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House of Lords Hansard

National Health Service (Charges to Overseas Visitors) (Amendment) Regulations 2017

16 November 2017
Volume 785

    Motion to Regret

    Moved by

  • That this House regrets that the National Health Service (Charges to Overseas Visitors) (Amendment) Regulations 2017 do not clarify how upfront charging can work without increasing barriers to healthcare for vulnerable groups, how they will not breach equality legislation through the potential use of racial profiling as a means to identify chargeable patients, and how the extension of charging to community services will not lead to patients being prevented from accessing preventative care programmes; and further regrets that they have been introduced without sufficient assessment of the effectiveness and value for money of the bureaucratic process proposed (SI 2017/756).

  • My Lords, I am moving this Motion because I believe the regulations on charges for overseas visitors do not clarify how up-front charging can work without increasing barriers to healthcare for very vulnerable groups. They do not explain how they will not breach equality legislation through the potential use of racial profiling as a means of identifying chargeable patients. The regulations do not show how the extension of charging to community services will not lead to patients being prevented from accessing preventive care programmes. I also believe that it is a matter for further regret that these regulations have been introduced without sufficient checks of the effectiveness and value for money of the very bureaucratic process proposed.

    Let me say at once that, on the face of it, charging overseas visitors to use our hard-pressed NHS is entirely reasonable. But the Government’s latest plans to extend charges to community services will raise very little money, place a huge bureaucratic burden on the NHS and deny healthcare to very vulnerable people. The UK already charges some overseas visitors for most hospital care after treatment. Patients who are not eligible for free care include short-term visitors, undocumented migrants and some asylum seekers whose claims have been refused. There are already processes in place for hospitals to identify and bill such patients. We understand that in addition to these regulations, the Government are considering extending charging to A&E and GP services.

    Under the regulations that came into force last month, all community services receiving NHS funding, including charities and social enterprises, are now legally required to check every patient’s paperwork, including passports and proof of address, before they receive a service to see whether they should pay for their care. Charges are up front, with non-urgent care refused. As a person will need to provide paperwork and/or a passport to prove eligibility, there is a distinct possibility that people who are entitled to free care on the NHS will be denied treatment because they do not have it at hand. Particularly vulnerable groups here include the elderly, asylum seekers, homeless people and mentally ill people. Moreover, if patients continually have to provide details every time they need healthcare, this risks them waiting longer, with an inevitable increase in bureaucracy.

    Asylum Matters, in conjunction with a number of other organisations, has commented in response to the Minister, who has written both to Members of this House and to MPs in the House of Commons to allay fears about how patient ID checks will be carried out. He says that the changes do not require a patient to provide a means of identification to qualify for free care. He says that, while that may be helpful in demonstrating eligibility, other information will be used by trained NHS staff to ensure that the residency status of a patient is identified. He says that the regulations simply require that a relevant body must make such inquiries that it is satisfied are reasonable in the circumstance to determine whether charges should be made. The problem is that those protections are not built into the regulations. They may be in the guidance but guidance can be changed at any point, and they cannot be enforced if NHS organisations choose to insist on further proof of a patient’s ID.

    I have been written to by many people, and I would like to refer to a very important paper sent to me by Natalie Bloomer, in which she refers to the father of a newborn baby who recently received a letter from his local hospital demanding to know whether his eight day-old child was entitled to free healthcare. The parents wondered if they had received the letter due to the mother’s foreign-sounding maiden name. When the father went back to the hospital, it quickly told the family to disregard the letter. For me, this highlights the whole problem of this wretched and miserable policy. It is quite clear to me that, apart from the dreadful impression and reputation it gives of our country, many people who legitimately live here and have every right to NHS treatment are going to be challenged by the NHS. I find this absolutely despicable.

    I gather that the Secretary of State has claimed that charging regulations simply bring us into line with our European neighbours. Of course, this is complete nonsense. The work done by Doctors of the World, which I have seen, has been researched comprehensively, and the fact is that many European countries, particularly the ones we tend to compare ourselves with, actually provide a more comprehensive package of free healthcare—for instance, to undocumented migrants.

    I receive many briefings and letters from reputable organisations. This regret Motion has been backed by many trusted and well-respected bodies, including the BMA, the Royal College of Midwives, Doctors of the World UK, the National AIDS Trust, Asylum Matters and Freedom from Torture. Many of them represent groups which will be intimately affected by the regulation introducing overseas charges and extending it.

