Select Committee on Home Affairs Minutes of Evidence

Examination of Witnesses (Questions 819 - 839)



  David Winnick: Dr Nathanson, Dr Chisholm, Mr Phillips, I am very pleased that you have been able to come along and give evidence to us on the whole concept of identity cards. We have received your written documentation and obviously we have some questions. My colleague, Mr Marsha Singh, would like to ask you some questions.

  Q819  Mr Singh: I think I am right in saying that you support the Government in trying to reduce inappropriate use of the health service but that you are concerned about the possible bureaucracy that that might involve and you are concerned about emergency treatment and infectious diseases. Do you think those areas should be contained within the Bill or are you happy to leave them to Regulation later on?

  Dr Nathanson: In terms of supporting the concepts behind the Bill and eligibility to access, we are happy with the concept of that being helpful but we have a big caveat about that, which is we keep hearing figures postulated about how much money the NHS spends on patients who have no right of access, but in fact there is no fact on this. We do think it is very important that we actually understand just how much money the NHS is spending inappropriately and how much it could save or otherwise recover, because the cost of the bureaucracy of introducing this system in terms of health alone could be greatly in excess of that, so that major overall caveat should be in place. The question of putting things on the face of the Bill is actually quite important. It seems to us, however, that what we need to make certain of is that the provision of services to those most at need is exempt from the requirement to have the eligibility card with them at the time rather than how that is achieved. It is the outcome that we are most concerned about and we are concerned about that in terms of two different areas. It is both the way in which you describe the care that is excluded, that is emergency care and immediately necessary care or care for certain infectious diseases. We have a very real concern about what those definitions mean. Secondly, there are groups of particularly vulnerable people who might find it difficult to have with them cards at the right time at which they need to access services. So you are looking at a medical model of need and, secondly, a modelling of vulnerable people. If that can be encompassed on the face of the Bill to protect those then that would be fine, but we are equally happy with a system that protects that even if it is not on the face of the Bill.

  Q820  Mr Singh: When you are talking about vulnerable people, would you include people with mental health problems in that?

  Dr Nathanson: People with mental health problems or those who just find it difficult to be sufficiently organised to have documents with them, who are frightened of the system, and that will happen particularly with people who have mental health problems but it could happen at different times in people's lives when they face other major crises, when they are feeling particularly vulnerable and it will also happen for more people as they become more elderly.

  Q821  Mr Singh: You mentioned costs to the Health Service of this system and I was intrigued by that because I cannot see what those costs are. Is it not a simple matter of somebody going along when the ID system is operating and presenting their ID card? Where is the bureaucracy cost in that?

  Dr Nathanson: The question then is, who is going to test it? Who is going to make sure that it is that person's card? What is the process for that? For example, if we are talking about biometric data that has to be accessed every time services are accessed and particularly perhaps hospital services in, `are they emergency situations or not', then you could say that we might have to have biometric readers in many different places and, at the moment, those are quite expensive pieces of kit. So, that is one of the costs. The second is that you actually have to have people in place to chase up those who have had care because the care is needed but perhaps not covered under the immediately necessary and therefore they are not eligible for free care and you have to chase them to get the money back. Clearly, there are some hospitals, for example, in the UK where there may be substantial amounts of care offered to people who have no right of eligibility for the NHS and who already have systems in place to chase that and who may get quite good recovery of significant sums. But, for many other units, it might be so rare that to have somebody in place and machinery in place may be a complete waste of money and it is that balance that concerns us.

  Q822  Mr Singh: I know that you are particularly concerned about GPs policing access to healthcare and certainly smaller practices or single practitioners; do you think that is going to be a particular problem?

