This paper explores the development and operation of law and policy concerning the charging of overseas visitors for healthcare in England from the beginnings of the NHS to the present day. It highlights how this has been a highly contentious issue for decades, often linked with immigration policy, and is an area that still lacks comprehensive reliable empirical data to inform the debate. It explores and analyses the recent reforms to the NHS Overseas Charging Regulations introduced in 2015 and 2017. It demonstrates the problems in implementing the most recent regulations in an era of the ‘hostile environment’ and argues that the approach which has been taken can be seen as undermining the covenant of trust between patient and clinician and thus the fundamental principles of the NHS.