    They are not the only ones to oppose this new policy. An open letter addressed to the Secretary of State, published by 193 organisations and 880 individuals, has called for the regulations to be dropped as soon as possible. Among the signatories were 300 doctors, 50 nurses, the former NHS chief executive Sir David Nicholson, the Royal College of Paediatrics and Child Health, and Amnesty International. Not only were they all agreed that the introduction and extension of charges will place a greater burden on the NHS, but this is the kind of thing that the Conservative Government pledged to cut down—the wretched bureaucracy involved and the time that will be spent by staff trying to make these charges work. The Royal College of General Practitioners has flagged up the possibility the new system could end up overstretching already strained family doctors at medical centres. The Catholic Bishops’ Conference, in its letter, spoke of the catastrophic consequences of the new regulations and asked for them to be suspended.

    Not only is this a ludicrous action by the Government, it will have no impact whatever on the finances of the NHS. The estimate is that it will bring a £200,000 saving—how ridiculous. The point I want to make in the debate tonight is that these rules are now already law. The Catholic Bishops’ Conference has asked for the regulations to be suspended, and I hope the Minister can announce that he is going to do that, but at the least there should be an early independent review of how the new charges are operating. Until then, there can be no question of extending charges to yet more services. I beg to move.

  • My Lords, I thank the organisations that have briefed us. Sending a joint briefing was particularly helpful, not because it reduces the paper but because it increases the force of the content. It came from Asylum Matters, Doctors of the World UK, NAT and Freedom from Torture. We have had briefings from others too. I also thank the noble Lord, Lord Hunt. Like him, I understand that some charging of visitors is entirely reasonable, but—and it is a very big but—the noble Lord has raised some very pointed questions wrapped up in the text of his Motion, and I hope that the Minister will be able to respond to those point by point.

    This is not a new problem for some groups but it is now worse. During the passage of the Immigration Bill, now the Immigration Act 2014, the points were put forcefully—especially, I remember, by those concerned with maternal health and by doctors who were working with a wide range of immigrants. I remember hearing from Doctors of the World UK that, before the regulations which followed that Act came into force, there were queues round the block at their clinic of people who were anxious about what their position would be afterwards.

    The charging then was presented as an innocuous extension of the system, and really very beneficial. There was a lot of talk about health tourism blocking access for those of us who are not tourists. I began to think that the world must be full of people who had had their pregnancy confirmed and immediately booked a flight for the due date minus however many weeks the chosen airline applied as the cut-off for carrying pregnant women. At that time, it became clear that many hospitals found the charging system then in force so burdensome that it had simply defeated them, and there was a good deal of criticism of those that were defeated, I recall. This time around, again there has been considerable protest from people who have seen at first hand the effect of what the pre-23 October regulations require.

    When I looked for the government impact assessment on the regulations, I found an evaluation by Ipsos MORI of the overseas visitor and migrant NHS cost recovery programme, published in January this year but apparently started in 2014. The paragraph on the costs and benefits of implementation made startling reading—which I found difficult because I printed it off in such a small font. It made me doubt whether there really was benefit to the implementation. What continued valuation will there be? This is another way of asking the question that the noble Lord, Lord Hunt, asked: will the Government consult before extending the charges into other health services, including A&E and GP services? The letter that the Secretary of State wrote in response to the open letter seems to say these things are so because they are so. I am sure that there cannot be as relaxed an attitude as that seems to suggest.

  • The impact assessment, when I got to it, gave the option that has been adopted as the preferred one because it generates the maximum benefit for the NHS. I think that is a little something as against nothing. I am not at all clear that it takes into account the impact on public health. The impact assessment says that the income from the previous regulations raised between £97 million and £146 million over three years. Was that worth it, given the public health risks from communicable diseases and the deterrent to people who, in fact, are not required to pay—something that was a real concern in 2014—and so on?

