An applicant for a skilled worker visa pays the surcharge before leaving home. The rate is £1,035 for each year of the permit, taken at application, and no hospital ever sees it arrive. Added up across all visa holders, the figures are far from small. Gross receipts passed £2.6bn in 2024/25, about 1.1% of total health spend, up from £1.78bn the year before after the rate rose by two thirds in February 2024. A line of that size invites a question that ministers and health leaders have yet to answer. What happens to health budgets when the visa queue shortens?

The question is live because the queue is shortening. Provisional net migration was 171,000 in the year to December 2025, almost half the previous year's figure, largely because fewer non-EU nationals came to work. Government policy points towards further reductions, and in workforce planning it has set a target of cutting the share of new NHS recruits from outside the UK from about a third to 10% by 2035. Health and care visa holders are exempt from the surcharge, so that target does not reduce the receipts directly. Falls in other work and study routes would.

The dependence should not be overstated. The Home Office collects the money, deducts its costs and passes the balance to health departments in the four nations through the Estimates process, in Barnett shares, and part of the total goes to the Consolidated Fund. I found no sign that it is earmarked. At 1.1% of spend it is no lifeline, though a percentage point of health spending is a sum any finance director would notice.

The yield depends on visa volumes set elsewhere in government, and the rate rests on evidence that is thinner than either side admits. Official documents say the charge reflects average use of health care by payers, estimated with proxy measures. When the rate rose in 2024, a Lords committee observed that it had risen far faster than NHS spending, which had grown by 25% since the previous increase, and traced the gap to a revised method for estimating migrants' use. The Home Office replied that the new method showed high use in some areas, including community and mental health services. An independent analysis due to be published suggests the charge may overestimate the cost of payers' care. No national study of service use by migration status has drawn on data from 2021 onwards, a period in which the migrant population changed markedly.

The two camps read that uncertainty differently. Supporters say the charge secures a fair contribution from people who use the service, and point out that the 2024 rise honoured a manifesto commitment to cover the full cost of treating payers. Critics say payers already contribute through income tax, national insurance and VAT, so they pay twice, and that the cost estimates may be inflated. Each position rests on a number that nobody outside government can test.

For NHS leaders and the health department, the practical lesson is to treat the income as a variable. Because applicants pay for the whole period of a visa at the point of application, receipts are likely to track the number of visas granted in each year. A budget that assumes a steady flow carries a risk that moves with immigration policy, and no trust or region can plan around it.

Policymakers could do two things. They could state what the surcharge is for, since cost recovery and a source of income call for different levels and different safeguards. They could also publish the method behind the rate and commission fresh evidence on service use since 2021, which would settle a good part of the argument or at least narrow it.

A charge described as cost recovery cannot also serve as a dependable source of income when its level rests on a method nobody can check and its yield depends on decisions taken in another department. Until ministers say which it is, health leaders should budget for it as a variable and ask for the evidence that would let them do otherwise.

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