New Clause
8Charges
to overseas visitors ‘(1) The
National Health Service (Charges to Overseas Visitors) Regulations 1989
(S.I. 1989/306) are amended as
follows— (2) In
regulations 4, paragraph (c) after the second “Kingdom”,
insert “or under the Human Rights Convention, whether or not
such application has been
decided.” (3) In
regulation 4, paragraph (1), sub-paragraph (c), leave out “which
has not yet been determined”’.—(Sandra
Gidley.) Brought
up, and read the First
time.
Sandra
Gidley: I beg to move, That the clause be read a Second
time. This
new clause is similar to the amendment tabled by my noble Friend
Baroness Tonge in the other place. It seeks to end the situation where
refused asylum seekers, including children, the elderly, victims of
torture and other seriously ill and extremely vulnerable people, can be
denied secondary health care unless they can pay for it. There are many
who regard this policy as inhumane. It puts asylum seekers’
lives at risk and is likely negatively
to impact on public health in general. The policy is also very difficult
for health care professionals to administer and
enforce. It
may be worth providing some background to this. In 2004, as part of the
National Health Service (Charges to Overseas Visitors)(Amendment)
Regulations, the Government introduced charges for all refused asylum
seekers to access hospital care except for emergencies. In practice
that has meant that treatment in an A and E department is free but all
other hospital and specialised medical care is chargeable; that strikes
many as a blunt instrument. That includes patients on section 4
support, pregnant women, children, cancer patients, diabetics and those
needing treatment for HIV/AIDS. Treatment for most communicable
diseases, except HIV/AIDS, is an exception to this rule and can be
provided free of charge; there seems to be an anomaly in not including
HIV/AIDS. Given how difficult it has become for asylum seekers to
access health care, it is questionable whether they will come forward
for screening or treatment for diseases such as tuberculosis or mental
health problems.
The rationale
at the time for this policy seemed to centre on health tourism. That
was something the media were concerned about at the time, but there has
been relatively little evidence that it was a significant problem. The
occasional person will come to the UK specifically to access health
care, but there is no evidence that that is the prime motivation for
most people entering this country. In 2009, the Royal College of
General Practitioners
concluded: “There
is no evidence that asylum seekers enter the country because they wish
to benefit from free health
care.” It
also stated that GPs have a
“duty of care to
all people seeking
healthcare” and “should
not be expected to police access to healthcare and turn people away
when they are at their most
vulnerable.” The
Royal College of Psychiatrists has also
observed: “The
psychological health of refugees and asylum seekers currently worsens
on contact with the UK asylum
system.” During
its scrutiny of the Bill, the Joint Committee on Human Rights
noted: “We
remain as concerned as we were more than two years ago when we
concluded our inquiry into the Treatment of Asylum Seekers that
a highly vulnerable group of people in the UK...continue to be
denied access to fundamental
healthcare”. In
the first two years following the introduction of the regulations, the
Refugee Council worked with dozens of refused asylum seekers who had
been denied or charged for the health care they urgently needed. To
give a snapshot of the sort of cases that have fallen foul of the
regulations, 15 women and two girls were charged more than
£2,000 for maternity care and in some cases were denied that
care if they could not pay in advance. I would contend that the unborn
children had a right to care in utero, but others decided differently.
Ten people who needed operations for different medical conditions or
treatment for injuries sustained in the UK were denied treatment, as
were people with cancer. A gentleman with bowel cancer was admitted to
A and E, but his operation was cancelled when he was unable to pay for
it and he was told to come back when his condition deteriorated. There
are many similar examples.
Refused asylum
seekers face considerable obstacles to accessing care, including
confusion about entitlements, GPs using their discretion whether or not
to register or treat them, language barriers and so on. This all paints
a very confused picture. Despite having been refused asylum in the UK,
some of these people have horrendous stories. They sometimes have
health problems linked to torture, poverty in their country of origin
or even mental health problems caused by their detention. The numbers
may be relatively small but the problems are quite specific. I alluded
earlier to the problem women asylum seekers face; if they are pregnant,
they do not get good anti-natal care.
2.45
pm There
was a successful legal challenge to this policy in April 2008, but the
ruling was overturned on appeal by the Government. The Court of Appeal
handed down its judgment on 30 March, finding that failed asylum
seekers cannot be considered ordinarily resident in the UK and are not
exempt from charging, even if they have lived in the UK for a year.
However, the court also found that existing guidance is unlawful as it
is not sufficiently clear on what treatment should be considered urgent
and immediately necessary.
In response,
the Department of Health issued interim guidance on the 2 April 2009.