  Dr Chisholm: I think that certainly as far as general practitioners are concerned, they would be concerned about the workload implications of any system and, if it is relatively simple and non-bureaucratic as a way of proving entitlement, then I think that general practitioners are broadly supportive of the approach that those who are entitled to receive NHS care should be enabled to receive that care and those who are not entitled should not receive care at public expense. I do think there are issues about the simplicity of the system and I think that, as far as general practice is concerned, I would like to distinguish between the steps that might be taken when a patient is seeking to register with a practice and what they do each time they receive care. Our preference would be that they would establish their entitlement at the time of registration with special and appropriate arrangements being made for the frail, the vulnerable, those lacking capacity and those with mental health problems in order that they are not denied the care they need purely because they are finding problems with the system. I would like to make that distinction between registering with a practice and the routine need to prove entitlement each time that a patient is seen. I think also there are issues about checking the biometric data. I think there is a world of difference between, let us say, a receptionist checking a card and a photograph on a card compared with the need to check fingerprints or check iris data or whatever, which clearly would have significant workload implications and also significant implications in terms of cost to the public purse.

  Q823  David Winnick: Is this a problem at the moment regarding registration? If someone comes along to a GP surgery to register, surely there are certain checks which already occur.

  Dr Chisholm: In general, people register in one of two ways: they either bring along their medical card or they do not and, if they do not, then another form is filled in which relies on them providing information about their name, address and date of birth. The checking is then done by the primary care organisation so, in England, the primary care trust, and the equivalent organisations in the other three countries, rather than the checking being done by the primary healthcare team. Doctors and their staff do not actually themselves take any steps to confirm that an individual is living where they say they are living.

  Q824  David Winnick: It is not really their job, is it?

  Dr Chisholm: No, it is not their job and obviously the patient has a vested interest in giving the address in that although most care is now premises based, if they are requiring a home visit, it is helpful if the address matches up.

  Dr Nathanson: One of the key issues as well is the concept that, when patients register with general practices, very often, people do not move to a new area and think `where is the GP?' and go and register, possibly with the exception of mothers with young children who are more likely to. Many others only register when they suddenly need care, when they are acutely ill and, in those circumstances of course, doctors would usually provide the care, if it were necessary, while the process of the checks are going on.

  Q825  Mr Singh: Maybe we are making a mountain out of a molehill. If a person's rights or entitlements are established when a person first registers with a GP, then, if the GP is referring them for medical treatment to hospital, the GP could confirm that person's entitlement. So, there does not need to be another check at the hospital level. The only real issue would be emergency care in terms of hospitals.

  Dr Nathanson: Yes except of course that very often people go to hospitals in situations which are not necessarily full emergencies but are this `somewhere in between' state being dealt with in primary care. In other words, whether it is an appropriate or inappropriate use of the hospitals, that is where people will get some of their care and they may not have been registered with a GP. It is particularly likely of course that people will go to hospitals for care which a GP could provide if they are not registered, so that is both transient populations but also populations who just have not got round to registering. That may even be increasing with the difficulty of recruiting more people into primary care at the moment. So, yes, for the patient who is registered with a GP if the check is done at registration, it is not a problem in terms of access to the types of secondary care which would be excluded from the emergency provisions, that is the elective care. That would all be covered in the one check. The problem is the person who turns up at hospital needing urgent-ish care, as it were, and it does take us into this long and complex problem of how you would model what is immediately necessary care, which is quite important.

  Q826  Mr Singh: Would it not be better, rather than trying to deal with these issues through legislation, to deal with them through codes of practice which can be tested and improved and tested and improved?

  Dr Nathanson: Absolutely and one of the things we are doing at the moment is that we are talking already to both the health departments and to the Home Office about the ways in which we would want to see a system work, whether by codes of practice or regulation or in whatever way it is set up because we think it is very important that the system which is designed to protect the public purse from inappropriate use does not in fact damage the health either of individuals or of the public more generally.

  Q827  Mrs Curtis-Thomas: I understand when you say that the costs associated with people who access medical services when they have no entitlement to do so is not known. This Committee knows that we have a number of people in this country who have accessed the country illegally and are working illegally and presumably they also seek health services as and when the need arises. So, perhaps the problem is significant. I just want some clarification from you because I think what I am hearing is that doctors have a reluctance per se in asking people for identification and is that true and, moreover, would there be an attempt, for instance, if somebody presents with a medical health problem, to retrospectively ensure that that individual was in fact eligible for health services? I hear you talking about significant parts of the population being exempted and then the presumption is that they will not be checked either because their condition makes them not automatically the excluded special interest group.

