Immigration Bill

NAT (National AIDS Trust) and the Entitlement Working Group (IB 09)

The Immigration Bill: Health impacts for migrants and the wider community

Submission from NAT (National AIDS Trust) on behalf of the Entitlement Working Group [1]

Summary

1. The Entitlement Working Group (EWG) is a consortium of health, migrant and refugee organisations. The EWG believes that proposals to change the system of regulating migrant NHS access will have a serious negative impact on the health of our communities.

2. Extending charging rules to primary care and introducing new eligibility checks will make it more difficult for everyone living in the UK to access treatment, not only migrants. By creating a barrier to primary care access, the proposed rules will also have a disastrous impact on public health efforts to diagnose and treat infectious disease, provide antenatal care and achieve herd immunity in immunisation programmes.

3. The introduction of the Immigration Health Charge (Clause 33) will mean that migrants who are already contributing to the NHS through income tax, national insurance and VAT will unfairly have to make a further contribution before they are given permission to enter or extend their stay in the UK.

4. By defining ‘ordinary residence’ to mean permanent residence/indefinite leave to remain (Clause 34), The Bill completely overturns the well-established principle that everyone who is living, working, studying and otherwise contributing to our communities on a settled basis should be able to access NHS health services.

5. Despite the recent publication of qualitative and quantitative research papers on migrant use of the NHS, the Government has not yet produced evidence about how many chargeable migrants are using NHS services, how many of this group are charged, or how much of this debt is being recouped.

Proposals regulating migrant NHS access

6. The Immigration Bill Chapter 2 clauses 33 and 34 directly address the issue of migrant access to NHS services. These provisions are part of a broader programme of changes to migrant NHS access proposed by a joint Home Office-Department of Health consultation. The consultation closed in August 2013. The Home Office released their response to coincide with the second reading of the Bill, but the Department of Health has not yet published a response.

7. Although only two elements of this proposed overhaul of migrant NHS access are included within the Bill (the rest will be in secondary legislation next year), the EWG strongly recommend that the Bill Committee consider all of the proposals in the round, as part of their scrutiny of Chapter 2.

8. The full programme of reform of migrant access to the NHS consulted upon by the Home Office and Department of Health contains the following elements:

· Introduction of an NHS surcharge to be applied as part of the immigration permission process (clause 33 – see below).

· Providing a legislated definition of ‘ordinary residence’, the key test of eligibility for free NHS care (clause 34 – see below).

· Extending charging rules, which currently only apply to secondary care, to primary care and A&E departments.

· Allowing UK expatriates to use the NHS while visiting the UK if they have paid at least seven years of national insurance (NI) contributions.

· Creating a legal gateway for the Home Office to share relevant information about patients’ residency status with the NHS, to facilitate the charging regime.

· Redesigning the process of patient registration with the NHS in order to capture charging information on a shared electronic record.

9. The proposals to extend charging to primary care and A&E services are particularly concerning from the perspective of public health and cost-effectiveness in the use of NHS resources. No new primary legislation would be needed to implement the proposed extension of NHS charges to primary care in the four nations. [2] However, when considering Clauses 33 and 34 the Committee should be aware that these are merely two components of this much broader programme of restricting migrant access to healthcare services.

10. Putting in place additional barriers to GP access for some patients will necessarily make it harder for all patients, regardless of residency status, to use free NHS services. The Government has consulted on the creation of a new central register of patients indicating their charging information. For such a system to be implemented, it is probable that all patients would eventually need to re-register with the NHS and would need to prove their identity each time they access services.

11. There is a significant public health risk associated with restricting access to primary care. Primary care is the key site for diagnosis of infectious diseases including TB and HIV. Usually diagnosis is the result of a GP recommending a test as part of a routine visit – not because the patient has actively sought a test. Anything which delays or prevents someone with an infectious disease from visiting a GP will therefore contribute to the spread of infectious diseases within our community .

12. For example, 1 in 4 people living with HIV in the UK d oes not yet know they have it (rising to around 30% amongst African-born people) , and i t is estimated that well over half of new HIV infections are unintentionally passed on by this undiagnosed group . Conversely, people who are diagnosed and on treatment are significantly less likely to transmit HIV to others. [3] Research has also shown that people from BME backgrounds are more likely to use HIV testing servi ces from a GP, compared to other at-risk group s , and this trend has increased over time . [4] One study found that black African people living in England who had undiagnosed HIV infection were much more likely to test at a GP surgery, than their HIV negative counterparts . [5] This suggests that restricting GP access will have an even greater impact on HIV diagnosis rates amongst migrants than it would for the general population. While the Government has made assurances that HIV treatment will remain exempt from charges, this public health commitment will be undermined if migrants are not able to access HIV testing.