That makes it clear that immediately necessary treatment, including
maternity care, must never be withheld; urgent treatment for conditions
such as cancer, which would deteriorate significantly if untreated,
should not be withheld; trusts should not pursue charges beyond what is
reasonable; and non-urgent treatment that can wait until the person
returns home should not be started until payment has been made. By
contrast, in Scotland, refused asylum seekers receive free health care
until they return home, and in Wales, the Welsh Assembly have confirmed
that they will not charge refused asylum seekers for access to
secondary health care despite the outcome of the appeal.
The new
interim guidance is welcome, but it does not address the fundamental
concerns relating to the charging regime and the way guidance has been
implemented since 2004. There has been a lot of confusion and the new
clause is an attempt to clarify some problems from the past. The policy
remains burdensome on health care professionals. They may have to
assess when a patient is likely to return home, or whether waiting
until that time would lead to an unacceptable deterioration in the
patient’s condition. This can be difficult and time consuming.
It is also inappropriate to make health care professionals consider a
person’s immigration status when their duty of care should be
their only concern. In addition, there are still likely to be
differences of opinion between clinical and non-clinical staff as to
which cases are immediately necessary or urgent, because hospitals will
not be reimbursed for the treatment they give to refused asylum
seekers.
We are moving
into the argument about whether it is a good thing to charge for health
care, but if people do not come forward there are public health risks,
because they may not be screened for treatment or they may not receive
inoculations. The policy is not consistent with the ethos of the NHS
constitution, which we discussed at length earlier in the
Committee.
Mr.
Andrew Turner: How many asylum seekers live in England,
and how many in Wales and Scotland?
Sandra
Gidley: I do not have that information, but if the hon.
Gentleman is interested we can table a question to the Home Office and
it will provide the
answer. In
May 2009, the committee on economic, social and cultural rights voiced
its concern over the low level of support for and difficult access to
health care for rejected asylum seekers. The charging structure also
runs counter to other Government policy objectives on public health,
social exclusion, combating HIV/AIDS and TB, and the Every Child
Matters
agenda. Restoring
refused asylum seekers’ access to free secondary health care
would ensure more efficient use of NHS resources. Treatment that
prevents or cures illnesses is obviously more efficient and effective
than waiting for a condition to deteriorate until it reaches the
thresholds of immediately necessary or urgent treatment, which cannot
wait until the person is expected to return home. That
conclusion was also reached by the Joint Committee on Human Rights,
which repeated a previous recommendation
that “free
primary and secondary healthcare be provided for all those who have
made a claim for asylum or under the ECHR whilst they are in the UK, in
order to comply with the laws of common humanity and the UK’s
international human rights obligations, and to protect the health of
the nation”.
It also stressed the
very difficult position of refused asylum seekers who cannot be
returned and recommended that the Government issue guidance to set out
clearly their entitlement to free health care while they remain in the
UK. If
the Department of Health issues further guidance before that has been
done, it should help to ensure the proper implementation of existing
guidance and relieve some of the burden on health care professionals by
specifically stating that the decision whether to treat somebody rests
entirely with the commission. That was confirmed in another place by
Baroness Thornton on 6 May
2009. Refused
asylum seekers on section 4 should be exempt from charges as the grant
of section 4 support means that the Government accept that those people
are temporarily unable to return home and would otherwise be destitute.
All HIV treatment should be considered immediately necessary. That has
been recommended by the British HIV Association and there is clearly a
public health implication here. The Government should also take steps
to reimburse hospitals in areas where large numbers of asylum seekers
are grouped so they do not have to bear an unreasonable extra cost from
properly implementing the guidelines. There would obviously be a
disproportionate impact on those
areas. Earlier,
a comment was made from a sedentary position about how much all this
would cost. The more important question is, how much less would it cost
if we treated early? Community-based health care is cheaper than
secondary health care. Seeing a nurse at a GP’s practice costs
£33 an hour. Seeing the GP costs £116 per hour of patient
contact. Prompt referrals to hospitals for care that is required can be
very cost-effective. For example, seeing a doctor who is a medical
consultant based in a hospital costs £163 per patient-related
hour and out-patient attendance at a hospital for a face-to-face
meeting, non-consultant led, would cost £55 for first attendance
and £71 for the
follow-up. Compare
that to the cost of treating someone whose condition is allowed to
deteriorate until care is absolutely
necessary. The average cost for a journey in an emergency ambulance is
£263, or £344 in a paramedic unit. If surgery is
required, the cost for a surgical consultant to perform an operation is
£388 per hour. Similar arguments can be extended to mental
health issues. In short— [Interruption.]The hon.
Member for Eddisbury has spoken at length on a number of amendments.
The first one I speak at length on, he seeks to mock me. He is being
rather churlish.
