for screening?
The general principle should be that the applicant pays for their test, but that if the scholarship awarding body wants to cover the cost, they should either provide the applicant with an advance of funds, or allow them to reclaim the fee. Posts may, at their discretion, pay for the cost of the test for FCO funded scholars (e.g Chevening).
UK Border Agency, Visa Services Directorate would expect the use of Posts' discretion to cover the test fee on behalf of an applicant to be very limited. This discretion also applies to those in other categories.