13. Similarly, in response to continued high rates of TB in the UK - which has one of the highest incidences of TB in Western Europe - Public Health England has emphasised the importance of recent migrants having prompt access to GP services. The Tuberculosis in the UK 2013 Report state s that: "To ensure that new migrants are identified for LTBI screening, and are rapidly diagnosed if they develop active disease, there must be no barriers to accessing primary health-care services." [6]

14. There will also be an impact on other public health interventions including efforts to get pregnant women into prompt ante-natal care, the Health y Child Programme, and immunisation programmes . Measles, for inst ance, has a vaccine coverage target of over 95%. Though our vaccination rate is rising, still only 91.2% of children at the age of two have received their first dose of the MMR vaccine. [7] NICE, in its 2009 recommendations on how to reduce differences in up-take, highlighted several groups as being at particular risk of not being immunised including "those from some minority ethnic groups, those from non-English speaking families, and vulnerable children, such as those whose families are travellers, asylum seekers or are homeless". [8] The challenge to achieve herd immunity for key diseases like measles will only increase when some families living in our communities face barriers to seeing a GP.

15. Any barriers to accessing primary care impacts on child morbidity and feasibly, mortality, as well as increasing the burden on the already over-stretched A&E services. There are also significant child protection implications from these proposals. Ending universal access to the Health Child Programme will affect the ability of services to identify problems in child health, development and safety [9] , and thus, the power of services to make an early intervention.

16. We would also argue that these measures are contrary to the UK ’s international and national legal obligations. The special place that children have in the world is enshrined in the United Nations Convention on the Rights of the Child (UNCRC) 1989, ratified by the UK . Articles 3 and 24 are particularly relevant:

"In all actions concerning children, whether undertaken by public or private social welfare institutions, courts of law, administrative authorities or legislative bodies, the best interests of the child shall be a primary consideration."

Article 3, UNCRC

"States Parties shall strive to ensure that no child is deprived of his or her right of access to such healthcare services."

Article 24 , UNCRC

The applicability of this to all children regardless of immigration status is further emphasised in the Committee on the Rights of the Child’s General Comment No. 6.  Paragraph 12:

"The enjoyment of rights stipulated in the Convention are not limited to children who are citizens of a State Party and must therefore, if not explicitly stated otherwise in the Convention, also be available to all children – including asylum-seeking, refugee and migrant children – irrespective of their nationality, immigration status or statelessness."

The UK therefore has an obligation to ensure that no child is deprived of their access t o healthcare. F urthermore, the NHS has a specific duty to safeguard and promote the welfare of children, as outlined in UK law in Section 11(4) of the Children Act 2004, carrying on from the duties first enshrined in the Children Act 1989. The UK Border Agency (now the Home Office) is now under the same duty by virtue of section 55 of the Borders, Citizenship and Immigration Act 2009.

17. NHS England London ha ve also recently indicated that they consider primary care access to be the key to addressing the extreme health inequalities across the capital, highlighting in particular the disproportionate impact of HIV and TB on poorer areas. In an interview with the Evening Standard, NHS England London's Medical Director, Dr Andy Mitchell, stated that: "It needs a rethink about how primary care is delivered and how we transform the hospital system with a view to making sure there is 24/7 equality of access and care, including at weekend… In the poorer parts of London , where you have ethnic minority groups and disadvantaged individuals, these people don't register with primary care and don't access healthcare services - or are not aware of how to access them." [10] Experts in public health, health inequalities and health-seeking behaviour amongst disadvantaged populations agree that primary care services should be made more, not less, accessible to vulnerable migrant populations.

18. Discouraging people from attending primary care services will also lead to greater costs in subsequent treatment and care, as common health conditions go undiagnosed and untreated. For example, the lifetime treatment and care costs of type II diabetes which is diagnosed early and managed through monitoring and lifestyle changes is £845. If early diagnosis does not occur and the patient only seeks healthcare when they are ill enough to require drugs, this would add an additional £1,263 in treatment costs alone. At this stage the patient is also more likely to experience future health problems related to their diabetes. In general, the cost of treating type II diabetes-related complications is approximately nine times more expensive when diabetes has not been diagnosed and treated in the primary health setting. [11]

19. HIV care in the first year after diagnosis costs the NHS twice as much if the patient is diagnosed late, because of the significant rates of morbidity associated with late diagnosis.  Thereafter, the costs of HIV care remain 50% higher for each year following diagnosis. [12]

20. There is already evidence that many migrants who are eligible for free primary care are unable to register with a GP, despite the absence of relevant charging rules. [13] It seems certain that any new requirement to prove residency status and therefore entitlement will have a deterrent effect on a greater number of migrant individuals and families than are strictly covered by the rules.