    Yesterday, I received an email from someone who had heard from the manager of a local practice for asylum seekers and refugees about a woman who had been to the local hospital and asked for a pregnancy termination. They told her that it would cost £1,000 because of the new regulations. In fact, this woman is entitled to free secondary care. She was understandably very distressed by this. The issue was sorted out and a “training need” was identified by the hospital. However, she had the confidence that many people in such a situation would not have had. One can easily imagine a woman getting into the most considerable difficulty by seeking another route to a termination. We risk these charges being equivalent to the Home Office rules that preclude those without status from working and so drive them underground into the illegal economy. What safeguards are there to ensure access to urgent treatment, prevent early discharge and prevent denial of treatment so that it becomes urgent?

    The Home Office has already turned landlords into immigration officers. Now the Department of Health is requiring doctors to police access to the NHS. I appreciate that this is not directly a matter for the Minister, but I suggest that the best way to treat the many asylum seekers who have mental health problems would be to deal with the underlying problem of the asylum claim.

    Then, as the noble Lord, Lord Hunt, said, there is the bureaucracy and the cost. I would be surprised if the Minister’s experience does not accord that of many of us. When seeking treatment from the NHS, the healthcare is excellent but the administration is dire. What impact will the extra burden have?

    Does it have to be so? Compare Wales, Northern Ireland and Scotland. The health services in Scotland are extended to individuals and their families whose claim for asylum has failed. This is, I understand, part of its refugee integration strategy. It is quite right. Integration is about people not feeling, or being regarded as, “other ”.

    There is concern, too, which has just been expressed, about inequalities in treatment and racial profiling. That is something to which the House is paying attention as we go through the Data Protection Bill. I was shocked to be briefed that the Home Office has recently started contacting asylum seekers asking them to sign a consent form to give the it access to their personal medical records. Any information obtained may then be used to inform decisions taken on an individual’s case, including how to progress removal from the UK if an application for asylum is unsuccessful. That is what I have been briefed. I have not had the opportunity to check it out, but neither have I any reason to doubt it.

    The regulations raise issues about trust between healthcare professionals and their patients, the disproportionate effect on people who are marginalised, and the removal of healthcare from very vulnerable groups—undocumented migrants—whose needs are intensified by destitution. The regulations affect individuals and I believe they raise big ethical issues as well. I support the noble Lord very much.

  • My Lords, I am grateful to the noble Lord, Lord Hunt, for raising this issue. I am concerned about the additional barriers to care that may be faced by people with mental health conditions and learning disabilities. We know that such patients already face significant barriers to both mental and physical healthcare. For example, we know that people with psychosis already face significant barriers to both mental and physical healthcare. We know that people with psychosis face a mortality gap of 10-15 years, mainly from physical comorbidities. We also know that migration itself appears to increase the risk of psychosis, and the science behind this is developing rapidly.

    It is not easy to divide, “immediately necessary” and “otherwise urgent” care, which is exempt, from routine care, which is chargeable. I speak from the standpoint of someone who has cared for patients with mental illness and with learning disabilities over many years as a psychiatrist, and also as a past president of the Royal College of Psychiatrists. The principle of early intervention to avoid a later crisis is widely recognised and promoted by the health service. Such intervention needs to occur very early. Identifying and intervening on low-level symptoms avoids escalation to more severe presentations that require intensive treatment and expensive admission to hospital. I am worried that the checks that have been put in the regulations will mean that patients, whether eligible or ineligible for free care, may wait longer and may need to be in crisis before they can access services. If this occurs, it will produce more suffering, increase risks, and cost the health service more.

    These costs do not feature in the Cost Recovery Impact Assessment, published by the Government in July. I am aware of examples of asylum seekers who arrive in this country with symptoms of post-traumatic stress disorder, and my concerns extend to the mental health of their children during periods of extreme uncertainty. Their mental health needs would not seem to meet the criteria for urgent care.

    My other area of concern is the accuracy of decisions to deny care to a patient. The exemption for,

    “immediately necessary, or otherwise urgent”,

    treatment is a clinical one, as stated in the Government’s impact assessment. However, the British Medical Association, of which I am also a past president, has asked for clarification on the procedure when a person is unable to pay, including what safeguards are in place to prevent further or serious harm to themselves or the wider public as a result of them being denied treatment.

    I am concerned that the process of administrative checks alongside a clinical test of urgency will be burdensome, costly and rushed. Once information is on a patient’s summary record, it may be difficult to change it or to amend errors. Such circumstances could lead to a failure to identify those entitled to free care. This may be even more complicated in patients who have impairment of capacity, communication difficulties, or other mental health conditions. Challenging administrative errors and information on digital records in the health service can be difficult for all of us, let alone those with impaired capacity, communication and learning disabilities, or autism.