Sandra
Gidley: I must correct that—it was the hon. Member
for Hemel Hempstead, who has been brief in his comments. In short, the
amendment— [Laughter.] I could go on for longer
if the Committee requires, but I will not. [Interruption.]
Yes, there are a lot more yellow pages of notes, so the
Conservative Whip should be careful before he comments further because
I could probably speak on this matter until 5 o’clock if I so
wished, but other important amendments need to be discussed. He can
have it whichever way he
likes. The
amendment would create fairness in a situation which is unfair on a lot
of failed asylum seekers and does not treat them compassionately. It is
ironic that the Government, in the form of the Department for
International Development, put a lot of resource into improving health
care in some of those countries, yet refuse the same people treatment
if they are in this country. That is not
fair. Mr.
Andy Slaughter (Ealing, Acton and Shepherd's Bush) (Lab):
I congratulate the hon. Lady, who was taking a bit of flak, on bringing
the matter forward. Having said that, it does not sit easily with the
Bill and I am not sure that the new clause is the way to address what
is a complex issue—in several parts, as she suggested. However,
one has to take one’s opportunities where one can. She has done
that and she was right to do so.
This is a
matter of concern to my constituents and to
me—particularly to refugee organisations in my constituency, my
law centre and other practitioners who represent refugees and asylum
seekers. I am not sure that the original legislation was well conceived
by the Government back in 2004, but we are where we are and the hon.
Lady has indicated some of the problems that have come from
that. I
want to highlight three separate areas. The first, which has already
been mentioned, is refused asylum seekers under section 4. This appears
to be entirely anomalous and I do not think that the new clause is
dealing with that. It might deal with it in passing, but the issue goes
much
further. I
shall listen carefully to the Minister. I hope that we get some
indication—if not today, then in the near future—of the
Government’s intention. It is a highly anomalous situation
whereby asylum seekers who are due for return are, with the
Government’s agreement, not being returned for good and
practical reasons—often to do with temporary situations in their
country of return. In such circumstances, the Government do not have a
leg to stand on in withholding health
care. The
second problem, which recent legal proceedings have highlighted, is
that the situation is confusing to medical practitioners and to asylum
seekers. That has led either to asylum seekers not receiving the proper
care to which they are entitled, such as primary care or maternity care,
or to the types of care that are available not going far enough. I
agree that the new guidance issued in April 2009 is helpful in
clarifying some of those anomalies, but it shows that there were
anomalies and confusion, and that there is continuing confusion in some
areas. I
hope that the Government look at the matter again. It is principally an
issue for regulations under secondary legislation and guidance, rather
than primary legislation. However, the Committee offers an opportunity
to ask the Government to look again at the circumstances in which there
is either a clear humanitarian need or a pressing practical need for
conditions to be dealt
with. One
of those conditions is HIV, which is primarily excluded from treatment.
I cannot see why that condition does not fall under the type of urgent
and necessary care that would allow immediate treatment, with later
charging, if necessary, rather than being excluded from other
contagious and infectious conditions. That is another area that I hope
the Government address. It appears that the Liberal Democrats wish to
go further than simply repealing the legislation
wholesale. During
the Division, I had an opportunity to talk to my hon. Friend the Member
for Hendon (Mr. Dismore), who chairs the Joint Committee on
Human Rights, and who, in April 2009, produced a powerful argument
along those lines. The Government should look at it again. The cost
arguments can go backwards and forwards. The costs in terms of overall
health service spending are clearly de minimis, although I am not
saying that they are not large. However, there are substantial
arguments that the bureaucracy, the waste of clinical time and the
delay in treatment that permits a condition to worsen are on purely
practical, let alone humanitarian, grounds matters that should be
looked at again. I am talking of conditions such as cancer, which,
perhaps in its early stages, may not receive the type of secondary
treatment necessary in this respect, but which in later stages clearly
would receive
treatment. I
believe, as probably all hon. Members believe, that when asylum
applications have failed and due process has been carried out, it is
right to return people to their country. Indeed, people who abuse the
asylum process in that way do no service to genuine asylum seekers.
However, for those caught up in the process of bureaucratic delay and
who remain in the United Kingdom—we have heard about the
anomalies between the different constituent countries—the system
is not achieving a great
purpose. I
do not believe that a large number of people come as bogus asylum
seekers to receive medical treatment or significantly delay their
return for spurious reasons to prolong that medical treatment. In the
end, the Government will need to decide largely to abandon the position
they have taken—on practical as much as humanitarian grounds.
Today, I emphasise the point of detail I have raised, which is
essentially to do with failed asylum seekers not being returned because
of a Government decision or because of conditions where treatment is in
fact urgent and necessary, requiring care that may fall outside the
provisions. I
look to the Minister to explain the Government’s line and to say
whether further announcements or guidelines will be
produced.
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