21. Proposals to extend charging to emergency treatment from A&E departments are similarly unworkable and would seriously affect the ability of healthcare professionals to meet the needs of patients. A&E is already an extremely challenging environment from the perspective of patient flow. If the need to authenticate entitlement to NHS access is added into this mix, processes will be delayed and patients will suffer. It is inevitable that in such a high-pressure environment, staff would resort to ‘short cut’ methods of identifying chargeable patients. This will lead to discrimination based on appearance and will unfairly target BME groups.

Clause 33: Immigration Health Charge (‘surcharge’)

22. The Bill introduces an Immigration Health Charge which will apply to anyone seeking permission to enter or remain in the UK. The Home Office has indicated in their consultation response that the surcharge is likely to be set at £150 per year for students and £200 for all other migrants. [14] The surcharge will also have to be paid for any in-country extensions of immigration permission (although the Home Office has indicated that this would not apply to anyone who entered the country prior to the introduction of the surcharge).

23. The surcharge is proposed as a way for migrants to contribute to the costs of any NHS treatment and care they may need to access while in the UK. However, migrants who are living, working and studying in the UK are already contributing to the NHS through taxation as do all other residents - through income tax, VAT and national insurance (NI).

24. The NHS is not a contribution or insurance-based system. The introduction of a contribution principle for migrants is a move away from the universal principles upon which the NHS was founded. Section 33(5a) of the bill indicates it is likely that the surcharge will go into the Consolidated Fund. This means it will effectively be a further tax on migrants, and increase to already significant visa costs, without any guarantee it will directly fund NHS costs.

25. The Home Office estimates that the surcharge will apply to 407,000 out-of-country and 280,000 in-country applications per year - or up to 700,000 migrants per year coming into the new system of contributions. [15] This compares to the estimated 580,000 irregular migrants currently living to the UK who do not have the required visa or permit and who will not be covered by the new system. [16] While there are some in this group who are working and could afford to pay for healthcare, there are others who are amongst the most vulnerable in our society, including refused asylum seekers. This group already struggles to access NHS services, including GP services which should be universally available. Introducing a surcharge on new migrants applying to enter the UK will not address the unmet health needs of this highly marginalised section of our community.

Clause 34: Ordinary residence

26. Patients may be charged for using NHS services if they are not ‘ordinarily resident’ in the UK (or otherwise exempt from charging). Clause 34 of the Bill introduces for the first time a definition of who should be considered ‘ordinarily resident’: any person who requires leave to enter or remain in the United Kingdom. In short, only those who have reached permanent residence/indefinite leave to remain may be considered ‘ordinarily resident’.

27. While ‘ordinary residence’ is not defined in the current charging regulations it is on the whole well-understood. In lieu of a legislated definition, the commonly used test is to establish whether someone is:

"living lawfully in the United Kingdom voluntarily and for settled purposes as part of the regular order of their life for the time being, whether they have an identifiable purpose for their residence here and whether that purpose has a sufficient degree of continuity to be properly described as ‘settled’."

28. This understanding of ordinary residence is a useful concept for healthcare access, as it reflects the settled nature of migrants’ residence in the UK - even when they are some years away from permanent residence as defined by immigration control rules. This approach supports a health system which meets the needs of people currently living, working, studying and otherwise contributing to communities in the UK.

29. Comparisons drawn by the Home Office between eligibility for welfare benefits (which migrants are only entitled to upon permanent residence) and NHS access are inappropriate and unhelpful. As established above, access to the NHS is not only essential to the wellbeing of individual migrants and their families, it is vital for the public health of their communities also.

Evidence base provided by the Government

30. The full programme of proposed regulation of migrant access to the NHS was set out as Government policy prior to the release of any evidence, either about the NHS use by overseas visitors or the success of current efforts to recoup costs from chargeable migrants. This is a ‘solution’ for a problem which has not yet been established.