    What safeguards are in place to prevent errors in requiring up-front payment? Without robust safeguards, those most in need of care may be those least able to prove they have a right to it. I would support the suspension of these regulations for further thought, but if this does not happen, can the Minister tell the House what are the arrangements for reporting the impact of these regulations on the mental and public health of the population who are at risk?

  • My Lords, I refer to my entry in the register of interests. The regret Motion at first appears to imply that charging overseas visitors is something new. The requirement for the NHS to charge overseas visitors has been in place for 35 years—but, unfortunately, compliance and recovery rates have historically been extremely low.

    I thank the NHS workforce for the fantastic job that they do; they are now treating levels of demand not seen before. Do noble Lords not think it only fair that any overseas visitor using our NHS should make a financial contribution, just as we all do when we are on holiday abroad and possibly want to access medical help?

    It is important to emphasise that NHS England, NHS Improvement and the department have published guidance to support the embedding of the regulations, producing an average price list so as to better inform and enable patients to look at the up-front charges for anyone not eligible for free NHS care. Those people can then make informed choices about their care here or at home.

    I am informed that, in order to protect the most vulnerable and to protect public health, the department remains committed to ensuring that vulnerable groups are always able to receive free care and that no patient will be denied urgent or immediate healthcare, regardless of their immigration status or ability to pay. This includes all maternity care in every setting, including diagnostic, and the treatment of infectious diseases.

    Back in July, the department introduced new regulations to support improved cost recovery and make it fairer and more efficient for both the patient and the healthcare system. It saw recovery increase from £89 million to £360 million—all being transferred back into our front-line services.

    Finally, with careful monitoring and ongoing assessments and with better use of existing data sources to improve efficiency, we will be able to see for ourselves the financial effectiveness and value for money through this process. These figures will be published in the new year.

  • My Lords, I first congratulate my noble friend Lord Hunt on initiating this debate. Like him—and other speakers—I acknowledge that the NHS is under significant pressure and that there have been charges for a very long time. However, I say to the noble Baroness, Lady Redfern, that, if there is a problem with cost recovery, these regulations are not the answer.

    I am prompted to intervene in this debate because of an organisation in Bolton, my home town: a local group called City of Sanctuary. Its role is to create a culture of welcome and safety for refugees and asylum seekers. As a Member of the other House, I had a considerable amount of casework dealing with refugees, asylum seekers and failed asylum seekers, so I know that its work is extremely important and that it has a great deal of direct experience. It has raised concerns about vulnerable groups, particularly those I have mentioned. I note that this category is not mentioned by the Minister in his letter.

    There are three points I want to raise. I have read the Minister’s letter to all Members with care and I thank him for it. He tries to be reassuring, but I am afraid that he does not allay all the concerns that some of us have on the basis of the evidence that has been presented to us.

    The Minister says that the regulations require that up-front charging for non-urgent or immediately necessary care will become a legal requirement. That is the basis of these regulations. But there is an immediate problem with the definition of “non-urgent” or “needing immediate care”. I think particularly of those people, such as refugees and others, whose full medical history is not known, may not be available or may not be fully evident, or who may not have proper cognisance of it themselves. It can be a very real problem, I suggest, for both the patient and the doctor. The medical groups who have expressed concern about this have made a very strong case.

  • I recognise that the Minister says in his letter, in paragraph 5, I think, that the most vulnerable in our society will never—and I note the word “never”—be charged. He goes on to specify and include reference to refugees and asylum seekers. Can I ask him about failed asylum seekers? The noble Baroness, Lady Hamwee, mentioned the situation in Scotland, Wales and Northern Ireland where, I understand, they are exempt from charges. If that is the case and there is to be a difference in England, I really would like to know why.

    The Minister also needs to recognise some of the difficulties that exist for those groups in proving that they are eligible for free treatment. The vulnerable groups that we have been talking and hearing about today may find it very difficult to provide the kind of evidence that is required. This is not the only area in which this happens. At Prime Minister’s Questions yesterday, we heard about someone who did not have a passport or a driving licence and could not provide the evidence for universal credit. This is a general problem across a whole range of fields. How do people prove entitlement? This area is just one example. People may not have their passport or it may have expired. They may not have proper ID or proof of residence, or they may not understand what it is that they are required to provide.