  Dr Nathanson: We are not saying that they should be exempted but we are saying that if people who are clearly particularly vulnerable at that time or even permanently arrive needing to access care and do not have an entitlement card with them, then the presumption must be to treat them if that care is needed. That is not to say that you should say that these people would never have cards because there may be other very distinct advantages to that card. The issue about cost is an important one and there is ongoing research to try to find out just how much use is made of the NHS in its various forms, as it were, by people who are not strictly entitled to it by a number of bits and pieces of research. Looking particularly at secondary care, in secondary care, most hospitals, particularly those with the more transient populations or in areas where there are more likely to be or it is thought that there are more people who have no eligibility, already have systems in place for doing this. For example, areas where there is a large tourist population. Hospitals have long had a system when people access care of finding out if they are eligible and billing them if they are not and recovering most of the money—it is a majority, as we understand it, that is recovered in that way. There are other areas where they probably do not see more than the most minute number and it may actually be not cost effective to chase those. That is not saying that they would not want to if they could but we have to again make sure that the bureaucracy does not cost more than the money it is meant to recover. In terms of care, it does take us always back to this issue about how you define the care that is needed and, in a sense, what we are looking at here is a medical modelling which is what we would prefer to find because, if you have the right modelling for care, it relieves a lot of our concerns about the processes because it means that people who are vulnerable because they are acutely ill for whatever reason will get the care that is necessary and we would actually argue that it is necessary not just on humanitarian grounds but that it probably makes good economic sense as well.

  Q828  Mrs Curtis-Thomas: So, you would argue for exclusion for those? Even if they were not covered by identity, they should still have access to free care?

  Dr Nathanson: If people need care, they must receive it.

  Q829  Mrs Curtis-Thomas: So, you are saying that?

  Dr Nathanson: Yes. Let me give you an example and the kind of example we would look at is that of somebody who has been an asylum seeker and who has now been denied permission to stay and are waiting to leave the country. They no longer have access, they are not eligible to full NHS care. We are not suggesting, for example, that people in that situation will be put on an NHS waiting list for a hip replacement, that would be inappropriate, but let us suppose that that individual has insulin-dependent diabetes and they have no money and they cannot afford to pay for the insulin prescription. We could end up in the daft situation where they go into a coma because they are not getting their insulin, they are admitted to hospital and they get the full emergency treatment which they would get even though they are not eligible for other care because emergency care would be provided. They get better, they get sent home with a small supply of insulin; they run out of that, they cannot afford to buy any more, they again decline until they are in a coma and again are in emergency treatment which costs a lot of money whereas ongoing provision of free insulin would cost us almost nothing. It is that kind of model that we are concerned about. What is emergency and immediately necessary care? Antenatal care, care for somebody with a number of very serious medical conditions but where they are not going to die tomorrow if we do not give them care immediately, so it may not be immediately necessary, but the cost in terms of their health problems and potentially the cost to us as we have to deal with them when they become emergencies could be substantial and we just think that that is a grouping that needs to be looked at very carefully.

  Q830  David Winnick: It might be considered as common humanity.

  Dr Nathanson: Indeed, but one could also say that it does make economic sense as well which is always a good backup for common humanity!

  Dr Chisholm: Essentially, we are asking for sensitivity and discretion in the application of the system in two particular areas: one of them is in relation to vulnerable patients where the system ought to exercise sensitivity and discretion in deciding whether care is provided if they are, because of their vulnerability, finding problems in producing or dealing with the bureaucracy of the system. The other area where sensitivity and discretion is required is in the areas that Dr Nathanson has been describing, the borderline between emergency and immediately necessary care and care that is not so defined, and I think that allowing some sensible discretion there is going to be wise in order to prevent the very problems that have been described.

  Q831  Mr Prosser: Dr Nathanson, I just want to pursue the same theme a little further. All of us would give sympathy to the cases you have given and, if nothing else, we want commonsense written into the Bill but how would you actually write those sorts of sensitivities and those sorts of discretions into the Bill? Can you look at other legislation with respect to the duties and limitations that the medical profession carry out where there are clauses and the draftsmen have come up with remedies which provide you with the comfort you want and that we all want?