31. To coincide with the second reading of the Bill, the Department of Health published the findings of quantitative and qualitative research it had commissioned into "visitor and migrant use of the NHS in England". [17] Both studies (which were conducted by two different research companies) clearly state that there is currently no systematic data collection about NHS use by migrants, chargeable or otherwise.

32. The findings of the quantitative study are a "top down estimate" [18] of migrant NHS use modelled from "incomplete data, sometimes of varying quality, and a large number of assumptions". [19] The researchers used Census Data and the notoriously unreliable International Passenger Survey (IPS) to create an estimate of how many migrants would be using the NHS on a given day, and how much their services would cost to provide. No new data about actual migrant use was revealed by the quantitative study, which drew exclusively on sources already in the public domain. An old Department of Health study - which showed that only around 40% of invoices for NHS charges were recouped – was fed into the model as the only known data source on the issue.

33. The quantitative researchers repeatedly caveat the findings of their model, stating that "any point is just a likely value in a plausible range." That is to say, their much-publicised estimate of a £1.76 billion cost of NHS services for all visitor and migrants is only "50% likely to be in the range £1.53 billion to £1.94 billion". This is not the quality of evidence base on which to create an entirely new system of NHS access.

34. It is also worth emphasising that the estimate of £1.76billion is almost entirely accounted for (£1.43billion) through use of the NHS by regular migrants, who would almost always be entitled to free treatment due to the settled nature of their residence in the UK. Most in this group would have no resource to public funds so would be self-supporting and in most cases paying not only VAT but income tax and national insurance. The £1.76billion figure excludes "deliberate health tourism", which the researchers tentatively estimate as costing £60-80million per year. The total does include the estimate £50million cost of treating UK expats who are living in non-EEA countries.

35. The qualitative study commissioned by the Department of Health has been emotively sub-titled ‘observations from the front line’, giving an impression that the reader should see the provision of acute healthcare services (and in some cases, routine GP appointments) as a battle in which migrants and overseas visitors are the enemy. The views of NHS staff which are reported in the research show great confusion about current charging rules within primary and secondary care. Participants in the research (and occasionally the authors) conflate migrant access to primary care, which is not covered by charging rules, with access to secondary care. The researchers also report examples of the current charging rules being applied discriminatorily, with only certain patients being asked the residency questions set out in Department of Health guidance (because of their ethnicity).

36. The conclusions to the qualitative study include an observation that NHS staff believe that temporary migrants are using health services in significant numbers, with negative consequences for their ability to deliver primary and secondary healthcare services. At the same time, however, the researchers noted that overseas visitor officers (OVO) expressed frustration that of the patients they questioned, very few were in fact chargeable migrants. [20] It therefore seems far from conclusive that there is in fact a problem of NHS use and ‘abuse’ by overseas visitors, beyond the perception of some staff.

37. While the research has flaws, the findings of this qualitative study may be helpful in highlighting current problems with implementing charging rules and pressure points on which to focus improvements. The qualitative research also asked participating OVOs to keep a daily diary of their charging activities, which could be a possible model for better data collection in future. However, the Committee should question how appropriate it is for the Government to present the anecdotal reports and opinions of a sample of NHS staff as ‘evidence’ upon which to entirely rebuild the way in which our population (migrants and otherwise) access NHS services.

38. The conclusion most obviously suggested by the qualitative study - but not made by the researchers - is that the Government should immediately clarify with all clinical commissioning groups (CCGs) that: there is universal entitlement to primary care services; but that having GP registration and/or NHS number does not entitle someone to free secondary care.

39. In the same week as the Government’s qualitative and quantitative research was published, the journal PLOS ONE also published a study on medical tourism conducted jointly by researchers from the London School of Hygiene and Tropical Medicine (LSHTM) and the University of York. This study (which FOI-ed UK hospitals in addition to using IPS data) showed that the UK is in fact a net exporter of ‘medical tourists’, to non-EEA as well as EEA countries. Overall, the numbers of medical tourists were small, however. While the researchers noted that there are of course risks to the UK of accepting medical tourists, there were also opportunities and that the UK economy has benefited from patients travelling to the UK for treatment. [21]

40. The LSHTM/University of York study does not directly address the questions about migrant NHS use which need to be answered in order to properly scrutinise the Government’s proposals for regulating access to NHS services. However, it does highlight that there are other dimensions to ‘health tourism’ than those presented in the Home Office/Department of Health narrative. It is very possible that the NHS gains more than it loses by being part of an international system of patient exchange. These are important questions if the sustainability of the NHS is to be assured. It would be short-sighted to embark on an extensive programme of redesigning NHS access for overseas visitors without having considered all sides of the issue.