    The difficulties that have arisen for these groups in terms of getting the advice that they need—given all the government cuts to advice services—have made the problem worse. Many people simply do not understand the system. This can lead to delays, which can lead to a deterioration in health conditions and, indeed, could lead to the denial of treatment, which could cause the NHS to have to spend more on more dramatic intervention later. I am sure that the Minister believes what he wrote in his letter about vulnerable people not being charged, but I think that he needs to be aware of the complexity of the difficulties that many people face.

    Mention has been made of the case study by my noble friend Lord Hunt and the individual whom he was concerned about. I have been given at least four examples of case studies where people who have been eligible have not been able to get the immediate treatment that they needed or have been billed for it, which has caused concern and a lack of understanding about what was going on—and I am very happy to forward those cases to the Minister so that he can look at them. It causes hardship and confusion, and can lead to other medical problems later.

    The third point that I want to raise is the statement in the Minister’s letter that he does not want to see unintended consequences; that is very important. It is important in probably every bit of legislation that we pass and every regulation that is introduced, because it is easy for unintended consequences to creep in and cause real disruption and difficulties. It is one of the reasons why piloting projects is actually rather a good idea on most occasions.

    Some mention has been made of these difficulties. My noble friend mentioned racial profiling, and I think we have already seen some evidence of this in the NHS as well as elsewhere. That should concern us all, and we should always take steps to avoid it. There is also a real concern, which has been expressed by many people in the medical profession—my noble friend mentioned the letter signed by a distinguished group of people—about the bureaucracy involved, and the difficulty that all NHS staff, from receptionists to consultants, will face in terms of knowing what they themselves should be doing, let alone in explaining it to their patients.

    I hope that the Minister will be willing to think again, to look at the evidence and to hear the concerns. I hope that he will review the situation, look again at the guidance and realise that this is not a quick way of getting more money into the National Health Service.

  • My Lords, the National Health Service is a cherished national institution, historically the envy of the world, and in theory none of us has a problem with overseas visitors using it. However, we currently have a huge issue of capacity. Unfortunately, it is not clear that we have the capacity to treat on the NHS all the overseas visitors that we would like to treat. Already the NHS is in breach of vital targets, such as waiting times for operations and to start treatment for cancer. Consequently, our cancer survival is the worst in western Europe, Canada and Australia. Only a few countries in eastern Europe have worse survival for common cancers.

    We all love the National Health Service, so it is only right that anyone using our very valued NHS should make a fair financial contribution to help ensure its sustainability and the continued provision of world-class facilities—just as the British taxpayer does. Although I do not agree with the Motion, I am pleased that the noble Lord, Lord Hunt, tabled it, because it allows this House the opportunity to discuss matters relating to it, and the implementation.

    I have no interest to declare, but I have been taking an interest in health tourism since I raised an Oral Question on this subject in March 2014, and we have seen great progress from the Government since then. Indeed, it was mentioned as an objective in my party’s manifesto. Over the past four years the Government have prioritised improved cost recovery, and as a result we have achieved more than ever before, with identified income for the NHS from overseas visitors quadrupling from £89 million to £360 million. All that income is, of course, directed back into front-line services. That sounds good. However, it should be recognised that £200 million of the £360 million comes from the immigration health surcharge, and in return 450,000 IHS visas are issued every year. Therefore, for £200 for immigrants and £150 for students—a subject that has been debated in this House—free NHS treatment is offered, without exclusion of pre-existing conditions, for nearly half a million people.

    The regret Motion shows that the noble Lord, Lord Hunt, is concerned about racial profiling but, at the time of registration and to avoid any form of discrimination on arrival for a new hospital appointment, the same baseline question must be asked by an overseas visitor manager of every patient, in every department—using, according to the guidance, these exact words:

    “Where have you lived in the last 6 months?”.

    If the patient replies “In the UK only”, no further questions are asked regarding residency or immigration status. That is it. If the answer given is yes, there are to be no further questions. I fear that it will soon become common knowledge that, in the NHS, care is free to anyone who answers yes to this single baseline question.

    This is spelled out in chapter 11, on page 88, of the Department of Health Guidance on Implementing the Overseas Visitor Charging Regulations.

