Immigration Bill

Written evidence from UNISON (IB 49)


1. UNISON welcomes the opportunity to submit evidence to the Public Bills Committee on the Immigration Bill. UNISON represents more than 450,000 healthcare staff employed in the NHS, and by private contractors, the voluntary sector and general practitioners. In addition, UNISON represents over 300,000 members in social care. There is also a wider interest in the NHS and on issues related to decent housing among our total membership of more than 1.3 million workers.

2. UNISON’s response is focused on a number of aspects of the Bill that is of particular concern to the union and its members, principally restrictions to migrants’ access to the NHS.

3. This submission provides evidence of UNISON’s concerns around the legislation affecting UNISON healthcare staff and for the NHS that remains unanswered and unresolved.

Charges for NHS services

4. UNISON believes that free access to primary medical care is vital for individual and public health as well as for NHS finances.

5. UNISON believes that significant barriers exist for implementing a system of charging for primary care. It will place huge burdens on already overstretched NHS services, lead to delays in urgent and necessary care for patients, will cost significant amounts of money to implement and will increase inequality and damage the relationship of trust patients have with healthcare staff. UNISON also challenges the premise that non-EEA migrants do not make a ‘fair contribution’ to the NHS and does not believe that charges for primary care services makes financial or healthcare sense. It will also send a very damaging message for those non-EEA migrant workers who currently work directly for the NHS, GPs or their contractors.

6. The government has admitted that the current system of charging for secondary care is not effectively enforced. However, charging non-EEA migrants for primary care would have massive IT and administrative implications which have not been costed. UNISON believes that this would be financially prohibitive. The implications for all NHS users means that any system that could administer this would have to be comprehensive, reliable and able to track a large number of variables of eligibility. UNISON believes that the proposed changes are unworkable for the same reason that the current charging regimes are not effective. Health workers are already finding themselves in the uncomfortable position of having to act as immigration officials but restrictions to primary care access will have a deeper impact as this is where most people first make contact with the health service. Instead of spending their time enforcing immigration legislation, healthcare staff want to deliver high quality personalised care to patients. Introducing charges undermines access to healthcare and the ethos of the NHS to provide care free at the point of need

7. Anything which deters people living in the UK from seeking medical advice early, through primary care, will cost the NHS more when they eventually become ill or develop complications. This is particularly concerning when considering the importance of early treatment for infectious diseases, maternity care and progressive conditions. While treatment for HIV and TB would be free and would prevent onwards transmission, this benefit can only be gained if the infection is first diagnosed. Rates of undiagnosed HIV and late diagnosed HIV are 25% and 50% respectively. Primary care is also the location of immunisation programmes, for example MMR where 95% herd immunity is needed. Women who commence antenatal care early in their pregnancy have better maternal and child health outcomes that those commencing care later and reduced need for costly interventions.

8. Furthermore, it places healthcare professionals in an intolerable position when they are already facing existing pressures to meet urgent needs in a very challenging healthcare environment. Any system which could accurately tell healthcare staff who to charge and who not to charge whilst also not being ‘intrusive’ for non-chargeable users would be difficult to achieve. In the event of any breakdown, short cuts taken to identifying chargeable patients could lead to discrimination.

9. UNISON therefore believes that the design proposal is fundamentally flawed. It will be extremely expensive, place greater pressure on services which are currently underfunded and very stretched for very little benefit. Indeed, the main outcome of will be to undermine the health of vulnerable groups of people, and an undermining of the ethos of the NHS. It will also intrude into the relationship between all patients and the NHS, as everyone will be required to prove their eligibility for free care. The Government have not yet explained how this will operate without harming patient care or undermining the relationship between patients and healthcare staff.

10. Accessing healthcare would therefore become dependent on IT systems. Any breakdown or lack of speed in updating patient records might mean that non-EEA migrants who are eligible for care might be denied it. There are also significant data protection issues not only for non-EEA migrants but for all NHS patients.

11. Over and beyond the other concerns we have, UNISON believes that on issues of efficiency, cost-effectiveness and practicality alone are troubling. The Department of Health need to have a ‘new burden’ doctrine similar to the CLG department so that any new costs and roles are fully funded.

12. UNISON also has many non-EEA migrant members working in the NHS. Under these proposals they will find themselves having to pay for vital care for themselves and their families, perhaps within their own workplace for the very services they provide to other people.