  Dr Nathanson: I think, sadly, we have not found anything in any legislation that gives this kind of protection, but there are some examples that we can look at in regulations that have come out of legislation that gives a degree of this and that is the sort of thing we would like. We would like to see doctors working with Government departments to write regulations which are sensible and which do not undermine the Bill but in fact bring into it this humanity which would actually make it work and which will actually, I think, significantly reduce people's fears, certainly in terms of the health area.

  Q832  Mr Prosser: Do you think it should be widened to other vulnerable people, people who are addicted to alcohol or to drugs, people with chaotic lives?

  Dr Nathanson: I think we would want to see in the regulations the ability to act flexibly for those people. The difficulty is, do you want to prescribe it very precisely because for many people say with drug dependencies including alcohol dependency, for much of their life, they are not living in such a chaotic state that they could not use the system as it is designed, but there may be times in their lives when they cannot produce the right evidence of identity and they may be the people who are, at that time in their lives, moving away from where they had previously been registered and that is where again there is this issue of having some flexibility to treat in the hope of returning them to a state where they can then cooperate with the requirements of the regulations or of the law.

  Q833  Mr Prosser: Is it not the case that, even at the moment under whatever regulations and limitations persist now, every day GPs in the surgeries and consultants are using commonsense and applying discretion in a humane way and in a sensible way?

  Dr Nathanson: Yes, absolutely, and, in talking to colleagues last week, we were given examples of the way in which somebody working in an accident and emergency unit would say to somebody who was not eligible for NHS treatment, "No, that is not something that would require free treatment. That is not something where your illness/medical condition is such that it would be an emergency or something immediately necessary" and in fact they find when saying this to the patient that they say, "You are the fourth hospital that has told me this; maybe I should try giving up getting access to this" because there is clearly a consistency. In fact, I think there is remarkable consistency on most patients. There will be occasional patients on whom two doctors might slightly disagree but it would be rare.

  Q834  Mr Prosser: Mr Phillips, in your evidence, you talk about being able to convince all communities that the new potential ID cards will not disadvantage them or discriminate against them etc. Do you want to amplify on that now that you have seen the draft Bill?

  Mr Phillips: Yes. I think there are a few simple points here. First of all, there is a pretty profound lack of evidence about the potential impact on different ethnic groups and communities in this country. One of the first things that we notice is that we still have not yet had a proper race impact assessment on the proposal and we think that would be an important thing at this stage plus, were there to be a move to a compulsory scheme, that would also need a separate impact assessment. Secondly, there is the issue of perception in that, whether or not the proposal is favoured, it will certainly without any doubt cause some anxiety amongst many minority communities in this country. There is some evidence from the Home Office's own survey on this with the focus groups and so on and they are questions which are still unanswered. For example, foreign nationals who might be the first category to carry them compulsorily and that in itself raises a question but the issue is, who is a foreign national? Some people who have lived here for 30 years are still foreign nationals and you might have situations in which two people in a house out of seven are compelled to carry identity cards. The third point that I want to make particularly in relation to minority communities is that there is a question which you have to some extent been hinting at which is what is on the card. To what extent it is an entitlement card and to what extent it is truly an identification card because there is a point at which, with certain kinds of information, there ceases to be an identity card and becomes, from the point of view of some minority communities anyway, an immigration status card and that in itself potentially creates some substantial issues.

  Q835  Mr Prosser: Do you have any way of addressing that in the Bill? Have you given any thought to a form of words which would address those concerns or would you want separate regulation outside of the Bill?