    Furthermore, it clearly states at chapter 11.16:

    “Administrative staff must avoid discrimination when asking these questions”.

    Needless to say, vulnerable groups will be excluded from up-front charging. The guidance issued by the NHS specifically excludes asylum seekers, trafficked people and every other variety of vulnerable grouping. Furthermore, the guidance confirms that up-front charging will apply only to patients presenting for elective treatment. GP services and A&E are, of course, specifically excluded.

    Health tourism is a huge issue. On 1 February 2016, my noble friend Lord Bates, the then Minister in this department, gave an estimate to the House that the cost to the NHS was some £2 billion. Possibly unlike the noble Lord, Lord Hunt of Kings Heath, I am pleased that the Government are now running 35 pilot schemes in 19 NHS trusts to ask patients for two forms of identification to show ordinary residence. Again, this is just for elective surgery, for which there is plenty of time to plan, not emergencies such as complicated pregnancies, where we have seen real evidence of people coming specifically to the UK and literally being taken to hospital from the airport for free—for them—using extremely expensive medical assistance. Needless to say, in Europe if one is unfortunate enough to have to go to hospital, anecdotal and other evidence says that the first thing the hospital asks is to look at your insurance or E111. Our system of state-funded and provided medicine has for too long been lax in properly obtaining payment where it is due.

    The real issue we should be discussing is how inadequate we are in terms of OVMs. In September 2017, Professor Meirion Thomas, who has become the country’s expert in this area purely as a matter of public service, sent freedom of information requests to NHS trusts. He asked eight acute trusts in London, two acute trusts in Birmingham and eight acute trusts in Greater Manchester for details of their OVMs. The trusts in London and Birmingham do have OVMs, but a grossly inadequate number. I will not bore your Lordships’ House with the numbers but the proportions are frightening. However, in Manchester, the results are even worse. Only one trust—the Christie hospital—has an OVM, and I would be pleased to provide my noble friend the Minister with details, should he so wish. This research proves that the NHS is not prepared for new legislation: seven acute trusts in Manchester have no mechanism for up-front charging. Therefore, I am afraid that I cannot support this regret Motion. The question we have to ask at another time is not how up-front charging can work in terms of the Motion, but how we are going to implement this to ensure a fair playing field for those who pay for and deserve proper treatment.

  • My Lords, I thank all noble Lords who have contributed to the debate. While, as ever, I disagree with the Motion in the name of the noble Lord, Lord Hunt, I am grateful to him for raising the topic of cost recovery for the NHS from overseas visitors. It is a very important policy issue and it is crucial that the objectives of these regulations, and the safeguards that we have put in place, are discussed and understood by Members of the House.

    In July this year, my department introduced amendment regulations to extend and improve the recovery of NHS costs from overseas visitors who are not ordinarily resident in the UK. This followed a period of public consultation in 2015-16. The Government’s response to that consultation, which set out our intentions, was published in February 2017.

    Let me first be clear about the principles that sit behind our policy on cost recovery. As my noble friend Lord Leigh has said, the NHS is a cherished national institution. It is paid for by millions of British taxpayers, who care deeply about it being used fairly, so we must protect it carefully. Our country has always welcomed visitors and the NHS is no different, but I hope noble Lords also agree that it is only right that, when using its services, visitors should also make a fair financial contribution to the NHS’s sustainability. On that basis I welcome the support in principle of the noble Lord, Lord Hunt, and the noble Baroness, Lady Hamwee, for cost recovery. However, it would be wrong not to point out that, when specific proposals come forward, they seem less robust in offering that support.

    This principle was not introduced by this Government; regulations and guidance requiring cost recovery from overseas visitors have been in place for over 30 years, as my noble friend Lady Redfern pointed out. As the number of visitors to the UK has grown over the years, the Government have supported the NHS to identify more income than ever before, quadrupling that income over four years to £360 million. The regulations we are discussing today continue this policy of seeking fair payment for NHS services provided and allow the NHS to take further action to support cost recovery in a way that is more efficient, more equitable and more effective.

  • In particular I draw your Lordships’ attention to two of the amendments the Government have made. The first is the extension of charging to NHS-funded secondary care provided outside a hospital and by non-NHS providers. This corrects an anomaly whereby secondary care services provided to overseas visitors in an NHS hospital were chargeable, whereas the very same services provided in the community or by, for example, a non-NHS provider, but still paid for by the NHS, were not. This change therefore ensures fairness in charging and a framework that aligns with our ambitions for new integrated models of care, which will see more people treated in their communities.