13. Migrant workers in this country already face huge uncertainties regarding their immigration status, due to changes to immigration rules after they are in the country, or because they are unfairly dismissed by their employers or because they were recruited by agencies under false pretences. These proposals are likely to increase their vulnerability to exploitation at work and damage their health and well-being.  

14. Furthermore, many migrant workers lose their immigration status as a result of changes to immigration rules when they are in the country or because they were unfairly dismissed by their employers or because they were recruited by agencies under false pretences. They have contributed to the NHS through NI contributions and general taxation like their co-workers.

15. UNISON also has concerns about the changes to the current ‘ordinary residence’ qualification. The current definition recognises the important eligibility criteria of the ‘settled’ nature of someone’s life in the UK, which better captures the principle of ‘fair contribution’. It is also a broad definition which does not link eligibility to specific immigration and residency status, categories which are subject to regular change by the Home Office, and therefore avoids the risk of unintentionally excluding those who are entitled to, and need, NHS care.

16. There is already extensive evidence that current charging policies have a disproportionate impact on vulnerable groups, including destitute asylum seekers and other undocumented migrants who have no recourse to public funds and this will only increase as further barriers are created to healthcare access. The Health Service Journal reported on 6 November 2013 that an internal NHS report had found that "Despite improvements [in GP registration among vulnerable groups], homeless people, asylum seekers and other transient groups are still frequently being refused registration by GP practices. Information suggests registration is a particular barrier for migrants or those with perceived ‘irregular’ immigration status. There is a continued misunderstanding about immigration status and entitlement and confusion about whether proof of address is a requirement."

17. UNISON believes that such local misunderstandings will only become more widespread under the new arrangements. Confusion about people’s migration status might prove to be fatal in the delivery of urgent and necessary care. There are already many problems with the existing system, with a number of cases of vulnerable people being unable to access care for serious illnesses or life threatening diseases.

18. Extending such a confusion to primary care, where the vast majority of UK health needs are met will only make matters worse for vulnerable migrants.

Equality impact

19. Under these proposals, BME people and some nationality groups are much more likely to be expected to pay for their healthcare access. In addition, BME people who are EEA nationals will face increasing scrutiny about their eligibility for free NHS care. Spot checks on public transport have already highlighted the issue that BME people are expected to be able to prove their identity on request. Along with NHS charging, the Immigration Bill more widely is highly likely to deepen this problem.

20. Women in abusive domestic situations, whether they are EEA or non-EEA nationals, might find their identity papers withheld by abusers as a way of reducing access to healthcare and other essential services. Since the proposals do not exempt children, the same could apply to those children being abused or neglected. As dependents, they will be vulnerable to losing their healthcare entitlement following domestic abuse and/or family breakdown. Children also have a range of age-specific health needs, which are met by primary care. They are also particularly affected by infectious diseases. Children of migrants who are born in the UK will also experience follow-on effects on any restriction on maternity services, which are vital to their healthy start in life.

Landlord checks

21. UNISON’s migrant worker and BME members have expressed concerns that whatever their immigration status, they will come under increasing scrutiny and pressure when accessing any number of services as a result of the Immigration Bill. They are already likely to face discrimination when trying to access decent housing but private landlord checks will worsen their situation. Whether the documentation is readily available or not it all rests upon the confidence of landlords that they can assess these documentation as legitimate and the willingness of landlords to accept them as tenants. Landlords who choose to accept tenants by pre-screening them for nationality and race will not face any penalty or challenge.

22. While the Home Office proposes to formulate rules and guidance to avoid this and help landlords and tenants ‘easily establish legal status and identity’, UNISON is deeply concerned that landlords will be rewarded and not penalised by the Home Office proposals for not renting accommodation to anyone merely perceived as being foreign nationals.

23. The Home Office acknowledges the risk posed to women escaping domestic violence but states that the Home Office advice service would "assess the need to allow a tenancy to proceed pending production of evidence". This means that any woman fleeing violence and without access to her papers would have to disclose this fact to private landlords. It is likely that the landlord would exclude such tenants for all the reasons outlined above, particularly the risk that if papers are not obtained, they would have to undertake the letting process again. While women’s refuges are exempt, the crisis being experienced by women’s services across the UK, particularly those specialist services aimed at BME women means that such support is less and less accessible to the women who require them.

24. One of the stated aims of the proposals is to end the exploitation of migrants of irregular status by unscrupulous landlords. However, it is highly likely that these proposals will exacerbate this, not just for migrants of irregular status but for all migrants and any people perceived to be migrants who might now find it harder to access housing.

November 2013

Prepared 20th November 2013