Immigration Bill

Written evidence submitted by the Royal College of Midwives (IB 60)

The Royal College of Midwives (RCM) is the trade union and professional organisation that represents the vast majority of practising midwives in the UK. It is the only such organisation run by midwives for midwives. The RCM is the voice of midwifery, providing excellence in representation, professional leadership, education and influence for and on behalf of midwives. We actively support and campaign for improvements to maternity services and provide professional leadership for one of the most established clinical disciplines.

1. The RCM is  primarily concerned with sections 33 and 34 of the Immigration Bill, which affect the rights of migrants to access NHS services. The RCM is convinced that there is insufficient evidence to justify the proposals, that extending charging would have negative health outcomes, and that there is inadequate detail in the current Bill to fully predict the impact of the proposals.

Insufficient evidence for the proposals

2. The RCM is concerned about the absence of evidence justifying the proposed changes. While the Department of Health, and its commissioned researchers, have produced (very unreliable) estimates of the costs incurred by the NHS in providing care to migrant groups, no comparable estimates have been made of the fiscal contributions that those migrants make. It is worth noting that recent research [1] from The Migration Observatory at the University of Oxford notes that the majority of studies find a small but positive fiscal impact of immigration. Other research [2] released this month by the Centre for Research and Analysis of Migration at University College London found an overall positive fiscal impact of immigrants from EEA countries, but noted that both non-EEA immigrants and UK natives have a negative fiscal impact. Accordingly, there is no clear case that charging for access to NHS services needs to be extended.

Potential for significant health harms

3. The RCM’s primary concern is that charging at the point of care entails significant risks for the health and wellbeing for people living in the United Kingdom. While these charges already exist for some groups of people, section 34 of the Bill would significantly increase the number of people being charged. The Department of Health estimated [3] that more than 700,000 people would be affected by new charges if the definition of ordinarily resident was changed. This entails two specific problems:

a. Misapplication of the charging rules means that people could be denied access to immediately necessary treatment. Maternity care is classified as ‘immediately necessary treatment’. This means that while a person may be charged for the care they receive, they should not be denied access to the care if they are unable to pay. In practice, this has not been as straightforward as it appears. While we are not aware of any examples of women being denied care in the last few years, the Tenth Report [4] of the Joint Human Rights Committee in 2007 made note of numerous examples of women being denied access to care during 2006. The withholding of antenatal care from women during pregnancy means that risks cannot be managed and women will be more likely to have negative outcomes. Refusing to support a woman while she gives birth because she is unable to pay for care can lead to serious health problems for the woman (as in one reported case). These cases are not only appalling for their health consequences, but the NHS is likely to incur significantly higher costs in later emergency treatment if earlier preventative care is denied. Cases such as these are exceptional, but completely unacceptable. As well as entailing negative health outcomes and higher costs, they constitute a blatant breach of the human right to medical care.

b. The second, and probably more widespread issue, is women avoiding care or treatment because of the charges they would incur. Charges for maternity care can be in the thousands of pounds, and for many vulnerable women they will be well in excess of what is affordable. This is an important part of the reason why trusts are only able to recover 40% of invoiced charges. Reluctance to attend care is likely to be exacerbated by women not having sufficient knowledge and understanding about the importance of early and on-going antenatal care for their health and the health of their baby. It is not uncommon for the NHS to have no prior knowledge of such women until they present at the hospital in labour. This creates a higher risk of worse health outcomes and higher costs for the NHS.

4. Lastly, the RCM is concerned that any system which requires charges to be made at the point of care will impose significant administrative and clinical costs on the NHS. Administrative systems will need to be in place to determine liability for charging for each person who receives care services, and it is highly likely that part of the burden will fall on health care professionals.

Insufficient detail in the Bill

5. The changes in section 33 of the Bill provide for reducing the number of people being charged at the point of care by introducing charges as part of visa applications. Once a migrant levy is paid as part of the visa application, a person is in principle entitled to receive NHS care free at the point of care.

6. With respect to the number of people being charged at the point of care, sections 33 and 34 therefore work in two different directions. Because section 33 provides for details of the migrant levy to be established in secondary legislation, it is impossible to predict at this stage whether the net effect will be more or fewer people being subject to charging at the point of care. However, the Department of Health has expressed its intention to retain charges at the point of care for both short-term visitors and illegal immigrants. The RCM opposes these charges for the reasons outlined above, and believes that further detail about who will and will not be subject to charges, and for what aspects of care these charges will apply, should be set in primary legislation.

November 2013