    Noble Lords have raised concerns that this extension might deter patients from seeking preventive care programmes. Let me be clear. If we are discussing charging for secondary care services—which is already the case in hospitals—it is right in principle and in practice for the same services to be charged for in non-hospital settings. It makes no sense to distinguish between the two; indeed, it is inequitable and arbitrary to do so. Instead, as all noble Lords have pointed out, the right thing to do is to make sure that particularly vulnerable groups can receive special attention, regardless of their ability to pay or their immigration status. I reiterate the point that I made in the letter, which was highlighted by the noble Baroness, Lady Taylor, that that is why no refugee, asylum seeker, looked-after child or victim of trafficking or slavery will ever be charged for care.

    We have also been careful to exempt from charging the diagnosis and treatment of specific infections that could put the health of the wider public at risk. This includes infectious diseases—which was raised tonight—such as pandemic flu and sexually transmitted infections. Finally, no one will be charged for primary medical care, which includes GP care, even if it is received outside a practice.

  • In the list the Minister gave, he did not deal with the point that the noble Baroness, Lady Hamwee, and I raised about failed asylum seekers who are still living in England.

  • For clarity, they are not covered under the exemptions.

    The second change the amendments make is to the requirement that any care not deemed immediately necessary or urgent by a clinician is paid for up front. The published guidance, again, for nearly 30 years, has recommended this. This practice ensures that a chargeable patient can make an informed choice about their care and therefore does not unwittingly incur debts when they could instead, for example, choose to wait for treatment until they have travelled home. Given that our NHS is facing unprecedented levels of demand, I hope noble Lords will agree that mandating this position is a sensible approach and that it will help make sure that all users of the NHS make an equitable contribution to ensure its continued success and viability.

    The noble Lord, Lord Hunt, has asked whether this practice will not create barriers between vulnerable patients and treatment and result in racial profiling as the front line seeks to determine eligibility for free care. I have already drawn noble Lords’ attention to the exemptions in place and the fact that all GP and A&E services remain free for all. I am also clear that immediately necessary or urgent treatment—such as all maternity services—will never be withheld, regardless of the patient’s ability or desire to identify themselves or pay. To reassure the noble Baroness, Lady Taylor, and other noble Lords, it is for clinicians, and no one else, to determine whether a treatment is immediately necessary or urgent.

    On whether patients may face discrimination, this is always unacceptable and not compliant with anti-discrimination legislation. As my noble friend Lord Leigh pointed out, our guidance is clear that simple, short questions should be asked by trained staff of all patients whose records do not already indicate residency status to assist in identifying those not eligible for free care. That information can then be captured in the patient record for the future.

    To support the implementation of these regulations, we have developed with front-line staff a “cost recovery toolbox” containing extensive guidance and template letters to patients and clinicians, as well as patient and staff-facing leaflets and posters and a web-based forum for peer support. As my noble friend Lady Redfern pointed out, working with NHS England and NHS Improvement, the department has published operational guidance to support the introduction of the regulations. This includes an average price list to provide consistency in up-front charging. The department has recruited a senior, experienced cost recovery team of NHS professionals who have led improvement visits to over 20 NHS trusts over the last six months. Action plans are in place for each trust and the team will support improvement and the sharing of best practice across the wider NHS.

    I would like to end on an issue which has been raised by many noble Lords in this debate: the assessment carried out before we introduced these changes. As I have explained, up-front charging did not represent a change in policy, but instead has existed for many years before the consultation on other amendments. Over the course of the consultation and decision-making process, the Government carefully considered the impact the charges may have and published a full impact assessment alongside the regulations. This concluded that the package of changes would identify up to £40 million a year for the NHS. This is additional income and takes into account any administrative costs associated with the changes. I will also place in the Library copies of the equality assessments carried out by my department to inform the regulations, so that Members of the House will be able to review how the impact on vulnerable and protected groups was very carefully considered prior to the introduction of these changes.