  Mr Phillips: The first thing would have to be, as I said, a proper impact assessment but, in relation to the Bill itself, I think that the most important thing would be to establish that there would be minimal information on this card. There are issues about what would be on the register and so on. We think, for example, for a whole variety of reasons, anything that goes beyond purely biometric information becomes a problem. It is one thing to have a card which identifies you but a card which moves into the arena of discretion raises a number of things. Once you are into entitlement, what then happens, and we know—and I can elaborate on this if you wish—from other experiences is that what tends to happen, with the best will in the world, is that those who have to do the checks will apply a differential filter as to who they ask to produce the card. So, at the moment you have a piece of information which can be demanded which might differentiate by ethnicity and so on, then you create a different sort of problem. One other point which perhaps is not quite so obvious but is one that I think will be raised by a number of communities is the issue about the cost of change of information and keeping the information up to date. If you are going to be fined £1,000 or whatever it might be if you do not keep your information up to date, this will undoubtedly have a differential impact on different kinds of communities particularly, for example, the 100,000 or more gypsies and travellers in this country who are not settled. If there is an address on the card and they have to keep this up to date every time they move, we can begin to see chaos, catastrophe and all sorts of problems there. I think that the summary is, first of all, let us understand exactly what might happen and there are techniques by which we can do that before we get into passing legislation but, secondly, in the legislation, I think any pressure or anything that will reduce the amount of information held on the card to that which is essentially biometric, which by the way could include ethnicity, is helpful.

  Q836  Mr Prosser: As you know, for the last two years or so, people who have been making asylum claims in the country have already been provided with an identity card which is called an ARC card which has a biometric chip on it. Has the introduction of that card made it easier for asylum seekers by proving their identity very clearly and precisely or has it caused some of the problems which we have heard about not necessarily in today's evidence but the general sort of evidence and critiques about identity cards?

  Mr Phillips: The upside of the ARC is that it has, I think in many circumstances, made it simpler and quicker for people to identify themselves and therefore in relation to, for example, illegal working, this is a plus. However, I think that there is an issue that arises which is to do with the updating of the system, which we have some anecdotal evidence of in relation to the ARC, the application registration card, which is that we know that, if people have to continually update their cards, especially if they are not entirely settled and so on, there are all kinds of real practical and organisational difficulties that gives rise to and, yet again, we have the issue about the £1,000 civil penalty for not updating. This again comes into play here. So, the signal from the ARC is that it may make things quicker but, in terms of the proposal that is made in the Bill, it could create difficulties which are quite severe for some ethnic groups.

  Q837  Bob Russell: Six months ago, the Home Secretary announced the award of contracts to run the NHS care record scheme which will provide all 50 NHS million patients with an individual electronic NHS carer card which will detail key treatments and care within either the Health Service or social card. Do we need an identity card as well or should that information be put on the identity card?

  Dr Nathanson: There are several points here. The first is that this is a grand scheme and we are all hoping that it will work because there are huge advantages to all of us in having a single electronic health record. It is the classic thing where you are knocked down by a bus when you are nowhere near home and they need to know whether you have allergies, whether you are under any other medical treatment and so on.

  Q838  Bob Russell: Would the individual have that card?

  Dr Nathanson: The individual under the NHS scheme will not have a card at the moment on which there will be health information, so there are key questions here about how you will identify that the patient here is the person to whom this record applies, although there will be a standard NHS number applying to each individual. At the moment, there is not a single NHS number, just to make life complicated, and we actually potentially have different numbers, particularly if you move north and south of the border with Scotland, but there are moves to simplify that. This is one of the things that has been recognised for many years. Also, if you go into one hospital, those notes will never get to another hospital. So, it is linking all of that together. One could very cynically say, name a major public sector scheme's computerisation that has worked flawlessly, but that is because I am terribly cynical about this. There are real issues of potential good from this. The benefits of an ID card in relation to that might be if the majority of people normally always carried an identity card. Then, when they are knocked down by the bus in another city, it would be the card that identified them, that fed into the machine in the hospital to which they are taken and that brought up the key things on their records and that could potentially be advantageous but I think we are very many years away from that at the moment.

  Dr Chisholm: There are other reasons why identity cards are being proposed and I think that it would be inappropriate to have medical information contained on the identity card.

  Q839  Bob Russell: Why?

  Dr Chisholm: Our wish is that such information should be excluded. Why? Not least because we would want the public to be reassured that other people who had access to their identity card were not able to access personal health information. I think that will be, irrespective of technological solutions, a genuine fear in terms of public perception. I think that, as Dr Nathanson has said, it is possible that the ID card might in some way help to link to the electronic patient record in terms of healthcare professionals who have a need to know information, but I think that our preference would be basically to keep the two systems separate and not to include medical information.

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