Immigration Bill

Written Evidence from the British Medical Association (IB 03)

The British Medical Association (BMA) is an independent trade union and voluntary professional association which represents doctors and medical students from all branches of medicine all over the UK. With a membership of over 152,000 worldwide, we promote the medical and allied sciences, seek to maintain the honour and interests of the medical profession and promote the achievement of high quality healthcare.


Executive summary

· The BMA fully accepts there is a need to protect the public purse by limiting access to healthcare in some circumstances and preventing the deliberate misuse of scarce resources. However, any measures introduced should be practical, necessary and appropriate.

· The findings of the Department of Health (DH) audit of NHS use by visitors and temporary migrants should have been released before the Bill was published.

· Provisions in the Bill need to be viewed in the context of additional, forthcoming proposals from the DH on administering overseas visitors’ charges. We have consistently stated that potentially extending the charging system to primary medical services would imply considerable costs and complications.

· The Bill introduces a change to the residency criteria so that eligibility for free NHS services is dependent on migrants having indefinite leave to remain (ILR). However, many migrants who do not have ILR in the UK are working, paying tax, and making National Insurance contributions. The proposals for a health surcharge will mean that this group of migrants will have to make another separate payment for their healthcare, which is unfair.

· We are concerned about the equity of these changes as there are significant variations in the length of time it takes for individuals to become eligible for ILR.

· The introduction of a health surcharge could make the UK a less attractive destination for skilled workers from outside the EEA, including doctors and other healthcare professionals.

· A system is already in place which allows the NHS to recover the cost of treating patients who are not eligible for NHS care, including from EU citizens. Rather than changing the residency criteria and introducing a new health surcharge, the BMA believes improvements ought to be made within the current charging system in order to ensure charges are imposed when they should be, and costs are recouped.

Introduction

1. The Government consulted on proposals to regulate migrant access to the NHS earlier this year alongside other potential changes, most notably extending the scope of charging to include primary medical services [1] , [2] . The BMA fully accepts there is a need to protect the public purse by limiting access to healthcare in some circumstances and preventing the deliberate misuse of scarce resources. We felt strongly that the proposals in the consultation went far beyond what is necessary and appropriate in order to achieve these goals. We raised significant concerns regarding these proposals on practical, economic and public health grounds [3] .

2. The rationale given for the changes in the accompanying impact assessment to the Bill is that the current arrangements are too generous and leave the NHS ’open to abuse‘. The Department of Health (DH) commissioned a two-phase independent ‘audit’ of NHS use by visitors and temporary migrants, and this was to gather information from NHS staff to estimate the scale of the challenge and the size of the financial burden resulting from NHS ‘use and abuse’ by non-residents [4] . On 22 October 2013, the DH published highly detailed quantitative and qualitative assessments of visitor and migrant use of the NHS in England [5] . The DH feels that the assessments support the case for changes to the current charging system. We are considering the assessments in closer detail but given the complexity and volume of the research published, it is clear that the Government should have published the findings of the audit before the proposed changes in the Bill were announced.

3. It is difficult to discuss the provisions in the Bill in isolation, as the Government has also indicated that there will be additional, forthcoming proposals in due course from the DH on administering overseas visitors’ charges. In response to the Government’s prior interest on an extended charging system, we consistently stated that GPs and other healthcare professionals do not have the capacity or the resources to administer an extended charging system that could require GPs to extensively vet every single patient when they register with a new practice. This would cause inconvenience to all patients and put additional strain on already overstretched GP services that are currently under pressure from rising patien t demand and falling resources. Furthermore, i t is doubtful that the expensive bureaucracy required to support an extended charging system would recoup enough money to cover the costs of establishing such a system.