    All noble Lords have asked about the implementation of these changes and it is right, of course, that we proceed cautiously, sensibly and that we review how we are doing. So I am very aware of the need to keep the impact of these regulations under careful review in order to make sure they are implemented as planned and with no unintended consequences. My department will therefore undertake a full, formal review of how these amendment regulations are implemented, and monitor delivery closely, particularly where healthcare is provided to the most vulnerable. If further action is needed I will commit to update the House accordingly.

    I hope I have been able to reassure all Members of this House about the long-standing principles that underpin our approach to cost recovery, the care that has been taken to protect vulnerable groups, and the reflective approach we will take during the implementation of these policy changes. I believe that they provide an equitable and reasonable step forward in making sure that all the NHS’s users, wherever they come from, make a fair contribution to the sustainability of the NHS, which is what British citizens expect. On that basis, I ask the noble Lord, Lord Hunt, to withdraw his motion.

  • My Lords, I am very grateful to all noble Lords who have taken part in this debate. The fact we spent nearly an hour on it as last business on a Thursday is testimony to the importance of the matter, which is why I welcome so many noble Lords having stayed to take part. I will not push this to a vote, and I will withdraw the Motion, but I do think it is an opportunity to raise some very important points with the Government.

    First, the noble Baroness, Lady Hamwee, made some very important points about the analysis of the impact assessment, the doubtful financial benefits set against the bureaucratic costs, and the impact this may well have on some of the most vulnerable people—the very people who, not just from their point of view but the public health point of view, need to access these services.

    Secondly, from the evidence that I have received—and I have received many such examples—there is a real concern that people who are legitimately entitled to NHS services may get turned away. The noble Baroness, Lady Hollins, rightly asked what the safeguards were to prevent this.

    I think it right that we talk about racial profiling because again, there is some evidence that, in spite of what the Minister said and what is promised in guidance, this is taking place in some parts of the country. The NHS has many organisations—we have a lot of community organisations—but it turns out that staff who are given such responsibility may not be aware of the importance of this issue and its sensitivity. The obvious case here is British people with foreign-sounding names being challenged in a way which I think is inappropriate.

    The Minister did not respond to the point from the noble Baroness, Lady Hamwee, about the Home Office requiring medical records. I do not know whether he will be prepared to respond to her in writing; I understand that the question goes much wider than his brief today, but I am concerned about the ethics of the Home Office requiring people to open their medical records.

    The noble Baroness, Lady Hollins, was of course right to point out the barrier to people with mental health and other disabilities. This is not just about who is eligible: having to produce evidence to legitimise a right to treatment could prove difficult for vulnerable people who find everyday living hard and challenging.

    Like my noble friend Lady Taylor, I say to the Minister—the noble Baroness, Lady Redfern, and the noble Lord, Lord Leigh, both spoke about this—that I have no problem with the principle of cost recovery. I accept that it is right that the NHS seek to recover costs from the people who are not eligible for NHS treatment. My problem, particularly with these regulations, is that I have a feeling they will be counterproductive and I doubt they will raise very much in the way of resources. My noble friend also teased out the point about the position of failed asylum seekers, who seem to be particularly vulnerable. I welcome what the Minister said about unintended consequences; that is a very important point.

    Operational guidance, which the Minister referred to, is one thing. I would have preferred to see some of the points he has made and reassurances he has given in the regulations, rather than operational guidance. I also noted with great interest what he had to say about accident and emergency and GP services. From the confidence with which he said it, can I take it that the Government intend that they will remain free for all in future? Perhaps I can ask him quite what he meant by that, because in the briefings that I have had people have emphasised that it is the Government’s intention to extend the charges to accident and emergency services and GP services.

  • We are talking about the regulations that we are implementing, and they do not introduce that. That is the point I was making.

  • Noble Lords will interpret that response in the way they wish to. That is a bit disappointing.

    The Minister has promised a review. I very much welcome that. He said it would be a full, formal review; let us hope it will also be an independent one. Asylum Matters has reminded me, in the most efficient way that that organisation works, that of course in 2016, a review was promised. I hope this time, we will actually get such a formal review.

    Having said that, this has been an important debate. A lot of people are looking with great interest at what your Lordships have discussed tonight. We knew we were not going to be able to stop these regulations but I hope we have expressed those legitimate concerns. I am grateful to noble Lords for taking part and beg leave to withdraw the Motion.

  • Motion withdrawn.

    House adjourned at 6.58 pm.