41. In summary, the quantitative and qualitative evidence published to accompany the Immigration Bill does not reveal anything new about the current costs to the NHS of treating overseas visitors and migrants - both those who are currently chargeable and those who are entitled to free care due to the settled nature of their stay in the UK. The Department of Health does not know how many chargeable migrants are using NHS services, how many of this group are charged, or how much of this debt is being recouped. The rules which exist are poorly understood and implemented. The Government does not have in place the solid foundation of evidence which would be needed to justify the introduction of an extensive and costly re-design of the NHS charging rules for migrants, which would in turn have an impact on the ability of all UK residents to easily access the healthcare services they need.

October 2013


[1] Members supporting this submission: Alma Mata, Doctors of the World UK , Horn of Africa Health and Wellbeing Project, Maternity Action, Migrant Rights Network, NAT (National AIDS Trust), Still Human Still Here, Terrence Higgins Trust.

[2] Home Office. Controlling immigration – regulating migrant access to health services in the UK : results of the public consultation . 22 October 2013.

[3] The HTPN 052 randomised clinical trial showed a 96% reduction in transmission amongst discordant heterosexual couples who commenced ART early and achieved an undetectable viral load. http://www.hptn.org/web%20documents/HPTN052/HPTN%20Factsheet_InitiationART4Prevention.pdf

[4] Between 2006 and 2009, one in three BME individuals were diagnosed outside of the sexual health clinic setting, compared to one in five white individuals. M. Kall et al. 2011. Where do we diagnose HIV? Monitoring new diagnoses made in no-traditional settings. Health Protection Agency [now Public Health England ]. Poster 161, presented at the BHIVA Conference, Spring 2011.

[5] B. Rice etc al. 2013. HIV testing in black Africans living in England . Epidemiol. Infect. 141(8):1741-8

[6] PHE. 2013. Tuberculosis in the UK - 2013 Report . p33. http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1317139689583

[7] HSCIC. MMR vaccine: coverage for young children by age two at highest level in 14 years. Health Social Care Information Centre, 2012. Available here: http://www.hscic.gov.uk/article/2381/MMR-vaccine-coverage-for-young-children-by-age-two-at-highest-level-in-14-years ( accessed 20th July 2013).

[8] NICE . Reducing differences in the uptake of immunisations (including targeted vaccines) among children and young people aged under 19 years. National Institute of Clinical Excellence. 2009.

[9] Department of Health. Giving all children a healthy start in life. Department of Health 2013

[9]

[10] " London 's rich get 18 more healthy years". London Evening Standard . 18 September 2013.  

[10] http://www.standard.co.uk/news/health/londons-rich-get-18-more-healthy-years-8824143.html

[11] All costs are calculated at 2010 prices. For full details of how costs were calculated see Matrix Evidence, Economic evaluation of extending entitlement to healthcare to irregular migrants, Doctors of the World, October 2011.

[12] NICE 'Increasing the uptake of HIV testing among black Africans in England and increasing the uptake of HIV testing among men who have sex with men - Costing report - implementing NICE guidance' 2011

[13] See “Access to healthcare in Europe in times of crisis and rising xenophobia” (Doctors of the World International Network, 2013).The full epidemiological report including all UK statistics “Access to healthcare of excluded people in 14 cities of 7 European countries” social and medical data collected in 2012 can also be downloaded at www.mdm-international.org

[14] Home Office. Controlling immigration – regulating migrant access to health services in the UK : results of the public consultation . 22 October 2013.

[15] Home Office. Controlling immigration – regulating migrant access to health services in the UK : consultation . 3 July 2013

[16] Prederi. Quantitative assessment of visitor and migrant use of the NHS in England – Exploring the data . October 2013.

[17] Prederi. Quantiative Assessment of Visitor and Migrant Use of the NHS in England . October 2013 and Creative Research. Qualitative Assessment of Visitor and Migrant use of the NHS in England- Observations from the front line. October 2013 https://www.gov.uk/government/publications/overseas-visitors-and-migrant-use-of-the-nhs-extent-and-costs

[18] Prederi, 2013, p4

[19] Prederi, 2013, p11

[20] Creative Research, 2013, p18

[21] Hanefeld J, Horsfall D, Lunt N, Smith R (2013) Medical Tourism: A Cost or Benefit to the NHS? PLoS ONE 8(10): e70406. http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0070406

Prepared 6th November 2013