Changing the qualifying residency criteria for access to free NHS treatment

4. The Bill introduces a change to the residency criteria such that eligibility for free NHS services is dependent on migrants having indefinite leave to remain (ILR). There are significant variations in the length of time it takes for individuals to become eligible for ILR. A medical student, for example, comes to the UK on a Tier 4 visa and remains on this visa for seven or eight years. It is only once the individual has moved from Tier 4 and completed five years on Tier 2, or after completing a total of ten years in the UK to meet the ten year long residence rule, that they would become eligible for ILR. The BMA has questioned the equity of these changes, given the significant differences in the length of time individuals would be subject to a charge, ranging from five to ten years.

5. Many migrants who do not have ILR in the UK are working, paying tax and making National Insurance contributions. They would effectively be paying twice for their healthcare.

6. Rather than adopting the ILR principle, we believe the current ordinary residence principle should be maintained, with improvements being made within the current charging system; this would help ensure charges are imposed when they should be. We would welcome clearer guidance on what the current ordinary residence principle entails and better training of the staff who assess whether charges should be made.

7. We note that in some cases, there appears to be a misconception that patients who receive free access to primary medical services should always be given free care in hospitals; this misconception needs to be corrected.

8. We would also like to see improvements in existing systems for recovering costs of treating overseas patients from within the EEA.

The potential impact of a health surcharge

9. The BMA is concerned that proposals for a health surcharge risk having a negative impact on the UK’s attractiveness as a destination for skilled workers, particularly in shortage occupations where the economy cannot find sufficient workers from the UK or EEA workforce.

10. In the UK, consultants in emergency medicine, haematology and old age psychiatry are on the shortage occupation list. Non-consultant, non-training medical posts in anaesthetics, general medicine and psychiatry are also on the list.

11. We have raised concerns that the imposition of a health surcharge, when combined with visa application fees and maintenance requirements, risks having an impact on the UK’s ability to attract high quality migrants to medical jobs on the shortage occupation list. This could have a negative impact on patient care.

12. As mentioned above, the move to amend the criteria for ordinary residence to be applicable to those only with permanent residence will lead to some individuals paying the health surcharge longer than others. We have concerns about the equity of such an arrangement.

Exceptions for particularly expensive discretionary treatments

13. The Bill includes provisions for migrants who have paid the health surcharge to be able to access free NHS care to the same extent as a permanent resident, subject to some exceptions for particularly expensive discretionary treatments. We have raised queries about the justification and reasoning behind this: the proposal for the health surcharge is that it would be set at a fair and appropriate level to include all anticipated health costs during an individual’s stay. It is unclear why it is appropriate to exclude some services, given that the surcharge is supposed to represent a fair contribution.

Secondary legislation relating to the health surcharge

14. The Government has outlined proposals to produce secondary legislation to establish which groups will be required to pay the surcharge, to set the level of the surcharge and to provide further information on how the surcharge will operate and the services covered.

15. We believe that given the important nature of each of these aspects of the health surcharge, the Government ought to make any Statutory Instruments subject to widespread consultation and the affirmative procedure.

October 2013

References


[1] Sustaining services, ensuring fairness: a consultation on migrant access and their financial contribution to NHS provision in England’ :

[1] https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/210438/Sustaining_services__ensuring_fairness_consultation_document.pdf

[2] Controlling Immigration- Regulating Migrant Access to Health Services in the UK :

[2] http://www.ukba.homeoffice.gov.uk/sitecontent/documents/policyandlaw/consultations/34-healthcare/

[3] For further information, please see the BMA’s response to the ‘ Sustaining services, ensuring fairness: a consultation on migrant

[3] access and their financial contribution to NHS provision in England’:

[3] http://bma.org.uk/about-the-bma/what-we-do/lobbying/westminster/migrant-access-to-nhs

[4] Sustaining services, ensuring fairness: a consultation on migrant access and their financial contribution to NHS provision in England’, page 5:

[4] https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/210438/Sustaining_services__ensuring_fairness_consultation_document.pdf

[5] Department of Health, 22 October 2013:

[5] https://www.gov.uk/government/news/new-report-shows-the-nhs-could-raise-up-to-500-million-from-better-charging-of-overseas-visitors

Prepared 30th October 2013