Immigration Bill



The Academy of Medical Royal Colleges

The Academy is the umbrella body for UK medical Royal Colleges and Faculties. The Academy speaks on standards of care and medical education across the UK. By bringing together the expertise of the medical Royal Colleges and Faculties it drives improvement in health and patient care through education, training and quality standards.

Professor Terence Stephenson was elected Chairman of the Academy in 2012 by his peers. Professor Stephenson was previously President of the Royal College of Paediatrics and Child Health. He is Nuffield Professor of Child Health, Institute of Child Health, at University College, London.

Determining an Academy position

Academy policy is determined by the Academy Council which comprises the Presidents of all member organisations. At its July meeting the Council considered the Department of Health consultation paper "Sustaining Services, Securing Access - A consultation on migrant access and their financial contribution to NHS provision" and agreed its overall position in terms of a response. The Academy prepared a response to the consultation which was then signed off by members. The Academy is, therefore, confident that it speaks with the support of its member Colleges and Faculties.

The Academy has no view on the Immigration Bill as whole and is only able to speak on issues directly relating to healthcare and migrant use of NHS services.

Academy response to "Sustaining Services, Securing Access"

The Academy recognised the underlying rationale behind the proposals and the principle that migrants could be expected to make payments for healthcare in the UK received from the NHS. Members were, however, anxious that concerted efforts to implement these policies should not:

· In anyway undermine the duty of care of doctors to patients.

· Create a bureaucratic process and burden that outweighs any tangible benefits.

Doctors’ professional duty

The opening sentence of the GMC’s Good Medical Practice, the code by which doctors are regulated, states that "Patients must be able to trust doctors with their lives and health". It goes on to say almost immediately afterwards "Make the care of your patient your first concern". The belief that doctors’ foremost concern is for the health of their patients is not an abstract concept but at the core of their ethos and practice and is the basis of the trust between doctor and patient. This should not be underestimated.

The Academy is not saying that pursuit of charging proposals is automatically incompatible with these requirements but is clear that there is a danger that the relationship between doctor and patient could be undermined and it might appear that care of the patient was not the doctor’s first concern. It is essential, therefore, that arrangements for the charging of individuals or the checking of eligibility are removed from the sphere of the personal interaction between clinician and patient.

Therefore the statement in the Qualitative Assessment of Visitor and Migrant Use of the NHS in England" written for the Department of Health by Creative Research that a culture change is required in the NHS for "clinicians and other staff to understand the rules governing this [charging of patients], their role in ensuring it happens, and how treatment that is non-urgent should not be provided" will cause real concern to clinicians.

Access to treatment

The Academy is clear that no-one should be denied access to immediate necessary treatment wherever they may be irrespective of their means and status. We also welcome the stated principle that any measures should do nothing to increase health inequalities.

We believe the proposed exemption of charges in relation to infectious disease (including STIs) is essential for public health purposes. The Academy also recommended that the proposed exemption should be extended to include the overall health needs of migrants with mental health problems including developmental disorders and intellectual disabilities. Migrants with mental health and related problems are likely to lack the financial means to pay for the mental health care they need and, equally importantly, may lack the insight required to seek the help they need to avoid crisis situations. They may also lack the insight and means to seek help for any associated physical health problems.

Burden and benefit – The practicality of proposals

The challenge of effective implementation should not be underestimated. The Academy is clear that it makes no sense at all to introduce a system that places a bureaucratic burden on hard pressed clinicians and NHS organisations in either secondary or primary care for relatively marginal financial gain simply to meet the requirements of the current political climate. We therefore welcomed the statement in "Sustaining Services, Securing Access" that any charging system "could not be introduced unless or until robust new systems were in place to support a streamlined process of screening and charging".

The qualitative and quantitative assessments of visitor and migrant use of the NHS in England published for the Department of Health recently make clear what an extraordinarily complex issue this is and how difficult it is to obtain accurate information. It seems clear from the two studies that more could be done in many instances to recover costs that are due although it seems unlikely that full recovery is ever going to be a realistic possibility.

The Bill’s proposal for an initial levy appears attractive from an administrative point of view although we recognise the concern that it could actually have a perverse consequence. In addition a levy in itself does not lighten the screening process. If, as seems to be proposed, the income from any levy would not go back to those providing treatment, it will do little to help the immediate financial pressures of providing care to migrants in those organisations.

Many health and social care staff are themselves migrant workers who are providing an invaluable contribution to the NHS and social care. Designating these staff as not ordinarily resident and then charging them to access the services they are themselves providing would seem somewhat perverse.

Next steps

The Academy and medical Royal Colleges and Faculties are keen to discuss possible arrangements with the Government to ensure that a scheme brought in for logical reasons is practical, proportionate and does not create unintended adverse consequences.

October 2013

Prepared 30th October 2013